Health literacy: Implications for concordance and compliance
In 2002, a study of diabetes patients published in JAMA was hailed as the first piece of research to show that poor health literacy had an adverse effect on health outcomes.1 Subjects who were found, through testing, to have poor health literacy also exhibited poor glycaemic control and higher rates of retinopathy. The authors called for targeted interventions to improve diabetes outcomes among patients with poor health literacy. The Pharmaceutical Journal reported the results of this study, and showed particular interest in the racial and ethnic inequalities that had emerged.2 A pharmacist offering a tailored service to a multiracial community in London responded that his success lay beyond simple translation of materials: engagement with community leaders and patients from these communities was essential.
One of the challenges in studying health literacy is its complex interrelationship with sociodemographic factors, such as ethnicity and level of education. Health literacy is, however, becoming recognised as a distinct measure in its own right. The JAMA diabetes study indicated that patients with “inadequate” health literacy had doubled odds of retinopathy after adjustment for other sociodemographic variables, but one-third of the subjects with a high school education or less had perfectly adequate health literacy. The 1992 National Adult Literacy Survey (NALS) in the US showed that almost half of the adult population had literacy or numeracy deficiencies or both.3 The American Medical Association (AMA) Ad Hoc Committee on Health Literacy noted that 5 per cent of those adults had learning difficulties, and 15 per cent were born outside the United States, but the committee noted that “the vast majority of adults with poor literacy are white, native-born Americans”.4 The underlying message from this research is that it is too easy to make assumptions about the understanding and ability of different population groups, and such assumptions should be avoided.
Further evidence comes from a large study of 3,260 US senior citizens aged 65 years or older enrolled in the Medicare national health insurance plan. It showed that 22 per cent could not calculate the correct timing for dosing drug therapy.5 When data were adjusted for level of education and cognitive impairment, age was found to be strongly associated with health literacy: 16 per cent of those aged 65 to 69 years had inadequate health literacy, compared with 58 per cent of those aged 85 years or older. This has significant implications for the safe use of medicines in this population, among whom polypharmacy is common.
The concept of health literacy, and the means by which it is measured, is all too often confined to issues of reading and writing. The implications for pharmacy practice are obvious: poor literacy skills will cause problems with reading the instructions on medicine labels and comprehending patient information leaflets. But the World Health Organization definition of health literacy6 embraces much broader issues: “Health literacy represents the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways that promote and maintain good health.”
Professor Donald Nutbeam, until recently head of public health at the Department of Health, outlined a tripartite framework for health literacy that included three elements of health literacy: functional, critical and interactive (see Panel 1).7 He believed that previous work had been unnecessarily narrow, and not in the broad spirit of the WHO definition.
Functional health literacy
The AMA Ad Hoc Committee on Health Literacy noted that a person’s functional health literacy might be significantly worse than his or her general literacy.4 This is because health materials of the same complexity as general materials have the added complication of unfamiliar vocabulary and concepts — functional literacy is context-specific. Studies of health literacy have, as yet, been limited to its functional aspects: an excellent recent review of this area by the US pharmacists Miranda Andrus and Mary Roth details major studies and issues for pharmacy practice.8 For example, a large study of functional health literacy among US hospital patients showed that 42 per cent of participants were unable to comprehend directions for taking medicines on an empty stomach.9
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Citation: The Pharmaceutical Journal URI: 10986700
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