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Health literacy: A barrier

to pharmacist–patient
communication and medication
Lucy Nkukuma Ngoh

Received July 12, 2007, and in revised form

Abstract March 13, 2009. Accepted for publication
July 13, 2009.
Objectives: To present a summary of the existing literature on medication non- Lucy Nkukuma Ngoh, PhD, is Associate Pro-
adherence, health literacy, and use of written patient information in health care and fessor of Pharmacy Administration, College
of Pharmacy, Ferris State University, Big
pharmacy in particular. Rapids, MI.
Data sources: Searches of Medline, PubMed, and International Pharmaceuti-
cal Abstracts databases were conducted using one or more of the following terms: Correspondence: Lucy Ngoh, PhD, College
of Pharmacy, Ferris State University, 220
adherence/nonadherence, compliance/noncompliance, printed/written information, Ferris Dr., Big Rapids, MI 49307. Fax: 231-
literacy, patient education, communication, and health literacy. These terms were 591-3829. E-mail:
combined with the following search terms: drug information, readability, medication/ Continuing pharmacy education (CPE)
drug, patient, pharmacy/pharmacist, and prescription. References of pertinent ar- credits: See learning objectives below and
ticles were hand searched to retrieve additional articles. assessment questions at the end of this ar-
ticle, which is ACPE universal activity num-
Data extraction: By the author. ber 202-000-09-219-H04-P in APhA’s educa-
Data synthesis: Articles were grouped and summarized into three broad cat- tional offerings. To take the CPE test for this
article online, go to
egories (nonadherence, health literacy, and communicating health information to education, and follow the links to the APhA
patients), with an emphasis on the use of written patient information in health care CPE Center.
and pharmacy practice in particular. The complexities inherent in nonadherence
Disclosure: The author and APhA’s editorial
behavior, health literacy, and patient education are summarized, and suggestions staff declare no conflicts of interest or finan-
for enhancing medication adherence, especially for patients with low health literacy cial interests in any product or service men-
tioned in this article, including grants, em-
skills, are provided. ployment, gifts, stock holdings, or honoraria.
Conclusion: The health literacy skills of American adults have not changed
considerably during the previous decade. This makes use of written patient medica-
tion information in pharmacy practice problematic for some patients. Limited health
literacy has been associated with poorer health, medication nonadherence, medica-
tion errors, higher medical expenses, and increased hospitalization. A need exists
for identifying patients with limited health literacy and tailoring medication counsel-
ing to their needs.
Keywords: Health literacy, medication adherence, pharmacist–patient commu-
J Am Pharm Assoc. 2009;49:e132–e149.
doi: 10.1331/JAPhA.2009.07075

Learning objectives
■■ Describe the rate of adherence to prescribed medication regimens.
■■ List the consequences of medication nonadherence.
■■ Define health literacy and its prevalence.
■■ Describe ways to assess patients’ health literacy status.
■■ Describe strategies for improving communication with patients, especially those with limited health literacy skills.
■■ Evaluate the readability of written patient information materials by hand.
■■ List at least six recommendations for using pictorial aids in health communication.
ACPE Activity Type: Knowledge-Based

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atients’ nonadherence with medical and medication being less knowledgeable about their diseases,1,11,12,18–20 more
recommendations is a major public health problem.1–9 likely to have poorer health outcomes,2,13,15,21–23 and more likely
Nonadherence is encountered in varying degrees in all to be hospitalized.24–26
areas of U.S. health care, involving an estimated 38% of pa-
tients on short-term treatment, 43% of patients on long-term Objectives
treatment, and 75% of patients advised to make lifestyle The goal of this article is to present a summary of the ex-
changes.10 Health, behavioral, and social scientists have accu- isting literature on health literacy and its effect on medica-
mulated substantial literature on the prevalence of poor adher- tion nonadherence and pharmacist–patient communications
ence, its determinants, and interventions during the previous 4 and the use of written patient information in health care and
decades.1,11 Social, economic, medical, and behavioral factors pharmacy.
have all been shown to affect adherence.12,13 Although other
variables such as pharmacologic and psychosocial factors con- Search strategy
tribute to nonadherence,14 problems with patient adherence Potentially relevant articles were identified by search-
and medical errors may also be based on poor understanding ing the Medline, PubMed, and International Pharmaceutical
of health information.2,15 For many patients, lack of health lit- Abstracts databases using the following terms: adherence/
eracy skills is a major obstacle to effective health communica- nonadherence, compliance/noncompliance, printed/written
tion.2,16 information, literacy, patient education, communication, and
Reviews of more than 300 studies have shown that health health literacy. These terms were combined with the following
information cannot be understood by many patients.17 This search terms: drug information, readability, medication/drug,
communication mismatch has been associated with patients patient, pharmacy/pharmacist, and prescription. References
of pertinent articles were hand searched to retrieve additional
articles. The selection was limited to English-language articles
At a Glance published from 1990 through 2006.
Synopsis: The current work summarizes the com-
plexities of health literacy, medication nonadherence, Medication adherence
and patient education and provides suggestions for Compliance was defined more than 2 decades ago as “the
promoting medication adherence, particularly among extent to which a person’s behavior (in terms of taking medi-
patients with low health literacy skills. Pharmacists cations, following diets or executing other life-style changes)
play a key role in recognizing patients with low health coincides with medical or health advice.”3 This term was later
literacy skills and providing strategies to enhance un- criticized for implying paternalism. The terms adherence and
derstanding and adherence in this population. For concordance have replaced compliance. Adherence is favored
medication information to be understood and adher- because of its connotation that the patient–provider relation-
ence to be promoted, pharmacists should speak clearly ship is based on respect and collaboration.27 It also includes
and slowly, use appropriate vocabulary, avoid medi- the patient in the determination and success of therapy more
cal jargon, explain the specific steps of the regimen, accurately than the term compliance.1 The World Health Or-
review the most important details, and encourage pa- ganization has adopted the following definition of adherence:
tients to ask questions. Simplified written instructions “The extent to which a person’s behavior, taking medication,
and/or visual aids should also be used to enhance pa- following a diet, and/or executing lifestyle changes, corre-
tient recall. sponds with agreed recommendations from a health care pro-
Analysis: Although no single intervention strat- vider.”28 In the literature, the terms adherence and compliance
egy can improve the medication adherence of all pa- have been used interchangeably29; adherence will be used in
tients, considerable research suggests that success- this article.
ful attempts to improve adherence depend on certain
Costs of nonadherence
key factors, including realistic assessment of patient
Underuse of medications caused by problems with adher-
knowledge and understanding of the regimen, clear and
ence or persistence (i.e., the length of time patients continue
effective communication between health professionals
to take medications as directed) exacts a tremendous toll on
and patients, and the nurturance of trust in the thera-
patients’ health and the nation’s economy. Approximately
peutic relationship. Pharmacist interventions can help
125,000 deaths annually are attributed to nonadherence, and
reduce the burden associated with the adverse effects
up to 11% of hospital admissions and 40% of nursing home
of limited health literacy on medication-related issues
admissions can be attributed to lack of adherence with medica-
that affect patient knowledge, self-care for chronic dis-
tion therapy.12 Medication-related problems, some of which are
eases, health status, and risk of hospitalization. This
caused by nonadherence, costs U.S. society an estimated $177
can lead to better appreciation of pharmacist interven-
billion annually in total direct and indirect health care costs.30
tions by patients, prescribers, third-party payers, and
Medication nonadherence is also costly for pharmacies and the
society at large.
pharmaceutical industry. Some 140 million prescriptions, val-

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ued at $2.8 billion, go unfilled annually.12 Furthermore, medi- Other investigators have estimated medication adherence
cation nonadherence is involved in an estimated 30 to 50% of by determining the number of tablets or capsules missed (or
cases in which medications do not produce their therapeutic taken at inappropriate time intervals) or the number of days
goals, thereby reducing treatment benefits and confounding without therapy and reported the average number of tablets or
clinicians’ assessments.31 capsules missed, average number of days without medication,
or average deviation from the prescribed consumption time.34
Measurement of adherence Research suggests that only about 50% of patients typically
No generally accepted gold standard exists for measuring take their medications as prescribed,11 only 50 to 60% of pa-
adherence behavior.32 Several strategies have been used29,33–35; tients are adherent to prescribed medications over a 1-year pe-
they are categorized as direct or indirect. riod,9 and adherence rates are typically higher among patients
Direct methods include observation of medication intake with acute conditions33 compared with long-term medication
and biological assays of a drug, its metabolite(s), or a tracer regimens, for which adherence ranges from 17 to 80%.35
substance in blood or urine.33,34 Observation verifies adher- A 2006 survey commissioned by the National Community
ence, yet necessitates direct patient–clinician encounters and Pharmacists Association reported that nearly three of every
does not elucidate medication intake dynamics.32 Biological as- four American patients do not always take their prescription
says are intrusive,34 expensive, burdensome to the health pro- medication as directed.41 Nonadherence occurs among pa-
vider, and susceptible to distortion by the patient.33,34 Assays tients of all ages, social classes, and ethnic groups and amidst
are most useful for medications whose serum concentrations patients participating in various forms of health care delivery.42
are monitored, such as the antiepileptic agents phenytoin and Medication nonadherence in the home setting often involves
valproic acid. using more or less than the prescribed dosage (36%), com-
Indirect methods include patient questionnaires, self- pletely omitting one or more prescribed medications (28%),
report, pill counts, rates of prescription refills, collateral re- taking an extra dose (12%), using an unauthorized medication
ports from family members or clinicians, assessment of the (8%), or taking medication at the wrong time (7%).43
patient’s clinical response, electronic medication monitors,
measurement of physiologic marker, and patient diaries.31,33,36 Factors contributing to nonadherence
Questionnaires (or questioning the patient), patient diaries, Adherence is a multidimensional phenomenon,44 and as
and assessment of clinical response are relatively easy meth- interest surrounding adherence behavior has developed, a
ods but can be susceptible to misrepresentation. Self-report number of theoretical models have been forwarded to account
and collateral reports are uncomplicated, inexpensive, and for the various factors that influence adherence behavior.45,46
feasible in clinical settings but are prone to recall and social Among these models are social behavioral theories including
desirability response bias. Collateral reporting depends on the the Health Belief Model,47 the Common Sense Model,48 and the
family member or clinician’s familiarity with the patient.37,38 Self-Efficacy Theory.49
Pill counts (i.e., pills dispensed, remaining, and prescribed), The Medication Adherence Model provides an elaborate
although easy to perform, are invalidated when patients hoard analysis of how three key constructs influence medication-
or discard drugs.37,38 Furthermore, patients may not accurately taking behavior50: (1) the patient’s representation of his or
recall the date that they started taking the medication. her illness (e.g., perceived severity), (2) the patient’s cogni-
Electronic monitors provide precise and detailed informa- tive function (e.g., comprehension, long-term memory), and
tion on patients’ behavior in taking medications, but they do not (3) external cues or strategies used by the patient to enhance
provide information as to whether the patient actually ingested medication-taking behavior (e.g., social support, reminder de-
the correct drug or correct dose. Also, the cost of electronic vices). The patient’s cognitive function construct may be criti-
monitoring limits the feasibility of the devices. They provide cal for proper medication use and in the pharmacist–patient
the most accurate and valuable data on adherence in difficult interaction. This is because the patient’s ability to adhere to
clinical situations. Prescription refill rates provide an accurate the prescribed treatment regimen may be compromised if he or
measure of overall adherence in a closed pharmacy system she cannot obtain and understand basic information about how
such as the Department of Veterans Affairs Health Care Sys- to take the prescribed medication.51–53
tem but are problematic when patients use a number of non-
networked pharmacies32,37,39; they are not useful for medica- Health literacy
tions that do not require subsequent refills. Also, although refill Healthy People 2010 defines health literacy as “the degree
rates provide a proxy measure, patients’ true medication-tak- to which individuals have the capacity to obtain, process, and
ing behavior may remain unknown. In summary, although using understand basic health information and services needed to
one method in a particular situation might be advantageous, a make appropriate health decisions.”54 Thus, health literacy re-
combination of methods tends to maximize accuracy.40 lates to both the cognitive and functional skills used to make
Medication adherence rates health-related decisions.55 This definition also implies that lit-
Medication adherence rates have been reported by some eracy goes beyond the ability to read a sentence to the abil-
researchers as the percentage of the prescribed doses of medi- ity to comprehend the written word. Health literacy includes
cation actually taken by the patient during a specified period.33 numeracy skills such as calculating blood glucose levels and

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measuring medications. Furthermore, it requires knowledge of children). Individuals with basic health literacy would have
health topics in addition to basic literacy skills. trouble providing two reasons why someone with certain symp-
Literacy, the foundation of health literacy,17 has been de- toms might have a specified test, even when using information
fined as “an individual’s ability to read, write, and speak Eng- from a clearly written, accurate pamphlet. Those with below
lish and compute and solve problems at levels of proficiency basic health literacy would not be able to recognize a medical
necessary to function on the job and in society, to achieve one’s appointment on a hospital appointment form or be able to de-
goals, and to develop one’s knowledge and potential.”56 Illiter- termine how often a person might have a specified medical test
acy means being unable to read or write. An individual who has from a clearly written pamphlet containing basic information.
limited or low literacy skills is not illiterate.57 Patients with basic or below basic health literacy frequently
A person’s health literacy skills may be worse than his or cannot read written information given to them by health profes-
her general literacy skills. A report from the Institute of Medi- sionals.
cine (IOM) states that, generally, individuals with limited lit-
eracy skills also have limited health literacy—an inability to Risk factors for low health literacy
“obtain, process, and understand basic health information Poor health literacy is a problem that affects individuals
and services needed to make appropriate health decisions.”17 from all segments of society regardless of their age, gender,
Limited literacy skills are associated with lack of understand- race/ethnicity, income, or social class.62 Individuals at highest
ing of written or oral health communication.58 According to the risk are the economically disadvantaged, elderly, or chroni-
American Medical Association, poor health literacy skills are cally ill.63 Certain ethnic or racial groups also have high rates of
a stronger predictor of an individual’s health status than age, low health literacy, with 66% of Hispanics and 58% of blacks
income, employment status, education level, or racial/ethnic having basic or below basic literacy skills in the NAAL study.60
group.59 However, the most common demographic profile of an individ-
ual with low health literacy is white race and born in the United
Prevalence of low health literacy States.64 Groups with especially high prevalence of low literacy
Data from the U.S. Department of Education 2003 Nation- are listed in Table 1.
al Assessment of Adult Literacy (NAAL) study60 indicate that
a large segment of the population lacks sufficient general lit- Effectively communicating health
eracy to effectively undertake and execute medical recommen- information
dations. Nearly 90 million adult Americans (36% of the adult Most of the health education information that is provided to
population) are limited in their ability to read and understand patients, both oral instructions and written information, is pre-
health information, including medication labels.17 Individuals sented in a format that is too complex for the average person to
with limited health literacy cannot circle the date of a medi- understand.2,58,65–67 This communication mismatch is one of the
cal appointment on a hospital appointment slip or identify how causes of nonadherence.2,10,68,69 Approximately one-third of all
often a person should have a specified medical test, based on patients and two-thirds of physicians know someone who has
information in a clearly written pamphlet.5 Almost one-third of had health problems because they did not understand how to
adults older than 65 years have very poor health literacy skills. take a prescription medication correctly.70 Inadequate under-
Adults who receive Medicare or Medicaid and those with no in- standing or misunderstanding of medication instructions and
surance have lower-than-average health literacy.5 More than information includes not understanding how to properly admin-
one-third of English-speaking patients and more than one-half ister the medication and not comprehending the importance of
of primarily Spanish-speaking patients at U.S. public hospitals medication therapy.2,13,71 Patients may believe, for example,
have low health literacy.61 that medications such as antidepressants and corticosteroids
NAAL data indicate that only 12% of U.S. adults have pro- are not working and stop taking them before the intended ef-
ficient health literacy skills. Individuals with proficient health fects of the medications can be produced.29
literacy skills can deal with complex and challenging health Effective communication every time medications are dis-
literacy tasks (e.g., calculating an employee’s share of health pensed can make a critical difference.72–74 Although the effect
insurance costs for a year using a table showing how the em- of pharmacist–patient communication is unstudied within the
ployee’s monthly cost varies depending on income and family context of health literacy, research on physician–patient com-
size, finding information required to define a medical term by munication shows that physicians commonly overestimate
searching through a complex document and evaluating infor- patients’ literacy levels and rarely consider limited literacy
mation to determine which legal document is applicable to a skills in their assessment of whether patients understand what
specific health situation). action is needed.69 Individuals with low literacy skills are dis-
Of the other patients, 52, 22, and 14% have intermedi- advantaged in their ability to obtain, process, and understand
ate, basic, or below basic health literacy skills, respectively.60 both written and verbal information.65 This makes communi-
Those with intermediate skills can deal with most health liter- cation about taking medications a critical factor in the phar-
acy tasks that they encounter (e.g., using an over-the-counter macist–patient interaction. Improved communication between
drug label to identify substances that may cause an adverse pharmacists and patients has the potential to enhance patients’
drug interaction, using a childhood immunization chart to find understanding of the prescribed medication regimen and what
the proper age range when certain vaccines may be given to
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to expect from medication therapy and hence avoid medication the regimen, review the most important details, and encourage
nonadherence related to these issues. their patients to ask questions.43,57,65 Also, pharmacists need to
consider and convey how the recommendation fits practically
Oral communication into their patients’ lifestyles and how the information can bene-
Patients with low health literacy skills rely heavily on fit patients.57 The Partnership for Clear Health Communication
oral communication and need help in remembering what they has excellent recommendations for patient involvement that
hear.75–77 They prefer to receive oral rather than written health centers on three questions that health care providers should
information.78 Unfortunately, in many cases, this is not what encourage patients to ask about their health care visits:
they get from their pharmacists. In a study of more than 300 (1) What is my main problem?
pharmacies in eight states, most shoppers (89%) received (2) What do I need to do?
written information, 25% of them never talked with a pharma- (3) Why is it important for me to do this?
cist, and 63% received oral information regarding new pre- A complete discussion of this topic and downloadable re-
scriptions. Further, the majority of shoppers received no oral sources can be obtained at
advice or reinforcement about how long to take medications,
how to manage adverse effects or precautions, or when the Written communication
medications would begin to work. Although most shoppers in Written instructions on the use of medications are among
this study received written information, only 5% were provided the most important materials that patients receive.87 The im-
with any review of the patient information leaflets.79 portance of written instructions in patient education is re-
Communication problems are not automatically resolved flected by one of the goals of Healthy People 2010 (i.e., 95%
by patients’ desire for oral communication and health provid- of patients getting new prescriptions should also receive
ers’ attempts to meet this need. A substantial gap exists be- useful written medication instructions about the dispensed
tween the words and language used among health profession- medicine).54 The benefits of written medication information
als and those of their patients.76,80–82 Many people, including have been well documented.88–93 Health organizations and
those who are highly literate, have trouble understanding com- professionals use written patient information materials as
monly used health terms,83 including medical words, concept part of patient education or health promotion efforts, in sup-
words, category words, and value judgment words.83,84 These port of preventive, treatment, and adherence objectives.94
“words to watch” can be made understandable by explaining When used as an adjunct to verbal counseling, written infor-
them with common words, using examples, or using visual mation can reinforce specific instructions or warnings. It can
aids.83,84 Appendix 1 (electronic version of this article, avail- also provide a means for introducing supplemental informa-
able online at gives some examples of plain- tion that may be difficult to convey during a brief counseling
language alternatives to these “words to watch.” session.95 Pharmacy-distributed patient education materials
Patients, particularly those with limited health literacy include details concerning adverse effects, medication inter-
skills, are more interested in information that improves their actions, purpose of the medication, what to do in the event of
sense of well-being and helps them deal with immediate health adverse effects, expected duration of therapy, and what to do
problems.57 This information can sometimes be difficult for if a dose is missed.88
health professionals to provide, especially when dealing with Despite the widespread availability and benefits of writ-
patients who have limited literacy and/or health literacy skills. ten materials, many such resources are of little value to pa-
The literature on physician–patient communication indicates tients with limited literacy and/or health literacy skills.2,18,96
that although patients with limited literacy may want and need Simply giving patients written information does not ensure
information clarified, they tend to ask fewer questions69,78 and that patients understand the information. Literacy studies
may hide their limited understanding out of shame and embar-
rassment.69,85 Patients want information about the indication of Table 1. Groups and characteristics often associated with
medications, expected benefits, duration of therapy, and poten- high prevalence of low literacy
tial adverse effects, in addition to information identifying the Elderly
drug’s name, directions for use, and warnings.86
Female gender
Given that patients at all health literacy levels have prob-
Not completing high school
lems understanding medical information,62 the relative paucity
of vocabulary and restricted knowledge base among people Immigrants
with low health literacy skills put them at an even greater risk Incarceration
for difficulties in understanding and integrating oral commu- Income status classified as poor or near poor
nication. Thus, when pharmacists provide oral counseling, Living in the south or northeast (rather than west and midwest)
patients with low literacy and/or low health literacy skills may Lower socioeconomic status
still not understand the information presented to them. For Member of minority group
information to be understood and adherence to be promoted, Lower cognitive ability
pharmacists should speak clearly and slowly, use appropriate Chronic disease
vocabulary, avoid medical jargon, explain the specific steps of Source: References 55, 87, 100, 130, 137, 138, 146.

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show a gap of more than 5 years between most patients’ read- Cognitive capacity
ing capacities and the reading levels required to understand Cognition is the portion of a person’s comprehension,
written educational materials.97 Also, although the average memory, and recall used to perform tasks that require some
adult American reads at an 8th grade level,2 the average knowledge, skills, or ability.46 The implication therefore is that
health education information material is written at the 12th patients must understand what they are supposed to do before
grade level.62 In a study that examined the distribution and they can follow medical recommendations.
quality of patient medication leaflets provided in U.S. pharma- A study designed to determine the prevalence of low func-
cies, patients rated 36% of the leaflets as difficult to read.98 tional health literacy among Medicare managed care enrollees
Another study examining the readability of commonly used found that 47.5% of adults with inadequate literacy skills incor-
pharmacy patient education materials found that only 2% had rectly described the timing of medication doses after reading
readability scores at or below the 8th grade level; 69% scored the label on a prescription vial compared with 24.4% of those
in the 9th to 12th grade range, and 29% scored above the with marginal and 11.5% of those with adequate literacy skills.
12th grade level.88 Also, 54.3% of respondents with inadequate literacy skills
To provide optimal medication information to patients, could not describe how to take medication on an empty stom-
written materials must be written at an appropriate reading ach compared with 33.7 and 15.6% of those with marginal and
skill or grade level for the intended audience.95 A text’s read- adequate literacy skills, respectively.110
ability (i.e., the ease at which it can be read and understood), In a recent multisite study that investigated the success
is one of the factors that affects its appeal.96,99 Findings from with which patients understand instructions on medication
one study indicated that, compared with prescription warning labels, 46.3% misunderstood one or more of the prescription
labels with text written at the 3rd grade level or below, labels label instructions. The prevalence of incorrect answers among
with text written at the 6th to 7th grade level are 4.3 times patients reading at the 9th grade level or above (adequate lit-
more likely to be misinterpreted and those with text at the 8th eracy), those reading at the 7th to 8th grade level (marginal
grade level are 12.9 times more likely to be misinterpreted.100 literacy), and those reading at or below the 6th grade level (low
The National Work Group on Literacy and Health recom- literacy) was 37.7, 51.3, and 62.7%, respectively. More than
mends that health materials be written at a 5th grade read- one-third of patients with adequate literacy skills (38%) mis-
ability level but recognizes that this level is still too difficult understood at least one of the label instructions. Patients with
for about 25% of the population.101 Ideally, health education low literacy were less able to understand the meaning of all five
materials should be written at the 3rd to 4th grade level.102 medication labels than those with adequate literacy. For exam-
ple, for the instruction, “Take two tablets by mouth twice daily,”
Medication knowledge most patients (71%) with low literacy could read the instruc-
Patients’ ability to participate in their care and deci- tion correctly. However, only 35% accurately demonstrated the
sion making depends largely on their knowledge and literacy correct number of tablets to be taken daily. The majority of the
skills,103 and several authors have reported that patients’ misunderstood label instructions were related to dosing such
knowledge of medications is positively associated with adher- as teaspoonful versus a tablespoonful or to frequency or du-
ence.104–108 ration of use. The frequency of mistakes was higher when the
One study involving 2,659 patients with limited literacy medication instructions included multiple varying numbers,
skills examined patients’ ability to process numbers (numer- such as, “Take one tablet by mouth twice daily for 7 days.” Tak-
acy) and other concepts related to medication use. Overall, ing a greater number of prescription medications was also as-
42% of patients gave incorrect answers for “how to take a sociated with misunderstanding label instructions.111
medication on an empty stomach,” 33% for “how many pills In a portion of the above study,111 patients were assessed
of a prescription should be taken,” 23% for “how many times based on whether they could accurately read and state the in-
a prescription can be refilled,” and 13% could not understand structions for guaifenesin (“Take two tablets by mouth twice
directions to take medication four times a day.109 daily”) and correctly demonstrate how many tablets were to be
A gap between what patients ought to know to use dis- taken daily. Patients at all literacy levels were better able to
pensed medications appropriately and what they actually read label instructions than to demonstrate the correct num-
know was also found in a study that evaluated the effects of ber of tablets to be taken. The investigators suggested that
low literacy, medication regimen complexity, and sociodemo- verifying whether patients or their surrogates can accurately
graphic characteristics on medication management capac- describe and demonstrate how to take prescribed medications
ity among 152 mostly elderly participants (mean age 65.4 safely needs to occur during medication review. Most patients
years). In the study, 38% of the patients were unable to iden- with literacy problems were unable to follow the prescription
tify all of their medications, despite being able to look at the medication directions, “Take 1 tablet X times a day,” with the
bottle, label, or tablets.9 More than one-half (57%) of those X being a number.112 With this instruction, patients took the
with inadequate literacy skills were unable to identify all of prescribed medication at inappropriate times or intervals or in
their medications compared with 25% of those with marginal the wrong quantities. When the direction is written as “Take 1
literacy and 7% of those with adequate (reading level of 9th tablet every X hours,” patients are more likely to understand
grade or higher) literacy skills. the directions and follow them correctly. Other recommenda-

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of 1990, which made patient-centered practice mandatory for

Table 2. Steps to enhance understanding among patients Medicaid beneficiaries through collection of patient informa-
with low health literacy tion, prospective drug use review, and patient counseling.122
Slow down and take time to assess patients’ health literacy skills. According to a 2004 telephone survey that examined the
Use “living room” language instead of medical terminology. receipt of medication information at pharmacies, only 31%
Show or draw pictures to enhance understanding and subsequent of patients reported receiving instructions from their phar-
recall. macists about how to take a new medication and only 29%
Limit information given at each interaction and repeat instructions. were told how much to take.123 Although no single intervention
Use a “teach back” or “show me” approach to confirm under- strategy can improve the medication adherence of all patients,
standing. This approach involves having clinicians take respon- decades of research studies suggest that successful attempts
sibility for adequate teaching by asking patients to demonstrate to improve patient adherence depend on certain key factors,
what they have been told (i.e., teach back to you how to take their including realistic assessment of patients’ knowledge and un-
medications) to ensure that education has been adequate. derstanding of the regimen, clear and effective communication
between health professionals and their patients, and the nur-
Use of assistance devices such as pillboxes.
turance of trust in the therapeutic relationship.124
Avoid asking, “Do you understand?”
Be respectful, caring, and sensitive, thereby empowering patients Patient education
to participate in their own health care. Patient education is “the process of influencing patient
Tailor information to the individual by giving examples and explain- behavior and producing the changes in knowledge, attitudes
ing relevance. and skills necessary to maintain or improve health.”125 Lack of
Ensure understanding through open-ended questioning and dem- patient education can be an important predisposing factor in
onstration techniques. nonadherence to prescription medication instructions because
Source: References 58, 66, 78, 133. understanding and recall of medication instructions depend on
getting accurate information in the first place.126 Lack of pa-
tient education is a concern for all patients but especially for
tions for educating patients with low literacy skills include us- patients with low health literacy skill.
ing simple language, having patients repeat back instructions A study of 483 asthma patients found an association be-
to confirm understanding, and using assistance devices such tween reading ability and asthma knowledge. Among patients
as pillboxes, graphic medication schedules, pictographs, and reading below the 3rd grade level, 89% had poor metered-dose
other multimedia aids.113 Table 2 provides more information on inhaler technique compared with 48% of patients reading at
enhancing understanding and recall of medication instructions. the high school level.20 In another study of 227 human immu-
Adherence is a multidimensional phenomenon44 caused by nodeficiency virus–seropositive adults, patients with limited
varied and complex factors, including the patient’s knowledge health literacy skills were less adherent to antiretroviral ther-
and confidence in their ability to follow recommended behav- apy, and this effect persisted after controlling for other vari-
iors.114 Patients want practical, concise information focused on ables.127 In the study, patients with limited health literacy skills
action and motivation.78 Patients who are informed and effec- often cited confusion with prescribed regimen as a reason for
tively motivated are also more likely to adhere to their treat- nonadherence. Patients with low literacy skills were also re-
ment recommendations.115,116 Studies have found that both ported in a study that examined patients’ understanding and
patient satisfaction and patient adherence are enhanced by use of oral contraceptive pills to be less likely to understand
patients’ involvement and participation in their care.117,118 how to correctly use birth control methods.128

Challenges with low health literacy

Implications for pharmacy practice Clinicians encounter patients with limited health literacy
Substantial evidence indicates that inadequate health on a daily basis.87 Patients with limited literacy and/or health
literacy adversely affects adherence behavior, patients’ literacy skills are more likely to have difficulties understanding
knowledge, self-care for chronic diseases, and health care and executing proper medication use.20,111,109,129 A report by the
costs.25,119,120 The IOM report To Err Is Human68 noted that Agency for Healthcare Research and Quality on health literacy
management of complex medication therapies, especially in concluded, “Low reading skills and poor health are clearly re-
elderly patients, is extremely difficult and requires special at- lated.”130 In addition, evidence indicates that communication
tention to the ability of the patient to understand and remem- barriers such as limited English proficiency and limited health
ber the amount and timing of a dose, as well as behavioral literacy are associated with lower quality of care and place pa-
modifications required by the regimen. Some patients with tients at risk for poor clinical outcomes.21,131
limited literacy and/or health literacy skills may not be get- All this information gives pharmacists more reasons to
ting this special attention from their pharmacists. Study find- pay particular attention to their interactions with patients who
ings121 show that the quality and amount of counseling about have limited health literacy skills and other communication
medications in community pharmacies are inadequate and do barriers. The philosophy of pharmaceutical care calls for phar-
not meet the intent of the Omnibus Budget Reconciliation Act macists to identify, resolve, and prevent medication-related

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problems.132 Routine identification of patients with limited lit- Identifying low literacy patients. A report from the Ameri-
eracy and/or health literacy skills and development of interven- can Pharmacists Association indicated that pharmacists are
tions to prevent inappropriate use of prescribed medications not paying sufficient attention to the literacy status of their
may increase patient knowledge and self-care skills and, ulti- patients.136 The report highlighted the findings from a survey
mately, adherence and outcome. of community pharmacies71 showing that most pharmacists
were unaware of the limited literacy skills of many of their
Pharmacists’ role in unintentional medication patients. Also, many of the pharmacists thought that they did
nonadherence not have to worry about literacy issues because they did not
Poor medication adherence is not simply a “patient” prob- have low-income patients. These findings are supported by
lem. The pharmacist is also involved. Studies of the reasons other reports.65,87,137,138
for patients not following medical advice have used models Generally, patients with limited literacy skills cannot be
that place primary emphasis on patients and their motivations, identified by their appearance or speech, and most describe
predispositions, or level of “psychological readiness.”35 These themselves as able to read English “well” or “very well.”138 Iden-
models tend to neglect the possibility that nonadherence can tifying patients who may have limited health literacy skills can
be unintentional.133,134 be difficult.65 Asking patients questions such as, “How many
Some patients may be motivated to adhere to the pre- years of school did you complete?” or “Can you read?” does not
scribed regimen but fail to do so because of misunderstanding accurately assess their literacy level.58,87,97,139,140 A survey of
associated with factors such as low health literacy or language Medicare managed care enrollees found that 27% of those who
barriers. Misunderstanding of the regimen and language bar- graduated from high school had inadequate or marginal health
riers are essential elements of unintentional nonadherence.135 literacy, as did 17% of those with some college education.107
Given the extent of the limited literacy and health literacy Also, in a study of preoperative veterans who were predomi-
problem in the United States and the association between nantly white and had at least a high school education, 12% had
limited health literacy and medication nonadherence, poor inadequate or marginal health literacy. Health literacy did not
health, and treatment outcomes, pharmacists have a critical correlate with self-reported years of education.108
role to play. Communicating more effectively with patients In short, patients with limited health literacy do not fit a
about medications is necessary for helping them achieve de- stereotype. Many well-groomed, articulate, intelligent-sound-
sired therapeutic outcomes from medication therapy. Being ing individuals have limited health literacy.138,58,141 Most indi-
aware of the patient’s skills, including literacy and health lit- viduals with limited literacy are often embarrassed and go to
eracy skills, is a necessary first step in this endeavor because great lengths to hide their inability to read or understand medi-
different communication strategies may be needed for en- cal information.57,65,78 One study showed that 40% of patients
hancing the pharmacist–patient interaction and subsequently with low literacy felt shame, 67% had not told their spouse,
improving adherence. However, awareness alone is not suf- 53% had not told their children, and 19% never told anyone.142
ficient. Patients with limited literacy and/or health literacy Red flags. Pharmacists may need other tools and clues or red
skills have to be identified. flags in practice to help identify patients with limited literacy.

Table 3. Signs of and tips for identifying patient health literacy problems
Aloofness or withdrawal during physician/provider explanations
Asking staff for help
Be alert for possible vision and/or hearing problems
Frequent errors in medications or self-care instructions
Unable to name medications
Unable to explain a medication’s purpose
Inability to keep appointments
Making excuses (e.g., “I forgot my glasses”)
Observe if a surrogate reader accompanies patient
Postponing decision making (e.g., “May I take the instructions home?,” “I’ll read through this when I get home”)
Take note if forms are incompletely filled out, possibly only with name provided
Take note of patients who do not know the name of medications they have been taking for a long time
Watch for a chronic pattern of nonadherence
Watch for patients who fail to look at printed material (or they fail to turn it right side up)
Written materials handed to a relative or other person accompanying the patient
Watching others (mimicking behavior)
Patients say they are taking their medication, but laboratory tests or physiological parameters do not change in expected fashion
Source: References 66, 76, 119, 129, 143, 159–161.

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A patient who fills out registration forms or other health ques- others have relied on screening questions. Chew et al.151 found
tionnaires incompletely or incorrectly or takes medications three screening questions to be predictive of limited health
the wrong way may do so because of limited health literacy literacy skills in a sample of men receiving medical care at a
skills.143 Some clues to limited health literacy are listed in Table Veterans Administration clinic: (1) ‘‘How often do you have
3. However, an absence of clues does not necessarily indicate problems learning about your medical condition because of
that a patient has adequate health literacy. Some experts have difficulty understanding written information?’’ (always, often,
advised approaching all patients as if they have limited health sometimes, occasionally, or never), (2) ‘‘How often do you have
literacy and to communicate with them accordingly.144 someone help you read hospital materials?’’ (always, often,
Screening tests. Another approach pharmacists can take is sometimes, occasionally, or never), and (3) ‘‘How confident
to use screening tests in identifying patients with low health are you filling out medical forms by yourself?’’ (extremely, quite
literacy. Instruments for measuring literacy in the health care a bit, somewhat, a little bit, or not at all). These researchers
setting have focused on the ability to read and, in some cases, found the question about hospital materials to be most effec-
use numbers.130 tive at identifying patients with limited health literacy. They
The two frequently used instruments are the Rapid Esti- concluded that limited literacy in health care settings can be
mate of Adult Literacy in Medicine (REALM) and the Test of detected with a single question and that the single question is
Functional Health Literacy in Adults (TOFHLA).17,145,146 REALM more effective than demographic characteristics. These find-
is a 66-item word recognition and pronunciation test that ings have been supported by other researchers.152
measures the domain of vocabulary. The words are arranged
in order of complexity by the number of syllables and pronun- Communicating to enhance medication adherence
ciation difficulty starting with simple one-syllable words such Provider–patient communication is a contributing factor
as “pill” and ending with multisyllable words such as “antibiot- in patient satisfaction, adherence, and health outcomes.153,154
ics.” It can be administered and scored in less than 3 minutes Studies have also shown that people understand and remem-
by personnel with minimal training, making it easy to use in ber what is important to them and have demonstrated signifi-
clinical settings.147 Scores on REALM vary from 0 (no words cant differences between what patients want to know and what
pronounced correctly) to 66 (all words pronounced correctly). health professionals think they should know.155,156 A descriptive
The scores can be grouped into three categories of literacy: in- study of the information that patients with hypertension prefer
adequate (0–44, representing a reading level at or below the to receive about medications to improve adherence reported
6th grade, marginal (45–60, 7th to 8th grade level), and ad- that 90% of patients wanted to know about adverse drug reac-
equate (61–66, 9th grade or above).9 The test provides both an tions, 96% wanted to know about the benefits of the medica-
assessment of general reading skills and an indication of the tion, and 82% wanted more information about their disease.
individual’s health literacy skills. It is available only in English. Other frequent concerns were related to duration of therapy
TOFHLA measures reading fluency and is available and lifestyle effects.157
in both English and Spanish. The standard test includes a Effective communication with patients, especially those
17-item test of numerical ability and a 50-item test of reading with low health literacy skills, has the potential of not only
comprehension and takes about 22 minutes to administer.148 bridging the communication gap between practitioners and
A short version of the test (S-TOFHLA) is also available; it their patients but also improving patients’ understanding of
takes about 7 minutes to administer. Both tests identify indi- the prescribed medication regimen and providing patients with
viduals who are likely to have poor background health knowl- information that they desire and want to know. Patients with
edge and difficulty understanding both written and oral health limited literacy and/or health literacy skills may be empow-
messages.149 Scores on TOFHLA categorize patients as hav- ered when pharmacists communicate using oral and/or writ-
ing low, marginal, or adequate health literacy skills.150 ten means that convey pertinent medication information and
Recently, a new screening test, the Newest Vital Sign ensure that each patient understands the prescribed behavior.
(NVS), was developed.146 It consists of a nutrition label for ice Difficulties may be addressed and potentially resolved before
cream with six questions about the information contained in they lead to nonadherence with prescribed medications. Fur-
the label. The patient’s response to each of the questions is thermore, collaboration with the patient may enhance shared
scored as correct or incorrect. One point is assigned for each decision making, which might lead to better adherence.158
correct answer. Patients who score 4 to 6 are classified as hav-
Oral communication
ing adequate health literacy skills. Those who score 2 to 3 are
Most patients prefer medical advice that is simple and easy
classified as “possibly” having low health literacy, and those
to understand.57,119,159–161 Pharmacists can simplify their advice
with a score of 0 to 1 are classified as “likely” having low health
to patients by providing essential instructions only and using
literacy. NVS takes approximately 3 minutes to complete. It is
nonmedical language.59,83,143 Online Appendix 1 gives some ex-
fairly short, moderately accurate, and appears to identify indi-
amples of plain-language alternatives to medical terms.
viduals with limited reading capacities better than demograph-
Pharmacists can make their instructions interactive by
ics alone.145 NVS is available in both English and Spanish.
having patients do, write, say, or show something to demon-
Although some researchers have used REALM, TOFHLA,
strate their understanding.16 Also, because patients forget
S-TOFHLA, or NVS to identify individuals with limited literacy,
more than one-half of the information from oral explanations

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immediately after they hear it,162 strategies aimed at improv- pictorial aids, however, pictorial aids designers need to take
ing patients’ recall of medical instructions must be used to into account the educational level of the target group and the
assist patients with their prescribed medication regimens. environment, both culturally and ecologically.57,138,168–170 Picto-
Recall can be aided by presenting instructions in a clear and rial aids that are useful in one population might not be used suc-
simple manner, using concrete and specific advice, repeating cessfully in another.168,170 Thus, pharmacists should make sure
and stressing the importance of the critical components of the that patients interpret pictorial aids correctly when using them
advice, checking understanding, and providing feedback.58,78 in their practice. Telling patients the correct meaning of an in-
Other suggestions to enhance adherence include color coding correct pictorial aid has been found to substantially increase
the prescription vials based on the time of day a dose needs to its correct interpretation later.171 Training patients in the use of
be taken29 and using organizers and reminders such as blister pictorial medication information to improve its use as a medica-
packs, calendars, dosage counters, and special containers.85,163 tion administration aid has been suggested.2,170 Recommenda-
Pharmacists have an opportunity to access a patient’s tions on the use of pictorial aids in improving health communi-
cognitive structure during the counseling process to ensure cation are presented in Table 4.
that the prescribed instruction is comprehended and can be
recalled when needed.46 When pharmacists interact with pa- Other resources for enhancing communication
tients at this level, they can successfully engage in patient with patients
education that empowers patients to better adhere to pre- Pharmacists can use several available resources to en-
scribed medication regimens, which might result in better hance their communication with patients, especially those who
therapeutic outcomes. are challenged by health literacy issues. They can, for example,
register and take a free online course, “Unified health commu-
Use of written materials nication 101: Addressing health literacy, cultural competency,
Pharmacists can use a number of formulas to evaluate the and limited English proficiency,” that was developed by the
readability of the most commonly used written patient medica- Health Resources and Services Administration.172 The course
tion information materials in their practice. Most of the formu- is designed to help health professionals improve their patient
las are applicable to narrative language (running text) but not communication skills, increase their awareness and knowledge
to lists, charts, and tables.164 Also, the majority of them estab- of the three main factors that affect their communication with
lish readability based on two factors: (1) the number of difficult patients (health literacy, cultural competency, and low English
words (usually words with three or more syllables) in a sample proficiency), and implement patient-centered communication
and (2) a higher grade level. Pharmacists can test for read- practices that demonstrate cultural competency and appro-
ability by hand or using computer software. The Fry method is priately address patients with limited health literacy and low
an easily used means of checking readability.165 It is relatively English proficiency.172 The Health Sciences Library at the Uni-
simple and yields accurate results.95,164,166 Obtaining results for versity of North Carolina at Chapel Hill maintains a list of health
typical patient leaflets and materials when using the Fry meth- literacy resources, many of which can be useful to pharmacists
od without electronic aids only takes about 15 to 20 minutes. (online Appendix 3).173 The list includes information on low lit-
Several word-processing software programs, including Mi- eracy education materials that are designed by several national
crosoft Word, can be used to test readability of passages. These organizations and are available to the public. Other suggested
computer tests provide a quick analysis of readability along with strategies are presented in Tables 2 and 5.
information such as the number of words per sentence and the
number of sentences per paragraph. However, they may not be
as accurate as manual calculations and should be used only as
a very rough measure of readability155 because the score from
such programs is based on word length (the number of charac- Table 4. Recommendations for using pictures in health
ters between spaces) and sentence length (the number of words communication
between periods). Also, the readability score does not consider
content.143,166 Instructions for calculating readability levels us- Ask how you can use pictures to support key points
ing the Fry method are provided in online Appendix 2.167 Minimize distracting details in pictures
The Gunning-Fog test is another simple readability test. Use simple language in conjunction with pictures
Schrock166 provides directions for these and other readability Closely link pictures to text and/or captions
formulas along with information on Readability PLUS software. Include people from the intended audience in designing pictures
Have health professionals plan the pictures, not artists
Use of pictorial aids
Evaluate pictures’ effects by comparing response to materials with
Patients of all literacy levels can benefit from picture-based
and without pictures
information, but patients with limited literacy skills are espe-
Orienting instructions are important when patients are first intro-
cially likely to benefit.2,77,168,169 Research findings have shown
duced to pictorial aids
that pictorial aids enhance patient recall, comprehension, and
Make sure that patients interpret pictorial aids correctly
adherence to medication regimens, particularly when combined
Source: References 2, 168–171, 173.
with written or oral instructions.2,77,168 To reap the benefits of

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Looking ahead: Pharmacist–patient are especially in need of help. These patients may rely more
interactions on verbal explanations than written medication information
Health care delivery continues to shift from inpatient materials. To enhance medication adherence in this patient
to outpatient settings, and the practice of quality control population, more intensive communication and educational
over medication use is becoming more the responsibility strategies are needed, as well as a collaborative approach
of the patient and less the responsibility of the provider.109 to care.30 Pharmacists’ interactions with these patients
These trends indicate the importance of the pharmacist–pa- could be a critical factor in determining whether they under-
tient interaction in ensuring that patients have the skill and stand the prescribed medication instructions and behaviors.
knowledge needed to perform self-care medication-taking General strategies might not be adequate for meeting their
behaviors. Pharmacists have the essential technical knowl- unique needs. Patients should be given the opportunity to
edge for assisting patients with their medication information assess the potential risks in a proposed treatment and its
needs and medication-taking behavior. Despite this knowl- potential effect on the quality of their lives.10 Pharmacists
edge, rendering the assistance that patients need might be might need additional resources, such as training, time, au-
difficult because of certain operational aspects of pharmacy tomation, and technicians, to make this vital service avail-
practice and the motivation and attitudes of pharmacists. able to patients.
Results from a national survey indicated that pharma- With appropriate administrative support, pharmacists
cists prefer devoting more of their time to consultation and must work with all patients to find viable communication
drug use management activities in community settings.174 strategies to improve patient comprehension of prescribed
The results also showed that pharmacists have not been medication instructions and, hopefully, adherence with
afforded a full opportunity to engage in these activities to medication regimens. A recently published study of a com-
the desired extent.174 Functional barriers such as time con- prehensive pharmacy program composed of patient educa-
straints, lack of resources, and lack of management support tion and custom blister-packed medications was associated
to counsel patients can affect pharmacists’ ability to engage with substantial and sustained improvements in both adher-
in patient education. The involvement and collaboration of ence and therapeutic outcomes.175 In today’s health care en-
pharmacy employers is essential for developing solutions to vironment, medications play a major role in increasing qual-
improve clear communication between pharmacists and all ity and years of healthy life. With the aging of the population
patients but particularly between pharmacists and patients and the likely increase in chronic diseases, medications will
with limited literacy and/or health literacy. Although, in gen- continue to be an integral part of the health care system.
eral, patients have problems understanding medical infor- Pharmacist interventions can help reduce the burden as-
mation, patients with limited literacy and/or health literacy sociated with the adverse effects of limited health literacy
on medication-related issues that affect patient knowledge,
self-care for chronic diseases, health status, and risk of
Table 5. Practice behaviors that can enhance oral hospitalization. This can lead to better appreciation of phar-
communication with low health literacy patients macist interventions by patients, prescribers, third-party
Limit teaching objectives payers, and society at large. Ultimately, this might result in
Use simple sentences and plain language reimbursement for more of the services that pharmacists
Limit points to two or three at a time provide to their patients and an enhancement of the public’s
Give many examples view of pharmacy’s professional image.
Demonstrate procedures such as counting pills
Repeat and summarize Conclusion
Use drawings, diagrams, or models to illustrate what is being Although pharmacy-specific recommendations are still
communicated lacking for the most part, the need for health literacy educa-
Encourage questions tion for pharmacists and students remains high. Such educa-
tion should promote awareness of how to recognize patients
Communicate with patient at eye level
with low literacy skills and provide strategies to enhance
Make learning participatory (enhances long-term memory of the
understanding and adherence in this population. Although
information and checks patient’s comprehension)
the information provided in this article is not exhaustive or
Organize your information and present the most important comprehensive, it can assist pharmacists in their efforts to
messages at the beginning and end communicate more effectively with all patients in a way that
Be positive and encouraging enhances their understanding of prescription medication in-
Encourage the desired behavior structions. By teaming with patients, physicians, and other
Create a shame-free environment and offer assistance when professionals, pharmacists can overcome health literacy
needed barriers and help ensure the delivery of appropriate patient
Use “teach back” or “show back” techniques to assess and education, potentially resulting in improved medication-
ensure understanding taking behavior and adherence to prescribed medication
Source: References 66, 78, 138, 159. therapy.

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Assessment Questions
Instructions: The assessment test for this activity must be taken online; please see “CPE processing” below for further in-
structions. There is only one correct answer to each question. This CPE will be available at no later than
August 31, 2009.

1. What percent of patients typically take medications 5. Which of the following is the strongest predictor of
as prescribed according to the World Health Organi- an individual’s health status according to the Ameri-
zation? can Medical Association?
a. 10% a. Age
b. 20% b. Employment status
c. 30% b. Income
d. 40% d. Poor health literacy skills
e. 50%
6. Which of the following is the most frequent demo-
2. What percent of patients are adherent with taking graphic profile of an individual with low health lit-
prescribed medications during a 1-year period? eracy in the United States?
a. 10–20% a. Black
b. 30–40% b. Asian American
c. 50–60% c. Hispanic
d. 70–80% d. White, native-born American

3. According to authors described in this article, what 7. Who is not at risk for medication nonadherence?
should always be considered whenever a patient’s a. Elderly
condition is not responding to therapy? b. Ethnic minorities
a. Adverse drug effects c. Those with low income and education levels
b. Poor adherence d Those with high income and education
c. Suboptimal dose strength of the prescribed drug e. None of the above alternatives is correct.
d. Wrong medication therapy
8. Approximately how many adult Americans have diffi-
4. Medication nonadherence is thought to account for culty reading and understanding health information?
what percent of cases in which medications do not a. 10 million
produce their therapeutic goals? b. 50 million
a. <20% c. 90 million
b. 30–50% d. 140 million
e. <10 million
c. 60–80%
d. >80%

CPE Credit:
To obtain 2.0 contact hour of continuing pharmacy education credit (0.2 CEUs) for “Health literacy: A barrier to pharma-
cist–patient communication and medication adherence,” go to and take your test online for instant
credit. CPE processing is free for APhA members and $15 for nonmembers. A Statement of Credit will be awarded for a
passing grade of 70% or better. You have two opportunities to successfully complete the posttest. Pharmacists who com-
plete this exercise successfully before August 1, 2012, can receive credit.

The American Pharmacists Association is accredited by the Accreditation Council for Pharmacy Education as a
provider of continuing pharmacy education. The ACPE Universal Activity Number assigned to the program by the
accredited provider is 202-000-09-219-H04-P.

“Health literacy: A barrier to pharmacist–patient communication and medication adherence” is a home-study continuing
education activity for pharmacists developed by the American Pharmacists Association.

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Health literacy reviews

9. Which of the following is correct? 14. Patients with limited health literacy skills would be
a. Health literacy refers only to the ability to read medi- most likely to make mistakes in interpreting which of
cal information. the following label instructions?
b. A person’s health literacy may be worse than his/her a. Take two tablets by mouth twice daily for 7 days
general literacy. b. Take two tablets by mouth every 12 hours
c. Health literacy includes the ability to process numbers c. Take two tablets by mouth two times daily
(numeracy) and navigate the health care system. d. Take two tablets by mouth twice daily
d. Alternatives b and c are correct.
15. Patients with limited health literacy skills would be
10. Health literacy assessment instruments include least likely to make mistakes in interpreting which of
which of the following? the following label instructions?
a. Newest Vital Sign (NVS) a. Take two tablets by mouth twice daily for 7 days
b. Rapid Estimate of Adult Literacy in Medicine (REALM) b. Take two tablets by mouth every 12 hours
c. Test of Functional Health Literacy in Adults (TOFHLA) c. Take two tablets by mouth two times daily
d. All of the above alternatives are correct. d. Take two tablets by mouth twice daily

11. Which health literacy assessment strategy can be 16. Which of the following formulas has been recom-
easily used by pharmacists? mended for checking readability by hand?
a. REALM a. The Fry formula
b. TOFHLA b. The Gunning-Fog formula
c. NVS c. Readability Plus
d. Single-question health literacy assessments d. Alternatives a and b are correct.

12. Which of the following is false? 17. Which of the following statements on the use of vi-
a. Almost one-third of adults older than 65 years have sual aids is false?
very poor health literacy skills. a. Picture-based information can benefit only patients
b. Adults who receive Medicare or Medicaid have lower- with limited health literacy skills.
than-average health literacy. b. Research findings indicate that visual aids enhance
c. Low literacy affects patients’ health and their partici- patient adherence to medication regimens.
pation in medical care decision making and patient- c. Pictorial aids that are used successfully in one culture
centered care. can be used successfully in other cultures.
d. Study findings indicate that the quality and amount d. Telling patients the correct meaning of an incorrect
of counseling regarding medications in community pictorial aid has been found to considerably increase
pharmacies are adequate and meet the intent of the its correct interpretation later.
Omnibus Budget Reconciliation Act of 1990. e. Alternatives a and c are false.

13. Patients with limited health literacy skills can be

identified by their The following case applies to questions 18 through 20:
a. Appearance. J.T. is a 58-year-old white man who has been a patient
b. Educational status. of your pharmacy for more than 10 years. His medical
c. Speech. history includes diabetes, hypertension, and asthma.
d. None of the above alternatives is correct. His current medications include glyburide/metformin (5
mg/500 mg) twice daily, lisinopril/hydrochlorothiazide
(20 mg/12.5 mg) once daily, albuterol hydroflouroalkane

CPE Processing:
Get your documentation of credit now! Completing a posttest at is as easy as 1-2-3.
1. Go to Online CE Quick List and click on the title of this activity.
2. Log in. APhA members enter your user name and password. Not an APhA member? Just click “Create one now” to open an
account. No fee is required to register.
3. Successfully complete the CPE exam and evaluation form to gain immediate access to your documentation of credit.

Live step-by-step assistance is available Monday through Friday 8:30 am to 5:00 pm ET at APhA Member Services at 800-
237-APhA (2742) or by e-mailing

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reviews Health literacy

2 puffs every 4 to 6 hours as needed, fluticasone/salme- 18. Which of the following statements would be true if
terol inhaler (250 mcg/50 mcg) twice daily. J.T. has a health literacy problem?
a. He could be well groomed.
J.T. was recently hospitalized with heart failure. He was b. He could have a college degree.
discharged after 3 days and given a new prescription for c. He could be an articulate, intelligent-sounding indi-
digoxin 0.125 mg, alternating with 0.25 mg every other vidual.
day. He comes to your pharmacy to fill his prescriptions. d. He could go to great lengths to hide his inability to
You ask him how he is feeling, and he says, “I am feel- read or understand medical information.
ing much better, but my doctor keeps on prescribing me e. All of the above alternatives are correct.
the wrong medications. I take all my medications but I
keep having one health crisis after another.” You ensure 19. Which of the following techniques can the pharma-
him that digoxin is a good heart medication but that he cist use to assess J.T.’s understanding of the pre-
needs to take it as directed. You tell him that he should scribed medication instructions?
stop taking the medication and contact his doctor im- a. Ask “Do you understand?”
mediately if he experiences vision changes (e.g., yellow- b. Ask open-ended questions
green or blurred vision). c. Use the “teach back” technique
d. Alternatives b and c are correct.
In order to not keep him waiting, you quickly fill his pre-
scription and hand it to him. You are about to attend to 20. The National Work Group on Literacy and Health rec-
the next patient when you realize that you did not put ommends that patient education materials for J.T.
the medication information sheet into J.T.’s medication be written at which of the following grade readability
bag. You go after J.T. and hand the medication sheet levels?
to him (wrong side up). You wait a few minutes for J.T. a. 8th
to read the medication information and ask him if he b. 7th
understood the information. Without turning the sheet c. 6th
right side up, he says, “Yes, but I will read it more care- d. 5th
fully later when I get home.” At this point, he says, “I
think I also need a refill for my inhaler.” You ask the
name of the inhaler that he wants refill and he says,
“You know the one that I have been taking for a very
long time. It is in your computer. I still have enough of
the new inhaler at home.” You look in his profile and see
that all his medications are 3 months past their refill

e149 • JAPhA • 4 9 : 5 • S e p /O c t 2009 Journal of the American Pharmacists Association

149 8/28/09 10:11 AM

Appendix 1. Medical word examples: words frequently used by doctors and in health care institutions

Problem word Translation into plain language

Analgesic Pain killer

Anti-inflammatory Lessens swelling and irritation
Ailment Sickness; illness; problem with your health
Alleviate symptoms Help you feel better
Allergen Something that causes an allergy
Benign Will not cause harm; is not cancer
Condition How you feel; health problem
Directed Told by your doctor, nurse or other health care provider
Diagnosis Cause of your illness
Dosage Dose; how much medicine you should take
Dysfunction Problem
Edema When body fluids build up too much, often with swelling; swelling
(depending on context)
Fluid level How much water your body has
Glucocorticoid Something your body makes that reduces swelling and fever
Inflammation Swelling and soreness, as when you hit your thumb with a hammer;
may refer to organs inside the body, not just arms/legs
Inhibitor Drug that stops something that is bad for you
Interaction How things work together; drug interaction: some drugs change the
way other drugs work; some drugs do not work well together
Internist Doctor
Intermittent Off and on
Lesion Wound; sore; infected patch of skin
Membrane Thin covering (over a part of the body)
Mg Milligram; very small amount used to measure drugs
Nocturia Going to the bathroom a lot at night
Nonprescription Over the counter; can be bought without a doctor prescribing it
Nutrient Something in food that is good for you
Oral By mouth
Procedure Something done to treat your problem; operation
Refrain Stop; stay away from
Restart Start again
Syncope Blackout; loss of consciousness
Scored tablet Tablet with a line that makes it easy to cut in half
Triage Nurse A person who can tell you the best place for care
Vertigo Dizziness

Concept Word Examples: Words used to describe an idea, metaphor, or notion.

Active role Taking part in
Area Part; patch; place
Avoid Stay away from; do not use (or eat)
Advocacy Support
Aspect Point of view; part; item
Associated with Goes along with
Collaborate Work together
Coordinate Make all parts of your care work together; talk with other doctors,
nurses, or other health care providers
Contributes to Also causes
Diet What you eat; your meals
Dietary cholesterol Cholesterol from food
Enlarge Get bigger
Factor Other thing
Gauge Measure; get a better idea of; test (dependent on context)
Intake What you eat or drink; what goes into your body
Initially At first; to start with
Landmark Very important (adj.); Important event, turning point
Monitor Keep track of
Normal range Where it should be; common amount
Option Choice
Prevalent Common; happens often
Pros and cons Pluses and minuses
Prioritize Put in right order; put first things first; put things in order of
Referral Ask you to see another doctor; get a second opinion
Triad Group of three
Type vs. amount Kind and how much
Wellness Good health; feeling good
Category Word Examples: Words that describe a group or subset and may be unfamiliar.
Activity Something you do; something you do often, like drive a car
Adverse (reaction) Bad
Animal product Food with fat that makes your cholesterol high
Anti-inflammatory Lowers swelling and fever
Cognitive Learning; thinking
Coordinate care giving Plan the right kind of care and how much care; plan and set up help
as needed
Good posture Sitting straight and standing tall
Hazardous Not safe; dangerous
High-intensity exercise Use example, such as running
Generic Product sold without a brand name; like ibuprofen (contrast with
brand-name Advil)
Lowest avg. wholesale price Cheapest (or rephrase to use verb; costs less)
Noncancerous Not cancer
Poultry Chicken, turkey, etc.
Prosthesis Replacement for a body part, such as a man-made arm
Social contact Staying in touch with family and friends
Support Help with your needs—for money, friendship or care

Value Judgment Word Examples: Words that may need an example or visual to convey their meaning
with clarity.

Adequate Enough (Example: adequate water is 6 – 8 cups a day)

Adjust Fine tune; change
Adjustment A change (Example: sleep on your back instead of your stomach)
Cautiously With care; slowly (Example: making sure to hold on to handrails)
Considerable Quite a bit of; a lot of
Excessive Too much (Example: If blood soaks through the bandage)
Increase gradually Add to (Example: add 5 minutes of exercise a week)
Moderately Not too much (Example: don’t exercise so much that you get out of
Progressive Gets worse (or better); ongoing change
Routinely Often (Example: every day, every week)
Significantly Enough to make a difference
Temporary For a limited time; for about an hour, a day, etc. (Example: for less
than a week)

Appendix 2. Calculating readability using the Fry method167

(1) Select three 100-word passages from the material you wish to test. Count out exactly
100 words for each passage, starting with the first word of a sentence (omit headings). If
you are testing a very short pamphlet that may have only a few hundred words, select a
single 100-word sample to test.
Readability levels may vary considerably from one part of your materials to another.
Therefore, select the three samples from different content topics, if possible.
Additional information: Count proper nouns. Hyphenated words count as one word. A
word is defined as a group of symbols with a space on either side (i.e. “IRA,” “1994,” and
“&” are each one word.)
(2) Count the number of sentences in each 100 words, estimating the fractional length of
the last sentence to the nearest 1/10. For example, if the 100th word occurs five words into
a 15-word sentence, the fraction of the sentence is 5/15 or 1/3 or 0.3.
(3) Count the total number of syllables in each 100-word passage. You can count by
making a small check mark over each syllable. For initializations (e.g. IRA) and numerals
(e.g. 1994), count one syllable for each symbol. So, “IRA” = three syllables and “1994” =
four syllables.
(4) Calculate the average number of sentences and the average number of syllables from
the three passages. This is done by dividing the totals obtained from the three samples as
shown below.
Number of sentences Number of syllables
1st 100 words 5.9 124
2nd 100 words 4.8 141
3rd 100 words 6.1 158
Totals 16.8 423
Divide totals by 3 5.6 average 141 average

(5) Refer to the Fry graph. On the horizontal axis, find the line for the average number
of syllables. On the vertical axis, find the line for the average number of sentences. The
readability level of the material is found at the point where the two lines intersect. In this
example, the readability level is 8th grade.

Using the Fry Method on short documents

When your document has fewer than 100 words, you can use an adaptation of the Fry
(1) Divide 100 by the number of words in the passage.
(2) Count the number of syllables and sentences in the passage.
(3) Multiply the figures from step 2 by the number you got in step 1.
(4) Plot the ‘adjusted’ numbers on the Fry graph.
Appendix 3. The Health Sciences library at University of North Carolina-Chapel Hill
health literacy resources list (reproduced with permission of Jean Blackwell)



Web Sites

AskMe3 - Partnership for Clear Health Communication

AMA Health Literacy Kit – American Medical Association

Pfizer Clear Health Communication Initiative

Health Literacy Consulting

Health Literacy Fact Sheets - Center for Health Care Strategies

Quick Guide to Health Literacy - US Dept. of Health and Human Services

Health Literacy Project - Institute of Medicine

Clear Health Communication Initiative – Pfizer

Health Literacy Studies - Harvard School of Public Health

Simply Put – Centers for Disease Control and Prevention

Writing Easy-to-Read Materials - Center for Medicare Education

Clear & Simple: Developing Effective Print Materials for Low-Literate Readers -
National Cancer Institute

How to Write Easy-to-Read Health Materials – MedlinePlus


Fry’s Readability Graph and Directions

SMOG Readability Formula - University of Utah Health Sciences Center

Words to Watch Fact Sheet

Substitute Word List - University of Utah Health Sciences Center

Plain Language Initiative

Easy-to-Read Health Materials - MedlinePlus

Culture Clues - University of Washington Medical Center


Health literacy: help your patients understand

Chicago, Ill.: AMA Foundation and American Medical Association, 2003
DVD (23 min.) and CD-ROM (23 min.)
online video - needs Windows Media Player or Real Media

Health Literacy: A prescription to end confusion

Institute of Medicine, 2004
online video (3 min.) – needs Windows Media Player or RealTime

In plain language: the need for effective communication in medicine and public
Harvard School of Public Health, 2000
1 videocassette (14 min.)

Low health literacy: you can’t tell by looking

AMA Foundation, 2001
online video (18 min.) - needs Windows Media Player or Real Media

Overcoming patient language barriers

Irvine, CA: Concept Media, 2001
2 videocassettes (56 min.)

Treatment adherence: how to improve patient compliance

Secaucus, N.J.: Network for Continuing Medical Education, 2002
1 videocassette (46 min.)

Secret survivors: the plight of functionally illiterate adults in the health care
Syracuse, NY: Literacy Volunteers of America, 1992
1 videocassette (17 min.)


Advancing health literacy: a framework for understanding and action/ Christina

Zarcadoolas, Andrew F. Pleasant, David S. Greer. San Francisco, CA: Jossey-Bass, 2006

Easy does it! Plain language and clear verbal communication training manual.
Ottawa: National Literacy and Health Program, Canadian Public Health Association,

Good medicine for seniors: guidelines for plain language and good design in
prescription medication. Canadian Public Health Association, 2002

Handbook of health communication / edited by Teresa L. Thompson et al. Mahwah,

N.J.: Lawrence Erlbaum Associates, 2003

Health literacy and patient safety: help patients understand: manual for clinicians,
2nd ed. / Barry D. Weiss. AMA Foundation, 2007

Health literacy: a prescription to end confusion / Institute of Medicine; Lynn Nielsen-

Bohlman et al. Washington, D.C.: National Academies Press, 2004

Health literacy from A to Z: practical ways to communicate your health message /

Helen Osborne. Sudbury, Mass.: Jones and Bartlett, 2005

Health literacy in primary care: a clinician's guide / Gloria G.Mayer and Michael
Villaire. New York: Springer Pub., 2007.

Health literacy of America’s adults: results from the 2003 National Assessment of
Adult Literacy. National Center for Education Statistics, 2006

Health literacy style manual/prepared by Maximus for Covering Kids & Families;
funded by the Robert Wood Johnson Foundation, 2005

Pfizer principles for clear health communication, 2nd ed. Pfizer, 2004

Literacy and health outcomes/ prepared by RTI International-University of North

Carolina Evidence-Based Practice Center; Nancy D. Berkman et al. Rockville, Md.:
Agency for Healthcare Research and Quality, 2004

Teaching patients with low literacy skills, 2nd ed. / Cecilia Conrath, Doak, Leonard G.
Doak, Jane H. Root. Philadelphia: J.B. Lippincott, 1996

TOFHLA: Test of Functional Health Literacy in Adults, 2nd ed. / Joanne R. Nurss et
al. Snow Camp, NC: Peppercorn Books, 2001

Understanding health literacy: implications for public health/ Joanne G.

Schwartzberg et al. Chicago IL: AMA Press, 2005

“What did the doctor say?” improving health literacy to protect patient safety. The
Joint Commission, 2007

Working with your older patient: a clinician's handbook

National Institute on Aging, 2004

Writing health information for patients and families: a guide to creating patient
education materials that are easy to read, understand and use, 2nd ed./ Lindsay
Wizowski, Theresa Harper, Tracy Hutchings. [Hamilton, ON]: Hamilton Health
Sciences, 2006

Last updated: November 2007

Jean C. Blackwell, MLS, AHIP

Health Sciences Library
UNC – Chapel Hill