- Email: [email protected]
Health literacy of student pharmacists
Currents in Pharmacy Teaching and Learning xxx (xxxx) xxx–xxx
Contents lists available at ScienceDirect
Currents in Pharmacy Teaching and Learning journal homepage: www.elsevier.com/locate/cptl
Research Note
Health literacy of student pharmacists Cheyenne Newsomea, a b
⁎,1
, Indika Mallawaarachchib, Jessica Conklina, Gretchen Raya
University of New Mexico College of Pharmacy, 2502 Marble Ave NE Albuquerque, NM 87106, United States Texas Tech Health Sciences Center, 5001 El Paso Drive El Paso, TX 79905, United States
AR TI CLE I NF O
AB S T R A CT
Keywords: Health literacy Pharmacy students Pharmacy education
Introduction: The primary purpose of this study was to assess the health literacy levels of doctorate of pharmacy students. A secondary objective was to determine if a correlation exists between age, degree prior to pharmacy school, work experience, and health literacy status among these students. Methods: Participants were first year doctorate of pharmacy students at an accredited college of pharmacy in the Southwestern United States. The design was cross-sectional. Health literacy scores were collected using the Newest Vital Sign (NVS) in English. Health literacy was dichotomized with a score of 0–3 indicating inadequate and 4–6 indicating adequate. A two sample ttest or Fisher's exact test was used to compare cofactors between health literacy groups. Results: Of the 72 first year students, 64 (88.9%) participated. The median NVS score was 5 (lower quartile 5, upper quartile 6). Nearly 90% of students (n = 57) obtained a score of ‘‘always adequate literacy.’’ Student age, having a degree before pharmacy school, nor healthcare work experience were significantly different between the two groups. Discussion: If students enter pharmacy school with a high level of health literacy, they may have difficulties relating to and appropriately educating patients with low health literacy. Knowing this information, we can tailor our teaching about health literacy in curriculums to include strategies that assist students to understand what patients with low heath literacy may experience when interacting with the healthcare system. Conclusions: Nearly all student pharmacists in the study displayed high health literacy and no correlations to collected characteristics were noted.
Introduction The Institute of Medicine defines health literacy as “the degree to which individuals can obtain, process, understand, and communicate about health-related information needed to make informed health decisions.”1 Poor health literacy is a major cause of patients’ inability to take medications properly and are the root cause of a significant amount of adverse drug events.2,3 Patients with chronic medical conditions who have low health literacy have been shown to have increased mortality and morbidity.4–8 Additionally, it is estimated that low health literacy increases health care costs by $106–238 billion per year.9 It is important for student pharmacists to understand patients’ health literacy status to provide the best possible care to these patients. Developing communication skills to effectively work with a broad range of people and recognize social determinants of health are required by the Accreditation Council for Pharmacy Education (ACPE) Key Element 3.6 of Standards 2016.10 To achieve this Standard, pharmacists
⁎
Corresponding author. E-mail addresses: [email protected] (C. Newsome), [email protected] (I. Mallawaarachchi), [email protected] (J. Conklin), [email protected] (G. Ray). 1 Present address: WSU Spokane, Department of Pharmacotherapy, PO Box 1495, Spokane, WA 99210-1495, United States. https://doi.org/10.1016/j.cptl.2017.11.005
1877-1297/ © 2017 Elsevier Inc. All rights reserved.
Please cite this article as: Newsome, C., Currents in Pharmacy Teaching and Learning (2017), https://doi.org/10.1016/j.cptl.2017.11.005
Currents in Pharmacy Teaching and Learning xxx (xxxx) xxx–xxx
C. Newsome et al.
must be aware of each patient's health literacy level and consider altering their communication strategies for patients with low health literacy. Early in their career, medical professionals may be unaware of the high prevalence of poor health literacy. Approximately onethird of Americans have limited health literacy, meaning pharmacists will frequently interact with patients who have low health literacy.11 Health literacy can be challenging to determine based on discussions or interactions with another person. A study of physician residents using their clinical interactions to determine patients’ literacy found that the residents greatly overestimated their patients’ literacy abilities. Of the 164 patients whom the residents felt had no literacy problems, 59 patients (36%) failed a literacy screen.12 While health literacy and written literacy are different skills, this study shows that new healthcare professionals may overestimate patients’ actual abilities. Explanations for the discrepancy between providers’ perceptions and their patient's true abilities are not known. To date, few studies have examined the health literacy of students. A study in Greece found most college students had fair to high health literacy.13 To our knowledge, no study has ever evaluated health literacy levels among pharmacy or medicine students. Many may assume that pharmacy students would also have high health literacy. This study analyzes this assumption and discusses the implications pharmacy students’ health literacy may have on quality of patient care. The primary purpose of this study was to assess the health literacy levels of doctorate of pharmacy students. A secondary objective was to determine if a correlation exists between age, college degree, and work experience and health literacy status among these students. Methods The University of New Mexico Health Sciences Center Human Research Review Committee approved this study. In this prospective observational study, a health literacy screening was administered to students during their first year in a four-year doctor of pharmacy program. Students were eligible for inclusion if they were enrolled in the University of New Mexico College of Pharmacy Self-Care Therapeutics class (PHRM 719) during the chosen study year. PHRM 719 was selected as it is a course taken by all first-year students, attendance is mandatory for students and learning is driven by student discussion. As a result, small groups of students could be removed from the course for questioning without significant disruption in learning. The assessment of students’ health literacy occurred in January and February of their spring semester. This assessment was administered to students early in the pharmacy school program to determine the level of health literacy before they receive specific training in health literacy. The opportunity to participate in this research was offered to students during group case discussions. Researchers visited the classroom, explained the nature of the project and the procedures for the protection of human subjects, and invited students to voluntarily participate. The first-year student pharmacists were individually brought into a separate classroom and verbally administered the English version of the Newest Vital Sign (NVS), a validated health literacy assessment.14 The NVS was selected as the screening tool because it can be administered in three to five minutes and is a validated tool for measuring health literacy. To perform the NVS, the participant was provided an image of an ice cream nutrition label. The administrator then verbally asked each participant six questions related to the ingredients and the information on the label. During the exam, the administrator recorded the number of accurate answers. Participants’ previous degree(s), age, and healthcare work experience were also verbally collected for demographic information. Four administrators interviewed the students for data collection. The administrators were trained on the NVS and demographic questions. None of the administrators were involved in PHRM 719. A convenience sampling design was used for the recruitment of participants. The primary endpoint was the score of health literacy assessment. Health literacy score was dichotomized based on number of correct questions as determined by the developer of the NVS: Limited or possibly limited health literacy (NVS 0–3) and adequate health literacy (NVS 4–6). The categories of limited or possibly limited health literacy were combined due to small sample size and the ultimate goal of identifying any student without adequate health literacy. Age was summarized using mean and standard deviation and categorical variables were summarized using frequency and percentage. Age was compared between health literacy groups using two-sample t-test while categorical variables were compared between health literacy groups using Fisher's exact test. STATA version 13 (StataCorp, College Station, TX) was used for statistical analysis. Results Of the 72 students enrolled in the course, 64 (88.9%) participated. The participants ranged in age from 21 to 35 years (mean 24.2 years, standard deviation 3.2 years). Nearly half the students (56.3%) had a degree before starting pharmacy school. A large majority (79.7%) of students had previous healthcare work experience. The median NVS score was 5 (lower quartile 5, upper quartile 6). Eleven percent of students (7/64) had possibly less than adequate health literacy and the remaining 89% (57/64) had adequate health literacy. Of the seven students who scored below adequate, one student scored a zero, one student scored a 2, and the five remaining students scored a 3. The students’ demographic information compared by health literacy group is displayed in Table 1. Although there were no statistically significant differences found between the two health literacy group levels and age, prior degree, or work experience, it should be noted that a greater percentage of students with adequate health literacy did have a prior degree and work experience. In general, more students had prior healthcare work experience and a degree, possibly explaining the reason why this sample of students had more adequate health literacy. 2
Currents in Pharmacy Teaching and Learning xxx (xxxx) xxx–xxx
C. Newsome et al.
Table 1 Demographic characteristics of participants by health literacy category. Variable
Less than adequate health literacy (n = 7)
Adequate health literacy (n = 57)
P-value
Age, in years Degree before entering pharmacy school, n (%) No Yes Healthcare work experience before entering pharmacy school, n (%) No Yes
22.4 ± 1.4
24.4 ± 3.2
0.120
4 (57.1) 3 (42.9)
24 (42.1) 33 (57.9)
0.689
2 (28.6) 5 (71.4)
11 (19.3) 46 (80.7)
0.623
Discussion Our study corroborates other studies of college students finding an adequate level of health literacy for the great majority.13,15 This could be due to the majority of students having a college degree and healthcare work experience. There was a study evaluating the health literacy of the undergraduate population conducted at the same institution as this study. They used a written format for the NVS score, but otherwise the methodology was very similar. The study found more than 90% of the undergraduate participants scored at the adequate health literacy level.15 The high rate of adequate health literacy is not surprising, but it shines a spotlight on the discrepancy between these pharmacy students having adequate health literacy and nearly one-third of patients having low health literacy. In our study, these first-year pharmacy students enter pharmacy school with this high level of health literacy. Because they enter pharmacy school with this high level of health literacy, they may have difficulties relating to and appropriately educating patients with low health literacy. Knowing this information, we can tailor our teaching about health literacy in pharmacy curriculums to include strategies of helping pharmacy students understand what patients with low heath literacy may experience when interacting with the healthcare system because pharmacy students may not have had these experiences. Given the high rate of proficient health literacy of pharmacy students in this study, one could consider how pharmacy curriculums can include training in health literacy and effective strategies for working with low health literacy patients. Strategies that have been shown effective include the “teach-back method,” utilizing open-ended questions to patients, use of metaphors when explaining concepts, and creative technology tools.16–20 As previously discussed, patients with low health literacy cannot be identified by looking at a patient or analyzing their background.11 For this reason, another important strategy is applying universal precautions, encouraging pharmacists to counsel and interact with each patient under the assumption that the patient has low health literacy. For clinicians who prefer to implement health literacy screening tools in their practice, the Short Assessment of Health Literacy, Rapid Estimate of Adult Literacy in Medicine—Short Form, and the Newest Vital Sign can be administered in only a few minutes.14,21 Pharmacy students may not understand or encounter the challenges that patients with low health literacy face. Key Element 4.1 of ACPE Standards 2016 discusses the need for pharmacists to examine and reflect on their own skills and abilities.10 This self-awareness is important in the realm of health literacy. Most pharmacy students may have high health literacy and understanding their background and ability relative to their patients can provide them important insight. While the majority of students displayed high health literacy, 11% did not have adequate health literacy. While the absolute number of students may be small, the impact of a pharmacist with low health literacy providing direct patient care may have adverse consequences. If a pharmacist with low health literacy counsels or coaches a patient would the patient be exposed to higher risks of adverse events, poor outcomes, transitions of care problems, or other risks due to the pharmacist's poor health literacy? There are no studies that currently examine the relationship of health literacy score to performance on specific practice tasks such as counseling, empathy, dispensing error rates or others. If there is a correlation, are there specific interventions or skills test pharmacy students should undertake to prove competence in health literacy? This study assessed health literacy in the first year of the pharmacy school curriculum. A future study could examine if health literacy status improves in these students with progression through the curriculum and the specific interventions that are effective at improving the health literacy of students. A limitation to this study is that it was performed at a single site and had a small sample size. While no statistical differences found for age, previous work experience, or degree before entering pharmacy school, the study may have been underpowered to detect a correlation between these factors and health literacy category. Gender, language, and other factors that have been shown to impact health literacy level were not captured or analyzed.22 Thus the effects of these attributes on pharmacy student health literacy are still unknown.
Conclusions Most pharmacy students in this study scored as adequate level of health literacy on a questionnaire. Future studies should explore pharmacy students’ ability to effectively empathize and interact with patients of low health literacy and what interventions can effectively improve health literacy for the minority of students without adequate health literacy.
3
Currents in Pharmacy Teaching and Learning xxx (xxxx) xxx–xxx
C. Newsome et al.
Conflicts of interest None. Financial disclosures This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
11. 12. 13. 14. 15. 16.
17. 18. 19. 20. 21. 22.
Berkman ND, Davis TC, McCormack L. Health literacy: what is it? J Health Commun. 2010;15(Suppl 2):9–19. Budnitz DS, Layde PM. Outpatient drug safety: new steps in an old direction. Pharmacoepidemiol Drug Saf. 2007;16(2):160–165. Institute of Medicine. Standardizing Medication Labels: Confusing Patients Less, Workshop Summary. Washington, D.C: National Academies Press; 2008. Al Sayah F, Majumdar SR, Williams B, Robertson S, Johnson JA. Health literacy and health outcomes in diabetes: a systematic review. J Gen Intern Med. 2013;28(3):444–452. Cavanaugh KL, Wingard RL, Hakim RM, et al. Low health literacy associates with increased mortality in ESRD. J Am Soc Nephrol. 2010;21(11):1979–1985. Devraj R, Borrego M, Vilay AM, Gordon EJ, Pailden J, Horowitz B. Relationship between health literacy and kidney function. Nephrology. 2015;20(5):360–367. Schillinger D, Grumbach K, Piette J, et al. Association of health literacy with diabetes outcomes. J Am Med Assoc. 2002;288(4):475–482. Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients' knowledge of their chronic disease. A study of patients with hypertension and diabetes. Arch Intern Med. 1998;158(2):166–172. Bailey SC, Brega AG, Crutchfield TM, et al. Update on health literacy and diabetes. Diabetes Educ. 2014;40(5):581–604. Accreditation Council for Pharmacy Education. Accreditation Standards and Key Elements for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree (“Standards 2016”). Published February 2015. Available at: 〈https://www.acpe-accredit.org/pdf/Standards2016FINAL.pdf〉. Accessed 23 November 2017. Kutner M, Greenberg E, Jin Y, et al. The Health Literacy of America's Adults: Results From the 2003 National Assessment of Adult Literacy. NCES 2006-483. Washington, DC: US Department of Education, National Center for Education Statistics; 2006. Bass 3rd PF, Wilson JF, Griffith CH, Barnett DR. Residents' ability to identify patients with poor literacy skills. Acad Med. 2002;77(10):1039–1041. Vozikis A, Drivas K, Milioris K. Health literacy among university students in Greece: determinants and association with self-perceived health, health behaviours and health risks. Arch Public Health. 2014;72(1):15. Weiss BD, Mays MZ, Martz W, et al. Quick assessment of literacy in primary care: the newest vital sign. Ann Fam Med. 2005;3(6):514–522. Mas FS, Jacobson HE, Dong Y. Health literacy level of Hispanic college students. South Med J. 2014;107(2):61–65. Jacobson K. Strategies to Improve Communication Between Pharmacy Staff and Patients: A Training Program for Pharmacy Staff. Rockville, Md: Agency for Healthcare Research and Quality; Published 2008. Available at: 〈https://www.ahrq.gov/professionals/quality-patient-safety/pharmhealthlit/pharmlit/ pharmtrain.html〉. Accessed 23 November 2017. Lam AY, Nguyen JK, Parks JJ, Morisky DE, Berry DL, Wolpin SE. Addressing low health literacy with "Talking Pill Bottles": a pilot study in a community pharmacy setting. J Am Pharm Assoc. (2003). 2017;57(1):20–29 [e3]. Ley P. Communicating With Patients: Improving Communication, Satisfaction, and Compliance. New York: Croom Helm; 1988. Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163(1):83–90. Yeung DL, Alvarez KS, Quinones ME, et al. Low-health literacy flashcards & mobile video reinforcement to improve medication adherence in patients on oral diabetes, heart failure, and hypertension medications. J Am Pharm Assoc. 2017;57(1):30–37. Kirsch I, Jungeblut A, Jenkins L, Kolstad A, eds. Adult Literacy in America: A First Look at the National Adult Literacy Survey (NALS). Washington, DC: U.S. Department of Education; 1993. Health Literacy Measurement Tools (Revised). Agency for Healthcare Research and Quality, Rockville, MD. 2016. Available at: 〈http://www.ahrq.gov/ professionals/quality-patient-safety/quality-resources/tools/literacy/index.html〉. Accessed 23 November 2017.
4
Contents lists available at ScienceDirect
Currents in Pharmacy Teaching and Learning journal homepage: www.elsevier.com/locate/cptl
Research Note
Health literacy of student pharmacists Cheyenne Newsomea, a b
⁎,1
, Indika Mallawaarachchib, Jessica Conklina, Gretchen Raya
University of New Mexico College of Pharmacy, 2502 Marble Ave NE Albuquerque, NM 87106, United States Texas Tech Health Sciences Center, 5001 El Paso Drive El Paso, TX 79905, United States
AR TI CLE I NF O
AB S T R A CT
Keywords: Health literacy Pharmacy students Pharmacy education
Introduction: The primary purpose of this study was to assess the health literacy levels of doctorate of pharmacy students. A secondary objective was to determine if a correlation exists between age, degree prior to pharmacy school, work experience, and health literacy status among these students. Methods: Participants were first year doctorate of pharmacy students at an accredited college of pharmacy in the Southwestern United States. The design was cross-sectional. Health literacy scores were collected using the Newest Vital Sign (NVS) in English. Health literacy was dichotomized with a score of 0–3 indicating inadequate and 4–6 indicating adequate. A two sample ttest or Fisher's exact test was used to compare cofactors between health literacy groups. Results: Of the 72 first year students, 64 (88.9%) participated. The median NVS score was 5 (lower quartile 5, upper quartile 6). Nearly 90% of students (n = 57) obtained a score of ‘‘always adequate literacy.’’ Student age, having a degree before pharmacy school, nor healthcare work experience were significantly different between the two groups. Discussion: If students enter pharmacy school with a high level of health literacy, they may have difficulties relating to and appropriately educating patients with low health literacy. Knowing this information, we can tailor our teaching about health literacy in curriculums to include strategies that assist students to understand what patients with low heath literacy may experience when interacting with the healthcare system. Conclusions: Nearly all student pharmacists in the study displayed high health literacy and no correlations to collected characteristics were noted.
Introduction The Institute of Medicine defines health literacy as “the degree to which individuals can obtain, process, understand, and communicate about health-related information needed to make informed health decisions.”1 Poor health literacy is a major cause of patients’ inability to take medications properly and are the root cause of a significant amount of adverse drug events.2,3 Patients with chronic medical conditions who have low health literacy have been shown to have increased mortality and morbidity.4–8 Additionally, it is estimated that low health literacy increases health care costs by $106–238 billion per year.9 It is important for student pharmacists to understand patients’ health literacy status to provide the best possible care to these patients. Developing communication skills to effectively work with a broad range of people and recognize social determinants of health are required by the Accreditation Council for Pharmacy Education (ACPE) Key Element 3.6 of Standards 2016.10 To achieve this Standard, pharmacists
⁎
Corresponding author. E-mail addresses: [email protected] (C. Newsome), [email protected] (I. Mallawaarachchi), [email protected] (J. Conklin), [email protected] (G. Ray). 1 Present address: WSU Spokane, Department of Pharmacotherapy, PO Box 1495, Spokane, WA 99210-1495, United States. https://doi.org/10.1016/j.cptl.2017.11.005
1877-1297/ © 2017 Elsevier Inc. All rights reserved.
Please cite this article as: Newsome, C., Currents in Pharmacy Teaching and Learning (2017), https://doi.org/10.1016/j.cptl.2017.11.005
Currents in Pharmacy Teaching and Learning xxx (xxxx) xxx–xxx
C. Newsome et al.
must be aware of each patient's health literacy level and consider altering their communication strategies for patients with low health literacy. Early in their career, medical professionals may be unaware of the high prevalence of poor health literacy. Approximately onethird of Americans have limited health literacy, meaning pharmacists will frequently interact with patients who have low health literacy.11 Health literacy can be challenging to determine based on discussions or interactions with another person. A study of physician residents using their clinical interactions to determine patients’ literacy found that the residents greatly overestimated their patients’ literacy abilities. Of the 164 patients whom the residents felt had no literacy problems, 59 patients (36%) failed a literacy screen.12 While health literacy and written literacy are different skills, this study shows that new healthcare professionals may overestimate patients’ actual abilities. Explanations for the discrepancy between providers’ perceptions and their patient's true abilities are not known. To date, few studies have examined the health literacy of students. A study in Greece found most college students had fair to high health literacy.13 To our knowledge, no study has ever evaluated health literacy levels among pharmacy or medicine students. Many may assume that pharmacy students would also have high health literacy. This study analyzes this assumption and discusses the implications pharmacy students’ health literacy may have on quality of patient care. The primary purpose of this study was to assess the health literacy levels of doctorate of pharmacy students. A secondary objective was to determine if a correlation exists between age, college degree, and work experience and health literacy status among these students. Methods The University of New Mexico Health Sciences Center Human Research Review Committee approved this study. In this prospective observational study, a health literacy screening was administered to students during their first year in a four-year doctor of pharmacy program. Students were eligible for inclusion if they were enrolled in the University of New Mexico College of Pharmacy Self-Care Therapeutics class (PHRM 719) during the chosen study year. PHRM 719 was selected as it is a course taken by all first-year students, attendance is mandatory for students and learning is driven by student discussion. As a result, small groups of students could be removed from the course for questioning without significant disruption in learning. The assessment of students’ health literacy occurred in January and February of their spring semester. This assessment was administered to students early in the pharmacy school program to determine the level of health literacy before they receive specific training in health literacy. The opportunity to participate in this research was offered to students during group case discussions. Researchers visited the classroom, explained the nature of the project and the procedures for the protection of human subjects, and invited students to voluntarily participate. The first-year student pharmacists were individually brought into a separate classroom and verbally administered the English version of the Newest Vital Sign (NVS), a validated health literacy assessment.14 The NVS was selected as the screening tool because it can be administered in three to five minutes and is a validated tool for measuring health literacy. To perform the NVS, the participant was provided an image of an ice cream nutrition label. The administrator then verbally asked each participant six questions related to the ingredients and the information on the label. During the exam, the administrator recorded the number of accurate answers. Participants’ previous degree(s), age, and healthcare work experience were also verbally collected for demographic information. Four administrators interviewed the students for data collection. The administrators were trained on the NVS and demographic questions. None of the administrators were involved in PHRM 719. A convenience sampling design was used for the recruitment of participants. The primary endpoint was the score of health literacy assessment. Health literacy score was dichotomized based on number of correct questions as determined by the developer of the NVS: Limited or possibly limited health literacy (NVS 0–3) and adequate health literacy (NVS 4–6). The categories of limited or possibly limited health literacy were combined due to small sample size and the ultimate goal of identifying any student without adequate health literacy. Age was summarized using mean and standard deviation and categorical variables were summarized using frequency and percentage. Age was compared between health literacy groups using two-sample t-test while categorical variables were compared between health literacy groups using Fisher's exact test. STATA version 13 (StataCorp, College Station, TX) was used for statistical analysis. Results Of the 72 students enrolled in the course, 64 (88.9%) participated. The participants ranged in age from 21 to 35 years (mean 24.2 years, standard deviation 3.2 years). Nearly half the students (56.3%) had a degree before starting pharmacy school. A large majority (79.7%) of students had previous healthcare work experience. The median NVS score was 5 (lower quartile 5, upper quartile 6). Eleven percent of students (7/64) had possibly less than adequate health literacy and the remaining 89% (57/64) had adequate health literacy. Of the seven students who scored below adequate, one student scored a zero, one student scored a 2, and the five remaining students scored a 3. The students’ demographic information compared by health literacy group is displayed in Table 1. Although there were no statistically significant differences found between the two health literacy group levels and age, prior degree, or work experience, it should be noted that a greater percentage of students with adequate health literacy did have a prior degree and work experience. In general, more students had prior healthcare work experience and a degree, possibly explaining the reason why this sample of students had more adequate health literacy. 2
Currents in Pharmacy Teaching and Learning xxx (xxxx) xxx–xxx
C. Newsome et al.
Table 1 Demographic characteristics of participants by health literacy category. Variable
Less than adequate health literacy (n = 7)
Adequate health literacy (n = 57)
P-value
Age, in years Degree before entering pharmacy school, n (%) No Yes Healthcare work experience before entering pharmacy school, n (%) No Yes
22.4 ± 1.4
24.4 ± 3.2
0.120
4 (57.1) 3 (42.9)
24 (42.1) 33 (57.9)
0.689
2 (28.6) 5 (71.4)
11 (19.3) 46 (80.7)
0.623
Discussion Our study corroborates other studies of college students finding an adequate level of health literacy for the great majority.13,15 This could be due to the majority of students having a college degree and healthcare work experience. There was a study evaluating the health literacy of the undergraduate population conducted at the same institution as this study. They used a written format for the NVS score, but otherwise the methodology was very similar. The study found more than 90% of the undergraduate participants scored at the adequate health literacy level.15 The high rate of adequate health literacy is not surprising, but it shines a spotlight on the discrepancy between these pharmacy students having adequate health literacy and nearly one-third of patients having low health literacy. In our study, these first-year pharmacy students enter pharmacy school with this high level of health literacy. Because they enter pharmacy school with this high level of health literacy, they may have difficulties relating to and appropriately educating patients with low health literacy. Knowing this information, we can tailor our teaching about health literacy in pharmacy curriculums to include strategies of helping pharmacy students understand what patients with low heath literacy may experience when interacting with the healthcare system because pharmacy students may not have had these experiences. Given the high rate of proficient health literacy of pharmacy students in this study, one could consider how pharmacy curriculums can include training in health literacy and effective strategies for working with low health literacy patients. Strategies that have been shown effective include the “teach-back method,” utilizing open-ended questions to patients, use of metaphors when explaining concepts, and creative technology tools.16–20 As previously discussed, patients with low health literacy cannot be identified by looking at a patient or analyzing their background.11 For this reason, another important strategy is applying universal precautions, encouraging pharmacists to counsel and interact with each patient under the assumption that the patient has low health literacy. For clinicians who prefer to implement health literacy screening tools in their practice, the Short Assessment of Health Literacy, Rapid Estimate of Adult Literacy in Medicine—Short Form, and the Newest Vital Sign can be administered in only a few minutes.14,21 Pharmacy students may not understand or encounter the challenges that patients with low health literacy face. Key Element 4.1 of ACPE Standards 2016 discusses the need for pharmacists to examine and reflect on their own skills and abilities.10 This self-awareness is important in the realm of health literacy. Most pharmacy students may have high health literacy and understanding their background and ability relative to their patients can provide them important insight. While the majority of students displayed high health literacy, 11% did not have adequate health literacy. While the absolute number of students may be small, the impact of a pharmacist with low health literacy providing direct patient care may have adverse consequences. If a pharmacist with low health literacy counsels or coaches a patient would the patient be exposed to higher risks of adverse events, poor outcomes, transitions of care problems, or other risks due to the pharmacist's poor health literacy? There are no studies that currently examine the relationship of health literacy score to performance on specific practice tasks such as counseling, empathy, dispensing error rates or others. If there is a correlation, are there specific interventions or skills test pharmacy students should undertake to prove competence in health literacy? This study assessed health literacy in the first year of the pharmacy school curriculum. A future study could examine if health literacy status improves in these students with progression through the curriculum and the specific interventions that are effective at improving the health literacy of students. A limitation to this study is that it was performed at a single site and had a small sample size. While no statistical differences found for age, previous work experience, or degree before entering pharmacy school, the study may have been underpowered to detect a correlation between these factors and health literacy category. Gender, language, and other factors that have been shown to impact health literacy level were not captured or analyzed.22 Thus the effects of these attributes on pharmacy student health literacy are still unknown.
Conclusions Most pharmacy students in this study scored as adequate level of health literacy on a questionnaire. Future studies should explore pharmacy students’ ability to effectively empathize and interact with patients of low health literacy and what interventions can effectively improve health literacy for the minority of students without adequate health literacy.
3
Currents in Pharmacy Teaching and Learning xxx (xxxx) xxx–xxx
C. Newsome et al.
Conflicts of interest None. Financial disclosures This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
11. 12. 13. 14. 15. 16.
17. 18. 19. 20. 21. 22.
Berkman ND, Davis TC, McCormack L. Health literacy: what is it? J Health Commun. 2010;15(Suppl 2):9–19. Budnitz DS, Layde PM. Outpatient drug safety: new steps in an old direction. Pharmacoepidemiol Drug Saf. 2007;16(2):160–165. Institute of Medicine. Standardizing Medication Labels: Confusing Patients Less, Workshop Summary. Washington, D.C: National Academies Press; 2008. Al Sayah F, Majumdar SR, Williams B, Robertson S, Johnson JA. Health literacy and health outcomes in diabetes: a systematic review. J Gen Intern Med. 2013;28(3):444–452. Cavanaugh KL, Wingard RL, Hakim RM, et al. Low health literacy associates with increased mortality in ESRD. J Am Soc Nephrol. 2010;21(11):1979–1985. Devraj R, Borrego M, Vilay AM, Gordon EJ, Pailden J, Horowitz B. Relationship between health literacy and kidney function. Nephrology. 2015;20(5):360–367. Schillinger D, Grumbach K, Piette J, et al. Association of health literacy with diabetes outcomes. J Am Med Assoc. 2002;288(4):475–482. Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients' knowledge of their chronic disease. A study of patients with hypertension and diabetes. Arch Intern Med. 1998;158(2):166–172. Bailey SC, Brega AG, Crutchfield TM, et al. Update on health literacy and diabetes. Diabetes Educ. 2014;40(5):581–604. Accreditation Council for Pharmacy Education. Accreditation Standards and Key Elements for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree (“Standards 2016”). Published February 2015. Available at: 〈https://www.acpe-accredit.org/pdf/Standards2016FINAL.pdf〉. Accessed 23 November 2017. Kutner M, Greenberg E, Jin Y, et al. The Health Literacy of America's Adults: Results From the 2003 National Assessment of Adult Literacy. NCES 2006-483. Washington, DC: US Department of Education, National Center for Education Statistics; 2006. Bass 3rd PF, Wilson JF, Griffith CH, Barnett DR. Residents' ability to identify patients with poor literacy skills. Acad Med. 2002;77(10):1039–1041. Vozikis A, Drivas K, Milioris K. Health literacy among university students in Greece: determinants and association with self-perceived health, health behaviours and health risks. Arch Public Health. 2014;72(1):15. Weiss BD, Mays MZ, Martz W, et al. Quick assessment of literacy in primary care: the newest vital sign. Ann Fam Med. 2005;3(6):514–522. Mas FS, Jacobson HE, Dong Y. Health literacy level of Hispanic college students. South Med J. 2014;107(2):61–65. Jacobson K. Strategies to Improve Communication Between Pharmacy Staff and Patients: A Training Program for Pharmacy Staff. Rockville, Md: Agency for Healthcare Research and Quality; Published 2008. Available at: 〈https://www.ahrq.gov/professionals/quality-patient-safety/pharmhealthlit/pharmlit/ pharmtrain.html〉. Accessed 23 November 2017. Lam AY, Nguyen JK, Parks JJ, Morisky DE, Berry DL, Wolpin SE. Addressing low health literacy with "Talking Pill Bottles": a pilot study in a community pharmacy setting. J Am Pharm Assoc. (2003). 2017;57(1):20–29 [e3]. Ley P. Communicating With Patients: Improving Communication, Satisfaction, and Compliance. New York: Croom Helm; 1988. Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163(1):83–90. Yeung DL, Alvarez KS, Quinones ME, et al. Low-health literacy flashcards & mobile video reinforcement to improve medication adherence in patients on oral diabetes, heart failure, and hypertension medications. J Am Pharm Assoc. 2017;57(1):30–37. Kirsch I, Jungeblut A, Jenkins L, Kolstad A, eds. Adult Literacy in America: A First Look at the National Adult Literacy Survey (NALS). Washington, DC: U.S. Department of Education; 1993. Health Literacy Measurement Tools (Revised). Agency for Healthcare Research and Quality, Rockville, MD. 2016. Available at: 〈http://www.ahrq.gov/ professionals/quality-patient-safety/quality-resources/tools/literacy/index.html〉. Accessed 23 November 2017.
4