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Pharmacotherapy: A Pathophysiologic Approach is written to help you advance the quality of patient care through evidence-based medication therapy derived from sound pharmacotherapeutic principles. The scope of this trusted classic goes beyond drug indications and dosages to include the initial selection, proper administration, and monitoring of drugs. You will find everything you need to provide safe, effective drug therapy across the full range of therapeutic categories.

Presented in full-color, the Tenth Edition is enriched by more than 300 expert contributors, and every chapter has been updated to reflect the latest in evidence-based information and recommendations. This sweeping updates include tables, charts, algorithms, and practice guidelines. This edition is also enhanced by a timely all-new chapter on Travel Health.
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Pharmacotherapy: A Pathophysiologic Approach, 10e >

Chapter e1: Health Literacy and Medication Use
Oralia V. Bazaldua; DeWayne A. Davidson; Ashley Zurek; Sunil Kripalani

Limited health literacy is common and must be considered when providing medication
management services.
Some groups of people are at higher risk for having limited literacy skills, but in general,
you cannot tell by looking.
Patients with limited health literacy are more likely to misunderstand medication
instructions and have difficulty demonstrating the correct dosing regimen.
Limited health literacy is associated with increased healthcare costs and worse health
outcomes, including increased mortality.
Despite numerous efforts to improve safe medication practices, current strategies have
been inadequate, and this may have a larger impact in patients with limited literacy.
Most printed materials are written at higher comprehension levels than most adults can
The United States Pharmacopeia has set new standards for prescription medication labeling
to minimize patient confusion.
Several instruments exist to measure health literacy, but some experts advocate “universal
precautions” under which all patients are assumed to benefit from plain language and clear
Obtaining a complete medication history and providing medication counseling are vital
components in the medication management of patients with limited health literacy.
Every day, thousands of patients are not taking their medications correctly. Some take too much.
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Others take too little. Some use a tablespoon instead of a teaspoon. Parents pour an oral antibiotic
suspension in their child’s ear instead of giving it by mouth because it was prescribed for an ear
infection. Others are in the emergency department because they did not know how to use the; ir
asthma inhaler. It is not a deliberate revolt against the doctor’s orders but rather a likely and an
unfortunate result of a hidden risk factor—limited health literacy.
Literacy, at the basic level, is simply the ability to read and write. When these skills are applied to
a health context, it is called health literacy, but health literacy is more than just reading and writing.
Health literacy, as defined by the Institute of Medicine (IOM), is “the degree to which individuals have
the capacity to obtain, process, and understand basic health information and services needed to
make appropriate health decisions.” A growing body of evidence associates low health literacy with
less understanding, worse outcomes, and increased cost. These poor outcomes have led this topic to
receive national attention. Health literacy has been made “a priority area for national action” by the
IOM1,2 and Healthy People 2020.3 As a result, federal policy initiatives promoting health literacy
continue to be highlighted in Healthy People 2020, the Patient Protection and Affordable Care Act of
2010, and the Plain Writing Act of 2010.4 A National Action Plan to Improve Health Literacy (Table
e1-1) has also been developed by the Department of Health and Human Services (HHS).5 Likewise,
the Agency for Healthcare Research and Quality (AHRQ),6,7 the National Institutes of Health (NIH),8
and Centers for Disease Control and Prevention (CDC)9 have each dedicated websites to this topic
and have provided funding to support studies and interventions that are specifically relevant to
health literacy. Additionally, state and private sector organizations, such as America’s Health
Insurance Plans (AHIP) and the American College of Physicians (ACP) Foundation, have led efforts to
improve health literacy following the IOM’s call to action.10 Indeed, health literacy should be a
national priority for the medical community as its consequences are far-reaching and cross-cutting.
TABLE e1-1 Goals of the National Action Plan to Improve Health Literacy5
Develop and disseminate health and safety information that is:

Promote changes in the healthcare system that improve:
health information


informed decision-making
access to health services

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Goal Incorporate accurate, standards-based, and developmentally appropriate health and science
information and curricula in child care and education through the university level
Support and expand local efforts to provide:

adult education
English language instruction
culturally and linguistically appropriate health information services in the community

Build partnerships, develop guidance, and change policies
Goal Increase basic research and the development, implementation, and evaluation of practices
and interventions to improve health literacy
Goal Increase the dissemination and use of evidence-based health literacy practices and
More than one of every three American adults has difficulty understanding and acting on health
information.11 Patients with limited health literacy have less knowledge about how to manage their
disease;12 they misunderstand dosing instructions and warning labels on medication containers;13,14
they are less likely to read or even look at medication guides;15 their ability for medication
management is limited as these persons are less able to identify or distinguish their medications from
one another;16,17 and they are less able to use a metered-dose inhaler (MDI) properly.18 Limited
health literacy skills have also been documented in caregivers of seniors19 and in parents of
children.20 There is no question that limited health literacy is associated with adverse health
outcomes21 including an increased mortality rate22 and increased healthcare costs.23
Current strategies for safe medication use have not been effective for the general population and are
likely less useful for persons with limited health literacy. All health professionals need to acknowledge
that limited health literacy is common and may be a barrier to improving health outcomes in their
patients. They need to implement strategies for clear communication in order to enhance appropriate
medication management. This chapter will review what is known about health literacy and present
the evidence available as it relates to medication use.
Clinical Controversy…
Is there a shared meaning of health literacy? While the IOM has provided a concise definition of
health literacy, some argue that the field of health literacy has become so dynamic that experts in the
field do not have a shared meaning for this term.

According to the National Assessment of Adult Literacy (NAAL), 36% of Americans have limited
health literacy skills, meaning that out of four levels, they function at the lowest two.11 The NAAL
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survey was administered randomly to 19,000 adults (greater than or equal to 16 years of age) across
the United States and final results were reported in four skill levels: below basic, basic, intermediate,
and proficient. Fourteen percent of Americans had health literacy skills that were considered below
basic, 22% were at the basic level, 52% were at intermediate, and only 12% were considered
proficient (Fig. e1-1). The below basic level is substantially below that which is necessary to function
within the healthcare setting. Individuals in the basic level have skills to perform simple everyday
literacy activities. They can read, understand, and use information in short and “simple” documents.
Intermediate literacy levels include skills necessary to perform moderately challenging literacy
activities. (Note that the NAAL considered interpreting prescription drug labels an intermediate level
task.) Individuals in the proficient level would have the least difficulty navigating the healthcare
system. This group can analyze, integrate, and synthesize complex information. Approximately 3% of
people surveyed were excluded from the analysis due to language barriers or cognitive disabilities.
Thus, if you add this 3% to the 36% of people that measured at the two lowest levels and consider
the estimated American population of 2020, approximately 130 million Americans have limited health

Percent of adults in each health literacy level. Percentages are from Kutner et al.11 The values in
parentheses estimate the number of American adults (greater than or equal to 15 years of age) in
each literacy level, based on 2015 population projections,(from

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It is generally not possible to tell if someone has limited health literacy simply by looking at or
talking to them. Many persons with limited health literacy learn to hide it very well and many are
known to keep this secret to themselves. In one study, two-thirds of persons surveyed (68%)
admitted to not telling their spouse about their reading difficulties and more than one-half had not
told their children.25 In a study of internal medicine residents and students, few of them recognized
low literacy as a potential factor in patient nonadherence and hospital readmission.26 It is important
to note that health literacy is a context-dependent skill, meaning that people who function well in
one environment may still struggle when presented with healthcare tasks. Thus, even people with
adequate education levels may find it difficult to navigate the healthcare system due to lack of
familiarity with the context. While it is important to remember that people of all ages, nationalities,
and income groups are at risk for limited health literacy, there are some groups that are at
particularly high risk that should be mentioned (Table e1-2).11 This information can help assess the
potential risk of limited health literacy in the patient population being served.
TABLE e1-2 Groups at High Risk of Limited Health Literacy
Age 65 or older

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Spoke another language prior to formal education
Have less than a high school diploma
Live at or below the poverty line
Rate their overall health as poor
Have Medicaid, Medicare, or no insurance
Data from reference 11.
As the Latino population in the United States continues to increase to over 28% as it is projected by
2060,24 this group and those with limited English proficiency (LEP) are at a high risk for limited health
literacy and inappropriate medication management. Not only do they have lower health literacy
scores than the overall population,11 but more than one-half of Latinos are known to have LEP.27
Unfortunately, most pharmacies in the United States are not equipped with appropriate translation or
interpreter services. In a telephone survey of 764 pharmacies, nearly 57% reported limited or no
translation services available.28 In fact, 45% of pharmacies admit to not being satisfied with their
ability to communicate with patients that have LEP. In 2012, the United States Pharmacopeia (USP)
set new standards for prescription container labeling and recommends that whenever possible,
directions be provided in the patient’s preferred language as well as English to minimize the risk of
Practices that serve Latinos or patients with LEP should be cognizant of their high risk and employ
strategies for providing clear communication about appropriate medication management.
What happens when adults with limited literacy become parents? Not surprisingly, a systematic
review of the literature concludes that child and parent literacy seem to be associated with important
health outcomes.30 Similar to data found in adults, children with limited literacy had worse health
behaviors. If their parents had limited literacy skills, these children had worse health outcomes. In a
study of 1,500 parents, Medicaid-insured parents had less education than those with commercial
insurance and were more likely to request unnecessary antibiotics for their children.31 In asthmatic
children, limited parental health literacy is associated with a greater incidence of emergency
department visits, hospitalizations, missed school days, and greater use of rescue medications.32 In
another study, caregivers with low health literacy were more likely to report use of a nonstandardized
dosing instrument.33
While interventions in general are lacking, there are more that target improvement in knowledge
than outcomes. One intervention using pictograms, brief counseling and the teach-back method
improved the likelihood of parents correctly dosing medicines and adhere to the regimen.34 Similarly,
parents with low health literacy were less likely to make a dosing error with infant acetaminophen
after receiving text-plus-pictogram instructions compared to text only recipients.35 As in the adult
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population, effective interventions that improve outcomes and minimize health disparities are

Table e1-3 provides a comprehensive list of studies to date evaluating health literacy and medication
use. In particular, it provides a summary of the studies evaluating the effect of health literacy on
medication knowledge and understanding, medication management, and medication adherence.
One study evaluated the effect of health literacy on adverse drug events and found no association.36
TABLE e1-3 Studies Evaluating Limited Health Literacy and Medication Use
Citation and Literacy

Decreased understanding of how to take medicines:
Take on empty stomach → 65% incorrect

Williams et al.37 (TOFHLA)

How many pills to take → 70% incorrect
How many refills left → 42% incorrect
Decreased understanding of instructions on prescription labels:

Davis et al.13 (REALM)

Two times more likely to misunderstand
Increased misinterpretation of drug warning labels:

Davis et al.14 (REALM)

Three to four times more likely to misinterpret
Decreased understanding of mechanisms and side effects:

Fang et al.38 (S-TOFHLA)

Warfarin works by thinning blood → 30% incorrect
Bleeding/bruising most common → 51% side effect incorrect

Yin et al.33 (TOFHLA)

Marks et al.39 (REALM)

Decreased awareness of weight-based dosing among caregivers of
88.6% unaware
Decreased medication knowledge including name, dose, indication, and
side effects:
80% had medication knowledge score (MKS) below the median

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Citation and Literacy
Mosher et al.36 (REALM)

Decreased medication knowledge (name/indication):
Health literacy level

% correct of names








P < 0.001

P < 0.001

Medication Management
Decreased ability for proper use of metered-dose inhaler (MDI):
Williams et al.18 (REALM)

88% with limited literacy had poor the MDI technique, compared
with 48% of those with higher literacy levels
Decreased ability to demonstrate correct dosing:

Davis et al.14 (REALM)

65% could not demonstrate, “Take two tablets by mouth twice daily”
Decreased ability to name their medications:

Persell et al.17 (S-TOFHLA)

40.5% of those with limited health literacy vs 68.3% of other
Decreased ability to identify all of their medications:

Kripalani et al.16 (REALM)

10-18 times the odds of being unable to identify
Decreased adherence

Kalichman et al.40

Increased nonadherence to antiretroviral therapies:
Three to four times more likely to be nonadherent in last 2 days
Decreased adherence to antiretroviral medications:

Graham et al.41 (REALM)

40% of those with limited health literacy vs 64% of other patients
Increased likelihood to be nonadherent with antiretroviral therapies:

Wolf et al.42

3.3 times more likely to be nonadherent

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Citation and Literacy

Decreased adherence to medication refills:

Kripalani et al.43 (REALM)

Two times more likely to be nonadherent
Decreased medication taking adherence:

Noureldin et al.44

Lindquist et al.45

Bauer et al.46 [3-item

Karter et al.47 [single

54.2% of those with inadequate health literacy vs 69.4% of other
More likely to have unintentional nonadherence after hospital discharge
47.7% (inadequate HL) vs 20.5% (adequate HL), p = 0.002
Patients with diabetes had more time without sufficient pill supply to
newly prescribed antidepressants:
41% vs 36%, p< 0.01
Nonadherent patients more likely to report inadequate health literacy:
51% vs 30%
Health literacy was associated with medication adherence:

Osborn et al.48 (REALM)

r = 0.12, p < 0.02
Increased adherence
Increased adherence to daily multivitamins by infant caregivers:

Hironaka et al.49

Two times as likely to report high adherence
No effect on adherence
Health literacy is not independently associated with adherence:

Gatti et al.50 (REALM)

Paasche-Orlow et al.51
Mosher et al.36 (REALM)

52.4% vs 50.1% (difference not significant)
Low health literacy not associated with lower odds of adherence:
Adjusted odds ratio = 1.93 (not significant)
Health literacy is not associated with medication adherence:
Health literacy level

% of medications taken (p = 0.14)

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Citation and Literacy


Bains et al.52 (REALM-R)


Health literacy was not significantly related to medication adherence
Inconclusive effect on adherence

Gazmararian et al.53

Suggestive but not conclusive that low health literacy predicts poor refill

Kripalani et al.43 (REALM)

No consistent relationship found between health literacy and
self-reported adherence

Decreased Knowledge and Understanding
A number of studies have shown that patients with limited health literacy have less knowledge about
their disease and how to manage it. For example, among patients with diabetes, 94% of those with
adequate health literacy knew the symptoms of hypoglycemia, compared with only 50% of those
with inadequate health literacy.12 Similarly, persons with limited health literacy did not know about
factors that could lower blood pressure such as weight loss and exercise. Other studies have also
correlated limited health literacy with less knowledge about asthma, reproductive health, human
immunodeficiency virus (HIV) infection, discharge instructions, and heart health.21
Several studies also confirm the association between limited health literacy and decreased
understanding of appropriate medication use.13,14,15,33,37,38,40,54 A study to examine patients’ ability
to understand instructions on medication labels concluded that lower health literacy was
independently associated with misunderstanding of instructions.13 Patients with inadequate and
marginal health literacy had a relative risk of 2.32 and 1.94 of misunderstanding label instructions,
Warning labels are routinely used with prescription medications, yet a recent study indicated that
these labels may not be useful for patients with limited health literacy. In fact, patients with low
health literacy have a three times greater likelihood of incorrect interpretation of prescription
warning labels and have a potential for misuse of their medications.14 For example, in the warning
label that states, “Do not chew or crush, swallow whole,” some patients were interpreting it as “chew
pill and crush before swallowing.” Another study found an association between limited health literacy
and deficits in warfarin-related knowledge.38
Lastly, patients with limited health literacy have difficulty understanding medication guides, which are
educational materials mandated for some products by the FDA, and most admit to never looking at
Decreased Ability for Medication Management

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Limited health literacy has also been associated with a decreased ability for “medication
management”—the ability to self-administer a medication regimen as it has been prescribed.16
Examples of functional skills necessary for medication management include correct identification of
medications, opening the appropriate containers, proper selection of the correct dose, and timing of
administration,54 as well as appropriate use of containers such as MDIs, nasal sprays, and eye drops.
Studies indicate that patients with limited health literacy are unable to name or identify their own
medications.16,17 Persell and colleagues conducted a study to assess the relationship between health
literacy and patient recall of their antihypertensive medications.17 He found that only 40.5% of
patients with inadequate health literacy were able to name any of their antihypertensive medications,
compared to 68.3% of those with adequate health literacy. In this same study, inadequate health
literacy was also associated with a greater number of unreconciled medications (64.0% vs 37.8%).
Similarly, in another study, patients with inadequate literacy skills had 10 to 18 times the odds of
being unable to identify all of their medications, compared with those with adequate literacy skills.16
In a study to determine the relationship of literacy to the MDI technique of asthma patients,
researchers concluded that inadequate literacy was strongly correlated with improper MDI use.18
Compared with patients with adequate health literacy, more patients with inadequate health literacy
were unable to demonstrate proper MDI use (88% vs 48%).
Uncertain Effect on Medication Adherence
Results of studies evaluating the relationship between limited health literacy and medication
adherence are conflicting. Several studies in patients using antiretroviral medications for treatment of
HIV infection indicate that patients with limited health literacy are less likely to be adherent to their
medications.40,41,42 Persons with inadequate health literacy were more likely to have lower refill
adherence,43 decreased medication taking,44 and more likely to have unintentional nonadherence
after a hospital discharge.45 In contrast, several studies concluded that health literacy is not
independently associated with adherence,36,50,51,52 another study showed a strong trend,53 and yet
another study actually found an increase in adherence.49
A major barrier to consolidating data from adherence studies is that there is no generally accepted
“gold standard” for measuring medication adherence, making overall conclusions difficult. Further
studies are needed to adequately determine the true relationship between health literacy and
medication adherence.
Clinical Controversy…
What is the effect of limited health literacy on medication adherence? Current evidence is
inconclusive regarding the overall effect that limited health literacy has on medication adherence.
Some studies show that limited health literacy decreases adherence, others show it actually increases
adherence, yet others show no effect. More research is needed to answer this question.
Worse Health Outcomes
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The AHRQ has published two reports that summarize the literature available regarding the
association between health literacy and outcomes.55,56 In the first report, they identify most of the
studies evaluated as being “fair or good,” and overall, they report that there is an association
between lower literacy and adverse health outcomes.55 In one study evaluating the association of
health literacy with diabetes outcomes, the investigators found that patients with limited health
literacy have worse control of their diabetes and are more likely to report complications such as
retinopathy and cerebrovascular disease.57 In a recent study, the majority of patients with poorly
controlled diabetes (A1c greater than 8%) were more likely to believe that their diabetes was well
controlled if they had low health literacy. Thus, they may be less likely to make changes to improve
The second AHRQ report reinforces the initial link between limited health literacy and worse health
outcomes.56 Patients with limited health literacy have a higher risk for emergency care use, less use
of preventive services, poorer skills in taking medications, and more hospitalizations. Low health
literacy was also found to be a significant, independent risk factor for hospital reutilization within 30
days after hospital discharge.59 This can be costly since accountable care organizations will be
reimbursed less for hospital reutilization within 30 days of discharge.
Unfortunately, inadequate health literacy has even been linked to increased mortality in communitydwelling elderly persons.22 Baker and colleagues studied 3,260 Medicare managed-care enrollees to
determine whether low health literacy independently predicted all-cause mortality. Crude mortality
for persons with inadequate health literacy levels was more than twice as high as in those with
adequate health literacy (39.4% vs 18.9%). Even after adjusting for confounding factors such as
demographics, socioeconomic status, and baseline health, participants with inadequate health
literacy had a hazard ratio of death of 1.52 compared with participants with adequate health literacy.
The authors concluded that inadequate health literacy independently predicts all-cause mortality in
community-dwelling elderly persons. A different study of older adults confirmed the increased risk of
mortality in those with low health literacy (hazard ratio = 1.40).60 In a cohort study of patients
hospitalized for acute heart failure, low health literacy was associated with a 32% increased risk of
death. This increase was found after adjusting for age, gender, race, insurance, highest level of
education, hospital length of stay, and comorbid conditions.61
Increased Healthcare Costs
A systematic review concludes that the economic implications of limited health literacy are
substantial.23 Patients with limited health literacy tend to seek medical care when they are sicker,
leading to higher use of emergent care and longer hospitalizations. Thus, it is no surprise that caring
for persons with limited health literacy is associated with higher healthcare costs. At the health
system level, limited health literacy may account for a 3% to 5% increase in total costs.23 The
increased cost at the individual patient level may range anywhere from $143 to $7,798. Howard and
colleagues found that persons with inadequate health literacy incur higher healthcare costs and use
medical services inefficiently, especially emergency department care.62 Another approximation of the
cost of limited health literacy to the American economy ranged from $106 billion to $238 billion
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annually, equal to about 7% to 17% of all personal healthcare expenditures.63 A large-scale study
demonstrated higher healthcare costs in the Veterans Health Administration (VHA) patients. Of
92,749 veterans, the mean per patient cost for those with inadequate and marginal health literacy
was significantly higher ($31,581) compared with the cost of those with adequate health literacy
($17,033). It is estimated that the healthcare cost of veterans with marginal and inadequate health
literacy was $143 million dollars more over a 3-year period.64 Victor Dzau, the president of the
Institute of Medicine, stated that the lack of health literacy costs the United States more than $100
billion annually.2

Despite our most sophisticated efforts to encourage safe medication use, our current strategies
have been insufficient and ineffective, especially for patients with limited health literacy. Figure e1-2
depicts the maze of medication information that patients are expected to navigate and several of the
barriers that patients with limited health literacy may encounter.

Medication information maze. Communication barriers and the complexity of current medication
information make it difficult for a patient to achieve appropriate medication management. These
barriers are even more significant in a patient with limited literacy skills. This figure depicts several of
the barriers that patients may encounter in the process of obtaining medication information.

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Patient Information Leaflets
Numerous studies indicate that most health information handouts are written at a level far
beyond that which an average adult can understand.1 The average American adult reads at about the
eighth grade level and most handouts exceed these levels. In a survey of 251 primary care adult
patients, only 23% reported having ever looked at the accompanying medication guides.62 Patients
with lower literacy were less likely to have looked at the medication guides (16.7% vs 32.9%). Because
of this, and the fact that the medication guides were written at the 11th and 12th grade level, the
authors concluded that they probably were not useful to patients with limited literacy skills. Raynor
and colleagues also found that consumer medication information handouts do not meet people’s
information needs.65 People did not value the written information they received about medicines,
and providing the leaflets did not increase their knowledge. People tended to want information that
was tailored to them with a balance of both benefit and harm. They also wanted information before
the drug was prescribed to decide if it was the right medicine for them; this is often not done.
Overall, they found a gap between what the patients wanted and what the medicine leaflets
Medication Labels
Poor medication labeling has been cited as a potential cause for medication errors. Indeed, the USP
attributes about one-third of all medication errors to confusion with product labeling.66 Shrank et al.

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assessed 85 labels on pharmacy-dispensed medications for format, context, and variability.67 Their
evaluation concluded that the most prominent portion of the label included the name of the
pharmacy or logo in 84% of all the labels reviewed. In addition, the smallest font sizes were used to
display the medication name (an average of 8.9 points) and medication instructions (9.3 points).
Color and boldface were used to highlight items most useful to the pharmacist as opposed to
highlighting the information that is most useful to the consumer. Warning instructions were highly
variable among all labels depending on the pharmacy.
A group of health literacy experts has pointed out, “Inadequate patient understanding of
prescription dosing instructions and warnings is prevalent and a significant safety concern.”68 In a
report published by the IOM, experts advocate for standardization of prescription medication labels
in efforts to minimize patient confusion and improve patient safety. This report examines what is
known about how medication-container labeling affects patient safety and discusses evidence-based
approaches to address the identified problems. As precedents for such national standards, the report
cites the successfully reformed nutrition facts food product label and standardization of over-thecounter labels by the FDA.
Based on the available evidence and expert recommendations, the USP released a new set of
standards in 2012 for patient-centered medicine labels.29 Enforcement will be at the discretion of
each state, but it is expected that applying these standards will reduce adverse drug events and
medication misuse. The standard provides a universal approach on how prescription labels should be
organized in a “patient-centered” manner. For example, the label should include the indication for
use and provide explicit instructions in the patient’s preferred language. Medical jargon should be
avoided. For instance, use heart instead of cardiac and use numeric instead of alphabetic characters
(eg, 2, not two). A list of USP standards is presented in Table e1-4 with examples that incorporate
them shown in Fig. e1-3.
TABLE e1-4 USP Prescription Container Label Standards to Promote Patient Understanding29
Organize the prescription
label in a patient-centered

Place label elements in an order and format that makes it easy for
patients to find and understand
Format the label in a way to stress what is essential to the patient by:

Emphasize instructions and
other information important
to patients

Making prominent the information that patients must have in
order to use medications correctly and safely (ie, patient name,
drug name and strength, and directions)
Placing dosing instructions in the same order every time (ie,
dose > route > frequency)
Making less prominent and placing away from dosing
instructions less important information such as pharmacy name,
prescriber, fill date, etc.

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Examples of evidence-based medication labels incorporating recommendations from the ACP and
United States Pharmacopeia Chapter 17.70,71 Notice that the most important parts are in the left
section, in larger font, and highlighted. Numbers are used instead of words; directions are explicit
and on individual lines. These labels also include the indication for use in the upper right section, and
a Universal Medication Schedule (UMS) graphic in the lower left. (Data from references 69,70,71.)

In addition to the USP standards, the ACP Foundation also recommends the use of a universal
medication schedule (UMS) to convey and simplify dosage and/or use instructions; a visual aid with
standard intervals (eg, morning, noon, evening, and night) can simplify dosing and reinforce text
instructions (see bottom of Fig. e1-3).68,69
Counseling by Physicians and Pharmacists
Communication failure has been reported to be the underlying cause of about 10% of adverse drug
events.72 Patients with limited health literacy are significantly less likely to ask questions of their
providers.73 About one-half of the prescriptions taken each year are used improperly, and an
estimated 96% of patients do not ask questions about their medications.74
Unfortunately, verbal counseling by prescribers and pharmacists has been disappointing. Though the
exact prevalence of counseling behaviors is uncertain, one report indicated that patients received
verbal counseling about 24% of the time from prescribers and only 14% of the time from
pharmacists.75 In addition, when physicians make an effort to communicate when prescribing new
medications, they often fail to communicate critical elements of medication use. Tarn found that

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physicians only communicate about three of the five expected elements of drug information (name
of medication, purpose, dose and timing, duration, and adverse effects) when initiating new
In efforts to improve these numbers and thus medication safety, Healthy People 2010 made verbal
counseling by prescribers and pharmacists an objective. The goal is for 95% of patients to receive
verbal counseling from prescribers and pharmacists on the appropriate use and potential risks of
Medication Names
Over the past decade, the FDA approved 293 new molecular entities, all of which needed brand and
generic names.77 Despite the intricate process of naming a drug and guidelines developed by the
United States Adopted Names Council, drug mix-ups still occur in the dispensing process.78 If these
mix-ups occur with health professionals, imagine the confusion it causes to the consumer with
limited health literacy. It can be overwhelming and dangerous.
A 2007 study assessed the relationship between health literacy and patient recall of their
antihypertensive medications.17 Overall, regardless of their literacy level, more than 40% of patients
were unable to name any of their antihypertensive medications. When considering literacy levels,
patients with limited health literacy fared worse in terms of recalling the names of their blood
pressure-lowering medications (31.7% vs 59.5%). After adjusting for age and income, this difference
was almost threefold (odds ratio, 2.9). In another survey of 100 patients, researchers found that
participants could provide the names of only 55.8% of their medications.79
The United States Adopted Names Council follows a set of guiding principles when naming new
medications. The very first guiding principle is “A nonproprietary name should be useful primarily to
healthcare practitioners, especially physicians, pharmacists, nurses, educators, dentists, and
veterinarians.”80 Notice that consumers or patients are not considered in this guiding principle, even
though they are the very ones who need to know the name the most. We should “resolve to do

Informal Assessments
The shame associated with limited literacy often prevents patients from receiving appropriate
medical care, as they tend to hide their reading problem. In addition, healthcare providers often do
not consider low health literacy in their patient care.26,81 As previously mentioned, certain groups are
at higher risk for limited health literacy, but even people with adequate literacy levels who are
unfamiliar with the healthcare context may have difficulty navigating the healthcare system and often
go undetected.

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Common Signs
The following are common signs that may suggest a person has limited health literacy skills:1,25,82
1. Reads slowly
2. Has difficulty telling a coherent story
3. Fills out forms incorrectly or incompletely
4. Uses excuses such as, “I forgot my glasses,” “I’ll read this later,” or “I don’t have time to read this
now. Can I take it home?”
5. Brings along a friend or family member for assistance
6. Fails to show up for appointments or is late for refills
7. Does not ask questions for clarification
8. Has difficulty following instructions
9. Nods in agreement or expresses understanding but does not truly understand information
Medication Review
A medication review may be very useful in identifying patients with limited health literacy skills. If the
refill history is accessible, one might find that they often forget to refill their medications on time or
never pick them up. They may not be able to verbalize a list of their medications despite having a
short list. If the medication bottles are available, the patient can be asked to state the name, use, and
dosing instructions for each of their medications. Patients with limited health literacy may not be able
to respond accurately. They may say, “I take them just like it says on the bottle,” or they have to look
at the pill color and shape before they can respond.
If patients have a medication reconciliation list from their last visit, they may hand over the list to the
health professional and say, “This is everything that I am taking.” However, when probing a little
further, they likely do not know the contents of that list, and it may not be exactly what they are
taking. When asked to read a medication label that says, “Take one tablet by mouth once daily at
bedtime,” they may recognize the pill and say it reads, “Take one every day,” because they have
memorized the instructions that may or may not match the container label. When picking up refills,
patients with limited health literacy may ask the pharmacist for the old bottles because they depend
on their personal markings such as an X on the cap.83
Formal Measures
Because of the high prevalence of inadequate health literacy, many experts recommend that
health professionals practice “universal precautions” by trying to communicate as clearly as possible

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with all patients and family members.84 Others suggest that professionals should screen patients’
health literacy and then tailor communications accordingly. It is not clear which approach is best.
Clinical Controversy…
Should patients be tested for limited health literacy and then receive appropriately tailored health
information? Although several instruments have been developed to screen and assess literacy levels,
some advocate for the use of “universal precautions” so that all patients will receive clear
communication in language that is plain and easy to understand.
A number of instruments have been developed to assess health literacy in both English and Spanish.
These instruments can identify patients with “low,” “marginal,” “inadequate,” or “below basic” skills, all
of which mean that the patient has limited health literacy. An article by Mancuso provides a
comprehensive review of health literacy assessment tools.85
Two of the most widely used measures of health literacy are the Rapid Estimate of Adult Literacy in
Medicine (REALM)86 and the Test Of Functional Health Literacy in Adults (TOFHLA).87 These tests are
mainly used in research, but they can be used in practice. Additionally, a survey revealed that patients
do not mind having their literacy assessed in the clinical setting. More than 98% of patients agreed to
a literacy assessment in a routine health visit, including 46% of patients with limited literacy skills.88
The REALM is a word-recognition test and estimates health literacy based on patients’ ability to
pronounce a list of medical terms. The TOFHLA consists of a reading comprehension section to
measure prose literacy and a numeracy section. Passages with health information have words that
have been deleted, and the patient is to choose the correct word from a list of four options. The
Newest Vital Sign (NVS) assesses health literacy by having patients review a nutrition label and
answer six questions about the label.89
While there are continued calls for comprehensive measures of health literacy, there is just as much
interest in developing specialized versions as well as short versions of instruments for rapid
assessment of literacy skills. Helitzer and others have developed a disease-specific web-based tool
called TALKDOC which measures women’s health literacy of Human Papilloma Virus and cervical
cancer.90 The Parental Health Literacy Activities Test (PHLAT) and its Spanish version have been
developed to assess the literacy and numeracy skills, such as preparing infant formula correctly and
dosing medication accurately, that parents need to safely care for infants and children.91,92 In
addition to shorter versions of the REALM (shortened-REALM)93 and TOFHLA,94 one-item measures
have been developed and evaluated for rapid screening of health literacy skills which have
subsequently been incorporated into a 4-item brief health literacy screening tool called
As with all tests, each has its limitations. For example, S-TOFHLA does not assess numeracy unlike its
parent test, TOFHLA. While the NVS was validated in people of all races with an average age of 41
years, a smaller study of African Americans with a mean age of 73.2 years determined that the NVS
took 8 minutes longer to administer and was overall not as applicable in this age group.100 Griffin et

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al.101 and Haun et al.102 found significant variation in categorizing test-takers between inadequate
and marginal health literacy in groups given both the REALM and S-TOFHLA assessments. Further,
the BRIEF tool was validated in a predominately white male English-speaking veteran population
which may not be generalizable to other populations.95
Table e1-5 provides a list of these commonly used assessment tools.
TABLE e1-5 Methods to Assess Health Literacy

One-Item Measures96,97,98,99,103
“How confident are you filling out medical forms by
yourself?” (0, extremely; 1, quite a bit; 2, somewhat; 3, a
little bit; 4, not at all)
“¿Qué tan seguro(a) se siente al llenar formas usted
solo(a)?” (0, extremadamente; 1, mucho; 2, algo; 3, un
poco; 4, para nada)


“How often do you have someone help you read
hospital material?” (0, none of the time; 1, a little of the
time; 2, some of the time; 3, most of the time; 4, all of
the time)

Positive answers for low health
literacy are “somewhat,” “a
little bit,” or “not at all”
Positive answers for Spanish
speakers are: “a little bit” or
“not at all”
Positive answers are “some of
the time,” “most of the time,”
and “all of the time”

Multi-item Measures
Assessment Tool Description

Assessment of
Adult Literacy



Main purpose was to measure
general literacy but included
items specifically to assess
health literacy

Shortened rapid
estimate of adult
literacy in

Word recognition list. Patients
read a list of 66 common
medical words and are scored
on correct pronunciation


Patients must fill in words that
Short test of
have been deleted
functional health systematically from a sample
literacy in adults text of common health
instructions; words are
selected from a list of


Below basic
(Not for
survey done
every 10
0-44 Low

45-60 Marginal
61-66 Adequate

0-16 Inadequate

17-22 Marginal
23-36 Adequate

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One-Item Measures96,97,98,99,103


multiple-choice options.
Excludes numeracy testing
Short Assessment
of Health Literacy
for Spanish

Based on REALM and reading
a list of common medical
words in Spanish (includes
two association words; key
(SAHLSA-50)104,a and distracter)
Newest Vital Sign

Patients review a nutrition
label and answer 6 questions 6
about the label

Based on REALM and
SAHLSA-50 (includes two
Short Assessment
association words; key and
of Health Literacy
distracter). High correlation
—Spanish and
between words used in both
English (SAHLversions and adequate to
compare Spanish and English
speakers together
Brief Health
Screening Tool

Patients answer four
questions and respond on a
5-point Likert scale

Self-administered medical
Medical Term
word recognition test.
Recognition Test
Contains 40 medical words
and 40 nonwords


0-37 Inadequate


0-1 indicates >50% likelihood
of marginal or inadequate
literacy; 2-3 indicates
possibility of limited literacy;
and 4-6 adequate literacy


0-14 Inadequate

4-12 Inadequate


13-16 Marginal
17-20 Adequate
0-20 Low


Based on NAAL with four
Health Literacy
domains of health literacy
Skills Instrument skill assessment:
10-item short
reading/writing, numeracy,
form (HLSI-SF)107 listening, and information
seeking (Internet navigation)


21-34 Marginal
35-40 Functional
<70% Below basic literacy


70-81% Basic literacy
≥82% Proficient literacy


for the REALM, a Spanish version is available for all methods. SAHLSA-50 is available only in
Data From references 11, 89, 93, 94, 95, 104,105,106,107.

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Increase Health Literacy Awareness
The first step toward improving communication on medication management in individuals with
limited health literacy is to recognize that limited health literacy is very common. A survey revealed
that pharmacists in only 7% of community pharmacies attempt to identify literacy-related needs
among the individuals they serve.81 Most pharmacists seemed to be surprised and unaware that
some of their customers may have difficulty reading. In fact, only 12% of American adults have
proficient health literacy skills.
Therefore, it is very likely that most health professionals, including pharmacists, will be serving
individuals with limited health literacy skills. As such, it has been recommended that professional
schools incorporate health literacy into their curricula and areas of competence.1 Much work remains
to be done in this area but efforts are under way. This chapter itself is a tribute to these efforts.
Some disciplines are promoting health literacy awareness by incorporating the need to address this
cross-cutting topic in their accreditation standards.108 Some pharmacy schools are developing
pharmaceutical care labs to introduce pharmacy students to the implications of limited health literacy
on medication management.109 Students complete assigned readings on misunderstanding
prescription labels, watch a video on health literacy, and are asked to lower the reading grade level of
a patient education document. Most students were able to lower the reading grade level of the
document but were surprised at the amount of effort required. The authors concluded that this
exercise helps the students understand the complexities of limited health literacy and affects their
ability to communicate appropriately with patients—especially those with limited health literacy. In an
introductory program, third-year pharmacy students determined the impact of using health literacy
communication tools in a group of independent-living senior residents. They found that using these
health literacy tools increases patient understanding, empowerment, and commitment to medication
adherence.110 Medical schools and residency programs have also explored different ways to
incorporate this topic in their training. A 2-hour workshop was developed for physician residents to
improve assessment of adherence and their medication counseling skills. One month after this
intervention, physicians reported a significant improvement in these areas.111
Obtain a Complete Medication History
Perhaps one of the most essential components necessary to improve medication management in
patients is obtaining a thorough and complete medication history. This is important for all patients
regardless of their health literacy level. However, because patients with limited health literacy have
difficulty naming their medications and are more likely to mismanage their medications, taking a
complete, baseline history of what they are taking is especially valuable.
Medication histories are equally important in all clinical settings, including hospitals, communities,

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home health, long-term institutions, and ambulatory centers. The importance of medication
reconciliation (comparing a medication list to what a patient should be receiving) is also
acknowledged by the hospital accreditation body, the Joint Commission.112 This organization
recognized that this is a crucial step in promoting medication safety and minimizing medication
errors. Implementation of this requirement continues, and research is necessary to examine its
effectiveness and implementation.
Table e1-6 provides a list of recommended strategies and questions for obtaining a complete and
accurate medication history.113,114,115 A video example of how this can be done in a manner sensitive
to health literacy is also available at:
TABLE e1-6 Helpful Strategies and Questions for Obtaining a Complete Medication History
Before speaking to the patient, if available, obtain a list of their most current medications from
their medical records or electronic health system
This will help elicit information that the patient may have forgotten
A quick review may also reveal patterns about their refill history
Determine person responsible for medicine regimen
Do you take your medications on your own, or does someone else like a family member or
friend help you take them?
If patient has a caregiver helping with the medication regimen, include them in the interview
General questions
Do you have your medication containers with you?
If yes, the patient may use them to proceed and answer the following questions
If not, ask if they have a list of the medications they take and proceed
What are your medication allergies?
How many different doctors write prescriptions for you?
Which pharmacies do you use to fill your prescriptions? What is their contact information
(phone number and address)?
How do you pay for your medicines? What is the name of your insurance plan?
What language do you prefer to have on your medicine containers?

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Determine complete list of medicines
For each medicine that you take, please tell me the (1) name and dose, (2) the reason you take it
(indication), and (3) exactly how you take it… How many times a day?
Do you take any medicines that you buy over-the-counter without a prescription such as Tylenol or
Do you take any herbal products, home remedies, vitamins, or other dietary supplements?
Do you take any medicines that you bring from another country such as Canada or Mexico?
Do you take any medicines that are bought over the Internet?
Do you get medicines from other places such as a dialysis unit or another clinic (eg, vitamin B12
Do you use medicines that are not taken by mouth? For example, patches, inhalers, suppositories,
creams, drops, liquids, injectables, nasal sprays?
Do you have medicines that you take only once a week or once a month?
Assess adherence
How do you remember to take your medicines on a regular basis so that you do not forget a dose
(eg, pill box, leave pill bottle by toothbrush, set alarm, line up pill bottles)?
How many doses of your medicines have you missed in the last week?
On a scale of 0-10, how well do you remember to take your medicines every day or as prescribed? 0
means you forget to take them all the time, and 10 means you never miss a dose.
When did you take the last dose of each medicine?
If medication containers are available, look at the last refill date and determine if the patient is
current on his or her refills. Look at the date it was filled, how many doses were dispensed, and how
many are left now as a rough indicator of adherence.
The following articles are sources for the development of this table:
Sullivan C, Gleason KM, Rooney D, et al. Medication reconciliation in the acute care setting: Opportunity
and challenge for nursing. J Nurs Care Qual 2005;20:95-98.
Kripalani S, Trobaugh AK, Coleman EA. Hospital discharge. In: Williams MV, Hayward R, eds.
Comprehensive Hospital Medicine. Philadelphia: WB Saunders (Elsevier Inc); 2007:77-82.
Cua YM, Kripalani S. Medication use in the transition from hospital to home. Ann Acad Med Singapore

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Conduct a Pharmacy Health Literacy Assessment
A pharmacy health literacy assessment measures how well the pharmacy is serving patients with
limited health literacy skills.116 It is an important first step to improve the quality of medication
management for individuals with limited health literacy. The assessment tool developed with funding
from AHRQ is comprehensive and is made up of three complementary parts: (a) an “assessment tour”
completed by objective auditors (here, barriers for clear communication are noted as well as the
physical environment of the pharmacy and staff interaction with patients), (b) a survey completed by
staff (this helps determine how “friendly” the pharmacy environment is toward individuals with
limited health literacy), and (c) focus groups with pharmacy patients (here, the intent is to collect
detailed feedback from patients about their experience with pharmacy services). After all the data are
collected and summarized, a tangible action plan should be developed for improved services to help
individuals with limited health literacy.
Personalize Health Information
A study in hypertension knowledge demonstrated that personalizing health information to learning
style preferences and literacy level improves patient understanding. Participants in the intervention
group answered many more questions correctly than the control participants. The combination of
assessing each person’s health literacy as well as their learning preference provided a more powerful
mechanism to enhance learning than either alone.117
Improve Medication Counseling Skills
Perhaps a key point to remember about this chapter is the vital importance of proper medication
counseling. The National Conference of Pharmaceutical Organizations (NCPO) agreed that
appropriate medication use should be a key goal of healthcare reform. In a policy statement of 2009
entitled, “From Reform to Revolution: Maximizing the Power of Proper Medication Use in Patient
Care,” the group emphasizes, “Policymakers must consider the importance of … appropriate
counseling on the use of medications.”118 In a study to improve hospital discharge instructions,
several interventions were implemented before the patients were sent home. The usefulness of each
intervention was evaluated with a follow-up telephone call to 125 patients after discharge. The top
three interventions that patients found most useful were (1) speaking with a pharmacist about their
medications before discharge, (2) receiving an illustrated medication list, and (3) a follow-up
telephone call after discharge. Patients with limited health literacy indicated the greatest benefit.119
The following ten points provide suggestions on how to improve medication-counseling skills. A
video on how to improve the quality of discharge medication counseling is also available at:
1. Take the time to counsel: Despite the focus on increasing verbal counseling about medications
by prescribers and pharmacists in Healthy People 2010 (objective 17-5),75 progress has been
limited. In fact, midterm review of the tracking data showed no change for prescribers and a 2%
worsening by pharmacists.120 Taking the time to provide verbal counseling about medications

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is especially crucial in patients with limited health literacy.
2. Create a relaxed and nonthreatening environment: Many patients with low health literacy are
embarrassed about the difficulty they have understanding health-related information. While
they may not take the initiative to disclose this information, they are amenable to discussing
health literacy and learning in the right environment. Thus, a first step toward effective
medication counseling is to create a friendly and relaxed environment for the patient.83 Take
the time to listen and give the patient enough time to feel comfortable. Try to understand the
patient’s perspective.
3. Use plain language:121 Speak clearly using plain and common words. Pay attention to the
patient’s own terms and use them back.122 Table e1-7 has examples of alternative lay terms to
common medical terms. Avoid vague terms. For instance, oral and written instructions should
be to “take medication 1 hour before breakfast,” not “take medication on an empty stomach.”
Tell patients what you want them to do. Use instructions such as “Stop taking this medicine if
you get pregnant” instead of “This medicine should not be taken during pregnancy.” Another
example is, “Do not drink alcohol with this medicine,” which is preferred over, “Alcohol should
not be mixed with this medicine.” In addition, use identifiers such as the time of day. For
example, say, “Take 1 tablet in the morning and 1 at bedtime,” rather than, “Take twice daily.”
4. Show the patient each medication while counseling: Open the medication containers so that the
patient can see the colors and shapes of the tablets or capsules.123 This will help them recall
your instructions. For liquids, show patients or caregivers the correct dose with a marking on an
oral syringe. This has been found to be the most accurate dosing method for liquids.124
5. Focus on one to three key points and repeat them frequently: Limit the number of messages and
only tell patients what they need to know. Skip details that are “nice” to know.121 Reinforce
these same key messages by repeating them.
6. Have patients repeat instructions: An evidence-based strategy of verifying patient understanding
is to use the “teach-back” method.125,126 Patients are asked to repeat the instructions or
information they were given to ensure that the key concept has been understood and
remembered. If the concept is not repeated correctly by the patient, the health professional
clarifies and tailors the explanation and reassesses patient recall. This cycle of explaining,
assessing, and clarifying is repeated until the concept has been understood. It is termed “the
interactive communication loop in clinician–patient education” by Schillinger and colleagues.125
They found that when physicians applied this interactive communication strategy for their
patients with diabetes, glycemic control improved.
Findings of a study assessing patient understanding of prescription labels suggest that
professionals should go further by asking patients to “demonstrate” or “show” how they will use
medications. Davis and colleagues found that even though some patients could verbalize the
correct instructions on the label (eg, take 2 tablets twice daily), they could not “demonstrate”
the correct dose.13 Of note, this group also included persons with adequate health literacy level.
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7. Encourage patients to ask questions: Never ask, “Do you have any questions?” Instead, ask,
“What questions do you have?”122 Create an environment in which patients feel comfortable
asking questions. The professional might say, “Sometimes I give people a lot of information
about their medicines and it can be confusing … so I would like to ask you, what questions do
you have?”
8. Use pictures or illustrated medication schedules: Research indicates that pictures help patients
understand how to take their medicines,127,128 and these may be particularly useful in patients
with limited health literacy skills. A review of the literature found that pictorial aids improve
recall, comprehension, and adherence.128 Researchers have developed prototype illustrated
medication schedules (Fig. e1-4),129 as well as a guide on how to create simple versions using
word-processing software.130 These daily schedules provide the patient with a picture of the
actual medicine, the name of the medicine, the indication, and specific dosing instructions.
Assessment of such tools reveals that more than 80% of patients thought they were useful and
easy to understand.129 Other work confirms that these illustrated daily medication schedules
improve medication self-efficacy and adherence among at-risk, community-dwelling older
9. Supplement the interaction with patient-friendly educational material: Written medication
information can be helpful to supplement and reinforce specific counseling points if it is easy to
read. Nonwritten material may also be useful in communicating medication information to
patients. Alternative forms to written information include pictures/pictograms, videos,132
audiotapes, modules on disks, and interactive Internet sites. Most of the health education
available in these formats focuses on specific disease topics, and studies indicate that these
modalities are increasingly effective.133,134 However, some of these new media focus solely on
medication information; research on their effectiveness is limited. Table e1-8 provides some
helpful resources for pharmacists and patients.
10. Review complete regimen and consolidate all medicines into their daily schedule: In addition to
providing information about each individual medication to the patient, it is important to
consider its use in the context of their full medication regimen. This is especially necessary
when a regimen includes multiple medications each with specific requirements such as taking
on an empty stomach or taking at bedtime. Patients may be easily confused with multiple
requirements and either make their regimen more complicated than necessary or compromise
their care by not taking their medications appropriately.
TABLE e1-7 Examples of Suggested Alternatives for Common Medical Termsa
Medical Term



Chest pain



Adverse reaction Side effect
Acid reflux


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Medical Term





Trouble sleeping


Under the skin




On the skin




High blood pressure


Birth control


examples of alternatives to medical terms are available in both English (
/wp-content/uploads/2011/12/AskMe3_WordsToWatch_English1.pdf) and Spanish (
/wp-content/uploads/2011/12/AskMe3_WordsToWatch_Spanish1.pdf) on the Ask Me 3 website of the
National Patient Safety Foundation.
TABLE e1-8 Electronic Resources for Pharmacists and Their Patients
For pharmacists
Includes taking the best possible medication history presentation, taking a
good medication history video, best possible medication history pocket cards,
good discharge counseling video, and ROI calculations
Requires user to sign up for free to access materials
HRSA health literacy section—free online course to improve communication with
MedlinePlus Drugs, Herbs, and Supplements
Patient counseling information
Spanish translation available
National Council on Patient Information and Education

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Comprehensive resource on safe medication use
Plain Language Medical Dictionary
Translate medical terms to easier to understand terms
For patients
Helpful tabs:
“My medicine list”—also in Spanish
“Medication tips and tools”
Has section on “what you should know about…” (vaccines to
prevent disease, using antibiotics wisely, etc.) and has section on
“how to administer” (PDF flyers on how to administer eye drops,
inhalers, etc.)
Can also perform a medication quick search—provides text information
MedlinePlus Health Topics
Education on over 975 diseases, illnesses, and health conditions in patient
friendly language
Spanish translation available
FDA Consumer Drug Information
Medication reminders for patients in addition to those listed in Table e1-11
Mango Health—Medication Manager
Medisafe Medication Reminder, Prescription, and Pill Organizer

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Pill Reminder—All in One
iTunes App Store
And many more…
Audio Medication Patient Counseling
Free 30-day trial; free for students
Can search by disease state or medication name
Google Translate
iTunes App & Goggle Play stores
iTunes App Store
Contains thousands of translated questions and instructions (categories:
history of present illness, past medical history, medications and allergies, etc.)


Personalized illustrated daily medication schedule. Visual tools such as this may help patients keep
better track of all the medicines they take on a regular basis. (For information on how to create such
tools, visit:

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Numerous studies have proven that most health education handouts are written at a higher grade
level than what most adults can read.1 Most health information is written at a 12th grade level or
higher, but the average American reads at about the 8th grade level. Thus, it is important to keep in
mind some general principles that are known to make handouts easy to read. They may be helpful
either in creating material or as a checklist for determining the appropriateness of a handout.
Some of the principles are very similar to the ones used in verbal communication such as using plain
language, focusing on one to three key messages, and incorporating suitable illustrations. However,
the reader is referred to a more comprehensive reference created by the NIH to improve
communication between the government and the public.135 This plain-language initiative provides a
number of useful tips on creating written handouts that are easy to read.

Technology is now more pervasive and easier to access in the United States than ever. With cellular
phones, tablets, computers, and other devices such as “smart” thermostats, watches, and medical

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sensors becoming smaller, faster, and cheaper, their use and adoption has also increased. Having a
computer in the home has risen from 8.2% in 1984 to 83.8% in 2013. Likewise, internet use at home
has also risen from 18% in 1997 to 74.4% in 2013.136
Despite these advances, there are still stark disparities in technology use and internet access among
different incomes, education levels, age groups, geography, and ethnicities (Table e1-9).
TABLE e1-9 Computer and Internet Use for Households: 2013136
Household Characteristics

% Households WITH

% Households WITH some
Internet Access

Age of householder
14-34 years



35-44 years



45-64 years



65 years and older















Metropolitan area



Nonmetropolitan area



< $25,000









Race and Hispanic origin of
White alone, non-Hispanic
Black alone, non-Hispanic
Asian alone, non-Hispanic
Hispanic (of any race)
Limited English-speaking
Metropolitan status

Household income

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Household Characteristics

% Households WITH

% Households WITH some
Internet Access




$150,000 and more



Less than high school graduate



High school graduate (includes







Educational attainment of

Some college or associate’s degree
Bachelor’s degree or higher

Adapted from: File T, Ryan C. Computer and Internet Use in the United States: 2013. American
Community Survey Reports, ACS-28. Washington, DC: U.S. Census Bureau, 2014.
A 2013 US Census Bureau report showed that the majority of households with a computer were
English speaking, younger, had a higher income, more education and lived anywhere in the United
States. A similar pattern can be seen with regards to internet access. Only 58% of the older
population had internet access. Households that were black or Hispanic (61.3%, 66.7%) tended to
have less internet access compared with whites and Asians (77.4%, 86.6%). Households with internet
access also tended to be English speakers, have a higher income, more education, and live in
metropolitan areas. The same report revealed that compared to having a computer at home,
households that were most likely to have only handheld devices were low-income (7%), black or
Hispanic (9.1% each), or younger (9.5%).136
A Pew Research Center survey in 2015 showed that 92% of Americans have a cell phone (68%
smartphones, 34% traditional cell phones). An important finding was 7% were classified as
“smartphone-dependent” users, meaning that they have a smartphone, but do not have internet at
home other than their mobile data plan, nor do they have other device options for accessing the
internet such as a computer or laptop. These users tended to be low-income, black, or Hispanic. In
terms of how smartphones were used, 97% use their smartphone for text messaging, 92% for phone
calls, 89% for internet, and 88% for email. Young users (age 18-29) also use their smartphones heavily
for social networking services (91%) compared with other age groups. Figure e1-5 shows that 62% of
respondents have used their smartphone to look up information about a health condition.137

More than one-half of smartphone owners have used their phone to get health information, do
online banking. (Used with permission from "U.S. Smartphone Use in 2015." Pew Research Center,

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Washington, D.C. (April 1, 2015).

Technology and Health Literacy
As healthcare continues to shift to more electronic resources and connectivity, the most vulnerable
populations may incidentally be left behind. While more than 90% of the US population has cell
phones, there is a significant difference in how they are being used when comparing persons with
marginal or low health literacy to those with adequate health literacy. Those with adequate health
literacy were more likely to own a smartphone, text message, and access the Internet for email, web
browsing, and health information. They were also more likely to contact their healthcare provider
through these means compared to those with marginal or low health literacy.138
Though more than 50% of those with low health literacy were able to text message, less than half
reported that they performed any of the other tasks including email. This was significantly less
compared with at least 75% of those with marginal health literacy reporting they regularly perform all
of those tasks on their phones.138 Additionally, those with low health literacy were more likely to use
social networking sites and phone apps than search engines to obtain health information, and also
preferred text messaging and radio to receive this information.139 Thus, it appears that text messaging
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and social networking sites may be the best way to electronically reach those with low health literacy;
however, these disparities should be a reminder that a digital divide exists especially with those with low
literacy skills.
Unfortunately, when it comes to internet use for health access services, such as patient portals,
patients with low health literacy were 70% less likely to sign on or complete their access despite
having internet access.140 Among the 59% of US elderly who use the Internet, an even smaller
percentage of those with low health literacy (9.7%) used it for health information purposes compared
with those with adequate health literacy (31.9%).141 As more technology is incorporated into our
healthcare system, our most vulnerable populations will need our close attention to minimize the
already growing health disparities.
Technology and Medication Adherence
Table e1-3 shows that the current evidence for the association between health literacy and
medication adherence is inconclusive. However, nationwide, an estimated 75% of Americans have
trouble taking their medicine as directed; approximately 125,000 annual deaths are due to
nonadherence. Indeed, poor adherence is a major public health challenge, and it makes sense that
persons with low health literacy may have even a bigger challenge.
Current technology trends have helped to address primary nonadherence, which is not filling or
picking up a prescription, by increasing the use of electronic health records (EHRs) to electronically
transmit prescriptions or “e-Prescribe” medications directly to the pharmacy. This eliminates the need
for patients to carry a paper prescription to the pharmacy. This solution has also allowed for
prescription insurance formularies to be available to the prescriber at the point of entry to help
reduce patient costs and waiting time by selecting drugs that are cheaper or do not require prior
authorizations, both of which are barriers to obtaining medication. Prescription insurance plans and
pharmacies have also begun to share patient claims information, refill history data, and missed refill
alerts with connected providers to help reduce duplication, coordinate care, reconcile medications
among other prescribers, and increase patient safety.142
While primary nonadherence and discontinuation of medications are being addressed on a national
level, compromised execution or the inconsistent use of medication by the individual patient has
been a bigger challenge. In efforts to improve medication adherence, different technologies are
emerging to help with this issue. Table e1-10 provides examples of technologies available to help
with medication adherence. Two literature reviews provide evidence that text messaging improves
medication adherence rates, at least in the first 6 months, but conclude that larger and longer studies
need to be conducted.143,144 Electronic medication dispensing devices, such as MedicaSafe, are
available to not only help remind patients to take their medication but also allow prescribers to
monitor progress.145 This may have importance with medications that are costly such as recently
marketed hepatitis C treatments or when adherence is extremely important such as with tuberculosis
treatment or post-transplant immunosuppression.
TABLE e1-10 Examples of electronic technologies to improve medication adherence

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Alarm clock

Electronic Reminders

Email reminder


Cell phone calendar

Easily accessible

Text messaging

Sound alerts

Dose-Alert Pill reminder
Proteus Discover system
Smart Pills


May require internet/cellular

Smart Bottles


Sound & light alerts

Smart Caps

SMARxT Med Reminder

Notification and tracking

e-pill Multi-Alarm TimeCap

Caution with cap switching

Electronic Medication


Moderately expensive

Philips Medication
Dispensing Service

Controlled access capability

Med-E-Lert Automatic Pill

Notification and tracking
Need to replenish monthly
Free or very inexpensive

Cell phone apps:
Mobile Technology


Easy to difficult usability
Pictures & visual reminders

Insurance plan

May require internet

Medication adherence

Gamification and rewards
May be limited by operating

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Lastly, as mobile technology has become widely available, so have applications (apps) that can be
used on smartphone devices. The results of using apps to improve medication adherence have been
mixed, but there is some trend to overall improvement in self-care behavior and attitudes.146 One
randomized controlled study has shown that an app can improve medication adherence in the elderly
who tend to use less modern technology.147 Dayer et al. reviewed more than 160 apps available in
2012 and ranked them based on a number of attributes (Table e1-11).148 Many other apps are
available that connect patients directly to their pharmacy and are designed to provide refill reminders
as well as easily request refills. Although more studies are needed to evaluate the effect of
technology-based adherence interventions, current trials suggest combinations of in-person
communication WITH automated reminders or triggers are more effective.149
TABLE e1-11 Top 10 Rated Medication Adherence Apps and Operating System148
Application Name

iPhone Android

1. MyMedSchedule



2. MyMeds



3. MedSimple



4. Med Agenda


5. RxmindMe Prescription


6. Dosecast



7. TRxC (Beta)



8. MediMemory


9. PillManager


10. MedsIQ Individual/Multi-user


Systems available in 2016 are shown in bold.

Limited health literacy is a prevalent problem that has often been overlooked. However, it is now
considered a priority area by the federal government and a number of national organizations.
Research is under way to better understand its effect on health and to develop effective
interventions. The role of health literacy on medication use is still being evaluated, but there is no
question that it is a significant one. Health professionals need to consider that many of their patients
may have limited literacy skills. In particular, health literacy is an important concept to consider in
efforts to improve appropriate medication use.

Favorite Table | Download (.pdf) | Print

American College of Physicians


America’s Health Insurance Plans
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Agency for Healthcare Research and Quality


Centers for Disease Control and Prevention


Electronic Health Record


Food and Drug Administration


Health and Human Services


human immunodeficiency virus


Institute of Medicine


limited English proficiency


metered-dose inhaler


National Assessment of Adult Literacy


The National Conference of Pharmaceutical Organizations


National Institutes of Health


Newest Vital Sign

PHLAT Parental Health Literacy Activities Test
REALM rapid estimate of adult literacy in medicine
TOFHLA test of functional health literacy in adults
WRAT-3 Wide Range Achievement Test

universal medication schedule


United States Pharmacopeia


Veterans Health Administration

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