Health literacy
6th Oct, 2022


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Jacqui Fahey (00:06): Welcome to Common Ground, a podcast series discussing new research and interesting projects in the field of complementary medicine. Hello, my name is Jacqui Fahey, Head of Education at vital.ly.

We did encounter some audio problems which we tried to clear up and edit as much as possible, but apologies for that, and we hope you still enjoy this episode. The transcript is also available to read on your podcast and vital.ly platforms. Thanks.


Today on Common Ground, I'll be speaking with Manuela Boyle. Manuela has recently been engaged in a PhD scholarship with the University of Adelaide, Faculty of Medicine and Health, to further research aspects of health literacy, this is after completing a Master of philosophy to research the same topic. Additionally, Manuela is a member of the Research Standards Committee of the International Health Literacy Association in the USA. Manuela’s goal is to increase global awareness of the importance of health literacy with tangible options. Manuela is passionate about supporting and improving preventative health and social prescribing in both private and public settings, and believes improving individual communities health literacy can reduce health disparities associated with social determinants such as income, education, marginalisation, and disadvantage.

Welcome to Common Ground, Manuela.

Manuela Boyle (01:35): Thank you for having me. Very happy to be here.

Jacqui Fahey (01:38): Thank you Manuela. What is your background and how did you come to specialise in health literacy?

Manuela Boyle (01:45): Well I'm a naturopathic practitioner, and I'm also a clinical nutritionist. I decided to further my education a while ago, and I completed a Masters of Health Science and then I went into the Masters of Public Health. I thought, well, let's have a look at this health from the public perspective. And somewhat that gave me a bit of a taste of health literacy. It was a concept that I knew, I thought I knew about, and I really realised that I needed to know much more about it. So I decided then to do a Master of Philosophy and original research. It's taking me now to well, you know, recently, more recently to start a PhD in the area of Health literacy. I think that's my passion and it would be forever interest for me. But the reason though, what passion comes from is that the current design of today's healthcare system requires that, you know, patients and families and demonstrate multiple skills, including an understanding, giving consent in practice, interacting with healthcare professionals like us or professions like GP’s and medical specialists.

And also requires that patients and families apply health information to different situations in a variety of life events. That made me understand and made me realise earlier on in the process that all this, this particular skill set is not something that people are born with. It really is a lot more complex, and generally speaking, people don't receive that knowledge. It's profoundly, it constitutes a significant obstacle for people to truly be engaged in their own healthcare management and generally to reach good health. So as a healthcare professional, I felt that that was the basic starting point from which to build upon. And so therefore I thought, well, what can I do about this? How can I just, just support, how can I better support my patients? And from then onwards, basically I decided to learn more. That just needed to go and find that information. And here I am.

Jacqui Fahey (04:31): Yes. Wonderful. Could you explain for the audience what is health literacy?

Manuela Boyle (04:36): Yeah, so as I mentioned, health literacy is a set of individual skills that comprise the ability to find, understand, critically evaluate, communicate, and using information in the everyday life. So it's really, I see it as a bottom up perspective. It is focus on understanding people from the, you know, from our perspective, I guess we need to understand people as lifelong learners. And understanding the, the differences, of course. So health literacy in general relates to all health decisions that people make in their lives. It has to be considered as a multidimensional concept, so health literacy is not just about the ability to read and write.

Manuela Boyle (05:26): It goes well beyond that. And it does expand to include the quality communication between the patient and healthcare provider, trust in that relationship, and also the competence in maintaining good health and navigating the healthcare system. It has been demonstrated by multiple scholars that health literacy, saves time, saves cost to the healthcare system, and definitely saves lives. People with low or limited healthcare health literacy level have a much higher hospital admission, for example, a much higher rate of healthcare issues. They, in other words, there's many more people in emergency rooms who have low or limited health literacy levels compared to those who have a good health literacy level. Or even from a feasibility study studies that done all over the world, it shows that yes, it makes perfect sense to have people with a better or higher mobile robust health literacy level.

Jacqui Fahey (06:38): It does make sense. And what are some of the statistics on health literacy in Australia?

Manuela Boyle (06:43): Look, the last time it was checked, actually goes back to 2006, it was a while ago. The Australian Bureau of Statistics conducts various surveys every so often. And so we don't have the most recent, I suppose, data. Going back a little bit, it shows that yes, only 41% of adult Australians had good enough, I suppose, health literacy level. They would just allow them to meet the complex demands of everyday life. So with that though, we need to take into consideration that the person’s health literacy can be influenced by their cultural beliefs like language, disability, education, income, health status. For example, the Australian Bureau Statistics survey showed that health literacy was a lot lower in people who speak English as a second language, it was only 26%. It was higher, of course, people who have completed bachelor’s degree it was also higher amount people with higher income than compared to those with the lower income. So there was actually quite a significant difference.

So yeah, that's important to understand, I guess potentially, and I'm not getting into the inside out of this and just mentioning that there would be a new set of data coming out hopefully next year when it comes to health literacy in Australia and it would be reflective of the COVID pandemic would be reflective, all the most recent issues that affected everyone really. And that would just potentially give us a new set of data, but I don't know what it's going to come up, so.

Jacqui Fahey (08:48): You've mentioned a few factors there to consider, cultural aspects and I was just thinking also while you're answering that, is pain, you know, when patients are in pain and, you know, information is being delivered to them, you know, quite often when you're sitting across your practitioner, whether that be your GP, your specialist, or your naturopath, and you're in pain and discomfort and you're trying to take in that information, I'm sure that would be affecting your understanding and your compliance. Do you alter communication when you have sort of patients that are just so unwell, they're chronically ill?

Manuela Boyle (09:27): Oh, absolutely. That's why I would like to add, complementary medicine practitioners are in an absolutely the best position to improve and increase health literacy level, amongst their patients, and really even at a communities level. Of course, I think that complementary medicine practitioners have or demonstrate consistently to have that humility, to have that empathy, to really put themselves in their patient's shoes and understand the difficulties that sometimes really is there when there is that traditional patient encounter. So of course, when people are in pain or they're afraid, or they're, typically disempowered, there's a lot of them that I, we see, I see my practice, or they're going through particularly heavy treatment, same hospitals, or they really are, yes, of course they're in pain, they're uncomfortable, they don't know how to express that pain or that feeling uncomfortable.

How many times complementary medicine practitioners ask their patients, ‘What's your energy like?’

This is intangible but it's a very important starting point because it is something that in other healthcare settings, this is never asked. The other thing is also to, it's quite important for complementary medicine practitioners to really understand how people actually do their task of accessing, understanding and praising and retrieving basically, the health information in their everyday life within their context. So that's important. The second thing really is that to recognise that the health literacy is absolutely connected in that communication aspect. It's the way people communicate is very different. And it's just, it's a bit like fine tuning, taking up time, I suppose, but quickly enough or timely enough tuning in. Tuning into the patient, understanding where they're coming from.

Focus also on health literacy diversity. Absolutely. There are people, patient, people in general who are really at the highest risk of being left behind because diversity, cultural diversity practices, like I said, preexisting beliefs are clearly need to be recognised, and sometimes they're not immediately discussed right out there. And so that is an important, it's really important to understand that part. And finally, of course, recognise the role of traditional and local wisdom and knowledge. Certainly, I mean, this has to be very much taken into consideration because again, other than time tuning, is really, it has to be kept as a humble approach, respecting the person in front of you as a sensing being, obviously as we know it. But people need to be heard no matter what it is. So, but again, because we are holistic practitioner, we are in a really great, in a driver seat, if you like, you know, and support the health literacy and empower the patient in the process.

Jacqui Fahey (13:09): Yes. So for a practitioner that's listening today. Are there any must dos and don'ts in health literacy? You know, when they're, they're putting their material together, they've got you know, they're in practice, you know, and their patients are coming through each week. Are there any sort of must dos and don’ts’s?

Manuela Boyle (13:29): Yeah. Okay. So I'll start with the don’ts I suppose because there's only the one really that I believe it's important. So first of all, it's really essential not to patronise the person in front of us no matter, you know, no matter the preexisting knowledge in healthcare. But it is now what it is. Huge. well, you know, it's still important first of all to hear, to understand and to listen and fine tuning,  no matter what the belief system is, that is also, like I said, really very important to, not necessarily to participate or partake on something that the practitioner may not believe in, but at the very least not to, what can I say, diminish or demean really the person in front of us, because you just don't know how, and this person has a right to that conclusion.

So just put that aside, perhaps if something that the practitioner's not really interested in or doesn't think is actually good for the patient, rather than if you feel like, you know, breaking the spirit of the patient in front of us so we can put a point across. Just simply put it aside. You can always go back to that later on. So there's plenty of must do’s of course. And that starts from, like I say, listening, understanding, fine tuning, and then truly translating complex information into tangible, sensible, and easy to understand concepts. So for example, using a whiteboard, designing using pictures, anything that helps communicating is important. And sometimes, this has to be done in an appropriate way, using what we call the teach back system in other words, asking in way that is actually, you know, comes across as being fine. Asking the person in front of us, whether in fact the concept is clear or not, just asking to repeat what they heard. Because sometimes it's not exactly what we, what we want the patient to understand. Sometimes it's not really kind of clear. Oftentimes it's not unusual for patients to not know at all what their diagnosis is.

People come in and say, Oh, you know, my doctor said I've got this and that. And so when you, when I ask, they said, What do you understand then? What's this is all about? And I say, no, can you please repeat it? And I realised that the reason why they ask me, rather than asking their specialists or their GPs or other people, other practitioners, it's because with me, in this context of health literacy, they feel safe and they feel safe in their being vulnerable.

So in turn, I feel honoured with this, but also have a greater responsibility to reassure, to provide the right facts, simple facts. And then with that, with knowledge, there is, like I said, the empowerment. And then I like to believe that my patient, and I'm sure with that there many other complementary medicine practitioners with exactly the same thing, but at the time this patient is a client, this person leaves the office as a better person in that in knows more, can makes decision there are meaningful for their own lives.

Jacqui Fahey (17:38): Because there's a lot to, it can be a lot to absorb for the patient whilst they're in the consult. So I've noticed with some of the practitioners I've sought helpful my health when they print out a picture and they sort of start drawing and it might be various body parts and systems and sometimes there's big words, you know, for our patients. So like you're saying, it's simplifying it and whether it be through pictures. But yeah, I found personally the usage of images is very helpful. And writing sort of some content next to that, which the patient can take away. So, you know, you can look at that and go, right, okay, that could be part of my healing journey.

 Manuela Boyle (18:21): Absolutely. And I also, another tool perhaps that can be potentially used by practitioners to fill in this way, I guess it, I think what, that's what I do anyway. I do provide a summary in writing. Summary of the consultation, I can provide you pictures, I can hand them over, I can email them. I can just give them those you know perhaps in audio file if the consultations online. So there's a lot about a lot of additional, or perhaps there's a little bit more work at the beginning to set this the context. But later on you'll have a much easier, I suppose ongoing conversation, I guess with, with the patient you can see them, you really thriving and becoming quite engaged in their own healthcare, when they don't see you in practice, because obviously the maintenance, the support of the patients wellbeing doesn't stop. That continues on once they go back home or they go back to their work or their daily lives. So if we are making changes, those are, you know, lifestyle changes that have to be maintained. It's important that collaboration starts, that the basic fundamentals are put in place right through the time of consultation onwards.

Jacqui Fahey (20:08): When you are with the patient, when you're in clinic, and say for example, the patient has a new diagnosis of, say psoriasis, whether it was diagnosed by yourself or not, it's just psoriasis and they don't know a lot about the condition of psoriasis. Do you have prepared different health literacy on various health conditions and so say you might have a handout on psoriasis or you might have an audio file on psoriasis. Do you kind of make a decision whilst you're there with the patient and you go, well, actually this type of information looks to be suitable for this type of patient and you give them the appropriate health literacy information?

Manuela Boyle (20:49): Yes. So that's certainly a good way. I always suggest, well, I do suggest to first of all, ask the patient what he or she knows about the condition or the diagnosis. Maybe might be absolutely surprised in that there are you know, patients are experts, some of them are and others are just too scared or intimidated or they just don't want to see it by some, what they want to know it, but not necessarily all there clearly. So there is a fine tuning about this. It's just the way of evaluating the patient when sits in front of you and see the kind of person you, you are, you're dealing with. It's look, remember that the approach, unfortunately, patients receive in general or mainstream healthcare settings is quick.

May have five to 10 minutes. Specialist appointments are oftentimes also quick in that, specialists are also overwhelmed with appointments, et cetera, and they are perhaps impersonal.

So it is, first of all, is to, especially if it is this is I'm talking about new patients to make them feel safe. This is the place where you're coming to know, I'm on your side. Let's look at this understanding then what, what, what they know. And then if they don't know anything at all or very basic, then yes, of course, you start by giving basic information. I mean, I always suggest or make available recent research. I have a virtual library that comprises hundreds, maybe thousands of peer review papers. I said, would you like to read something? Are you happy to read this? Because if you're not, don't worry about it. We go to some other form of information, perhaps the summary of some of the research, in depth research, et cetera.

So it really does depend. Some of my patients certainly happy to receive the peer review papers. I do recommend them to read them all and maybe highlight things perhaps they don't understand. We can discuss in the next appointment. But in general though yes, I would say the health literacy level of most patients is not great. So it means that yes, you want to provide information, they are easy, they're factual, and this is where to source that information. So healthcare providers, complementary medicine practitioners that have really the duty, the responsibility to find, to provide information in a simple, clear, in plain language to check the patients have understood the information before in the conversation, but they also had the responsibility to source that information from reliable sources.

Jacqui Fahey (24:06): Yes.

Manuela Boyle (24:07): Clearly. You know, it goes two ways, right? Yes. Not just if you push away, push information that is false information or confused or just simply yeah, well, poor quality, you will continue on maintaining a low-level health literacy also with your patient. So yeah, we need be important in what we do.

Jacqui Fahey (24:31): Yes, it is, isn't it? And actually to the point of, you know, credible sources, you know, how would you handle and maybe you've had it in clinic before, a patient coming in saying, I've learned this from Dr. Google or various websites. And I guess you take a patient through credible sources, you know, to sort of say, well, Dr. Google is sure one source, but it's you know, how do you explain that to a patient? What's your process there?

Manuela Boyle (24:58): Well look in general, I then already understand this particular person then is obviously goes on the internet, right? So I know that the internet is clearly something that this person uses and is potentially a source in that, other than books or other form of information. So, fine. So what I do, I obviously turn on my computer, which is usually always on. Then I look at Google and I say, Well, do you know that there is a thing called Google Scholar? And say, Oh, I don't know. So I type Google Scholar, this is how you get Google Scholar. Google Scholar is the most, going to say, the more appropriate source of information compared to the other, you know, cousin.

So we go to Google Scholar, and then did you know there is a thing called Pubmed, and then that research is peer reviewed. And then I said, But you know, what's peer reviewed? Say, Oh, no, I don't know what's peer reviewed is. Okay, well this is research. There is, has been reviewed by, supported by universities, not pharmaceutical, not, this is just research per se. And, and you know, we can see a lot of great things here. And if it is something that is potentially really not a great type of information that come up with something really kind of weird and totally, irrelevant, then I say, Okay, let's have a look if Google Scholar agrees with the other Google, and let's see if we can find anything here that makes sense. And if we don't find this, well, you know what? Probably I would just leave it mm-hmm.
It's not that important. So it's a matter of demonstrating without patronising.

Jacqui Fahey (26:47): Yes, that's right. Exactly. It's respecting, isn't it? We're on this journey and we are here to facilitate in, you know, good education, critical health literacy. How has your knowledge of health literacy helped you as a practitioner in clinical practice?

Manuela Boyle (27:04): Oh, hugely. Hugely. I think that I just I couldn't do it any differently. My patients, I, generally speaking people who are very much, I think I've probably, potentially, probably the most, I'm not say most disempowered, but certainly significantly disempowered, those are typically people who have had recent diagnosis of cancer. They, I don't know which way to look at, they usually quite desperate. They're usually quite scared. They're just, you know, they're just really in a pretty much of a black hole. Providing health literacy, providing those tools and seeing a person in front of me that goes from being in a dark space into a radiant solar up, empowered person is just wonderful. Even though nothing changes when it comes to their treatment, of course, I'm not clearly can I say, painting, you know, the situation in a different way than what it is. Some people I see are palliative care patients or terminal patients. And so it's difficult, but I like to see their situation factually. So without the fear, the more you know, the more empowered you are. I absolutely agree on this statement completely. It's not my statement. I read a time and time and time again from various sources of health literacy scholars and amazing people around the world who are expert in health literacy.

So I translate what they have in something that I can manage so that they have more, they get to a point where we call owning the illness. And what does it mean? It means to take it from the up, not from the down. In other words, being empowered, be strong, be engaged. And when you are in that position, the fear, the uncertainty, and the despair, it just significantly decreases. So nothing has changed really. It's just the mindset that changes. So for me, if, if I didn't do this, I couldn't be in practice, I just, I couldn't.

Though, it is an important aspect. It's important to keep the conversation and support a conversation with a healthcare, other healthcare practitioner specialist, so that it becomes the standard conversation that is patient centered. So they're in the middle, they're patient centred and ways liaising or various practitioners doing the things that they, everybody's, you know, suppose stronger ways, but at times though there's not, it's not always very easy to do so, some people who are want to continue on with me information is not something I'm prepared to do. And so sometimes it's just, just I can't. But oftentimes though I say 99.9% of the times that changing that perspective, improving in that trust, making them feel in a safe space, making them feel that they can actually get it, understand it, it's not the end of the world, but we can all collaborate in making this journey to be successful is actually, it requires knowledge. It requires to have an empowered person in front of you. It really does. And I keep on using the word empowerment because patients, especially those with significant diagnosis, are typically disempowered.

So changing it around is important.

Jacqui Fahey (31:22): Absolutely. And could you give if you're happy to share, could you give some examples of how health literacy has helped you in clinical practice?

Manuela Boyle (31:32): Yes, certainly. Well, it has helped a lot when it comes to clarifying the diagnosis. So the diagnostic, the understanding that, what it is really, that the person is being diagnosed with, whether it could be some form of autoimmune disease to a more simpler diagnosis that is definitely, is clear in the asset. That's what it is. This is it.

Second is about also the prescribing. So when we, I suppose, prescription, what does, what is important for the patients to know. And it is once again, the responsibility of the good healthcare provider, complementary medicine, to convey clear information.  Information that is backed by research. And that research has to be available to the patient. Whether the patient likes it or not, she can decide not to, that can be bothered to read it, that's okay. But it's available. And so they can be sent through links, through having, I suggest definitely to create virtual library so available with availabilities, immediate availabilities, either printouts or sending it through emails, you know, for backing basically what we do, but not, but not from the point of view of I suppose validating what we do, you know, be validation, obviously not what we're doing. It's to further enrich the health literacy of the person in front of us.

Jacqui Fahey (33:24): Yes, I understand. Yeah. Yes.

Manuela Boyle (33:27): The other part, of course, that also helped a lot, that helps a lot in clinical practice, is to really keep in mind that we deliver a holistic, patient centred type of healthcare, patient centred healthcare.

Manuela Boyle (33:58): Well, that when the third aspect, it's also very important is that to engage the person, the patient, the client, into their own healthcare management.

So giving tasks which are tangible, and they giving the ABC on what to do, and then keep giving them some responsibilities, some tasks, some things to do. That when they come back to the follow up appointments, now you see somebody who's actually, is owning the illness, if you know what I mean. That is owning their own, their participatory to Yes. Their own work.

Jacqui Fahey (34:40): Yes. Instead of just, Here, take this, you'll get better. Tell us more about the research standards committee of the International Health Literacy Association.

Manuela Boyle (34:52): Oh, sure. Well, so the International Health Literacy Health Association is a non, not the for-profit organisation. It's a member based organisation, people passionate about health literacy. It's within the Health Literacy Association, there are different committees, and I'm really very proud to be part of the research standing committee. And the standing committee members are tasked with running and growing the organisation. So I'm, all the members are elected through an open application process from 23 different countries around the world. So the research committee in particular, the research standing committee, which I'm part of, is the one that's dedicated in creating libraries, in sourcing the appropriate, not appropriate, but let's say the, the factual information in creating also sourcing funds and grants for university and students potentially from poor countries, for example, in advising governments and organisations of, you know, supports and funds, et cetera, going towards improving, for example, refugees health literacy level or migrant communities health literacy level, women's health have literacy, especially when it comes through sexual health. So there's a whole lot of various projects going on. But I think that the committee I'm part of is pretty cool because it really does give statistics and data and where the funds should go to and what kind of research is needed in particular areas.

Jacqui Fahey (37:00): Yes. Yeah. Right. Okay. Fantastic. And are there any sort of resources for practitioners if they wanted to look into that? How could they be a part of maybe joining such or getting updates? Yes.

Manuela Boyle (37:12): So yes, they can certainly join. There are, in Australia, we have a few organisations quite active in health literacy. Well, in Sydney, there is, the health literacy hub is very well recognised all around the world being quite, quite out there, really with various initiatives at university, but also at you know, for everyone really. But you know, there really are many initiatives happening in Australia, but I think it is reflective of the global interest in in health literacy. And it's, I believe also this is so exciting because there interest part from public health, from healthcare, from naturopathic, complementary medicine, from mainstream medicine. So you also come in together and say, Oh, maybe we have to do something about this improving people's, you know, capacity and skill set. I keep on saying that this idea came from us.

Manuela Boyle (38:18): Because this is really what we do and what a complementary, I believe, most complementary healthcare professionals have been doing from the very beginning of time. But I guess, you know, sometimes you do things before they actually are labeled in certain ways.

Jacqui Fahey (38:37): Yes and wanted to ask you, in your biography it says you are passionate about improving social prescribing. What is social prescribing?

Manuela Boyle (38:47): That's right. So this is another one of those things that also complementary medicine professionals have been doing for the beginning of time. So social prescribing is also sometimes known as community referral. In the means of enabling health professionals to refer people to a range of local non-clinical services. Social prescribing comes, what's created more recently in United Kingdom where the NHS, which is their Medicare system, universal health is a wonderful thing that is become, is basically crumbling through, just overwhelmed with requests. The number of people attending, is just can't keep up. So the GPs thought about, well, maybe we should just not just give a quick pill to somebody who potentially may not do anything really. What about if we are going to refer to others, this person, this patient to others in order to improve the health and wellbeing. And so social prescribing, for example, is about, well, you know, you are diabetic, you have to take this medication, but I'm also going to prescribe you that you walk every day and possibly in the woods.

Jacqui Fahey (40:12): Right.

Manuela Boyle (40:12): Or, you know, by the beach, or I'm also going to prescribe that you are, you know, I don't know that you go to bed, I don't know, a certain time at night, and that you try to, you know, have a restful sleep. So some changes in lifestyle, something that we do it you know, on that clinical practice on a, you know, every day, I suppose. But this is now sort of coming into the understanding more and more of GPs and practice nurses and people in, you know medical centres where again, the five to 10 minutes consultation is now not only ceased prescription of medication, but also prescription of lifestyle changes on a more specific way. And sometimes okay, there are also referral to non-clinical services, for example, to well, I'm not saying naturopath yet, but to say, I don't know, exercise physiologist versus physio versus, I don't know, massage therapies versus a, like health student are becoming more present within primary care, quick primary care centres.

Jacqui Fahey (41:26): Oh, okay. Yeah. So with social prescribing, say from the complementary medicine perspective, that's the lifestyle interventions isn't it? which, which we've been doing for as part of our, our training. It is in practice.

Manuela Boyle (41:38): It is, That's right. It is also, but also remember, it also aims to support individuals to take greater controls of their own health. And so in that it attaches to health literacy. And I hope in that five to ten minutes of a clinical encounter between a GP and a patient, if the GP prescribes that this patient will please walk, I don't know, half an hour every day outside in you know, in the outdoors, that the reason for that is also conveyed as well. They will be just making social prescribe a lot more health literate.

Jacqui Fahey (42:19): Yes. And where to next for you Manuela with your journey with health literacy? What's the future holding for you?

Manuela Boyle (42:27):  I really hope that I will, my PhD will be a swift.

Jacqui Fahey (42:34): Yes.

Manuela Boyle (42:26): The focus is on actually on adult cancer survivors, people who have gone through their cancer treatments, I suppose, the active treatments and what, the how advocacy will impact the health behaviour and health communication in our own self management. So I'm really very interested in can wait to do this and to be able to take it to, to do an end. And for other, well, we'll see, I'm waiting for two publications to come up, but, you know, all takes time. So I'm still quite busy in practice that I will need to scale it down once we get into the brunt of the PhD.

Jacqui Fahey (43:26): Yeah. Well, Manuela thank you so much for sharing such helpful insights for, about practitioners and also members of the public listening today. Thank you so much.

Manuela Boyle (43:36): My pleasure. Thank you so much for having me. It was great.

Jacqui Fahey (43:39): Thanks for tuning into this episode today. We appreciate your support. And feel free to leave us a review. We'd love to hear from you. Thank you.