Literacy may also be an additional concern. In the US:

• 44% of those living in poverty are also at lowest literacy level ^[8]
   
• A large percentage of those at or below poverty level are immigrants^[8]
   
• 44% of those over age 65 read at the 5th grade level or lower^[9]
   
• Anxiety can negatively affect literacy, further complicating patient comprehension^[10]
   
• Studies show that low reading skills and lower health outcomes are related^[11]
   
• Literacy skills limit the daily functioning of 21% of the people in America. An additional 27% have marginal literacy skills which limit the ability to read, write, speak in English, and develop knowledge^[12].

In addition:

• Inadequate literacy skills are present in patients from a broad variety of backgrounds (U.S. born, immigrant, all races and classes)^[12]

As a separate issue, we should consider health literacy. When applied to health communication, this leads to the following challenges:

• Illiteracy can affect understanding of even the most basic terms such as screening, malignant, terminal, tumor, lesion^[12]
   
• 90 million people have difficulty understanding and using health information ^[13]
   
• Health literacy levels can be far below the general literacy level of a given patient^[13]
   
• Patients may not understand instructions for taking medications, appointment slips, or informed consent^[12]
   
• What physicians feel is “everyday” language may not be so perceived by the patient^[12]
   
• Culture can also play a special role in health literacy. Some words, phrases or conditions are perceived / understood differently in different cultures. Be careful about labeling such differences as illiterate as this can be perceived as demeaning or patronizing, further straining a medical relationship.

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