Patients admitted to hospitals come with a variety of different education levels and reading abilities. It is the responsibility of all health care providers, including nurses, physicians and pharmacists, to ensure that patients understand all of the written instructions they receive regarding their treatment, such as patient education handouts and the instructions that accompany their medications. Many hospitals do assess the education levels of patients, but the instructions provided are written primarily on the sixth- to eighth-grade reading level. What about those patients whose literacy level is less than the sixth grade, or who are not able to read at all?

In 1992 the National Adult Literacy Survey (NALS), conducted by the National Center for Education Statistics, affirmed that at least one quarter of all Americans–some 40-44 million people–are functionally illiterate, and that another 40 million Americans’ literacy skills are marginal.1 More recently, Rose Mary Pries, program manager for patient health education at the Department of Veterans Affairs, estimated that more than 90 million people in the United States have difficulty reading.2

According to the NALS, Americans of color–including Hispanics, African Americans and Asians–have disproportionately low literacy levels compared to the Caucasian majority population. Now consider the tremendous growth of immigrant populations in the United States. These immigrants, who may speak little or no English, are a major part of our health care system.

In 2005 the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) introduced a new standard that addresses the health care industry’s responsibility to provide treatment instructions that match the patient’s literacy level.3 In my work at the Dallas Veterans Affairs Medical Center, I have focused on complying with this new JCAHO requirement. As a cardiology nurse practitioner working in the medical center’s congestive heart failure clinic, I often received referrals from primary care providers for patients who were labeled as noncompliant with their medications. Upon assessment of these patients, I found one commonality–low literacy.

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It wasn’t that the patients did not want to take their medications as ordered. The problem was that they could not understand the instructions printed on their prescription labels. I found patients taking less than or more than the prescribed dose of medications, based on what they thought they “remembered” from the verbal instructions they were given. As a result, these patients’ blood pressures were elevated and their heart failure was not controlled. Some patients had BNP (B-type natriuretic peptide) levels as high as 5,000 (the normal range is 5-100). Others had 1-4+ edema and poor weight control. Some of these patients had more than one bottle of the same medication and were taking pills from both bottles simply because they could not read.

To develop a solution for this problem, I first performed a thorough literature search on patient education and low literacy skills. I learned that low-literacy patients are abundant in our health care systems. Fetter4 disclosed that when patients are unable to read and comprehend basic health care instructions, serious negative consequences can result. Patients can take the wrong medication or the wrong dose of medication, resulting in increased morbidity and mortality. It was documented throughout the literature that health care professionals have the responsibility to evaluate the patient’s level of literacy and his/her ability to understand and follow instructions, and then use that information to develop or utilize the most effective resources for enhancing patient comprehension of instructions.

Next, I looked at the Area Health Education Center (AHEC) checklist, a tool for evaluating the appropriateness of reading materials for low-literacy patients. It includes four items that stress the significant criteria that must be used for successful development of low-literacy materials:

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1. Organization–measures whether the material has an attractive cover, whether the most important need-to-know information is stressed first and whether no more than three to four points are presented at a time.

2. Writing style–conversational, with little or no medical jargon.

3. Appearance–ample space between sentences, pages uncluttered, a high degree of contrast, font size at least 12 points, illustrations that are simple and that amplify the text.

4. Appeal–culturally, gender- and age-appropriate materials that match the needs of the targeted audience; materials that are interactive by suggesting actions, asking questions and soliciting responses.5

One Picture Is Worth a Thousand Words

Now I was ready to start designing and implementing a protocol for teaching low-literacy patients to take their medications correctly. According to a recent study by Houts et al, pictures that closely link written or spoken text can, when compared to text alone, markedly increase attention to and recall of health education information.6 These authors further state that all patients can benefit from this technique, but patients with low literacy skills are especially likely to benefit. Armed with this knowledge, I decided to create a system focusing on the use of universal symbols that would visually communicate the written words printed on the medication bottle.


I found computer clip-art symbols that could be understood by people from a variety of racial and ethnic backgrounds and that were large enough to be easily located by the patient (see illustration below). For daily medications, I chose a rooster with the sun coming up to indicate the morning dose. For the bedtime dose I chose a bed. For PRN medications, I chose a sad face to indicate that the medication should be taken as needed. I also added a clock symbol alongside the sad face and circled the number of hours between doses. I copied these symbols onto silver-dollar-sized self-adhesive stickers and stuck them on the patient’s medication bottles.

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Then came the process of explaining the system to patients. Before sitting down with a patient, I made sure all of the patient’s medications were sorted and labeled with the appropriate label. Verbal instructions began with an emphasis on making sure the patient understood the symbols that were placed on the medication bottles. Next, I reviewed all of the bottles with the patient and a family member (when present). I then filled the patient’s pillboxes–one for morning medications and one for evening medications. The PRN medications were not placed in the pillboxes. I spent time with the patient until I was certain he/she understood the PRN medication as well as the amount of time between doses.

I always asked the patient to repeat the instructions back to me so I would know for certain that comprehension had taken place. The majority of medications can be ordered with once or twice daily dosing and I tried to stay within those guidelines to make it easy for the patient. I placed the same symbol on the bottom of the pillbox as on the medication bottle. I usually use two different color pillboxes and this was very helpful for getting the patient to understand the difference between morning and evening doses.

When the patient had a clear understanding of how to the system worked, I advanced the patient to filling his/her own pillboxes. First, I taught the patient to place all of the morning medications in one group and the same for the bedtime medications. If a medication was to be taken twice a day, I had the patient place the bottle with the morning group first; once the morning pills were dispensed, I had them place the bottle in the bedtime group.

Next, I taught the patient to open only one bottle at a time. If he/she poured too many pills, I had them return the pills only to the bottle that was open. Once the correct number of pills had been placed in the pillbox, I told the patient to close the medication bottle and move it to a new area away from the pill bottles still to be opened. I followed this process with both groups of medications.

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Finally, I had the patient repeat this process weekly until there was absolute certainty that he/she understood the process.

Real Results

I identified low-literacy patients by having them bring all of their medications to the first clinic visit. I would ask the patient to read the directions on the medication bottle. When the patient could not read the labels of several medications, I knew there was a literacy problem. I approached the patient by saying, “I have a way to teach you how to take your medications accurately so you can improve your disease and feel better.”

The first patient I taught to use this system was a congested heart failure patient. His BNP was 4,300 and his blood pressure was 218/116. This patient had been hospitalized 14 times in one year to try to control his heart failure. It was well documented that the patient was noncompliant with his medications but the reason for the noncompliance had never been documented.

Since being taught to understand and manage his self-medication regimen, this patient has not had a hospital admission for the past three years. His blood pressure is under control as well, with readings of 98/60 to 106/70 consistently. The cost savings to our facility alone are reason to maintain this teaching style with low-literacy patients.

More than half of all Americans may be unable to read and understand written instructions about how to take their medications. When patients are unable to comprehend basic instructions, poor health outcomes are the result. Low-literacy patients fail to follow instructions because they lack understanding, not because they are intentionally noncompliant. Nurses, physicians and pharmacists must take the lead in ensuring that the patient understands the instructions that accompany his/her medications. Every patient should be assessed for literacy skills and then provided with instructions in an appropriate format that is specifically matched to his/her reading level.

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Creativity and innovative teaching strategies are a must with low-literacy patients. Nurses, with their unique emphasis on holistic, patient-centered care, are in the ideal position to design and deliver practical interventions that will help these patients be successful as they engage in self-medication.


1. Kirsch, I., Jungleblut, A., Jenkins, L., and Kolstad, A. (1993). Adult Literacy in America: A First Look at the Findings of the National Adult Literacy Survey. U.S. Department of Education, National Center for Education Statistics.

2. Pries, Rose Mary (2006). “Educating Veterans with Lower Literacy Skills” (PowerPoint presentation).
3. Joint Commission for Accreditation of Healthcare Organizations (2005). Educating Hospital Patients and Their Families.

4. Fetter, M.S., (1999). “Recognizing and Improving Health Literacy.” Journal of the Academy of Medical Surgical Nurses, Vol. 8, No. 4, pp. 226-227.

5. Wilson, F.L. (2000). “Are Patient Information Materials Too Difficult to Read?” Home Healthcare Nurse, Vol. 18, No. 2, pp.107-115.

6. Houts, P., Doak, C.D., Doak, L.G. and Loscalzo, M. (2006). “The Role of Pictures in Improving Health Communication: A Review of Research on Attention, Comprehension, Recall, and Adherence.” Patient Education and Counseling, Vol. 61, No. 2, pp. 173-190.


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