2 Communicating health information: hidden barriers and practical approaches

Kayce M. Shealy, PharmD, BCPS, BCACP, CDE

Neyda V. Gilman, MLS

Introduction

According to the 2003 National Assessment of Adult Literacy, 36% of US adults aged 16 years or older have health literacy skills at a basic level or below.¹ For adults greater than 65 years old, this jumps to 59%, with 29% of those having below basic skills. There are many definitions, but generally health literacy is defined as the “degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”² Even broader, information literacy is defined as being able to “recognize when information is needed and have the ability to locate, evaluate, and use effectively the needed information.”³ These skills are necessary for patients to be able to understand their health and their current or potential treatments. With poor health literacy, patients are less likely to understand what their health provider is telling them, to see how different aspects of their health tie together, or to know what steps they need to take to keep or improve their health. Additionally, patients with limited health literacy are more likely to experience poorer health outcomes and increased healthcare costs.^4-7

In 2009, The Calgary Charter was created by individuals from Canada, the US, and the UK to identify the core principles of health literacy. The definition of health literacy defined by this document includes the important component of the health provider having the information literacy skills necessary to recognize and efficiently solve their own information needs.⁸ Health literacy is important for pharmacists to be able broaden their knowledge and stay current with health and medical research. An information literate pharmacist is also more aware of his or her patient’s health literacy and has the skills needed to find needed information for the patient, the patient’s prescribing provider, and his or herself as necessary.

Assisting patients with their health literacy and understanding of even one piece of health information can have a beneficial rippling effect, including increasing their comfort and willingness to discuss health questions or concerns with health care providers.^9-11 Patients with improved health literacy are also more likely to discuss screening and treatment options, as well as follow recommended treatment procedures and healthy lifestyle habits in order to reduce health risks.

Case

CC: “I need some refills on my meds.”

HPI: Steve tells the pharmacy technician that he needs to refill his “pink round pill, his blue rectangle pill, and his white round pill, and there may be one or two other ones.” While the technicians are submitting the refill requests, you take time to review Steve’s medication profile (see below).

PMH: Depression; hypertension; T2DM

FH: Noncontributory

SH: Current tobacco use

Medications:

Allergies: NKDA

SDH: Steve completed high school, and currently works at the local post office.

Additional context: Once his prescriptions are ready, you ask Steve if you may take a few minutes to review his medications and other health information. During the counseling, you observe that although Steve has been taking the same medications for the past year, he is unsure as to the exact purpose of each. In addition, he admits to missing some of his follow up appointments with his primary care provider due to various reasons.

Case Questions

1. From this one interaction with Steve, how would you classify his health literacy? Are there any red flags that led you to your conclusion?

2. What concepts and/or techniques can be used when communicating with Steve to ensure his complete understanding?

3. What things should be considered when looking for appropriate health information for patients?

4. What additional resources are available for you to learn more about methods to improve health literacy?

Author Commentary

Limited health literacy is linked with poor health outcomes.^4-7 Patients with limited health literacy are more likely to utilize emergency room services, have more hospitalizations, and are less likely to utilize preventive services like mammography or receive influenza vaccinations compared to their more health literate counterparts. Focused interventions, such as those recommended in the Health Literacy Universal Precautions, have been shown to improve health literacy. In addition, delivery of the interventions by a healthcare professional, like a pharmacist, increases efficacy of the intervention.

While communication skills overlap with health literacy skills, they are not the same thing. It is important to remember that just because a person may have great communication skills, he or she may not necessarily be health literate. In order to effectively communicate about health, especially with a range of levels of health literate individuals, it is necessary to be health literate yourself. Some patients with health literacy issues may benefit by bringing their prescribing providers into the conversation. Prescribing providers and pharmacists who have an understanding and awareness of the importance of health literacy may have improved communication that allows enhanced learning about their patient’s medications and concerns, further benefiting their patients. Positive experiences while communicating with pharmacists could also lead to more open and honest communication and collaboration.

Health literacy not only affects individual patients, but also can affect health-systems due to the costs of increased hospitalizations and healthcare utilization overall. Organizations like Joint Commission recognize the important impact that health literacy plays on patient safety and have encouraged institutions to incorporate policies that facilitate enhanced patient-provider communication.

There are many tools available to formally assess a patient’s health literacy; however, their routine use in practice may be limited due to the time necessary to administer. Quick assessments such as the Single Item Literacy Screener or Newest Vital Sign may be useful for the general population, and assessments such as the Literacy Assessment for Diabetes are more suited for specific patient populations.

Patient Approaches and Opportunities

Health literate pharmacists can positively affect patients. Pharmacists may be able to take more time discussing the patient’s health than other health professionals. They also are able to have their discussions in a different environment than a cold clinical office. By being health literate themselves, and assessing and acknowledging their patients’ level of health literacy, pharmacists can help patients improve understanding of their health information. With this understanding, patients are more likely to take steps to improve their health, including improved drug adherence.¹²Pharmacists should apply the Health Literacy Universal Precautions during each patient encounter. Be sure to provide clear communication that incorporates words, numbers, and images that are familiar to the patient or population with whom you are communicating. Strategies that can improve spoken communication include using the patient’s own words; limiting content presented to 3-5 key concepts and repeat; encouraging questions; and incorporating the teach-back method. Utilizing these strategies can help increase patients’ understanding of health information.

Other strategies to help improve health literacy include using clear, basic, and respectful language, a moderate speaking pace, open-ended questions, and easy-to-understand materials including images and diagrams. Other strategies include making and sharing action plans with patients, and directing patients to resources for additional literacy and/or math skill training, as well as community resources as applicable. Example resources include Medline Plus’ Medical Encyclopedia and Word Part appendix, as well as simple articles such as healthywomen.org’s post on health literacy. Regardless of the patient’s health literacy level, having a health literate provider enhances the patient-provider relationship.⁸