Table 3 List of health literacy attitude

A1. expresses the attitude that effective communication is essential to the delivery of safe high-quality health care

A2. expresses the attitude that because the “culture” of healthcare includes special knowledge, language, logic, experiences and explanatory models of health and illness, every patient encounter can be considered a cross-cultural experience

A3. expresses acceptance of an ethical responsibility to facilitate the two-way exchange of information in “shared decision making” to the degree and at the level desired by the patient and their family

A4. acknowledges patients’ autonomous right to both informed consent, and “informed refusal” of recommended evaluations or treatments

A5. expresses empathy with patients’ potential sense of shame around low literacy (or health literacy) issues

A6. expresses a non-judgmental non-shaming respectful attitude toward individuals with limited literacy (or health literacy) skills

A7. expresses empathy with the common experience of the health care system as a confusing, stressful, frustrating, intimidating, and frightening physical and virtual environment for many patients

A8. expresses the attitude that every patient has the right to understand their health care, and that it is the health care professional’s duty to elicit and ensure patients’ best possible understanding of their health care

A9. expresses the attitude that it is a responsibility of all members of the healthcare team to be trained and proactive in addressing the communication needs of patients

Items not retained

 • exhibits the attitude that all patients are at risk for communication errors, and that one cannot tell who is at risk of communication errors simply by looking, or through typical health care interactions—a universal precautions approach is required with all patients

 • expresses the attitude that it is a responsibility of the health care sector to address the mismatch between patients’ and health care providers’ communication skills and tactics