Many people have limited health literacy skills. Even strong readers may have difficulty with unfamiliar health terms and concepts. The complexity of the U.S. health care system can exacerbate health literacy challenges.

Health care organizations should assume that anyone may have difficulty understanding health care information and navigating the health care environment. A first step is the organizational adoption of health literacy universal precautions, communication practices in which providers interact with all patients as if they may have difficulty understanding health information, regardless of their background or educational level.1

Even with universal precautions in place, it may be helpful for health care organizations to evaluate patient health literacy through informational identification strategies. The information below outlines both simple informal strategies, as well as more formal options, for organizations seeking to develop appropriate services and materials for specific patient populations.

Health Literacy Fact Sheet Series

This fact sheet is part of a series addressing the impact of limited health literacy and providing strategies for organizational improvement. For more information, visit www.chcs.org/health-literacy.

Informal Patient Assessments

Adults with limited literacy or health literacy report feeling a sense of shame about their abilities.2 They may hide their reading struggles from everyone, including health care providers.3 Do not surprise them with a literacy test. Doing so may embarrass and alienate them. There are, however, informal ways to identify people who may have limited literacy skills. For example, do patients:  

  • Miss appointments frequently?
  • Fail to complete or accurately complete registration forms?
  • Identify pills by looking at them rather than reading their label?
  • Struggle to provide a coherent, sequential medical history?
  • Avoid following up on tests or referrals?
  • Use statements such as “I forgot my reading glasses,” “I’ll read through this when I get home,” or “I’m too tired to read” when asked to discuss written material?

To conduct an informal literacy assessment, health care providers can casually ask the questions listed below. The answers often illustrate whether individuals are struggling to understand health information.

  • Would you please show me how you are going to use your inhaler (or other item), so I know if I explained it well enough? (This is an example of a “Teach-Back” tactic.)
  • I’m guessing a family member or friend may ask you what you found out at today’s appointment. What are you going to tell them? (Also a “Teach-Back” tactic.)
  • People like to learn about health issues in different ways. Do you prefer written materials? A conversation? Videos? Or a different method?

Health Literacy Snapshot

A primary care physician notices that many of her diabetic patients do not schedule follow-up appointments and often miss their scheduled foot and eye exams. Since many of the patients in her clinic have limited literacy skills, she realizes that many of them may not be aware of or understand the importance of follow-up appointments and other exams. She asks a member of her care team to reach out to her patients, use the “teach-back” method to discuss the importance of these appointments, and jointly create individualized plans with minimal barriers to follow-through.

Formal Health Literacy Assessments

Formal health literacy assessments can help health care organizations systematically identify patients with limited health literacy skills. This should only be done if the organization has committed to integrating quality improvement practices to better serve people identified with limited health literacy skills. Ideally such health literacy assessments should be scheduled in advance, conducted only with full patient consent, and administered outside of the clinical setting. This will help alleviate fears of going to future medical appointments. Trained, trustworthy, and culturally diverse staff should administer the assessments, and patients should receive meaningful compensation for their time.

Below are several common tools used to assess individuals’ health literacy skills.

Important Considerations for Assessing Health Literacy Levels

  • Use a combination of informal and formal measures to gain a more nuanced understanding of individuals’ abilities.
  • Conduct assessments in private, with sensitivity and respect, to ensure that patients do not feel ashamed, inferior, or like targets of a study.
  • Distinguish limited literacy or health literacy skills from cognitive decline, a developmental disability, or a mental health disorder.
  • Differentiate English proficiency from health literacy. Individuals who are not proficient in English (but are proficient in another language) can have limited literacy or limited health literacy skills. Or they may function quite high in either or both.

Endnotes

  1. Agency on Healthcare Research and Quality. AHRQ health literacy universal precautions toolkit (2nd edition). (2020, September). U.S. Department of Health and Human Services. https://www.ahrq.gov/health-literacy/improve/precautions/toolkit.html
  2. Wolf, M.S., Williams, M.V., Parker, R.M., Parikh, N.S., Nowlan, A.W., & Baker, D.W. (2007). Patients’ shame and attitudes toward discussing the results of literacy screening. Journal of Health Communication, 12(8): 721–732. https://doi.org/10.1080/10810730701672173
  3. Baker D.W., Parker, R.M., Williams, M.V., Ptikin, K., Parikh, N.S., Coates, W., & Imara, M. (1996). The health care experience of patients with low literacy. Archives of Family Medicine, 5(6): 329–334. https://pubmed.ncbi.nlm.nih.gov/8640322/
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