Thank you for publishing the article, “Steps for improving health literacy” [May 2016]. Health literacy is an unrecognized contributor to many adverse health outcomes. A health-literate healthcare organization can do much to help patients understand health information and use the information to make decisions about their health. However, there are two points recommended in the article that should be updated.

It is no longer recommended that patients with low health literacy be identified. Instead, Universal Health Literacy Precautions are recommended.1 While some providers are concerned that using plain language with health-literate patients will offend, studies show that patients with adequate health literacy prefer to receive health information in an easier to understand format.2

Further, research indicates that patients with limited literacy will avoid contact with the healthcare system if they fear that their literacy issues will be discovered.3 When Universal Precautions are used, all patients receive health information in a way that they are able to understand, and no one is subject to stigmatization due to low health literacy.

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It is important to ensure that written materials for patients are easy to understand, but this involves much more than writing to a particular grade level. Writing style and formatting are equally important when developing patient education materials.4 The Centers for Medicare & Medicaid Services offers a toolkit to help healthcare organizations develop documents that are reader friendly. When evaluating the readability of a document, Flesch-Kincaid is no longer recommended, since it underestimates reading level (Centers for Medicare & Medicaid Services). If a readability formula is used, the Simple Measure of Gobbledygook (SMOG) or Fry methods are preferred (Centers for Medicare & Medicaid Services).

Again, thank you for addressing health literacy as an important healthcare topic. I hope that you will consider future articles to update and expand on the information presented.—RUTH DE REGO, DNP, ANP-BC, Albuquerque, N. Mex. (213-1)


  1. AHRQ health literacy universal precautions toolkit, Second Edition. Rockville, MD: Agency for Healthcare Research and Quality. Published June 2016. Accessed June 14, 2016.
  2. Meppelink CS, Smit EG, Buurman BM, et al. Should we be afraid of simple messages? The effects of text difficulty and illustrations with low or high health literacy. Health Commun. 2015;30(12):1181-1189; doi: 10.1080/10410236.2015.1037425
  3. Easton P, Entwhistle VA, Williams B. How the stigma of low literacy can impair patient-professional spoken interactions and affect health: insights from a qualitative investigation. BMC Healh Serv Res. 2013;13:319; doi: 10.1186/1472-6963-13-319
  4. Toolkit for making written material clear and effective. Baltimore, MD: Centers for Medicare and Medicaid Services. Accessed June 14, 2016.

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