Health literacy and illness cognitions in Irish community pharmacy patients taking oral anti-coagulants

Candida Halton MSc1, Dr Tina Cartwright CPsychol AFBPsS2, Dr Suzanne McCarthy3; Keith O’Hourihane MPharm(Hons), MPSI4


  • Stroke is the third most common cause of death and the most common cause of acquired major physical disability in Ireland.5
  • Four in ten Irish adults have health literacy levels which are not sufficient to manage their health.6 Graphic showing four out of ten adults have insufficient health literacy levels
  • Pharmacies are the most accessible healthcare provider, in common with most of Europe.7
  • Pharmacies are developing anti-coagulant services to support patients. Provision of these at pharmacy (instead of hospitals or clinics) increases patient access and may offer cost savings.8

The current study

  • This is the first study to investigate health literacy competencies and illness cognitions, and their associations, in community pharmacy patients taking oral anti-coagulant medicines.
  • The study also considered contextual influence of treatment: comparing patients taking non-vitamin K antagonist oral anticoagulants (NOACs), which require low intervention, and warfarin which requires frequent INR monitoring (International Normalized Ratio: a measurement of blood coagulation) and a more stringent dietary regime.
  • Health literacy was measured using a newly validated tool, which enabled evaluation of an expanded concept of literacy, including functional, interactive and critical aspects in these patients.

What are illness cognitions?

  • A patient’s implicity beliefs about their illness, providing them with a framework or lens through which to view and understand their condition and its symptons.9
  • They have five attributes: illness symptons (identity); factors that led to the illness (cause); duration and consistency of the illness (timeline); impact of the illness and emotional burden (consequence); and confidence in personal and treament efficacy (control).10
  • Similar to health literacy, illness cognitions are dynamic, modifiable and have been shown to predict patient outcomes.11
  • Disease management behaviour, including self-care and adherence to treatment, is driven by a patient’s cognitive representation of their illness.10

Two photographs: the first is a photograph of a blue pharmacy frontage, the second is of a female pharmacist at work.


A convenience sample of patients (n=100) from Irish community pharmacies (n=5) completed validated measures of health literacy: the Health Literacy Questionnaire (HLQ)11; illness cognitions: the Brief Illness Perceptions Questionnaire (BIPQ)5 and medicines history: Brief Medicines Questionnaire (BMQ)12; using computer tablets in store. Eligible patients were >18 years and had been on either warfarin or a NOAC, for >6 months.


  • Mean scores for the nine HLQ scales demonstrated a high level of literacy in the sample.
  • Mean scores for the BIPQ measure showed low perceived illness burden.
  • Self-reported adherence was high (92%).
  • No significant differences were found for the two anti- coagulant treatments.
  • Associations were explored between health literacy and illness cognitions, these were highly significant between health literacy abilities and illness identity; emotional burden and treatment control (p = .01).

Table 1 shows the study’s population.

Associations between health literacy and illness cognitions

  • Associations were strongest for illness coherence (‘how well do you feel your understand your illness’) and health literacy scales 1, 2 and 4. These scales focus on functional (scale 2) and interactive (scales 1 & 4) health literacy abilities.
  • An association between higher perceived treatment control and health literacy scale 6 was also significant. Scale 6 measures active engagement with HCPs.
  • An inverse relationship was seen for the disease timeline (‘how long do you think your illness will continue?’) and scale 2. This links a lower self-rated ability to gain health information with a shorter perceived disease trajectory.
  • Lower functional literacy (scale 8) was also associated with lower emotional illness impact.
  • Participants with higher levels of concern about their illness also had higher scores in critical health literacy (scale 5).

Table 2 shows correlations between Health Literacy and Illness Cognitions.


The study found high levels of adherence, health literacy and low perceived illness in a cohort of community pharmacy patients taking anti-coagulant medicines. Findings were similar between types of pharmacological treatment. Associations of interest were found between an expanded concept of health literacy and illness perception agributes. This may warrant further research given the evidence for impact on patient outcomes for both constructs.


  • Anti-coagulant patients in a community pharmacy sekng were found to have high health literacy ability, low perceived disease burden and high adherence.
  • The community pharmacy environment may provide a beneficial sekng for anti-coagulant services.
  • Significant associations between illness cognitions and health literacy warrant further research.

Practice considerations

  • Study findings point to community pharmacy as an important and beneficial care seeking for anti-coagulant patients.
  • Health literacy ability and illness cognitions have both been shown to be context-specific, this study offers a contribution this evidence-base.
  • The results initiate a discussion about the relationship between health literacy and illness cognitions, which may in the future guide intervention development and impact.

  1. Department of Psychology, University of Westminster ↩︎

  2. Department of Psychology, University of Westminster ↩︎

  3. School of Pharmacy, University College Cork ↩︎

  4. Pharmacy First Plus, Republic of Ireland ↩︎

  5. Irish Heart Foundation. (2008). Irish Na)onal Audit of Stroke Care. Dublin: Department of Health and Children. ↩︎

  6. Sorensen, K., Pelikan, J. M., Rothlin, F., Ganahl, K., Slonska, Z., Doyle, G., et al. (2015, April). Health literacy in Europe: comparative results of the European health literacy survey (HLS-EU). The European Journal of Public Health , 1-6. ↩︎

  7. PGEU. (2014). Brussels. ↩︎

  8. Irish Pharmacy Union. (n.d.). Home. Retrieved September 12, 2016 from Irish Pharmacy Union: hgp:// ↩︎

  9. Broadbent, E., Petrie, K. J., Main, J., & Weinman, J. (2006). The brief illness percepBon quesBonnaire. Journal of Psychosoma)c Research , 60, 631–637. ↩︎

  10. Leventhal, H., Bodnar-Deren, S., Breland, J. Y., Hash-Converse, J., Phillips, L. A., Leventhal, E. A., et al. (2012). Modeling health and illness behavior: The approach of the commonsense model. In T. A. A. Baum, Handbook of health psychology (2nd ed ed., p. 908). New York, NY: Erlbaum. ↩︎ ↩︎

  11. Broadbent, E., Wilkes, C., Koschwanez, H., Weinman, J., Norton, S., & Petrie, K. J. (2015). A systemaBc review and meta-analysis of the Brief Illness PercepBon QuesBonnaire. Psychology & Health , 30 (11), 1361-1385. ↩︎ ↩︎

  12. Osborne, R. H., Bagerham, R. W., Elsworth, G. R., Hawkins, M., & Buchbinder, R. (2013). The grounded psychometric development and iniBal validaBon of the Health Literacy QuesBonnaire (HLQ). BMC Public Health , 13 (658). ↩︎