Health Literacy Is Positively Associated With Medication Adherence

Oncology Nursing News, October 2021, Volume 15, Issue 5

Sap Partners | Schools of Nursing | <b>Rutgers School of Nursing</b>

Health care professionals and nurses play an important role in providing health information to patients and their families.

Health literacy (HL) does not refer only to an individual’s ability to read, write, listen, and speak a language. The definition expands to the ability to gather and use information to make informed health decisions. Health care professionals and nurses play an important role in providing health information to patients and their families.1 The ways that information and patient education is organized, presented, and communicated can influence health care consumers.

As chronic disease diagnoses continue to increase in the United States, prescription instructions become more complicated, and the probability of medication nonadherence becomes greater.2 Educating patients about cancer treatment and medication regimens in a way that matches their needs and preferred learning methods eases achievement of medication adherence.3 Additionally, patient outcomes, satisfaction, and overall safety can be optimized when interventions are designed to match the needs of the learner. Thus, investigators involved in a pilot study implemented the Rapid Estimate for Adult Literacy in Medicine (REALM) HL assessment of adult oncology patients before their treatment began to discover whether its use would assist in individualizing patient-education methods and impact oncologic therapy and symptom management. In addition, they were interested in nurses’ reactions to using this tool for tailoring patient education.

Investigators were interested in the program’s ability to improve medication adherence and symptom management in patients being treated for cancer in the ambulatory setting; in addition, they sought nurses’ reactions to implementing the program. Charts of 34 patients who were given a diagnosis of cancer and who had received an initial chemotherapeutic infusion were retrospectively reviewed, and 19 infusion nurses were surveyed. Specific educational modalities used were selected according to a patient’s REALM HL score along with the patient’s choice of learning method.

Symptom-management variables measured included self-reported medication adherence, pain score, and self-reported incidence of nausea and vomiting. The pain raw score was added to the total number of medication doses missed and episodes of nausea/vomiting to produce a total cumulative symptom-management score, with a lower score indicating better symptom management. Symptom-management scores for the initial and second patient visits were compared; this was repeated for the second and third patient visits and was compared with that of the second patient visit, and the second patient visit was compared with a third patient visit.

Management of symptoms noted at the second visit were compared between 2 patient groups; group 1 had a HL score of 60 or less (lower reading level), and group 2 had a HL score of 61 to 66 (higher reading level).

Nursing compliance with documentation was also measured.

Initial data collection revealed that either the REALM-HL screening tool was not being administered as intended, or information was not being documented as expected. A need for re-education was identified, and instruction was again provided to participating nursing staff. Chart audits of the 34 initial patient visits after re-education revealed that less than 1% of the charts had missing symptom-management documentation. A survey of nursing perceptions indicated that nurses had greater awareness of the impact of HL on patient education and better documentation of symptom management after the repeated instruction.

Approximately 80% of patients who completed the REALM-HL screening tool had a score of 61 to 66 (ie, high-school reading level), indicating high HL (Table); this suggested that patients could read most patient education materials. Approximately 18% of the patients had a score of 45 to 60 (ie, seventh- to eighth-grade reading level), which indicated a predisposition to challenges in reading most patient-education materials and need for low-literacy materials. Only 3% of the patients scored in the range of 19 to 44 (ie, fourth- to sixth-grade reading level), which indicated a compromised ability to read instructions on prescription bottles and a consequent need for low-literacy materials.

Upon assessment, most patients identified more than 1 preferred learning style (Figure 1). Considering the first style identified by patients, the 2 predominately preferred learning styles were reading/writing (88.2%) and aural/listening (55.9%). Kinesthetic learning was not identified as the preferred learning style for any of the patients assessed. More than half of nurses surveyed (56%) believed that administration of the HL screening tool to new infusion patients impacted the education that they provided (Figure 2). Furthermore, 37% of the nurses reported that administration of the HL screening tool increased their awareness of the impact of HL on a patient’s symptom management (Figure 3).

None of the findings on symptom management was statistically significant. However, 100% medication adherence was achieved when the staff educated patients with guidance from the teaching algorithm. The nurses acknowledged greater awareness of how the REALM HL score and patient-preferred learning method could impact symptom management. This particular finding was crucial, since nurses play an integral role in providing health information to patients and their families—and understanding of this information can be influenced significantly by the communication method used.

Evaluation of this program serves as a foundation for other departments within the cancer center and the health care system to improve patient outcomes and decrease hospitalizations and spending related to medication nonadherence. It also reinforces the need for leadership to appraise changes and tools implemented within the practice environment. 


  • Johnson A. Health literacy: how nurses can make a difference. Aust J of Adv Nurs. 2015;33(2):20-27.
  • Zullig LL, McCant F, Melnyk SD, Danus S, Bosworth HB. A health literacy pilot intervention to improve medication adherence using Meducation technology. Patient Educ Couns. 2014;95(2):288–291. doi:10.1016/j.pec.2014.02.004
  • Kean CC, Iverson L, Boylan A. Evaluation of a chemotherapy and medication education process for patients starting cancer treatment. Clin J Oncol Nurs. 2016;20(4):364-366. doi:10.1188/16.CJON.364-366