American College of Physicians: Internal Medicine — Doctors for Adults ®

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Low health literacy leads to mistakes, poorer outcomes

From the June ACP Observer, copyright 2006 by the American College of Physicians.

By Deborah Gesensway

Do your patients really understand common warning stickers or dosage instructions on a medicine bottle?

While most patients can figure out “take with food” (84%) and “medication should be taken with plenty of water” (59%), only 8% in a recent health literacy study of patients in three states comprehended “do not take dairy products, antacids or iron preparations within one hour of taking this medication.”


Terry C. Davis, PhD



“I don’t even understand what [that] means,” said Terry C. Davis, PhD, professor of medicine and pediatrics at Louisiana State University Health Science Center-School of Medicine in Shreveport, La. Dr. Davis is a pioneer in the health literacy field and Chair of ACP Foundation’s Patient–Centered Health Literacy Advisory Board.

“Does that mean that if I’m taking vitamins, I can’t take this medicine?" she asked. And although patients with higher literacy levels are more likely to understand a label, she cautioned, they “get less than you think.”

At an Annual Session presentation on “Health Literacy: A Silent Epidemic Hurting You and Your Patients,” Dr. Davis was part of a panel that shared the troubling results of another study: Although people knew what “take two tablets by mouth twice daily” meant, when handed a pill jar and asked to show how to follow those instructions, only half could do so correctly.

Those results underscore the fact that health literacy “is a matter of patient safety," said Dr. Davis. "It’s easy to make a mistake.”

And, she warned, appearances can be deceiving. “You cannot know by looking or talking to a person what [his] literacy level is,” she said. Being articulate can be a cover for not being able to read. “These are your patients, your neighbors, your families."

Literacy and health outcomes

Not only are some of the lowest functional literacy skills associated with a disproportionate number of people with chronic disease, but research has documented the relationship between low literacy and poorer health outcomes, said Darren A. DeWalt, ACP Member, assistant professor of general internal medicine at the University of North Carolina in Chapel Hill, N.C., another session panelist.

For instance, when people with diabetes have low literacy levels, “they have more long-term sequelae of diabetes,” he said. “Patients with HIV have higher viral loads. Patients with depression have more severe depression on average. And people with low literacy are more likely to be hospitalized.”

The problem is compounded by a health care system that relies on those with chronic illness to self-manage and follow complicated regimens. That's not only difficult because of their low literacy level, but also because of the nature of illness itself. “We know that when people are not feeling well, they have more trouble reading and understanding,” he said.

This point is illustrated in the "Health Literacy: A Silent Epidemic" CD distributed by ACP Foundation as part of its Health Literacy Initiative. That initiative is designed to educate physicians about health literacy issues and help patients better understand health information. (You can download the CD.)

Strategies that work

To begin to address such problems, Drs. DeWalt and Davis urged internists to rethink how they run their office and communicate with patients.

Some strategies that have been shown to improve patient comprehension include:

  • Encouraging patient participation.

  • Using drawings and other visual aids.

  • Limiting the number of issues raised during each visit.

  • Incorporating the “teach-back method in discussions with patients.

“I say, ‘Tell me what you’re going to do when you get home.’ Then, I can clarify until I know they have understood,” Dr. DeWalt said, describing the teach-back method. Patients with low literacy are often afraid to ask questions because they are embarrassed and ashamed that they can’t read well, he pointed out.

"There can be a large difference," he said, "between a patient's capacity and the demands placed on them by the nature of their disease and their symptoms."

Deborah Gesensway is a freelance health care writer in Toronto.

The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.

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Health literacy conference

ACP Foundation is holding its fifth annual National Health Communication Conference Nov. 29, 2006, in Washington. Check the ACP Foundation site for more information.

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