Health Literacy Support — Apply strategies to enhance health literacy and client education

The concept of health literacy emerged gradually as healthcare systems recognized that clinical expertise alone cannot ensure favorable outcomes if patients cannot understand, interpret, or act upon the information they receive. Throughout much of the twentieth century, the prevailing assumption was that patients simply needed to comply with medical directives, and communication was largely a one-directional flow from provider to patient. The consequences of this assumption became strikingly apparent through research revealing that nearly half of American adults struggled to comprehend basic health materials, including medication instructions, insurance forms, and discharge summaries. Within occupational therapy, the recognition that client education is not merely an adjunct but a core intervention catalyzed a paradigm shift toward client-centered communication that respects the learner's cognitive, cultural, and linguistic context.

For the Certified Occupational Therapy Assistant, these developments raise a critical practical question: how can a COTA systematically evaluate a client's literacy capacity and then tailor educational interventions—from home exercise program handouts to adaptive equipment training—so that every client, regardless of educational background, language, or cognitive status, can participate meaningfully in their own care? The strategies explored in this lesson directly address that question and align with NBCOT Domain 1 competencies in information gathering and collaborative practice.

Before implementing any strategy, a COTA must internalize the foundational principles that underpin health literacy–informed practice. Personal health literacy is defined as the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others (Healthy People 2030). Organizational health literacy is the degree to which organizations equitably enable individuals to find, understand, and use information and services. These two dimensions are inseparable in clinical practice; even a highly literate individual may struggle within a system that produces confusing documentation or fails to provide culturally congruent materials. The principles below form the conceptual scaffold upon which all health literacy interventions rest.

The diagram above represents the iterative nature of health literacy–informed practice. Stage 1 (Assess) involves using screening tools such as the Rapid Estimate of Adult Literacy in Medicine (REALM) or the Test of Functional Health Literacy in Adults (TOFHLA), along with informal observation of red-flag behaviors such as stating "I forgot my glasses" when asked to read a form. Stage 2 (Simplify) translates clinical information into plain language at or below a sixth-grade reading level. Stage 3 (Educate) delivers the content using a combination of verbal instruction, visual aids, physical demonstration, and return demonstration. Stage 4 (Verify) uses the teach-back method to confirm comprehension without shaming the client. Finally, Stage 5 (Adapt) closes the loop by modifying strategies based on what the verification step reveals, and the cycle begins again at reassessment.

Screening Tools for Health Literacy

A COTA working under the supervision of an OTR must be proficient in identifying indicators of limited health literacy, whether through formal screening instruments or clinical observation. Formal tools include the REALM, which presents the client with a list of 66 medical terms of increasing difficulty and scores pronunciation accuracy to estimate reading grade level. The S-TOFHLA (Shortened Test of Functional Health Literacy in Adults) uses reading comprehension passages with fill-in-the-blank cloze items and a numeracy section involving prescription label interpretation. A particularly efficient option is the Newest Vital Sign (NVS), a six-question tool based on a nutrition label that assesses both reading and numeracy in approximately three minutes. In OT settings, informal assessment often proves most practical: observing whether a client correctly identifies medication bottles, noting avoidance of written materials, and monitoring the accuracy of return demonstrations all serve as proxy indicators of functional literacy.

Communication Frameworks

Several evidence-based communication frameworks guide COTA practice. The Ask-Tell-Ask method begins by asking the client what they already know, then telling them the new information in simple terms, and finally asking them to reflect or ask questions. The Chunk-and-Check technique involves breaking information into small, digestible segments ("chunks") and pausing after each segment to check for understanding before proceeding. The Show-Me Method is particularly relevant to OT: after demonstrating an adaptive technique (such as using a sock aid), the COTA asks the client to show how they would perform the task independently, allowing real-time correction and reinforcement.

Effective client education in occupational therapy extends far beyond handing a patient a photocopied exercise sheet. The COTA must strategically select and combine instructional modalities based on the client's assessed literacy level, preferred learning style, cognitive status, and cultural context. Research in adult learning theory—particularly Knowles' principles of andragogy—demonstrates that adult learners are most motivated when they perceive the immediate relevance of information to their daily lives and when they can actively participate in the learning process. The modalities described below should therefore be framed around the client's own occupational goals, such as returning to cooking, managing medications independently, or bathing safely.

When selecting modalities, the COTA should consider several client factors simultaneously. A client with limited English proficiency (LEP) benefits most from visual and kinesthetic approaches supplemented by interpreter-assisted verbal instruction. A client with mild cognitive impairment may benefit from errorless learning—a kinesthetic technique in which the practitioner physically guides the client through the correct performance before allowing independent practice, thereby preventing the encoding of incorrect motor patterns. Written materials should always be designed using the SAM (Suitability Assessment of Materials) criteria: readability at or below the sixth-grade level (assessed using tools like Flesch-Kincaid), adequate white space, culturally appropriate images, and explicit action steps rather than abstract medical explanations.

The following worked example demonstrates how a COTA applies the Health Literacy Intervention Cycle with a specific client. This scenario integrates assessment, material adaptation, multimodal education, and verification.

Health literacy strategies are powerful tools, but like any clinical intervention, they have both strengths and limitations that the COTA must understand to apply them judiciously. The table below compares advantages and challenges across the major strategy categories.

Health literacy support in OT does not exist in isolation; it intersects with broader frameworks of health promotion, self-management support, and interprofessional education (IPE). As a COTA progresses in their career, they will encounter increasingly complex scenarios where health literacy demands interface with motivational interviewing, chronic disease self-management programs, shared decision-making, and community-based participatory research. Understanding these connections prepares the entry-level COTA for advanced practice contexts and situates health literacy within the broader occupational therapy vision of enabling participation across all life domains.

The Occupational Therapy Practice Framework (OTPF-4) situates health literacy support within the health management occupation, defined as developing, managing, and maintaining routines for health and wellness promotion. As healthcare continues to shift toward value-based care models and patient-reported outcomes, the ability of COTAs to empower clients through effective education will become an increasingly critical metric of clinical quality. The AOTA Vision 2025 explicitly identifies health literacy as a domain where occupational therapy can demonstrate its unique value within interprofessional teams by addressing the functional dimensions of understanding and acting upon health information.