739031
research-article2017
AOPXXX10.1177/1060028017739031Annals of PharmacotherapyRajah et al
Research Report
An Interprofessional Evaluation of Health Literacy Communication Practices of Physicians, Pharmacists, and Nurses at Public Hospitals in Penang, Malaysia
Annals of Pharmacotherapy 2018, Vol. 52(4) 345–351 © The Author(s) 2017 Reprints and permissions: sagepub.com/journalsPermissions.nav https://doi.org/10.1177/1060028017739031 DOI: 10.1177/1060028017739031 journals.sagepub.com/home/aop
Retha Rajah, PhD1, Mohamed Azmi Hassali, PhD1, and Ching-Jou Lim, PhD1
Abstract Background: Health care practitioners carry a tremendous responsibility to differentiate the varying need of information and customized communication according to a patient’s health literacy (HL) level. Objectives: To assess and compare the HL communication practices among physicians, pharmacists, and nurses serving at public hospitals in Penang, Malaysia. Methods: A pretested, self-administered questionnaire was used to collect data from study participants of 6 public hospitals using stratified sampling. Descriptive and inferential statistics used to analyze the data with level of significance was set at P < 0.05. Results: Of 600 distributed questionnaires, 526 (87.6%) were adequately filled and returned. Almost 19.0% (n = 98) of the respondents admitted that they did not frequently use simple language and avoid medical jargon during communication with patients. Only about half of the respondents reported frequently using other HL communication practices that include handing out education material to patients (52.2%, n = 275), asking the patient to repeat information (58.9%, n = 310), and asking patients’ caregivers to be present during explanation (57.4%, n = 302). Comparatively, drawing pictures to ease patients’ understanding (40.1%, n = 211) was the less-frequently practiced HL communication techniques. Health practitioners in the age group >41 years (P = 0.046), serving 10 years and more (P = 0.03) and those who have heard the term or concept of HL (P = 0.004) have statistically significantly higher mean score of HL communication practices than other groups. Conclusions: The gap in the HL communication practices among physicians, pharmacists, and nurses warrants educational intervention, and standardized HL communication techniques guidelines are needed in the near future. Keywords communication, teaching/training, patient education, health care policy, education, counseling
Introduction Effective communication between patients and health care practitioners is the foundation of a high-quality and patientcentered health approach. Numerous studies have established the importance and positive influence of good communication in improving treatment compliance, patient safety, and overall patient satisfaction.1-3 One of the integral elements associated with health care communication is patient’s health literacy (HL), which involves the ability to obtain, process, and comprehend basic health information or instruction to make appropriate health decisions.4 Patient’s HL was reported to be a strong predictor of health outcomes compared with sociodemographic variables such as age, education level, or ethnicity.5,6 In the study by Schillinger et al,5 inadequate HL was associated with worse glycemic control after adjusting for age, sex, education, language, and duration of diabetes. Similarly, another study reported that inadequate HL independently associated with
mortality in the elderly population after adjusting for age, gender, race, income, and education.6 In addition, patients with inadequate HL were more likely to suffer from poor compliance with treatment,7-9 increased emergency care use, and increased risk of hospitalization.7,10 Because health care practitioners hold the key role as health informant in clinical settings, they hold a great responsibility to provide information in the best manner to patients of various HL levels to understand and act on the information. Given the current health care service situation, the health care practitioners as well the entire transdisciplinary 1
Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia Corresponding Author: Retha Rajah, Discipline of Social Science and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Pusat Pengajian Sains Farmasi, Penang, Minden 11800, Malaysia. Email:
[email protected]
346 team have limited time with patients. Often patients claimed that health care practitioners do not take the time to adequately explain their illnesses, treatment options, and even medication administration. Clinicians admitted that time is a restriction factor in most of the health care settings11-13; therefore, they usually rushed the patients and provided them with written materials. However, they often fail to verify the patients’ understanding of the supplementary reading aid, which subsequently leads to misinterpretation of medical information. At the same time, health care practitioners were often reported to assume that their patients are functionally literate and able to understand the medical terms used,14-16 although this may not always be the case. Study findings consistently support patients emphasizing the need for health care professionals to tailor health information delivered to their level of understanding.13,17 Unfortunately, despite the increasing recognition of the importance of HL communication practice in creating a more prepared and proactive clinical team that enables patients to become more informed about their health, there is scarce data on the HL communication practices of physicians, pharmacists, and nurses. In most health care institutes, these 3 professions are the trusted and primary health information resources, particularly among patients with inadequate HL. To date, only 1 similar study in the United States, more than 10 years ago had evaluated the HL communication practices in these professional groups.18 The study, however, was only conducted during patient safety and health care quality seminars, which did not intend to show HL communication practices in real clinical settings. Furthermore, factors influencing the use of HL communication practices have yet to be explored. The present study aimed to evaluate and compare the HL communication practices used by physicians, pharmacists, and nurses who were involved directly in the patient care of all public hospitals in the state of Penang, Malaysia. Besides, it also sought to determine the association between health care practitioner–related characteristics and use of HL communication practices.
Methods A cross-sectional survey was conducted from July to September 2017 in all the public hospitals of Penang, a state in Northern Malaysia, involving physicians, pharmacist, and nurses. The health care system in Malaysia has been characterized by strong public sector presence, whereby government hospitals and health clinics act as the primary source of care. In 2015, there were 2.5 million hospital admissions in Peninsular Malaysia.19 Penang is one of the most populated states with 6 public hospitals that provide services to the urban, suburban, and rural populations. A study conducted in one of these hospitals reported that the majority of the participants were poorly educated (no formal education or
Annals of Pharmacotherapy 52(4) primary education) and in the lower-income group (less than RM1000; US$ 233).20 According to the report on the education attainment of the labor force in Penang, an estimated 1.3% of the population was without any formal education, and 12.7 % had only primary education (6 years of schooling).21 The sample population size was determined using the Cochrane formula for continuous data, considering most of the questions applied scales assessment with the assumption of a 95% CI and 5% margin of error. The sample size was calculated for each category of health care practitioner based on the response rate from prior studies.17-19 The minimum sample size required was 200 for physicians, 200 for pharmacists, and 126 for nurses. However, a sample of 200 health care practitioners for each profession was used given the similar nature and response rate targeted. The sample size was stratified to each of the facilities based on the proportion of physicians, pharmacist, and nurses working during the data collection period. The questions on the practice of HL communication were developed based on extensive literature review and expert opinions. Besides, questions were included to assess respondents’ sociodemographic and work-related information. Prior to the distribution of the survey instrument, content validity was performed among 5 expert panels—mainly academicians and representatives from the government hospitals. Furthermore, it was pretested among 7 health care providers to determine its face validity. The amendment was made accordingly before conducting a pilot study among 80 health care providers (25 physicians, 25 pharmacists, and 30 nurses). The pilot study data were used to revise the questions in terms of clarity and interpretability as well as reliability analysis and not included in the final analysis. Internal reliability of 0.87 was obtained using the Cronbach α for the practice of HL communications. An α value of 0.7 and above was considered satisfactory.22 The questionnaires were distributed using the drop-andcollect method over the 2-week period. A representative from each profession in the respective hospitals was approached to assist in the distribution of questionnaires, and follow-up visits to the representative were arranged to increase the response rate. Written consent was obtained from all study participants before administering the questionnaire. No personal identifiers were included in the questionnaires. After 2 weeks, the questionnaire was collected by the assigned personnel at each hospital. A reminder was sent a week apart to those hospitals with low response through the hospital directors. Descriptive statistics were used to elicit the respondents’ sociodemographic and work-related characteristics. HL communication practice was assessed using 5-point Likert scales (always, often, sometimes, seldom, never). Health care providers with responses of “always” or “often” were categorized as frequent users of HL communication practice
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Rajah et al Table 1. Demographic and Professional Characteristics of Study Respondents (n = 526). Designation, n (%) Demographic and Professional Characteristics
Physician, 158 (30.0)
Gender Male 69 (43.7) Female 89 (56.3) Age, years, mean (SD) 29.5 (4.3) Age group, years 20-30 112 (70.9) 31-40 42 (26.6) >40 3 (1.9) Missing Years in service, mean 4.4 (3.5) (SD) Number of years in service 0-5 112 (70.8) 6-10 37 (23.4) >10 8 (5.1) Missing Place of graduation Local graduate 107 (67.7) Overseas graduate 51 (32.3) Heard the term or familiar with concept of health literacy Yes 69 (43.7) No 89 (56.3)
and those with responses of “sometimes,” “seldom,” or “never” were categorized as not frequent users of HL communication practice. The χ2 test was then used to determine the association between the categorical variables. The 1-way ANOVA and independent-sample t-test were used when appropriate to estimate differences in HL communication practices with regard to the health care practitioner’s sociodemographic and work-related information. Tukey’s post hoc test was used to determine whether there were significant differences among the 3 groups. Statistical significance was defined as P ≤0.05. All statistical analyses were conducted using IBM SPSS Statistics 22. Ethical approval for conducting this research was obtained from the Medical Review and Ethics Committee, Ministry of Health Malaysia. The registration ID for the National Medical Research Register is NMRR-15-2208-28623.
Results Of 600 eligible respondents, 526 completed and returned the questionnaires, for an overall response rate of 82.6%. The majority of the respondents were pharmacists (35.7 %), followed by nurses (34.2%) and physicians (30.0%). Overall, the sample population was predominantly female (77.8%) and consisted of local graduates (82.3%).
Pharmacist, 188 (35.7)
Nurse, 180 (34.2)
Total, 526 (100.0)
36 (19.1) 152 (80.9) 28.6 (3.1)
12 (6.7) 168 (93.3) 31.8 (8.8)
117 (22.2) 409 (77.8) 29.9 (6.1)
135 (71.8) 51 (27.2) 0 (0.0)
106 (58.9) 41 (22.7) 33 (18.3)
4.7 (3.0)
8.4 (8.1)
353 (67.1) 134 (25.4) 36 (6.8) 3 (0.6) 5.9 (5.7)
122 (64.9) 57 (30.3) 9 (4.8)
97 (53.9) 25 (13.9) 57 (31.7)
147 (78.2) 41 (21.8)
179 (99.4) 1 (0.6)
331 (62.9) 119 (22.6) 74 (14.1) 2 (0.4) 433 (82.3) 93 (17.7)
98 (52.1) 90 (47.9)
95 (52.8) 85 (47.2)
262 (49.8) 264 (50.1)
The mean age of the sample was 29.9 years, and the average years of service was 5.9. More nurses than physicians and pharmacists were found in the >41-year-old age group and among those with 10 and more years of service. Only about half (49.8%) claimed that they had heard the term or were familiar with the concept of HL, and the finding was consistent across the 3 professions. A complete description of the demographic and workrelated characteristics of study respondents are depicted in Table 1. Table 2 summarizes the HL communication practices and the comparison among physicians, pharmacists, and nurses. Overall, almost 19.0% (n = 98) of the respondents admitted that they did not frequently use simple language and avoid jargon during communication with patients. In addition, about half of the respondents reported that they frequently used other HL communication practices, including handing out education material to patients (52.2%, n = 275), asking the patient to repeat information (58.9%, n = 310), and asking patients’ caregivers to be present during explanation (57.4%, n = 302). Comparatively, underlining the key points in the information handouts (49.0%, n = 258) and drawing pictures to ease patients’ understanding (40.1%, n = 211) were the less-frequently practiced HL communication techniques.
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Annals of Pharmacotherapy 52(4)
Table 2. Comparison of Health Literacy Communication Practices Among Physicians, Pharmacists, and Nurses. Level of Practice, n (%) Practice
Designation
Frequent
Not Frequent
P Value
I use simple language and avoid medical jargon terms
Physicians Pharmacists Nurses Total Physicians Pharmacists Nurses Total Physicians Pharmacists Nurses Total Physicians Pharmacists Nurses Total Physicians Pharmacists Nurses Total Physicians Pharmacists Nurses Total Physicians Pharmacists Nurses Total Physicians Pharmacists Nurses Total
138 (32.2) 164 (38.3) 126 (29.4) 428 (81.3) 63 (22.9) 108 (39.3) 104 (37.8) 275 (52.2) 76 (24.5) 108 (34.8) 126 (40.6) 310 (58.9) 107 (35.4) 86 (28.5) 109 (36.1) 302 (57.4) 70 (27.1) 88 (34.1) 100 (38.8) 258 (49.0) 96 (29.0) 112 (33.8) 123 (37.2) 331 (62.9) 88 (26.3) 121 (36.2) 126 (37.6) 335 (63.4) 80 (37.9) 59 (28.0) 72 (34.1) 211 (40.1)
20 (20.4) 24 (24.5) 54 (55.1) 98 (18.7) 95 (37.8) 80 (31.9) 76 (30.3) 251 (47.8) 82 (38.0) 80 (37.0) 54 (25.0) 216 (41.1) 51 (22.8) 102 (45.5) 71 (31.7) 224 (42.6) 88 (32.8) 100 (37.3) 80 (29.9) 268 (51.0) 62 (31.8) 76 (39.0) 57 (29.2) 195 (37.1) 70 (36.6) 67 (35.1) 54 (28.3) 191(36.3) 78 (24.7) 129 (41.0) 108 (34.3) 315 (59.9)
41d Number of years of servicea
