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Culturally Effective Care Toolkit: Literacy and Health Literacy

Health literacy has been defined as "the degree to which individuals have the capacity to obtain, process and understand basic health information needed to make appropriate health decisions and services needed to prevent or treat illness" ( Patients with a low literacy level may have difficulty understanding verbal and written instructions, understanding and managing chronic diseases, completing medical history or insurance forms, accessing health care services, and understanding the importance and consequences of high-risk behavior. Studies have demonstrated an association between high literacy level and knowledge of the use of health services such as emergency department instructions, childhood health maintenance procedures, and informed consent. Additionally, researchers have identified a positive relationship between high literacy level and knowledge of asthma, HIV/AIDS, postoperative care, and others (

Assessment of Literacy Levels
To determine a patient’s or family’s health literacy level, providers can use one of many assessment tools. The severity or chronic nature of the patient’s clinical scenario are factors that modulate the emergent need for health literacy assessment and the long-term effect of literacy level on medication adherence, disease management, and ultimately, health outcomes. Because health literacy involves not just patients’ ability to read but also to understand messages relating to health and health care, providers should assess all patients’ health literacy levels to provide the best care. Pediatricians need to communicate with all patients and parents, but particularly those with low literacy, at a level they can understand. Specific communication techniques such as asking the parent to say in their own words what they understood and posing inviting questions to the family are encouraged.
Chapter 6 Tools and Resources

American Academy of Pediatrics. Abrams MA, Dreyer BP, eds. Elk Grove Village, IL: American Academy of Pediatrics; 2009
This book provides the framework for implementing a plain language approach to communication in your office and specific steps you can take to ensure the information you present to patients and their parents is clearly understood. Included are 25 reproducible plain language patient education handouts in English and Spanish. There is a charge to purchase this publication.
Continuing medical education (CME)-bearing opportunity features practical tips and checklists for practice operations, assessment, patient materials, and additional resources for practicing physicians.
Tool 6C: Health Literacy Assessment Tool: Rapid Estimate of Adult Literacy in Medicine (REALM)
The REALM is a medical-word recognition and pronunciation test for screening adult reading ability in medical settings. It can be administered and scored in less than 3 minutes by personnel with minimal training, making it easy to use in clinical settings. It is available in English only. There is a cost associated with administering this tool.
Tool 6D: Health Literacy Assessment Tool: Test of Functional Health Literacy in Adults (TOFHLA)
The TOFHLA includes a 17-item test of numerical ability and a 50-item test of reading comprehension. It takes up to 22 minutes to administer. It is available in English only. There is a cost associated with administering this tool.
Tool 6E: Health Literacy Screening Tool: Newest Vital Sign
This tool identifies patients at risk for low health literacy. The tool’s main advantages in the clinical setting are that it can be administered in 3 minutes, it is available in English and Spanish, and it can be ordered at no cost.
Online CME-bearing opportunity is designed to help providers improve communication with their patients.
Tool 6G: Rhode Island Health Literacy Project: Health Literacy Toolkit: Better Communication for Better Care
Toolkit includes tips and resources for providers to address health literacy in practice, as well as resources for patients.
Tool 6H: Children’s Health Fund: Health Education Materials
This Web site provides health education materials for low literacy patients and families. Materials are available in English and Spanish.
Resource 6A: Center for Health Care Strategies: What is Health Literacy? Fact Sheet
Fact sheet provides practical tips for assisting patients and families with low literacy.
Report provides an overview of health literacy.
This report describes several promising practices for implementing health literacy in primary care practices.

Doak CC, Doak LG, Root JH. 2nd ed. Philadelphia, PA: JB Lippincott Co; 1996
This book covers a wide range of topics, including educational theories, tests for literacy skills, assessments of the suitability of materials, as well as discussion and examples of understandable visuals.

The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. This content is for informational purposes only. It is not intended to constitute financial or legal advice. A financial advisor or attorney should be consulted if financial or legal advice is desired.
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