State of the Art and Science
Jun 2003

Reducing the Effects of Low Health Literacy

Faith Lagay, PhD
Virtual Mentor. 2003;5(6):222-224. doi: 10.1001/virtualmentor.2003.5.6.cprl1-0306.


According to the National Adult Literacy Survey, nearly half the US population is either functionally illiterate or marginally literate. Members of these groups are limited in their ability to read and understand text and are unable to write, for example, a brief letter explaining an error in a bill.1

Such widespread limited literacy has special significance for physicians and other health care professionals. Low literacy and, specifically, low health literacy—the term that refers to a patient's ability to understand common health care communications, such as prescription instructions, test results and insurance forms—affects adherence to treatment that, in turn, may affect treatment outcomes. Studies show, for example, that among surveyed patients, 28 percent did not know when their next appointment was, 42 percent did not understand the instruction "take medication on an empty stomach," and 86 percent could not understand the rights and responsibilities section of a Medicaid application.2-4 Low health literacy can also discourage patients from attempting to seek health services. In fact, literacy is the single best predictor of health status, correlating more closely with health status than age, income, employment status, education, or race and ethnicity.5-8

For several years, reducing the health effects of low health literacy has been a priority of the American Medical Association Foundation and the American Medical Association. Their recently produced health literacy kit, entitled Help Your Patients Understand, places responsibility for patients' understanding squarely on the shoulders of health professionals. The kit contains a comprehensive manual for clinicians; a video documentary about low health literacy; a CD-ROM with digital files of the manual, video, and presentation hand-outs; a physician questionnaire that can be used to obtain Category 1 CME credits; patient literature and buttons for office staff; and additional resources for education and involvement.

From the AMA Foundation and AMA health literacy kit's comprehensive manual, Health Literacy: A Manual for Clinicians, here are (1) a checklist for patient-friendly office procedures and (2) 6 steps to improved interpersonal communication with patients.

Checklist for Patient-friendly Office Procedures9

  1. Exhibit a general attitude of helpfulness.
  2. When scheduling appointments,
    1. Have a person, not a machine, answer the phone.
    2. Collect only necessary information.
    3. Give directions to the office.
    4. Help patients prepare for the visit: Ask them to bring all their medications and a list of questions.
  3. Use clear and easy-to-follow signage.
  4. Ask staff to welcome patients with a general attitude of helpfulness.
  5. During office check-in procedures,
    1. Provide assistance with completing forms.
    2. Collect only essential information. Provide forms in patients' languages.
    3. Provide forms in an easy-to-read format [eg, large print, uncrowded on the page].
  6. When referring patients for tests, procedures, or consultations,
    1. Review the instructions.
    2. Provide directions to the site of referral.
    3. Provide assistance with insurance issues.
  7. When providing patients with information,
    1. Routinely review important instructions.
    2. Provide handouts in an easy-to-read format.
    3. Use nonwritten modalities, eg, diagrams and pictures.

Six Steps to Improving Interpersonal Communication with Patients10

  1. Slow down. Communication can be improved by speaking slowly and by spending just a small amount of additional time with each patient. This will help foster a patient-centered approach to clinician-patient interaction.
  2. Use plain, nonmedical language. Explain things to patients as you would explain them to a family member.
  3. Show or draw pictures. Visual images can improve the patient's recall of ideas.
  4. Limit the amount of information provided, and repeat it. Information is best remembered when it is given in small pieces that are pertinent to the tasks at hand. Repetition further enhances recall.
  5. Use the teach-back or show-me technique. Confirm that patients understand by asking them to repeat back your instructions.
  6. Create a shame-free environment. Make patients feel comfortable asking questions. Enlist the aid of others (patient's family, friends) to promote understanding.


  1. These National Adult Literacy Survey results were cited in: American Medical Association Foundation and American Medical Association. Health Literacy: A Manual for Clinicians. Chicago: AMA Foundation and AMA; 2003:8. All information and statistics in this article come from Health Literacy: A Manual for Clinicians in which original sources for the data can be found.

  2. Williams MV, Parker RM, Baker DW, et al. Inadequate functional health literacy among patients at two public hospitals. JAMA. 1995;274(21):1677-1682.
  3. Baker DW, Parker RM, Williams MV, et al. The healthcare experience of patients with low literacy. Arch Fam Med 1996;5:329-334.

  4. Fact Sheet: Health Literacy and Understanding Medical Information.Lawrenceville, NJ: Center for Health Care Strategies; 2002.

  5. Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients' knowledge of their chronic disease: a study of patients with hypertension or diabetes. Arch Int Med. 1998;158(2):166-172.
  6. Williams MV, Baker DW, Honig EG, Lee TM, Nowlan A. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest. 1998;114(4):1008-1015.
  7. Weiss BD, Hart G, McGee D, D'Estelle S. Health status of illiterate adults: relation between literacy and health status among persons with low literacy skills Am Board Fam Pract. 1992;5:257-264.

  8. Baker DW, Parker RM, Williams MV, Clark WS, Nurss J. The relationship of patient reading ability to self-reported health and use of health services. Am J Public Health. 1997;87(6):1027-1030.
  9. AMA Foundation, 20.

  10. AMA Foundation, 25.


Virtual Mentor. 2003;5(6):222-224.



The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.