Health literacy: Patients remember 80% of what they are told if pictures are used, only 14% if given only spoken instructions

21 October, 2023

This statement brings to mind the requirements of *clinician-patient communication, Should the information to patients during and after consultations be spoken, written or pictorial? Perhaps surprisingly in the studies below pictorial information is shown to be best remembered.

Kessels RPC. Wrote in “Patients' memory for medical information. J R Soc Med. 2003;96(5):219–222: [ ]

“Clearly, memory for medical information is a prerequisite for good adherence to recommended treatment. Ley's 3 model on effective communication in medical practice < ) stresses the importance of memory next to factors such as the understanding of information and satisfaction with the treatment. 40-80% of medical information provided by healthcare practitioners is forgotten immediately.

The greater the amount of information presented, the lower the proportion correctly recalled; furthermore, almost half of the information that is remembered is incorrect.

For the forgetting of information there are three basic types of explanation — first, factors related to the clinician, such as use of difficult medical terminology; second, the mode of information (e.g. spoken versus written); and, third, factors related to the patient, such as low education or specific expectations. “Here, I discuss only the second and third, since the communication skills of clinicians have been thoroughly reviewed elsewhere.

“The form or mode of information is also highly relevant. In most instances, medical advice is spoken, but this is not a very successful method. Written information is better remembered and leads to better treatment adherence. However, written instructions do present difficulties to patients with low education or literacy and to non-native speakers, so other options have been investigated.

For example, cartoons have been used to improve adherence to wound-care advice in patients just released from the emergency department: those who received the cartoon instructions displayed better compliance and answered more questions correctly. Patients with low education benefited more from the cartoon method than did patients with high education have used pictographs— picture-writing—in cancer and HIV/AIDS. With spoken medical instructions only 14% of the information was remembered correctly, compared with over 80% when pictographs were used. Simple pictographs, with a clear and direct link between the picture and its meaning, are most effective.

Hashim MJ, Mustafa H, Al Abdouli AO, et al. in “Health education materials for arab patients: content and design preferences”. Med Princ Pract. 2013;22(4):411-414 wrote

"Communication is essential for the effective delivery of health care, and is one of the most powerful tools in a clinician’s arsenal. Unfortunately, there is often a mismatch between a clinician’s level of communication and a patient’s level of comprehension. In fact, evidence shows that patients often misinterpret or do not understand much of the information given to them by clinicians."

He goes on to give an illustration of how health illiteracy feels:

"Making your practice patient-friendly Imagine that you are one of the nearly 36% of adults in the United States who had basic or below basic general and health literacy skills on the NAAL. You can’t read and fully understand an article in a newspaper. You can’t fill in a government application for Social Security, Medicare, or Medicaid benefits. You can’t follow a bus schedule or a map. You don’t really understand what a cancer screening test is, or the meaning of words like “rectum,” “tumor,” “prostate gland,” or “mammogram.” Perhaps English is your second language.

"Your naicisyhp has dednemmocer that you have a ypocsonoloc. Ypocsonoloc is a test for noloc recnac. It sevlovni gnitresni a elbixelf gniweiv epocs into your mutcer. You must drink a laiceps diuqil the thgin erofeb the noitanimaxe to naelc out your noloc."

("Your physician has recommended that you have a colonoscopy. Colonoscopy is a test for colon cancer. It involves inserting a flexible viewing scope into your rectum. You must drink a special liquid the night before there examination to clean out your colon." )

" There are many reasons why patients do not understand what clinicians tell them, but key among them is inadequate health literacy—i.e., a limited ability to obtain, process, and understand basic health information and services needed to make appropriate health decisions and follow instructions or treatment."

HIFA profile: Richard Fitton is a retired family doctor - GP. Professional interests: Health literacy, patient partnership of trust and implementation of healthcare with professionals, family and public involvement in the prevention of modern lifestyle diseases, patients using access to professional records to overcome confidentiality barriers to care, patients as part of the policing of the use of their patient data. Email address: richardpeterfitton7 AT