Mary Beth Nierengarten, PhD

Of the many socioeconomic factors that predict health outcomes, health literacy may not be as well recognized as other factors such as race/ethnicity, education level, employment, and income. Yet data suggest that health literacy may be a stronger predictor than all of these factors. Such data highlight the influence of poor health literacy on health outcomes, including increased mortality, lower patient satisfaction with care, lower quality of care, worse patient safety, higher health care costs, and overuse of emergency department.

“Health literacy skills are a social determinant of health, and strong skills mitigate health problems and risks,” said Andrea Green, MD, Associate Professor of Pediatrics and Director of the Pediatric New American Clinic, University of Vermont, Burlington.

Defining health literacy as “the ability of people to get health information, understand it, and use it to make better decisions concerning their health,” Dr. Green emphasized the need for practitioners to recognize, identify, and improve health literacy in their patients and caregivers during a presentation she gave at the recent American Academy of Pediatrics (AAP) meeting. As reflected in the title of her presentation, “Strategies to Improve Health Literacy for Diverse and Underserved Populations,” she spoke on the needs and challenges to improving health literacy in diverse and underserved populations while emphasizing that the scope of the problem extends to all populations. It is estimated that nearly one-half, or 90 million adult Americans, have difficulty understanding and acting on health information, she said.

As such, clinicians need to be aware that health illiteracy is a common problem that reaches into all socioeconomic and educational levels of society. However, its reach into diverse and underserved communities, such as immigrant and ethnic communities, can be particularly challenging given the extra burden of cultural and language barriers.

The information provided by Dr. Green for pediatricians in her AAP presentation can be adapted for use by obstetric providers to ensure that women during and after pregnancy are receiving and understanding the information they need to avoid serious complications that if unrecognized and untreated could lead to severe maternal morbidity and even mortality. In addition, improving health literacy for women during the postpartum period can help them transition into parenting.

According to Sharon T. Phelan, MD, Professor of Obstetrics and Gynecology, University of New Mexico, Albuquerque, many women do not understand the warning signs that may indicate a serious condition during the later stages of their pregnancy or in the first few weeks postpartum. Women need to be educated about symptoms that may indicate conditions such as appendicitis, sepsis, postpartum cardiomyopathy, delayed preeclampsia, and postpartum depression. This is especially important in the first few weeks postpartum when women may attribute potential symptoms of one of these conditions to normal fatigue brought on by the exhaustion of caring for a newborn.

“Given the increase in health literacy issues, obstetric providers need to reassess their routine postpartum period evaluations,” said Dr. Phelan. “Whether this involves postpartum visits at 2 weeks, home visits or office calls at 1 week, or some other approach, obstetric providers need to facilitate this contact.”

In addition, she said, “obstetric providers need to evaluate the resources that women have after clinic hours and on the weekend to get questions answered and to be seen if they have a complaint or concern, especially one of the warning signs we give them.”

Acknowledging that screening patients and/or their caregivers for health literacy may be uncomfortable for providers as well as patients, Dr. Green encouraged clinicians to practice what she called universal health literacy precautions. “Just as we wash our hands before and after every patient visit to protect all patients from communicable diseases, health care professionals should seek to promote better understanding for all patients, not just those we think need extra assistance,” she said.

This means identifying patients, and importantly, their caregivers who have difficulty understanding the medical information and instructions imparted to them in the clinic. For obstetric providers, it is critical to ensure that women and their families understand the symptoms that may emerge, particularly late in a pregnancy and in the few weeks after, that may indicate a serious condition that needs early diagnosis and treatment.

To this end, Dr. Green described a number of “red flags” that may indicate a patient and/or caregiver has poor health literacy: frequently missed appointments, incomplete registration forms, non-compliance with medications, inability to name medications or explain their purpose or dosing, identifying pills by looking at them versus reading the label, inability to give coherent history, asks fewer questions, and doesn’t follow through on tests or referrals.

To assess health literacy in patients and/or caregivers, Dr. Green provided a list of standardized screening tests that can be employed (Table 1).

For providers who prefer a simpler screening approach, she cited evidence showing the effectiveness of asking three simple questions to identify health literacy (Table 2).

In talking about strategies to improve health literacy, Dr. Green focused primarily on interventions that clinicians can employ in the clinic to improve patient and caregiver health literacy. However, she emphasized the importance of strategies that also need to be employed at the healthcare system level and at the community level to fully address the challenges of health illiteracy.

“Regardless of where interventions take place, however, interventions need to address language barriers, cultural barriers, and low health literacy simultaneously,” she said. 

Critical to bridging these barriers is ensuring that clinicians communicate medical information in a clear and straightforward way. Dr. Green highlighted three basic ways to make communication clearer: 1) use of plain language that employs concrete familiar words and short sentences to describe a medical issue instead of using standard medical terminology; 2) use of analogies and images to communicate complex topics; and 3) asking open-ended questions that can help the clinician determine the patient’s level of understanding. (

For more information on plain language materials and resources from the Centers for Disease Control and Prevention [CDC]

Along with paying attention to the language used to talk to patients, Dr. Green also highlighted several key ways to improve the effectiveness of communication in healthcare settings. One way is to use the Teach-Back method. In this method, clinicians ask patients to restate information or instructions given to ensure that they understand and remember it. This method also allows clinicians to assess what a patient’s perception is about information provided to them. “The health care provider should ask patients to repeat in their own words what they need to know or do, in a non-shaming way,” said Dr. Green. “This may be tricky, and a small dose of humility goes a long way.” (

For more information on this method, see Teach-back! Training toolkit)

One way of assessing whether a patient has understood and remembered the information discussed in the clinic is to employ a program designed by the National Patient Safety Foundation called “

” that encourages patients to know 3 things before they leave the clinical visit (Table 3).

A second strategy that Dr. Green emphasized as important, particularly as it pertains to immigrants as well as people born in America with limited proficiency in the English language, is the use of interpreters.

Although she emphasized that federal law mandates that interpreter services be rendered for any patient with limited English proficiency, she said that many health care providers remain unaware that they need to provide an interpreter for these patients and that reimbursement for these services often is lacking.

Data show, however, that use of trained interpreters is associated with improved outcomes, including patient satisfaction, appropriate use of resources, and reduction in liability.

Dr. Green encouraged clinicians to use trained medical interpreters, either in the clinic or remotely (via teleconference), and emphasized that interpreters with more extensive training (> 100 hours) make far fewer errors of clinical significance than those with less training or those without specific medical training.

She provided a number of tips for working with interpreters in the clinic (Table 4), as well as resource sites for translated written material to hand out to patients (Table 5).

Health literacy is critical for good health. Despite this, many patients do not understand basic medical information and instructions. Such health illiteracy is widespread across all populations, but has the extra burden of language and cultural barriers in diverse and underserved populations. Clinicians can help improve the health literacy of their patients/caregivers by intervening with some simple but effective measures that focus on delivering medical information in a clear and simple way and ensuring the information is understood by the patient/caregiver. Including an interpreter to help bridge language and cultural barriers in patients who are not proficient in English is essential to address health illiteracy in diverse and underserved populations.

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