Health Literacy Universal Precautions Toolkit, 2nd Edition


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To successfully manage their health, people must be able "to obtain, process, and understand basic health information and services needed to make appropriate health decisions."1 Known as health literacy, this ability involves using reading, writing, verbal, and numerical skills in the context of health.1 Being health literate, however, also depends on the complexity of the health information given to patients and the tasks they are asked to perform. A national survey showed that 88% of U.S. adults do not have the health literacy skills needed to manage all the demands of the current health care system and 36% have limited health literacy.2

Research shows that clinicians have trouble identifying patients with limited health literacy.3-6 Although some groups have higher rates of health literacy limitations, such as some racial/ethnic minority and older populations, limited health literacy is seen in all sociodemographic groups.2 Moreover, managing one's health can be more challenging in times of stress. When patients or caregivers are anxious or overwhelmed with too much information, their ability to absorb, recall, and use health information can decline,7 compromising their ability to manage their health.

What Are Health Literacy Universal Precautions?

Because limited health literacy is common and is hard to recognize, experts recommend using health literacy universal precautions. Practicesshould assume that all patients and caregivers may have difficulty comprehending health information and should communicate in ways that anyone can understand. Health literacy universal precautions are aimed at—

  • Simplifying communication with and confirming comprehension for all patients, so that the risk of miscommunication is minimized.8
  • Making the office environment and health care system easier to navigate.
  • Supporting patients' efforts to improve their health.

Everyone gains from health literacy universal precautions. Research shows that interventions designed for people with limited health literacy also benefit those with stronger health literacy skills.9-10 Communicating clearly helps people feel more involved in their health care and increases the chances of following through on their treatment plans.9 All patients appreciate receiving information that is clear and easy to act on.

Why a Health Literacy Universal Precautions Toolkit?

The purpose of this Toolkit is to provide evidence-based guidance to support primary care practices in addressing health literacy. The Toolkit can help practices reduce the complexity of health care, increase patient understanding of health information, and enhance support for patients of all literacy levels.

The Toolkit comprises 21 tools addressing 4 domains that are important for promoting health literacy in your practice:

  • Spoken Communication.
  • Written Communication.
  • Self-Management and Empowerment.
  • Supportive Systems.

The Toolkit appendix contains over 25 resources, such as sample forms, PowerPoint presentations, and worksheets that practices may use or revise to suit their needs. For a complete list of tools and appendices, go to the Table of Contents.

In addition, AHRQ has created a companion guide with concrete advice based on the implementation experiences of diverse primary care practices. At least one person—such as a practice facilitator, quality improvement specialist, or health literacy team leader—should read, "Implementing the AHRQ Health Literacy Universal Precautions Toolkit: Practical Ideas for Primary Care Practices" before you get started.

What is the Evidence for a Focus on Health Literacy?

Individuals with limited health literacy experience a variety of negative outcomes. They have more restricted knowledge of their health problems, make more errors taking medicine, use more inpatient and emergency department care, receive fewer preventive services, and have worse health status and higher health care costs.11-14
Fortunately, primary care practices can enhance outcomes for their patients by addressing health literacy in their office environments and clinical procedures. Addressing health literacy is associated with improved health outcomes.15 Below are a few illustrative research studies showing how good health literacy practices can improve specific health behaviors and outcomes for patients.

Colon Cancer Screening: This study shows how teaching clinicians to communicate more effectively can increase participation in colon cancer screening.16

Depression Management: This study shows that, when low-literate patients with depression were referred to literacy programs, their symptoms significantly improved compared to control participants, who just received depression treatment.17

Diabetes and Heart Failure Management: These studies show that, when patients receive self-management education using effective communication techniques, diabetes and heart failure control are improved.9, 18-20 

How Can Addressing Health Literacy Support Your Practice Goals?

Addressing health literacy in your practice can serve both your patients' needs and your practice's other goals. Many of the action steps recommended in this Toolkit are consistent with and may help qualify your practice for certification as a patient-centered medical home (PCMH). Linking the implementation of the health literacy tools to your practice's other quality improvement activities and/or PCMH-related efforts can help increase staff buy-in as well as the efficiency and "pay-off" of your work.

This link takes you to a Crosswalk (PDF, 347 KB) that presents the linkages between the tools included in the Toolkit and the PCMH certification standards (as of 2014) of the following three major accrediting organizations:

  • The National Committee for Quality Assurance (NCQA).
  • The Joint Commission.
  • The Utilization Review Accreditation Committee (URAC).

The Crosswalk is provided as a resource to help primary care practices identify tools that are relevant to specific certification standards. Implementation of these tools may contribute to your efforts to attain PCMH certification. However, we cannot guarantee that implementation of a given tool will result in a practice successfully meeting a given certification standard. It is also important to note that accreditation standards are updated frequently. Check the most recent PCMH standards to ensure you have the latest guidelines.

Addressing health literacy is important to achieve patient safety goals. Both the AMA and The Joint Commission have provided guidance on improving health literacy to improve patient safety.22, 23

Implementation of specific tools in this Toolkit also may support practices and clinicians in their efforts related to Maintenance of Certification and Meaningful Use. To make the most of their quality improvement work, we encourage practices to consider how their health literacy-related efforts can also address these other goals.

Who Should Use this Toolkit?

This Toolkit is designed to be used in any primary care setting, although some tools are applicable to other settings as well. The Toolkit can help practices with little or no experience addressing health literacy as well as those that are already engaged in health literacy-related quality improvement work. With an extensive set of tools to choose from, even practices with substantial health literacy experience can benefit from this Toolkit.

Can Your Practice Improve Its Health Literacy Environment?

Yes! This Toolkit has been tested in primary care practices and community clinics. Participating facilities showed that they could make changes to improve the way they communicate with and support their patients.

Just like these practices, your practice can benefit from this resource. The Toolkit can guide you in addressing health literacy limitations among your patients and help you to achieve your practice's other goals.

Getting Started

To get started, we recommend that you begin by implementing Tools 1 through 3. These Tools will help you establish the foundation you need to successfully implement health literacy-related quality improvement efforts in your practice.

For those practices that want to jump right in and try a tool, go to the Quick Start Guide, a one-page guide that will help you get started.


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2. Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacy of America's Adults:  Results from the 2003 National Assessment of Adult Literacy (NCES 2006–483). U.S. Department of Education. Washington, DC: National Center for Education Statistics; 2006.
3. Powell CK, Kripalani S. Brief report: Resident recognition of low literacy as a risk factor in hospital readmission. J Gen Intern Med Nov 2005;20(11):1042-1044.
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5. Lindau ST, Tomori C, Lyons T, Langseth L, Bennett CL, Garcia P. The association of health literacy with cervical cancer prevention knowledge and health behaviors in a multiethnic cohort of women. Am J Obstet Gynecol May 2002;186(5):938-943.
6. Rogers ES, Wallace LS, Weiss BD. Misperceptions of medical understanding in low-literacy patients: implications for cancer prevention. Cancer Control Jul 2006;13(3):225-229.
7. Martin LR, Williams SL, Haskard KB, DiMatteo MR. The challenge of patient adherence. Therapeutics and clinical risk management. 2005;1(3):189.
8. Brach C, Keller D, Hernandez LM, et al. Ten attributes of health literate health care organizations. Washington DC: Institute of Medicine of the National Academies. 2012.
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10. DeWalt DA, Malone RM, Bryant ME, et al. A heart failure self-management program for patients of all literacy levels: A randomized, controlled trial. BMC Health Services Research 2006;6:30.
11. Eckman MH, Wise R, Leonard AC, et al. Impact of health literacy on outcomes and effectiveness of an educational intervention in patients with chronic diseases. Patient Education and Counseling 5// 2012;87(2):143-151.
12. DeWalt DA, Berkman ND, Sheridan S, Lohr KN, Pignone MP. Literacy and health outcomes:  A systematic review of the literature. J Gen Intern Med Dec 2004;19(12):1228-1239.
13. DeWalt DA, Hink A. Health literacy and child health outcomes: a systematic review of the literature. Pediatrics Nov 2009;124 Suppl 3:S265-274.
14. Rudd RE, Anderson JE, Oppenheimer S, Nath C. Health Literacy: An Update of Public Health and Medical Literature. In: Comings JP, Garner B, Smith C, eds. Review of Adult Learning and Literacy. Vol 7. Mahway, NJ: Lawrence Erlbaum Associates:175-204.
15. Berkman ND, DeWalt DA, Pignone MP, et al. Literacy and Health Outcomes. Evidence Report/Technology Assessment No. 87 (Prepared by RTI International-University of North Carolina Evidence-based Practice Center under Contract No. 290-02-0016). AHRQ Publication No. 04-E007-2. Rockville, MD: Agency for Healthcare Research and Quality; January 2004.
16. Pignone M, DeWalt DA, Sheridan S, Berkman N, Lohr KN. Interventions to improve health outcomes for patients with low literacy. A systematic review. J Gen Intern Med Feb 2005;20(2):185-192.
17. Ferreira MR, Dolan NC, Fitzgibbon ML, et al. Health care provider-directed intervention to increase colorectal cancer screening among veterans: results of a randomized controlled trial. J Clin Oncol Mar 1 2005;23(7):1548-1554.
18. Weiss BD, Francis L, Senf JH, Heist K, Hargraves R. Literacy education as treatment for depression in patients with limited literacy and depression: a randomized controlled trial. J Gen Intern Med Aug 2006;21(8):823-828.
19. Rothman RL, DeWalt DA, Malone R, et al. Influence of patient literacy on the effectiveness of a primary care-based diabetes disease management program. JAMA Oct 13 2004;292(14):1711-1716.
20. Murray MD, Young J, Hoke S, et al. Pharmacist intervention to improve medication adherence in heart failure: a randomized trial. Ann Intern Med May 15 2007;146(10):714-725.
21. Schillinger D, Handley M, Wang F, Hammer H. Effects of self-management support on structure, process, and outcomes among vulnerable patients with diabetes: a three-arm practical clinical trial. Diabetes Care Apr 2009;32(4):559-566.
22. American Medical Association Foundation. (2007). Health literacy and patient safety: help patients understand (Vol. 2007). Chicago: American Medical Association Foundation.
23. The Joint Commission. (2007). What did the doctor say?: improving health literacy to protect patient safety. Oakbrook Terrace, IL: The Joint Commission.

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Page last reviewed February 2015
Page originally created February 2015
Internet Citation: Introduction. Content last reviewed February 2015. Agency for Healthcare Research and Quality, Rockville, MD.
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