A health literacy education-focused intervention to improve community pharmacy adoption of universal precautions

Background Health literacy is quickly becoming an important social determinant of health. Limited health literacy has a major impact on consumers’ ability to access, understand and use health information, as well as navigate complex healthcare systems. In the context of pharmacy, this can cause inappropriate medicine use and non-adherence, leading to medication misadventure and potential life-threatening consequences. It also has a costly impact on the health care system. The impact of limited consumer health literacy in the pharmacy setting in Australia has yet to gain significance. Health literacy awareness in the Australian pharmacy setting is low, yet pharmacies are at the forefront of healthcare in the community and are thus well-positioned to manage the issue of limited consumer health literacy. This requires pharmacists and pharmacy staff members to be skilled communicators, providing information to consumers at an appropriate level of complexity. Educational initiatives to increase the adoption of communication techniques by pharmacists and pharmacy staff members that focus on increasing consumer understanding of health information should be employed. A potential approach to achieving this is the use of communication techniques known as ‘universal precautions’. The universal precautions framework includes techniques to increase consumer engagement, such as use of open-ended questions (e.g. ‘What questions do you have?’), the teach-back method and demonstrating device technique where appropriate. Aims The overall aim of this research was to promote the adoption of universal precautions in community pharmacies in Australia using a health literacy education-focused intervention. Methods The research project was divided into five phases, four of which were led by the PhD candidate: - Phase 1 was an online survey to explore the various methods used to teach health literacy in schools of pharmacy in English-speaking countries. - The HeLP phase (not led by the PhD candidate) involved the design, development and implementation of a health literacy education-focused intervention for community pharmacists and pharmacy staff members in Australia. The purpose of this phase was to create an education-focused intervention designed to encourage the adoption of universal precautions by pharmacists and pharmacy staff members participating in the research project. This intervention was then evaluated in Phases 2, 3 and 4 of the project. - Phase 2 explored community pharmacists’ and pharmacy staff members’ motivations towards implementing health literacy training and how this may influence their intentions to do so. This phase utilised four types of mailed questionnaires designed for pharmacists and pharmacy staff members who were recruited in the HeLP phase of the research project. Factor analysis was undertaken to determine the underlying factors, followed by ordinal logistic regression to determine how these factors relate to intentions to implement the health literacy education-focused intervention and applyuniversal precautions with consumers - Phase 3 was an evaluation of the efficacy and effectiveness of the health literacy education-focused intervention on pharmacists’ and pharmacy staff members’ communication practice behaviours with consumers, particularly the use of universal precautions. Pre- and post-intervention data collection was conducted in this phase. Researcher-administered consumer questionnaires were conducted in-pharmacy before and after participating consumers interacted with a pharmacist or pharmacy staff member to determine the application of universal precautions. Simulated patients were also used pre- and post-intervention to objectively determine the uptake of universal precautions by pharmacists and pharmacy staff members. Pharmacists and pharmacy staff members were recruited in the HeLP phase of the research project. Consumers were recruited in-pharmacy by a research officer. Data analysis involved the use of Pearson’s Chi squared analysis. - Phase 4 involved focus groups with participating pharmacists and pharmacy staff members to explore their opinions on the usability, perceived effectiveness and ease of implementation of the health literacy education-focused intervention. Data in this phase was collected and transcribed, then analysed using thematic analysis based upon the grounded-theory approach. Participants were pharmacists and pharmacy staff members recruited using mailed invitations from the pool of participants recruited in the HeLP phase of the research project. Key findings The Phase 1 study incorporated results from 21 pharmacy schools in a total of six English-speaking countries. The study highlighted that the most favoured method by pharmacy academics to deliver health literacy education to pharmacy students in English speaking countries was through lectures and small-group learning sessions (38.1%; 8/21 for each). This study helped inform the delivery method of the health literacy education-focused intervention for community pharmacists and pharmacy staff members. In the HeLP phase, an evidence-based health literacy education-focused intervention was designed and developed, focusing on the use of universal precautions with consumers. The purpose of the HeLP phase was to create an education-focused intervention to encourage participating pharmacists and pharmacy staff members to adopt the use of universal precautions with consumers to help enhance the provision of health and medicines information. The intervention was underpinned by a train-the-trainer approach. The intervention was developed in two components: an initial train-the-trainer component, which aimed to train selected ‘pharmacy trainers’ from each pharmacy in the delivery of health literacy training, and an in-pharmacy delivery component, implemented by the pharmacy trainer in the pharmacy. A total of 77 community pharmacies from New South Wales, Victoria and Western Australia were recruited into the project. Pharmacies were block randomised into three groups: two experimental groups (receiving either face-to-face [Group 1, n=26] or electronic [Group 2, n=26] train-the-trainer training) and a control group (Group 3) that received no training. In Group 1, 20/26 pharmacies completed the intervention and in Group 2, 11/26 pharmacies completed the intervention. An additional 3/26 in Group 1 and 6/26 in Group 2 partially completed the intervention, while 3/26 and 9/26 pharmacies from Group 1 and Group 2, respectively, withdrew from the project. This study highlighted the barriers associated with implementing continuing education training into community pharmacies. This education-focused intervention was then evaluated using a variety of quantitative and qualitative research methods in Phases 2, 3 and 4 of the research project. This was conducted to determine the openness of participants to integrate the intervention and adopt universal precautions with consumers (Phase 2), the efficacy and effectiveness of the intervention (Phase 3), and to gather qualitative feedback regarding various aspects of the intervention for potential future revisions. Phase 2 revealed that pharmacists and pharmacy staff members are generally favourable towards undertaking health literacy training. Factor analysis was used to extract correlated factors, followed by ordinal logistic regression to determine the association of these factors to intentions to undertake health literacy training (the dependent variable). Following analysis, it was found that particular extracted factors, for example, having positive attitudes and beliefs towards applying health literacy training to consumer counselling, were significantly associated with having an intention to implement health literacy training (p<0.001). Preparedness and sustainability for implementation, and relevance of universal precautions and their potential benefits, were also associated with intentions to undertake training (p<0.001). Phase 3 demonstrated that the health literacy education-focused intervention had a significant impact on the use of the phrase ‘What questions do you have?’ by participating pharmacists and pharmacy staff members. Patient-recall data showed that the face-to-face group (Group 1) and the electronic group (Group 2) were significantly more likely to use the phrase compared to the control group (Group 3), post-intervention (RR: 4.86; CI: 2.27-10.52; p