Health Literacy Tools and Resources

photo“Nurses at a large maximum security prison are teaching patients about sexually transmitted diseases. While the inmates await their chronic care appointment in the clinic holding area, they are given written material printed from the Centers for Disease Control website. During the nurse portion of the chronic care visit, each inmate is asked if they received the material and if they have any questions. If they have no questions, the nurse documents successful patient teaching on the topic in the medical record.”

This example (page 11) from the Essentials of Correctional Nursing invites us to think about the situation and to “Describe flaws in this process and suggest improvements in the teaching method.”  Last week’s post pointed out that at least 36% of the population have limited health literacy. The following are “best practices” to improve health communication. How many would apply to the case example above?

Identify the audience and focus the message: Our ability to understand and act upon communication is effected by the factors listed below:

  • age
  •  gender
  •  race
  •  ethnicity
  •  religion
  •  sexual orientation
  •  economic experience
  •  language
  •  communication ability
  •  occupation
  •  life experiences
  •  attitudes
  •  behavior
  •  social experiences


  •  cultural experiences
  •  beliefs

Communication of health information will be more relevant if it is sensitive to the characteristics of the intended audience. For example, would youth at a detention facility prefer to receive information about basic oral hygiene via a cartoon with rap music or in a film of a dentist in an office setting brushing a large set of false teeth? These options and many more are available for free on Youtube, just type in the search term, oral hygiene. The more the information and it’s delivery can be tailored to the preferences of the audience the more successful the communication will be.

Best Practices for Oral Communication: The problem with verbal information is that patients only retain about half of what they are told and they are uncomfortable asking to have information repeated.  To increase patients’ retention the following are considered “best practices”:

  • speak slowly and keep the message simple
  • limit the amount of advice to no more than 4 points
  • cover the most important point first
  • advice should focus on patient behavior that is the most important to a good outcome
  • organize information logically with the simplest coming before more complicated information
  • give concrete, specific and vivid instructions; avoid abstract or general statements
  • use active rather than passive voice
  • use plain language and a thesaurus to avoid medical terminology or jargon

Best Practices for Print Communication: Patients prefer to have pictures or graphics accompany written information. Pictures also improve comprehension.  Printed material should not replace personal interaction and is most effective when it reinforces verbal information. Patients prefer information presented with simple visuals especially when ill or adjusting to a new diagnosis. The following are “best practices” for print communications:

  • the most important point should appear first
  • use 12 point font, limit sentences or lines to 40-50 characters.
  • use headings and bullets to break up text
  • avoid using all capital letters (this is akin to shouting), italics or fancy script
  • use a lot of white space in the margins, between points and to separate paragraphs or ideas
  • avoid decoration; all print material should be specifically relevant to the point being made
  • pictures are encouraged when the picture
    is linked to the text
    is concrete, not complex
    supports key points
    is without unnecessary detail

Evaluate the Patient’s Understanding of the Message: Don’t assume that the patient understands if they don’t ask any questions.  In fact asking patients to restate what they have been told is among the top patient safety practices recommended by the Agency for Healthcare Research and Quality in their 2001 report.  This technique, referred to as “teach-back”, improves retention and allows the nurse to correct misunderstandings.  The following are tips on how to evaluate patient comprehension:

  • Ask open ended questions. In the example above it would be better if the nurses asked “What questions do you have about sexually transmitted diseases?” rather than “Do you have any questions about STDs”
  • Questions that start with “what” or “how” are more likely to be open ended.
  • Ask the patient to tell you in their own words what they understand. One way to do this is to say “I want to make sure I didn’t leave anything out so would you please tell me in your own words what we have discussed” or “What will you tell your (family member) about your condition?”
  • Present the patient with a problem or scenario to see if the patient can apply the information. The nurse might ask the patient receiving STD education “What should you do if you experience pain and burning upon …”
  • If the patient is unclear about one of the points, re-phrase the information rather than repeat it.

The flaws in the example at the beginning of this post are:

  • the material provided does not appear to have been selected with a specific audience in mind
  • printed material was used in lieu of oral communication
  • there was no evaluation of the patient’s understanding of the information given

Here are some tools and resources to address health literacy:

1. Clear Language and Design evaluate readability, examples, online Thesaurus

2. Plain language thesaurus

3. More on Plain Language

4. Creating easy to understand materials

5. Clear & Simple: Developing Effective Print Materials

6. Health Literacy Tools

7. Gateway to Health Communication and Social Marketing

8. Health Communication, Health Literacy, and e-Health

What resources have you found particularly helpful in addressing the care of patients with low health literacy? Please tell about your experience, success and resources addressing health literacy in the correctional population by responding in the comments section of this post.

To read more about correctional nursing practice order your copy of the Essentials of Correctional Nursing directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

Photo Credit: Catherine Knox 2/28/2013

Assessing Health Literacy in Correctional Health Care

Doctor gives the patient a prescription or referralAmong the characteristics of the incarcerated population described in Chapter 1 of the Essentials of Correctional Nursing the following are also associated with low health literacy:

  • Lower educational attainment than the general community
  • Disproportionate representation of African Americans and Hispanics
  • A growing number of elderly inmates.

Thirty-six percent of all adults in the United States have limited health literacy (Agency for Healthcare Research and Quality, March 2011). Persons who have not completed high school, live in poverty, did not speak English before starting school, are a racial minority or are elderly are also more likely to have limited health literacy.  Difficulty reading and comprehending can be embarrassing and stigmatizing for patients who have compensated for their problem over time with a number of coping strategies.  Often patients considered noncompliant with care are instead not sufficiently health literate to carry out the plan. Finally health care clinicians routinely overestimate the ability of patients to understand medical information (Cornett, 2009).

Limited Health Literacy is Associated with Poor Health

People with low health literacy are more likely to report their health as poor. They make less use of preventive services and have higher rates of hospitalization and use of emergency services. Persons with low literacy are more likely to have chronic conditions (high blood pressure, diabetes, asthma, and HIV) and are less likely to manage the condition effectively.  Patients with limited health literacy are sicker when they access the health care system (AHRQ 2011, Institute of Medicine, 2004).  Interventions to improve comprehension and increase self- management behavior reduced hospitalizations and emergency room visits and increased use of preventive health screening (AHRQ 2011).

What is Health Literacy?

Many times health literacy is assumed to be the same as reading and comprehension skills. Health literacy actually includes in addition to reading and comprehension, the ability to understand numbers and calculations and to act on health information.  Healthy People 2010 defined health literacy as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (United States Department of Health and Human Services, 2000).  Just to get a sense of what is involved in health literacy take the Newest Vital Sign a screening test developed by the Pfizer Clear Health Communication Initiative.  The tool uses a food label to screen for health literacy and it only takes about three minutes to administer. It is a good exercise in understanding what patients need to be able to do to be health literate.

Clues that a Patient May Have Low Health Literacy

Patients are often embarrassed about low literacy and will not readily admit to needing help. Others may not even be aware of deficient in health knowledge and skill. The following behaviors may be a clue that a patient is having trouble understanding health care information or instructions:

  • Making an excuse when asked to read or fill out paperwork such as “I don’t have my glasses.”
  • Checking no on a health history to avoid follow up questions.
  • Missing appointments or making errors in medication dosing.
  • Irritability, nervousness, confusion, or indifference during health care encounters.
  • Identifying medications by color, size or shape rather than name and purpose.
  • Following directions literally.
  • Holding written material closer to read, lack of visual focus on reading material, using a finger to point at the words.

This list isn’t to suggest that when someone displays these behaviors that the nurse should conclude that the patient has low health literacy but instead to adjust approach, consider asking a follow up question or offer to assist in a non-judgmental manner.

What resources have you found particularly helpful in addressing the care of patients with low health literacy? Please tell about your experience, success and resources addressing health literacy in the correctional population by responding in the comments section of this post.

To read more about how to assess and address health literacy order your copy of the Essentials of Correctional Nursing directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.


Cornett, S. (September 1, 2009). Assessing and addressing health literacy. Online Journal of Issues in Nursing, 14 (3)

Berkman ND, et. al. (March 2011). Health Literacy Interventions and Outcomes: An Updated Systematic Review. Evidence Report/Technology Assesment No. 199. (Prepared by RTI International–University of North Carolina Evidence-based Practice Center under contract No. 290-2007-10056-I. AHRQ Publication Number 11-E006. Rockville, MD. Agency for Healthcare Research and Quality.

National Research Council. (2004). Health Literacy: A Prescription to End Confusion. Washington, DC: The National Academies Press.

United States Department of Health and Human Services. (2000) Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington DE: US Government Printing Office. Accessed 2/17/2013 at


Photo Credit: © Alexander Raths

Cultural Competency

CULTURE. Wordcloud illustration.Inclusion of a patient’s cultural preferences into the plan of care when at the same time the correctional setting demands that we be “firm, fair and consistent” in all our interactions with offenders is a distinguishing feature of correctional nursing. Weiskopf describes this feature as nurses negotiating the boundaries between custody and caring (2005).  Incorporating the patient’s cultural preferences into nursing care has been part of the ANA’s Corrections Nursing: Scope and Standards of Practice since the first edition in 1995 (2007, pg. 74).

Failure to address ethnicity, culture and language has been found to exacerbate health disparities and lower health care quality according to a recent Cochrane Review (Horvath 2011). Cultural and racial minorities are disproportionately represented in the corrections population. The health needs of these groups are discussed at length in the Essentials of Correctional Nursing.  In correctional settings inmates do not get to choose their health care provider and likewise nurses cannot pick their patients, therefore it is inevitable that challenges, misunderstandings and conflict resulting from diverse cultures will occur.

Cultural competence is the ability to effectively provide nursing care to patients from different cultures. Take moment to think about your experiences addressing patients’ cultural preferences when providing nursing care in the correctional setting. What successes would you like to share? Please write us in the comments section of this post?  The paragraphs below describe how to build cultural competency.

Self-Awareness: First we must become aware of how our own views may differ from others.  Mark Fleming, PhD., with the Missouri Department of Corrections, described this as “being willing to take a step on a journey of transformation…” in a recent interview with Lorry Schoenly at  A starting place for this journey is to assess our cultural competence. One great resource was specifically developed for primary health care providers and can be accessed at

Communication: As we experience more diversity, the potential for conflict and misunderstanding increases and the ability to communicate effectively becomes even more important (Pearson, 2007). Effective patient-centered communication is characterized by:

  • an absence of assumptions
  • use of open-ended questions
  • active listening
  • expression of empathy
  • non judgmental words and behavior

What are the tools within the organization that support diversity? How do policies, procedures and clinical protocols support cultural differences and preferences for care?  Are qualified interpreters available for communication with patients?  Have staff been taught how to conduct an effective patient encounter when using an interpreter?  Are patient information materials culturally relevant? Communication tools that support culturally sensitive healthcare delivery can be accessed at

Knowledge: Cultural competence is a dynamic rather than static process so one class in cultural diversity isn’t enough.  Understanding how illness is experienced by different cultural groups enables nurses to better tailor care for individual patients.  We may be able to leverage help from the ethnic and cultural resources at our facility and within the community to deliver health care that is more relevant and effective with particular patients. These resources may also be able to provide meaningful emotional and social support for the patient.    A free online course in culturally competent care specifically developed for nurses is available at and offers 9 CE credits.

Summary:  My favorite tool is a list of 37 concrete things that demonstrate cultural competency in providing primary health care services. The list can be posted in the clinical area as a handy reference. It also can be used to compare against actual practice and then to build an improvement plan. This resource may be obtained at   Read more about the cultural diversity and related health care needs of our patient population in the Essentials of Correctional Nursing.  Order your copy of the book directly from the publisher and use promotional code AF1209 for $15 off and free shipping at


American Nurses Association. (2007). Corrections Nursing: Scope & Standards of Practice. Silver Spring, MD: American Nurses Association.

Horvath, L. (2011) Cultural competence education for health professionals. Cochrane Database of Systematic Reviews, (10)

Pearson, A. (2007). Systematic review on embracing cultural diversity for developing and sustaining a healthy work environment in healthcare. International Journal of Evidence Based Healthcare. (5), 54-91.

Registered Nurses’ Association of Ontario (2007). Embracing Cultural Diversity in Health Care: Developing Cultural Competence. Toronto, Canada

Weiskopf, C. S. (2005). Nurses experience of caring for inmate-patients. Journal of Advanced Nursing, 49, 336-343.

Photo Credit: © Login –