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CE Article: Address health literacy by adopting patient-centered approaches*

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After reading this article, you will be able to:

  • Discuss tactics of the Health Literacy Collaborative (HLC) program aimed at enhancing health literacy
  • Identify techniques that can improve health literacy in patients and family members
  • List strategies to increase patient understanding of health information
  • Describe the state of health literacy in adult education

In 2003, staff members at Iowa Health System (IHS) identified poor health literacy as an ongoing issue and began developing a system that would "improve the health of the people and communities we serve," says Mary Ann Abrams, MD, MPH, health management consultant in the IHS Department of Clinical Performance Improvement. "Health information directed toward patients is often too technical for most to understand, regardless of educational background, reading level, or level of health literacy," Abrams says.

The HLC is a program designed to educate staff members about the importance of communicating health information clearly to patients and family members.

By developing the HLC, the hospital aimed to "create a patient- and family-centered environment fostering effective communication that enables individuals to read, understand, and act on healthcare information," says Abrams.

According to the U.S. Department of Education's 2003 National Assessment of Adult Literacy, 36% of the U.S. adult population has only basic or below basic health literacy levels. Read more about the state of health literacy in adult education.

In addition, even patients who have advanced literacy skills may have trouble reading and understanding complex, specialized medical terminology, especially if they are sick, faced with difficult choices, and/or elderly, according to "The Crucial Link between Literacy and Health," published in the November 18, 2003, Annals of Internal Medicine. Read about the skills patients need for health literacy.

Key points of the HLC address the idea of simplifying communication between healthcare providers, patients, and patients' families.

This includes:

  • Awareness, education, and training
  • Collaborative partnerships and patient involvement
  • Interpersonal and verbal communication
  • Reader-friendly print material

Three questions to understand

One of the programs that IHS is most proud of is the "Ask Me 3" technique.
"Ask Me 3 is a program designed to help promote shared information between healthcare providers and patients," says Robert Dickerson, MSHSA, RRT, performance improvement specialist at IHS.

Originally developed by the National Patient Safety Foundation's Partnership for Clear Health Communication, this program teaches staff members to encourage patients to ask their providers three essential questions to better understand their illness and any other concerns that may arise.

These questions are:

  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 questions can be found on posters strategically placed on the walls throughout IHS facilities.

"It was important that the staff embrace the program and not just look at it as a burden," says Dickerson. "The goal was interactive communication."

Months after the Ask Me 3 program was put in place, Dickerson received comments from the nursing staff relaying how the Ask Me 3 technique helped lay the foundation for communication—showing that IHS met its goal.

The "teach-back" technique is also used by IHS to address health literacy concerns and is the most popular technique among staff members, says Abrams.

Similar to Ask Me 3, the teach-back technique asks the patient to repeat back what the nurse said in his or her own words. This allows the nurse to assess the patient's understanding of the information and clarify anything that may be unclear.

In addition to these programs and techniques, IHS encourages staff to use new or revised (i.e., reader-friendly) materials with the patients and their families. This includes anything from admission and consent forms to disease education materials on diabetes and heart disease in accordance with the New Readers of Iowa—a group of people who learned to read as adults and who have come together to educate, advocate, share information, and promote public awareness on behalf of adult literacy.

IHS monitors ongoing feedback from the new and revised materials by training nurses to work with patients using the Ask Me 3 and teach-back techniques. Abrams also ensures that health literacy is discussed at staff meetings to promote awareness.

Health literacy growth and education

Helen Osborne, MEd, OTR/L, president of Health Literacy Consulting, founder of Health Literacy Month, and host of the podcast series Health Literacy Out Loud, says patients' understanding of their healthcare has grown in the past few decades out of necessity.

"First, patients and families are taking more responsibilities," says Osborne. "The burden is really falling on [patients], and they need to understand what to do. Second, appointments are getting shorter, hospitalizations are shorter, and people go home with more medications."

Additionally, many patients, especially those who are younger, assume that healthcare is something within their control and ask more questions, says Osborne. There is also a type of partnership forged when a wealth of information is shared between providers and patients, she says.

Health literacy has become a bigger issue today because of greater general awareness by professional organizations and agencies, Abrams says. Read about patient-centered efforts issued by The Joint Commission (formerly JCAHO) that raised health literacy awareness.

IHS is adapting to this trend by continuing the use of the teach-back technique to assess and ensure understanding, Abrams says. It is also focused on embracing an all-encompassing approach to health literacy.

"There needs to be a focus on skill building as health communication goes beyond the spoken word and written materials. It includes drawing pictures, telling stories, and using metaphors. My philosophy is to communicate in whatever ways work," says Osborne. "It takes a champion like Mary Ann Abrams to really make a systemic difference. You need high-level advocates to make sure health literacy becomes a part of everyday practice."

Future goals

With the success of the teach-back and Ask Me 3 techniques, IHS is looking to introduce more programs to help with health literacy.

"Our new aim is to improve quality and safety by fostering effective communication that enables all IHS patients to read, understand, and act on health information," says Abrams.

IHS' strategies include:

  • Reliable use of teach-back by nurses
  • Incorporation of reader-friendly principles into all newly developed written materials for patients and families
  • Creation of a patient- and family-centered environment that welcomes questions

By introducing these new strategies, Abrams hopes to see a 5% increase in IHS affiliate and composite HCAHPS scores for four health literacy-related domains—communication with nurses, communication with doctors, communication about medicines, and discharge information—by the end of this year.


  1. "Health Literacy." National Network of Libraries of Medicine. Accessed March 6, 2009. Available at
  2. "Facts about patient-centered communications." The Joint Commission. Accessed March 6, 2009. Available at
  3. "Health Literacy in Adult Education." U.S. Department of Education. Accessed March 6, 2009. Available at

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