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
- 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
- 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
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
- 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
Thompson C. Health illiteracy interferes with care. Am J
Health-Syst Pharm 2001;58:1294-5
Information on AMA's Health Literacy Introductory
Health literacy introductory kit (contains videotape of patient
vignettes). $25 for AMA nonmembers. Contact Joanne G. Schwartzberg
at 312 464 5355.