People with low health literacy levels are more likely to suffer poor health, incur higher health costs and die young. What can pharmacists do to tackle this healthcare crisis?

Health literacy is about an individual’s ability to make sound health decisions in the context of everyday life and is an important aspect of their capacity to manage their health. Low health literacy compromises people’s ability to understand their health needs and to navigate complex healthcare systems, with profound consequences for their health.

People with low health literacy have poorer health status, are less likely to make healthy living choices, experience higher rates of hospitalisation and emergency admissions and incur substantially higher health service costs. While low health literacy was once seen as an individual’s lack of knowledge and skills regarding health issues, it is now recognised as a ‘systems issue’ reflecting the complexity of both health information and the healthcare system.

Determinants of health, such as education, employment, housing, income, environment, ethnicity, not having English as a first language and gender, can impact on people’s ability to understand and act on health promotion messages as well as function effectively in clinical settings. A BMJ study found that a third of older adults in England have difficulty understanding basic health-related written information, and linked this poorer understanding to higher mortality rates.

Research recently highlighted by the Royal College of General Practitioners shows that 43 per cent of adults fail to fully understand information that contains text, such as signs in hospital, leaflets and health guides, while one in three doesn’t understand numerical information. The research highlighted examples such as a patient failing to have an x-ray because the hospital department was labelled ‘radiology’, and patients thinking that ‘chronic’ means serious rather than long-term.

Health literacy can also have an impact on the management of long term conditions. For example, American studies have shown that asthmatic patients with low health literacy are likely to have less knowledge about correct inhaler use, and have more emergency admissions. And diabetic patients with low health literacy are more likely to have complications such as retinopathy and cerebrovascular disease.

Understanding health

Yet health literacy involves more than simply people’s ability to understand the information they’re given, says Theo Raynor, professor of pharmacy practice at the University of Leeds. ‘It’s also about their ability to understand the health system and navigate their way around it.’

Professor Raynor describes medication literacy as a sub-section of health literacy, and says that pharmacists play a big role in two aspects of this. ‘One is we need to help people to improve their own health literacy, but at the same time we need to make sure that the information we give them is as easy to understand as possible. Community pharmacists are right in the middle of this.’

Community pharmacists should talk to every patient on the basis that they are a lay person who doesn’t know a lot about medicines, regardless of any assumptions about their intelligence, advises Professor Raynor. ‘If you have a high- powered lawyer, they don’t want complicated advice, they want straightforward advice. Just because they’re an expert in their field, doesn’t make them an expert in medicines. Make sure that we use very everyday words – everybody wants that, however well-educated they are.’

This reflects the current philosophy in the USA, which is moving away from measuring health literacy and towards ‘universal precautions’ to make written information, hospital signage, etc, as simple as possible.

Health literacy involves an understanding of all aspects of healthcare including, for example, availability of free prescriptions, says Professor Raynor. ‘It’s about the knowledge to get the best out of healthcare.’

Pharmacists need to think about what they say and how they say it. One of the most effective ways of testing whether people have understood something is by using ‘teach-back’. This involves asking them to repeat things back in a non- judgemental way, to get a sense of whether they have understood what they’ve been told.

Targeting health literacy

Pharmacists should be directly targeting improvements in health literacy, says Rob Darracott, chief executive of Pharmacy Voice. ‘They are perfectly placed to offer advice and information to the local population using language patients and the public can understand.’

Services such as MURs and NMS ensure that patients receive the care and support they need to make the most of their medicines and that they have an opportunity to ask questions about their condition or their medicines. ‘Done well, as a proper two-way conversation, these interactions can do much to improve health literacy, particularly if they are used to put the patient or member of the public in the driving seat.’

Many CPPE courses aimed to improve conversations with patients and the public also aim to improve health literacy. Mr Darracott suggests that pharmacists should start with the open learning programme on patient-centred care and ask themselves: ‘Do the interactions I have with the public follow similar lines?’

Pharmacists in Manchester are involved with a health literacy project that is ‘designed to take the health literacy challenge where it should all start, in schools’, says Mr Darracott. Although the project is still in its early stages, supporting the effective use of prescribed medicines in schools is a long-standing challenge. ‘The appropriate use of self-care, and patient and public rights and responsibilities in a publicly funded health care system are all matters that should find their way onto a balanced school curriculum.

The Sainsbury’s Wells Family Challenge has been cited as another example of pharmacists’ role in improving health literacy. Regular pharmacy advice over the course of a year showed significant health improvements, including 65 per cent of adults losing weight, with an average weight loss of 4kg. Importantly, 58 per cent of participants reduced their risk of a stroke or heart attack, half had significantly lowered cholesterol levels, and 70 per cent of those involved were still doing 30 minutes of daily physical activity a year later.

Research has shown that most patient information leaflets in GP waiting rooms (and possibly therefore pharmacies) are written at a level too complex for nearly half of the population. Author of this research, senior lecturer in general practice at Keele University and chair of the Health Literacy Group UK Dr Jo Protheroe, suggests that GPs and pharmacists could review the written information they have on display and consider whether any needs replacing with more appropriate versions.

Dr Protheroe agrees that MURs and NMS are opportunities to improve health literacy. ‘Pharmacists and GPs have an opportunity not only to take account of patients’ health literacy with good, common sense explanations,’ says Dr Protheroe, ‘but also improve health literacy by not just saying “the blue inhaler”, but by saying “the blue inhaler, salbutamol”. Then when patients next have a discussion with their GP or A&E they know what is being talked about. It’s important to be clear we are not talking about dumbing down – rather, giving clear, honest information using lay language, and avoiding overly medical terminology.’

Fairness and equity

Health literacy is central to ensure fairness and equity in the NHS, concluded a recent stakeholder meeting that included NHS England, RCGP, professional and patient advocacy groups. It also resolved that health literacy is key to more effective use of resources, through increased understanding of how best to access and use health services. Improved health literacy would also give people the confidence and skills to enable decision-making that is shared between doctors and patients, as well as ensuring that patients take a full role in developing services that fit with the needs of local populations.

New initiatives must be targeted at those with the greatest need, including those with the lowest health literacy skills, suggested the meeting. One such initiative, the NHS drive for digital inclusion, may do much to increase access, information and health literacy skills among those with the greatest need. 

The figures on health literacy

  • There is a strong relationship between health literacy and self-assessed health, so that people with higher health literacy feel better. The proportion of people reporting ‘good’ or ‘very good’ health increases steadily from below 30 per cent up to more than 80 per cent for the highest general health literacy values.
  • A comparative study of health literacy across eight EU member states (Austria, Bulgaria, Germany, Greece, Ireland, the Netherlands, Poland and Spain) found that nearly half of respondents showed limited health literacy, although levels varied considerably between countries. About 12 per cent of respondents across the eight countries have inadequate general health literacy, and 35 per cent problematic levels. While less than two per cent of Dutch respondents had inadequate health literacy, this figure is almost 27 per cent among Bulgarians.
  • Low levels of health literacy are estimated to cost the US economy $106 to $236 billion annually.
    There is limited information about levels of health literacy in England, but it does have low levels of basic general literacy and numeracy. The Skills for Life survey found that 46 per cent of the population scored at a literacy level below that required to achieve their full potential, with three per cent of people being functionally illiterate. The figures are worse for numeracy, with 75 per cent scoring at a level below that required to meet their full potential and 5 per cent being functionally innumerate.
  • A survey of patient information producers found that fewer than half provided services that address the needs of people with low health literacy, and only 10 per cent had a specific policy or strategy. Barriers include limited funding, understanding of needs and how to develop appropriate resources.


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