Understanding health literacy barriers to improve shared decision making when optimising medications involving complex therapeutic regimes

It is inevitable that as we get older it is more likely that we will develop different diseases. The more diseases we accumulate over time (multimorbidity), the more likely we are to take many medicines (polypharmacy). Many of the medicines that are prescribed are done so to prevent the diseases that we have from getting worse or from other diseases occurring. Currently, just half to three-quarters of patients benefit from the first drug offered in the treatment of diseases, and many people suffer side-effects from drugs.

Potentially inappropriate medications (PIMs) are those where the potential risks associated with use outweigh the potential benefits; 20-60% of elderly patients are taking at least one PIM. Deprescribing, the process of withdrawal of an inappropriate medication, has been proposed as an intervention to reduce the harm associated with inappropriate polypharmacy. Both prescribers and patients need to be supported to make an informed decision about the benefits and risks of continuing medications in the absence of an evidence base that is representative of a complex multimorbid state.

There are several barriers to shared decision making such as lack of time, scarce trustworthy information and the attitude of clinicians. From the patient’s perspective, limited health literacy (LHL) has been reported as a significant barrier to clear communication and appropriate decision making. LHL and low numeracy have been associated with a range of adverse health effects, including worse self‐management skills [1]; poor adherence to medication [2]; greater risk of hospitalization, emergency care visits and lack of preventative care; worse health status; and lower quality of life [3]. Systematic review of patient education materials available to aid deprescribing revealed that most are pitched above average reading levels making them inaccessible for low health literacy populations [6]. Furthermore, the advent of incorporating genomic information into prescribing decisions adds a further layer of complexity when communicating uncertainty and complexity around prescribing.

Therefore not all medicines that are prescribed in complex patients with multimorbidity are doing them good and may actually be doing them harm. For many patients, drugs were started at a time in their life when benefit outweighed the potential for harm. As time goes by, and further diseases accumulate, this benefit to harm ratio can change and consideration needs to be given to stopping some drugs in order to improve quality of life. The time at which this occurs varies from patient to patient and is not always easy to define. Added to this, there may be genetic differences in the way that we respond to drugs that are also contributing to the risk: benefit profile. Communicating this uncertainty in the context of LHL and low numeracy, presents a particular challenge for both patients and prescribers alike.

Ensuring the right person, gets the right treatment, at the right dose will reduce the risk of side-effects, increase treatment effectiveness, and reduce costs for healthcare systems. In order to support patients with LHL and low numeracy to make informed decisions about discontinuing medicines and changing them based on genomic information we need to develop education materials that are accessible.
This project aims to engage relevant stakeholders including patients, their carergivers and prescribers (both primary and secondary care setting) to assess i) attitudes towards medicines optimisation and genomic information ii) accessibility of patient education materials and iii) development of education materials for deprescribing and genomic information that specifically target those with LHL and low numeracy.

Application is by CV and covering letter. The covering letter must detail your interest in the studentship, related experience and training and suitability for the position. Applications are to be sent to Dr Lauren Walker, [Email Address Removed].