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Author: Susan Koch-Weser
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Medical Interviewing and the Doctor-Patient Relationship
Fall 2011
S. Koch-Weser, ScD
Tufts University School of Medicine

Health Literacy Implications for Health Status and Clinical Practice


Health literacy as currently understood goes far beyond a person’s ability to read and understand plain text. The most common definition is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. It has been used by the U.S. Department of Health and Human Services in Healthy People 2010 and the Institute of Medicine (IOM) in “Health Literacy: A Prescription to End Confusion”.

Health Literacy includes a number of different skill areas:

Skill Area

Examples of materials and situations that draw on the skills

Print Literacy

(reading, writing)

Prose, documents, forms, tables, charts

Oral Literacy

(Listening, speaking)

Conversations, question asking, describing symptoms


(Basic math & more advanced concepts)

Medication dosing, determining ‘normal’ ranges, understanding risks (probability), using charts and tables

Cultural and conceptual knowledge

Interpreting symbols, diagrams, decoding body language, fitting new information into models of disease processes, understanding the purpose of forms and office procedures

Although the definition focuses us on individual skills, the LITERACY DEMANDS of a situation also determine how an individual with a particular skill level will function. Thus health literacy is a complex, social determinant of health and efforts to address health literacy must focus not only on improving the skills of individuals, but also on developing the skills of providers and the simplification of procedures, forms, and even signage.

Prevalence of low health literacy

Roughly 90 million Americans have functional health literacy skills that prevent them from accessing, understanding, interpreting, and applying most of the health information provided to them every day. In 2003 the U.S. Department of Education commissioned the National Assessment of Adult Literacy (NAAL) and included health items to assess health literacy in a representative sample of US Adults. Respondents were classified into the following health literacy levels:

  • Proficient 12%

  • Intermediate53%

  • Basic21%

  • Below Basic14%

Adults at a basic or below basic level would find it challenging to read the vast majority of patient education materials produced today, or to read a prescription label and determine what time to take a dose.

Although limited health literacy skills affect adults across all age, racial, ethnic and educational groups, the NAAL identified vulnerable populations: elderly (65+), ethnic and racial minorities, immigrants, those with low income or limited education, and people with chronic mental or physical health conditions.

Health Literacy and Patient Care

Patients make many health related decisions in daily life. Health literacy affects a person’s ability to interpret and use quantitative data i.e. reading a peak flow meter or calculating the amount of cough medicine to give a child of a given age and weight. Informed decision-making involves interpreting and weighing risk, having a basic level of biological literacy, and being able to articulate and share questions and concerns. The research and practice literature shows that we make assumptions all the time about how well patients are able to perform these tasks. In doing so, we often adversely affect patient health and diminish potential therapeutic impact. There is a large body of literature linking health literacy to various health and health care outcomes, including:


  • Correct interpretations of prescriptions (Williams MV, et. at. JAMA, 1995)

  • Proper metered-dose inhaler technique (Williams MV, et al. Chest, 1998)

  • Adherence to ART (Kalichman SC, et al. Journal of Gen Internal Med, 1999)

  • Glycemic control (Schillinger D, et. al. JAMA, 2002)


  • Stage of presentation for prostate cancer (Bennett CL, et. al. Journal of Clinical Oncology, 1998)

Access to care/use of services

  • Ability to navigate the health system to obtain necessary services (Baker DW, et al. Archives of Family Medicine, 1996)

  • Risk of hospital admission among elderly managed care enrollees (Baker DW, American Journal of Public Health, 2002)

What to do: Universal Precautions

You can’t usually tell health literacy level by looking, and for many adults with limited health literacy, being identified brings on feelings of shame. It is better to take universal precautions and work to improve communication with all patients. Some things you can do (from Center for Health Care Strategies, Inc.

  • Prepare patients prior to their visit. Have staff tell patients what information will be needed (medicines they are taking, insurance, reasons for visit) and suggest that they can bring a family member.

  • Don’t ask “Do you understand,” rather to verify understanding or to uncover health beliefs ask patients to “teach back” or explain what they understand to you as they would to a friend.

  • Tailor medication schedules to fit a patient’s routine to help with adherence.

  • Use commonly understood words. For example, “keeps bones strong” rather than “prevents osteoporosis.”

  • Slow down, listen, and limit information given at each visit to just a few key points. Most patients remember less than half the information provided.

  • Focus on clearly laid out action steps, behaviors rather than medical facts.

Learning Objectives and Competencies

By the end of the lecture, you will be able to:

  • Define what is meant by the term "health literacy."

  • Explain how "health literacy" encompasses more than ability to read.

  • Explain how poor numeracy skills and non-verbal communication can adversely impact clinical outcomes.

  • Recognize the impact of low health literacy on shared decision-making and informed consent in clinical practice.

  • Recognize what the current research shows about the prevalence of the problem.

  • Cite several indicators of low health literacy.

  • Recognize ways in which providers and health care institutions can address the problem.

Specific competencies students are expected to perform within the context of practice after this lecture:

  • Optimize the interviewing setting for your patient’s comfort and understanding.

  • Identify situations in your interview where poor health literacy is a concern and describe steps that might remedy them.

  • Identify examples in your interview where low health literacy had an impact on shared decision-making and informed consent.

  • Describe ways in which these problems of low health literacy can be addressed with your patient.

Suggested Readings:

Doak, C. C., Doak, L. G., & Root, J. H. (1996). Teaching patients with low literacy skills. Philadelphia: J.B. Lippincott.

Institute of Medicine. (2004). Health Literacy: A Prescription to End Confusion. Washington DC: National Academy of Sciences.

The Joint Commission. (2007). "What did the Doctor say?" Improving health literacy to protect patient safety. Oak Brook Terrace, IL: The Joint Commission

Osborne, H. (2005). Health literacy from A to Z : practical ways to communicate your health message. Sudbury, Mass: Jones and Bartlett.

Schwartzberg, J. G., VanGeest, J., & Wang, C. (2005). Understanding health literacy : implications for medicine and public health. Chicago, IL: American Medical Association.

Web-based Resources:

AMA Foundation, Health Literacy Initiative

Harvard School of Public Health, Health Literacy Studies

Health Resources and Services Administration

MEDline plus

National Network of Libraries of Medicine

Unified Health Communication 101: Addressing Health Literacy,
Cultural Competency, and Limited English Proficiency

World Education, Health Literacy Special Collection