Journal of General Internal Medicine

, Volume 21, Issue 8, pp 884–887 | Cite as

How health care systems can begin to address the challenge of limited literacy

  • Michael K. Paasche-Orlow
  • Dean Schillinger
  • Sarah M. Greene
  • Edward H. Wagner


The growing literacy and health literature calls attention to the ways in which the U.S. health care system is inadequate and even unjust, not only for the estimated 90 million U.S. adults with limited literacy, but for many other users to the system. We have presented 3 overarching principles for health system transformation that focus on promoting productive interactions between patients and providers, reorganizing health care delivery, and embracing a community level and ecological perspective. We believe that instituting such changes could improve the quality of care not only for patients with limited literacy, but for all health care consumers, and could contribute to the development of a more “health literate” society.

Key words

health care systems self-management health literacy literacy 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    DeWalt DA, Berkman ND, Sheridan S, Lohr KN, Pignone MP. Literacy and health outcomes: a systematic review of the literature. J Gen Intern Med. 2004;19:1228–39.PubMedCrossRefGoogle Scholar
  2. 2.
    Understanding and promoting health literacy (R01) PAR-04-116. Available at: Accessed April 7, 2005.Google Scholar
  3. 3.
    Ratzan SC, Parker RM. Introduction. In: Selden CR, Zorn M, Ratzan SC, Parker RM, eds. National Library of Medicine Current Bibliographies in Medicine: Health Literacy. Available at: Accessed May 9, 2006. Vol. NLM Pub. No. CBM 2000-1. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services; 2000.Google Scholar
  4. 4.
    Fang MC, Machtinger EL, Wang F, Schillinger D. Health literacy and anticoagulation-related outcomes among patients taking warfarin. J Gen Intern Med. 2006;21:841–6.PubMedCrossRefGoogle Scholar
  5. 5.
    Adams K, Corrigan JM. Institute of Medicine. Priority Areas for National Action: Transforming Health Care Quality. Committee on Identifying Priority Areas for Quality Improvement. Washington, DC: National Academies Press; 2003.Google Scholar
  6. 6.
    Improving chronic illness care: A National Program of the Robert Wood Johnson Foundation. Available at: Accessed May 9, 2006.Google Scholar
  7. 7.
    Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract. 1998;1:2–4.PubMedGoogle Scholar
  8. 8.
    Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: translating evidence into action. Health Aff (Millwood). 2001;20:64–78.CrossRefGoogle Scholar
  9. 9.
    Improving patient safety through informed consent for patients with limited health literacy: an implementation report. National Quality Forum. Available at: Accessed May 9, 2006.Google Scholar
  10. 10.
    Sudore RL, Landefeld CS, Williams B, Barnes D, Lindquist KS, Schillinger D. Use of a modified informed consent process among vulnerable patients: a descriptive study. J Gen Intern Med. 2006;21:867–73.PubMedCrossRefGoogle Scholar
  11. 11.
    Schillinger D, Bindman A, Wang F, Stewart A, Piette J. Functional health literacy and the quality of physician-patient communication among diabetes patients. Patient Educ Couns. 2004;52:315–23.PubMedCrossRefGoogle Scholar
  12. 12.
    Kalichman SC, Rompa D. Functional health literacy is associated with health status and health-related knowledge in people living with HIV-AIDS. J Acquir Immune Defic Syndr. 2000;25:337–44.PubMedCrossRefGoogle Scholar
  13. 13.
    Mancuso CA, Rincon M. Asthma patients’ assessments of health care and medical decision making: the role of health literacy. J Asthma. 2006;43:41–4.PubMedCrossRefGoogle Scholar
  14. 14.
    Bass PF, Wilson JF, Griffith CH, Barnett DR. Residents’ ability to identify patients with poor literacy skills. Acad Med. 2002;77:1039–41.PubMedCrossRefGoogle Scholar
  15. 15.
    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. 2002;186:938–43.PubMedCrossRefGoogle Scholar
  16. 16.
    Seligman H, Wang F, Palacios J, Wilson C, Daher C, Schillinger D. Physician notification of their diabetes patients with limited health literacy: a randomized, controlled trial. J Gen Intern Med. 2005;20:1001–7.PubMedCrossRefGoogle Scholar
  17. 17.
    Houts PS, Doak CC, Doak LG, Loscalzo MJ. The role of pictures in improving health communication: a review of research on attention, comprehension, recall, and adherence. Patient Educ Couns. 2006;61:173–90.PubMedCrossRefGoogle Scholar
  18. 18.
    Wofford JL, Smith ED, Miller DP. The multimedia computer for office-based patient education: a systematic review. Patient Educ Couns. 2005;59:148–57.PubMedCrossRefGoogle Scholar
  19. 19.
    Krishna S, Balas EA, Boren SA, Maglaveras N. Patient acceptance of educational voice messages: a review of controlled clinical studies. Methods Inf Med. 2002;41:360–9.PubMedGoogle Scholar
  20. 20.
    O’Connor AM, Stacey D, Rovner D, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2001; CD0001431.Google Scholar
  21. 21.
    Lewis D. Computer-based approaches to patient education: a review of the literature. J Am Med Inform Assoc. 1999;6:272–82.PubMedGoogle Scholar
  22. 22.
    Friedman RH, Stollerman J, Rozenblyum L, et al. A telecommunications system to manage patients with chronic disease. Medinfo. 1998;9:1330–4.PubMedGoogle Scholar
  23. 23.
    Bickmore T, Giorgino T. Health dialog systems for patients and consumers. J Biomed Inform. 2006 (in press).Google Scholar
  24. 24.
    Wagner EH, Bennett SM, Austin BT, Greene SM, Schaefer JK, Vonkorff M. Finding common ground: patient-centeredness and evidence-based chronic illness care. J Altern Complement Med. 2005;11(suppl 1):S7-S15.PubMedGoogle Scholar
  25. 25.
    DeWalt DA, Pignone M, Malone R, et al. Development and pilot testing of a disease management program for low literacy patients with heart failure. Patient Educ Couns. 2004;55:78–86.PubMedCrossRefGoogle Scholar
  26. 26.
    Rothman R, Malone R, Bryant B, Horlen C, DeWalt D, Pignone M. The relationship between literacy and glycemic control in a diabetes disease-management program. Diabetes Educ. 2004;30:263–73.PubMedGoogle Scholar
  27. 27.
    Davis TC, Wolf MS, Bass, PF III, et al. Low literacy impairs comprehension of prescription drug warning labels. J Gen Intern Med. 2006;21:847–51.PubMedCrossRefGoogle Scholar
  28. 28.
    Parker RM, Kindig DA. Beyond the IOM health literacy report: are the recommendations being taken seriously? J Gen Intern Med. 2006;21:891–2.PubMedCrossRefGoogle Scholar
  29. 29.
    O’Connor PJ, Desai J, Solberg LI, et al. Randomized trial of quality improvement intervention to improve diabetes care in primary care settings. Diabetes Care. 2005;28:1890–7.PubMedCrossRefGoogle Scholar
  30. 30.
    Rosenthal MB, Frank RG, Li Z, Epstein AM. Early experience with payfor-performance: from concept to practice. JAMA. 2005;294:1788–93.PubMedCrossRefGoogle Scholar
  31. 31.
    Rosenthal MB, Frank RG. What is the empirical basis for paying for quality in health care? Med Care Res Rev. 2006;63:135–57.PubMedCrossRefGoogle Scholar
  32. 32.
    Casalino L, Gillies RR, Shortell SM, et al. External incentives, information technology, and organized processes to improve health care quality for patients with chronic diseases. JAMA. 2003;289:434–41.PubMedCrossRefGoogle Scholar
  33. 33.
    Castle NG, Brown J, Hepner KA, Hays RD. Review of the literature on survey instruments used to collect data on hospital patients’ perceptions of care. Health Serv Res. 2005;40:1996–2017.PubMedCrossRefGoogle Scholar
  34. 34.
    Health Literacy and Patient Safety. Joint Commission on Accreditation of Healthcare Organizations. Available at: Accessed May 9, 2006.Google Scholar
  35. 35.
    Baker DW. Reading between the lines: deciphering the connections between literacy and health. J Gen Intern Med. 1999;14:315–7.PubMedCrossRefGoogle Scholar
  36. 36.
    Pignone M, DeWalt D, Sheridan S, Berkman ND, Lohr KN. Interventions to improve health outcomes for patients with low literacy: a systematic review. J Gen Intern Med. 2005;20.Google Scholar
  37. 37.
    Roter D. Health literacy and the patient-provider relationship. In: Schwartzberg JG, VanGeest JB, Wang CC, eds. Understanding Health Literacy: Implications for Medicine and Public Health. American Medical Association Press; 2005:87–100.Google Scholar
  38. 38.
    Rudd RR, Renzulli D, Pereira A, Daltroy L. Literacy demands in health care settings: the patient perspective. In: Schwartzberg JG, VanGeest JB, Wang CC, eds. Understanding Health Literacy: Implications for Medicine and Public Health. American Medical Association Press; 2005:69–84.Google Scholar
  39. 39.
    Schillinger D, Chen AH. Literacy and language: disentangling measures of access, utilization, and quality. J Gen Intern Med. 2004;19:288–90.PubMedCrossRefGoogle Scholar
  40. 40.
    Rootman I, Ronson B. Literacy and health research in Canada: where have we been and where should we go? Can J Public Health. 2005;96(suppl 2):S62-S77.PubMedGoogle Scholar
  41. 41.
    Sentell TL, Halpin HA. Importance of adult literacy in understanding health disparities. J Gen Intern Med. 2006;21:862–6.PubMedCrossRefGoogle Scholar
  42. 42.
    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. 2006;21:823–8.PubMedCrossRefGoogle Scholar
  43. 43.
    Nutbeam D. Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century. Health Promot Int. 2000;15:259–67.CrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2006

Authors and Affiliations

  • Michael K. Paasche-Orlow
    • 3
  • Dean Schillinger
    • 1
  • Sarah M. Greene
    • 2
  • Edward H. Wagner
    • 2
  1. 1.UCSF Division of General Internal Medicine, San Francisco General HospitalUniversity of CaliforniaSan FranciscoUSA
  2. 2.MacColl Institute for Healthcare Innovation, Center for Health StudiesGroup Health CooperativeSeattleUSA
  3. 3.Section of General Internal Medicine, Department of MedicineBoston University School of MedicineBoston

Personalised recommendations