The physicians’ ability to treat patients keeps improving but the advances may come to naught if the patients’ ability to follow their instructions fails to keep pace.
Good communication is vital in all areas of our life. It ensures that we are well connected with each other and our environment; yet, so often it is the least practiced skill. In healthcare, good communication can be lifesaving. A young Dr Gordon Calnan recognised the significance of this when he inscribed the following paraphrase of Socrates teachings into his clinical medicine reference in about 1947: “You must first cure the soul….and the cure is fair words”.
For an aging population, literacy skills are becoming more significant. It is recognised that these skills decline with age and lower literacy is associated with poorer health. A 2008 Canadian report indicated that six out of 10 adults did not have adequate health literacy skills, whilst those with the poorest skills have the worst health outcomes. The Tasmanian Adult Literacy Action Plan, 2010-2015 quotes similar figures, from an Australian Bureau of Statistics survey, showing inadequate literacy in 49% of Tasmanians.
‘Seek first to understand, then to be understood’
Literacy is complex, however it is succinctly enshrined in habit five of Stephen Covey’s book, The 7 Habits of Highly Effective People: ‘seek first to understand’.
In the purest sense, literacy is an ability to read and write, however the term has evolved to encompass a complex set of abilities that allow us to understand and communicate effectively. Wikipedia is used by many to gain understanding and, in this instance, outlines well the many factors which govern literacy ability, including: numeracy, education, cultural background, reading skills, and (in today’s information overloaded society) the many ways of distributing information.
If we accept the premise that literacy promotes understanding, then literacy itself is dependent upon good communication techniques, irrespective of the media used. It is not a one-sided affair with individuals considered to be ‘lacking’ due to low literacy levels. In healthcare, a paternalistic approach is no longer considered appropriate or effective, and good health outcomes rely upon improved health literacy.
Better literacy, a better life
Anne McMurray’s review, quoted in Wikipedia, is helpful to our understanding:
“Where there are adequate levels of health literacy, that is where the population has sufficient knowledge and skills and where members of a community have the confidence to guide their own health, people are able to stay healthy, recover from illness and live with disease or disability.”
Societal benefits are clear: reduced healthcare costs and a healthier population highlight some of the benefits attainable through improved literacy.
The many levels of literacy described can be daunting when developing ways to improve skills, however it is important to persist, given the documented benefits are evident, particularly within the health arena.
National strategies that recognise the significance of good literacy to contribute to better health have emerged and continue to evolve as our understanding of the issues improve.
Improving our own communication skills will firstly enable us to help others to better understand our meaning, to overcome barriers to communication and assist those at risk because of poor literacy skills.
Communication and the Health Plan
The goal is to understand. This is achieved through persistence, the skill of asking the right questions and, more importantly, through learning the skill to listen.
Assimilating verbal information, then clarifying our understanding by using questions, relevant or not, helps everyone to understand the important messages. When understanding is achieved, the plan becomes a powerful and dynamic tool. The patient takes ownership, and the journey to better health begins.
Medicines often form part of the health plan and the Australian Pharmaceutical Formulary (APF) describes a number of pertinent questions that can be asked by the patient or health professional. These are not mutually exclusive questions; their purpose is simply to guide us. It is important to let the conversation flow and not be restricted by trying to remember a list of questions, as they will come into focus at the right moment, when we let our listening skills dominate the conversation and not let the words get in the way. Some example questions include:
- Is a medicine needed?
- Which medicine is required?
- What dose is required?’
- Are there adequate instructions for use? (‘As directed’ is not acceptable).
- Would additional written information be helpful?
- Is the written or verbal information appropriate and understandable?
- Is a medicine management aid required?
- Is there a complete medicine record which includes complementary, over-the-counter (OTC), and nutritional supplements?
- Is a medicine review required?
- Are there any allergies or sensitivities?
- What is the aim of treatment?
- Are we achieving the treatment aim?
- Is the cure worse than the disease?
This list is limited only by our ability to listen and respond appropriately. We have two ears and one mouth. The guiding principle is to use them in the same proportion.
Developing the Health Plan
Once the health goal is clearly defined, it remains to determine the right path. When medicines become central to this goal it is important to consider:
- The expected outcome
- Product quality
- The potential for side-effects or unexpected outcomes
- The potential for interaction with other agents, including food
- The requirements for an optimal result
- Co-morbidities that may reduce the therapeutic effect or be adversely impacted by the medication used
- The cost to the patient and/or the healthcare system, and
- Review timelines for effectiveness or ongoing need.
It is healthy to review and question what we do in all things. Any plan must be appropriate to the need and workable by all concerned; ultimately the plan depends upon the patient accepting and taking ownership. This involves complete and effective communication, frequent review, honest feedback, and dynamic responsiveness to change.
As healthcare professionals, it is important to relate the patient’s needs to our own; after all, they are not dissimilar. We each have priorities and healthcare is no different in this respect. Dealing with the primary concerns of the patient is consistent with an optimised therapeutic plan. This acknowledgment helps the patient to take ownership of their health plan and often assists with the attainment of other healthcare priorities.
Literacy and Medicine Management
Complex medicine regimens and the tendency toward polypharmacy, whether intended or by personal choice, highlight the need to ensure there is sound understanding at all levels. In the patient group classified as ‘senior’ or ‘ageing’, more than 90% are known to take more than one medicine. Polypharmacy is common in clinical practice, with the risk of interaction high.
We are each responsible for our own good health. Taking responsibility begins with understanding, and this begins with good communication; leading to the development of a dynamic health plan involving the full participation of all parties.
Improving health literacy; improving health outcomes
It is evident there is no single solution for improving health literacy, particularly within a multicultural environment. Improved technology has led to an abundance of health information that allows the consumer to be saturated with data, quality, or bias; yet the central messages are still not understood.
It has been recognised that health literacy is an investment and a major determinant in any effective medicines policy, provided the consumer is included as a vital voice in the current debate. The National Prescribing Service (NPS) has done much to address the issue of health literacy in Australia and their approach reflects international trends. The provision of peer reviewed, best practice information for both the health professional and consumer has helped address the barrier of bias that can confuse good health literacy. The messages for both the consumer and health professional are clear, concise, relevant to best practice and available in many languages. The symposium on Consumer education and health literacy, at the Asia Pacific Conference on National Medicines Policies in 2013, proposed that this approach meets agreed criteria which allows for: “access to unbiased information on medicines and health. Understanding needs more than just good information – messages must be clear, simple, objective and motivate for appropriate action.”
There is much that remains to be done to address this most basic of issues and the task involves us all. We can begin by listening and talking.
- Canadian Council on Learning (CCL). Health literacy in Canada: a healthy understanding 2008. Ottawa: CCL; 2008.
- Fugh-Berman A. Herb-drug interactions. Lancet 2000; 355(9198):134-8.
- Pharmaceutical Society of Australia (PSA). Australian pharmaceutical formulary and handbook. 22nd ed. Parkville: PSA; 2012.
- Smith A, Bennett C (Conveners). Symposium 4: Consumer education and health literacy. Asia Pacific Conference on National Medicines Policies. Aust Prescr 2013; 36 Suppl 1:S1-56.
- Smith M, Lo W, Bindra J. Prescribing for refugees. Aust Prescr 2013;36: 146-7.
- Health literacy. Wikipedia; 2015.
- Covey SR. The 7 habits of highly effective people®. New York: Simon and Shuster; 1989.
- McMurray A. Community health and wellness: A socio-ecological Approach. 3rd Ed. Sydney: Mosby Elsevier; 2007.
- National Prescribing Service. NPS Medicinewise. Canberra, Australia.
- Department of Education. Tasmanian Adult Literacy Action Plan 2010-2015. Hobart: Tasmanian Government; 2010.