Universal Precautions for Health Literacy

This month, KN Editorial Board member and special section editor Glenda Payne interviewed Cindy Brach, MPP, lead for health literacy at the Agency Healthcare Research and Quality, about ways nephrology professionals can recognize issues in health literacy and more effectively bridge communication gaps.

Why the interest in health literacy, and why now? Current buzzwords such as “patient-centered,” “patient engagement,” and “improved experience of care” depend on clear communication. Miscommunication happens frequently, due to a mismatch in the health literacy of the members of the health care team (provider or patient). According to Richard Carmona, the former US Surgeon General, “Health literacy is the currency for success in everything we do in health, wellness, and prevention.” How can nephrology professionals recognize issues in health literacy and more effectively bridge communication gaps?

What is health literacy? How is this different from literacy or reading grade level?

Health literacy has traditionally been defined as an individual’s capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. A person’s health literacy depends on how complicated health information is, and how complex health-related tasks are. A national survey revealed that only 12% of adults in the United States are able to understand and use all the types of health information that are currently being distributed (1). Many people who read well have limited health literacy. They have difficulty understanding written medicine instructions, finding information in complex documents, and extracting information from graphs and charts. Additionally, health literacy includes the ability to verbally communicate—both listening and speaking, the ability to understand and use numbers, and the ability to navigate the health care system.

How can patients or families with limited health literacy be identified?

There is no evidence that identifying patients and families with limited health literacy is effective (2). Health literacy is dynamic. At one visit an individual may be able to absorb and follow up on health information; at another time the same individual may be tired, scared, or feeling sick and not be able to understand or act on information as easily.

Patients should, however, be asked about their literacy, and the health care team should be prepared to refer them to reading and math resources in the local community. The Agency for Healthcare Research and Quality (AHRQ) Health Literacy Universal Precautions Toolkit (Tool 20) describes the DIRECT approach to see whether patients would like to improve their reading skills (3).

What is meant by “universal precautions” for health literacy, and why is this recommended?

Health literacy universal precautions structure the delivery system as though everyone may have limited health literacy. It’s just like blood safety: where everyone’s blood is treated as if it could be infected. When an organization has implemented health literacy universal precautions, it becomes easier for patients and families to understand what to do to take care of their health, and easier for them to navigate the health system. Health literacy universal precautions include a wide range of activities, such as making way-finding signage clear, offering help with forms, reviewing written materials together, confirming understanding at multiple points in every encounter, making referrals easy, and proactively following up.

What patient benefits are possible if the health care team routinely uses educational techniques that recognize and address health literacy barriers?

When health care teams use techniques like encouraging questions and communicating clearly (e.g., using plain nonmedical language and visual aids, and limiting the amount of information provided at any one time), patients are more likely to become engaged in their health care. They’re likely to be less frustrated, feel that their health care team cares for them, and be able to make health care decisions collaboratively.

Are there potential benefits for the health care team if they deploy educational techniques that recognize and address health literacy barriers?

Absolutely. Health care providers often mistake misunderstanding for noncompliance and then resent patients’ failure to take responsibility for their health. If they use health literacy techniques, they should see patients become empowered and better able to manage their conditions. This may lead to fewer calls for clarification, fewer medicine errors, and quicker progress toward health goals.

Individuals with kidney failure are more likely to be older, to belong to a racial or ethnic minority, and to have lower socioeconomic status and lower educational levels. How would using techniques that recognize and address health literacy barriers make the care of patients with kidney failure more effective?

This is a population that is at high risk for limited health literacy. Using the teach-back method (see previous page) to confirm understanding is especially important. When health care professionals use this method, they ask patients to teach back information in their own words. If patients are unable to teach back, or simply parrot back what was said to them, the health care professional reteaches the information and checks again for comprehension. Using teach-back helps catch the misunderstandings before they create problems. An online course, Always Use Teach-back! Training Toolkit, is available for free (4).

Recently Nephrology News & Issues referenced an article by Dr. Veena Joshi in the World Journal of Nephrology. Joshi reviewed the scientific literature from 1990 to 2014 on quality of life in people with chronic kidney disease. His review found that most of what treatment teams typically focus on (e.g., laboratory results, Kt/V, electrolyte status, hemoglobin) was found to have “little or no association with quality of life.” Joshi found that self-efficacy, influence on dialysis care practice, treatment satisfaction, and different types of counseling and rehabilitation interventions had a positive association with quality of life. How could health literacy universal precautions potentially improve patients’ quality of life?

The demands on people with chronic kidney disease are great. They struggle to understand their disease, make lifestyle changes, choose from among treatment options, take their medicines, make and keep appointments, and handle insurance. Health care organizations that adopt health literacy universal precautions can potentially increase patients’ quality of life by reducing the demands on them and by providing more effective assistance in dealing with this chronic disease. In addition to the interpersonal techniques mentioned above (e.g., communicating clearly, encouraging questions, and confirming understanding), health care organizations can use these techniques:

  1. Design telephone systems so patients don’t get frustrated and hang up.
  2. Select and review with patients written materials that are easy to understand and act on, and make alternative audiovisual materials available.
  3. Follow up with patients proactively.
  4. Provide language assistance and be culturally competent.
  5. Reconcile medicines, check that patients and families know when and how much to take, and help them establish reminder systems.
  6. Refer patients to community resources.
  7. Help patients with insurance and medicine discounts.
  8. Secure referral appointments and exchange information directly.
  9. Get and respond to feedback from patients and families about what would make things better for them.



Kutner M, et al. The Health Literacy of America’s Adults: Results from the 2003 National Assessment of Adult Literacy. Washington, DC, National Center for Educational Statistics, 2006.


Paasche-Orlow MK, Wolf MS. Evidence does not support clinical screening of literacy. J Gen Intern Med 2008; 23:100–102.


Brega A, et al. AHRQ Health Literacy Universal Precautions Toolkit, 2nd Ed. Rockville, MD, Agency for Healthcare Research and Quality, 2015. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2.html. AccessedJuly 2, 2015.


Always Use Teach-back! training toolkit. 2015. http://www.teachbacktraining.org/. Accessed July 2, 2015.