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Health Literacy

Delivering the Message Right Improves Patient Safety and Reduces Liability

What is Health Literacy?

Health literacy, according to the Institute of Medicine, "is the ability to obtain, process and understand basic health information and services needed to make appropriate health decisions and follow instructions for treatment. According to the Department of Health and Human Services, "Without clear communications, we cannot expect people to adopt the healthy behavior and recommendations that we champion. When people receive accurate, easy-to-use information about health issues, they are better able to take action to protect and promote their health and wellness."

How is Health Literacy Measured?

The National Assessment of Adult Literacy (NAAL) is a survey conducted by the US Department of Education. The main purpose of the NAAL is to measure the general literacy skills of American adults; in addition the survey assessed specific health literacy skills.

The assessment found that 22% of American adults have only basic health literacy skills, which means that they can perform the basic task of reading and for example, might understand a short pamphlet about a screening exam. However, they would have difficulty understanding typical patient education handouts or health insurance coverage information.

About 14% of the American adult population have skills below basic level. These individuals are generally unable to perform the basic skills needed to participate fully in today's world. Limited health literacy affects people of all ages, races, incomes and education levels, but the impact of limited health literacy disproportionately affects the elderly, persons with limited education and minority groups. Unemployed persons, those with limited income and individuals insured by Medicaid are also more likely to have limited health literacy.

Literacy and Health Outcomes

Studies have shown that individuals with lower health literacy have poorer health status than the rest of the population. Limited health literacy can result in less knowledge about healthy life choices, poor understanding of medical instructions, medication errors resulting from lack of understanding as well as a lack of self-empowerment.

Clinician Communication Skills

It is important to recognize that even individuals with high literacy levels may have difficulty understanding health information when it is delivered using medical jargon and physiological concepts unfamiliar to the individual. According to Dr. Barry Weiss of the AMA Foundation, "there is often a mismatch between a clinician's level of communication and a patient's level of comprehension. In fact, evidence shows that patients often misinterpret or do not understand much of the information given to them by clinicians. This lack of understanding can lead to medication errors, missed appointments, adverse medical outcomes and even malpractice lawsuits."

While there is little that clinicians can do to boost the general literacy skills of their patients, there are strategies every provider can use to enhance patients' understanding of medical information. By making healthcare patient-focused, communicating in easy-to-understand language and verifying patients' understanding of information provided, clinicians can deliver more effective care to all patients (AMA Manual for Clinicians).

Risk Management Recommendations for Effective Patient Communications:

  • Assess the literacy levels and language needs represented by the patients/community served.
  • Train staff to recognize and respond appropriately to patients with literacy and language needs.
  • Use well trained medical interpreters for patients with low English proficiency.
  • Adopt the universal precautions approach to health literacy. Make clear communications and plain language the standard for all patient communication.
  • Provide a comfortable atmosphere/environment. Do not appear hurried or distracted.
  • Speak slowly and clearly, loudly if indicated. Make good eye contact.
  • Assess the patient's ability to self-manage their own health care. Assure the patient understands when to seek health care and recognizes the need to pursue preventive health strategies.
  • Ask open-ended questions about their health history and clinical symptoms.
  • Encourage patient to ask questions.
  • Provide patient discharge and other instructions in written and verbal language the patient understands. Provide the patient with a medication list, information about medications, diagnosis, results of procedures and laboratory tests and plans for follow-up care. Verify patient understanding.
  • Utilize accepted methods to probe for patient understanding:
    • Visuals: Draw pictures, use three dimensional aids, media.
    • Print materials: Large print, fifth or lower grade level, key points.
    • Teach back: Ask the patient to repeat back or teach back to the clinician the clinical information or instructions discussed.
    • Show back: Ask the patient to show back to the clinician the patient care process reviewed.
    • Telephone: Have patient repeat back their understanding of telephone instructions, test results or patient follow-up appointments/studies.
    • Ask me three questions: Ask the patient to answer three key questions from the patient encounter.
    • Note: all levels of patients have difficulty with multi-step instructions.
  • Design the informed consent process to include forms written in simple sentences and in the language of the patient; use teach back during the informed consent discussion; and engage the patient in a dialogue about the nature and scope of the procedure.
  • Reduce the barriers for low health literacy patients entering the health care system.
  • Place patient follow-up calls.

In Summary:

The reading and arithmetic skills required to understand and successfully participate in today's healthcare systems far exceed the abilities of many average adults. Clinical professionals and staff members can reduce untoward events and poor outcomes related to communication breakdowns through a comprehensive patient assessment and adoption of the universal precautions approach to health literacy.

References and Resources:

Centers for Medicare and Medicaid Services,

Culturally and Linguistically Appropriate Services (CLAS) Standards, Office of Minority Health,

Guidance to Federal Financial Assistance Recipients Regarding Title VI, U.S. Department of Health and Human Services, Office for Civil Rights,

Health Literacy and Patient Safety Toolkit, AMA,

Health Literacy Universal Precautions Toolkit, AHRQ,

Improving Health Literacy to Protect Patient Safety, The Joint Commission,

Interpreter Standards, National Council on Interpreting in Healthcare,

Iowa Healthcare Collaborative, Health Literacy Toolkit,

AMA: Office guide for communicating with Limited English Proficiency Patients