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To promote understanding, assume every patient has a health literacy problem

From the October 31, 2001 issue

PROBLEM: Many people have trouble functioning well as patients, even health professionals. Whether limited by knowledge, socioeconomic factors, emotional or clinical state, or cultural background, their level of health literacy - the ability to read, understand, and act on healthcare information - is often dangerously low. A popular television show, ER, portrayed this problem last week when a Spanish-speaking woman misunderstood the directions for taking INH (isoniazid). The prescription label stated to take the medication "once" daily. But in Spanish, "once" means "eleven." In the show, the patient died from taking such an excessive dose (see our March 26, 1997 issue, for a similar, real-life problem when using "once" on prescription directions for a Spanish-speaking patient). Other examples of patients who've had difficulty reading and understanding medication directions are plentiful. The elderly patient who couldn't tell if he'd picked up his bottle of COUMADIN (warfarin) or CELEBREX (celecoxib). Young mothers who, after reading the acetaminophen label, couldn't accurately state their child's dose. Teenagers who've misunderstood directions for contraceptive jelly and have eaten it on toast every morning to prevent pregnancy. But lest you believe that poor health literacy is an isolated problem with the elderly, disabled, uneducated, or certain socioeconomic classes, here's some startling facts from AMA's Health Literacy Introductory Kit, which includes a videotape (see our web site for information and references):

  • More than 40% of patients with chronic illnesses are functionally illiterate.
  • Almost a quarter of all adult Americans read at or below a 5th grade level while medical information leaflets are typically written at a 10th grade reading level or above.
  • An estimated three out of four patients throw out the medication leaflet stapled to the prescription bag without reading it.
  • Only half of all patients take their medications as directed.
  • Low health literacy skills have increased our annual healthcare expenditures by $73 billion.

Furthermore, people who have difficulty reading or understanding health information are ashamed and often hide the problem. In addition, low literacy isn't obvious. Researchers have reported poor reading skills in some of the most poised and articulate patients.

SAFE PRACTICE RECOMMENDATIONS: Patient education requires a new approach - assume that everyone has a literacy problem. After all, people at all literacy levels prefer simple, straightforward instructions and written materials. Here are some things to keep in mind:

  • Offer small amounts of information at a time. First tell patients what they truly need to know to follow directions. Emphasize desired behavior, not the medical facts. Leave background information for later encounters.
  • Provide written materials at a 5th grade reading level or lower. Use clear captions, ample white space, and pictures, diagrams, or videotapes to help explain concepts. Most people, even those who read well, depend on visual clues to reinforce learning and spark memory.
  • Involve patients. Use focus groups of patients to help write personally relevant and culturally sensitive education materials. After they understand the information ask patients how you should explain it to others. Use a different focus group of patients to review the final materials and highlight any word or concept they do not fully understand.
  • Verify that the patient understands. Avoid asking yes/no questions and instead ask patients to show and tell you how they would take their medicine so that you can spot problems.
  • Keep your eye on evolving technology. For example, talking prescription labels (Talking Rx from Millenium Compliance or Envision's ScripTalk), recording devices for prescription instructions (Asko Corporation's Aloud), and electronic pill organizers and reminders (Epill) are now being tested or are already on the market.


AMA: Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs. Health literacy: report of the Council on Scientific Affairs. JAMA. 1999;281: 552-557.

Anon. Look for new ways to simplify forms. Healthcare Risk Management. 2001;23: 28.

Anon. Simplify, no matter how much it hurts. Healthcare Risk Management. 2001;23:29.

Thompson C. Health illiteracy interferes with care. Am J Health-Syst Pharm 2001;58:1294-5

Web sites:

Asko Corporation:
Center for Health Care Strategies:
Envision America:
Millenium Compliance Corporation
National Council on Patient Information and Education:

Information on AMA's Health Literacy Introductory Kit

Health literacy introductory kit (contains videotape of patient vignettes). $25 for AMA nonmembers. Contact Joanne G. Schwartzberg at 312 464 5355.

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