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Health Literacy


Health Literacy

In Healthy People 2010, health literacy is 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.”

What are some examples of health literacy?

  • Understanding instructions on medicine (eg, timing or dosage of medication)
  • Understanding medical education handouts
  • Understanding a doctor’s directions and consent forms
  • Determining a healthy weight range for a person of a specified height, based on a body mass index (BMI) graph
  • Identifying what is permissible to eat/drink prior to a medical test when provided with a list of instructions
  • Understanding the appointment slip to determine when a follow-up appointment is scheduled
  • Using a chart to determine when children should receive a particular vaccine

Expectations of patients in managing a chronic condition:

Change daily habits

  • Food
  • Activity
  • Measures
  • Limitations

Monitor symptoms

  • Use tools
  • Note changes

Take medications

  • Differentiate
  • Follow directions:
    • Time, dose, day
    • Refill

Access care when needed

  • Complete forms
  • Make and keep appointments

Interact with health professionals

  • Describe symptoms
  • Report changes
  • Ask questions
  • Comprehend instructions
  • Follow new directions

How is health literacy different from general literacy?
Health literacy encompasses much more than simply having the ability to read. It includes reading, listening, analytical thinking, and decision-making skills. Health literacy is not always correlated to years of education or general reading ability.

Individuals need to have the ability to understand how to:

  • Understand and interpret visual information, such as graphs
  • Work with a computer and numbers
  • Obtain and apply relevant information in order to become a savvy patient

Some of the basic tasks that patients are expected to have the ability to do include:

  • Evaluating information for credibility and quality
  • Analyzing relative risks and benefits
  • Calculating dosages
  • Interpreting test results
  • Locating health information
  • Describing their symptoms adequately and explaining their concerns
  • Understanding spoken medical advice or treatment options

How many people are not health literate in the United States?
It is estimated that 93 million people in the United States, nearly half of the total population, have difficulty understanding and using health information. This includes 52% of high school graduates and 61% of adults 65 years of age and older. These people tend to take medications erratically, miss follow-up appointments, and fail to understand directions on medicine bottles. According to the Report on the Council of Scientific Affairs, Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association, “Groups with the highest prevalence of chronic disease and the greatest need for health care had the least ability to read and comprehend information needed to function as patients.”

What are the effects of low health literacy for patients?
Direct effects of low health literacy include noncompliance or medication errors. The indirect effects are more difficult to measure, but may include insurance issues, accessibility to health care, and poor health behavior choices. Low health literacy is linked to higher rates of hospitalizations and higher use of expensive emergency services.

Here are some examples of how patients without adequate health literacy are at risk:

  • Not filling or refilling a medication
  • Having inappropriate dosing or timing of medication
  • Failing to recognize side effects of medication
  • Feeling unsafe and unwelcome, and failing to seek medical care
  • Having repeat visits, tests, or procedures
  • Poorly preparing for and/or cancelling evaluative studies
  • Experiencing loss of earnings and job productivity

What are the effects of patients with low health literacy on health care providers?

  • Interruptions and callbacks to clarify instructions
  • Need to reschedule missed appointments, tests, and procedures for which patients did not understand how to prepare properly
  • Repeated office visits for unchanged or worsened conditions, because patients did not understand previously prescribed or recommended treatment
  • Suspension of care until problem becomes emergent
  • Poor communication or miscommunication between physician and patient, which is the leading reason for patient dissatisfaction and increases the risk for lawsuits
  • Inability to understand bills
  • Improperly completed insurance forms
  • Inability to provide medical or medication histories

What are the effects of low health literacy for society?
Individuals with limited health literacy incur medical expenses that are up to four times greater than those with adequate literacy skills. This costs the health care system billions of dollars each year. Patients with low functional literacy use more health care services, including having longer hospital stays and more trips to the emergency room.

Nonadherence is estimated to result in nearly 125,000 deaths per year from cardiovascular disease, 10% of all hospital and 23% of all nursing home admissions, $1.5 billion in lost patient earnings, and $50 billion in lost productivity. Estimates have attributed 112 million unnecessary medical visits and an extra $300 billion per year in excess spending because of nonadherence.

What are some research findings on the impact of health literacy?

  • Cancer screening information sometimes is ineffective, resulting in patient diagnosis at a later stage
  • Treatment options sometimes are not fully understood
  • Informed consent documents are too complex for some patients, which may result in suboptimal decisions about accepting or rejecting interventions


  • Inadequate health literacy is independently associated with worse glycemic control and higher rates of retinopathy


  • Inadequate literacy is correlated to poorer understanding of asthma and improper use of a metered-dose inhaler:
    • More than one half of study participants reading at a sixth-grade level or less reported going to the emergency room when they had an attack, while less than one third of literate patients report the same
    • Less than one third of patients with the poorest reading skills knew that they still should see a physician when their asthma was not symptomatic, while 90% of literate patients knew that they still should see their doctor

Hypertension and diabetes

  • Nearly one half of the patients with hypertension or diabetes had inadequate functional health literacy:
    • These patients had significantly less knowledge of their disease, important lifestyle modifications, and essential self management skills, despite having attended formal education classes

Safe communication universal precautions
For all communications

  • Use plain, nonmedical language
  • Slow down
  • Break information down and use short statements
  • “Chunk and check,” or organize information into two or three key concepts, then check for understanding
  • Ask patients to teach-back what they are told
  • Document with a SOAP UP note for cueing and confirming patient understanding and planning for health literacy follow-up


U–Use teach-back to check for understanding
P–Plan for health literacy help

Communication aids

  • Aim for a fifth- to sixth-grade reading level on all written information
  • Offer to read aloud and explain
  • Underline, highlight, or circle key points
  • Use visual aids to help navigate the health care system and understand health information (eg, posters, models, pictures, signs, maps, etc)
  • Provide a trained interpreter, when appropriate

Systemwide communication strategies

  • Improve office safety culture by training all staff
  • Simplify paperwork demands on the patient and avoid duplications
  • Ensure medication review and/or reconciliation for all patients at all encounters
  • Schedule time for patient education and questions
  • Provide reminder calls to patients
  • Use SBAR (Situation-Background-Assessment-Recommendation) for staff-to-staff communication about patient understanding
  • Identify community literacy resources

Characteristics of a shame-free environment

  • Exhibit a general attitude of helpfulness
  • When scheduling an appointment:
    • Have a person (not a machine) answer the phone
    • Collect only necessary information
  • Give directions to the office
    • Help patients prepare for the visit by asking them to bring in all of their medications and a list of any questions they may have
  • Use clear and easy to follow signage
  • During office check-in procedures:
    • Provide assistance with completing forms
    • Collect only essential information
    • Offer forms in the patient’s language
    • Provide forms in an easy-to-read format
  • When referring patients for tests, procedures, or consultations:
    • Review the instructions
    • Provide directions to the site of referral
    • Provide assistance with insurance issues
  • When providing patients with information:
    • Routinely review important instructions
    • Provide handouts in an easy-to-read format
    • Use nonwritten modalities

Ask Me 3
Ask Me 3 is a patient education program designed by the National Patient Safety Foundation to promote communication between health care providers and patients in order to improve health outcomes.

The program encourages patients to understand the answers to three questions:

  • What is my main problem?
  • What do I need to do?
  • Why is it important for me to do this?

References and recommended readings

American Medical Association. Health literacy.
Available at:
Accessed January 18, 2012.

American Medical Association. Health literacy and patient safety: help patients understand.
Available at:
Accessed January 18, 2012.

Ask me 3.
Available at:
Accessed January 18, 2012.

Harvard School of Public Health. Health literacy studies.
Available at:
Accessed January 18. 2012.

National Network of Libraries of Medicine.  Health literacy.
Available at:
Accessed January 18, 2012.

Rudd RE. Health literacy studies overview.
Available at:
Accessed January 18, 2012.


Review Date 1/12



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