Use proven strategies to meet the health literacy challenge

Assess the situation and implement policies that include training staff

Clear communication is in the best interest of everyone — health care institution and consumers — for many reasons. It improves patient satisfaction. Patients leave an institution dissatisfied when they fail to get information, or it is delivered so quickly they can’t understand it, or the vocabulary or concepts are too complex, says Sue Stableford, MPH, MSB, director of AHEC Health Literacy Center at the University of New England in Biddeford, ME.

Clear communication improves patient safety and quality of care. The Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations recommends patients partner with health care systems. This means patients are able to check medications they are given to make sure they are right, and to understand the procedures and treatments. Yet, for such partnerships to take place, there must be clear communication and patients must feel comfortable asking questions.

Legal challenges often result from poor communication. According to case law, even if a consent form is signed, it is not legal and valid if the patient did not understand what he/she was agreeing to, says Stableford.

Poor communication can be costly. When forms are difficult to understand, they are often filled out incorrectly and must be mailed again. Unclear verbal or written instructions often means more work for staff who might spend much time answering questions about disease management over the telephone.

"I have been told repeatedly by clinical care providers that they have to counsel and reschedule tests for patients because they haven’t understood the preparation instructions. When that happens, it is very costly for the institution and inconvenient for the patient, and they are not happy," says Stableford.

Although there are many benefits to implementing policies and procedures that lead to better communication between patients and staff members, often facilities do not have them in place because administrators do not realize there is a problem. However, patient education managers are usually fully aware of the impact of low health literacy because they have seen how difficult it can be to educate a patient who can’t read or write well, or is simply unfamiliar with the medical terminology for a health problem. Because of their knowledge, they might want to take the lead in trying to get an initiative addressing low health literacy off the ground at their health care institution.

Regardless of who leads the way, the first step to improving health literacy problems is to raise awareness, says Sandra Cornett, PhD, RN, director of OSU/AHEC Health Literacy Program at The Ohio State University in Columbus.

The best way to raise awareness is to use national and local statistics on literacy skills, she adds. The National Adult Literacy Survey, completed in 1992-93, shows there are many vulnerable populations. These populations include the elderly, people with chronic conditions, and those who speak English as a second language.

A new study, the National Assessment of Adult Literacy, will be released this summer and, unlike the old survey, it includes a health literacy component, according to Cornett. Decision makers should be shown the research that links low health literacy to poor health outcomes. "Health literacy in and of itself is an indicator that you will have some problems with health outcomes," she explains.

It is important to note, Cornett adds, that the institution will save money when communication is improved.

To determine how to improve communication, a task force or committee should be assembled, and it should encompass all areas that might have health literacy problems including the business office. The committee should do a facilitywide literacy audit or assessment to uncover barriers that make it difficult for people with low literacy to successfully use services.

Cornett says that the barriers might be grouped in four areas: promotion/publicity; print/electronic materials; verbal communication; and staff sensitivity to literacy.

Often patients with low literacy even have trouble accessing health care, says Janet Ohene-Frempong, MS, president of JO Frempong & Associates, a plain-language and cross-cultural communications consulting firm based in Elkins Park, PA.

People use to go to one site for treatment, but now they have to navigate entire systems. Often they get lost trying to follow directions, so it is important to anticipate these problems and provide clear directions. For example, signs using common terms, such as kidney rather than renal, also are helpful.

Another barrier to health care is the denial of benefits because application forms are incorrect or incomplete. People can’t get the benefits they are qualified to have because of poor reading skills, says Ohene-Frempong.1

Once problem areas are identified, the committee can write policies and procedures to address them. There are a multitude of policies that might be appropriate. For example, a policy could call for patient education materials to be at the appropriate level of literacy and language to meet the skills of the populations the institution serves. A policy also could require staff to use health materials written in plain language for teaching patients.

A process could be implemented to review all documents, such as consent forms, advance directives, and the patient Bill of Rights, to make sure they are in plain language. Policies also might require the institution to develop nontraditional approaches to communication such as audiotapes, videotapes, pictographs, and dialogue and storytelling.

The type of policies and procedures implemented depend on what is found in the organizational assessment and what efforts the committee sees as necessary to meet the challenges. "I would strongly suggest the committee not try to tackle all the problems at once," says Cornett.

She advises institutions to pick a starting point. And she emphasizes the changes will make health care better for everyone, not just patients with limited literacy. "There are a lot of proficient readers who still have low health literacy because, whenever you are trying to impart information that is outside the context of that person’s frame of reference, it is difficult information," explains Cornett.

Staff training a must

One policy that must be implemented at all health care facilities is staff training. This will enable them to more effectively teach patients with low literacy skills. A session on health literacy awareness should be a part of all new employee orientation. Also, staff need to learn how to assess patients for health literacy and use appropriate teaching strategies when problems are identified.

For example, people who have low health literacy skills cannot take factual information from one lesson and apply it to another situation, says Cornett. The educator must do that for them. If the health care provider is teaching the patient how to pace him- or herself during an activity because of fatigue problems, every situation will have to be addressed, such as walking up a flight of stairs, doing chores around the house, etc.

"The higher-literate person can take those principles and apply them to another situation in their life, but the person who has low literacy can’t. You have to find out enough about [which] situations they may find themselves in after they go home and talk to them about how they [should] pace their activity," says Cornett.

Staff members responsible for written communications need to learn how to create plain-language materials. While this includes those who create forms and directions, patient education materials can be effective tools for people of all reading abilities if designed correctly.

Patient-friendly materials have four elements, says Ohene-Frempong:

1. They are not limited to text but have illustrations as well.
2. The text in a patient-friendly pamphlet is well organized and broken up so there is not a wall of words on the paper that intimidates people. Also, it is made readable by the sentence format.
3. Questions and answers or a checklist engages the reader.
4. The material must address the patient’s issues providing information that is relevant to him or her.

To provide incentive for following the policies and procedures set in place, staff need to be evaluated on their ability to communicate appropriately with people with low health literacy. "One of the ways that you make using those skills a priority is to tie them to staff performance appraisals," says Cornett.

In addition to training, staff need a variety of health communication resources to help them do their job effectively. "You are building a communication structure that is going to basically enhance the individual interaction between a staff person and a patient. That might be everything from making sure that all the patient education materials are easily located and developed in plain language to interpretation and translation services," Cornett explains.

Institutions also should consider establishing a learning center or library for patients and consumers. These libraries should contain collections of plain language materials in English and in various languages that target the patient groups they serve.

To address the problem of health literacy, an institution needs to be committed to developing a strategic plan that will take place over time.


1. Williams MV, Parker RM, Baker DW, et al. Inadequate functional health literacy among patients at two public hospitals. JAMA 1995; 274:1,677-1,682.