How to tell if a patient has limited health literacy—and what to do about it

While it’s easy to tell if a patient has jaundice, you can’t tell if a patient is health illiterate just by looking at him or her. However, recognizing and addressing health illiteracy is just as important to your patients’ well-being as making accurate clinical diagnoses.


Aniruddha Malpani, MD“If patients do not understand their disease or their doctor’s instructions, they are more likely to skip medical tests; not take their medications on time; and have difficulty managing chronic conditions.”
-Aniruddha Malpani, MD, medical director of Malpani Infertility Clinic in Mumbai, India


There are many myths about patients who likely have limited health literacy skills, such as[s2If !is_user_logged_in()]…

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  • they have a low IQs and are slow learners
  • they look different than patients with high literacy skills
  • their number of years of schooling correlates with literacy skills
  • they will tell you that they have limited literacy skills.

It’s common to make mistakes when estimating a patient’s health literacy. Some doctors and staff may assume that poor patients are health illiterate, or that rich patients understand everything. Both of these stereotypes are incorrect—health illiteracy affects people of all socioeconomic levels, from all walks of life.

If patients do not understand their disease or their doctor’s instructions, they are more likely to skip medical tests; not take their medications on time; and have difficulty managing chronic conditions such as high blood pressure or diabetes.

The list of problems that can plague patients with low health literacy is long:

  • delayed diagnosis
  • a higher number of visits to the doctor
  • increased hospitalization
  • more likely to be overcharged, overtested, and overtreated.

Therefore, recognizing health illiteracy in your patients and intervening is critical to their good health.

Recognizing when patients need help

There are some clues that can help you recognize if a patient might need extra help. For example, if patients complete their medical forms incorrectly, or if they leave many blanks, it may be due to limited literacy skills. Taking medications incorrectly also can be a clue to patients’ lack of understanding of medical terms.

Poor communication has many side effects, and your low-literate patients may:

  • miss appointments frequently
  • have difficulty complying with treatment or medication instructions
  • not follow through with tests or referrals to other providers
  • not read—or comprehend—the patient educational materials you provide
  • forget names of their medications
  • not be able to explain what a medication is for.

Despite these clues, limited health literacy is often a hidden problem. Most people with low health literacy skills go undetected by their doctors, because they go to great lengths to hide their literacy problems. They are ashamed and tend to carry a lot of emotional baggage.

Many low-literate patients are surprisingly smart and have figured out ways to hide their limited literacy skills from others by memorizing things that they have heard before or by making intelligent guesses that cleverly camouflage their lack of understanding.

Key Point: It’s important to identify patients in your medical practice who have low health literacy so that you can intervene and provide them with the information and counseling that they need for better clinical outcomes.

It’s also important to remember that even people with proficient literacy skills can fail to understand complex instructions and health information when they are ill, and many patients avoid asking questions so as not to appear unintelligent, or because they feel that they might annoy a busy physician.

One way to assess whether your patients have adequate health literacy skills is to conduct a “brown bag medication review.” Ask patients to bring in all the medications they take—both prescription and nonprescription—to their next appointment. Ask the patient to name the medications one by one; explain what each is for; and how often they take them.

You may suspect low literacy skills if the patient struggles to read the label on the bottle or if he or she pours out the pills to look at them. Also, while a patient may have memorized dosage instructions such as “take 1 pill every 8 hours,” probing questions such as, “When was the last time you took a pill?” may give more clues as to how well the patient really understands these instructions.

There are several formal health literacy assessment tools available for use in the clinic, such as:

While these resources can help you assess your patients’ level of health literacy scientifically, their major limitation is that they only give an approximation of reading skills and are incapable of assessing other important aspects of health literacy, such as understanding, motivation, and the ability of individuals to access or use information concerning health and healthcare.

Universal precautions

It’s safe to assume that nearly every patient can at times have difficulty understanding health information. Universal precautions are a method of minimizing risk for all patients, because you do not know which patients are having trouble understanding at any given time. The idea is similar to taking universal precautions against the transmission of blood-borne infectious diseases when providing medical care, because you do not know which patients are HIV- or hepatitis-positive.

Many healthcare professionals find it challenging to practice universal precautions, because they have to change the way they think and talk to their patients. They also may fear that they are “dumbing down” the information, or that patients will be insulted by their use of simple language. However, patient surveys have shown this not to be true. Most patients prefer simple and clear communication and plain language helps patients move up the ladder of health literacy.

In brief, universal precautions in the context of health literacy include 4 main areas:

  • improving spoken communication
  • improving written communication
  • improving self-management and empowerment
  • improving support systems.

Improving spoken communication includes using “plain language” and the “teach-back” technique for clear verbal communication. Improving written communication involves selecting and creating written materials that patients can understand and make use of easily. Improving self-management and empowerment means increasing self-efficacy and self-care, thus improving adherence to treatment.

Improving support systems involves collaborating with professionals and organizations inside and outside the healthcare system to help patients carry out the advice of healthcare professionals.

To help healthcare practices implement health literacy universal precautions, the Agency for Healthcare Research and Quality has created a Health Literacy Universal Precautions Toolkit (http://www.nchealthliteracy.org/toolkit/) for health professionals. This resource provides step-by-step instructions for healthcare professionals and offers a systematic approach to simplifying medical care and helping patients get the right medical care.

Physician change agents

Low health literacy affects all of us. It costs the country hundreds of crores of rupees each year, in terms of unnecessary illnesses, wasted productivity, and increased morbidity and mortality rates due to issues such as medication nonadherence.

Health literacy is an issue of social equality, and we need to develop programs that enable people with this challenge to make better use of health services. Doctors can act as powerful agents of change.

Aniruddha Malpani, MD Dr. Malpani is medical director of Malpani Infertility Clinic in Mumbai, India, medical director of the HELP-Health Education Library for People, and author of a physician and patient education blog. He is an angel investor in Plus 91, which offers customized Web sites for doctors.

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