3

Chapter

Health Literacy and

Client Compliance
Bruce J. Novotny
Charles J. Wayner

What we have here is (a) failure to communicate.

The movie Cool Hand Luke

HEALTH LITERACY
Introduction
According to the 1993 National Adult Literacy Survey
(NALS), the average educational attainment of adults in the
United States is above the 12th grade level (Kirsch et al, 1993).
However, educational level doesnt translate into a corresponding level of reading or comprehension. Forty to 44 million
adults surveyed have difficulty locating the expiration date on a
drivers license, determining the location of a meeting on a form
or reading a medicine label. Another 50 million Americans
have only marginal literacy skills; these people have difficulty
locating an intersection on a street map and identifying and
entering background information on a Social Security application. Unfortunately, despite increasing education, the average
reading skills of U.S. adults are between the 8th and 9th grade
levels (Stedman and Kaestel, 1991).
Much of health care information, including insurance forms
and advertising, is often written far above the high school level.
Several studies report that the reading level of patients with
various chronic diseases falls between grade levels six and 10,
whereas the readability of health materials prepared for them
falls between seven and 13 (IOM, 2004). More than 300 studies, conducted over three decades assessed various health-related materials (e.g., informed consent forms and medication
package inserts), found that a mismatch exists between the

reading levels of the materials and the reading skills of the

intended audience. Most of the assessed materials exceeded the
reading skills of the average high school graduate (Rudd et al,
2000). Table 3-1 lists several problems associated with inadequate health literacy (Zarcadoolos et al, 2006).

Implications to Veterinary Medicine

For the most part, pet owners mirror the general population.
That being the case, it is highly likely that the same issues the
human health care system faces related to health literacy reside
in the pet-owning population. Unfortunately, this has never
been studied to any great degree in veterinary medicine, but the
ramifications of this revelation are alarming.
Clients depend on our medical expertise and our ability to
translate that skill into information they can relate to and act
upon. The pets health and well-being depend on our ability to
effectively communicate our intended meaning to the owner.
Although we may believe we are communicating with pet owners, we may in fact be adding substantially to their confusion,
uncertainty and frustration about doing whats best for their pet.
Poor communication with clients can result in less than
optimal short- and long-term care. As preventive and therapeutic medical advocates for pets, veterinarians and other
health care team members have an obligation to help pet
owners make informed decisions about their pets care.
Providing accurate information about proper pet nutrition is

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Small Animal Clinical Nutrition

Table 3-1. Problems caused by inadequate health literacy.*

Improper use of medications
Inappropriate use or no use of health services
Poor self-management of chronic conditions
Inadequate response in emergency situations
Poor health outcomes
Lack of self-efficacy and self-esteem
Financial drain on individuals and society
*Adapted from Zarcadoolas C, Pleasant AF, Greer DS.
Advancing Health Literacy. San Francisco, CA: Jossey-Banks,
2006.

Table 3-2. Examples of skills needed for health.*

Promote and protect health and prevent disease
Understand, interpret and analyze health information
Apply health information over a variety of life events and situations
Navigate the health care system
Actively participate in encounters with health care professionals
Understand and give consent
Understand and advocate for rights
*Adapted from IOM. (Institute of Medicine.) Health Literacy: A
Prescription to End Confusion. Washington, DC: National
Academies Press, 2004; 1-322.

as necessary as appropriate medicine and surgery. It is a sobering thought to consider that the number of pet deaths attributable to poor communication may meet or exceed surgical or
anesthetic-related deaths.
Because there is little in the way of insights about this problem in veterinary medicine, issues about the human health literacy crisis will be discussed. Readers should associate these
data to the client-pet-veterinary and veterinary team interface
and challenge themselves to make a concerted effort to
enhance communication skills to better care for the pets and
people they serve.

Definitions
Health literacy may be defined as the degree to which individuals have the capacity to obtain, process and understand basic
health information and services needed to make appropriate
health decisions (Ratzan and Parker, 2000; Healthy People
2010). A 1999 report from the Council on Scientific Affairs of
the American Medical Association refers to functional health
literacy as the ability to read and comprehend prescription bottles, appointment slips and other essential health-related materials (AMA, 1999).
Other proposed definitions include:
Health literacy is a constellation of skills, including the ability to perform basic reading and numerical tasks required to
function in the health care environment (AMA Ad Hoc
Committee).
Health literacy has three levels: 1) functional health literacy, which refers to the communication of information, 2)
interactive health literacy, which deals with the develop-

ment of personal skills and 3) critical health literacy, which

is needed for personal and community empowerment
(Nutbeam, 1998).

Understanding Health Literacy

Health literacy includes more than simply obtaining information. Health literacy embraces writing, numeracy, listening,
speaking and conceptual knowledge (IOM, 2004). Health literacy emerges when expectations, preferences and skills of individuals seeking health information meet equivalent goals of
those providing information and services (IOM, 2004).
Education, language and culture mediate health literacy skills
(IOM, 2004). Equally important are the communication and
assessment skills of health care professionals. Furthermore,
their patients must navigate the media, marketplace and governmental agencies to obtain health information (IOM, 2004).
Even people with strong literacy skills may have trouble
obtaining, understanding and using health information; for
example, an accountant may not know when to schedule a pap
smear and a chef may be unable to prepare health conscious
meals (IOM, 2004).
As mentioned above, 90 million adults (47% of the adult population) may lack the literacy skills to effectively use the U.S.
health care system (IOM, 2004). The majority of these adults
were born in the U.S. and speak English. Literacy levels are
lower among elderly persons, those who have lower educational
levels, those who are poor, minority populations and groups with
limited English proficiency such as recent immigrants (IOM,
2004). The gap between knowledge and practice is widened by
inadequate health literacy. People who lack an understanding of
health care usually present with more advanced disease, receive
fewer preventive care services and have poorer health outcomes
(IOM, 2004). As one example, diabetics with poor health literacy were more likely than patients with adequate health literacy
to have poor glycemic control and reported more retinopathies
(Schillinger et al, 2002).
In its report Healthy People 2010, the U.S. Department of
Health and Human Services included improved consumer
health literacy as Objective 11-2, and identified health literacy as an important component of health communication,
medical product safety and oral health. The 2003 Coalition
for Allied Health Leadership team completed a national survey of allied health professionals and educators to assess
awareness and needs concerning health literacy. Approximately one-third of all respondents were unaware of the
issues surrounding health literacy, or that health literacy
resources were available; denied knowledge of an impact of
health literacy on patient care for their specific profession or
had no institutional policy or goals to address health literacy.
The article states that inadequate health literacy adversely
affects health care outcomes and the quality of life of 90 million Americans. The cost to the health care system is $73 billion annually (Health Literacy Survey, 2004).
Literacy provides the skills that enable individuals to
understand and communicate health information and concerns. As mentioned above, educators do not associate literacy

Health Literacy/Client Compliance

33

Box 3-1. Health Literacy in an Older Man.

A 64-year-old man, with a history of noncompliance, was evaluated for a routine checkup. According to the resident, he hadnt
taken his medications for diabetes or a heart problem for several
weeks. Before leaving he received instructions about his medications, their importance and the proper doses. He disclosed he
would see his doctor for follow-up, but couldnt remember the persons name. He was given a handwritten discharge summary.
He was seen five months later at a community clinic. He said he
was taking his medications, but couldnt remember their names or
dosages. The regimen was reviewed a second time; dates for
blood tests were provided. He was scheduled for a recheck in two
weeks.
When he returned, a medical student made a diagnosis that no
one had considered: illiteracy. Many of his glucose values had
been written for future dates and he was unable to read his list of
medications. The man lived alone, dropped out of school in the
second grade and had never learned to read.
Despite avoiding jargon and use of simple language, his medical teamcomprised of many doctors, nurses and social workershad not guessed he couldnt read.
This patients problem is not uncommon. Fourteen percent of
the adults in the U.S. have substandard prose ability: ability to use
printed and written information to function in society, to achieve
ones goals and potential. According to The National Assessment
of Adult Literacy (NAAL), these substandard skills are no more
than the most simple and concrete literacy skills: ranging from
those completely illiterate to those who can identify short phrases.
Other facts: based on NAAL data, 12% of U.S. adults have doc-

with reading alone, but often consider literacy to represent a

constellation of skills including reading, writing, basic mathematical calculations and speech and speech comprehension
skills (Kirsch, 2001; Healthy People 2010) (Table 3-2).

Problems Associated with Inadequate Health

Literacy
Individuals with inadequate health literacy (as currently measured) report less knowledge about their medical conditions and
treatment, worse health status, less understanding and use of
preventive services and a higher rate of hospitalization than
those with marginal or adequate health literacy (Parker et al,
2003).
Inadequate health literacy is a hidden problem. People with
limited health literacy skills may be embarrassed to discuss or
even mention problems they encounter with the health care
system (Baker et al, 1996; Parikh et al, 1996).
Health care personnel assume patients are telling everything,
which is clearly not the case (Box 3-1). Studies show that a
large percentage of patients are noncompliant and that health
care professionals significantly underestimate how common
noncompliance is (Hall et al, 1988).
Two recent studies demonstrated a higher rate of hospitalization and use of emergency services among patients with limit-

ument illiteracy. That is, they lack the ability to read and understand transportation schedules and food and drug labels. These
people cannot read a television program to find what time a program will be aired. Twenty percent have below basic quantitative
literacy, the ability to perform fundamental quantitative tasks such
as comparing ticket prices for two events. Older people (i.e., >64
years) fared the poorest on the NAAL; 23% had below average
prose literacy, 27% below basic document literacy and 34% below
basic quantitative skills.
Survey results indicate more than one-third of English-speaking
patients and more than half of primarily Spanish-speaking patients
at U.S. hospitals have low literacy. Often, these people present in
the emergency room rather than a clinic because someone there
will always write the information down so they dont have to do it
themselves.
Patients with low literacy skills are often ashamed of their problem, with two-thirds never telling their spouses.
One clinician thinks that literacy screening should become a
new vital sign. But that approach is controversial; no one wants to
be embarrassed especially in front of his or her doctor. And there
is little time to collect more information now in clinical practice.
However, much has been written on the topic.
The patient described at the beginning of this case, with help,
enrolled in an adult reading course, but its still not clear if he takes
all his medications as prescribed.
The Bibliography for Box 3-1 can be found at
www.markmorris.org.

ed literacy. This higher use has been associated with higher

health care costs (IOM, 2004). The Institute for HealthCare
Advancement estimates that the average annual health care
costs of people with very low health literacy may be four times
greater than that of the general population (Sarasohn-Kahn,
2002). In a small Arizona study, patients with reading levels at
or below third grade had mean Medicaid charges $7,500 higher than those who read above the third grade (Weiss and
Palmer, 2004).
Inadequate health literacy is particularly common among
older adults and low-income patients. More than 66% of U.S.
adults age 60 and older have inadequate or marginal literacy
skills and about 45% of all functionally illiterate adults live in
poverty (AMA Foundation, 2000).
A study of 2,659 outpatients at two hospitals found that 42%
did not understand instructions to take medication on an
empty stomach. The same study found a 52% increase in the
risk of hospitalization among patients with inadequate literacy
compared with patients with adequate literacy (Williams et al,
1995). In the largest study of health literacy to date, one-third
of English-speaking patients at two public hospitals were
unable to read basic health materials. Twenty-six percent were
unable to understand information on an appointment slip and
60% did not understand a standard informed consent docu-

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Small Animal Clinical Nutrition

Box 3-2. Health Literacy and Language

Barriers.
Almost 50 million Americans (~19% of U.S. residents) speak a
language other than English at home. A total of more than 22
million have limited English proficiency, speaking less than
very well by their own admission. The decade leading up to
2000 experienced a 47% (more than 15 million people)
increase in the number of people who spoke a language other
than English at home.
Many patients who need medical interpreters have no
access to them. Results of one study showed that no interpreter was used in 46% of emergency department cases
involving people with limited English proficiency. Furthermore,
few clinicians receive instructions with how to work with interpreters.
Language barriers and deficits can cause great harm.
Patients are often nonadherent to medications, less likely to
return for follow-up visits and have higher rates of hospitalization and drug complications. Two cases follow:
Case 1: A two-year-old girl was diagnosed with an inner ear
infection and was prescribed an antibiotic. Her mother understood that her daughter should receive the prescribed medication twice daily. After carefully studying the label on the bottle
and deciding it didnt tell how to administer the medication, the
mother filled a teaspoon and poured the antibiotic into her
daughters painful ear.
Case 2: A young Spanish-speaking man stumbled into his
girlfriends house and said he was intoxicado. The Spanishspeaking paramedics took the work to mean intoxicated. The
patients intended meaning was nauseous. After 36 hours of
being worked up for a drug overdose, the patient was reevaluated and found to have an intracerebellar hematoma with
brainstem compression and a subdural hematoma. The young
man became a quadriplegic.
Family members, friends and untrained members of the
support staff are often used in these encounters, but commit
more errors than those with more training. Much work needs
to be done in this area given the changing dynamics of the
U.S. population.
The Bibliography for Box 3-2 can be found at
www.markmorris.org.

ment (Williams et al, 1995).

Racial and ethnic differences can contribute to communication breakdowns (Box 3-2). As many as 20% of Spanish-speaking Latinos say they do not seek medical advice due to language
barriers (IOM, 2002). A 2001 survey of 6,722 adults found that
minority populations are more likely to have difficulties communicating with their health care providers compared with
whites (Collins, 2001).
Even highly skilled individuals may find the health care system too complicated to understand, especially when poor
health, anxiety, effects of medication, etc. make them more vulnerable. Directions, signs and official documents, including

informed consent forms, social services forms, public health

information, medical instructions and health education materials often use jargon and technical language that make them too
difficult to use (Rudd et al, 2000).
Patients with inadequate health literacy and chronic illness
have less knowledge of illness management than those with
high health literacy (Kalichman and Rompa, 2000). Public
hospital patients with inadequate health literacy had higher
rates of hospitalization than those with adequate health literacy (Baker et al, 1996). Adults with limited health literacy have
less knowledge of disease management and of health-promoting behaviors, report poorer health status and are less likely to
use preventive services (IOM, 2004).
Adverse drug events are another aspect of inadequate health
literacy. One report found that 10% of adverse drug events were
linked to errors in the use of the drug as a result of communication failure (Leape et al, 1993).

Where do Patients Receive Health Care

Information?
Socioeconomic status, education level and primary language all
affect whether consumers will seek out health information,
where they will look, what type of information they prefer and
how they will interpret that information (IOM, 2004). There is
no single reliable answer.
Between 62 and 69% of adults at all literacy levels reported
obtaining information from family and friends. Between 94
and 97% of adults at all skill levels reported using radio and television to obtain information. Individuals with lower literacy
levels were less likely than those with higher skills to use newspapers and magazines for health information (69.5 vs. 90%).
The National Cancer Institute conducted the Health
Information Trends Survey (HINTS), one of the nations first
national surveys of health information sources in 2003 and
2005. HINTS databases are designed to provide information
regarding pattern of information use and opportunities to
inform Americans about cancer.
In a Gallup survey, the proportion of people who reported
getting a great deal or moderate amount of health or medical information from these sources follows: doctors (70%), television (64%), books (56%), newspapers (52%), magazines
(51%), nurses (49%) and the Internet (37%). The proportion of
people who reported a great deal or moderate amount of trust
and confidence in the health or medical information from the
sources follows: doctors (93%), nurses (83%), books (82%),
newspapers (64%), magazines (62%), the Internet (62%) and
television (59%) (Gallup Organization, 2002).
People have more ways than ever to get information, including telephone, fax, e-mail, the Internet, television, radio, print
media, family and friends, etc. More sources will be available in
the future, including automated monitoring of vital signs and
markers, increased use of wireless technology, among others.
But how do people access information today and how accurate
is that information? The National Cancer Institute sought to
answer some of these questions through HINTS. Some results
follow (Hesse, 2004):

Health Literacy/Client Compliance

Where would you go for cancer information? Provider
(50%), Internet (34%), Library (5%), Family (4%), Other
(4%), Print media (3%).
Where did you go for cancer information? Internet (49%),
Print media (27%), Provider (11%), Library (6%), Other
(4%), Family (3%).
Trust information by gender? There were no gender differences. Doctors came in first, followed by television. No differences existed among family/friends, newspapers, magazines, radio, television and the Internet.
Trust information by education? Those with no high school
diploma tended to trust their doctors and television far
more than family, friends, newspapers, magazines, radio
and the Internet.
When asked to agree or not with the statement
Everything causes cancer: 51% strongly agreed or agreed;
only 18% strongly disagreed.
When asked to agree or not with the statement Theres
not much people can do to lower their chances of getting
cancer: 72% strongly disagreed or somewhat disagreed.
When asked to agree or not with the statement There are
so many different recommendations about preventing cancer, its hard to know which ones to follow: 77% strongly
agreed or somewhat agreed.

Family and Friends

Personal stories may have the power to influence health behavior, especially in those with inadequate literary skills. One study
found that many individuals with inadequate literacy more
often obtained information about cancer from family and others who have had experience with a late-stage diagnosis rather
than from reading about the disease (Friedell et al, 1997).

The Internet
The Internet is estimated to reach more than 70 million people living in the U.S. with health information. About 90% of
15- to 24-year-olds have been online; 75% of these have used
the Internet at least once to obtain health information
(Rideout, 2004). Inadequate English literacy and disparities in
computer access decrease the likelihood that the information
will be available to, and understood by, all health consumers
(Houston and Allison, 2002). The quality and reliability of
online content can be problematic. A meta-analysis of consumer health information on the Internet found that 70% of
the studies analyzed concluded quality was a problem
(Eysenbach et al, 2002).

Health Care Professionals

A number of studies demonstrate that patients remember and
understand as little as half of what they are told by their physicians. In addition, because they have knowledge deficits,
patients with inadequate health literacy may be less equipped to
overcome discrepancies in understanding and memory when
they are at home and experience difficulties reading or interpreting instructions (IOM, 2004).
Limited education, training, continuing education and prac-

35

tice opportunities to develop skills for improving health literacy exist for allied health professionals and educators at the
national level (IOM, 2004).
Some evidence of a failure of communication exists with
patients who have inadequate health literacy as currently measured. Patients with chronic diseases and inadequate health literacy have poor knowledge of their condition and its management, often despite having received standard self-management
education (Williams et al, 1998, 1998a). Patients with inadequate health literacy have more difficulty accurately reporting
their medication regimens and describing the reasons for which
their medications were prescribed (Schillinger et al, 2003) and
may have poorer compliance (Kalichman et al, 1999).
Communication between a health care provider and patient
during outpatient visits may be hampered by several related factors. These include the relative infrequency and brevity of visits, language barriers, differences between providers and
patients agendas and communication styles and other cultural
barriers, lack of trust between the patient and provider, overriding or competing clinical problems and the complexity and
variability of patients reporting symptoms and trends in their
health status (IOM, 2004).
The average patient asks only two questions during an entire
medical visit lasting an average of 15 minutes, according to the
Bayer Institute of Health Care Communications. Studies show
that most patients are relatively uninformed about their condition or the most appropriate treatment despite the fact that
most patients state they want more information. Results of one
study revealed that doctors imparted information to patients for
an average of a little more than a minute during interviews that
lasted an average of more than 20 minutes. When asked how
much time they spent on patient education, the physicians
overestimated by a factor of nine. The study also found that in
65% of the cases, physicians thought patients wanted less information than they actually did (Terry, 1994).
An Institute of Medicine (IOM) report clarifies the links
between miscommunication and medical and health errors and
adverse events (2002). A variety of problems can result if culture and language are not accounted for including failure to
obtain accurate medical histories, failure to obtain informed
consent, inadequate health knowledge and understanding of
health conditions, inadequate treatment adherence (compliance), medication errors, decreased use of preventive and other
health care services and poor patient satisfaction. Customized
and tailored care based on patient needs and values and accommodating differences in patient preferences are integral to individualized care (IOM, 2001).
The concept that no one size fits all is fundamental to the
understanding of health literacy. Complex problems are rarely
resolved by simple solutions. However, scientific investigations
of interventions to minimize the impact of health literacy and
promote the development of health literacy skills are in its
infancy (IOM, 2004). Evidence-based approaches show promise for contributing to better outcomes (Chapter 2).
Health literacy must be understood and addressed in the context of culture and language (IOM, 2004). Competing sources

36

Small Animal Clinical Nutrition

of health information (including the national media, the

Internet, product marketing, health education and consumer
protection) intensify the need for improved health literacy.

Improving Health Literacy

Health literacy is fundamental to quality care (IOM, 2004).
Without improvements, the effect of many advances to
improve health outcomes will be diminished. Consequently, the
IOM of the National Academies (U.S.) has identified improving health literacy as one of two crosscutting issues in health
care requiring attention (IOM, 2003). The IOM reports that
enabling patients to understand their condition and its treatment, to make the best decisions for their care and to take the
right medications at the right time in the intended dose; that is,
to act in their own interest remains a neglected, final pathway
to high-quality health care (IOM, 2004).
A 1998 report from the U.S. Department of Health and
Human Services provided evidence from accumulated studies
that health, morbidity and mortality are related to income and
educational factors (Pamuk et al, 1998). Life expectancy and
death rates from cancer and heart disease, incidence of diabetes
and hypertension and use of health services were related to
family income. Death rates from chronic diseases, communicable diseases and injuries were inversely related to education (i.e.,
those with lower educational achievement were more likely to
die of a chronic disease than those with higher educational
achievement). In essence, the lower ones income or educational achievement, the worse ones health (IOM, 2004).
Approaches that appear to successfully improve health literacy include:
1. Provision of simplified/more attractive written materials
2. Technology-based communication techniques
3. Personal communication and education
4. Combined tailored approaches
5. Partnerships (collaborative measures between patient and
the health care team).
In all of these, using plain language (common words, defining unusual words, writing the way people talk); simple, specific and direct sentences; active, inflective voice; sequencing
ideas clearly and logically; being attentive to and respectful of
culture enhance the patients ability to understand and retain
information. It is also imperative to be cognizant of overt and
covert messages and to improve skills, materials and processes. This includes changing outdated approaches and encouraging professionals to improve verbal and written communication skills, including work with the adult education sector,
etc. (Rudd, 2002).
Professionals are also encouraged to write legibly or type, and
use simplified language with more white space, improved format and pictograms (See below.) or other graphic devices.
Pictograms may be especially useful for communicating information to consumers who speak English as a second language
and to those with lower reading ability levels (IOM, 2004).
The telephone can be a great means of delivering interventions such as health-related counseling and reminders, if the
caller has competent verbal communication skills. Tailored

print communications can improve health outcomes, but

research also shows that they are less effective at influencing
individuals who are not serious about making a behavioral
change (Revere and Dunbar, 2001; IOM, 2002).
Arcane language and jargon that are common to health care
workers are usually indecipherable to patients. Adults who have
difficulty reading or understanding written materials are often
embarrassed and devise ways to hide their inability to understand. If health care professionals invested more time to ask
their patients to explain exactly what they understand about
their diagnoses, instructions and bottle labels, the caregivers
would find many gaps in knowledge, difficulties in understanding and misinterpretations (IOM, 2004). These problems are
exacerbated by language and cultural variation, by technological complexity in health care and by intricate administrative
documents and requirements.
Female primary care physicians tend to engage in longer
visits and have more patient-centered consultations than
their male counterparts (Roter et al, 2002). Female physicians
engage in significantly more active partnership behaviors,
positive talk, psychosocial counseling, psychosocial question
asking and emotionally focused talk. Medical visits with
female physicians are, on average, two minutes (10%) longer
than those with male physicians.
Distinguishing between noncompliance and inadequate literacy may be difficult unless health care providers regularly ask
patients questions such as, Was I clear? Is there anything
youd like for me to go over again? These types of questions put
the burden of responsibility on the speaker rather than on the
listener. Researchers and the American Medical Association
advocate the importance of teachback. For example, asking
Just so we both agree, why dont you tell me what you would
do if XYZ happens? or to demonstrate how the patient would
do something, like monitor blood glucose concentration.
In veterinary medicine, this simple approach of having pet
owners relate back their understanding (without feeling like
theyve been put on the spot) can have dramatically positive
ramifications for pet care. Speaking clearly and being an attentive listener can express that you care. Empathy goes a long way
in building trust and establishing a relationship so that communication is successful. Focus on using basic words and making
the message clear.
A meta-analysis of 41 research studies showed that giving
patients more information is associated with increased patient
satisfaction, better compliance and better recall and understanding of medical conditions (Rankin and Stallings, 1996).

Technology-Based Communication
Its very hard to cover all the complex information needed to
make decisions in spoken and written words. Covering some
information with tools such as CD-ROMs before patients
meet with their doctors has increased satisfaction in at least one
study in human medicine.
According to the Memorial Sloan-Kettering Cancer
Center, New technology (i.e., a CD-ROM educational tool)
can save nurses time by eliminating the need for repetitive

Health Literacy/Client Compliance

teaching, and enrich patient teaching by allowing the nurse
more time to address individual concerns (Ginty and
Sullivan, 2001). A second study conducted at the same center
discussed the benefits that were realized after nurses used an
educational CD-ROM to supplement their teaching to preand postoperative cancer patients. According to the center,
The nurse is responsible for doing preoperative teaching,
much of which is standard and the same for every patient.
Nevertheless, it must be repeated for each patient. The CDROM covering standard pre- and postoperative topics was
very effective; 78% of patients who completed a follow-up
quiz had one or no answers wrong. Nurses estimated that the
program significantly decreased the time it took them to do
standard preoperative teaching, allowing them to focus on
patient-specific questions and concerns. The study concluded
that patients stated the animation, narration and photographs on the CD-ROM reinforced their understanding and
decreased anxiety (Vaziri and Gallagher, 2001).
Professional and public awareness of the health literacy issue
must be increased, beginning with education of medical students and physicians and improved patient-physician skills
(Schillinger et al, 2004). Such training of veterinary students,
veterinarians and all health care team members would no doubt
be of great benefit to pets and pet owners as well.

Pictographs
Pictographs (e.g., like simple drawings on road signs) have been
used in non-literate societies to help people remember spoken
instructions. Pictographs are designed to help people understand information quickly. One small study tested the hypothesis that pictographs can improve recall of spoken medical
instructions. Twenty-one junior college students listened to lists
of 38 actions for managing fever and 50 actions for managing
sore mouths. One of the action lists was accompanied by pictographs during listening and recall whereas the other was not.
Subjects did not see any written words during the intervention
and therefore, relied entirely on memory of what they heard.
Mean correct recall was 85% with pictographs and 14% without (p <0.0001) (Houts et al, 1998).

Impact of Health Literacy on Compliance

Health literacy has only recently reached the national agenda
in human medicine and for the most part, hasnt at all in veterinary medicine. Logically, many of the 90 million
Americans with inadequate health literacy own pets. It would
be imprudent to assume that they understand preventive protocols, diagnoses and treatments for their pets any better than
they do for themselves.
There is very little information about the exact relationship
between compliance and health literacy in human medicine
and none in veterinary medicine. Studies show, however, that
a large percentage of patients are noncompliant and that
health care professionals significantly underestimate the scope
of noncompliance (Hall et al, 1988). Likewise, compliance is
a major problem in veterinary medicine (See below.) (AAHA,
2003).

37

Conclusion
Health literacy is fundamental to quality care (IOM, 2004). A
former surgeon general recently stated that health literacy can
save lives, save money and improve health and well being of millions of Americanshealth literacy is the currency of success for
everything I am doing as Surgeon General (Carmona, 2003).
Peoples prior knowledge, beliefs and experiences influence
the way they interpret and use health information.
Furthermore, Americas increasing cultural diversity challenges
health communication activities. Until now, weve known little
about how people seek health information or how to bridge the
substantial discrepancies between the information they want
and need and what they receive (Croyle, 2004). Several books
are available to provide information about improving health literacy and compliance (Table 3-3).
Health literacy must be actively addressed by the medical
profession, and likewise, the veterinary profession should take
an aggressive approach to enhance veterinary health literacy.

CLIENT COMPLIANCE
Introduction and Background
Around 400 BCE, Hippocrates supposedly observed that some
of his patients failed to comply with medical instructions, thus
prolonging their recovery. He subsequently counseled his students that some patients would be less than honest about taking medication. In the early 1900s, tuberculosis patients who
failed to follow medical instructions were called defaulters
( Jaret, 2001). Patients were subsequently described as faithless, untrustworthy and unreliable over the following half
century when they failed to follow their physicians orders
(Steiner and Ernst, 2000). Unfortunately, noncompliance with
medical instructions remains a huge problem more than 2,400
years after Hippocrates warning.
Improving communication is an important aspect of improving compliance. The Food and Drug Administration (FDA)
supports higher-quality health information for the public. An
FDA study in 1999 found that 56% of people who saw a consumer-directed print advertisement for a prescription drug said
they read the brief summary not at all or a little. In a followup study in 2002, that number increased to 73%. During the
same three-year span, those saying they read almost all or all
decreased from 26 to 16%. Based on these data, the FDA wants
manufacturers to present key risk information in consumerdirected print advertisements in more consumer-friendly ways,
including use of clearer, less cluttered formats for presenting
risk information. The FDA also encourages manufacturers to
focus their risk disclosures on the most important and the most
common risks and to do so in language easily understood by the
average consumer (FDA, 2004).
Preventive and therapeutic noncompliance is a major issue in
human health care and, as well show, in veterinary medicine.
The number one problem in treating illness today is patients
failure to take prescription medications correctly, regardless of
patient age (AmericanHeart.org, 2004). Failure to take medica-

38

Small Animal Clinical Nutrition

Table 3-3. Additional resources for improving health literacy and

compliance.
Titles
Health literacy resources
Health Literacy

Publishers
Institute of Medicine
National Academies Press
500 5th Street NW, Lockbox 285
Washington, DC 20055

Understanding Health
Literacy: Implications for
Medicine and Public Health

American Medical Association

800-621-8335
www.amapress.com

Health Literacy in Primary

Care: A Clinicians Guide

Springer Publisher Company

11 West 42nd Street
New York, NY 10036
www.springerpub.com

Health Literacy from A to Z:

Practical Ways to
Communicate Your Health
Message

Jones and Bartlett Publishers

40 Tall Pine Drive
Sudbury, MA 01776
www.jbpub.com

Advancing Health Literacy:

A Framework for
Understanding and Action

Jossey-Bass
800-956-7739
www.josseybass.com

Compliance resources
The Path to High-Quality
Care: Practical Tips for
Improving Compliance

American Animal Hospital

Association
12575 West Bayaud Avenue
Lakewood, CO 80228
800-883-6301
www.aahanet.org

Veterinary Clinics of North

America: Small Animal
Practice
(March 2006; 36(2): 419-436)

WB Saunders Co.
6277 Sea Harbor Drive
Orlando, FL 32887
877-839-7126
[email protected]

Journal of the American

Veterinary Medical Association
Evaluation of client compliance
with short-term administration
of antimicrobials to dogs.
(Feb. 15, 2005; 226(4): 567-574)

American Veterinary Medical

Association
1931 N. Meacham Rd, Suite 100
Schaumburg , IL 60173
847-925-8070

tions as directed costs the U.S. economy $100 to $300 billion

annually (Fortune, 2004). In the U.S. today, the annual consequences of noncompliance include (epill.com):
An estimated 125,000 deaths.
23% of nursing home admissions (380,000 patients/$31.3
billion) are the result of patients failing to take prescription
medications accurately.
10% of hospital admissions (3.5 million patients/$15.2 billion) are the result of patients failing to take prescription
medications correctly.
Reduced productivity (absenteeism, impaired work performance [20 million workdays/$1.5 billion]).
Lengthened hospital stays (4.2 days) due to medication
noncompliance.
The American Heart Association presents the following
facts on its website to further define the scope of noncompli-

ance (AHA, 2004): Almost 49% of Americans use prescription

drugs and 30% use nonprescription medications.
Almost 29% stop taking their medicine before it runs out.
22% take less of the medication than is prescribed on the
label.
12% dont fill their prescriptions at all.
12% dont take medication after they buy the prescription.
At any given time, up to 59% of patients on five or more
medications are taking them improperly, regardless of age.
Adverse drug reactions may be the fourth to sixth leading
cause of death. Serious adverse drug reactions occur in 6.7%
of hospitalized patients.
The above data deal with health care compliance in the U.S.
Similar data exist for other developed countries. The World
Health Organization has published an excellent review about
the difficulties of compliance: Adherence to Long-Term
Therapies: Evidence for Action (WHO, 2003). Compliance data
from developing countries is even lower.
The information that follows summarizes much of the
existing knowledge about compliance in small animal veterinary practice. Promoting awareness of poor compliance rates
and acknowledging our ability and obligation to improve
them are the first steps in improving adherence to recommended services and products and their associated outcomes
for dogs and cats.

Definitions
Compliance has been traditionally defined as the extent to
which the patient (client in veterinary medicine) follows medical instructions (Sabate, 2001). Unfortunately, this definition
promotes a paternalistic relationship and suggests patients (or
clients) should be passive participants in health care.
Furthermore, this concept of compliance omits many nonmedical interventions that promote health including diet, exercise,
routine dental care and avoiding or minimizing behaviors that
increase the risk of illness. A better definition is the extent to
which a persons (or pet owners) behavior-taking (administering) medication, following a diet and/or executing lifestyle
changes-corresponds with agreed recommendations from a
health care provider (WHO, 2003). Another definition used in
veterinary medicine: the pets in your practice are receiving the
care that you believe is best for them (AAHA, 2003).
Compliance is thus a behavior and a measure (Hasford, 1999).
Veterinary clients are/will become surrogates for their pets in
this regard.
Compliance will be used throughout this article because the
term is firmly entrenched in the medical and dental literature
and is gaining in awareness in veterinary medicine. As mentioned above, compliance, as defined in human medicine, suggests a paternalistic relationship and connotes blame (as do
other terms such as control, adhere, prescribe, regimen, whats
best for you and will power), whether it be of patients, clients
or health care providers, and is associated with the outmoded
concept that the client is the sole source of noncompliance. The
concept of adherence may be a better way of capturing the
dynamic and complex changes required over long periods to

Health Literacy/Client Compliance

maintain optimal health for people or pets with chronic diseases (WHO, 2004). Adherence requires that the patient
(client in veterinary medicine) agree to treatment recommendations. Concordance takes the relationship further because it
fosters the concept of agreement between clients and health
care providers about whether, when and how medications
should be taken. Adherence is used synonymously with compliance in this chapter.
Based on the 2003 AAHA Compliance Study, veterinarians
strongly believe that compliance is all or mostly the clients
responsibility. Forty-one percent of veterinarians said clients
were responsible for noncompliance, whereas 19% said it was
the veterinarians; 36% indicated that clients and veterinarians
shared the responsibility (AAHA, 2003).

Compliance Research in Veterinary Medicine

The first compliance articles began to appear in the human
medical literature in the 1950s. Since then, thousands of articles have been published and dozens of businesses and websites
have been created to promote the concept of compliance. By
comparison, only a handful of articles have appeared in the veterinary literature. A sampling of the relevant literature follows
(Boxes 3-3 through 3-5).
In one study, 48% of the dogs visiting 36 veterinary clinics
were placed on the recommended heartworm preventive program. These dogs received 78% of the medication required to
fully comply with the clinics recommendations (Cummings,
1995). In another study involving cats with stable chronic renal
failure, compliance was not achieved in more than 40% of cats,
although cats receiving dietary therapy (i.e., foods restricted in
phosphorus and protein) were generally healthier and lived for
three times longer, on average. Limited food intake by cats,
owner resistance or both were cited as reasons for noncompliance (Elliott et al, 2000).
At least three studies measured compliance with short-term
antibacterial therapy in dogs. In one study, investigators
assessed compliance among 95 dog owners using a telephone
survey. Forty-four percent reported 100% compliance with
the treatment regimen and 88% reported a compliance level
of 80% or more. Compliance was significantly higher when
dog owners felt that the veterinarian spent enough consultation time. Compliance results were higher for dogs treated for
gastrointestinal (GI) infections compared with those treated
for other diseases (Grave and Tanem, 1999). In another study,
electronic monitoring (e.g., Which may mean as little as the
client opened a bottle with an electronic chip, whether the
client gave the medication or whether the pet regurgitated the
medication are variables.) showed owners administered an
average of 84% (range 7 to 104%) of an antibiotic given for
five to seven days. Return medication counts and client selfreports overestimated therapeutic compliance compared to
electronic monitoring. The majority of owners (71%) claimed
perfect compliance with the prescribed regimen (Barter et al,
1996). The third study reported that there was no difference
in compliance for regimens that included twice or three times
per day administration of an antibiotic (84%). However, only

39

Box 3-3. Human Oral Health Literacy

Studies.
Eight objectives in Healthy People 2010 concern the oral health
of U.S. adults, including goals to reduce dental caries, gingivitis, oral cancer and tooth loss, as well as to improve use of the
dental care system. The Surgeon General recognized that the
majority of people who need such information most, those in
low-income groups and those with lower education levels, also
are the ones who lack the information and skills (oral health literacy) to ask for and obtain specific preventive services or
treatment options.
One article in this review studied the readability of 24 educational materials for dental patients. The reading levels ranged
from the third to 23rd grade levels, more than 40% of which
were written above the seventh to ninth grade level. Many of
the materials contained grammatical errors and obscure jargon.
A second article examined the readability and distribution of
20 printed materials containing oral health educational information. Ninety-one percent of the materials were written
between the 9th and 15th grade levels.
A third article assessed the difficulty of dental words and
tested the readability of selected dental health education materials. Adolescents were asked to read aloud and describe the
meanings of 25 commonly used dental terms. Several words
were poorly understood, including gum disease, oral
hygiene, fluoride tablets and gingivitis. The four dental
health education brochures studied were written from 12.4 to
17.4 reading grade levels.
Yet another study assessed the readability of 19 oral cancer
educational pieces. Five pieces tested at the sixth and seventh
reading grade levels, nine at the eight and ninth grade levels,
and five at grades 10 through 13.
The Bibliography for Box 3-3 can be found at
www.markmorris.org.

34% gave doses within the designated optimal time period.

Compliance tended to be better with the twice-daily regimen
although the differences were insignificant (Barter et al,
1996a). It should be noted, however, that these percentages
were self-reported.
In dental compliance studies, owners of dogs were given
extensive instructions about brushing their dogs teeth. Six
months later, 53% were still providing the minimum care necessary to prevent periodontal disease (Miller and Harvey,
1994). Another study compared three dental homecare regimens, including daily toothbrushing and two different dental
foods, with a control group in 88 client-owned cats for six
months after a professional cleaning. A large-sized kibble with
dental properties was most efficacious in controlling calculus
formation and development of gingivitis. Toothbrushing compliance was only 40% at the end of the six-month study
(Theyse et al, 2002).

40

Small Animal Clinical Nutrition

Box 3-4. Compliance in Human Medicine.

Several types of noncompliance exist. Initial noncompliance
occurs when a patient receives a written prescription or calls a
pharmacy, but doesnt wait or return to pick up the filled prescription. Patients who fail to present a prescription are also
initial noncompliers. Varying compliance is used to describe the
process of taking a prescribed medication at a level less than
recommended. Hypercompliance occurs when a patient takes
a medication at a level above that prescribed. The term white
coat compliance is used to describe behavior in which a
patient who has been noncompliant takes medication at or
above the prescribed level around a recheck appointment.
Accordingly, both the physician and the patient may incorrectly believe the patient is receiving therapeutic benefit. Drug holidays refers to the behavior in which patients repeatedly and
abruptly discontinue and resume taking their medication.
Studies have shown that the amount of information forgotten by patients is a linear function of the amount presented and
is correlated with the patients medical knowledge, anxiety
level, and possibly age, but not with intelligence. Therefore, a
phased approach is preferable in patient education. Both oral
and written information should be provided (e.g., patient education booklets, medication cards, etc.) and special materials
should be developed to instruct patients with low literacy (e.g.,
picture schedule). Formal evaluation of patient education is
imperative.
Failure to attend appointments is often one of the first signs
that a patient is not complying with his or her treatment. Given
the difficulty of monitoring compliance directly, health care professionals may want to monitor patients attendance at clinic
appointments as a proxy measure.
Asking patients to complete diaries about medication use
has the advantage of providing details about how and when the
product was taken. However, whether diaries improve compliance hasnt been proven.
The Bibliography for Box 3-4 can be found at
www.markmorris.org.

The American Animal Hospital Association

Compliance Study
The American Animal Hospital Association conducted the
largest, most significant compliance study in veterinary medicine, which was funded by a substantial educational grant from
Hills Pet Nutrition, Inc. Results of the study were reported in
the book The Path to High-Quality Care: Practical Tips for
Improving Compliance in 2003. This comprehensive study
showed that millions of dogs and cats did not receive the best
care they could have. Although most practice teams thought
compliance with recommendations was high, few practices
actually measured compliance and the level of compliance in
almost all cases was significantly less than what practice teams
believed; 78% of veterinarians indicated that they were satisfied
with the levels of compliance in their practices (AAHA, 2003).
Researchers visited 52 practices and/or conducted in-depth

interviews with practice teams. More than 1,000 pet owners

were surveyed about the care they provided for their pets, their
desires relative to the information and care provided by their
veterinarian and their compliance with health care recommendations. Furthermore, data were gathered from the medical
records of almost 1,400 cats and dogs. These data were used to
quantify compliance and the opportunities that practices had to
improve pet care by improving compliance (AAHA, 2003).
The study quantified compliance in six areas:
Heartworm testing and prevention
Dental prophylaxis
Therapeutic foods
Senior screenings
Canine and feline core vaccinations
Preanesthetic testing.
Only dogs and cats seen by their veterinarian at least once
during the past 12 months were included in the study; extrapolation accounts for 51 million dogs and 44.2 million cats
falling into this category (AVMA, 2002). The AAHA compliance data do not include 10.6 million dogs and 22.7 million
cats that were not seen at a veterinary practice during the previous year.
More than seven million dogs were not in compliance with
their veterinarians protocol for heartworm testing. Almost 21.5
million owners did not give their dogs heartworm preventive
medication at all, failed to give medication for the number of
days recommended by their veterinarian, or (and maybe most
alarming) were never dispensed an adequate amount of preventive in the first place, or were never notified by the practice to
purchase follow-up doses. In endemic areas, compliance for
testing and preventive medication was 83 and 48%, respectively. The American Heartworm Association reported that more
than 244,000 dogs tested positive for heartworms in 2001
(AAHA, 2003).
The AAHA Compliance Study found a dental prophylaxis
compliance rate of 35% for dogs and cats with grade 2, 3 or 4
dental disease. Compliance was only 15% for those pets with
grade 1 disease. The study concluded that almost 15.5 million
dogs and cats with grade 2, 3 or 4 dental disease had not
received dental prophylaxis. Based on chart review, 23% of
those owners of pets with grade 2 or higher dental disease (3.6
million pets) did not receive a recommendation for treatment.
Millions more cats and dogs had grade 1 disease. Interestingly,
no grade was reported for 19% of the patients. The lack of a
reported dental grade may indicate that no exam was given or
poor medical record keeping (AAHA, 2003). The American
Veterinary Dental College defines quality dental health care as
completing a dental prophylactic procedure on any pet with
grade 1 to 4 dental disease. Veterinary health care teams failed
to adhere to these recommendations in a great many cases,
which has resulted in less than the best care for many patients.
Compliance with feeding a therapeutic food for six canine
conditions (i.e., kidney disease, bladder stones or crystals, food
allergies, chronic GI disease, acute GI disease and obesity) and
seven feline conditions (i.e., the same six canine topics plus
feline lower urinary tract disease) was included in the survey.

Health Literacy/Client Compliance

Compliance with feeding therapeutic foods was 19% for dogs
and 18% for cats. More than 11.6 million dogs and nine million cats with one of the diagnosed conditions were not fed an
appropriate therapeutic food at all or were not fed the food for
an appropriate period of time (AAHA, 2003). When all pets
with diagnoses that could benefit from treatment with a therapeutic food were considered, overall compliance was 5 to 7%,
which represented more than 52 million dogs and cats. The real
potential for improvement for all foods combined could be as
high as 20-fold. What was also disturbing is that 55% of pet
owners who fed a therapeutic food also supplemented the recommended food with other foods or treats. The primary reason
cited by clients was that they didnt know not to.
Thirty-five percent of the dogs and cats in a typical practice
are considered senior (i.e., mature). Senior screenings minimally included blood work and a urinalysis. About 17.9 million
dogs and 15.5 million cats considered to be senior had not
received a diagnostic screening in the past year. Only 32 and
35% of the dogs and cats had diagnostic screening tests performed (AAHA, 2003).
Compliance for core vaccinations (i.e., distemper, hepatitis,
leptospirosis, parainfluenza and parvovirus for dogs and viral
rhinotracheitis, calicivirus and panleukopenia for cats) was
87%, which was higher than for any other condition studied.
Still, 12.4 million dogs and cats were not protected against core
diseases. Compliance with other vaccinations was not studied
(AAHA, 2003).
Compliance with preanesthetic screening was 72% for dogs
and 65% for cats. Compliance was 90% for practices that
required preanesthetic blood work (AAHA, 2003).

Economic Aspects of Noncompliance

Poor compliance affects standards of care, overall pet health,
client satisfaction and practice economics. Every veterinary
health care team member and client is responsible for enhancing compliance. According to the AAHA Compliance Study,
the total additional revenue opportunity per veterinarian per
year is $639,700 to $660,700 for the conditions studied (2003).
Other practice productivity data are available (Wayner and
Heinke, 2006).

41

Box 3-5. What Veterinarians can Learn

from Physicians about Communication.
The Journal of the American Veterinary Medical Association
published an outstanding review titled What can veterinarians
learn from studies of physician-patient communication about
veterinarian-client-patient communication? (Vol. 224 [5],
March 1, 2004, pp 676-684). Several relevant points follow:
A gold standard does not exist for assessing physicianpatient interactions, nor for an accepted definition of the
physician-patient relationship.
Communication style should be tailored to the individual
patient.
The most common model for the physician-patient relationship is still paternalism. Relationship-centered care,
characterized as a partnership, in which negotiation and
shared decision-making is suggested as optimal. The
physicians role is suggested as an advisor or counselor.
Communication skills and dealing with clients have been
listed as the most important skills for success.
Effective communication can significantly improve medical
outcomes, including patient health and satisfaction,
adherence to medical recommendations and physician
satisfaction.
A controlling style including behaviors that maintain the
physicians power, status, authority and professional distance negatively affects patient satisfaction.
Factors suggested to improve client compliance include
establishing two-way communication and trusting relationships, a compassionate health care team, collaborative
planning of the treatment regimen, provision of specific
verbal and written instructions about medications and
timely encouragement.
Medical researchers have studied physician-patient interactions for 30 years. Four basic conclusions have
emerged: physician-patient interactions have an impact on
patient health, patient satisfaction, adherence to medical
recommendations and physician satisfaction.
The Bibliography for Box 3-5 can be found at
www.markmorris.org.

Improving Compliance
The AAHA Compliance Study concluded that compliance is
related to three factors: recommendation (by the veterinarian),
acceptance (by the client) and follow through (by the veterinary
health care team). This can easily be remembered as CRAFT,
where Compliance = Recommendation + Acceptance + Follow
Through. The AAHA study noted that: 1) compliance was
much lower than veterinarians believed and 2) clients would
very often comply if the practice made an effort to help them
comply (2003). Furthermore, a significant element of noncompliance is due to the fact that practice team members often do
not make recommendations to clients. Thus a positive compliance cascade cannot happen.
As part of the study, pet owners were asked to agree with one
of these statements:

I want my veterinarian to tell me about all of the recommended treatment options for my pet, even if I may be
unable to afford them.
I want my veterinarian to tell me only about the recommended treatments for my pet that he or she thinks are not
too expensive for me.
Ninety percent of respondents chose the first statement.
Furthermore, only 7% declined dental care due to cost.
Likewise, only 4% either discontinued or refused therapeutic
foods and only 5% declined senior screenings due to cost.
Cost was not a significant factor in the clients decision to
accept or decline health care. Despite these findings, veterinarians overwhelmingly cited cost and insufficient client
communication and education as the primary barriers to com-

42

Small Animal Clinical Nutrition

pliance (AAHA, 2003).

The AAHA study lists several follow through components
to augment recommendations. These include: scheduling procedures and follow-up appointments when the recommendation is made, providing clear instructions for at-homecare and
recheck exams (Almost 80% of pet owners indicated they
wanted verbal and written instructions.), sending reminders (In
the AAHA study, compliance was highest for core vaccinations, a service for which virtually every practice sends
reminders. Few practices send reminders for medication or
food refills. Sixty-five percent of pet owners said they would
welcome multiple reminders by phone, mail, e-mail or a combination. Seventy-two percent said they would like to receive a
phone call if they were overdue for a recommended treatment
or preventive service.) and making follow-up phone calls. More
than 82% of the pet owners surveyed indicated that they wanted to be able to discuss feeding and homecare instructions with
other members of the health care team, not just the doctors.
Practices that consistently followed-up with clients whose pets
were fed a new food reported a much higher percentage of
patients staying on the new food and a much higher compliance with recommended feeding guidelines (AAHA, 2003).
The AAHA Compliance Study identified six steps to
improving compliance and patient care:
Measure current compliance
Involve the entire health care team (and establish protocols
that are agreed upon)
Set compliance goals
Implement new protocols
Measure and track results
Celebrate success.
The AAHA Compliance Study found that a major cause of
veterinary care providers failure to make health care recommendations was their misjudgment of the clients willingness to
take action. The following represent reasons veterinarians cited
for noncompliance (AAHA, 2003):
Cost (60%)
Communication and client education (55%)
Client time or convenience (40%)
Perceived value (25%)
Process error at practice (15%).
Despite these perceptions 75% of pet owners agreed or
strongly agreed that their veterinarian made recommendations
that were good for the pet. Only 10% of pet owners agreed or
strongly agreed that their veterinarians recommendations were
motivated by a desire to make money. Cost wasnt a major barrier to adherence in the AAHA Compliance Study. However,
lack of an effective recommendation and lack of reinforcement
by the veterinary health care team were cited by clients as
important barriers to compliance. For example, veterinarians
claimed that they discussed nutrition and pet food with pet

owners during more than 90% of visits. Only 18 to 22% of pet

owners recalled such discussions. Reasons cited for lack of
client follow through include:
Unclear diagnosis or need for follow-up care
No one told me about the need for follow-up
Follow-up appointment not made or was too difficult to
make
No reminders were sent.
As an example, client acceptance of dental recommendations
doesnt depend on the degree of dental disease or the cost of the
procedure. Clients cited these reasons for lack of compliance:
Not enough education provided about the need for the
service (45%)
Follow-up visit not scheduled (15%)
Veterinary health care team didnt tell me about it (8%)
Pending appointment (5%)
Unclear diagnosis (5%)
Cat was too wild to catch (5%)
Other (7%).
Several other sources bear consideration for improving compliance (Table 3-3).

Conclusion
It is obvious that adequate health literacy is a major obstacle to
delivering optimal health care in human medicine. By extension, this issue is no less dramatic in veterinary medicine, and
the processes for improved communications and health literacy
cited in this chapter have direct relevance to pet care.
The health literacy issue is coupled to that of
compliance/adherence. As defined in the AAHA Compliance
Study, compliance in veterinary medicine is defined as, the pets
in your practice are receiving the care that you believe is best for
them. That is; if you, the attending veterinarian, believe specific products and services are important for a particular pets care,
does your health care team effectively communicate your beliefs
to the client in order for her/him to decide the next steps for
the pets care? Not all clients will take our recommendations,
but research suggests that better communication improves
medical care.
Health literacy, the degree to which individuals have the
capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions (Ratzan and Parker, 2000; Healthy People 2010) cannot
be assumed. Effective communication is paramount to practicing great medicine (Silverman et al, 2005; Cornell et al, 2007).

REFERENCES
The references for Chapter 3 can be found at
www.markmorris.org.