Originally published September 2013
Canada has one of the most highly-educated populations in the world, yet many Canadians do not have the skills necessary to adequately manage their health and healthcare needs.
There are more people in this country with low levels of health literacy (60%) than of literacy (48%).1 The challenge for physicians is to identify the issue and incorporate methods of clear communication that allow patients to understand medical information.
What is health literacy and why does it matter?
Health literacy is content specific. An individual may be able to read and write in certain contexts, but struggle to comprehend health-related vocabulary, materials, and instructions.
Health literacy involves a complex set of abilities which include being able to read and act upon health information, being able to communicate needs to health professionals, and being able to understand and act on health instructions. Many studies show that people of all ages and from all races, income, and education levels may have difficulty processing the information required to make basic health decisions.
As well, growing evidence links low levels of health literacy with increased negative health outcomes,2 for example in managing diabetes and health issues related to blood pressure. Low health literacy can also delay diagnosis, and affect medication compliance, return visits, quality of life, hospitalization, and mortality.3
Identifying issues — Confirming comprehension
The hectic pace of a physician's office, or of a clinic or hospital, makes it easy to overlook red flags that could indicate a patient is unable to provide accurate medical information or has not completely understood the healthcare discussion.
Several indicators may alert physicians to the need to confirm comprehension.4 For example, medical forms may not have been filled in completely or accurately. Patients who frequently miss appointments or fail to follow through with laboratory tests or referrals to consultants may not have totally understood the medical instructions. The inability to name the medication prescribed, explain why it has been prescribed, and when it should be taken could well be another indication of weak health literacy skills.
Physicians' increasing use of technology adds an additional concern when it comes to patient comprehension. Computer or ehealth literacy, while providing more efficient healthcare, may be aggravating the understanding of medical information for some patients. There are risks with providing patients with online information or engaging in electronic communication when a patient's computer literacy skills are weak. Before engaging with patients electronically, physicians should discuss how and when these systems are used, and take reasonable steps to confirm patient understanding.
Some health literacy issues are visible, while others are difficult to pinpoint. Patients may feel intimidated or embarrassed to admit they do not understand their physicians' explanations. Personal barriers, cultural beliefs, or social stigma may also make it difficult for individuals to gain proficiency in health literacy skills. Some people may feel they do not deserve more time with a doctor, while others are overwhelmed by their health condition.
Asking patients, in a respectful manner, to paraphrase what has just been explained may help physicians assess the level of comprehension: "So, let's go over this once more just to make sure that I was able to explain this clearly enough. Can you tell me what you will do and how you will do it when you are at home?"
If strategies confirming comprehension are undertaken in a sensitive manner, physicians will not risk insulting patients.
Does the patient understand the medical condition? 5
A stylish, well-dressed woman in her late 50s is asked what medications she takes. She says Lithium… and no, she doesn't know what it is, but she does know that she follows doctor's orders. On reviewing the label of her prescription, it is noted that she actually takes Lipitor and not Lithium. She has high cholesterol and is not a manic depressive.
Is the issue easy to spot?
A newly-arrived patient with diabetes speaks little or no English and is visibly bewildered by terms like blood glucose levels and hemoglobin A1C tests.
Or is it hidden?
A middle-aged mom is too ashamed to let on that she does not understand the words in the brochure on mammograms which her doctor has handed to her.
Is it typical?
An elderly patient with multiple medical conditions does not take his medication as often as he should because he is confused about which pills to take and when to take them.
Or is it unusual?
A Spanish-speaking international student understands that his prescription calls for a dose of 11 pills per day, instead of one…even though ‘once a day' is clear and legible on the label… ‘once' means 11 in Spanish.
Health literacy and informed consent
Much of a physician's work is done on the basis of consent that is implied either by the words or the behaviour of patients or by the circumstances under which treatment is given. When the treatment is likely to be more than mildly painful, when it carries appreciable risk, or when it will result in surgery, verbal or written expressed consent is required. For consent to treatment to be considered valid, it must be an "informed" consent, meaning that patients have been provided with information that allows them to reach an informed decision.
The explanation given by the physician, the dialogue between physician and patient about the proposed treatment, is an all important element of the consent process. The consent form itself is not the "consent." It is simply evidence — written confirmation — that the explanations were given and that the patient agreed to what was proposed.
Ethical and legal responsibility requires the physician to take steps to be reasonably confident that the patient has understood the information provided, particularly if there are language difficulties or emotional issues. By engaging in personal dialogue with a patient, the physician will be placed in the best possible position to be relatively satisfied that the patient understands the consent explanation.
In some cases, it might be suggested that a patient bring a friend or relative to an appointment during which the physician will provide medical counsel. If language is the issue, an interpreter may help the patient to review specific instructions.
A note by the physician in the record at the time of consent explanations can later serve as confirmation that a patient was appropriately informed, particularly if the note refers to any special points which may have been raised during the discussion.
Helping patients to understand
Given that patients with the lowest skill level in health literacy are also much more prone to negative health outcomes, it is important for physicians to select and frame the information they give to patients. Physicians should consider the characteristics of the populations served through their practice. While definitely not the only indicator of health literacy concerns, taking into account factors related to cultural diversity, age, and income can help physicians tailor their information to suit their community.
Some medical studies claim that most patients forget up to 80% of what is advised as soon as they leave the medical office or clinic.6 To enable patients to understand and retain the discussion, as well as to encourage compliance, there are a number of strategies physicians can consider implementing in their practice.
Physicians should try to create a shame-free environment. No one should be afraid to ask any question, no matter how silly it may seem. As well, it is important to sensitize office staff members to the issue of health literacy by providing them with information that may help identify patients who may need additional healthcare coaching.
Here are a few things for physicians to consider:
Use appropriate printed information, recognizing that comprehension and retention are much stronger when information is provided visually and verbally.
Encourage the use of pictograms, simple language, and avoid the use of medical jargon.
Speak at a slower pace and cover only 2 or 3 concepts at one time. Read written material aloud to patients and underline key points.
Ask patients to paraphrase what has just been explained.
Some patients may benefit from bringing a friend, relative, or interpreter to the counseling and planning portion of a meeting.
Consider scheduling an in-service meeting between patients and a staff member to discuss healthcare instructions.
Reading materials provided to all patients should err on the side of simplicity. It is suggested that a Grade 6 reading level is most appropriate. Readability calculators can determine the grade level of health messages in handouts and other medical materials.7
Remember that comprehension rises dramatically when materials are presented visually and verbally. Physicians may want to develop plain language documents encouraging patients to plan and prepare for their medical appointments by thinking about the questions they want to ask, how they might organize information to describe their concerns, list their medications or bring them to the visit, etc. 8
Discussions with patients should be held in settings which ensure privacy and confidentiality.
Canadian Council on Learning, Health Literacy in Canada:
A Healthy Understanding, 2008, ISBN 978-0-9809042-1-5.
Retrieved April 2013 from:
"Caring for Patients With Limited Health Literacy,"
The Journal of the American Medical Association (September 2011) Retrieved March 2013 from:
American Medical Association, "The ABCs of health literacy," American Medical News. Retrieved March 2013 from:
All examples of health literacy challenges are derived from examples retrieved April 2013 from: www.amednews.com.
Medical Protection Society, "Patients don't always understand,"
UK Casebook 3, August 2003. Retrieved March 2013 from:
Readability calculators such as the Flesch-Kincaid, the
Gunning-Fog or the SMOG readability calculator are examples of online tools that can automatically assess documents.
A good example is "It's Okay to Ask — Your Health is Important," published by the Health Quality Council of Alberta in January 2009. Retrieved April 2013 from: www.hqca.ca