Addressing the Cognitive 

Challenges in Patient Instruction 
to Bridge the Functional H
to Bridge the Functional Health 
Literacy Gap
Qing Zeng
 Patient Instruction

z Patient instruction is critical to patient self‐
Patient instruction is critical to patient self‐care.

z Proper discharge instruction is required by JCAHO
Proper discharge instruction is required by JCAHO.

z It can reduce re‐
It can reduce re‐admission rate (
admission rate (Qual
Qual Saf Health Care. 2006 
Dec;15(6):414‐‐7.))
Dec;15(6):414

z It can increase patient satisfaction (
It can increase patient satisfaction (Patient 
Patient Educ
Educ Couns. 
Couns. 
2005 Oct;59(1):56‐
2005 Oct;59(1):56‐68
68.) 
.) 
) 
Sample Instructions
 Cognitive Challenges

z Comprehension

z Recall

z Execution
Comprehension ‐‐ Readability
Comprehension 
 Recall

z According to one study, patients, on average, forget half 
of what they were told by a doctor within 5 minutes of 
l
leaving the outpatient consultation room. (Mayer RE 
i  th   t ti t  lt ti    (M  RE 
1990) 

z A
According to another study, only 37% of patients could 
di     h   d   l   %  f  i   ld 
recall their diagnosis and treatment and follow
recall their diagnosis and treatment and follow‐‐up plan 
correctly, immediately after being discharge from the ED 
y, y g g
(Logan PD 1996). 

z According to our own study, immediate recall rate is about 
g y,
44% and delayed recall is 27%. (Zeng  2008)
 How to Bridge the GAP?

z Simpler language

z Pictograph enhancement 

z Actionable information
 Simpler Language

z Vocabulary

z Syntax

z Example: 
z “Dressing: Aquacel
“Dressing  Aquacel
“Dressing: 
 Aquacel AG with 
AG with kerlix
kerlix over this QD”
z “Dressing: Cover the wound with 
“Dressing: Cover the wound with Aquacel
Aquacel AG with a kerlix
AG with a kerlix
wrap changed daily”
 Pictograph Enhancement

z Visual Similarity

z Arbitrary Convention
z Abstract Convention
z Concrete Convention
z Transposed Convention

z Semantic Association
z Comparison or Contrast
z Exemplification: Multiple
z Exemplification: Singular
z …….
Example
 Actionable Information
Asymmetry between Comprehension and Execution
Comprehension

Easyy Difficult
Easy

The top number of your blood

You can drive in 2 days.
pressure should be less than 1201.
on
Executio

Difficult

Try to eat < 25 grams of fat every

Diabetes Control: HbA1C less than
day and < 10 grams of saturated
7.0%3.
f t2.
fat
1 Comprehension: the concept of blood pressure is difficult because it involves several interrelated concepts such as normal and
abnormal ranges, measurement (mmHg), causes and consequences of hyper- and hypotension, among others.
2 Execution: difficult because it involves estimatingg the amount of fat in each pportion of food eaten throughout
g the day.
y Each meal
demands decisions regarding how much to consume based on the remaining amount of the daily allowance of fat.
3 Comprehension: the concept of glycated hemoglobin, its function, clinical meaning, and measurement is fairly difficult to grasp.
Execution: difficult because bringing down HBA1C involves continuous monitoring of blood sugar, diet, exercise, and medication
regimen.
 Precise

Precise No lifting more than 10 pounds for 1 week.

Imprecise Do strength‐building exercises using light weights to increase your 
strength and muscle tone.
t th  d  l  t
 Complete

Complete You will need to wear the monitor every day for 60 days.

Incomplete Check every day for signs of infection.
 Proper Use of Range

Proper You may call 801‐581‐3949 Monday‐Friday 8am‐4pm with any 

questions.
q

Improper Call your doctor if you gain 2‐3 pounds overnight or 

5‐6 pounds
6  d in a week.
i     k
 Consistent Use of Unit

Metric You should not eat more than 2000 mg of salt daily.

U.S. Units Do not lift more than 10 pounds for 1 week.

 Concrete Examples

Abstract Do not lift more than 10 pounds for 1 week. 

Concrete Do not lift more than 10 pounds for 1 week. (A gallon of milk = 8 
pounds.)
d )
 We Do the Math 

Calculation Make a follow up appointment in 3 month. 

No Make a follow up appointment in June. 
Calculation