January 20, 2009 Features

Health Literacy in Clinical Practice

First in a three-part series

By now it is likely you've at least heard the term "health literacy." This topic has appeared in The ASHA Leader (Hester & Benitez-McCrary, 2006; Rao, 2007), on ASHA's Web site, and perhaps even in discussions at your facility or with colleagues. The issues of communicating in plain language and improving the health literacy of all Americans are a national priority, with efforts underway in Congress, the American Medical Association, and the U.S. Surgeon General's office, among others.

Beyond Reading and Writing

Health communication involves complex topics—anatomy, medication dosages, etc.—and, more often than not, is stressful, upsetting, or just plain overwhelming. Health literacy is not only the written word, but also spoken (or signed) communication. People with good health literacy skills can understand and use health information to make health care decisions for themselves or their loved ones.

A person's health literacy is NOT dependent solely on education, socioeconomic status, native language, or disability. Even highly educated, literate people have difficulty processing, understanding, and using health-related information. The result is increased health care use, decreased adherence to medical recommendations, fewer preventative behaviors, and higher health care costs.

Readable and Appropriate

So the evidence demonstrates that health literacy is important. But what does it look like in practice? For face-to-face communication, resources are available from a number of sources. Paul Rao's article in The ASHA Leader (May 8, 2007) includes a discussion of good verbal communication strategies.

For written information, the key issues are readability and appropriateness. Readability includes the language level of the material (often conveyed in terms of grade level) and the layout and design. Appropriateness considers the information itself—is it the right information for that patient, considering his or her illness and personal situation? Is the message consistent with what the provider wants the patient to do? Is it consistent with the patient's values and beliefs? Is the information complete?

Providers need to evaluate materials before using them to ensure that the information given to patients is readable and appropriate. Literature suggests that although some providers evaluate materials that they share with patients, others simply stockpile information and either hand it out to patients or leave it in the waiting room for patients to select (McVea,Venugopal, Crabtree, & Aita, 2000). Reviews of patient education brochures from different organizations, including ASHA, have found that materials are written at a high language level and often do not use graphics well or have a reader-friendly layout (Kahn & Pannbacker, 2000). Therefore, providers cannot assume that the material they receive from a professional or government organization is acceptable for all patients.

Although it is possible to determine readability using freely available programs such as the SMOG (Simple Measure of Gobbledygook), it takes more careful critique to assess the overall appropriateness for patients. One such critique tool is the Suitability Assessment of Materials (SAM; Doak, Doak, & Root, 1996; available free of charge from the Harvard School of Public Health's Web site). In this tool, materials are scored on six factors—content, literacy demand, graphics, layout and typography, learning stimulation/motivation, and cultural appropriateness—and receive a rating of superior, adequate, or not suitable.

A Before-and-After Example

You may be thinking, "This all sounds great, but I'm still not sure if I get it." Don't worry; although practicing health literacy sounds simple enough—just be clear and make sure your patients understand—it is no simple task. Because audiologists and speech-language pathologists, like most health care providers, are well-versed in medical jargon, we don't always know we are using it.

We also worry we will be "dumbing down" the message and will offend our patients. Writing in plain language is not a matter of dumbing down information; rather, it is a matter of presenting the facts (the "need to know" versus the "nice to know") in a way that people can understand. It is also a matter of giving people something to do with the information.

If your father just had a stroke and is having trouble talking, you want to know what to do (the need to know), not necessarily how the brain functions and where the language centers are (the nice to know). You may want to know that information later, but your immediate needs are much more urgent and practical.

What Next?

As a health care provider, you have a responsibility to make sure that the written and verbal information you share with your patients is presented in a way that they can truly understand and use. Tools are available to help you. A good first stop is ASHA's Web page on health literacy. And stay tuned for the next article in this series to learn more about what ASHA is doing to improve patient education materials on communication and related disorders.

Amy Hasselkus, MA, CCC-SLP, associate director of health care services in speech-language pathology, can be reached at ahasselkus@asha.org.

cite as: Hasselkus, A. (2009, January 20). Health Literacy in Clinical Practice. The ASHA Leader.

Communicating Clearly About Health

Consider how a complex concept such as aphasia can be explained more clearly in written materials. In the example below, the first passage is from a current "Let's Talk" published by ASHA. The second is a revised version using shorter sentences, less jargon, and more white space. Simple Measure of Gobbledygook (SMOG) scores are included with each example to illustrate the education level required to understand each passage.

High Language Level, Less Comprehension:

Aphasia is estimated to affect more than one million individuals in the United States, yet few people have ever heard of it. So what is aphasia? It is an impairment of language that affects speaking, understanding, reading, and writing. Imagine knowing what you want to say and finding it impossible to get your ideas across to others. A person with aphasia might grope for words, say the wrong words, or say words that don't make sense.

(SMOG: grade 11)

Lower Language Level, Clearer:

What If You Couldn't Communicate?

When you have aphasia, it feels like living in a country where you don't speak the language. Suddenly you have trouble:

  • Having a conversation
  • Asking for help
  • Understanding directions
  • Reading and writing

You probably feel very alone and may be angry or sad.

(SMOG: grade 8) 

Help Patients Answer Key Questions

The National Patient Safety Foundation (NPSF) started the "Ask Me 3" program to help improve communication between patients and health care providers. The focus of this program is on three important questions for which patients need answers:

  • What is my main problem?
  • What do I need to do?
  • Why is it important for me to do this?

Information about Ask Me 3 is available on the NPSF Web site


Hester, E. J., & Benitez-McCrary, M. (2006, Dec. 26). Health literacy: Research directions for speech-language pathology and audiology. The ASHA Leader, 11(17), 33–34.

Kahn, A. &Pannbacker, M. (2000). Readability of educational materials for clients with cleft lip/palate and their families. American Journal of Speech-Language Pathology, 9, 3–9.

McVea, K., Venugopal, M., Crabtree, B. F., &Aita, V. (2000).The organization and distribution of patient education materials in family medicine practices.The Journal of Family Practice, 49, 319–326.

Rao, P. R. (2007, May 8). Health literacy: The cornerstone of patient safety. The ASHA Leader, 12(6), 8–9.


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