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Health literacy.

The concept of Health Literacy has been around for a number of years; as a health professional have you embraced this concept in providing safe/affordable patient care?

The Institute of Medicine defines health literacy as " The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions." Did you know that more than one out of three Iowans do not have the reading and writing skills to make good health decisions? Factors that increase the risk of low health literacy in Iowa include its rural landscape, an aging population, and a growing diversity. Thirty nine percent of Iowa's population lives in a rural community; 15% of Iowa's population in 2010 was 65 and over; and Iowa has a growing diverse population, from 2009 to 2010 the Latino population increased 5% (Des Moines Register, 2010 US Census Bureau, 2010).

Communication is essential for effective health care. What we often see in health care delivery is a mismatch between the health care provider's level of communication and the patient's level of comprehension. Evidence shows that patients often misinterpret or do not understand much of the information given to them by health care providers. (AMA) This lack of understanding can lead to poor health outcomes including: readmission to a hospital, missed visit to a health care provider, and medication errors. Low health literacy can also lead to a major financial impact for the State of Iowa. The "Health Policy Brief-The High Economic Cost of Low Health Literacy in Iowa" reports the economic impact of low health literacy ranges from $1.9 billion to $4.2 billion annually for the state of Iowa.

How as nurses in Iowa can we improve the health of Iowans? The Iowa Nurses Association (INA) took a significant first step by adopting the health literacy resolution at the annual convention in October 2010 and recognizing that the health of Iowa is impacted by the ability to obtain, process, and understand health related information and services. Now, how can we as individual nurses help to improve the care we provide and improve patient outcomes related to health literacy?

Lobby for policy and legislative support and funding for health literacy initiatives within the state of Iowa.

Utilize the many tools and services available to individuals and health care providers seeking information on effective communication. In October 2008 a steering work group met to address health literacy in Iowa. INA was a part of this work group along with:

* Des Moines University

* DeskActive

* Iowa Department of Education

* Iowa Department of Public Health

* Iowa Health System

* Iowa Hospital Association

* Iowa Medical Society

* Iowa/Nebraska Primary Care Association

* Iowa Pharmacy Association

* Mercy Clinic Inc.

* New Readers of Iowa

* Principal Financial Group

* University of Iowa (Geriatric Education Center and Center for Disabilities & Development)

* University of Northern Iowa Centers on Health Disparities and Immigration Leadership

* Wellmark Foundation

From the work conducted by this steering group, came the development of Health Literacy Iowa. Health Literacy Iowa's mission is to promote and facilitate the ability of all Iowans, to use effective communication to optimize their health. This work cannot be accomplished by any single person or group but a collaboration of health care professionals, employers, payers, policy-makers, patients, families, and the public.

Health Literacy Iowa envisions itself to be a hub, go-to source, for health literacy information, resources, and connections in the state of Iowa. Earlier this year, Health Literacy Iowa launched a website to begin this process of providing health literacy information. Plans for expansion include: education and training; organizational assessments, technical assistance, and coaching; plain language document review; support integration of health literacy into health promotion and disease prevention; and promote the integration of health literacy into early child development to name a few. To access the website go to

On the national level; the US Department of Health and Human Services released in May of 2010 the National Action Plan to Improve Health Literacy. This plan seeks to engage organizations, professionals, policymakers, communities, individuals, and families to improve health literacy. Guiding principles to this plan are based on that (1) everyone has the right to health information that helps them make informed decisions and (2) health services should be delivered in ways that are understandable and beneficial to health, longevity, and quality of life. To access the report go to

The Center for Disease Control and Prevention (CDC) website provides information and tools to improve health literacy and public health. The resources available on this website are for all organizations that interact and communicate with people about health. The site features health literacy organizations by state and planning tools to use the National Action Plan to Improve Health Literacy.

Within the state of Iowa, you may also join the Iowa Department of Public Health list serve at for personal stories and information regarding health literacy.

As nurses, we play an important role in health literacy. Nurses interact with patients and families on a daily basis in an effort to keep Iowans healthy. When talking with patient and families, talk in a way they understand. Many patients and their families are unable to interpret medical terms. Speak slowly and give clear, simple health information. For example, use" show" instead of "demonstrate".

The Center for Medicaid Services has determined specific readability guidelines for patient materials. The specific reading level for Iowa is a sixth grade level. Tools are available to access reading levels, such as the Fry Readability Formula which measures average number of syllables in words and words in a sentence. Standard word software readability programs are not always dependable and it is recommended to purchase a free-standing software program designed specifically for readability analysis if writing patient education materials.

Some guidelines to follow when developing written materials include:

* Be concise and include only need-to-know information. Limit the material to 3-5 main points. People that struggle to read will be overwhelmed with the large amount to read and may not read important health information.

* Use words with 1 to 2 syllables. Use direct language and make it personal. Use the word "you" instead of "the patient". Sentences should be short averaging 10-15 words per sentence.

* Pages should not be filled with text. Try to have 50% white space. "White space" is any area without text. Research has shown serif fonts (Times New Roman) are easier to read as they draw the reader's eye across the page and should be utilized for the main text. Sans serif fonts (Arial) work well for titles and headers. Use sparingly, italic type and all capital letters due to the fact they are hard to read. Utilize size 12 font for the general public and around 14 points for older readers.

* Visuals and graphics can simplify concepts and cut down on the amount of reading that is required. Pictures are easier to read than text. The best visuals support the text. Pictures should be real, simple appealing and culturally right.

Utilize "teach-back" to ensure the patient understands what they have been told. For example, you say, "I want you to tell me how you will take your medicine when you go home, so I can be sure I have explained everything correctly." Do not ask a patient, "Do you understand?"

For patient's that speak in a non-English language or have a disability like blindness or hearing impairment; ensure a trained, medical interpreter is available in the language they are able to understand. For example, the hearing impaired person may need to have a person able to sign for them to be able to understand.

Encourage patients and families to utilize the Ask-Me-3 communication tool when conversing with health care providers to promote understanding by asking these 3 important questions:

* What is my main problem?

* What do I need to do?

* Why is it important for me to do this?

For more information regarding Partnership for Clear Health Communication: Ask-Me-3 go to

Much work has been done in regards to health literacy but much more needs to be accomplished to ensure all patients are receiving quality patient care. Seek out the resources available to educate yourself to this vital need and incorporate health literacy initiatives into your daily patient care to improve health outcomes.

Over the last 5 years the author has been active in Trinity Regional Medical Center's (Iowa Health System) health literacy committee that works to provide health literate patient education materials and educate staff to health literacy initiatives. She has participated in the health literacy work groups at the system level as well as serving as the representative for Iowa Nurses Association with the Health Literacy Iowa steering group. She has directly worked to write educational materials at a 6th grade level and has utilized an on-lined software program for readability.


Health literacy and patient safety: Help patients understand, Manual for Clinicians, AMA Foundation, 2nd Editions, 2007

U.S. Department of Health and Human Service, Office of Disease Prevention and Health Promotion. (2010). National Action Plan to Improve Health Literacy. Washington, DC: Author

Creating Reader-Friendly Print Materials, Riffenburgh and Associates, 2005

The High Economic Cost of Low Health Literacy in Iowa, Vernon, JA, Policy Brief, September 1, 2009

By Diane Anderson, BSN, RN-BC
COPYRIGHT 2011 Iowa Nurses Association
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2011 Gale, Cengage Learning. All rights reserved.

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Author:Anderson, Diane
Publication:Iowa Nurse Reporter
Geographic Code:1USA
Date:Jun 1, 2011
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