Study Shows Low Levels of Health Literacy

October 14th, 2015. In the September issue of JAMA viewpoint, researchers Koh and Rudd explore the issues regarding consumer’s ability to understand medical information to improve their health.


Providers throughout the healthcare industry continue to advocate and offer resources, so that consumers fully understand their health and care. Despite messaging from health professionals, media, the Internet, and other sources, a significant number of patients still have difficulty with routine tasks such as taking the right medicine at the right time, properly self-managing diabetes, or correctly following hospital discharge instructions.


In this increasingly complicated health information environment, even the most sophisticated adult can be overwhelmed by unfamiliar medical terms, unexplained acronyms, and technical jargon. These limitations can greatly impact one’s health and numerous studies have identified limited health literacy as a culprit to poor health outcomes.


A 2006 report reveals only 12% of adults in the United States had a proficient state of health literacy whereby “individuals can obtain, process and understand the basic health information and services they need to make appropriate health decisions.” The 2011 Programme for the International Assessment of Adult Competencies (the third wave of adult literacy assessments conducted among 23 industrialized nations) also indicates continuing issues: US adults scored below the international average for literacy, numeracy, and problem solving in technology-rich environments.


To contribute to a healthier society, health literacy must improve in all its dimensions, including print literacy (writing, reading), oral literacy (listening, speaking), and numeracy (calculations, math concepts, and displays). Health literacy efforts are now extending well beyond a focus on written materials for individuals. Heightened attention by clinicians, institutions, and systems creates a new “Arc of Health Literacy” that promises broader reach and influence.




In the past, health care professionals often assumed that patients understood what they were being told unless the patient (or advocate) revealed otherwise. In current times, modern perspective encourages clinicians to assume the opposite and to ensure continued health, provide opportunities to review patient health and medical processes.


Some providers are now implementing the “teach-back method,” where practitioners ask patients to review and summarize, in their own words, their understanding of information provided to see if communication was successful. Instead of assuming the patient understands the information presented, practitioners can be proactive in checking successful communication and pose questions, in order to prompt conversation. (i.e. asking “What are your questions?” rather than “Do you have any questions?”) This lessens the tendency to feel embarrassed or inadequate and alerts the patient that having questions is normal.


Other providers have started to utilize Brown bag medication reviews, where patients are given the opportunity to bring all prescription drugs into a clinic visit. This provides a time for clinicians to revisit and reemphasize why and how each medication should be used. Many organizations have applied tactics to simplify explanations of potentially confusing concepts; e.g. using bar graphs to depict relative risk or recommending specific weight loss goals instead of percentages.



Institutions contribute to the care environment by constructing norms and standards for health professionals and staff, setting policies, supporting normative behaviors, and providing materials and tools for use and distribution. This includes orientation protocols and skill-building opportunities that support shared decision making between clinician and patient as well as, in some cases, understandable, personalized e-health tools. Institutions can create environments in which all patients feel comfortable asking basic questions, expect clearly articulated explanations and receive rigorously developed take-home materials for review.


In addition, policies and regulations can promote rigorous research in developing critical texts, both print and online (whether developed “in house” or contracted out). The Joint Commission has connected health literacy to patient safety. Hospitals committed to reducing errors and readmission rates can develop discharge instructions that follow recommended development processes, undergo pilot testing with members of the intended audiences, and receive careful assessment with available tools. In the same way, research-based communication principles can shape the design of electronic medical records (EMR) for sharing with other clinicians as well as with patients.


Organizations throughout the world have begun adapting the Institute of Medicine’s concept of a health-literate organization. A proposed health literate care model encourages organizations to integrate health literacy into areas such as delivery system design and clinical information systems. Both of these models urge less jargon, focus attention to faulty assumptions about the public’s comfort with math or scientific concepts, and have greater emphasis on rigorous formative research for the production of materials, forms, and instructions.



The Affordable Care Act has heightened the need for patients to understand technical insurance terms such as deductibles, cost sharing, premiums, provider networks, and drug formularies, in order for consumers to compare and contrast coverage options. Plain-language protocols that ensure reading ease and comprehension of materials are vital in guiding consumers seeking new coverage options and to help welcome and orient millions to new services.


Over the past twenty years, the scope of health literacy has broadened. The national health goals encourage coordinated system-wide action among a wide array of stakeholders but also call for partnerships to reach people regardless of age or cultural background, in the community as well as in the clinic setting. Efforts to aid the public to better understand healthcare continue to extended outside of patient care institutions to include those dedicated to preventive services and social services, as well as extending beyond the clinical sector to include public health efforts related to communication for epidemic and disaster management, as well as social service sectors such as the K-12 education system, statewide adult education programs, housing services, and occupational settings.


In addition to focusing on the needs of individual patients, the field now brings the promise of greater commitment and shared responsibility from clinicians, institutions, and care systems. Koh and Rudd  suggest the arc of health literacy bends toward population health and leveraging such an approach will comprehensively address the issue of limited literacy with the goal that someday all consumers will comprehend and feel confident about their health and care.



For providers seeking tactics to simplify explanations of medical terminology, concepts, and other areas: The Agency for Healthcare Research and Quality Universal Precautions Toolkit


For more information on integrated systems informed by health literacy:

The 2010 HHS National Action Plan to Improve Health Literacy

Healthy People 2020



Source: Koh, Howard K.; Rudd, Rima E., “The Arc of Health Literacy” JAMA Viewpoint, Vol. 314, No. 12, September 22/29, 2015