US Pharm. 2006;10:28-34.

Patient-centered care requires effective communication between clinicians and patients.1 For this to occur, patients must be health literate (i.e., able to read, understand, and act on health information). Health literacy not only enables patient-clinician communication in a confusing and complex health care system but also impacts health outcomes by reducing communication difficulties.2-4

A growing number of adults in the United States, especially those who speak English as a second language, are considered functionally illiterate and do not understand a variety of health information, such as medication labels, discharge instructions, consent forms, brochures, and oral instructions.5-7 Census data suggest 10% of adult Americans are currently functionally illiterate; more specifically, approximately 90 million illiterate adult Americans struggle to understand health information.6-8

Illiteracy is especially common among the elderly. 3 According to some estimates, two thirds of Americans 60 or older have inadequate or marginal literacy skills, and additional health care costs due to low health literacy may reach as high as $73 billion annually.9 Among community-dwelling older adults, inadequate health literacy is independently associated with poorer physical and mental health.10 Adverse events resulting from medication errors are a serious concern, especially since inadequate health literacy, poor adherence, and potentially inappropriate medication use are prevalent in older adults who reside independently in the community.11,12 Individuals with low health literacy may misinterpret or have difficulty understanding prescription drug warning labels and written patient education materials. This can have a huge impact on the health and well-being of older adults, who often struggle with the management of comorbidities that require complex medication regimens. Furthermore, low health literacy can interfere with use of preventive services (e.g., influenza or pneumococcal vaccination, mammography, or Papanicolaou testing) among many older adults in Medicare managed-care programs.13,14 It has been suggested that while inadequate literacy is not a major barrier to the access of outpatient health care, real or perceived barriers to their usual source of outpatient care appear to be associated with higher rates of emergency department utilization among low-literate individuals. 15 Data indicate that persons with inadequate health literacy incur higher medical costs and use an inefficient combination of services. 14

Taking these findings into consideration, researchers have begun to question patients' understanding of their own medical and medication history, as well as clinicians' abilities to solicit pertinent information from patients. Some researchers suggest that consent forms and other health education material be written at least three grade levels lower than the average educational level of the target audience.8 In addition, dyslexia (i.e., atypical processing of written stimuli based on abnormal functioning of the left-hemisphere reading system), although beyond the scope of this article, should not be overlooked as a barrier to obtaining information through the written word.16

Prescription Drug Warning Labels
In a recent study, researchers found a lower rate of correct interpretation of the eight most commonly used prescription drug warning labels among patients with low literacy skills compared to those with higher literacy skills.17 The researchers noted that some common causes of misinterpretation of prescription drug warning labels include multiple-step instructions, difficult reading level, use of icons, use of color, and message clarity.17

Patient Education Materials and Medication Adherence
Complexities related to the treatment and management of common conditions among the elderly (e.g., congested heart failure, diabetes mellitus, chronic obstructive pulmonary disease, asthma) can be overwhelming for any patient. In patients with low health literacy, in particular, obstacles and barriers to successful management of conditions may be amplified, since limited health literacy is associated with worse self-management skills.10 Patients may have difficulty understanding information on diet restrictions, medications, and laboratory monitoring.

One study examined whether consumer-directed, FDA-approved Medication Guides issued for potentially harmful medications are likely to be useful to patients with limited literacy.18 Researchers found that none of 40 Medication Guides were written in accordance with federal recommendations at a sixth- to eigth-grade reading level; instead, the Medication Guides were written at an estimated 11th- to 12th-grade reading level.18 In addition, most of the Medication Guides were considered unsuitable, since they did not provide a summary of content or limit the scope of information.18 While patients with low literacy were less likely to have looked at them, only 23% of all patients reported having looked at the medication guides or accompanying patient information materials.18 The researchers concluded that Medication Guides are not likely to be useful to patients with limited literacy skills. They made the following recommendations: (1) that the reading level of the Medication Guides be reduced; (2) that summaries or "highlights" be provided; (3) that the scope of the information provided be limited in order to increase the likelihood of use among individuals with limited literacy; and (4) that consumers be involved in the development of these materials.18

Another study found that more than half of patients who participated in a diabetes education program could not fully comprehend educational materials written at the fifth-grade level, while almost all written educational documents and oral instructions were presented at the ninth-grade level or above.19

Additionally, in a study that reviewed American Cancer Society literature, investigators found that the reading levels of sampled materials ranged from grades 5.8 to 15.6, with a mean reading level of grade 11.9.20 Most of the documents were deemed "probably too difficult" for many Americans to read and comprehend. The researchers advised raising awareness of patients' diverse reading skills and stressed the need to formulate a systemic method for developing materials that meet the needs of low-literate groups.20

It is important for clinicians to know that patients who misunderstand their diagnosis and treatment plans usually exhibit poor adherence to therapy (e.g., medication, diet, lifestyle changes).6 This is particularly important to the pharmacist, whether developing a pharmaceutical care plan or informally counseling a patient about medication therapy. The inclusion of family members in the patient education process may improve adherence with therapy.6

Single-Step Versus Multistep Instructions
Patient medication errors causing adverse events are a serious concern, especially among those with low health literacy. Davis et al. found that patients with low literacy had difficulty understanding prescription medication warning labels, and patients across all literacy levels had difficulty understanding multistep instructions.12 The researchers reported that single-step instructions were easier to understand and suggested that warning labels be developed with consumer participation. They recommended the use of short, concise messages created with familiar words and recognizable icons.12

Verbal Communication
Because patients with low health literacy have limited descriptive vocabulary, they might become frustrated and impatient when unable to communicate their medical history and, therefore, might deliver an inaccurate response. This potential occurrence should not be overlooked during a patient interview. Soliciting information may be a challenging task, but awareness of communication difficulties can be helpful. Effective communication methods for patients with low literacy can be found in TABLE 1.

Cultural Barriers
Cultural differences with regard to language or beliefs about health care are a barrier that many ethnic minorities face when attempting to access medical information; often, these problems are coupled with low socioeconomic status.21 A patient who speaks very little English may feel too embarrassed or impatient to admit to not being able to comprehend posed questions. As a result, the patient may respond with inaccurate or misleading answers about medical history or other pertinent information. Use of an informal interpreter may help avoid miscommunication and improve intercultural communication between clinicians and patients. In addition, access to a bilingual health care provider can also minimize miscommunication.

Hearing Impairment
As the populaton ages, health care practioners will encounter more individuals with hearing limitations. 1 In a Harvard Medical School study, participants who were deaf or hearing impaired suggested that clinicians ask patients about their preferred communication approach (e.g., lip-reading, sign language, writing notes). The study also revealed that asking patients to repeat critical health information (e.g., medication instructions) is one way to identify potentially dangerous miscommunication.1

Visual Aids
Efforts focused on making better use of methods of visual representation to improve low health literacy are ongoing.22 In the past, pictographs have been used in nonliterate societies to help individuals remember spoken instructions.23Today, researchers suggest they could be used to assist nonliterate patients in remembering spoken medical instructions.23 Additionally, by viewing illiteracy as a memory problem, research on learning and memory may be used in designing medication materials for this target group.23 Pharmacists may find this particularly helpful when counseling the elderly.

Evidence has demonstrated that pictographs improve comprehension of complex information.24 Furthermore, studies have shown that the use of pictographs has resulted in a positive effect in the acquisition and comprehension of drug information. Houts et al. found that mean correct recall was 85% with pictographs and 14% without, indicating that pictographs can enhance memory of spoken medical instruction.23 In a follow-up study, the researchers concluded that people with low literacy skills can recall large amounts of medical information for significant periods of time with the help of pictographs.25 However, they noted that the ultimate impact of pictograph use on symptom management and patient quality of life remains to be studied.25

Another study investigated whether the addition of illustrations to labels on pill bottles affects patient comprehension of instructions for proper use of medication or of information about possible side effects.26 Findings demonstrated that the addition of illustrations to medication instruction labels was associated with improved performance in 5% to 7% of patients and worsened performance in 7% to 9% of patients.26 Researchers concluded that the commonly used illustrations on the medication labels in this study were of little or no use in improving patients' comprehension of the accompanying written instructions. 26

Another visual aid utilized by some health care professionals is video recordings. Research has demonstrated that the content of video recordings should emphasize diagnosis and treatment, and information should be explained in simple language that avoids polysyllabic words.27 However, information provided by video recordings alone may have limited benefits.

Conclusion
Pharmacists and other health care professionals who serve the elderly need to embrace safe, efficient, and patient-centered care by communicating effectively with patients. While the written word remains one of the most important means for communicating medical information, pervasive low health literacy and illiteracy are problems that continue to limit the understanding of health information, compromise quality of health care, and lead to poor health outcomes. Research findings support modalities that improve written communication between adults with low health literacy and clinicians and provide more understandable information about diseases and medications; such methods can help with the avoidance of potential adverse drug events and improve quality of life and health-related outcomes.

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