Assessing and Addressing Health Literacy
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Assessing and Addressing Health Literacy
Sandy Cornett, PhD, RN
Abstract
The ability to communicate effectively with patients who have low health literacy
depends on our ability to recognize this problem and to create a patient-centered and
shame-free healthcare environment. Because of the shame and embarrassment these
patients experience, they often use their well-developed coping skills to mask their
limited literacy. Although a number of reading- and comprehension-assessment tools
are available, there is debate whether or not these tools should be used clinically. This
article provides guidance in regard to establishing an environment that promotes health
literacy, assessing health literacy levels, utilizing strategies to increase health literacy,
evaluating the learning that has occurred, and incorporating health literacy concepts
into the nursing curriculum.
Citation: Cornett, S., (Sept. 30, 2009) "Assessing and Addressing Health Literacy" OJIN: The
Online Journal of Issues in NursingVol. 14, No. 3, Manuscript 2. Available:
www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofCo
ntents/Vol142009/No3Sept09/Assessing-Health-Literacy.aspx
Keywords: assessing health literacy, evaluating learning, health literacy enhancement, healthcare
system navigation, guidelines for plain language materials, low health literacy cues, measuring low
health literacy, Newest Vital Sign (NVS), oral communication, plain language, printed
communication, photonovela, Rapid Estimate of Adult Literacy in Medicine (REALM), teach back
Test of Functional Health Literacy in Adults (TOFHLA), visuals in low health literacy materials
Although healthcare professionals generally assume that the health explanations and instructions
given to patients and families are readily understood, in reality these instructions are frequently
misunderstood, sometimes resulting in serious errors. A common reason for misunderstanding
health instructions may be the patient’s low health literacy skills. Unfortunately patients with
limited health literacy are often considered noncompliant (Baker et al., 1996), when the real
problem is a low level of health literacy.
The National Institute for Literacy (NIFL) (1991), views
literacy broadly as including more than an individual’s ability to
read. The NIFL has defined literacy as “an individual’s ability
to read, write, and speak in English, compute, and solve
It is important to remember that
even people with good literacy skills
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Assessing and Addressing Health Literacy
problems, at levels of proficiency necessary to function on the
job, in the family of the individual, and in society.” Healthy
People 2010 (United States Department of Health and Human
Services, 2000) also adopted a broad definition of literacy,
similar to the NIFL definition of general literacy in defining
health literacy 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."
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find that understanding healthcare
information is a challenge.
Dalton (2006) has described one low literacy patient as reporting the following experience:
I had some papers, but I didn’t know they were prescriptions and I walked around for a
week without my medication. I was ashamed to go back to the doctor, but a woman
saw the papers I had and told me they were prescriptions. It’s bad to not know how to
read. After getting my medicine I had to come back and ask how to take them because
I was urinating too much. They told me I was taking double the medication I was
supposed to. I had two bottles and I was taking one from each bottle, but it turned out
they were the same medication. But since I don’t know how to read, I didn’t know.
This patient’s experience, unfortunately, is not uncommon. To hear the stories of other patients
who have low health literacy as to what it is often like to communicate with health professionals,
view the on-line program, Health Literacy and Patient Safety: Help Patients Understand, produced
by the American Medical Association Foundation (2007).
The purpose of this article is to explore the most effective ways to assess and address low health
literacy so as to develop the ability to clearly and effectively communicate health information to
those who struggle with this problem. In this article I will provide guidance in regard to
establishing an environment that promotes health literacy, assessing health literacy levels, utilizing
strategies to increase health literacy, evaluating the learning that has occurred, and incorporating
health literacy concepts into the nursing curriculum.
Establishing an Environment that Promotes Health Literacy
It is important to remember that even people with good literacy
skills find that understanding healthcare information is a
challenge. They often don’t understand medical vocabulary and
the basic concepts in health and medicine, such as how the body
works or how to navigate the healthcare system (Wolf,
Gazmararian, & Baker, 2007; Wolf, Gazmarian, & Baker, 2005).
Stress and anxiety limit their ability to listen, learn, and remember.
Creating an environment that promotes health literacy requires
helping patients navigate the healthcare system; preparing them to
interact productively with their healthcare provider; and providing
a respectful and caring environment (Porche, 2009; Weiss, 2007).
Each of these necessary activities will be discussed below.
Filling out registration forms,
health histories, and consent
forms are particularly difficult
for those with low health
literacy skills.
Preparing the Patient to Navigate the Healthcare System
Filling out registration forms, health histories, and consent forms are particularly difficult for those
with low health literacy skills. Forms can even be a problem for those with good literacy skills.
Hence making simple changes in forms and registration procedures will benefit all patients. Weiss
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(2007) and Rudd and Anderson (2006) have recommended the following practices to keep the
registration and/or admission processes from becoming overwhelming to patients.
• Offer all patients help in completing forms. Provide this help in a confidential manner, preferably
in an area where they cannot be overheard by others. People are reluctant to discuss personal
matters, such as health problems and finances, in front of others.
• Simplify all forms using clear language, non-medical terms when possible, and easy-to-read
formats. Ask only for necessary information at registration or during admission to a facility.
Additional information can be provided at a later time.
Referrals for tests, consults with other providers, treatments, or procedures can be a problem for
persons with low health literacy. Often the patient is told to read the referral form and call to make
an appointment. The patient in this situation has to find out where to go, follow instructions given
to prepare for the referral, determine if insurance will pay for the service, and complete a new
registration form or additional paperwork. All this can be an overwhelming task for anyone, but
especially for those with low health literacy skills. The referral process can be made easier by
helping patients in the following ways (Mayer & Villaire, 2007; Weiss, 2007):
• Make written instructions clear and simple, using language that is easy to read and understand.
• Review the instructions with patients and check to be sure they understand the information. If
procedures require preparation, ask patients to tell you in their own words what preparation is
required.
• Place directions to the referral site and/or a map on the back of the referral form and review the
directions with them.
• Help patients with insurance issues.
• Call for an appointment for the patient before they leave the facility
Preparing the Patient to Interact Productively with Healthcare Providers
Helping patients prepare for the appointment is essential if they are to become an active partner in
their care. The American Medical Association Foundation (2007) encourages providers to tell the
patient what activities to expect when entering the healthcare system, asking patients to:
• Report new or different symptoms and anything that doesn’t seem quite right.
• Bring in a list of all their medications or the actual medication bottles for a review (prescription,
herbals, vitamins, minerals, and other over the counter drugs).
• Provide copies of recent test results or reports they may have from other healthcare providers and
personal health records if they have them.
• Make a list of 2-3 questions they wish to ask.
• Ask a family member or friend to come with them to help write down information and remember
what was said.
• Clarify what the doctor told them before they leave.
Preparing a Respectful and Supportive Environment
Patients with low literacy skills are often ashamed of this problem and rarely tell anyone (Baker et
al., 1996; Parikh, Parker & Nurss, 1996). Even patients with good literacy skills may feel
intimidated and avoid asking questions; this behavior may be misinterpreted to mean that they
understand the instructions when really they do not understand them.
One way to help patients feel respected and supported is to call them by their title and last name
unless they request that you use their first name. Remember that nonverbal behaviors convey
important messages. For example, if the receptionist or nurse is trying to check in a patient while
on the phone or doing other paper work at the same time, the message received is that the patient’s
presence is not important. Patients from other cultures often misinterpret nonverbal gestures, such
as the thumbs up or an OK sign made with the thumb and first finger, and consider them to be
offensive. Providers are encouraged to pay attention to the patient, use a warm, friendly tone, and
smile to let them know that are welcomed. Asking patients if they need any help will go a long way
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in developing rapport, as will picking up on any verbal or nonverbal clues that might indicate a
patient’s extreme anxiety or difficulty understanding what is happening.
Assessing Health Literacy
Knowing whether your patient has low health literacy skills is very important. This knowledge
enables you to match your verbal instructions and the readability level of materials to the health
literacy skills of your patient. It may also suggest the benefits of using non-printed teaching
materials, such as videotapes, audiotapes, demonstrations, models, pictograms, and other visuals. It
is also always important to remember that a patient’s poor communication skills may not indicate a
lack of intelligence, but rather a lack of these skills. People with low literacy skills often have the
ability to develop these skills; but have not had the opportunity to do so. The following discussion
will focus on clinical concerns regarding health literacy, concerns regarding health literacy testing,
the Newest Vital Sign, clues that help identify patients with low health literacy, and assessment
questions to identify low health literacy skills.
Clinical Concerns Regarding Health Literacy
A patient's literacy level is a concern in healthcare settings because
some patients are not aware that they have low literacy skills; they
...clinicians routinely
often overestimate their own abilities. In one study of low-literate
overestimate the ability of
patients, 75% had never told their spouse, 53% never told their
patients to understand
children, and one in five never told anyone about their reading
medical information.
problem (Parikh et al., 1996). Kirsch, Jungeblut, Jenkins, and Kolstad
(2005) reported that two-thirds to three-fourths of those reading at the
lowest reading level, i.e. a below basic level, which is a 5th grade leve
or below, report that they read “well” or “very well.” Patients who
read at the lower levels often arrange their lives in such a way that
they read what they can while compensating for their problem with a
number of coping strategies. Also of concern is the finding that
clinicians routinely overestimate the ability of patients to understand
medical information. This occurs even after they spent time with patients who did not understand
what they were told (Bass, Wilson, Griffith, & Barnett, 2002; Kelly & Haident, 2007).
Concerns Regarding Testing for Health Literacy
The trend to test patients’ literacy skills began about the time The Joint Commission (TJC) added
guidelines to their patient and family education standards to the effect that literacy levels need to be
taken into account when teaching. It is important to note that TJC standards do not require testing.
The development of specific tests for literacy in healthcare settings may have supported the trend to
formally test patient literacy. A reading skills test measures a person’s ability to decode words.
Decoding is an essential step in reading that requires transforming letters into words and
pronouncing the words correctly. These tests are effective for use in research purposes when a
person gives informed consent to be tested, but are often not appropriate for use in a general
clinical setting. They are not very user friendly in the clinical setting. People with low literacy
skills, who already feel stigmatized and fear exposure of their inability to read, may elect to go
elsewhere for their medical services if a literacy test becomes part of the routine care. Furthermore,
unless healthcare providers are trained to communicate effectively with these patients and to select
appropriate and easy-to-read materials, knowing a person’s literacy level does not improve care.
However, recently there has been some focus on developing screening tools that can be used in the
clinical setting. One such tool, the Newest Vital Sign (NVS), is described below. Yet other
researchers are continuing work to develop an assessment tool that will provide clinicians with an
easy way to get the information they need about their patients’ literacy levels. Table 1 describes
tests that measure recognition, pronunciation and/or comprehension.
There is fair evidence to suggest that possible harm outweighs any current benefits of literacy
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testing (Paasche-Orlow & Wolf, 2007). Patients may be harmed by testing in the form of shame
and alienation. Osborne (2005) has shared insights from Archie Willard, an adult learner, who first
learned to read when he was 54. Mr. Willard has given us a sense of what testing means to those
with low literacy skills by explaining:
As a dyslexic and an adult learner with reading problems, I speak for many other adult
learners. We hate having to take written literacy tests. People with other kinds of
handicaps are not continually asked to expose their weaknesses to whatever degree
they are handicapped. There is no physical pain in taking a written test, but when we
have to take a written test there is a lot of frustration inside each of us. We grew up
feeling humiliated because we had poor literacy skills and now we are adults. Written
tests are seen as another step backward for us and it turns us away.
The Newest Test of Health Literacy: The Newest Vital Sign
The Newest Vital Sign (NVS) is a quick and accurate bilingual (English and Spanish) screening
test for general literacy, numeracy, and comprehension skills applied to health information,
designed to be used in primary care settings. (Osborne et al., 2007; Weiss et al., 2005). This test
takes about three minutes to administer and consists of an ice cream container nutrition label.
Patients read the label while the provider asks six questions about how they would act on the
information. A scoring sheet, with the correct answers is used to record the responses. Patients with
fewer than four correct answers suggest the possibility of low health literacy. The Newest Vital
Sigh package is available at no cost and can be downloaded or ordered at the Pfizer Clear Health
Communication Initiative website (Pfizer, 2008).
Clues Indicating Low Health Literacy Skills
Most people with low literacy skills are masters at concealing
their deficit and are often quite articulate in speaking, so it is
difficult to realize that a problem exists. However, observing
closely and asking the right questions will provide ‘red flags’
that a problem exists with reading and comprehending
information. There are a number of characteristics and behaviors
that patients with low health literacy exhibit:
Most people with low literacy
skills are masters at concealing
their deficit and are often quite
articulate in speaking, so it is
difficult to realize that a problem
exists.
• Patients often make excuses when asked to read or fill out
forms. Examples include: “I don’t have my glasses,” “I’m too
tired to read ,” and “I’ll read this when I get home.”
• Poor readers often lift text closer to their eyes, or point to the
text with a finger while reading. Many times their eyes wander
over the page without finding a central focus.
• Patients may provide an incomplete medical history or check
items as “no” to avoid follow-up questions.
• Poor readers often miss appointments and/or make errors regarding their medication.
• Patients with low health literacy become skilled at listening and they often take instructions
literally to avoid mistakes. To identify their medications they look at the pills for color, size, and
shape, since they can’t read the labels.
• Patients often show signs of nervousness, confusion, frustration, and even indifference. They may
withdraw or avoid situations where complex learning is required.
• Patients often give incorrect answers when questioned about what they have read.
Watching for these indicators of low health literacy can pay large dividends in terms of improving
healthcare for these patients.
Assessment Questions to Identify Low Health Literacy Skills
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Asking a patient how far they went in school is not always a good indicator of reading ability. Mos
people who can’t read have been through the 10th grade, because young people must attend school
until they can legally drop out, usually at age 16. Most research shows a two to five year gap
between grade level achieved and reading skills (Kutner, Greenberg, Jin, & Paulsen, 2006). Asking
the following targeted questions can help identify low health literacy:
• Medical terms are complicated and many people find the words difficult to understand. Do you
ever get help from others in filling out forms, reading prescription labels, insurance forms, and.or
health education sheets?
• A lot of people have trouble reading and remembering health information because it is difficult. Is
this ever a problem for you?
• How happy are you with the way you read?
• How much time do you spend reading each day? What do you like to read? (Newspapers are 10th
grade reading level and news magazines are at the12thgrade level).
• When you have to learn something new or unfamiliar, how do you prefer to learn the
information? Do you like to learn by watching TV, listening to the radio, talking with people,
trying it yourself, or reading?
Another way to assess for low health literacy is to ask patients to read their prescription bottles and
then explain how to take their medication. Chew, Bradley, & Boyko, (2004) found three questions
to be an effective screening tool for those with below basic health literacy skills (5th grade level or
less), but not as effective for identifying patients with higher levels of health literacy skills.
1. How often do you have somebody help you read hospital materials?
2. How confident are you filling out medical forms by yourself?
3. How often do you have problems learning about your medical condition because of
difficulty understanding written information?
Wallace et al. (2006) evaluated the three questions from the Chew et al. (2004) study and
concluded that combinations of multiple questions were no more effective in identifying those with
low health literacy than one single question. They reported that the question “How confident are
you filling out medical forms by yourself?” was the most accurate of the three questions.
A Single Item Literacy Screener (SILS) (Morris, MacLean, Chew, & Littenberg, 2006) was found
to have good sensitivity when compared to other validated tools, for identifying patients with low
health literacy. This item asked “How often do you need to have someone help you when you read
instructions, pamphlets, or other written material from you doctor or pharmacist?” Responses
ranged from “1” (never) to “5” (always). The cut-off point of “2” captured all patients potentially in
need of assistance.
Utilizing Strategies to Increase Health Literacy
Effective communication strategies will both serve patients
with low health literacy and also benefit more literate
patients. This section will discuss oral and printed
communication as well as a newer type of printed material,
the photonovela, which is gaining popularity as an effective
way to communicate with patients having low health
literacy skills.
To increase retention, speak slowly and
limit...advice..., focusing the content of
the message on a patient’s actions or
behaviors that will result in the desired
health outcome...
Oral Communication
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Patients with low health literacy often have problems understanding information given verbally
during the patient-provider encounter (Schillinger, Bindman, Wang, Stewart, & Piette, 2004).
Research has shown that patients only understand and retain about half of what the provider tells
them, and that they do not feel comfortable asking providers to repeat or clarify information
(Schillinger et al., 2003). To increase retention, speak slowly and limit the amount of advice given
to patients, focusing the content of the message on a patient’s actions or behaviors that will result in
the desired health outcome, rather than on detailed facts. It also helps to organize the information
logically, focusing on the three to five most important ‘need to know’ points. Logical organization
starts with the easiest parts of a message first, then builds on this foundation; it breaks down
complex instructions into small units of information to help the patient grasp and understand the
information. In this way, patients will feel a sense of success in mastering the information. It is also
recommended that instructions be specific, concrete, and vivid, rather than general in nature.
People with low health literacy have difficulty with abstract words or general principles and they
often don’t know what they need to do if instructions are given in general terms (Doak, Doak, &
Root, 1996). For example, if a patient is told to take medicine twice daily, but not the specific
times, the patient may not know when to take it, and decide to take two tablets at the same time so
as not to forget the second dose of the day.
Using plain language when speaking
and writing means communicating in
every day or “living room”
language...
Using plain language when speaking and writing means
communicating in every day or “living room” language,
limiting the length of the message, and organizing information
so the receivers get the message quickly and clearly and in a
way that makes sense to them (Weiss, 2007). Healthcare
providers should avoid using jargon and medical terminology.
If it is necessary to use a medical term, make every effort to
explain the word in plain language. There are a number of
medical thesauruses available that can help you find an
alternative word for more difficult, complex medical terms (See
Table 2).
Reinforcing information is key for retention. Stop after giving each key point to solicit questions
and have patients repeat the material back to you. This technique is called ‘chunk and check.’ It
makes learning more interesting and helps patients to remember the information better.
Another effective method to improve retention and check for
understanding is the ‘teach-back’ technique. To use this
method, ask your patients to repeat the information they just
heard using their own words. One study found that 83.5% of
patients retained the information when asked to restate it
compared to 60.8% of those not engaged in teach-back
(Bertakis, 1977). This form of interactive communication to
assess comprehension was associated with better glycemic
control for patients with diabetes (Schillinger et al., 2003). A
report on Making Health Care Safer from the Agency for
Health Research and Quality (2001), stated that “Asking
patients to recall and restate what they have been told is one
of the top eleven patient safety practices based on scientific
evidence.”
Stop after giving each key point to
solicit questions and have patients
repeat the material back to you. This
technique is called ‘chunk and check.’
Printed Communication
Verbal instruction should be reinforced with printed instructional materials that are easy-to-read
and visual materials, including models and illustrations. These tools do not replace the personal
interaction; they can only help facilitate the interactive process between you and the learner, an
essential element of teaching. Guidelines for both written and visual materials will be presented
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below, along with the principles of Clear Health Communication. User-friendly and easy-to-read
materials provide repetition and help rephrase the information for better understanding.
There is a significant gap between patients’ reading and comprehension levels and the reading
difficulty of educational materials (Baker et al., 1996; Kutner et al., 2006). Most patient education
materials are written above the 8th grade level, with the average level falling between 10th and 12
grades (Estey, Musseau, & Keehn, 1994). Standard informed consent documents often require high
school- and college-level reading comprehension (Paasche-Orlow, Taylor, & Brancati, 2003).
Many patients, regardless of literacy level, prefer simple, easy-to-read materials written in plain
language especially when they are ill (Andrus & Roth, 2002; Mayeaux et al., 1996).
All patients can benefit from seeing pictures, but those most likely to benefit are the patients with
low literacy skills. Houts, Doak, Doak,& Loscalzo (2006) believe that providers should: (a)
determine how pictures can be used to support key points, (b) ensure that pictures are concrete
rather than complex, (c) remove unnecessary details to avoid distractions, and (d) closely link the
pictures to simple language print. Pre-testing visual materials with focus groups helps determine if
they are easily understood, correctly interpreted, and/or culturally appropriate.
Studies (Campbell, Goldman, Boccia, & Skinner, 2004; Doak et al., 1996; Dowse, n.d.; Houts et
al., 2006; Katz, 2006; Osborne, 2006) have shown that the use of pictures in health information
improves learner comprehension, especially when information about spatial relationships is
presented. In a study on the impact of illustrations on public understanding of cancer screening, the
addition of illustrations to written information resulted in a significant (27%) improvement in
understanding (Brotherstone, Miles, Robb, Atkin, & Wardle, 2006).
Table 3 lists available guidelines describing how to develop health information materials to ensure
that they are user-friendly, easy-to-read, and understandable to a wide audience. One of the most
widely used guidelines, Pfizer Principles for Clear Health Communication, includes five elements
(Pfizer, 2007):
1. Explain the purpose of the document: Define the purpose and benefits from the patients’
viewpoints.
2. Involve the learner: Focus on the desired patient behaviors and describe useful and realistic
actions for the learner to take.
3. Make the material easy to read: Use common words and active voice as if talking to
someone; use headings/subheadings to draw attention to the key messages.
4. Make the material LOOK easy to read: Include a lot of white space, use sharp contrast with
12 point font, and cue to direct attention to key points.
5. Select visuals that clarify the material and motivate the learner: Use realistic visuals,
graphics appropriate to the learner, and captions that clarify the point of the visual and
describe the recommended actions.
The Photonovela
One type of visual that is increasing in popularity for those with low literacy skills is the
photonovela. A photonovela is a health education item that is formatted like a comic book, but
contains photographs instead of drawings. It includes easy-to-read text to tell a story and stimulate
discussion with patients who struggle with low literacy levels. It is a popular form of entertainment
literature in Central and South America (Nimmon, 2007).
Often the learners themselves help write and design the photonovela. This creates an empowering
experience resulting in a piece of educational material that reflects a particular group of people in
the community. Those from the community who are not involved in the production of the
photonovela will identify with the message because it closely reflects their beliefs. The Harvard
School of Public Health (n.d.) has comprehensive information and examples of photonovelas
posted on their website <www.hsph.harvard.edu/healthliteracy>.
Steps for designing a photonovela include:
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Step 1: Acquire resources:
■ Large sheets of paper for storyboarding, markers and tape, digital camera, computer, Microsoft
publisher software or equivalent, and actors
Step 2: Develop the content by:
■
■
■
■
■
Choosing the topic, listing points to be covered, and selecting appropriate visuals and text
Drawing on a large piece of paper a grid with a section for each point.
Brainstorming ideas for photos and sketching pictures in the grids.
Adding text ideas to each grid.
Determining the final version of photos and text.
Step 3: Produce the photonovela by:
■ Selecting actors who match the ethnicity of the audience, having actors sign the necessary release
forms.
■ Setting the scene for each photo shoot, considering characters for each shoot, their gestures,
expressions, and various clothing items needed.
■ Shooting the photos with a digital camera, downloading the photos, and using software to
complete the layout.
■ Inserting the text into the “bubbles” for the dialogue.
■ Completing the final editing.
■ Translating into second language if necessary, using a native speaker for the translation.
Step 4: Pilot test:
■ Arrange a focus group, interview, or survey with a small group of people who are expected to use
the material.
■ During the pilot testing, assess whether the material attracts and holds attention, is accurately
perceived, and/or teaches the facts, principles, and interventions presented. Assess also how the
material affects the reader’s attitudes and intents to change behaviors, and how the plans for the
photonovela might be improved.
Evaluating the Learning
In addition to improving retention of information, the ‘teach-back’
method (described above) also demonstrates whether the patient
understood the information and provides an opportunity to correct
any misunderstandings and reiterate critical information that was
not remembered. You can approach ‘teach-back’ by asking:
...don’t assume that a person
understands just because they
don’t ask questions.
• ‘Please tell me in your own words what we have discussed.’
• ‘What might you tell your family or a friend about your
condition?’
Additional evaluation techniques include:
• Asking specific and relevant open-ended questions to see if patients can apply the information to
their situation, noting, for example, “Some people have problems remembering to take their
medicine” and asking “If this happens, what will you do?”
• Presenting a real world problem or scenario that could occur, and asking the person to solve the
problem by applying what they have learned, e.g. ask “What would you do if
________________happens?”
• Requesting that patients demonstrate the specific activity and how they could trouble shoot for
problems they may encounter doing the skill.
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In using the teach-back method, don’t assume that a person understands just because they don’t ask
questions. People may feel that asking a question will expose their ignorance, and they don’t want
to be embarrassed. Rather ask an open-ended question, for example, “What questions do you
have?” If a key point seems to be unclear, rephrase the information, rather than just repeating the
information as previously presented.
Incorporating Health Literacy Concepts into the Nursing Curriculum
Given that low health literacy is a major public health problem of the 21st century, it is imperative
that our current and next generation of nurses both learn about the burdens that low health literacy
places on individuals, on the healthcare system, and on society as a whole, and recognize how
nursing can take a leadership role in decreasing low health literacy.
Most current nursing curricula include the patient education process, but do not specifically speak
to low health literacy. When students are asked to define health literacy and low health literacy,
their answers usually consider only a person’s inability to read, rather than also considering the
patient’s comprehension, numeracy, or ability to act on health information. Health literacy concepts
can easily be integrated into segments of the curriculum that include communication and patient
education (Novitizky, 2009). Objectives, content outlines, and clinical activities to promote an
understanding of health literacy are described in Table 4.
Summary
Nurses play a major role in providing leadership that meets the
challenge of low health literacy in our society, both at the
Nurses play a major role in
individual level of care and within our organizations. We need
providing leadership that meets the
to know how to implement strategies to create a patientchallenge of low health
centered, shame-free environment that enhances health literacy
literacy...both at the individual level
not only for patients with low literacy, but for all patients.
of care and within our
Knowing how to assess patients’ ability to read and understand
organizations.
health information is essential if we are to identify the most
vulnerable patients who most need help addressing their low
health literacy. As of the writing of this article, evidence
suggests that this assessment is best done by using appropriate
assessment questions and looking for behavioral clues. Visuals
are important to increase comprehension and adherence to a
treatment plan. A variety of guidelines for preparing clear
health communication materials have been presented in this article. Photonovelas, a particular kind
of visual that tells a story with photographs and dialogue, and are being developed more frequently
for those with low health literacy, have been described.
It is important to begin now to teach future generations of nurses to communicate effectively both
orally and in writing with patients who have low health literacy. Teaching students and practicing
nurses how to utilize practices that address low health literacy in patients will not only benefit
individual patients, but will also help reduce health disparities in the twenty-first century and
beyond.
Author
Sandy Cornett, PhD, RN
E-mail: [email protected]
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Assessing and Addressing Health Literacy
Page 11 of 18
Dr. Cornett holds BS and MS degrees in nursing and a PhD in Adult Education and Instructional
Design. She currently serves as Director of the Area Health Education Center (AHEC) Clear Health
Communication Program at the Ohio State University College of Medicine, where she has prepared
over 6,000 students and practitioners in the health professions in the area of health literacy and
consulted with many organizations that need assistance with health literacy issues. She previously
served as Program Manager of Consumer Health Education at The Ohio State University Medical
Center, Columbus, Ohio, for over 20 years. During this tenure she implemented a patient education
system that included 3,000 titles of patient education materials, written below an 8th grade reading
level. For more information on health literacy see The Ohio State University’s AHEC Clear Health
Communication Program website at http://medicine.osu.edu/orgs/ahec/CHCP.
References
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Bass, P.F., Wilson, J.F., Griffith, C.H., & Barnett, D.R. (2002). Residents’ ability to identify
patients with poor literacy skills. Academic Medicine, 77, 1039-1041.
Bertakis, K.D. (1977). The communication of information from physician to patient: A method for
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Brotherstone, H., Miles, A., Robb, K.A., Atkin, W., & Wardle, J. (2006). The impact of
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Campbell, F. A., Goldman, B.D., Boccia, M.L., & Skinner, M. (2004). The effect of format
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Chew, L. D., Bradley, K. A., & Boyko, E. J. (2004). Brief questions to identify patients with
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Davis, T.C., Long, S.W., Jackson, R.H., Mayeaux, E.J., George, R.B., Murphy, P.W. et al. (1993).
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Dowse, R. (n.d.). Using visuals to communicate medicine information to patients with low literacy.
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Houts, P., Doak, C.C., Doak, L., & Loscalzo, M.J. (2006). The role of pictures in improving health
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Mayer, G.G., & Villaire, M. (2007). Health literacy in primary care: A clinician’s guide. New
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Paasche-Orlow M.K, Taylor, H.A., Brancati, F.L. (2003).
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Wolf, M.S., Gazmararian, J.A., & Baker, D.W. (2005). Health literacy and functional health status
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Table 1. Tests to Measure a Person’s Ability to Read and Comprehend Health Materials
Name of
Test
Description
Strength
Weakness
REALM –
Rapid
Estimate of
Adult
Literacy in
Medicine
Word
recognition
and
pronunciation
of healthrelated terms;
66 words
listed in 3
columns from
easy to hard
words
Valid with
standard tool,
Wide Range
Achievement
Test (WRAT)
(WRAT-R);
given in 3
minutes or less
Does not test
Davis et al., 1993
for
comprehension Terry Davis, Ph.D.
of the words
[email protected]
listed;
available only
in English;
does not test
for document
or numeracy
literacy
REALM-R
8-item version
of full
REALM
Valid with
WRAT-R;
given in less
than 2 minutes
Does not test
for
comprehension
of words
listed;
available only
in English;
does not test
for document
or numeracy
literacy
7-item word
recognition
test
Validated with
66-item
REALM;
given in less
than 2 minutes
Does not test
Arozullah et al.
for
2007
comprehension
of words
listed;
available in
English only;
does not test
for document
or numeracy
literacy
50-item tool
based on the
66-item
REALM
Validated tool;
given in 3-5
minutes
Does not test
Lee, Bender, Ruiz,
for
& Cho, 2006
comprehension
of words listed
(Revised)
REALM –
SF
(Short
Form)
SAHLSA50 – Short
Assessment
of Health
Literacy
for Spanish
Reference
Bass, Wilson, &
Griffith, 2003
Terry Davis, Ph.D.
[email protected]
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Assessing and Addressing Health Literacy
Page 15 of 18
-Speaking
Adults
TOFHLA –
Test of
Functional
Health
Literacy in
Adults
STOFHLA
(Short
form)
50-item
reading
comprehension
test using
modified
Cloze
technique at
4th 10th, and
19th grade
reading levels;
Tests reading
comprehension
and numeracy
skills;
Instrument of
choice when
detailed
evaluation of
health literacy
is needed for
research;
17-item
numeracy test;
Available in
English &
Spanish and in
large print
Validated with
36-item
full TOFHA
reading
comprehension
at 4th & 10th
grade reading
levels
Both sections
take 22
minutes to
give
Parker, Baker,
Williams, & Nurss,
1995;
Nurss, Parker, &
Baker, 2001
Peppercorn Books
& Press
Takes 12
minutes to
give
Baker, Williams,
Parker,
Gazmararian, &
Nurss, 1999
Table 2. Medical Thesauruses
Health
Resources and
Services
Administration
www.hrsa.gov/servicedelivery/language.htm
Clear Language
& Design Canada
www.eastendliteracy.on.ca/ClearLanguageAndDesign/thesaurus/
National Center http://depts.washington.edu/respcare/public/info/Plain_Language_
for Health
Thesaurus_for_Health_Communications.pdf
Marketing /
CDC- Plain
Language
Thesaurus for
Health
Communication
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Assessing and Addressing Health Literacy
Health
Resources &
Services
Administration
– Plain
Language
Principles and
Thesaurus for
Making HIPAA
Privacy Notices
More Readable
Page 16 of 18
ftp://ftp.hrsa.gov/hrsa/hipaaplainlang.pdf
Table 3. Guidelines for Development of Materials in Plain Language
The Plain
Language
Initiative Executive
Secretariat –
Canada
http://execsec.od.nih.gov/plainlang/guidelines/index.html
Scientific and
Technical
Information
Simply Put
www.cdc.gov/od/oc/simpput.pdf
Clear &
Simple:
Developing
Effective Print
Materials for
Low Literate
Readers –
National
Cancer Institute
www.nci.nih.gov/cancerinformation/clearandsimple
Quick Guide to www.health.gov/communication/literacy/quickguide/
Health Literacy
- Office of
Disease
Prevention and
Health
Promotion –
Health
Communication
Activities
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Assessing and Addressing Health Literacy
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Table 4. Integrating Health Literacy into the Nursing Curriculum
Learning
Objectives
Content
Learning/Clinical
Activities
Describe the
health literacy
problem in the
US and the
mismatch
between public
reading levels
and most health
materials.
A. Definition of
general literacy and
health literacy
B. 2003 NAAL study
results for general
and health literacy
C. Populations at risk
D. Reasons for low
literacy
E. Reading levels of
most health
materials
DVD of vignettes of
persons with low health
literacy with discussion
of coping strategies they
use. Identify barriers to
access, diagnosis,
treatment, and self-care.
Assess a
patient’s ability
to read,
understand, and
act on health
information.
A. Characteristics and
behaviors of poor
readers
B. Observations to
make
C. Questions to ask for
assessment of low
health literacy –
social history,
medication review
D. Screening tools –
NVS, SILS
Administer the NVS
and make observations
of patients at a clinic;
Simulated experience of
a poor reader; Develop
a list of questions for a
listening test.
Discuss the
impact of low
health literacy
on knowledge,
health
outcomes,
promoting
behaviors,
patient
adherence, and
healthcare costs
A. Studies on the gap
between adult
literacy skills and
healthcare system
demands
B. Risks/costs to
providers and
healthcare systems
C. Impact on society as
a whole
Make observations of
literacy- related
demands in various
healthcare settings and
discuss strategies for
improving the
environment.
Describe the
guiding
principles to use
when
communicating
and teaching
patients
A. Ensure a patientcentered, shamefree environment
B. Use Plain Language
(PL) for patient
teaching
C. Provide easy-toread and understand
information:
Analyze the assessment
process used in a variety
of health care settings;
Use role-play to
practice using ‘teach
back’ method; Use case
studies, video vignettes,
or role-play to practice
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Assessing and Addressing Health Literacy
◦
◦
◦
◦
appearance/appeal
organization
writing style
reading levels –
Simple Measure of
Gobbledygook
(SMOG), FRY
Index
◦ non-print materials
Page 18 of 18
using plain language;
Compare & contrast
two health-related
consumer Internet
resources; Use PL
criteria to analyze the
reading difficulty of
patient education print
material; Revise a piece
of difficult education
material; Develop a
piece (brochure) of
education material using
guidelines; Do a SMOG
on a piece of education
material; Determine
methods and materials
to use when teaching
case study patient with
low health literacy.
© 2009 OJIN: The Online Journal of Issues in Nursing
Article published September 30, 2009
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