Can We Talk … about Health Literacy Strategies?

Chronic kidney disease (CKD) is a complex medical condition that requires multiple self-management strategies including the ability to understand, implement, and maintain clinical recommendations and self-care treatment strategies (1). Heart disease, diabetes mellitus, and nephropathies are among the top 10 causes of death, with rankings of 1, 7, and 9, respectively (2). CKD affects approximately 26 million American adults in the United States, whereas millions of others are at increased risk (3).

Understanding and managing CKD requires the ability to “obtain, process, understand, and communicate about health-related information needed to make informed health decisions” (4). Low health literacy is associated with poor management of chronic illness and has a negative impact on an individual’s ability to optimize his or her health outcomes (5). Although reports from national data in 2010 showed that in the United States, nearly nine out of 10 adults were below the proficient level in health literacy, and more than 75 million adults had basic or below basic health literacy (6), the health literacy burden should not be placed solely on the individual. Enhancing health literacy must be a collaborative partnership between the health care professional, who provides information and care, the individual receiving care and information, and the health care system.

Enhancing health literacy and person-centered care

Addressing health literacy is a cross-cutting priority that is vital to providing safe, effective, person-centered care. Each member of the health care team must participate in spearheading the implementation of health literacy strategies into practice, with the ultimate goal of advancing health through the delivery of safe, high-quality health care. In an effort to lessen the complex demands that are currently being placed on persons managing chronic disease, health literacy efforts require changes in both organizational and professional practices.

In 2012, the Institute of Medicine published 10 attributes that can assist organizations in creating an environment that enables and empowers all health care consumers to access and benefit from their health care services (7).

The attributes of “health-literate organizations” begin with leadership setting the health literacy mission and vision, preparing the workforce to be health literate in an effort to meet the needs of all populations being served, and including members of the community in the planning and evaluating of health services. Health literacy strategies are integrated throughout all communications, including the assessment of patient understanding. Best practices are implemented and fully integrated throughout the organization to enhance culturally and linguistically appropriate communication and ultimately patient safety. To foster sustainability, organizations can develop patient education and health literacy committees that promote, sustain, and advance an environment that supports principles of equity, diversity, and health literacy (8). A health-literate organization creates a culture and expectation that requires all professionals to engage in the promotion of health-literate strategies and that ultimately prioritizes health literacy as a core organizational value (7).

Health care professionals have many responsibilities across an organization and therefore have a vital role in enhancing health literacy and the delivery of safe, effective, person-centered care. The culture of a health-literate organization fosters the use by all professionals of a “universal precautions approach” to health literacy rather than assuming an individual’s health literacy level. This approach will enable all persons to easily access, navigate, and use information and health care services.

Some specific strategies for enhancing health literacy

  • Always ask at the initial point of contact about a patient’s preferred language to discuss health care, and obtain appropriate interpretation services when necessary.
  • Begin where the patient is by asking what the patient already knows about his or her chronic disease. This approach may also help identify opportunities to enhance self-management skills.
  • Learn about and always use “plain language” in each patient–provider interaction to promote clear communication.
  • Incorporate the use of “teach-back” or “show-me” to ascertain understanding.
    • The use of teach-back should not be a question-and-answer session or quiz for the patient, but rather an opportunity to assess how well the professional did in explaining information using everyday language.
    • Teach-back also assists in identifying areas that require reinforcement or areas where barriers to learning may exist.
  • Review and reinforce key action steps numerous times, possibly in several different ways, to foster learning.
  • Summarize action steps, and end with “What questions do you have for me?” to provide a comfortable, shame-free environment. Phrasing the question in this fashion implies that you encourage and even expect questions and helps empower the patient to ask them when necessary.

Health literacy efforts must focus on enhancing communication and health maintenance skills so that patients can make informed health-related decisions and enhance adherence to their medical regimens (9). This is an important focus for patients managing chronic disease, where the aim is to improve overall adherence to medication and treatment regimens and ultimately enhance lifestyle behaviors. Health care professionals and health care organizations that prioritize health literacy as an essential component of care will provide person-centered care that will enhance patient safety, patient satisfaction, and ultimately patient outcomes.



Dageforde LA, Cavanaugh KL. Health literacy: emerging evidence and applications in kidney disease care. Adv Chronic Kidney Dis 2013; 20:311–319.


Elliott RW. Educating older adults with chronic kidney disease. Nephrol Nurs J 2014; 41:522–525.


The National Kidney Foundation. About chronic kidney disease.


Berkman ND, Davis TC, McCormack L. Health literacy: what is it? J Health Comm 2010; 15(Suppl 2):9–19.


Edwards M, et al. The development of health literacy in patients with a long-term health condition: the health literacy pathway model. BMC Public Health2012; Feb 14:130.


U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics. 2003 National Assessment of Adult Literacy (NAAL). 2010.


Brach C, et al. Attributes of a health literate organization. Institute of Medicine Discussion Paper. Washington, DC, National Academies Press, 2012.


Parnell TA, et al. Health literacy as an essential component to achieving excellent patient outcomes. Institute of Medicine Discussion Paper. Washington, DC, National Academies Press, 2014.


Freedman DA, et al. Public health literacy defined. Am J Prev Med 2009; 36:446–450.