Health Literacy in Nursing Practice: Assessment, Plain Language, and Teach-Back

Health literacy affects nearly every patient interaction and is a major driver of medication adherence, hospital readmissions, and health outcomes. This note reviews how to recognize low health literacy, communicate clearly with every patient, and confirm understanding using evidence-based strategies that show up frequently on nursing exams.

Definition

• Health literacy is the degree to which individuals can obtain, process, and understand basic health information needed to make appropriate health decisions.
• Low health literacy is associated with poor medication adherence, increased hospitalizations, worse health outcomes, and higher healthcare costs.

Prevalence and Risk Factors

• Nearly 9 out of 10 adults have difficulty using routine health information.
• Risk factors include older age, low education level, low income, non-English speaking background, and chronic disease.
• Older adults are at highest risk due to cognitive decline, vision and hearing impairment, and less experience with complex health systems.
• Do not assume a well-educated or wealthy patient has adequate health literacy — many patients hide reading difficulties.

Signs of Low Health Literacy

Low literacy often shows up indirectly. Watch for these clues:

• Behavioral: frequently missed appointments, not taking medications as prescribed, incomplete forms.
• Verbal cues: "I forgot my glasses" when asked to read; "I'll take this home to read."
• Response to teaching: asks few questions, nods without understanding, cannot teach back instructions.
• Medication clues: cannot name medications, does not know why they take them, opens bottles incorrectly.
• Forms: leaves large sections blank, makes errors on basic information (date of birth, address).

Shame and hiding are common. Patients may avoid reading, make excuses, or bring a family member to interpret.

Priority Assessment

• Ask: "How comfortable are you filling out medical forms?"
• Use the single-item literacy screener.
• Do not assume a patient understands just because they nod or say "yes."

The Universal Precautions Approach

• Universal precautions for health literacy means using clear communication strategies for every patient, not only those suspected of low literacy.
• This reduces stigma and ensures all patients receive understandable information.
• Key principles: plain language, limited information, confirmed understanding, and written materials at an appropriate reading level.

Plain Language Communication

Strategies that make information accessible:

• Use everyday words instead of jargon — "high blood pressure" instead of "hypertension."
• Use short sentences with one idea per sentence.
• Limit information to 3–5 key points; do not overload the patient.
• Organize logically — most important point first.
• Use active voice: "Take this medicine every morning," not "This medicine should be taken."
• Use visual aids — pictures, diagrams, videos.

Jargon to Avoid

Avoid terms like prn, NPO, stat, benign, lesion, oral, void, and non-compliant. Use concrete language: "Take this pill every morning at breakfast" instead of "Take this medication once daily."

The Teach-Back Method

Teach-back asks the patient to repeat instructions in their own words to confirm understanding. It is a test of how well the nurse explained, not of the patient.

• Frame without shaming: "I want to make sure I explained this clearly. Can you tell me in your own words how you will take this medicine?"
• For a procedure: "We just talked about what will happen during your test. Can you tell me what to expect so I know I did a good job explaining?"
• If the patient cannot teach back, re-explain using different words or methods — do not repeat the same explanation.
• Repeat teach-back until the patient correctly demonstrates understanding.
• Do not ask "Do you understand?" Most patients will say yes even when they do not.

Written Materials

• Reading level: 5th to 6th grade for most patient education materials. Even well-educated patients prefer simple materials.
• Font size: at least 12 point for older adults. Use sans-serif fonts (Arial, Helvetica).
• Use headings, bullet points, and white space; avoid dense paragraphs.
• Pictures should be simple, culturally appropriate, and directly related to the text.
• Action steps should be specific: "Take one pill every morning," not "Take as directed."

Medication Literacy

• Explain medication name and purpose in plain language: "This is metoprolol. It lowers your blood pressure and helps your heart work better."
• Make dosing instructions concrete: "Take one pill every morning at breakfast."
• Pill organizers help with multiple medications — assess whether the patient can open the organizer.
• Teach label reading — show where to find name, dose, and time.
• Explore adherence barriers: cost, forgetfulness, side effects, lack of understanding. Ask: "What makes it hard to take your medications?"

Numeracy (Understanding Numbers)

• Numeracy is the ability to understand and use numbers in health contexts (prescription labels, insulin doses, blood pressure readings).
• Use concrete numbers instead of ranges: "Take your blood pressure medicine when your reading is above 140," not "when it is high."
• Use analogies for risk: "Out of 100 people with this condition, 5 will have a complication," instead of "5% risk."
• Use teach-back for numeric information: "Can you show me how much insulin you will draw up?"

Cultural and Language Considerations

• Professional interpreters are required for patients with limited English proficiency. Do not use family members, especially children.
• Use culturally appropriate materials that reflect the patient's background.
• Explore health beliefs without judgment: "What do you think is causing your illness?" and "What treatments have you tried?"
• Low literacy and limited English proficiency are different. A patient may speak English well but have low literacy in English.

Common Exam Traps

• Do not ask "Do you understand?" — use teach-back.
• Do not assume a patient who nods or says "yes" understands.
• Do not use medical jargon (prn, NPO, void).
• Do not overload the patient — limit to 3–5 key points.
• Do not use family members as interpreters for health information or informed consent.

Key takeaways

• Health literacy is the ability to obtain, process, and understand health information; low literacy is common and leads to poor outcomes.
• Use universal precautions — clear communication with every patient — to avoid stigma and missed understanding.
• Use plain language, limit teaching to 3–5 key points, and use visual aids.
• Confirm understanding with teach-back; never ask "Do you understand?"
• Make medication and numeric instructions concrete and specific (e.g., "one pill every morning at breakfast").
• Always use a professional interpreter — not family — for patients with limited English proficiency.