Pharmacists’ Knowledge and Perceptions of Health Literacy

Abstract

Background: Health literacy is defined as the degree to which individuals have the capacity to obtain, process and understand basic health information needed to make appropriate health decisions. A review of literature revealed few studies that examined pharmacist’s knowledge of health literacy. Methods: The Pharmacist Professional Health Literacy Survey was distributed to a convenience sampling of community pharmacists in medically underserved counties of Southwest Georgia. Results: Of 75 pharmacists contacted, 39 completed the survey and were used in the evaluation. Most respondents reported no health literacy training and had never assessed health literacy with a validated questionnaire. More than half of the participants cited lack of knowledge about low health literacy as a major barrier to implementing health literacy screening for their patients. Time and cost were identified as major barriers to participating in health literacy training programs. Conclusion: Most pharmacists from this area had little exposure to evaluating health literacy. Pharmacy education postgraduate programs and continuing education training programs around this topic will heighten health literacy knowledge for the pharmacy profession. There is a need for a quick, easy to use, and effective tool for pharmacists to recognize and assess health literacy in patients.

Keywords

health literacy pharmacist training barriers screening

Introduction

According to the United States Health Resources and Services Administration (HRSA), health literacy is defined as “the degree to which individuals have the capacity to obtain, process and understand basic health information needed to make appropriate health decisions.”¹ American adult health literacy and numeracy skills were assessed during the National Assessment of Adult Literacy (NAAL) in 2003.² The 5 levels of literacy for the 2003 NAAL are (1) Non-Literate in English, (2) Below Basic, (3) Basic, (4) Intermediate and (5) Proficient. Results from this assessment showed that 22% of American adults have Basic health literacy and 14% have Below Basic health literacy.²

The United States Department of Education gives additional information on stratifying individuals within the five levels of literacy and defines Basic health literacy as “possessing skills necessary to perform simple and everyday literacy activities.”² Key abilities associated with basic health literacy include reasoning and understanding information in short, prose texts, simple documents, and locating easily identifiable quantitative information to solve simple one-step arithmetic operations. Below Basic health literacy indicates the ability to perform no more than the most simple and concrete literacy skills. Adults with Below Basic health literacy range from being non-literate in English to being able to locate easily identifiable information in short prose texts, follow instructions in simple documents, and locate numbers to use in simple quantitative operations such as addition.

The 2003 NAAL results reveal that low health literacy is more common in adults age 65 and older, individuals with lower education levels, those with low socioeconomic status, and individuals with Medicare, Medicaid, or no insurance.³ Older individuals living in rural areas are more likely to have poorer health outcomes which could be related to lower levels of health literacy.² The 2018 American Community Survey (ACS) reports the age, income, education level and poverty level of communities in the United States. Using the ACS, we evaluated data from fourteen counties in rural Southwest Georgia. Approximately 17% of the population of Southwest Georgia are 65 and older. The national poverty rate of the United States is 12.3%, while more than 20% of those living in Southwest Georgia are below the poverty line.^4,5 The survey also reported that less than 20% of Southwest Georgians have a bachelor’s degree and approximately 18% have no degree.^4,5 Of the 14 Southwest Georgia counties evaluated, 13 are designated by the United States Department of Health and Human Services (HRSA) as Medically Underserved Areas (MUAs) due to the shortage of primary care providers available to residents.¹

Access to health services impacts an individual’s health status physically, socially, and mentally.⁶ Low health literacy rates in this area combined with limited access can result in unmet health needs, delays in patients receiving care and potentially preventable hospitalizations.⁷ The statistics and designation of MUAs show that many adults in Southwest Georgia may have difficulty understanding and utilizing health information.

Healthcare providers should ensure effective communication with individuals of all literacy levels. They should also assess, evaluate, and understand their patient’s level of health literacy as it is an important component of the overall well-being of an individual.⁸ Studies show that limited health literacy has many consequences for the patient including greater difficulty naming medications and associated indications, poorer medication adherence, lower overall health status, and greater hospital admissions.^9-11

Pharmacists play a crucial role in our healthcare system and are often the most accessible member of the team. A review of literature revealed few studies that examined pharmacists’ knowledge of health literacy. A small study examined the frequency in which pharmacies identify patients with limited literacy skills and the strategies they use to improve adherence. Researchers identified 30 community pharmacies in Atlanta, Georgia with high percentages of patients with limited literacy skills. They conducted phone interviews and concluded that only two of the 30 participating pharmacies (7%) attempted to identify patients with limited literacy skills and provide additional assistance such as additional verbal counseling or repeating instructions to demonstrate understanding. Some pharmacists were unaware that their patients may have difficulty reading and three pharmacists (10%) noted they were not concerned about low literacy because they served middle-class areas and few Medicaid patients.¹¹ Pharmacists care for patients of various education levels, differing incomes, and diverse races and ethnicities, all of whom may have limited health literacy.¹² It is important to note that health literacy levels are affected by factors other than income status or being identified as someone receiving Medicaid benefits such as older age, not understanding specific medical terminology, or having to manage multiple chronic disease states.^1,3

The limited literacy skills of patients may go undetected because the problem is widespread and many patients may not readily admit to difficulty understanding information. Given that more than a third of US adults have Basic or Below basic health literacy, healthcare providers, including pharmacists may overestimate their patients’ ability to read and comprehend health related information such as prescription labels or written patient education materials such as medication leaflets and prescription informational printouts.^12,13 King and colleagues questioned more than 400 Mississippi pharmacists from various practice settings to define “Pharmacotherapy Literacy.”¹² Based on their responses, the final definition of Pharmacotherapy Literacy was “an individual’s capacity to obtain, evaluate, calculate and comprehend basic information about pharmacotherapy and pharmacy related services necessary to make appropriate medication-related decisions, regardless of the mode of content of delivery.”¹² It was concluded that a definition of health literacy specific to the pharmacy setting may improve medication consumption, safety, and the relationship between patients and their pharmacists.

Several surveys have been conducted in the United States to examine health literacy knowledge among other health professions. A study conducted by the University of Alabama at Birmingham created the “Knowledge of Health Literacy Questionnaire” to gain insight about healthcare providers’ knowledge of the impact of limited health literacy on patients and the healthcare system. The instrument was examined by experts in the fields of nursing, medicine, and health literacy for validity. Multiple healthcare professions were represented in this study including nursing, medicine, dentistry, and students from various healthcare fields. From this study, the researchers found that the majority of the participating healthcare professionals were unaware of the prevalence of limited health literacy (88%) and its economic impact for the United States (80%).¹⁴

Macabasco-Oconnell and collaborators used The Nursing Professional Health Literacy Survey to understand the knowledge and perceptions of health literacy in California nursing professionals.¹⁵ Validity was established by experts in the field of nursing. Survey results uncovered that while 80% of nursing professionals are familiar with the term health literacy, only 41% have received formal training in the area. Health literacy initiatives were also reported as being of low priority and were only available at 38% of their practice sites.¹⁵ This study also demonstrated that the economic impact of low health literacy was underestimated by the nursing profession.

The limited research of the pharmacist’s role, perceptions, and knowledge of health literacy identifies a need for further research. To address this lack of information, the authors sought to examine the knowledge and perceptions of health literacy among independent community pharmacists in counties of Southwest Georgia identified as MUAs with the possibility of a high percentage of patients with lower health literacy levels. There are no validated instruments currently being used to evaluate this information, thus the Knowledge of Health Literacy Questionnaire¹⁴ and the Nursing Professional Health Literacy Survey¹⁵ were adapted with permission to examine health literacy in the pharmacy profession.

Methods

Study and Survey Design

An electronic questionnaire entitled the “Pharmacist Professional Health Literacy Survey,” was approved by the Samford University Institutional Review Board. The survey was conducted to assess the knowledge and perceptions of health literacy of independent community pharmacists in MUAs of Southwest Georgia. The survey was created using the Qualtrics Online Survey Platform and consisted of three sections: General Health Literacy Knowledge, Practice-Based Health Literacy Perception, and Demographics. The first and second sections of the survey included questions regarding health literacy knowledge and application which were modified with permission from the Knowledge of Health Literacy Questionnaire¹⁴ and the Nursing Professional Health Literacy Survey.¹⁵ The last section included demographic questions that solicited information about the pharmacy education program attended, length of pharmacy practice, additional certifications held, and benefits of additional health literacy training. The Qualtrics anonymize response feature was used for the entirety of the survey to allow participants to remain anonymous.

Recruitment and Survey Distribution

We used a convenience sampling of independent pharmacies from our specific target area of 14 counties in Southwest Georgia which are listed as medically underserved to identify potential pharmacist respondents. Email addresses for pharmacists were systematically obtained. Independent pharmacy names were identified via Google’s web mapping service and pharmacies were contacted via phone by the primary investigator. The pharmacist was informed about the Pharmacist Professional Health Literacy Survey and their email address was requested. The survey link was distributed via email to independent community pharmacists in the 14 counties of Southwest Georgia who had provided a valid email address. Following the Pharmacist Professional Health Literacy Survey, participants could voluntarily complete an additional survey to be entered into a randomized drawing for one of four $25 Visa gift cards. The four winners received the Visa gift cards by mail once the survey period was complete.

Data Collection and Analysis

The survey link was to remain active for three weeks. Two reminder emails were sent on days seven and 14 during the collection period. The active survey period was extended beyond the initial 3-weeks due to a low response rate. After extending the survey period, additional weekly reminders were sent. De-identified data was collected online over a 9-week period via Qualtrics Survey Software. A secure user account was utilized by the researcher to access and analyze the stored data. Only completed surveys were analyzed.

Results

Of the independent pharmacies located in Southwest Georgia, email addresses were obtained for a total of 75 pharmacists. The 75 surveys yielded a preliminary response rate of 60% (n = 45). After excluding partially completed surveys, the final response rate was 52% (n = 39). Nearly 70% (n = 27) of the respondents completed a Doctor of Pharmacy (PharmD) program, 25.64% (n = 10) completed a bachelor’s program, with 5.13% (n = 2) of respondents completing both bachelors and doctorate pharmacy programs.

Respondents were also asked to indicate the number of years in pharmacy practice. Approximately one-third (35.9%) of the respondents have been practicing pharmacy for twenty or more years, 38.46% have been practicing for 10 to 20 years, and 25.64% of respondents have been in practice less than 10 years. Of the 39 independent pharmacists surveyed, none reported completing any residency training after pharmacy school; however, one respondent reported completing a Board Certification in Diabetes and Medication Therapy Management.

General Health Literacy Knowledge

There were ten (25.64%) respondents who reported never hearing the term “health literacy” prior to this survey. When asked to describe their level of health literacy knowledge, answers ranged from “a great deal” of knowledge (7.69%, n = 3) to no knowledge (15.38%, n = 6) with the majority (35.90%, n = 14) reporting “a moderate amount” of health literacy knowledge. Regarding specific health literacy training, only 28.21% (n = 11) have received training, leaving 71.79% (n = 28) of respondents having no training regarding patient health literacy. Table 1 presents the overall knowledge of health literacy and its effect on American patients and the United States economy.

Table 1.

Pharmacist’s Knowledge of Limited Health Literacy.

Item		Number of correct answers (total n = 39), %
Q4	The average American reads at a sixth grade reading level	12 (30.77)
Q5	30%–50% of the U.S. population has difficulty understanding healthcare information or instructions	9 (23.07)
Q6	Level of health literacy can be determined by
	Race/ethnicity	28 (71.79)
	Socioeconomic status	37 (94.87)
	Education level	38 (97.43)
	Gender	4 (10.26)
	Age	30 (76.92)
	Culture	30 (76.92)
Q7	Individuals with high levels of education may or may not have limited health literacy	31 (79.49)
Q9	Limited health literacy is estimated to cost the US economy $100–$300 billion annually	9 (23.08)

The pharmacists’ knowledge of the term “health literacy” was analyzed through an open-ended question where participants were asked to describe health literacy in their own words. About 49% of the pharmacist’s described health literacy as “the patient’s ability to understand health care information or terminology.” Approximately 22% of the participants stated that “health literacy is the ability of the patient to understand their health.” Other responses included “health literacy is anything a person uses to help them understand their health, including speaking, hearing, reading and writing,” “being capable of implementing the use of medical equipment and medications,” and “an understanding by the patient of their medications and what they are used for.”

Practice-Based Health Literacy Perception

Pharmacists were asked to describe the degree to which both their English speaking and non-English speaking patients are affected by low health literacy. Pharmacists reported that their non-English speaking patients were affected by low health literacy to a higher degree than their English speaking patients. Most respondents felt that low health literacy affected their English speaking patients a “moderate amount” to “quite a bit,” but felt that it affected their non-English speaking patients “a great deal.” These results are presented in Table 2.

Table 2.

Low Health Literacy Effects on English vs Non-English Speaking Patients.

	Ability to understand health information (total n = 39)		Ability to obtain appropriate health services (total n = 39)		Ability to follow through on recommended treatments (total n = 39)
	ES*	NES⁺	ES*	NES⁺	ES*	NES⁺
None	0 (0%)	0 (0%)	2 (5%)	0 (0%)	0 (0%)	0 (0%)
A little	2 (5%)	0 (0%)	5 (13%)	2 (5%)	3 (8%)	2 (5%)
A moderate amount	13 (33%)	3 (8%)	14 (36%)	5 (13%)	13 (33%)	2 (5%)
Quite a bit	26 (67%)	11 (28%)	12 (31%)	4 (10%)	14 (36%)	12 (31%)
A great deal	8 (21%)	24 (62%)	6 (15%)	24 (62%)	8 (21%)	21 (54%)
I do not know	0 (0%)	1 (3%)	0 (0%)	4 (10%)	1 (3%)	2 (5%)

*ES = English Speaking; ⁺NS = Non-English Speaking.

Assessing a Patient’s Level of Health Literacy

To gain an understanding of how pharmacists assess health literacy, participants were asked to respond to a series of questions with never, rarely, sometimes, often, or always. A majority, 92.31% (n = 36) of respondents reported never asking patients for the last grade they completed. Most respondents, 84.61% (n = 31) reported rarely or sometimes having patients repeat instructions back to them. When asked how often they question if a patient has difficulty reading medical information or completing forms, 75% (n = 29) reported rarely or never doing so. The majority, 87.18% (n = 34) of responding pharmacists reported never formally assessing a patient’s health literacy with a validated questionnaire and 74.36% (n = 29) claim to often/always use their “gut feeling” to assess health literacy.

Assisting Patient’s With Low Health Literacy

To evaluate their assistance to patients with low health literacy, pharmacists were asked to indicate various special methods and techniques they use in the community practice. Respondents were able to select all methods they currently utilize. These results are presented in Table 3. The majority, 92.31% (n = 36), of respondents stated that their current practice sites do not have a health literacy program or intervention in place. Very few respondents, 15.38% (n = 6) reported providing patients with health education materials designated specifically for low health literacy and they were equally divided on their opinion of the effectiveness of these materials. Only three pharmacists, 7.69%, reported that their practice site has intensive, individualized health education sessions for patients with low health literacy and only one pharmacist reported having a health literacy specialist at their pharmacy.

Table 3.

Q14: Methods or Techniques Used to Assist Patients with Low Health Literacy.

	Total utilized (n = 39)	Percentage, %
Orally review written instructions with patient	20	51.28
Have patient repeat instructions back to check understanding	12	30.77
Describe medical conditions, treatments, and instructions in layman’s terms	19	48.72
Provide the patient with health education materials	7	17.95
Provide the patient with health education materials designed specifically for patients with low health literacy	1	2.56
Have patient demonstrate instructions back to check understanding	10	25.64
Refer patient to other services such as a patient educator	3	7.69
Encourage patients to bring a family member or friend to appointments	11	28.21

Methods and Techniques Used to Improve Health Literacy

To evaluate assistance for patients with low health literacy, pharmacists identified special methods and techniques they use in the community practice. More than half of the respondents reported that they use techniques such as orally reviewing written instructions with patients and describing medical conditions, treatments, and instructions in layman’s terms. Another technique utilized by 11.63% of respondents was to have the patient repeat and/or demonstrate instructions back to the pharmacist to further check patient understanding. Each of these approaches is encouraged by pharmacists to allow for identification and correction of any misunderstandings. Regarding health education materials, only seven respondents (17.95%) reported providing patients with this information with one respondent (2.56%) providing materials designed specifically for patients with low health literacy.

Barriers to Implementing Health Literacy Screening in the Pharmacy

More than half the respondents (n = 20, 51.28%) reported lack of knowledge about low health literacy among pharmacists and staff as the major barrier, to implementing health literacy screening in the pharmacy. In a check-all-that-apply type question, there were 16 pharmacists (41.03%) who reported screening patients for their level of health literacy would embarrass or shame the patients. Another barrier to implementing screening was that the assessment and screening process would take too much time, reported by 23.29% (n = 17) of the pharmacists. Only 23% (n = 9) felt both that health literacy is a low priority and good health literacy assessment tools are not available as a barrier for implementation.

Barriers to Implementing Health Literacy Education Programs

When questioned about health literacy training, more than one-third (n = 22) of the respondents reported they do not have time to take part in a health literacy training program. Another barrier of implementation was a concern that it would be too difficult to implement training for the pharmacists. Approximately 15% of the pharmacists had concerns about health literacy programs costing too much money to implement. Interestingly, three participants reported that senior leadership is not supportive of health literacy education implementation for staff. Overall, 21% (n = 12) of the respondents felt that health literacy is a low priority compared to other pharmacy related problems.

Discussion

The Pharmacist Professional Health Literacy Survey provided valuable insight about the knowledge and perceptions of health literacy in independent pharmacists from this geographical location of the rural United States. About one-fourth (n = 10) of the 39 respondents reported never having heard the term “health literacy” prior to this survey. Most of the pharmacists surveyed were familiar with the term “health literacy.” However, the majority reported never receiving any specific training regarding this topic either in school or in a continuing education program. Less than one-third of the pharmacists were aware that the average reading level of American adults is 6th grade.¹⁶ This can be troubling for patients with limited health literacy as they require information presented in plain, clear language and the reading material attached to prescription medications may be written at a level above their comprehension. It is important that pharmacists consider their patients and their level of understanding regarding information about their medications and overall health. Many pharmacists were unaware of the financial impact limited health literacy has on the US economy with most respondents underestimating the yearly cost of low health literacy.

This study also revealed that many pharmacists believe that low health literacy interferes with both their English and non-English speaking patients’ ability to understand health information, to obtain appropriate health services and to follow through on recommended treatments. However, they still failed to formally assess patients’ level of health literacy. Rather they claimed to use their “gut feeling” to assess health literacy and could be missing key information that would help them provide quality care to patients.

Recognizing low health literacy can often be difficult as patients may feel embarrassed by their limited literacy and health literacy. Their embarrassment may lead to the use of phrases or behaviors such as “I forgot my glasses” or referring to pills by color rather than medication name as is often witnessed by the researchers. If these signs are missed, it leads to missed opportunities for pharmacists to assess and assist patients, enhance communication, and thereby improve overall health outcomes.

The Agency for Healthcare Research and Quality (AHRQ) has validated tools pharmacists can use to assess a patient’s health literacy. A common instrument to measure health literacy is the Rapid Estimate of Adult Literacy in Medicine (REALM). The REALM is a word recognition test that consists of 66 medical terms arranged in order of syllable number and pronunciation difficulty. This test can be completed by patients in two to three minutes. A shorter form of the REALM assessment consists of seven word recognition items designed to more rapidly assess a patient’s health literacy.¹⁷ Recent studies also suggest that a single-question such as “How often do you have someone help you read hospital materials?” may be sufficient to detect limited health literacy.¹⁸

These results of the Pharmacist Professional Health Literacy Survey are alarming as patients with limited health literacy would have trouble understanding normal health education materials that are not adequately modified for their use. While pharmacist respondents reported using and reviewing written instructions with patients, only one provided this information in a format designed for patients with low health literacy. Simply printing materials and attaching them to the medications does not ensure patients can read or understand them.

The Centers for Medicare and Medicaid Services created the Toolkit for Making Written Material Clear and Effective. This health literacy resource focuses on making written material in printed formats easier for patients with Basic literacy skills to read, understand and use.¹⁹ It offers detailed guidelines for writing and designing materials as well as methods for testing the material with readers. With nearly one-fourth of American adults having Basic health literacy skills, this toolkit could be a great resource for pharmacists to employ with their patients.¹ Effective communication with patients who have low health literacy could bridge the gap between community pharmacists and patients. Pharmacists are often the last opportunity for patients to receive instructions on proper medication use. Written material that addresses below basic literacy levels must be adapted for simplicity which often means including visuals to accompany the text.

In the practice-based perception portion of the survey, pharmacists identified barriers to implementing health literacy screening and health literacy education for pharmacists and patients. Lack of knowledge about health literacy was a major barrier to implementing health literacy screening by many respondents. Time restraints were a common barrier for both implementing health literacy screening and training programs for either pharmacists or patients. Another barrier was a concern that it would be too difficult to implement training and that the program would be expensive. Incorporation of effective health literacy training as part of the PharmD curriculum could address these barriers and concerns. Proper exposure to health literacy education prior to entering practice would allow pharmacists to become educated and prepared to assess and address health literacy issues with their patients.

Health literacy tools for pharmacies have been developed by AHRQ to evaluate health literacy preparedness. One tool available through the AHRQ is Strategies to Improve Communication Between Staff and Patients: Training Program for Pharmacy Staff which introduces the concept of low health literacy and provides techniques staff can utilize when communicating with patients.²⁰ Implementing health literacy programs for pharmacists will afford them the opportunity and ability to better assess, communicate, and serve their patients.

Limitations

Limitations exist with this attempt to gather information about community pharmacists’ knowledge of health literacy. One limitation is the small sample size. Not all independent pharmacies in the geographical region were included or responded to the survey. Only 52% (n = 39) of 75 identified pharmacists completed the survey which may have introduced some response bias to the data. Another limitation is that the study population may not be representative of all pharmacists in the United States as only Independent pharmacists were surveyed from one region of one state. The pharmacists were practicing in a rural area and the results may not correlate to their urban counterparts. While we based our survey on validated nursing surveys, this is a pilot study in pharmacists requiring duplication in other settings. Further validation of the results with a larger sample size and including pharmacists from other regions as well as other pharmacy settings is needed. Another limitation of the study would be the lack of providing a standard definition of health literacy to the participants as they may have all had varying personal definitions.

Conclusion

Findings show that many pharmacists from this area had little exposure to the term “health literacy” and were unaware of the financial bearing that health literacy has on the US economy. Limited health literacy affects the ability to understand health information, obtain appropriate health services and to follow through on recommended treatments for both English and non-English speaking patients of Southwest Georgia. However, patient health literacy level is infrequently assessed. Barriers to implementing health literacy screening in the pharmacy and for implementing health literacy education programs for pharmacist and patients were identified. It is vital that all pharmacists not only understand what health literacy is, but that they also receive the proper training to better assess health literacy and communicate with patients. Exposure to health literacy training programs will allow for heightened health literacy knowledge for the pharmacy profession, thus leading to enhanced patient pharmacist communication, improved medication adherence, decreased hospital admissions and enhanced health status for patients. Overall, further research is needed to form a quick and effective tool for pharmacists to improve their recognition of limited health literacy among patients.

Supplemental Material

sj-pdf-1-jpp-10.1177_08971900221074958 – Supplemental Material for Pharmacists’ Knowledge and Perceptions of Health Literacy

Supplemental Material, sj-pdf-1-jpp-10.1177_08971900221074958 for Pharmacists’ Knowledge and Perceptions of Health Literacy by Pilar Z. Murphy and Ashton P. Jester in Journal of Pharmacy Practice

Footnotes

Acknowledgments

A special thank you to Dr. Peter Hughes, PharmD, MSEd, BCPS, for assistance in narrowing the survey population and offering guidance in gathering pharmacist emails. A special thank you to the independent pharmacists of Southwest Georgia who participated in this research survey.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Pilar Z. Murphy

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