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Can J Public Health. 2003 Nov-Dec;94(6):408-12.

Literacy in primary care populations: is it a problem?

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  • 1Department of Family Medicine, McGill University, Montreal.



Almost half of Canadians experience difficulty using print media, according to the 1994 International Adult Literacy Survey. Our objectives were to estimate the prevalence of low-literacy patients in our practice, to determine whether reading grade level is associated with self-perceived health status in primary care, and to evaluate the reading difficulty of commonly used patient education pamphlets.


We surveyed a random sample of 229 patients aged 18 to 85 years presenting for scheduled and walk-in care. Main outcome measures were reading ability as estimated by word decoding skill with the validated Rapid Estimate of Adult Literacy in Medicine (REALM) and self-perceived health status using COOP/WONCA functional health measures. We assessed the reading difficulty of 120 commonly used patient education pamphlets using the Simple Measure of Gobbledygook (SMOG) formula.


The prevalence of low-literate patients was 9%. Poor reading ability in English was most likely among patients under 45 years of age not having completed high school, and among those whose maternal language was neither English nor French (immigrants). REALM scores and self-perceived health were weakly correlated but not significant statistically. The mean reading grade level of pamphlets was grade 11.5 (SD: 1.5). Seventy-eight percent of pamphlets required at least a high school reading level.


Literacy levels were higher than expected in our patient population; this finding may be due to the rapid assessment tool used, which may have underestimated the difficulty of using print media. Clearly, the vast majority of commonly used patient education materials would not meet the needs of low-literate patients, who may be more likely to experience poorer health. Providers need to be sensitive to the reading limitations of patients and patient education materials should be written at a lower reading level.

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