reviews

Health literacy: A barrier

to pharmacist–patient
communication and medication
adherence
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: ngohl@ferris.edu
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 www.pharmacist.com/
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-
nication.
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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 reviews Health literacy
P
atients’ nonadherence with medical and medication
recommendations is a major public health problem.1–9
Nonadherence is encountered in varying degrees in all
areas of U.S. health care, involving an estimated 38% of pa-
tients on short-term treatment, 43% of patients on long-term
treatment, and 75% of patients advised to make lifestyle
changes.10 Health, behavioral, and social scientists have accu-
mulated substantial literature on the prevalence of poor adher-
ence, its determinants, and interventions during the previous 4
decades.1,11 Social, economic, medical, and behavioral factors
have all been shown to affect adherence.12,13 Although other
variables such as pharmacologic and psychosocial factors con-
tribute to nonadherence,14 problems with patient adherence
and medical errors may also be based on poor understanding
of health information.2,15 For many patients, lack of health lit-
eracy skills is a major obstacle to effective health communica-
tion.2,16
Reviews of more than 300 studies have shown that health
information cannot be understood by many patients.17 This
communication mismatch has been associated with patients
At a Glance
Synopsis: The current work summarizes the com-
plexities of health literacy, medication nonadherence,
and patient education and provides suggestions for
promoting medication adherence, particularly among
patients with low health literacy skills. Pharmacists
play a key role in recognizing patients with low health
literacy skills and providing strategies to enhance un-
derstanding and adherence in this population. For
medication information to be understood and adher-
ence to be promoted, pharmacists should speak clearly
and slowly, use appropriate vocabulary, avoid medi-
cal jargon, explain the specific steps of the regimen,
review the most important details, and encourage pa-
tients to ask questions. Simplified written instructions
and/or visual aids should also be used to enhance pa-
tient recall.
Analysis: Although no single intervention strat-
egy can improve the medication adherence of all pa-
tients, considerable research suggests that success-
ful attempts to improve adherence depend on certain
key factors, including realistic assessment of patient
knowledge and understanding of the regimen, clear and
effective communication between health professionals
and patients, and the nurturance of trust in the thera-
peutic relationship. Pharmacist interventions can help
reduce the burden associated with the adverse effects
of limited health literacy on medication-related issues
that affect patient knowledge, self-care for chronic dis-
eases, health status, and risk of hospitalization. This
can lead to better appreciation of pharmacist interven-
tions by patients, prescribers, third-party payers, and
society at large.
e133 • JAPhA • 4 9 : 5 • S e p /O c t 2009 www.japha.org
133
being less knowledgeable about their diseases,1,11,12,18–20 more
likely to have poorer health outcomes,2,13,15,21–23 and more likely
to be hospitalized.24–26
Objectives
The goal of this article is to present a summary of the ex-
isting literature on health literacy and its effect on medica-
tion nonadherence and pharmacist–patient communications
and the use of written patient information in health care and
pharmacy.
Search strategy
Potentially relevant articles were identified by search-
ing the Medline, PubMed, and International Pharmaceutical
Abstracts databases using the following terms: adherence/
nonadherence, compliance/noncompliance, printed/written
information, literacy, patient education, communication, and
health literacy. These terms were combined with the following
search terms: drug information, readability, medication/drug,
patient, pharmacy/pharmacist, and prescription. References
of pertinent articles were hand searched to retrieve additional
articles. The selection was limited to English-language articles
published from 1990 through 2006.
Medication adherence
Compliance was defined more than 2 decades ago as “the
extent to which a person’s behavior (in terms of taking medi-
cations, following diets or executing other life-style changes)
coincides with medical or health advice.”3 This term was later
criticized for implying paternalism. The terms adherence and
concordance have replaced compliance. Adherence is favored
because of its connotation that the patient–provider relation-
ship is based on respect and collaboration.27 It also includes
the patient in the determination and success of therapy more
accurately than the term compliance.1 The World Health Or-
ganization has adopted the following definition of adherence:
“The extent to which a person’s behavior, taking medication,
following a diet, and/or executing lifestyle changes, corre-
sponds with agreed recommendations from a health care pro-
vider.”28 In the literature, the terms adherence and compliance
have been used interchangeably29; adherence will be used in
this article.
Costs of nonadherence
Underuse of medications caused by problems with adher-
ence or persistence (i.e., the length of time patients continue
to take medications as directed) exacts a tremendous toll on
patients’ health and the nation’s economy. Approximately
125,000 deaths annually are attributed to nonadherence, and
up to 11% of hospital admissions and 40% of nursing home
admissions can be attributed to lack of adherence with medica-
tion therapy.12 Medication-related problems, some of which are
caused by nonadherence, costs U.S. society an estimated $177
billion annually in total direct and indirect health care costs.30
Medication nonadherence is also costly for pharmacies and the
pharmaceutical industry. Some 140 million prescriptions, val-
Journal of the American Pharmacists Association
8/28/09 10:11 AM

ued at $2.8 billion, go unfilled annually.12 Furthermore, medi-
cation nonadherence is involved in an estimated 30 to 50% of
cases in which medications do not produce their therapeutic
goals, thereby reducing treatment benefits and confounding
clinicians’ assessments.31
Measurement of adherence
No generally accepted gold standard exists for measuring
adherence behavior.32 Several strategies have been used29,33–35;
they are categorized as direct or indirect.
Direct methods include observation of medication intake
and biological assays of a drug, its metabolite(s), or a tracer
substance in blood or urine.33,34 Observation verifies adher-
ence, yet necessitates direct patient–clinician encounters and
does not elucidate medication intake dynamics.32 Biological as-
says are intrusive,34 expensive, burdensome to the health pro-
vider, and susceptible to distortion by the patient.33,34 Assays
are most useful for medications whose serum concentrations
are monitored, such as the antiepileptic agents phenytoin and
valproic acid.
Indirect methods include patient questionnaires, self-
report, pill counts, rates of prescription refills, collateral re-
ports from family members or clinicians, assessment of the
patient’s clinical response, electronic medication monitors,
measurement of physiologic marker, and patient diaries.31,33,36
Questionnaires (or questioning the patient), patient diaries,
and assessment of clinical response are relatively easy meth-
ods but can be susceptible to misrepresentation. Self-report
and collateral reports are uncomplicated, inexpensive, and
feasible in clinical settings but are prone to recall and social
desirability response bias. Collateral reporting depends on the
family member or clinician’s familiarity with the patient.37,38
Pill counts (i.e., pills dispensed, remaining, and prescribed),
although easy to perform, are invalidated when patients hoard
or discard drugs.37,38 Furthermore, patients may not accurately
recall the date that they started taking the medication.
Electronic monitors provide precise and detailed informa-
tion on patients’ behavior in taking medications, but they do not
provide information as to whether the patient actually ingested
the correct drug or correct dose. Also, the cost of electronic
monitoring limits the feasibility of the devices. They provide
the most accurate and valuable data on adherence in difficult
clinical situations. Prescription refill rates provide an accurate
measure of overall adherence in a closed pharmacy system
such as the Department of Veterans Affairs Health Care Sys-
tem but are problematic when patients use a number of non-
networked pharmacies32,37,39; they are not useful for medica-
tions that do not require subsequent refills. Also, although refill
rates provide a proxy measure, patients’ true medication-tak-
ing behavior may remain unknown. In summary, although using
one method in a particular situation might be advantageous, a
combination of methods tends to maximize accuracy.40
Medication adherence rates
Medication adherence rates have been reported by some
researchers as the percentage of the prescribed doses of medi-
cation actually taken by the patient during a specified period.33
Journal of the American Pharmacists Association
134
Health literacy reviews
Other investigators have estimated medication adherence
by determining the number of tablets or capsules missed (or
taken at inappropriate time intervals) or the number of days
without therapy and reported the average number of tablets or
capsules missed, average number of days without medication,
or average deviation from the prescribed consumption time.34
Research suggests that only about 50% of patients typically
take their medications as prescribed,11 only 50 to 60% of pa-
tients are adherent to prescribed medications over a 1-year pe-
riod,9 and adherence rates are typically higher among patients
with acute conditions33 compared with long-term medication
regimens, for which adherence ranges from 17 to 80%.35
A 2006 survey commissioned by the National Community
Pharmacists Association reported that nearly three of every
four American patients do not always take their prescription
medication as directed.41 Nonadherence occurs among pa-
tients of all ages, social classes, and ethnic groups and amidst
patients participating in various forms of health care delivery.42
Medication nonadherence in the home setting often involves
using more or less than the prescribed dosage (36%), com-
pletely omitting one or more prescribed medications (28%),
taking an extra dose (12%), using an unauthorized medication
(8%), or taking medication at the wrong time (7%).43
Factors contributing to nonadherence
Adherence is a multidimensional phenomenon,44 and as
interest surrounding adherence behavior has developed, a
number of theoretical models have been forwarded to account
for the various factors that influence adherence behavior.45,46
Among these models are social behavioral theories including
the Health Belief Model,47 the Common Sense Model,48 and the
Self-Efficacy Theory.49
The Medication Adherence Model provides an elaborate
analysis of how three key constructs influence medication-
taking behavior50: (1) the patient’s representation of his or
her illness (e.g., perceived severity), (2) the patient’s cogni-
tive function (e.g., comprehension, long-term memory), and
(3) external cues or strategies used by the patient to enhance
medication-taking behavior (e.g., social support, reminder de-
vices). The patient’s cognitive function construct may be criti-
cal for proper medication use and in the pharmacist–patient
interaction. This is because the patient’s ability to adhere to
the prescribed treatment regimen may be compromised if he or
she cannot obtain and understand basic information about how
to take the prescribed medication.51–53
Health literacy
Healthy People 2010 defines health literacy as “the degree
to which individuals have the capacity to obtain, process, and
understand basic health information and services needed to
make appropriate health decisions.”54 Thus, health literacy re-
lates to both the cognitive and functional skills used to make
health-related decisions.55 This definition also implies that lit-
eracy goes beyond the ability to read a sentence to the abil-
ity to comprehend the written word. Health literacy includes
numeracy skills such as calculating blood glucose levels and
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 reviews Health literacy
measuring medications. Furthermore, it requires knowledge of
health topics in addition to basic literacy skills.
Literacy, the foundation of health literacy,17 has been de-
fined as “an individual’s ability to read, write, and speak Eng-
lish and compute and solve problems at levels of proficiency
necessary to function on the job and in society, to achieve one’s
goals, and to develop one’s knowledge and potential.”56 Illiter-
acy means being unable to read or write. An individual who has
limited or low literacy skills is not illiterate.57
A person’s health literacy skills may be worse than his or
her general literacy skills. A report from the Institute of Medi-
cine (IOM) states that, generally, individuals with limited lit-
eracy skills also have limited health literacy—an inability to
“obtain, process, and understand basic health information
and services needed to make appropriate health decisions.”17
Limited literacy skills are associated with lack of understand-
ing of written or oral health communication.58 According to the
American Medical Association, poor health literacy skills are
a stronger predictor of an individual’s health status than age,
income, employment status, education level, or racial/ethnic
group.59
Prevalence of low health literacy
Data from the U.S. Department of Education 2003 Nation-
al Assessment of Adult Literacy (NAAL) study60 indicate that
a large segment of the population lacks sufficient general lit-
eracy to effectively undertake and execute medical recommen-
dations. Nearly 90 million adult Americans (36% of the adult
population) are limited in their ability to read and understand
health information, including medication labels.17 Individuals
with limited health literacy cannot circle the date of a medi-
cal appointment on a hospital appointment slip or identify how
often a person should have a specified medical test, based on
information in a clearly written pamphlet.5 Almost one-third of
adults older than 65 years have very poor health literacy skills.
Adults who receive Medicare or Medicaid and those with no in-
surance have lower-than-average health literacy.5 More than
one-third of English-speaking patients and more than one-half
of primarily Spanish-speaking patients at U.S. public hospitals
have low health literacy.61
NAAL data indicate that only 12% of U.S. adults have pro-
ficient health literacy skills. Individuals with proficient health
literacy skills can deal with complex and challenging health
literacy tasks (e.g., calculating an employee’s share of health
insurance costs for a year using a table showing how the em-
ployee’s monthly cost varies depending on income and family
size, finding information required to define a medical term by
searching through a complex document and evaluating infor-
mation to determine which legal document is applicable to a
specific health situation).
Of the other patients, 52, 22, and 14% have intermedi-
ate, basic, or below basic health literacy skills, respectively.60
Those with intermediate skills can deal with most health liter-
acy tasks that they encounter (e.g., using an over-the-counter
drug label to identify substances that may cause an adverse
drug interaction, using a childhood immunization chart to find
the proper age range when certain vaccines may be given to
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135
children). Individuals with basic health literacy would have
trouble providing two reasons why someone with certain symp-
toms might have a specified test, even when using information
from a clearly written, accurate pamphlet. Those with below
basic health literacy would not be able to recognize a medical
appointment on a hospital appointment form or be able to de-
termine how often a person might have a specified medical test
from a clearly written pamphlet containing basic information.
Patients with basic or below basic health literacy frequently
cannot read written information given to them by health profes-
sionals.
Risk factors for low health literacy
Poor health literacy is a problem that affects individuals
from all segments of society regardless of their age, gender,
race/ethnicity, income, or social class.62 Individuals at highest
risk are the economically disadvantaged, elderly, or chroni-
cally ill.63 Certain ethnic or racial groups also have high rates of
low health literacy, with 66% of Hispanics and 58% of blacks
having basic or below basic literacy skills in the NAAL study.60
However, the most common demographic profile of an individ-
ual with low health literacy is white race and born in the United
States.64 Groups with especially high prevalence of low literacy
are listed in Table 1.
Effectively communicating health
information
Most of the health education information that is provided to
patients, both oral instructions and written information, is pre-
sented in a format that is too complex for the average person to
understand.2,58,65–67 This communication mismatch is one of the
causes of nonadherence.2,10,68,69 Approximately one-third of all
patients and two-thirds of physicians know someone who has
had health problems because they did not understand how to
take a prescription medication correctly.70 Inadequate under-
standing or misunderstanding of medication instructions and
information includes not understanding how to properly admin-
ister the medication and not comprehending the importance of
medication therapy.2,13,71 Patients may believe, for example,
that medications such as antidepressants and corticosteroids
are not working and stop taking them before the intended ef-
fects of the medications can be produced.29
Effective communication every time medications are dis-
pensed can make a critical difference.72–74 Although the effect
of pharmacist–patient communication is unstudied within the
context of health literacy, research on physician–patient com-
munication shows that physicians commonly overestimate
patients’ literacy levels and rarely consider limited literacy
skills in their assessment of whether patients understand what
action is needed.69 Individuals with low literacy skills are dis-
advantaged in their ability to obtain, process, and understand
both written and verbal information.65 This makes communi-
cation about taking medications a critical factor in the phar-
macist–patient interaction. Improved communication between
pharmacists and patients has the potential to enhance patients’
understanding of the prescribed medication regimen and what
Journal of the American Pharmacists Association
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to expect from medication therapy and hence avoid medication
nonadherence related to these issues.
Oral communication
Patients with low health literacy skills rely heavily on
oral communication and need help in remembering what they
hear.75–77 They prefer to receive oral rather than written health
information.78 Unfortunately, in many cases, this is not what
they get from their pharmacists. In a study of more than 300
pharmacies in eight states, most shoppers (89%) received
written information, 25% of them never talked with a pharma-
cist, and 63% received oral information regarding new pre-
scriptions. Further, the majority of shoppers received no oral
advice or reinforcement about how long to take medications,
how to manage adverse effects or precautions, or when the
medications would begin to work. Although most shoppers in
this study received written information, only 5% were provided
with any review of the patient information leaflets.79
Communication problems are not automatically resolved
by patients’ desire for oral communication and health provid-
ers’ attempts to meet this need. A substantial gap exists be-
tween the words and language used among health profession-
als and those of their patients.76,80–82 Many people, including
those who are highly literate, have trouble understanding com-
monly used health terms,83 including medical words, concept
words, category words, and value judgment words.83,84 These
“words to watch” can be made understandable by explaining
them with common words, using examples, or using visual
aids.83,84 Appendix 1 (electronic version of this article, avail-
able online at www.japha.org) gives some examples of plain-
language alternatives to these “words to watch.”
Patients, particularly those with limited health literacy
skills, are more interested in information that improves their
sense of well-being and helps them deal with immediate health
problems.57 This information can sometimes be difficult for
health professionals to provide, especially when dealing with
patients who have limited literacy and/or health literacy skills.
The literature on physician–patient communication indicates
that although patients with limited literacy may want and need
information clarified, they tend to ask fewer questions69,78 and
may hide their limited understanding out of shame and embar-
rassment.69,85 Patients want information about the indication of
medications, expected benefits, duration of therapy, and poten-
tial adverse effects, in addition to information identifying the
drug’s name, directions for use, and warnings.86
Given that patients at all health literacy levels have prob-
lems understanding medical information,62 the relative paucity
of vocabulary and restricted knowledge base among people
with low health literacy skills put them at an even greater risk
for difficulties in understanding and integrating oral commu-
nication. Thus, when pharmacists provide oral counseling,
patients with low literacy and/or low health literacy skills may
still not understand the information presented to them. For
information to be understood and adherence to be promoted,
pharmacists should speak clearly and slowly, use appropriate
vocabulary, avoid medical jargon, explain the specific steps of
Journal of the American Pharmacists Association
136
Health literacy reviews
the regimen, review the most important details, and encourage
their patients to ask questions.43,57,65 Also, pharmacists need to
consider and convey how the recommendation fits practically
into their patients’ lifestyles and how the information can bene-
fit patients.57 The Partnership for Clear Health Communication
has excellent recommendations for patient involvement that
centers on three questions that health care providers should
encourage patients to ask about their health care visits:
(1) What is my main problem?
(2) What do I need to do?
(3) Why is it important for me to do this?
A complete discussion of this topic and downloadable re-
sources can be obtained at www.askme3.org.83
Written communication
Written instructions on the use of medications are among
the most important materials that patients receive.87 The im-
portance of written instructions in patient education is re-
flected by one of the goals of Healthy People 2010 (i.e., 95%
of patients getting new prescriptions should also receive
useful written medication instructions about the dispensed
medicine).54 The benefits of written medication information
have been well documented.88–93 Health organizations and
professionals use written patient information materials as
part of patient education or health promotion efforts, in sup-
port of preventive, treatment, and adherence objectives.94
When used as an adjunct to verbal counseling, written infor-
mation can reinforce specific instructions or warnings. It can
also provide a means for introducing supplemental informa-
tion that may be difficult to convey during a brief counseling
session.95 Pharmacy-distributed patient education materials
include details concerning adverse effects, medication inter-
actions, purpose of the medication, what to do in the event of
adverse effects, expected duration of therapy, and what to do
if a dose is missed.88
Despite the widespread availability and benefits of writ-
ten materials, many such resources are of little value to pa-
tients with limited literacy and/or health literacy skills.2,18,96
Simply giving patients written information does not ensure
that patients understand the information. Literacy studies
Table 1. Groups and characteristics often associated with
high prevalence of low literacy
Elderly
Female gender
Not completing high school
Immigrants
Incarceration
Income status classified as poor or near poor
Living in the south or northeast (rather than west and midwest)
Lower socioeconomic status
Member of minority group
Lower cognitive ability
Chronic disease
Source: References 55, 87, 100, 130, 137, 138, 146.
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 reviews Health literacy
show a gap of more than 5 years between most patients’ read-
ing capacities and the reading levels required to understand
written educational materials.97 Also, although the average
adult American reads at an 8th grade level,2 the average
health education information material is written at the 12th
grade level.62 In a study that examined the distribution and
quality of patient medication leaflets provided in U.S. pharma-
cies, patients rated 36% of the leaflets as difficult to read.98
Another study examining the readability of commonly used
pharmacy patient education materials found that only 2% had
readability scores at or below the 8th grade level; 69% scored
in the 9th to 12th grade range, and 29% scored above the
12th grade level.88
To provide optimal medication information to patients,
written materials must be written at an appropriate reading
skill or grade level for the intended audience.95 A text’s read-
ability (i.e., the ease at which it can be read and understood),
is one of the factors that affects its appeal.96,99 Findings from
one study indicated that, compared with prescription warning
labels with text written at the 3rd grade level or below, labels
with text written at the 6th to 7th grade level are 4.3 times
more likely to be misinterpreted and those with text at the 8th
grade level are 12.9 times more likely to be misinterpreted.100
The National Work Group on Literacy and Health recom-
mends that health materials be written at a 5th grade read-
ability level but recognizes that this level is still too difficult
for about 25% of the population.101 Ideally, health education
materials should be written at the 3rd to 4th grade level.102
Medication knowledge
Patients’ ability to participate in their care and deci-
sion making depends largely on their knowledge and literacy
skills,103 and several authors have reported that patients’
knowledge of medications is positively associated with adher-
ence.104–108
One study involving 2,659 patients with limited literacy
skills examined patients’ ability to process numbers (numer-
acy) and other concepts related to medication use. Overall,
42% of patients gave incorrect answers for “how to take a
medication on an empty stomach,” 33% for “how many pills
of a prescription should be taken,” 23% for “how many times
a prescription can be refilled,” and 13% could not understand
directions to take medication four times a day.109
A gap between what patients ought to know to use dis-
pensed medications appropriately and what they actually
know was also found in a study that evaluated the effects of
low literacy, medication regimen complexity, and sociodemo-
graphic characteristics on medication management capac-
ity among 152 mostly elderly participants (mean age 65.4
years). In the study, 38% of the patients were unable to iden-
tify all of their medications, despite being able to look at the
bottle, label, or tablets.9 More than one-half (57%) of those
with inadequate literacy skills were unable to identify all of
their medications compared with 25% of those with marginal
literacy and 7% of those with adequate (reading level of 9th
grade or higher) literacy skills.
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137
Cognitive capacity
Cognition is the portion of a person’s comprehension,
memory, and recall used to perform tasks that require some
knowledge, skills, or ability.46 The implication therefore is that
patients must understand what they are supposed to do before
they can follow medical recommendations.
A study designed to determine the prevalence of low func-
tional health literacy among Medicare managed care enrollees
found that 47.5% of adults with inadequate literacy skills incor-
rectly described the timing of medication doses after reading
the label on a prescription vial compared with 24.4% of those
with marginal and 11.5% of those with adequate literacy skills.
Also, 54.3% of respondents with inadequate literacy skills
could not describe how to take medication on an empty stom-
ach compared with 33.7 and 15.6% of those with marginal and
adequate literacy skills, respectively.110
In a recent multisite study that investigated the success
with which patients understand instructions on medication
labels, 46.3% misunderstood one or more of the prescription
label instructions. The prevalence of incorrect answers among
patients reading at the 9th grade level or above (adequate lit-
eracy), those reading at the 7th to 8th grade level (marginal
literacy), and those reading at or below the 6th grade level (low
literacy) was 37.7, 51.3, and 62.7%, respectively. More than
one-third of patients with adequate literacy skills (38%) mis-
understood at least one of the label instructions. Patients with
low literacy were less able to understand the meaning of all five
medication labels than those with adequate literacy. For exam-
ple, for the instruction, “Take two tablets by mouth twice daily,”
most patients (71%) with low literacy could read the instruc-
tion correctly. However, only 35% accurately demonstrated the
correct number of tablets to be taken daily. The majority of the
misunderstood label instructions were related to dosing such
as teaspoonful versus a tablespoonful or to frequency or du-
ration of use. The frequency of mistakes was higher when the
medication instructions included multiple varying numbers,
such as, “Take one tablet by mouth twice daily for 7 days.” Tak-
ing a greater number of prescription medications was also as-
sociated with misunderstanding label instructions.111
In a portion of the above study,111 patients were assessed
based on whether they could accurately read and state the in-
structions for guaifenesin (“Take two tablets by mouth twice
daily”) and correctly demonstrate how many tablets were to be
taken daily. Patients at all literacy levels were better able to
read label instructions than to demonstrate the correct num-
ber of tablets to be taken. The investigators suggested that
verifying whether patients or their surrogates can accurately
describe and demonstrate how to take prescribed medications
safely needs to occur during medication review. Most patients
with literacy problems were unable to follow the prescription
medication directions, “Take 1 tablet X times a day,” with the
X being a number.112 With this instruction, patients took the
prescribed medication at inappropriate times or intervals or in
the wrong quantities. When the direction is written as “Take 1
tablet every X hours,” patients are more likely to understand
the directions and follow them correctly. Other recommenda-
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Table 2. Steps to enhance understanding among patients
with low health literacy
Slow down and take time to assess patients’ health literacy skills.
Use “living room” language instead of medical terminology.
Show or draw pictures to enhance understanding and subsequent
recall.
Limit information given at each interaction and repeat instructions.
Use a “teach back” or “show me” approach to confirm under-
standing. This approach involves having clinicians take respon-
sibility for adequate teaching by asking patients to demonstrate
what they have been told (i.e., teach back to you how to take their
medications) to ensure that education has been adequate.
Use of assistance devices such as pillboxes.
Avoid asking, “Do you understand?”
Be respectful, caring, and sensitive, thereby empowering patients
to participate in their own health care.
Tailor information to the individual by giving examples and explain-
ing relevance.
Ensure understanding through open-ended questioning and dem-
onstration techniques.
Source: References 58, 66, 78, 133.
tions for educating patients with low literacy skills include us-
ing simple language, having patients repeat back instructions
to confirm understanding, and using assistance devices such
as pillboxes, graphic medication schedules, pictographs, and
other multimedia aids.113 Table 2 provides more information on
enhancing understanding and recall of medication instructions.
Adherence is a multidimensional phenomenon44 caused by
varied and complex factors, including the patient’s knowledge
and confidence in their ability to follow recommended behav-
iors.114 Patients want practical, concise information focused on
action and motivation.78 Patients who are informed and effec-
tively motivated are also more likely to adhere to their treat-
ment recommendations.115,116 Studies have found that both
patient satisfaction and patient adherence are enhanced by
patients’ involvement and participation in their care.117,118
Implications for pharmacy practice
Substantial evidence indicates that inadequate health
literacy adversely affects adherence behavior, patients’
knowledge, self-care for chronic diseases, and health care
costs.25,119,120 The IOM report To Err Is Human68 noted that
management of complex medication therapies, especially in
elderly patients, is extremely difficult and requires special at-
tention to the ability of the patient to understand and remem-
ber the amount and timing of a dose, as well as behavioral
modifications required by the regimen. Some patients with
limited literacy and/or health literacy skills may not be get-
ting this special attention from their pharmacists. Study find-
ings121 show that the quality and amount of counseling about
medications in community pharmacies are inadequate and do
not meet the intent of the Omnibus Budget Reconciliation Act
Journal of the American Pharmacists Association
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Health literacy reviews
of 1990, which made patient-centered practice mandatory for
Medicaid beneficiaries through collection of patient informa-
tion, prospective drug use review, and patient counseling.122
According to a 2004 telephone survey that examined the
receipt of medication information at pharmacies, only 31%
of patients reported receiving instructions from their phar-
macists about how to take a new medication and only 29%
were told how much to take.123 Although no single intervention
strategy can improve the medication adherence of all patients,
decades of research studies suggest that successful attempts
to improve patient adherence depend on certain key factors,
including realistic assessment of patients’ knowledge and un-
derstanding of the regimen, clear and effective communication
between health professionals and their patients, and the nur-
turance of trust in the therapeutic relationship.124
Patient education
Patient education is “the process of influencing patient
behavior and producing the changes in knowledge, attitudes
and skills necessary to maintain or improve health.”125 Lack of
patient education can be an important predisposing factor in
nonadherence to prescription medication instructions because
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
patients with low health literacy skill.
A study of 483 asthma patients found an association be-
tween reading ability and asthma knowledge. Among patients
reading below the 3rd grade level, 89% had poor metered-dose
inhaler technique compared with 48% of patients reading at
the high school level.20 In another study of 227 human immu-
nodeficiency virus–seropositive adults, patients with limited
health literacy skills were less adherent to antiretroviral ther-
apy, and this effect persisted after controlling for other vari-
ables.127 In the study, patients with limited health literacy skills
often cited confusion with prescribed regimen as a reason for
nonadherence. Patients with low literacy skills were also re-
ported in a study that examined patients’ understanding and
use of oral contraceptive pills to be less likely to understand
how to correctly use birth control methods.128
Challenges with low health literacy
Clinicians encounter patients with limited health literacy
on a daily basis.87 Patients with limited literacy and/or health
literacy skills are more likely to have difficulties understanding
and executing proper medication use.20,111,109,129 A report by the
Agency for Healthcare Research and Quality on health literacy
concluded, “Low reading skills and poor health are clearly re-
lated.”130 In addition, evidence indicates that communication
barriers such as limited English proficiency and limited health
literacy are associated with lower quality of care and place pa-
tients at risk for poor clinical outcomes.21,131
All this information gives pharmacists more reasons to
pay particular attention to their interactions with patients who
have limited health literacy skills and other communication
barriers. The philosophy of pharmaceutical care calls for phar-
macists to identify, resolve, and prevent medication-related
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problems.132 Routine identification of patients with limited lit-
eracy and/or health literacy skills and development of interven-
tions to prevent inappropriate use of prescribed medications
may increase patient knowledge and self-care skills and, ulti-
mately, adherence and outcome.
Pharmacists’ role in unintentional medication
nonadherence
Poor medication adherence is not simply a “patient” prob-
lem. The pharmacist is also involved. Studies of the reasons
for patients not following medical advice have used models
that place primary emphasis on patients and their motivations,
predispositions, or level of “psychological readiness.”35 These
models tend to neglect the possibility that nonadherence can
be unintentional.133,134
Some patients may be motivated to adhere to the pre-
scribed regimen but fail to do so because of misunderstanding
associated with factors such as low health literacy or language
barriers. Misunderstanding of the regimen and language bar-
riers are essential elements of unintentional nonadherence.135
Given the extent of the limited literacy and health literacy
problem in the United States and the association between
limited health literacy and medication nonadherence, poor
health, and treatment outcomes, pharmacists have a critical
role to play. Communicating more effectively with patients
about medications is necessary for helping them achieve de-
sired therapeutic outcomes from medication therapy. Being
aware of the patient’s skills, including literacy and health lit-
eracy skills, is a necessary first step in this endeavor because
different communication strategies may be needed for en-
hancing the pharmacist–patient interaction and subsequently
improving adherence. However, awareness alone is not suf-
ficient. Patients with limited literacy and/or health literacy
skills have to be identified.
Identifying low literacy patients. A report from the Ameri-
can Pharmacists Association indicated that pharmacists are
not paying sufficient attention to the literacy status of their
patients.136 The report highlighted the findings from a survey
of community pharmacies71 showing that most pharmacists
were unaware of the limited literacy skills of many of their
patients. Also, many of the pharmacists thought that they did
not have to worry about literacy issues because they did not
have low-income patients. These findings are supported by
other reports.65,87,137,138
Generally, patients with limited literacy skills cannot be
identified by their appearance or speech, and most describe
themselves as able to read English “well” or “very well.”138 Iden-
tifying patients who may have limited health literacy skills can
be difficult.65 Asking patients questions such as, “How many
years of school did you complete?” or “Can you read?” does not
accurately assess their literacy level.58,87,97,139,140 A survey of
Medicare managed care enrollees found that 27% of those who
graduated from high school had inadequate or marginal health
literacy, as did 17% of those with some college education.107
Also, in a study of preoperative veterans who were predomi-
nantly white and had at least a high school education, 12% had
inadequate or marginal health literacy. Health literacy did not
correlate with self-reported years of education.108
In short, patients with limited health literacy do not fit a
stereotype. Many well-groomed, articulate, intelligent-sound-
ing individuals have limited health literacy.138,58,141 Most indi-
viduals with limited literacy are often embarrassed and go to
great lengths to hide their inability to read or understand medi-
cal information.57,65,78 One study showed that 40% of patients
with low literacy felt shame, 67% had not told their spouse,
53% had not told their children, and 19% never told anyone.142
Red flags. Pharmacists may need other tools and clues or red
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-
tionnaires incompletely or incorrectly or takes medications
the wrong way may do so because of limited health literacy
skills.143 Some clues to limited health literacy are listed in Table
3. However, an absence of clues does not necessarily indicate
that a patient has adequate health literacy. Some experts have
advised approaching all patients as if they have limited health
literacy and to communicate with them accordingly.144
Screening tests. Another approach pharmacists can take is
to use screening tests in identifying patients with low health
literacy. Instruments for measuring literacy in the health care
setting have focused on the ability to read and, in some cases,
use numbers.130
The two frequently used instruments are the Rapid Esti-
mate of Adult Literacy in Medicine (REALM) and the Test of
Functional Health Literacy in Adults (TOFHLA).17,145,146 REALM
is a 66-item word recognition and pronunciation test that
measures the domain of vocabulary. The words are arranged
in order of complexity by the number of syllables and pronun-
ciation difficulty starting with simple one-syllable words such
as “pill” and ending with multisyllable words such as “antibiot-
ics.” It can be administered and scored in less than 3 minutes
by personnel with minimal training, making it easy to use in
clinical settings.147 Scores on REALM vary from 0 (no words
pronounced correctly) to 66 (all words pronounced correctly).
The scores can be grouped into three categories of literacy: in-
adequate (0–44, representing a reading level at or below the
6th grade, marginal (45–60, 7th to 8th grade level), and ad-
equate (61–66, 9th grade or above).9 The test provides both an
assessment of general reading skills and an indication of the
individual’s health literacy skills. It is available only in English.
TOFHLA measures reading fluency and is available
in both English and Spanish. The standard test includes a
17-item test of numerical ability and a 50-item test of reading
comprehension and takes about 22 minutes to administer.148
A short version of the test (S-TOFHLA) is also available; it
takes about 7 minutes to administer. Both tests identify indi-
viduals who are likely to have poor background health knowl-
edge and difficulty understanding both written and oral health
messages.149 Scores on TOFHLA categorize patients as hav-
ing low, marginal, or adequate health literacy skills.150
Recently, a new screening test, the Newest Vital Sign
(NVS), was developed.146 It consists of a nutrition label for ice
cream with six questions about the information contained in
the label. The patient’s response to each of the questions is
scored as correct or incorrect. One point is assigned for each
correct answer. Patients who score 4 to 6 are classified as hav-
ing adequate health literacy skills. Those who score 2 to 3 are
classified as “possibly” having low health literacy, and those
with a score of 0 to 1 are classified as “likely” having low health
literacy. NVS takes approximately 3 minutes to complete. It is
fairly short, moderately accurate, and appears to identify indi-
viduals with limited reading capacities better than demograph-
ics alone.145 NVS is available in both English and Spanish.
Although some researchers have used REALM, TOFHLA,
S-TOFHLA, or NVS to identify individuals with limited literacy,
Journal of the American Pharmacists Association
140
Health literacy reviews
others have relied on screening questions. Chew et al.151 found
three screening questions to be predictive of limited health
literacy skills in a sample of men receiving medical care at a
Veterans Administration clinic: (1) ‘‘How often do you have
problems learning about your medical condition because of
difficulty understanding written information?’’ (always, often,
sometimes, occasionally, or never), (2) ‘‘How often do you have
someone help you read hospital materials?’’ (always, often,
sometimes, occasionally, or never), and (3) ‘‘How confident
are you filling out medical forms by yourself?’’ (extremely, quite
a bit, somewhat, a little bit, or not at all). These researchers
found the question about hospital materials to be most effec-
tive at identifying patients with limited health literacy. They
concluded that limited literacy in health care settings can be
detected with a single question and that the single question is
more effective than demographic characteristics. These find-
ings have been supported by other researchers.152
Communicating to enhance medication adherence
Provider–patient communication is a contributing factor
in patient satisfaction, adherence, and health outcomes.153,154
Studies have also shown that people understand and remem-
ber what is important to them and have demonstrated signifi-
cant differences between what patients want to know and what
health professionals think they should know.155,156 A descriptive
study of the information that patients with hypertension prefer
to receive about medications to improve adherence reported
that 90% of patients wanted to know about adverse drug reac-
tions, 96% wanted to know about the benefits of the medica-
tion, and 82% wanted more information about their disease.
Other frequent concerns were related to duration of therapy
and lifestyle effects.157
Effective communication with patients, especially those
with low health literacy skills, has the potential of not only
bridging the communication gap between practitioners and
their patients but also improving patients’ understanding of
the prescribed medication regimen and providing patients with
information that they desire and want to know. Patients with
limited literacy and/or health literacy skills may be empow-
ered when pharmacists communicate using oral and/or writ-
ten means that convey pertinent medication information and
ensure that each patient understands the prescribed behavior.
Difficulties may be addressed and potentially resolved before
they lead to nonadherence with prescribed medications. Fur-
thermore, collaboration with the patient may enhance shared
decision making, which might lead to better adherence.158
Oral communication
Most patients prefer medical advice that is simple and easy
to understand.57,119,159–161 Pharmacists can simplify their advice
to patients by providing essential instructions only and using
nonmedical language.59,83,143 Online Appendix 1 gives some ex-
amples of plain-language alternatives to medical terms.
Pharmacists can make their instructions interactive by
having patients do, write, say, or show something to demon-
strate their understanding.16 Also, because patients forget
more than one-half of the information from oral explanations
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immediately after they hear it,162 strategies aimed at improv-
ing patients’ recall of medical instructions must be used to
assist patients with their prescribed medication regimens.
Recall can be aided by presenting instructions in a clear and
simple manner, using concrete and specific advice, repeating
and stressing the importance of the critical components of the
advice, checking understanding, and providing feedback.58,78
Other suggestions to enhance adherence include color coding
the prescription vials based on the time of day a dose needs to
be taken29 and using organizers and reminders such as blister
packs, calendars, dosage counters, and special containers.85,163
Pharmacists have an opportunity to access a patient’s
cognitive structure during the counseling process to ensure
that the prescribed instruction is comprehended and can be
recalled when needed.46 When pharmacists interact with pa-
tients at this level, they can successfully engage in patient
education that empowers patients to better adhere to pre-
scribed medication regimens, which might result in better
therapeutic outcomes.
Use of written materials
Pharmacists can use a number of formulas to evaluate the
readability of the most commonly used written patient medica-
tion information materials in their practice. Most of the formu-
las are applicable to narrative language (running text) but not
to lists, charts, and tables.164 Also, the majority of them estab-
lish readability based on two factors: (1) the number of difficult
words (usually words with three or more syllables) in a sample
and (2) a higher grade level. Pharmacists can test for read-
ability by hand or using computer software. The Fry method is
an easily used means of checking readability.165 It is relatively
simple and yields accurate results.95,164,166 Obtaining results for
typical patient leaflets and materials when using the Fry meth-
od without electronic aids only takes about 15 to 20 minutes.
Several word-processing software programs, including Mi-
crosoft Word, can be used to test readability of passages. These
computer tests provide a quick analysis of readability along with
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-
ters between spaces) and sentence length (the number of words
between periods). Also, the readability score does not consider
content.143,166 Instructions for calculating readability levels us-
ing the Fry method are provided in online Appendix 2.167
The Gunning-Fog test is another simple readability test.
Schrock166 provides directions for these and other readability
formulas along with information on Readability PLUS software.
Use of pictorial aids
Patients of all literacy levels can benefit from picture-based
information, but patients with limited literacy skills are espe-
cially likely to benefit.2,77,168,169 Research findings have shown
that pictorial aids enhance patient recall, comprehension, and
adherence to medication regimens, particularly when combined
with written or oral instructions.2,77,168 To reap the benefits of
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141
pictorial aids, however, pictorial aids designers need to take
into account the educational level of the target group and the
environment, both culturally and ecologically.57,138,168–170 Picto-
rial aids that are useful in one population might not be used suc-
cessfully in another.168,170 Thus, pharmacists should make sure
that patients interpret pictorial aids correctly when using them
in their practice. Telling patients the correct meaning of an in-
correct pictorial aid has been found to substantially increase
its correct interpretation later.171 Training patients in the use of
pictorial medication information to improve its use as a medica-
tion administration aid has been suggested.2,170 Recommenda-
tions on the use of pictorial aids in improving health communi-
cation are presented in Table 4.
Other resources for enhancing communication
with patients
Pharmacists can use several available resources to en-
hance their communication with patients, especially those who
are challenged by health literacy issues. They can, for example,
register and take a free online course, “Unified health commu-
nication 101: Addressing health literacy, cultural competency,
and limited English proficiency,” that was developed by the
Health Resources and Services Administration.172 The course
is designed to help health professionals improve their patient
communication skills, increase their awareness and knowledge
of the three main factors that affect their communication with
patients (health literacy, cultural competency, and low English
proficiency), and implement patient-centered communication
practices that demonstrate cultural competency and appro-
priately address patients with limited health literacy and low
English proficiency.172 The Health Sciences Library at the Uni-
versity of North Carolina at Chapel Hill maintains a list of health
literacy resources, many of which can be useful to pharmacists
(online Appendix 3).173 The list includes information on low lit-
eracy education materials that are designed by several national
organizations and are available to the public. Other suggested
strategies are presented in Tables 2 and 5.
Table 4. Recommendations for using pictures in health
communication
Ask how you can use pictures to support key points
Minimize distracting details in pictures
Use simple language in conjunction with pictures
Closely link pictures to text and/or captions
Include people from the intended audience in designing pictures
Have health professionals plan the pictures, not artists
Evaluate pictures’ effects by comparing response to materials with
and without pictures
Orienting instructions are important when patients are first intro-
duced to pictorial aids
Make sure that patients interpret pictorial aids correctly
Source: References 2, 168–171, 173.
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Looking ahead: Pharmacist–patient
interactions
Health care delivery continues to shift from inpatient
to outpatient settings, and the practice of quality control
over medication use is becoming more the responsibility
of the patient and less the responsibility of the provider.109
These trends indicate the importance of the pharmacist–pa-
tient interaction in ensuring that patients have the skill and
knowledge needed to perform self-care medication-taking
behaviors. Pharmacists have the essential technical knowl-
edge for assisting patients with their medication information
needs and medication-taking behavior. Despite this knowl-
edge, rendering the assistance that patients need might be
difficult because of certain operational aspects of pharmacy
practice and the motivation and attitudes of pharmacists.
Results from a national survey indicated that pharma-
cists prefer devoting more of their time to consultation and
drug use management activities in community settings.174
The results also showed that pharmacists have not been
afforded a full opportunity to engage in these activities to
the desired extent.174 Functional barriers such as time con-
straints, lack of resources, and lack of management support
to counsel patients can affect pharmacists’ ability to engage
in patient education. The involvement and collaboration of
pharmacy employers is essential for developing solutions to
improve clear communication between pharmacists and all
patients but particularly between pharmacists and patients
with limited literacy and/or health literacy. Although, in gen-
eral, patients have problems understanding medical infor-
mation, patients with limited literacy and/or health literacy
Table 5. Practice behaviors that can enhance oral
communication with low health literacy patients
Limit teaching objectives
Use simple sentences and plain language
Limit points to two or three at a time
Give many examples
Demonstrate procedures such as counting pills
Repeat and summarize
Use drawings, diagrams, or models to illustrate what is being
communicated
Encourage questions
Communicate with patient at eye level
Make learning participatory (enhances long-term memory of the
information and checks patient’s comprehension)
Organize your information and present the most important
messages at the beginning and end
Be positive and encouraging
Encourage the desired behavior
Create a shame-free environment and offer assistance when
needed
Use “teach back” or “show back” techniques to assess and
ensure understanding
Source: References 66, 78, 138, 159.
Journal of the American Pharmacists Association
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Health literacy reviews
are especially in need of help. These patients may rely more
on verbal explanations than written medication information
materials. To enhance medication adherence in this patient
population, more intensive communication and educational
strategies are needed, as well as a collaborative approach
to care.30 Pharmacists’ interactions with these patients
could be a critical factor in determining whether they under-
stand the prescribed medication instructions and behaviors.
General strategies might not be adequate for meeting their
unique needs. Patients should be given the opportunity to
assess the potential risks in a proposed treatment and its
potential effect on the quality of their lives.10 Pharmacists
might need additional resources, such as training, time, au-
tomation, and technicians, to make this vital service avail-
able to patients.
With appropriate administrative support, pharmacists
must work with all patients to find viable communication
strategies to improve patient comprehension of prescribed
medication instructions and, hopefully, adherence with
medication regimens. A recently published study of a com-
prehensive pharmacy program composed of patient educa-
tion and custom blister-packed medications was associated
with substantial and sustained improvements in both adher-
ence and therapeutic outcomes.175 In today’s health care en-
vironment, medications play a major role in increasing qual-
ity and years of healthy life. With the aging of the population
and the likely increase in chronic diseases, medications will
continue to be an integral part of the health care system.
Pharmacist interventions can help reduce the burden as-
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
hospitalization. This can lead to better appreciation of phar-
macist interventions by patients, prescribers, third-party
payers, and society at large. Ultimately, this might result in
reimbursement for more of the services that pharmacists
provide to their patients and an enhancement of the public’s
view of pharmacy’s professional image.
Conclusion
Although pharmacy-specific recommendations are still
lacking for the most part, the need for health literacy educa-
tion for pharmacists and students remains high. Such educa-
tion should promote awareness of how to recognize patients
with low literacy skills and provide strategies to enhance
understanding and adherence in this population. Although
the information provided in this article is not exhaustive or
comprehensive, it can assist pharmacists in their efforts to
communicate more effectively with all patients in a way that
enhances their understanding of prescription medication in-
structions. By teaming with patients, physicians, and other
professionals, pharmacists can overcome health literacy
barriers and help ensure the delivery of appropriate patient
education, potentially resulting in improved medication-
taking behavior and adherence to prescribed medication
therapy.
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 reviews Health literacy

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 www.pharmacist.com 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 www.pharmacist.com 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.

e147 • JAPhA • 4 9 : 5 • S e p /O c t 2009 www.japha.org Journal of the American Pharmacists Association

147 8/28/09 10:11 AM

 Health literacy reviews

9. Which of the following is correct?
a. Health literacy refers only to the ability to read medi-
cal information.
b. A person’s health literacy may be worse than his/her
general literacy.
c. Health literacy includes the ability to process numbers
(numeracy) and navigate the health care system.
d. Alternatives b and c are correct.
10. Health literacy assessment instruments include
which of the following?
a. Newest Vital Sign (NVS)
b. Rapid Estimate of Adult Literacy in Medicine (REALM)
c. Test of Functional Health Literacy in Adults (TOFHLA)
d. All of the above alternatives are correct.
14. Patients with limited health literacy skills would be
most likely to make mistakes in interpreting which of
the following label instructions?
a. Take two tablets by mouth twice daily for 7 days
b. Take two tablets by mouth every 12 hours
c. Take two tablets by mouth two times daily
d. Take two tablets by mouth twice daily
15. Patients with limited health literacy skills would be
least likely to make mistakes in interpreting which of
the following label instructions?
a. Take two tablets by mouth twice daily for 7 days
b. Take two tablets by mouth every 12 hours
c. Take two tablets by mouth two times daily
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?
a. Almost one-third of adults older than 65 years have
very poor health literacy skills.
b. Adults who receive Medicare or Medicaid have lower-
than-average health literacy.
c. Low literacy affects patients’ health and their partici-
pation in medical care decision making and patient-
centered care.
d. Study findings indicate that the quality and amount
of counseling regarding medications in community
pharmacies are adequate and meet the intent of the
Omnibus Budget Reconciliation Act of 1990.
17. Which of the following statements on the use of vi-
sual aids is false?
a. Picture-based information can benefit only patients
with limited health literacy skills.
b. Research findings indicate that visual aids enhance
patient adherence to medication regimens.
c. Pictorial aids that are used successfully in one culture
can be used successfully in other cultures.
d. Telling patients the correct meaning of an incorrect
pictorial aid has been found to considerably increase
its correct interpretation later.
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 www.pharmacist.com/education 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 InfoCenter@pharmacist.com.

Journal of the American Pharmacists Association www.japha.org S e p /O c t 2009 • 49:5 • JAPhA • e148

148 8/28/09 10:11 AM

 reviews Health literacy
2 puffs every 4 to 6 hours as needed, fluticasone/salme-
terol inhaler (250 mcg/50 mcg) twice daily.
J.T. was recently hospitalized with heart failure. He was
discharged after 3 days and given a new prescription for
digoxin 0.125 mg, alternating with 0.25 mg every other
day. He comes to your pharmacy to fill his prescriptions.
You ask him how he is feeling, and he says, “I am feel-
ing much better, but my doctor keeps on prescribing me
the wrong medications. I take all my medications but I
keep having one health crisis after another.” You ensure
him that digoxin is a good heart medication but that he
needs to take it as directed. You tell him that he should
stop taking the medication and contact his doctor im-
mediately if he experiences vision changes (e.g., yellow-
green or blurred vision).
In order to not keep him waiting, you quickly fill his pre-
scription and hand it to him. You are about to attend to
the next patient when you realize that you did not put
the medication information sheet into J.T.’s medication
bag. You go after J.T. and hand the medication sheet
to him (wrong side up). You wait a few minutes for J.T.
to read the medication information and ask him if he
understood the information. Without turning the sheet
right side up, he says, “Yes, but I will read it more care-
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
dates.
e149 • JAPhA • 4 9 : 5 • S e p /O c t 2009 www.japha.org
149
18. Which of the following statements would be true if
J.T. has a health literacy problem?
a. He could be well groomed.
b. He could have a college degree.
c. He could be an articulate, intelligent-sounding indi-
vidual.
d. He could go to great lengths to hide his inability to
read or understand medical information.
e. All of the above alternatives are correct.
19. Which of the following techniques can the pharma-
cist use to assess J.T.’s understanding of the pre-
scribed medication instructions?
a. Ask “Do you understand?”
b. Ask open-ended questions
c. Use the “teach back” technique
d. Alternatives b and c are correct.
20. The National Work Group on Literacy and Health rec-
ommends that patient education materials for J.T.
be written at which of the following grade readability
levels?
a. 8th
b. 7th
c. 6th
d. 5th
Journal of the American Pharmacists Association
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
importance
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
breath)
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)
________________________________________________________________________________

Source: http://www.npsf.org/askme3/PCHC/download.php
Appendix 2. Calculating readability using the Fry method167

Directions
(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
method.156
Directions
(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)

_______________________________________________________________________

HEALTH LITERACY RESOURCES

Web Sites

AskMe3 - Partnership for Clear Health Communication

http://askmethree.org/

AMA Health Literacy Kit – American Medical Association

http://www.ama-assn.org/ama/pub/category/9913.html

Pfizer Clear Health Communication Initiative http://www.pfizerhealthliteracy.com/

Health Literacy Consulting

http://www.healthliteracy.com/

Health Literacy Fact Sheets - Center for Health Care Strategies

http://www.chcs.org/usr_doc/Health_Literacy_Fact_Sheets.pdf

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

http://www.health.gov/communication/literacy/quickguide/

Health Literacy Project - Institute of Medicine

http://www.iom.edu/?id=3827&redirect=0

Clear Health Communication Initiative – Pfizer

http://www.pfizerhealthliteracy.com/

Health Literacy Studies - Harvard School of Public Health

http://www.hsph.harvard.edu/healthliteracy/index.html

Simply Put – Centers for Disease Control and Prevention

www.cdc.gov/od/oc/simpput.pdf

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

http://www.ihconline.org/toolkits/HealthLiteracy/WritingEasyToReadMaterials.pdf

Clear & Simple: Developing Effective Print Materials for Low-Literate Readers -
National Cancer Institute
http://www.cancer.gov/aboutnci/oc/clear-and-simple/page1

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

1
http://www.nlm.nih.gov/medlineplus/etr.html

Fry’s Readability Graph and Directions

http://kathyschrock.net/fry/fry.pdf

SMOG Readability Formula - University of Utah Health Sciences Center

http://uuhsc.utah.edu/pated/authors/readability.html

Words to Watch Fact Sheet

http://www.pfizerhealthliteracy.com/media/words-to-watch.html

Substitute Word List - University of Utah Health Sciences Center

http://uuhsc.utah.edu/pated/authors/substitute2.html

Plain Language Initiative

http://www.plainlanguage.gov/

Easy-to-Read Health Materials - MedlinePlus

http://www.nlm.nih.gov/medlineplus/easytoread/easytoread_a.html

Culture Clues - University of Washington Medical Center

http://depts.washington.edu/pfes/cultureclues.html

Videos

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
http://www.ama-assn.org/ama/pub/category/8035.html

Health Literacy: A prescription to end confusion

Institute of Medicine, 2004
online video (3 min.) – needs Windows Media Player or RealTime
http://www.aed.org/ToolsandPublications/iom/

In plain language: the need for effective communication in medicine and public
health
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
http://www.ama-assn.org/ama/pub/category/8035.html

Overcoming patient language barriers

2
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
environment
Syracuse, NY: Literacy Volunteers of America, 1992
1 videocassette (17 min.)

Publications

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,
1998

Good medicine for seniors: guidelines for plain language and good design in
prescription medication. Canadian Public Health Association, 2002
http://www.nlhp.cpha.ca/Labels/seniors/english/cover.htm

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
http://www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf

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

Bohlman et al. Washington, D.C.: National Academies Press, 2004
http://www.nap.edu/books/0309091179/html/

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
http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2006483

3
Health literacy style manual/prepared by Maximus for Covering Kids & Families;
funded by the Robert Wood Johnson Foundation, 2005
http://coveringkidsandfamilies.org/resources/docs/stylemanual.pdf

Pfizer principles for clear health communication, 2nd ed. Pfizer, 2004
http://www.pfizerhealthliteracy.org/pdf/PfizerPrinciples.pdf

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
http://purl.access.gpo.gov/GPO/LPS47971

Teaching patients with low literacy skills, 2nd ed. / Cecilia Conrath, Doak, Leonard G.
Doak, Jane H. Root. Philadelphia: J.B. Lippincott, 1996
http://www.hsph.harvard.edu/healthliteracy/doak.html

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
http://www.jointcommission.org/NR/rdonlyres/D5248B2E-E7E6-4121-8874-
99C7B4888301/0/improving_health_literacy.pdf

Working with your older patient: a clinician's handbook

National Institute on Aging, 2004
http://www.niapublications.org/pubs/clinicians2004/index.asp

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
919-966-0958
jean_blackwell@unc.edu