​The Issue in Focus

Health literacy is "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). This definition, which was developed for the National Library of Medicine, has been used for Healthy People 2010 and Healthy People 2020 (IOM "Health Literacy").

The Institute of Medicine (IOM), which used the above definition in its 2004 report Health Literacy: A Prescription to End Confusion, further states that health literacy encompasses the following (IOM "Health Literacy"):

• Conceptual and cultural knowledge
• Oral literacy
• Listening skills
• Speaking skills
• Print literacy
• Writing skills
• Reading skills
• Numeracy (the ability to understand and use numbers)

Although organizations should consider all aspects of health literacy, most research has relied on measures of print literacy and numeracy (Berkman et al.). Such research is important; reading ability is a greater predictor of health status than racial or ethnic group, education level, income, or employment status (Weiss). To appreciate how a limited reading ability may affect understanding of written health information, consider the following example:

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. (Weiss)

In this example, words that are long or that may be unfamiliar are spelled backward.

Whom Does Low Health Literacy Affect?

The National Assessment of Adult Literacy (NAAL), which was most recently conducted in 2003, estimated that 14% and 22% of U.S. adults have below basic and basic ability, respectively, to read health-related materials written in English. People with "basic" ability generally are able to understand only short, commonplace prose texts; understand simple nonprose documents (e.g., maps, food labels, schedules); and use easily identifiable quantitative information to solve simple, one-step problems. People with "below basic" ability may be able to locate information in such documents but may not be able to read or understand it. Only 12% of U.S. adults have proficient ability, which is necessary for tasks such as searching through a complex document to find the definition of a medical term and determining which legal document applies to a given healthcare situation. (Kutner et al.)

The 2003 NAAL found that certain groups are more likely to have low health-related reading ability; see Table. Groups with Lower Levels of Health-Related Reading Ability. The information is presented only to illustrate groups that may be particularly affected by reading difficulties. Immediately observable characteristics are inaccurate predictors of health literacy, and difficulty understanding health information can hamper anyone. A person may even have a high education level or be articulate yet still have low health literacy. Further, even people with adequate health literacy can have difficulty understanding health information at times. Organizations and staff must not assume, based on such characteristics, that a person has low or high health literacy.

In addition, people may hide or be unaware of their difficulty reading health information. In a study of 202 patients who presented for care at the emergency department (ED) or walk-in clinic of a large urban hospital, 33% of the subset of patients who had inadequate or marginal ability indicated that they did not have trouble reading and understanding what they read. Patients took the Test of Functional Health Literacy in Adults (TOFHLA), a research tool that measures people's ability to read and understand written health-related materials and ability to work with numbers in materials commonly encountered in healthcare (e.g., prescription labels). Research assistants also asked the patients hypothetical questions about difficulty reading and shame (e.g., whether they thought people would hide their difficulty reading) and then asked personal questions. Of the patients who had inadequate or marginal ability and admitted having trouble reading, 40% said they felt shame; 67% had never told their spouse about their difficulty, 53% had never told their children, and 19% had never told anyone. (Parikh et al.) As one expert states, "you can't tell by looking and you can't expect your patients to tell you" (Weiss).

Another study, which included 395 patients age 65 or older who were discharged after hospitalization for acute coronary syndrome, heart failure, or pneumonia, found that although 96% of the patients reported understanding the reason they had been in the hospital, in postdischarge interviews only 60% were able to accurately describe their diagnosis. Of the nearly one-third of patients who were discharged with a scheduled primary care or cardiology appointment, only 44% could accurately recall details regarding the appointment. (Horwitz et al.)

Research also shows that healthcare providers may be likely to overestimate patients' health literacy skills. In a study involving a group of 12 primary care physicians practicing at a U.S. Department of Veterans Affairs medical center, the physicians overestimated patient reading level in 25% of patients. The study enrolled 100 adult patients whose primary language was English and who did not have severe visual or speech impairment; they were predominantly older men. After a visit between the patient and physician, another person administered the Rapid Estimate of Adult Literacy in Medicine (REALM) to the patient. The REALM is a research tool in which the person reads aloud a list of 66 medical words; the REALM does not measure comprehension, but REALM scores are highly correlated with TOFHLA scores (Powers et al.). REALM scores equate to four levels of reading ability: third grade or lower, fourth through sixth grade, seventh or eighth grade, and high school. The physician then estimated where the patient's reading ability fit among the four categories.

Among the 74 patients who physicians believed had the highest literacy level, 28% actually scored in a lower category. Although the patients' REALM levels were not significantly associated with race, ethnicity, or gender, physicians overestimated the REALM level for 54% of African American patients, 11% of white non-Hispanic patients, and 36% of patients of other race or ethnicity. No significant association was noted between physicians' accuracy and whether the physician had seen the patient previously. (Kelly and Haidet)

Patient Safety and Health Outcomes

How Does Health Literacy Influence Behavior?

Research shows that people with low health literacy may have trouble understanding basic health concepts. They may not comprehend how the body functions or what specific organs do. They may not understand the link between lifestyle and health outcomes—for example, among people with hypertension, those with low health literacy skills are less likely to know that exercise and weight loss reduce blood pressure. Because they may have difficulty understanding probability and risk, they may not fully understand their condition or proposed treatments. Individuals with low health literacy are less likely to understand self-care instructions (e.g., which symptoms to watch for) and how to use necessary devices and medications. Many have difficulty understanding prescription labels and forms that they must fill out (e.g., Medicaid applications). Compared with the rest of the population, they are more likely to engage in unhealthy behaviors (e.g., smoking) and less likely to engage in healthy behaviors (e.g., breastfeeding). In every socioeconomic group, people with low health literacy have poorer health status. They may not recognize their own difficulties in understanding health information. (Weiss; ODPHP "Quick Guide . . . Older Adults")

In addition to health literacy, other factors that may influence a person's ability to understand health information include his or her experience with the healthcare system, the communication skills of staff members, and the complexity of the information (Weiss). Cultural, socioeconomic, and language factors often intersect with and complicate the issue of health literacy. For more information on the influence of culture and English proficiency in healthcare, see the guidance article Culturally and Linguistically Competent Care.

Low health literacy can also be a barrier to patient and family engagement—a concern because according to research, patient engagement can lead to measurable improvements in safety and quality (AHRQ "Guide"). Several resources are available to help healthcare organizations better engage patients in their care. The Agency for Healthcare Research and Quality's (AHRQ) Guide to Patient and Family Engagement in Hospital Quality and Safety includes many tools to promote patient engagement, including several that support health literacy efforts specifically. Other patient engagement resources that address health literacy are available from the American Hospital Association, the National Patient Safety Foundation, and the Nursing Alliance for Quality Care (see Resource List).

How Does Health Literacy Affect Health Outcomes?

When patients have difficulty understanding health information, they may be more likely to experience poor outcomes, adverse events, difficulty accessing care, gaps in care, inefficient care (e.g., excessive ED use, hospital readmission), loss of earnings or work productivity, or increased costs for child care or transportation (AMA). An AHRQ systematic review of 81 studies of health outcomes and 42 studies of interventions found that low health literacy is associated with poorer health outcomes, less use of preventive healthcare services, and more use of emergency care. Most studies included in the review addressed print literacy and numeracy; none addressed oral literacy. (Berkman et al.)

Evidence of moderate or high strength indicated that low health literacy is associated with the following (Berkman et al.):

• Poorer ability to demonstrate proper medication self-administration
• Poorer ability to interpret labels and health messages
• Higher rates of hospitalization
• Greater use of emergency care
• Lower use of mammography
• Lower rates of flu vaccination

In older adults, low health literacy is associated with higher mortality rates and poorer overall health status (Berkman et al.). For example, a study conducted in England found that adults age 52 or older who demonstrated low health literacy were more than twice as likely to die within five years as older adults with high health literacy (Bostock and Steptoe).

Health literacy issues can greatly affect individuals' ability to manage their health and perform self-care tasks. See Study: Health Literacy and Patient Understanding of Medication Labels for an illustration.

The risk is not just theoretical. A study of 471 patients discharged from the hospital found that 51% reported taking a medication that was not on the discharge list or not taking a medication that was on the discharge list. Likewise, 59% were unsure of or mistaken about the indication, dose, or frequency of their medication regimen. A significant factor related to the errors was low health literacy and numeracy. (Mixon et al.)

According to the AHRQ review, factors that may mediate the relationship between health literacy and health outcomes include the following (Berkman et al.):

• Social support
• Knowledge
• Self-efficacy (belief in one's ability to accomplish a task)
• Stigma
• Education
• Income
• Urban location

Health literacy may in turn mediate other types of disparities in health outcomes. For example, research indicates that health literacy may mediate the effect of race on long-term illness, self-reported health status, and quality of life (in terms of both physical and mental health). It may also mediate the effects of race and gender on misinterpretation of medication label instructions. (Berkman et al.)

Why Does Health Literacy Matter to Healthcare Organizations?

Because the evidence shows that health literacy is associated with poorer outcomes, healthcare organizations that fail to address health literacy face risks as well. Adverse events, poor outcomes, patient difficulty managing self-care, and overutilization or inefficient use of healthcare services may pose significant barriers to the organization's ability to fulfill its mission, in addition to posing operational, liability, financial, and reputational risks.

Lawsuits

Liability risks abound as well. Patients who do not understand their condition or treatment options cannot provide truly informed consent or refusal. Ineffective communication between patients and providers is a common cause of malpractice lawsuits (for more information, see the guidance article Communication). Communication problems often implicated in malpractice suits include the following (Weiss):

• The provider does not adequately explain the diagnosis.
• The provider does not adequately explain the treatment.
• The patient feels ignored.
• The provider does not understand or devalues the patient's or family members' perspective.
• The patient feels rushed.

​Regulations and Standards

Joint Commission

The Joint Commission addresses health literacy and related issues in its accreditation standards for hospitals and in its monograph Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals (see Resource List).

Accreditation standards that directly address health literacy issues include the following (Joint Commission):

• RI.01.01.03: The hospital respects the patient's right to receive information in a manner he or she understands.
• PC.02.01.21: The hospital effectively communicates with patients when providing care, treatment, and services.
• PC.02.03.01: The hospital provides patient education and training based on each patient's needs and abilities.

Healthcare organizations should familiarize themselves with these standards and their elements of performance. Other standards may also be relevant.

The Joint Commission's Roadmap specifically recommends integrating health literacy strategies into patient discussions and materials and suggests ways to do so. Even organizations that are not accredited by the Joint Commission may find the Roadmap to be a useful resource.

Action Plan​

​Identify Health Literacy Needs and Challenges

Action Recommendation: Determine the health and health literacy needs of the populations served, and collect information on current health literacy challenges the organization faces.

To inform health literacy planning and interventions, the organization should determine the needs of the populations served. Information to collect includes education level, preferred language, cultural background, age, and disabilities (Osborne). The organization may wish to collect such information for the general patient population and for specific subpopulations (e.g., ED patients, cancer patients). The organization may wish to ask members of the populations served how they prefer to get health information. For a discussion of why the source of information is an important consideration, see Where Do People Get Health Information?

Examination of risk management and quality improvement data, chart reviews, and surveys, as well as collection of other data, may provide clues (e.g., readmissions, staff concerns) about which conditions and self-care tasks people find most challenging. For example, staff can ask patients how they will carry out discharge instructions. Other issues the organization may wish to consider include whether patients and family members have difficulty navigating the healthcare system generally and the campus specifically, and how low health literacy may be affecting utilization of healthcare services (e.g., emergency care). In addition, hospitals may wish to use the assessment tools in the National Center for the Study of Adult Learning and Literacy's "The Health Literacy Environment of Hospitals and Health Centers" (see Resource List). The organization may also wish to identify current activities and programs that bolster health literacy (ODPHP "Quick Guide . . . Literacy").

Although some organizations are tempted to assess the health literacy levels of individual patients or populations using screening or assessment tools, such as the REALM or TOFHLA, health literacy experts instead recommend directing efforts toward presenting information in a way that all patients can understand (see the discussion Take Universal Precautions). Screening and assessment tools serve two purposes: conducting research and, as one expert states, "convincing nonbelievers" that health literacy is an issue that needs to be addressed. (Osborne and Weiss)

​Integrate Health Literacy into the Mission

Action Recommendation: Integrate health literacy into the organization's mission, goals, and strategic plan.

Leadership must appreciate the importance of health literacy, especially patients' need to understand and the organization's need to ensure that patients understand (e.g., through teach back). They must also consider how health literacy issues relate to the organization's mission, goals, and strategic plan. Health literacy—including specific goals—should be incorporated into all three, as well as into organizational policies and educational initiatives. Funding should be designated for health literacy improvement projects. (ODPHP "Quick Guide . . . Literacy") Risk managers can use the Ready, Set, Go tool that accompanies this article to garner leadership support.

A discussion paper from IOM outlines 10 attributes of health-literate healthcare organizations, summarized as follows (IOM "Ten Attributes"):

1. Making health literacy integral to the organization's mission and operations
2. Integrating health literacy into patient safety, quality improvement, planning, and evaluation
3. Preparing the workforce and monitoring progress
4. Involving populations served in designing and evaluating health information
5. Striving to meet the needs of populations with a range of health literacy skills without stigmatizing
6. Using health literacy strategies during interpersonal communication (including checking for understanding)
7. Making it easy to access and navigate health information and services
8. Developing and giving out easy-to-use materials
9. Addressing high-risk issues (e.g., care transitions, medications)
10. Communicating clearly about health plan coverage and costs to the patient

UnityPoint Health, an Iowa health system, offers a guidebook based on these 10 attributes to help healthcare organizations undertake organizational change to become more health literate. See Resource List for information on accessing the IOM discussion paper and the UnityPoint guidebook.

​Develop an Agenda and Set Objectives

Action Recommendation: Develop an agenda, and set objectives for measuring improvement.

The organization should consider forming an interdisciplinary team to develop a health literacy agenda and help generate specific ideas for incorporating health literacy initiatives. The organization should establish measurable health literacy objectives, such as specific changes in patients' knowledge, attitudes, behavior, or health outcomes. Health literacy issues should be included in evaluation criteria for specific programs. (ODPHP "Quick Guide . . . Literacy") Process measures may include how often staff supplement discussions with nonwritten material and check for understanding using teach back.

One large health system has shared how it approached health literacy improvement. Recognizing the prevalence of health literacy issues and the serious implications they pose, the system formed a collaborative to improve health literacy that has, in its first seven years, led to measurable improvements. Members of the collaborative include staff representatives from the nursing, patient education, quality improvement, risk management, legal, surgical services, and home health departments. At each of the senior affiliate hospitals, hospital leaders identify team leaders and members. Most team leaders have expertise in staff and patient education or quality improvement.

Health literacy was incorporated into the health system's strategic plan for clinical performance improvement. Strategies include using plain language and the teach-back method when communicating with patients and family members, using Ask Me 3 (see Resource List) to help patients and family members feel comfortable asking questions, delivering health literacy training through train-the-trainer methods, and providing ongoing staff education and support. Teams used the Institute for Healthcare Improvement's Model for Improvement to implement and test many small changes to spread health literacy interventions throughout the organization. The collaborative also works with outside groups, including the state medical society, hospital association, pharmacy association, public health department, and department of education.

Teams also revise and create new forms (e.g., admission forms, consent forms, disease education materials). Members of an outside support group for people who have difficulty reading or who learned to read later in life give vital feedback on the materials. Others who help revise and develop materials include risk managers, healthcare providers, surgical services staff, and members of the legal department. Teams consider developing materials in new formats in response to patients' answers to questions about how they prefer to learn new health information.

The collaborative has led to measurable improvements. From October 2006 to the second quarter of 2014, scores improved in all four domains of the Hospital Consumer Assessment of Healthcare Providers and Systems that relate to health literacy. The percentage of patients giving positive responses for communication with nurses increased from 72% to 79%, scores for communication with doctors increased from 76% to 80%, scores for communication about medicines increased from 58% to 63%, and scores for discharge information increased from 82% to 89%. Anecdotally, health system leaders and staff say that since the program was started, they have become more aware of patients' difficulty understanding health information and are "more likely to voice the need to consider materials from a health literacy point of view." (AHRQ "Program")

​Improve Access and Navigation

Action Recommendation: Improve access to health services and navigation of the physical environment.

Individuals with low health literacy often have difficulty navigating the healthcare system. Healthcare organizations may wish to conduct a walk-through (ideally, involving someone with low health literacy) to identify the barriers to access and navigation a patient may encounter throughout a typical stay. Issues to consider include the paperwork patients must fill out, including consent forms; difficulties patients may have in understanding their insurance coverage; rules and procedures patients must follow; paperwork patients receive regarding discharge, follow-up, or referral; and difficulties patients may face in arranging and obtaining postacute consultations, tests, and referrals (Weiss). Efforts may include improving patient flow and care coordination, making forms and signs simple and easy to understand, and establishing a patient navigator program. Healthcare organizations may wish to offer patients and family members help completing forms or understanding their insurance, Medicare, or Medicaid coverage.

People may also have difficulty navigating the physical environments in which care is provided. The design of the care environment should be as intuitive as possible and promote smooth patient flow. Campus maps and signs must be clear and easy to understand. Universal symbols may aid wayfinding (see the guidance article Culturally and Linguistically Competent Care for a discussion and examples of the universal symbols). (ODPHP "Quick Guide . . . Literacy"; Weiss)

​Assess and Develop Materials

Action Recommendation: Assess existing and develop new, easy-to-understand materials, being sure to involve users in development and testing.

Materials must be clear, simple, and usable. The organization should assess existing materials, including forms and instructions, and consider preparing new, user-friendly materials.

It is important to involve users when developing materials. Engaging users as early as possible in the planning process can help ensure that the materials are in formats users prefer and effectively tell users what they want to know.Health Literacy: Checklist for Creating or Evaluating Materials presents tips for developing easy-to-understand written, visual, audio, video, or interactive materials.

Materials should be evaluated, and they should be pilot tested and refined with groups of users. Tools are available to help healthcare organizations evaluate existing or newly developed materials. For example, AHRQ's Patient Education Materials Assessment Tool (see Resource List) uses a systematic method to evaluate and compare the understandability and actionability of patient education materials in print or audiovisual format.

Materials in nonwritten media may be helpful for people with all levels of health literacy. Models and other visuals should be developed to supplement oral communication. Audio, video, multimedia, and interactive formats are popular ways of communicating health information. The organization may also wish to consider new methods of delivering health information, such as social media (see the guidance article Social Media in Healthcare for more information).

In addition, contracts for relevant services (e.g., website development) should address health literacy concerns, the use of plain language, involvement of members of the target audience, and preimplementation testing. (ODPHP "Quick Guide . . . Literacy"; Weiss)

However, staff must understand that prepared materials, even those written in plain language or presented in multimedia formats, cannot stand alone. They can be used as a prompt for or supplement to discussion, but it is not safe to assume that patients will interpret them correctly on their own.

​Educate and Train Staff

Action Recommendation: Educate staff on health literacy and strategies to address it.

Health literacy improvement may require a fundamental change in how staff communicate with patients and family members. The organization should provide routine education and training on health literacy. Topics may include the prevalence of low health literacy, the potential effects of health literacy issues on patients and the organization, patients' need to understand and the organization's need to ensure that patients understand, organizational strategies that are in place, universal precautions for health literacy, plain language, and communication strategies to use (see Health Literacy: Handout for In-Person Communication).

Education and training should also address the attitudes of staff members, who may lack empathy for people with low health literacy. They may avoid looking for or acknowledging low health literacy, feeling that a problem they do not know about is a problem they do not have to address. They may rely on the patient's family and friends to coach him or her. Wittingly or otherwise, they may fault the person and believe that it is not their job to provide "remedial" help.

Therefore, the organization should cultivate a respectful, nonjudgmental, helpful attitude among staff. To do so, trainers may wish to simulate the difficulties people may face when they have trouble understanding health information. Examples include having staff members

• read the garbled text presented in the discussion The Issue in Focus,
• try to fill out a form written in a language they do not speak, or
• listen to someone read a paragraph about a technical, non-healthcare-related topic and then perform a task described in the passage (e.g., read a simple binary code).

​Collaborate

Action Recommendation: Consider collaborating with other providers and organizations.

Health literacy interventions may be more effective if the organization collaborates with primary care physicians, long-term care and home care providers, public health professionals, and community organizations (e.g., cultural centers, area agencies on aging). Initial steps may include sharing health literacy information and materials with these groups. Healthcare organizations may wish to review ODPHP's "National Action Plan to Improve Health Literacy" (see Resource List) and identify other providers and community groups to partner with and collaborative programs to implement.

Organizations and their partners should consider approaches that address health literacy among the general population as well. Ideas include working with journalists to improve their understanding of the issue and helping adult educators develop curricula that support health literacy (ODPHP "Quick Guide . . . Literacy").

​Develop Initiatives

Action Recommendation: Develop initiatives to improve health literacy in specific groups of patients or in broader populations.

In addition to preparing user-friendly materials and training staff, healthcare organizations and their partners should consider developing initiatives to improve health literacy. Interventions may target specific groups of patients or broader populations. Examples of health literacy initiatives include the following:

• Establish a health information center with materials in a wide variety of media.
• Show easy-to-understand videos on the organization's television channels and social media accounts. Consider targeting content by unit.
• Develop disease management programs.
• Create condition-specific support groups moderated by someone with training in health literacy.
• Post, distribute, or make available drawings that outline the steps for common self-care tasks (e.g., washing hands, testing blood glucose).
• Develop personalized medication schedules (e.g., "pill cards") for patients on discharge (AHRQ offers a guide for creating such cards; see Resource List).
• Host health fairs.

Some health literacy interventions have been found to improve health outcomes. For example, the AHRQ systematic review found that some intensive disease management programs reduced disease prevalence, disease severity, or both and that some self-management interventions increased self-management behavior. Health literacy interventions led to positive changes in subjects' use of healthcare services in all studies that examined the relationship. For example, interventions that involved intensive self-management and adherence reduced ED visits and hospitalizations. (Berkman et al.)

Evidence regarding the characteristics of effective health literacy interventions is emerging. The AHRQ review included 21 studies that assessed the effectiveness of a single strategy and 21 studies that assessed the effectiveness of a group of strategies. Interventions that improved health outcomes or appropriate use of healthcare services seemed to work by affecting mediating factors (e.g., knowledge, self-efficacy) or by changing behavior. Characteristics of interventions that were effective in improving health outcomes included the following (Berkman et al.):

• High intensity
• Basis in theory
• Use of pilot testing before full implementation
• Emphasis on skill building
• Delivery of the intervention by a health professional

Design features that appeared to improve comprehension in individuals with low health literacy in at least one study included the following (Berkman et al.):

• Presentation of essential information by itself
• Presentation of essential information first
• Use of easy-to-read materials
• Use of illustrated narratives
• Addition of video to oral narratives
• Use of a higher number to represent better quality in presentations of quality information
• Use of the same denominators to present baseline risk and treatment benefit
• Addition of icon arrays (pictographs that use a series of dots, human figures, or faces to represent a proportion of a population) to numerical presentations of treatment benefit

Health literacy initiatives may target specific conditions, units, or aspects of care. For example, one academic medical center describes how it standardized the discharge process using the Re-Engineered Discharge Project (Project RED). Coordinated by a nurse discharge advocate, the process focuses on improving the effectiveness of patient education and care coordination. Steps include educating the patient throughout his or her stay, arranging follow-up care that is convenient for the patient, using the teach-back method, and calling the patient a few days after discharge. An important component is the After-Hospital Care Plan, a spiral-bound, easy-to-understand booklet that contains information on the patient's discharge diagnosis and medications; a medication schedule; a calendar of future appointments and tests; steps to take in case of a change in condition; contact information for outpatient providers; information on diet, exercise, and home equipment; and materials to help the patient be engaged in follow-up care.

A randomized controlled trial involving 749 patients showed significant results in several areas. The rate of patient readmission within 30 days of discharge was 30% lower in the intervention group than in the control group, and the rate of ED visits was 33% lower. Compared with participants in the control group, a higher percentage of those in the intervention group understood their primary diagnosis when they left the hospital, felt that their questions were answered before they left the hospital, understood how to take their medication after discharge, and saw their primary care physician within 30 days after discharge. (AHRQ "Standardized")

​Take Universal Precautions

Action Recommendation: Adopt a "universal precautions" approach to health literacy.

Because staff may have difficulty identifying people with low health literacy, and because even people with high health literacy may have difficulty understanding health information at times, many experts recommend taking universal precautions—in other words, making all written and oral information easy to understand. Although it was developed for primary care practices, other types of organizations can also use tools from AHRQ's Health Literacy Universal Precautions Toolkit (see Resource List) to implement a universal precautions approach.

Some worry that people with adequate literacy skills will be insulted by plain-language materials and ways of communicating. They may feel that such materials and communication methods are "dumbed down." On the contrary, plain language and related strategies make information clearer and more accessible. (Mitty and Flores) In fact, research indicates that people of all literacy levels prefer and benefit from easily understood health materials (Weiss). Health Literacy Strategies for All Types of Communication presents strategies that staff can use in all types of communication with patients and family members.

People use and process only a small amount of information when making decisions. As information becomes more complex, people innately simplify it in order to consider only some of the information. Those who encounter too much information or information that is too complex may ignore some of it or limit their search. Therefore, focusing on a few key messages, presenting them in a clear manner, and checking for understanding are paramount. In addition, presenting health information in a way that supports people's belief in their ability to accomplish a task may make them more likely to attempt it. (ODPHP "Quick Guide . . . Literacy")

When developing or evaluating written, visual, audio, video, or interactive materials, organizations can useHealth Literacy: Checklist for Creating or Evaluating Materials to help ensure that the materials will be easy to use and understand. Staff may refer toHealth Literacy: Handout for In-Person Communication for tips on communicating clearly with patients and family members.

Universal precautions for health literacy should be used for all patients. However, additional strategies may be helpful for certain patient populations or individual patients. See Special Considerations for Older Adults for examples of considerations and strategies for working with older adults.

​Check for Understanding

Action Recommendation: Routinely check for patient understanding.

A critical element of ensuring that patients understand relevant health information is checking for understanding. One method of checking for understanding is the teach-back method. In this method, the staff member asks the patient to explain, in his or her own words, what he or she has been told or to demonstrate a skill (e.g., use a device, take medications). For example, staff can say, "I want you to explain to me how you will take your medication, so I can be sure I have explained everything correctly" (Weiss). During discharge, it is important to discuss how the patient plans to carry out discharge instructions and ask whether anything may prevent him or her from performing necessary tasks.

If the patient has trouble explaining the material or demonstrating the skill, the provider or staff member should take responsibility for the misunderstanding, not blame the patient. The provider or staff member can then try to communicate the information more effectively and clearly. Several repetitions may be necessary. Using materials in other formats (e.g., visual, video, interactive) or practicing the self-care tasks being discussed may help.

Staff may also notice signs that a patient or family member generally has difficulty reading or understanding health information. For example, people who do the following may have low health literacy (Weiss):

• Fill out forms incompletely or inaccurately
• Say that they will read written material later or at home
• Ask staff to read written information (e.g., saying that they forgot their glasses)
• Demonstrate an inability to name their medications, explain their indication, or properly describe how to take them
• Fail to comply with medication regimens
• Fail to experience a change in physiologic parameters even though they say they are taking the medications prescribed
• Fail to undergo recommended laboratory or imaging tests or complete referrals
• Regularly miss appointments

It is important to check for understanding even if the patient shows no signs of misunderstanding. As previously discussed, patients may feign comprehension, or they may not realize that they misunderstand.