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Health Literacy Resource Guide

September 11, 2019

In It Together

This guide provides a curated overview of health literacy resources, organizational assessments, client assessments, and toolkits that your HIV program can use to begin or enhance efforts to provide services that meet the needs of clients with limited health literacy. The resources in this guide can be adapted to a variety of health care settings.

Target audience

This resource guide can be used by Ryan White HIV/AIDS Program recipients and subrecipients, as well as other HIV service providers, to inform efforts to meet the needs of clients with limited health literacy. It may be particularly useful to your organization’s leadership and health literacy teams.

Why are health literate services important?

Health literate service provision increases patient activation and engagement, leading to improved health outcomes.  

Improving clients’ health literacy requires the engagement of staff across all levels of your organization. You may want to start a health literacy work group that includes leadership, clinical staff, non-clinical service providers, and clients with limited health literacy.

The Health Literacy Resource Guide

  1. Relationship Between Health Literacy and Culture: Resources in this section focus on the relationship between cultural competency and health literacy and provide information that health care organizations can use to improve their cultural competence.
  2. Organizational Frameworks for Providing Health Literate Services: This section describes overarching care models that health care organizations can use to incorporate health literate practices into all aspects of planning and operations.
  3. Organizational Assessments and Toolkits: This section contains comprehensive toolkits and assessments designed to look at health care organizations’ current communication environments, suggest improvements to organizational practices, and plan for implementation of those improvements. 
  4. Materials Improvement Tools: This section contains tools to help organizations create written materials for print and online media that meet the communication needs of clients of all health literacy levels. These tools focus on how to involve consumers when developing and testing materials, which is in an integral step in creating materials for clients. 
  5. Strategies to Improve Communication: This section contains evidence-based verbal communication strategies that health care providers can use in their interactions with clients to ensure that clients are able to obtain, process, and understand the basic health information they need to make appropriate health decisions.
  6. Further Reading and Training: This section contains health literacy data and findings that can help health care organizations justify investments in health literacy. This section also contains information about local health literacy initiatives.

Resources in this section focus on the relationship between cultural competency and health literacy and provide information that health care organizations can use to improve their cultural competence.

National Culturally and Linguistically Appropriate Services (CLAS) Standards

U.S. Department of Health and Human Services, Office of Minority Health

The CLAS Standards help organizations address the cultural and language differences that exist between the people who provide information and services and the people they serve. The CLAS Standards aim to improve health care quality and advance health equity by establishing a standard framework. The principal standard is to provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.

Culture, Language, and Health Literacy

U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA)

This page links to resources that health care organizations can use to recognize and address the unique culture, language, and health literacy of diverse consumers and communities. Resources are provided for the following topics:

  • General
  • Race/Ethnicity
  • Age
  • Gender
  • Special populations

Cultural Competency and Health Literacy Primer

Minority Health and Health Disparities, Maryland Department of Health and Mental Hygiene and University of Maryland School of Public Health

This primer helps health care organizations reduce health disparities and improve health outcomes through culturally-sensitive and effective communication with clients. The guide includes teaching tools to improve cross-cultural communication skills, deliver culturally and linguistically appropriate health care services to diverse populations, and develop programs and policies that support health literacy and culturally appropriate service delivery. Module topics include:

  • Health disparities
  • Community strategies
  • Bias and stereotyping
  • Effective communication skills
  • Use of interpreters
  • Self-reflection and culture of health professions

This section describes overarching care models that health care organizations can use to incorporate health literate practices into all aspects of planning and operations.

Health Literate Care Model

U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion

The Health Literate Care Model helps health care organizations infuse health literacy into all aspects of planning and operations. In order for health outcomes to improve, clients must be fully engaged in prevention, decision making, and self-management. The Health Literate Care Model weaves health literacy principles into the widely adopted Chronic Care Model and calls for health care providers to:

  • Approach all patients as if they are at risk of not understanding health information.
  • Employ a range of strategies for clear communication.
  • Confirm patients’ understanding.

When a health care organization adopts the model, health literacy becomes an organizational value infused into all aspects of planning and operations, including self-management support, delivery system design, shared decision-making support, clinical information systems to track and plan patient care, and community resources navigation assistance. The model is based on the Universal Precautions Approach to Health Literacy.

Attributes of a Health Literate Organization

Institute of Medicine (IOM)

The Ten Attributes of Health Literate Organizations are intended to guide health care organizations to ensure that all patients receive the greatest benefit possible from health care information and services. Organizations that aspire to embody these 10 attributes may use different strategies to assess and work towards health literate service provision, such as hiring diverse staff, securing language assistance for non-English speaking individuals, and allocating the fiscal and human resources necessary to support the development of a health literate organization.

View the attributes and strategies to support implementation

This section contains comprehensive toolkits and assessments designed to look at health care organizations’ current communication environments, suggest improvements to organizational practices, and plan for implementation of those improvements.

Making Health Literacy Real: The Beginnings of My Organization's Plan for Action

Centers for Disease Control and Prevention (CDC)

This easy-to-use template helps your organization get started in developing a plan to change organizational and professional practices to improve health literacy. Templates topics include:

  • Identifying internal and external health literacy advocates
  • Strategies to get buy-in
  • Commitment to planning
  • Opportunities for health literacy improvement
  • Developing an action plan
  • Next steps

The template also provides links to additional planning resources.

Universal Precautions Toolkit

Agency for Healthcare Research and Quality (AHRQ)

This toolkit provides step-by-step guidance and tools that health care organizations can use to assess their programs and practices and make improvements to provide quality care to clients of all literacy levels. The toolkit can help organizations reduce the complexity of health care, increase clients’ understanding of health information, and enhance client supports. While the toolkit is useful for all healthcare organizations, primary care practices may find it of particular value.

The toolkit contains tools to help organizations:

  • Improve spoken communication
  • Improve written communication
  • Improve self-management and empowerment
  • Improve support systems

The Health Literacy Environment of Hospitals and Health Centers

Harvard School of Public Health

This guide leads an organization through assessment, interpretation, and improvement of its health literacy environment. The guide and associated review tools offer an approach for analyzing literacy-related barriers to health care access and navigation. The Health Literacy Environment Review enables health care organizations to rate the following aspects of service provision:

  • Navigation
  • Print communication
  • Oral exchange
  • Technology
  • Policies and protocols

The guide also provides suggestions for interpreting findings that your organization can use to prioritize next steps for an institutional health literacy initiative. The appendices show examples of partnerships between health care facilities and community-based organizations, with activities to help prepare for the review. These activities will enable members of your team to identify existing literacy‐related strengths and limitations, and set the foundation for further analyses.

Enliven Organisational Health Literacy Self-Assessment Resource

Enliven Victoria (New Zealand)

This self-assessment resource is designed for use by health and social service organizations to assess and guide their health literacy activities. The resource provides a detailed explanation of how each of the IOM’s Ten Attributes of Health Literate Organizations can be operationalized, including a checklist assessment for each attribute. The checklist helps organizations know how they embody the tenets of health literacy and how they can improve. 

Organizational Communication Climate Assessment Toolkit (C-CAT)

American Medical Association (AMA)

This toolkit contains validated performance metrics designed to help a health care organization to determine whether it meets the communication needs of its clients. Organizations who use the C-CAT work with AMA-trained consultants to help them assess how effectively they communicate, which enables them to target resources for improvement exactly where they are needed. Nine areas are assessed:

  1. Leadership commitment
  2. Information collection
  3. Community engagement
  4. Workforce development
  5. Individual engagement
  6. Socio-cultural context
  7. Language services
  8. Health literacy
  9. Performance evaluation.

The assessment metrics have been validated in hospitals and clinics nationwide; seven of the nine reported C-CAT measures have been endorsed by the National Quality Forum (NQF).

Pharmacy Health Literacy Assessment Tool

Agency for Healthcare Research and Quality (AHRQ)

This assessment tool was designed for outpatient pharmacies of large, urban, public hospitals that primarily serve racial and ethnic minority populations, but can be adapted for use in other pharmacy and non-pharmacy environments. The assessment tool includes general questions for an assessment of the pharmacy's health literacy, a survey of staff, and patient focus groups, as well as administration instructions for each. The tool also provides guidance on how to use the results of the assessment. 

Joint Commission Roadmap for Hospitals

The Joint Commission

This roadmap inspires hospitals to integrate concepts from the communication, cultural competence, and patient- and family-centered care fields into their organizations. It highlights issues to address, provides example practices, and gives “how to” information to help hospitals meet their patients’ needs. The roadmap is structured around the main points in the health care continuum (admission, assessment, treatment, end-of-life care, discharge and transfer, and organizational readiness). The roadmap also includes checklists to assess communication and cultural competence.

Building Health Literate Organizations: A Guidebook to Achieving Organizational Change

Unity Point

This guidebook includes background information, resources, examples, and lessons learned to help you build a health literate health care organization. The guidebook contains chapters and a case study on key health literacy development areas that intersect with the attributes of health literate health care organizations:

  • Engaging leadership
  • Preparing the workforce
  • The care environment
  • Involving populations served
  • Verbal communication
  • Reader-friendly materials

The guidebook sections are intended to stand alone so that you can focus on improving on the areas that will be of greatest value to your organization.

This section contains tools to help organizations create written materials for print and online media that meet the communication needs of clients of all health literacy levels. These tools focus on how to involve consumers when developing and testing materials, which is an integral step in creating materials for clients.

Toolkit for Making Written Material Clear and Effective

Centers for Medicare and Medicaid Services (CMS)

This health literacy toolkit provides a detailed and comprehensive set of tools to help your organization make written material easier for clients to read, understand, and use. The toolkit explains how organizations can take a reader-centered approach to materials development and testing. The toolkit provides guidelines for the content, organization, style, visual design, and formatting of printed material, as well as culturally appropriate translation. The toolkit also provides information about testing written materials with clients.

This toolkit is intended to meet the needs of CMS audiences and to be used by the people who serve or assist them, such as outreach workers, agency staff, community organizations, care providers, family, and friends.

Clear Communication Index

Centers for Disease Control and Prevention (CDC)

The CDC Clear Communication Index is a tool to help you develop and assess communication materials. The index has 4 introductory questions and 20 scored items. The scored items represent the most important characteristics that aid and enhance people's understanding of information. The four parts of the index assess a material’s:

  1. Main message, language, visuals, and layout
  2. Behavioral recommendations
  3. Use and explanation of numbers
  4. Discussions of risks and probabilities

Each part is scored separately, with a final composite score at the end. The composite score also provides a list of areas in which your material could be improved in order to better serve people with limited health literacy.

Health Literacy Online: A Guide for Simplifying the User Experience

U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion (ODPHP)

This research-based guide will help you develop intuitive health websites and digital tools that can be easily accessed and understood by all users, including the millions of people with limited e-health literacy. The guide discusses why and how to design health websites and other digital health information tools so that they are accessible to all audiences. This guide instructs users to:

  • Prioritize the information needs and preferences of consumers
  • Involve end users as co-creators of web products
  • Design for viewing on a variety of devices (computers, tablets, phones, etc.)
  • Recognize that designing for limited-literacy users is designing for all users

The guide is intended to be used by anyone involved in creating online health content including writers and editors, content managers, digital strategists, user experience strategists, web designers, developers, and others.

This section contains evidence-based verbal communication strategies that health care providers can use in their interactions with clients to ensure that clients are able to obtain, process, and understand the basic health information they need to make appropriate health decisions.

Ask Me 3: Good Questions for Your Good Health

National Patient Safety Foundation

Ask Me 3®is an educational program that encourages clients and families to ask their providers three questions to better understand their health conditions and what they need to do to stay healthy, thereby helping clients to become more active members of their health care team. The questions include:

  1. What is my main problem?
  2. What do I need to do?
  3. Why is it important for me to do this?

The Ask Me 3 website contains:

  • Implementation Guide: Tips and strategies for implementing the Ask Me 3 concept and materials
  • Complementary Materials and Resources: Posters, flyers, and other educational promotional materials that are available for use, free of charge
  • Health Literacy Module: A 26-minute learning module that explains the importance of health literacy, helps providers identify potential at-risk populations and clients, and outlines best practices for improving patients’ understanding of health care information, as well as implementation guidance
  • Ask Me 3 Video: A video designed to promote Ask Me 3 among patients via internal closed-loop televisions. The video is available with both English and Spanish captions.

By promoting the Ask Me 3 program, health care organizations can improve client engagement, and foster an organizational culture of health literate, client-centered care.

Teach-back Method

The Teach-back Method is a research-based intervention that promotes adherence, quality, and patient safety. Teach-back is a way to ensure that health care providers have explained information clearly by asking a client (or family member) to explain in their own words what they need to know or do to keep themselves or their loved ones healthy. By doing so, the health care provider learns whether they need to re-explain the health information, or explain it differently. The Teach-back Toolkit contains:

  • An interactive, case-based Teach-back learning module enabling learners to identify and use key aspects of plain language and teach-back throughout the care continuum
  • Tips and tools to help managers and supervisors empower staff to always use teach-back

Universal Precautions Toolkit

Agency for Healthcare Research and Quality (AHRQ)

This toolkit provides step-by-step guidance and tools that health care organizations can use to assess their programs and practices and make improvements to provide quality care to clients of all literacy levels. The toolkit can help organizations reduce the complexity of health care, increase clients’ understanding of health information, and enhance client supports. While the toolkit is useful for all healthcare organizations, primary care practices may find it of particular value. The toolkit contains tools to help organizations:

  • Improve spoken communication
  • Improve written communication
  • Improve self-management and empowerment
  • Improve support systems

This section contains health literacy data and findings that can help health care organizations justify investments in health literacy. This section also contains information about local health literacy initiatives.

National Action Plan to Improve Health Literacy

Health and Human Services, Office of Disease Prevention and Health Promotion (ODPHP)

The National Action Plan to Improve Health Literacy seeks to engage organizations, professionals, policymakers, communities, individuals, and families to improve health literacy. The Action Plan is based on two core principles:

  1. All people have the right to health information that helps them make informed decisions.
  2. Health services should be delivered in ways that are easy to understand and that improve health, longevity, and quality of life.

The Action Plan contains seven goals that will improve health literacy and strategies health care organizations can use to achieve them.

Health Literacy Online Training Courses

Centers for Disease Control and Prevention (CDC)

CDC offers six online health literacy courses for health care professionals, with printable certificates of completion. These courses can help health care organizations increase staff awareness of the issue of health literacy and increase staff skills in providing quality care to all patients, regardless of the client’s health literacy skills. Courses include:

  • Health Literacy for Public Health Professionals
  • Writing for the Public
  • Speaking with the Public
  • Creating Easier to Understand Lists, Charts, and Graphs
  • Fundamentals of Communicating Health Risks
  • Using Numbers and Explaining Risk

State-Based Health Literacy Activities

This resource contains a list of health literacy activities taking place in each state. You can work with these organizations to learn more about health literacy or partner to improve your organization’s capacity to provide health literate services to your clients.

The Health Literacy of America's Adults: Results from the 2003 National Assessment of Adult Literacy

U.S. Department of Education, National Center for Education Statistics

This report summarizes results of an assessment of the health literacy status of American adults aged 16 and older. Results are reported according to four literacy performance levels—Below Basic, Basic, Intermediate, and Proficient, with examples of the types of health literacy tasks that adults at each level may be able to perform.

This report sheds light on the relationship between health literacy and other factors such as educational attainment, age, race/ethnicity, where adults get information about health issues, and health insurance coverage. It examines how health literacy is related to general literacy and numeracy. The report also provides information to help build effective policies and customized programs to address limited health literacy and guides the development of tailored health information.

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