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HealthDecember 28, 2020

Health literate healthcare organizations: Lessons from North Texas

By: Sarah Handzel, BSN, RN
According to the Center for Health Care Strategies, as many as 36% of adults in the United States have low health literacy.1

Low health literacy is more prevalent among certain portions of the population, including minorities, older adults, medically underserved individuals, and people who have low socioeconomical status.2 Several factors play into low health literacy among patients, such as healthcare providers using complex medical terminology, low educational skills, cultural barriers, and limited English language proficiency.2

A recent review published in the American Journal of Nursing3 (ANJ) highlights some of the many problems associated with low health literacy. In general, people with lower health literacy are more likely to have difficulty self-managing chronic illnesses, have more medication errors at home, are more likely to visit emergency departments, and are at greater risk of hospitalization.3 Clearly, healthcare providers and hospital systems must take steps to improve the health literacy levels of the people they serve.

The ANJ study examined health literacy policies in several North Texas healthcare institutions. The goal of the effort was to describe organizational leaders’ and clinicians’ perceptions of the 10 attributes of health literacy and examine the practice implications of these perceptions.

Ten attributes of health literate organizations

In describing the attributes of health literacy, the study authors turned to the Health Literate Health Care Organization 10-item questionnaire (HLHO-10), first developed by Kowalski and colleagues. According to this standard, health literate organizations:3

  1. Have leadership that makes health literacy integral to the organization’s mission, structure, and operations.
  2. Integrate health literacy into planning, evaluation measures, patient safety, and quality improvement efforts.
  3. Prepare staff members to be health literate while monitoring their progress.
  4. Include populations served in the design, implementation, and evaluation of health information and services.
  5. Meet the needs of populations with a range of health literacy skills while avoiding stigmatization.
  6. Use health literacy strategies in interpersonal communications while confirming understanding at all points of contact.
  7. Provide easy access to health information, services, and navigation assistance.
  8. Design print, audiovisual, and social media content for distribution, making it easy to understand and act upon.
  9. Address health literacy in high-risk situations such as care transitions and medication reconciliation.
  10. Communicate clearly what health plans cover and what individuals will need to pay for services.

Study design and methods

Data was collected from September 2018 to June 2019 from a total of 13 hospitals in North Texas. From among these facilities, 74 key informants, including nurses, physicians, social workers, registered dieticians, pharmacists, and others completed the HLHO-10 questionnaire. Most informants were executive leaders and midlevel managers, and the rest were clinical physicians and nurses.

Each health literacy attribute described in the HLHO-10 questionnaire was scored according to a Likert scale ranging from 0 = “not at all” to 7 = “to a very large extent.” In addition to answering the questionnaire, informants were also subject to a brief 30-minute interview to collect more information about common themes and discrepancies.

Results and implications for other healthcare organizations

After reviewing the data collected, the researchers found that no single healthcare organization had any systemic approach to improving health literacy. It was shown that leadership commitment is essential to improving health literacy, but so are individual literacy champions who take creative approaches to conveying important information to patients. Workforce training is also necessary, with the use of teach back and the development and evaluation of patient educational materials being an invaluable tool to help organizations move toward better health literacy.

In light of the problems caused by low health literacy, healthcare providers and administrative professionals can take several actionable steps to help improve organizational health literacy, such as:

  • Investing in education
  • Increasing awareness of health literacy
  • Offering onsite workforce training
  • Capturing data to help connect the dots regarding patient experiences with health literacy
  • Analyzing discharge call data to help identify systemic issues which could be improved

The results of this study support earlier research showing that many healthcare systems do not take a systemic approach to health literacy. To become health literate, these systems must integrate health literacy into the culture by embracing systemic transformation.

Sarah Handzel, BSN, RN
Freelance Health and Medical Content Writer, Wolters Kluwer Health
Sarah has over nine years’ experience in various clinical areas, including surgery, endocrinology, family practice, and pharmaceuticals. She began writing professionally in 2016 as a way to use her medical knowledge beyond the bedside to help educate and inform healthcare consumers and providers.
  1. “Health Literacy Fact Sheets.” Center for Health Care Strategies, 18 July 2019,
  2. “Health Literacy.” Official Web Site of the U.S. Health Resources & Services Administration, 13 Aug. 2019,
  3. Howe, Carol J. PhD, RN, DCES, FAAN, et al. “Original Research: Assessing Organizational Focus on Health Literacy in North Texas Hospitals.” NursingCenter, 2020,
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