Q1. Which of the following is the strongest predictor of a person’s health status?

1. a. Age
2. b. Income
3. c. Literacy skills
4. d. Employment status
5. e. Education level
6. f. Racial or ethnic group

A1. The correct answer is “c.” Although low health literacy can affect everyone regardless of background or educational level, studies on the issue show that limited literacy skills are a stronger predictor of an individual's health status than age, income, employment status, education level, and racial or ethnic group.

“Health Literacy: Report of the Council on Scientific Affairs.” JAMA 1999:281:552-557.

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Q2. Who is NOT at risk for low health literacy?

1. a. Elderly
2. b. Ethnic minorities
3. c. Those with low income and education levels
4. d. Those with high income and education
5. e. None of the above

A2. The correct answer is “e.” Everyone in the United States is susceptible regardless of age, race, education or income.

“Health Literacy and the Prescription Drug Experience: The Frontline Perspective from Patients, Physicians and Pharmacists.” RoperASW, September 2002.

Center for Health Care Strategies, Fact Sheet: “Who Suffers from Poor Health Literacy?”

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Q3. Health literacy refers only to the ability to read and understand written information.

1. a. True
2. b. False

A3. The correct answer is “b.” Health literacy is broader than general literacy; it includes the ability to process numbers (numeracy) and navigate the health care system.

“Health Literacy: A Prescription to End Confusion.” Institute of Medicine of the National Academies, April 2004.

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Q4. What percentage of patients forgets what the doctor told them as soon as they leave the office?

1. a. 80 percent
2. b. 50 percent
3. c. 10 percent
4. d. Less than 10 percent

A4. The correct answer is “a.” Up to 80% of patients forget what their doctor tells them as soon as they leave the office. And nearly 50% of what they do remember is recalled incorrectly.

“Patients’ memory for medical information.” Journal of the Royal Society of Medicine 2003:96:219-222.

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Q5. How many adult Americans have difficulty reading and understanding health information?

1. a. 9 million
2. b. 90 million
3. c. 150 million
4. d. Fewer than one million

A5. The correct answer is “b.” According to the Institute of Medicine, nearly half of all American adults --90 million people-- have difficulty understanding and using health information.

“Adult Literacy in America.” National Center for Education Statistics, U.S. Dept of Education, Office of Educational Research and Improvement (NCES 1993-275), April 2002.

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Q6. Which of the following are coping mechanisms used by patients with low health literacy?

1. a. Say they forgot their eyeglasses to avoid filling out forms or questionnaires.
2. b. Laugh about being forgetful when asked about their medical condition or treatments.
3. c. Nod politely when the doctor speaks and don’t ask any questions.
4. d. All of the above.

A6. The correct answer is “d.” People with low health literacy are often embarrassed or ashamed to admit they have difficulty understanding health information and instructions. They use well-practiced coping mechanisms that effectively mask their problem.

“20 Common Problems in Primary Care,” Barry D. Weiss, MD, editor. McGraw-Hill, 1999.

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Q7. Which of these statements about people with low health literacy is FALSE?

1. a. They are often less likely to comply with prescribed treatment and self-care regimens.
2. b. They fail to seek preventive care and are at higher (more than double) risk for hospitalization.
3. c. They remain in the hospital nearly two days longer than adults with higher health literacy.
4. d. Often require additional care that results in annual health care costs that are four times higher than for those with higher literacy skills.
5. e. None of the above.

A7. The correct answer is “e.” All of the statements are true. Low health literacy negatively impacts compliance, clinical outcomes and healthcare costs.

“20 Common Problems in Primary Care.” Barry D. Weiss, MD, editor. McGraw-Hill, 1999.

“Health Literacy and the Risk of Hospital Admission.” David Baker, MD, MPH, Ruth Parker, MD, et al. J Gen Intern Med1998:13:791-798.

Center on an Aging Society, Institute for Health Care Research and Policy (Georgetown University): Health Literacy Fact Sheet. March 2003.

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Q8. Health literacy is an issue only for those providers treating ethnic minorities.

1. a. True
2. b. False

A8. The correct answer is “b.” Although ethnic minority groups are disproportionately affected by low literacy, the majority of those with low literacy skills in the United States are white, native-born Americans.

Center for Health Care Strategies, Fact Sheet: “Who Suffers from Poor Health Literacy?”

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Q9. The average adult reading level in the United States is:

1. a. 10th grade or above
2. b. 8th-9th grade
3. c. 6th-7th grade
4. d. 3rd-4th grade

A9. The correct answer is “b.” The average adult American reading level is 8th to 9th grade. However, nearly 1 in 5 adults read at or below the 5th grade level; and nearly 2 out of 5 older Americans and minorities read at or below that level.

“Adult Literacy in America (NALS)” National Center for Education Statistics, U.S. Dept of Education, Office of Educational Research and Improvement (NCES 1993-275), April 2002.

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Q10. Encouraging patients to ask more questions during the exam will increase the length of their visit.

1. a. True
2. b. False

A10. The correct answer is “b.” Fearing lengthy appointments, most doctors allow patients to talk for an average of 22 seconds before taking the lead. Research shows, however, that if allowed to speak freely, the average patient would initially speak for less than two minutes. Encouraging questions during the initial visit may require a short-term time investment; however, the long-term payoff may include more accurate compliance, less follow-up visits, and shorter, more focused interactions as the patient proceeds through his/her condition.

British Medical Journal, vol. 325, p.682-683, September 2002.

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