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An Updated Overview of Medical and Public Health Literature Addressing Literacy Issues: An Annotated Bibliography of Articles Published in 2000 In January 2000, Rudd et al. published an annotated bibliography of medical and public health literature addressing literacy issues. Their search of the literature indicated a growing recognition of literacy issues and communication barriers within the health fields. The current bibliography serves to augment the initial search with more recent literature. The body of literature addressing literacy and health continues to grow, presenting exciting
opportunities for action and further research. Several studies focus on the
links between literacy and health, including a large multi-national study that
supports earlier findings of links between female literacy and children’s
health, here measured in terms of infant mortality rates (Robinson and Wharrad,
2000). Many studies continue to focus on materials assessment and make use of a
variety of readability scales to assess print and video materials. The
literature also includes evaluations of programs incorporating literacy and
health. Two articles emphasize the importance of expanding roles and definitions
(Roter, 2000; Nutbeam, 2000). This search followed the search guidelines set forth in the original annotated bibliography. The Med-Line database was searched for articles addressing literacy issues and health care and in health promotion/education between January 2000 and January 2001. The following keywords were used to identify literature that addresses literacy issues: literacy, illiteracy, illiterate, readability, educational status, and communication barriers. As in the original search, the last two terms, educational status and communication barriers were included in order to find articles related to, but not directly mentioning, literacy. The search was limited to articles published in the English language and those published since January 2000. The initial yield was then restricted to a set including only articles concerned with patients, health education, and materials. The following keywords were used to generate a cross-listing or articles: patient, health education, materials, health services, and health. This search was also limited to articles published in the English language since January 2000. The two search yields we cross-referenced. Based on of reading of the
abstracts, we eliminated unrelated articles, such as those articles focused on
provider education or those studies noting education but only addressing
education as a control variable. Most of the studies conducted in developing countries were also eliminated because of our focus on
issues related to low or limited literacy and not illiteracy. However, one multi-national study is included because it offers a cogent
follow up to the Grosse et al article published in the late 1980s. Studies from
industrialized nations such as Canada, Britain, Australia, New Zealand, Spain
are included. The final yield was 24 articles. These articles were collected and
reviewed. The annotation notes the
main focus of the articles and, when appropriate, key findings. The 24 articles were reviewed and grouped into one of the following categories. An Annotated Bibliography of the literacy and health literature 2000 Links Between Literacy and Health Gutiérrez-Fisac, J.L., Gispert, R., & Solà, J. (2000). Factors explaining the geographical differences in disability free life expectancy in Spain. Journal of Epidemiology and Community Health, 54(6), 451-5. Identifies the main factors that explain variations in Disability Free Life Expectancy at birth and at 65 years in Spain by province. The results of a multivariate analysis show that the most important explanatory factor for the provincial differences in Disability Free Life Expectancy is the illiteracy rate. Kalichman, S.C., Benotsch, E., Suarez, T., Catz, S., Miller, J., & Rompa, D. (2000). Health literacy and health-related knowledge among persons living with HIV/AIDS. American Journal of Preventive Medicine, 18(4), 325-31. Assesses the relationship between functional health literacy (as measured by the TOFHLA) and health status, understanding and knowledge of health status, perceptions of primary care givers, and perceptions of anti-HIV treatments. Patients with lower health literacy were less likely to have an undetectable viral load. Patients with lower health literacy had less understanding of their illness and treatment options. Mubbashar, M.H. & Saeed, K. (2000). WHO can help to combat mental health illiteracy. Bulletin of the World Health Organization, 78(4), 507-8. Outlines issues taken into consideration in setting WHO’s agenda for mental health. Stresses the importance of promoting “mental health literacy” to reduce stigma, stereotyping, discrimination, and the abuse of rights. Nichols-English, G. & Poirier, S. (2000). Optimizing adherence to pharmaceutical care plans. Journal of the American Pharmaceutical Association, 40(4), 475-85. Mentions low-literacy as a factor affecting medication adherence. Highlights the importance for practitioners to offer special considerations for populations with low-literacy in their efforts to enhance adherence to medications. These include attention to the risks of medication mismanagement, shame about low literacy, and difficulty understanding written materials accompanying medications. Nutbeam, D. (2000) Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century. Health Promotion International 15(3): 259-267. Explores the concept of health literacy for health education and communication while stressing the importance of education as a tool for social change. Offers an expanded definition based on three functional and skill levels: functional health literacy, interactive health literacy, and critical health literacy. This analysis draws from Paulo Freire’s pedagogy. Robinson, J. & Wharrad, H. (2000). Invisible nursing: exploring health outcomes at a global level. Relationships between infant and under-5 mortality rates and the distribution of health professionals, GNP per capita, and female literacy. Journal of Advanced Nursing, 32(1), 28-40. Explores the relationship between global distribution of health professionals, GNP per capita, female literacy, and health outcome indicators. Discusses the importance of female literacy on family health. Together, GNP and female literacy are associated with 80% of the variation in infant mortality rates. The number of physicians per 100 population explains only an additional 2% of the variation. Roter, D.L. (2000). The outpatient medical encounter and elderly patients. Clinics in Geriatric Medicine, 16(1), 95-107. Discusses the implications of elderly patients’ literacy levels for communication between them and their physicians. Patients and doctors may use different sets of vocabulary. Low-literate populations also may have difficulty understanding the structure and complexity of the physician's oral communications. However, few patients reveal their poor literacy to their providers. This complicates the process of taking medical histories and other routine aspects of the medical visit. Reviews and presents relevant literature citing the literacy rates among older adults and the consequences of low literacy in the health setting.
Literacy Levels of Patients,
Benjamin, D., Li, B.D., Brown, W.A., Ampil, F.L., Burton, G.V., Yu, H., & McDonald, J.C. (2000). Patient compliance is critical for equivalent clinical outcomes for breast cancer treated by breast-conservation therapy. Annals of Surgery, 231(6), 883-9.
Alexander, R.E. (2000). Readability of published dental educational materials. Journal of the American Dental Association, 131(7), 937-942. Assesses the reading level of 24 patient educational documents from several dental resources with the Flesch-Kincaid Formula. The reading level of the documents varied widely, ranging from a Flesh-Kincaid reading level of 3rd grade to 13th grade. One document contained sections reading at a 23rd grade level. Almost half [41%] of the documents were written at grade levels higher than the reading ability of the average US adult. Brock, T.P., Williams, D.M., & Beauchesne, M.F. (2000). Assessment of the readability and comprehensibility of a CFC-transition brochure. Annals of Allergy, Asthma & Immunology, 84(2), 211-4. Estimates the grade of reading difficulty of a brochure designed to educate patients about the change to CFC-free inhalation products. Compares baseline knowledge of patients in a pulmonary database at UNC Hospitals with patient knowledge after exposure to the brochure. The brochure was assessed using the SMOG, Rix, and Flesh-Kincaid formulae and yielded grade level scores of 14, 10, and 10.4 respectively. Knowledge about the transition to non-CFC inhalers was poor at baseline. After reading the brochure, participants changed their responses to some questions. However, their responses were still not consistently accurate. Chung, V., Horowitz, A.M., Canto, M.T., & Siriphant, P. (2000). Oral cancer educational materials for the general public: 1998. Journal of Public Health Dentistry, 60(1), 49-52. Reviews oral cancer educational materials from national and state organizations and agencies to determine the adequacy of materials available to patients. Materials were reviewed using the SMOG index to assess readability. The readability ranged from sixth to 13th grade. The study suggests that most materials about oral cancer are written at a grade level too high for the general public. This may explain why the public is so uninformed about these types of cancer.
Fitzmaurice, D.A.& Adams, J.L. (2000). A systematic review of patient information leaflets for hypertension. Journal of Human Hypertension, 14(4), 259-262. Reviews 61 patient information leaflets and Internet printouts for content, writing style, design, and readability. The Gunning Fog Index was used to assess readability. Researchers conclude that a variety of resources are available to patients. While some materials are of high quality, others are clearly inadequate. Few of the non-Internet leaflets presented a full range of information although, most of the leaflets had a mean FOG score of 11.5 or less. Harvey, H.D. & Fleming, P. (2000). A rapid appraisal method for the selection and pre-testing of environmental health leaflets. Journal of the Royal Society of Health.120(2), 112-6. Presents a rapid appraisal method for the selection and pre-testing of printed educational materials on environmental health topics. The method involves assessing the acceptability and feasibility of a leaflet among organization staff, assessing the readability of the proposed material using a standard readability test, and assessing the acceptability of the leaflet to the target audience. Outlines questions to ask at various stages of assessing materials and presents a case-study to field-test the method. Jackson, L.R. & Ward, J.E. (2000). An analysis of resources for indigenous women in New South Wales about cervical screening. Australian & New Zealand journal of Public Health, 24(3), 327-30. Reviews educational materials for Aboriginal women about cervical screening. Materials were analyzed for format, content, and readability. There was no significant difference in the readability scores of materials created for the general population and those created for Aboriginal women, despite the lower education levels of the target group. Most of the materials reviewed were not tailored for Indigenous women. Mohrmann, C.C., Coleman, E.A., Coon, S.K., Lord, J.E., Heard, J.K., Cantrell, M.J., & Burke, E.C. (2000). An analysis of printed breast cancer information for African American women. Journal of Cancer Education, 15(1), 23-7. Reviews 61 cancer-related publications intended for African American audiences. The materials were assessed for readability and cultural sensitivity using the Flesch Reading Ease, Flesch-Kincaid, and Cultural Sensitivity Assessment Tools. The study indicates that printed educational materials on breast cancer are not adequate for undereducated, economically disadvantaged African American women. Murphy, P.W., Chesson, A.L., Walker, L., Arnold, C.L., & Chesson, L.M. (2000) Comparing the effectiveness of video and written material for improving knowledge among sleep disorders clinic patients with limited literacy skills. Southern Medical Journal, 93(3), 297-304. Compares the relative effectiveness of an instructional video and a brochure (both assessed at a reading grade 12 level) to improve knowledge among sleep disorders clinic patients, many with limited literacy skills. The mean educational level of participants was grade 12, while mean reading level was grade 7-8. Those who viewed the video were significantly more likely to show improved knowledge in several areas. However, low-level readers struggled with both presentations. Patients requests materials with more information on treatment options rather than pathophysiology of the disease, more diverse ethnic representation, and more use of simple terms. The paper provides guidelines for educational material development. Powell, E.C., Tanz, R.R., Uyeda, A. Gaffney, MB., & Sheehan, K.M. (2000). Injury prevention education using pictorial information. Pediatrics, 105(1), e16. Compares pictorial and traditional textual educational materials for providing injury prevention information to low income families. One group of families was given the pictorial materials and another group was given the traditional textual materials. Recall of the subject matter was evaluated. Results indicate no significant difference between the two groups in recall of safety information several weeks after receiving it. Elder, J.P., Candelaria, J.I., Woodruff, S.I., Criqui, M.H., Talavera, G.A., & Rupp, J.W. (2000). Results of language for health: cardiovascular disease nutrition education for Latino English-as-a-second-language students. Health Education & Behavior, 27(1), 50-63. Presents the final evaluation of Language for Health, a federally funded initiative to develop heart disease prevention interventions for low-literate populations. Nutrition and heart health education was integrated into ESL classes. Results indicate long-term effects on nutrition knowledge and fat avoidance. Only short-term effects were seen on total cholesterol and blood pressure. High, P.C., LaGasse, L., Becker, S., Ahlgren, I., & Gardner, A. (2000) Literacy promotion in primary care pediatrics: can we make a difference? Pediatrics, 105 (4 Pt 2), 927-34. Evaluates an intervention promoting childhood literacy delivered by pediatric providers to low-income families as part of well-child visits. Results show that the intervention increased the amount that parents read to their children. Parents and children in the intervention group reported increased enjoyment of reading. Results indicate a strong association between this intervention and receptive and expressive vocabulary in older toddlers. Homer, C., Susskind, O., Alpert, H.R., Owusu, C., Schneider, L., Rappaport, L.A., & Rubin, D.H. (2000). An evaluation of an innovative multimedia educational software program for asthma management: report of a randomized, controlled trial. Pediatrics, 106(1), 210-5. Describes a randomized, controlled trial assessing the effectiveness of a multimedia educational software program about asthma for children ages 3-12. Children and parents in the intervention group engaged in an interactive educational computer program designed to teach children about asthma and its management. Children in the control group and their parents reviewed an age-appropriate asthma education book and played a non-educational computer game. Findings indicate a substantial reduction for both groups in the number of emergency room and unscheduled office visits for asthma, reported asthma severity, and impact of asthma on parental personal time. Those receiving the computerized instruction had significantly more improvements in asthma knowledge than did those in the control group. More to come: Mattern, J., Garrigan, S., & Kennedy, S.B. (2000). A community-based assessment of heat-related morbidity in North Philadelphia. Environmental Research, 83(3), 338-42. Oermann, M.H. & Wilson, F.L. (2000). Quality of care information for consumers on the internet. Journal of Nursing Care Quality, 14(4) 45-54. Treacy, J.T. & Mayer, D.K. (2000). Perspectives on cancer patient education. Seminars in Oncology Nursing, 16(1), 47-56. Horner, S.D., Surratt, D., & Juliusson, S. (2000). Improving reliability of patient education materials. Journal of Community Health Nursing, 17(1), 15-23.
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