An Updated Overview of Medical and Public Health Literature Addressing Literacy Issues: An Annotated Bibliography of Articles Published in 2002


by Emily Zobel, BA
Karen Rowe, MPH
Carmen Gomez-Mandic, MPH
March, 2003

Executive Summary

Introduction

Annotations


Citation: Zobel E, Rowe K, & Gomez-Mandic C. An updated overview of medical and public health literature addressing literacy issues: an annotated bibliography of articles published in 2002. Harvard School of Public Health: Health Literacy Website. 2003. Available at http://www.hsph.harvard.edu/ healthliteracy/ literature/lit_2002.html. Accessed "insert date."

Executive Summary

In January 2000, Rudd et al. published an annotated bibliography of medical and public health literature addressing literacy issues published between 1990 and 1999. Their search of the literature indicated a growing recognition of literacy issues and communication barriers within the health fields. We have added annual supplements to the initial search since its publication. This bibliography serves to augment the existing body of literature with articles published in 2002.

The most significant difference in this year’s bibliography is that there has been a marked increase in the body of literature addressing the issues of literacy and health. The number of articles published in public health and medical journals has almost doubled from last year. Specifically, there has been an increase in the area of computer literacy and health education in the information age. This issue emerged last year for the first time, but there is now much more attention being paid not only to issues concerning readability of Internet materials but also to the differences between print and computer based health education materials. 
This bibliography includes 45 citations which are arranged in the following categorical groups:

One article is listed under “Other” since it is a historical piece on literacy.

Introduction

The literature search followed the search guidelines set forth in the original annotated bibliography, published by NCSALL in January, 2000. The Medline database was searched for articles addressing literacy issues in health care and in health promotion/education between January 1, 2002 and June 1, 2002. 

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. 

The initial yield of items was restricted to a set, including only articles concerned with patients, health education, and materials. The following keywords were used to generate a cross-listing of articles: patient, health education, materials, health services, and health. This search was also limited to articles published in the English language since January 2002. The two search yields were cross-referenced. 

Based on an initial review of the abstracts, we eliminated unrelated articles, such as those focused on provider education or those only addressing education as a control variable. All studies conducted in developing countries were eliminated. A total of 45 articles were annotated for this bibliography.

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Literacy Levels of Patients Clients or Program Participants 

Al-Tayyib AA, Rogers SM, Gribble JN, Villarroel M, Turner CF. (2002) Effect of low medical literacy on health survey measurements. American Journal of Public Health, Vol. 92(9): 1478-1481.

Examines the relationship between assessed levels of medical literacy, respondent characteristics, and the quality of measurements made in the 1997/98 Baltimore Sexually Transmitted Disease and Behavior Survey. Two interview modes were used in this study: 1. audio computer-assisted self interviews in which the respondents completed the questions on a laptop computer and the skip patterns were automated; 2. computer assisted personal interviews. Researchers identified three types of errors that study participants made in completing the questionnaires (skip errors, logically inconsistent answers, and other errors). Overall those with lower literacy levels, as measured by the REALM, made more errors. Thus findings support a link between low literacy, as measured by the REALM, and participants’ inability to accurately complete a paper self-administered questionnaire (SAQ). The results also indicate that people with low medical literacy will provide answers on SAQs but they may respond to questions they do not completely understand. Skip errors were the most common among all respondents, thus illustrating the potential benefits of audio computer-assisted self-interviewing technologies that do not require respondent literacy (i.e., the respondents listen to the recorded questions and response categories). Computer-based technologies may help reduce the errors associated with low literacy and improve the quality of survey measurements.

Baker DW, Gazmararian JA, Sudano J, Patterson M, Parker RM, Williams MV. (2002). Health literacy and performance on the Mini-Mental State Examination. Aging & Mental Health, 6(1): 22-9.

Reports on a study which examined the prevalence of inadequate and marginal functional health literacy among 2,787 Medicare managed care enrollees in four communities. Each participant completed a survey to determine self-rated health, the Mini-Mental State Examination (MMSE), and the short version of the Test of Functional Health Literacy in Adults (S-TOFHLA). The mean scores of the MMSE and the S-TOFHLA were significantly associated. The authors conclude that functional health literacy and possibly many other domains of cognitive functioning are associated but not causally related. 

Baker, DW, Gazmararian JA, Williams MV, Scott T, Parker RM, Green D, Ren J, Peel J. (2002). Functional health literacy and the risk of hospital admission among Medicare managed care enrollees. American Journal of Public Health, 92(8), 1278-1283.

Explores the relationship between health literacy and hospital admission in a prospective cohort study of 3,260 new Medicare managed care enrollees 65 years of age or older across four U.S. cities. Subjects’ literacy levels were assessed using the S-TOFHLA. Subjects with inadequate and marginal literacy had a 30% and 20% higher risk of hospital admission, respectively, relative to those with adequate literacy. This relationship was modified by self-reported physical health; for subjects who reported that their physical health was below average literacy ability did not increase risk of hospital admission. Possible explanations for these findings are explored.

Bass PF 3rd, Wilson JF, Griffith CH, Barnett DR. (2002). Residents’ ability to identify patients with poor literacy skills. Academic Medicine, 77(10): 1039-41.

Determines whether residents could identify patients with poor literacy skills based on clinical interactions during a clinic visit. Residents interviewed a convenient sample of patients (n=182) and after the visit the residents were asked whether or not they felt that the patient had a literacy problem. The patients then completed the REALM-R assessment survey to determine their functional health literacy level. The residents reported that 90% of the patients (n=164) did not have any literacy problems. However, 36% (n=59) of this population scored at or below the sixth grade level which the researchers determined was insufficient. The authors suggest that a quick screening tool such as the REALM-R should be used to help providers identify patients with limited literacy abilities. They also suggest that issues of health literacy and communication should be incorporated into medical school curriculum.

Benitez O, Devaux D, Dausset J. (2002) Audiovisual documentation of oral consent; a new method of informed consent for illiterate populations. Lancet, 359: 1406-07. 

Describes a new method of obtaining and documenting consent of human participants in research. The study developed audiovisual documentation of oral consent (ADOC) using three methods: audio recording, video recording and photography, called triple media recording (TMR). Authors tested this new method of informed consent with a group of Guarani Indians living in Paraguay where illiteracy rates are very high. Using the ADOC method, 42 out of a possible 100 people consented to participate in the study. Authors note that the ADOC procedure or other similar standardized procedures enable valid informed consent to be obtained from illiterate populations for participation in clinical research. 

Benson JG, Forman WB. (2002). Comprehension of written health care information in an affluent geriatric retirement community: use of the Test of Functional Health Literacy. Gerontology, 48: 93-97.

Investigates the prevalence of poor comprehension of written health care information among a group of affluent, well-educated, residents living in a retirement community. The average age of the residents was 83 and the average number of years of formal education completed was 15. Ninety-three of the 180 residents, completed the English language large-print version of the TOFHLA. Overall, 30% of the individuals studied had poor comprehension of written health care information. Also, the researchers found that as age increased, reading comprehension decreased. Level of education had a positive effect on reading comprehension. The authors concluded that the prevalence of poor comprehension of written health care information in this elderly group of mostly college-educated individuals, may reflect age-related difficulty with skills required for TOFHLA performance.

Dreger V, Tremback T. (2002). Optimize patient health by teaching literacy and language barriers. AORN Journal, 75(2): 278, 280-283, 285, 287, 289-293, 297-300, 303-304.

Presents a home study program. The purpose of the program is to educate perioperative nurses about how literacy and language barrier problems adversely affect the provision of health care. The article provides information on the effects of literacy and language barriers on health care, explains specific interventions used with patients who have limited English proficiency, and outlines teaching interventions for communicating with patients who are illiterate.

Lindau ST, Tomori C, Lyons T, Langseth L, Bennett CL, Garcia P. (2002). 

The association of health literacy with cervical cancer prevention knowledge and health behaviors in a multiethnic cohort of women. American Journal of Obstetrics and Gynecology, 186(5): 938-43. 

Presents study findings that describe the relationship between health literacy, ethnicity and cervical cancer screening practices and evaluates physician recognition of low literacy. Researchers conducted 10-minute interviews as well as the REALM on 529 English speaking patients >18 years of age in ambulatory women's clinics in Chicago. Overall, controlling for literacy and other demographic factors, the study did not detect a significant variation in self-reported health and illnesses behaviors by ethnicity. However, an association between low-literacy and poor cancer screening knowledge and practices was found. Also, the study compared physicians' assessments of patient literacy to the REALM scores and found that physicians overestimated their patients literacy levels. Physicians incorrectly classified 45% of the inadequate readers and 64% of the marginal readers as having adequate literacy skills.

Schillinger D, Grumbach K, Piette J, Wang F, Osmond D, Daher C, Palacios J, Sullivan GD, Bindman A. (2002) Association of health literacy with diabetes outcomes. Journal of the American Medical Association, 288(4): 475-482.

Reports on a study that examined the association between health literacy and diabetes outcomes among patients. The study included 408 English and Spanish speaking patients older than 30 years who had type 2 diabetes. S-TOFHLA in English or Spanish was used to assess patients’ health literacy. They found that among primary care patients with type 2 diabetes, inadequate health literacy is independently associated with worse glycemic control and higher rates of retinopathy. Study implications point to the need for public health messages and interventions to target audiences with poor health literacy. 

Schultz M. (2002). Low literacy skills needn't hinder care. RN 65(4): 45-48.

Identifies nurses as patient advocates who are obligated to find ways to reach patients with low reading and writing skills in order to help them achieve good health practices. The author offers a number of concrete strategies and techniques for identifying patients with low literacy skills, assessing the reading level of patients (e.g. REALM), and improving nurse-patient interactions. The following strategies for communicating with patients are suggested: emphasize the benefits, involve the senses, emphasize your key points, instruct in small steps, personalize the message, seek frequent feedback, and cite examples that fit the patient's lifestyle and needs. 


Scott TL, Gazmararian JA, Williams MV, Baker DW. (2002). Health literacy and preventive health care use among Medicare enrollees in a managed care organization. Medical Care, 40(5): 395-404. 

Study examined whether older adults with inadequate health literacy were less likely to self-report use of four preventive health services (receiving influenza and pneumoococcal vaccinations, mammograms, and Papanicolaus smears) than individuals with adequate health literacy. They examined 2722 Medicare managed care enrollees 65 to 79 years old in four US cities. Health literacy was measured using the S-TOFHLA and a one-hour in-person survey. Almost one-third of the respondents had low health literacy skills. After controlling for other determinants of preventive service use, enrollees with inadequate health literacy were more likely to report failure to these preventive services. They also found that years of school completed was not independently associated with any of the preventive services in this study. Authors noted that Medicare managed care environment provides a unique opportunity for developing, implementing, and testing the effectiveness of interventions to increase preventive services use.

Sharp LK, Zurawski JM, Roland PY, O’Toole CO, Hines J. (2002) Health literacy, cervical cancer risk factors, and distress in low-income African-American women seeking colposcopy. Ethnicity & Disease, 12: 541-546.

Examines the relationship between health literacy, distress, and cervical cancer risk factors in women at high risk for developing cervical cancer. This cross-sectional, prospective study included 130 English-speaking African American women older than eighteen years who were referred for colposcopy. The REALM was used to measure health literacy and the Impact of Events Scale (IES) was used to measure psychosocial distress to a specific stressful event (i.e., needing a colposcopy due to an abnormal Pap test). Findings show that 45% of the women in the study have low levels of health literacy, and that psychosocial distress was significantly higher in women with low levels of health literacy compared to those with higher levels. Approximately 25% of the women with cervical abnormalities experienced severe distress. This result was consistent with other studies done on White or mixed ethnic populations. 

Williams MV, Davis T, Parker RM, Weiss BD. (2002). The role of health literacy in patient-physician communication. Family Medicine, 34(5): 383-9.

Researchers conducted a literature review using the MEDLINE database for January 1966 through July 2001 using the key words "literacy" and "health literacy" independently and in combination with the medical subject headings "physician-patient communication". Sixty-six articles were reviewed and divided into four categorizes: prevalence of inadequate health literacy in America; effect of health literacy on patient-physician communication; association of health literacy to outcomes; and interventions to enhance patient-physician communication. After summarizing the articles, the authors conclude that future research should focus on the effect of poor health literacy on patients' ability to communicate their history and physicians' ability to solicit information.

Williams MV. (2002). Recognizing and overcoming inadequate health literacy, a barrier to care. Cleveland Clinic Journal of Medicine, 69(5): 415-8. 

Highlights the evidence that inadequate health literacy has measurable adverse effects on patient's health and suggests that physicians need to develop strategies to improve patient's health literacy. Functionally illiterate adults are more likely to be older, poorer, less educated and have more health problems. Patients over 60 years of age have a particularly high prevalence of inadequate health literacy, and a patient's level of education does not guarantee that he or she can read. The author notes that patients may misunderstand medical terms. He also states that physicians can improve doctor-patient communication by learning to recognize ways patients deal with communication, simplifying patient education materials, and involving family and friends in helping deliver health information. Several other specific ways to improve understanding and communicating with patients with low health literacy are presented.

Zarcadoolas C, Blanco M, Boyer J. (2002) Unweaving the web: an exploratory study of low-literate adults’ navigation skills on the World Wide Web. Journal of Health Communication, 7: 309-324.

Presents findings from an ethnographic study that examined the web navigation skills of a group of low-literate adults (average reading level of 5th –7th grade). Researchers documented 24 participants’ navigation successes and barriers. They found that most study participants were pleased to explore the Internet, felt they would use the web more in the future, and could quickly learn web skills such as scrolling and using search windows. However, the group also experienced significant barriers to web use. Researchers claim that that simple changes in design and language as well as increased exposure to computers and the web will allow low-literate populations to overcome many barriers to web use. 

Editorials/Letters to the Editor

Gaston MA. (2002). Low literacy: a problem in health care. Journal of Dental Hygiene, 76(3); 172-3.

Reviews the statistics and prevalence of low literacy in America and poses limited health literacy as the reason why patients may not heed dentists’ advice or follow directions. The author also recommends some suggestions for improved communication such as creating a non-threatening environment, truly listening to patients and not interrupting their train of thought and using eye contact and open posturing.

Kickbusch I. (2002). Health literacy: a search for new categories. Health Promotion International, 17(1): 1-2.

The author defends the stance that health literacy should be added to the larger category of health promotion. As defined by the World Health Organizations, the goal of health promotion is to "increase people's control over their health and its determinants". Therefore, the task of health promotion is to identify and measure those factors which increase one's control over their own health, both within their everyday lives and within the health care setting which is the very core of and goal of health literacy construct.

Merriman B, Ades T, Seffrin JR. (2002). Health literacy in the information age: communicating cancer information to patients and families. CA: A Cancer Journal for Clinicians, 52(3): 130-3.

Describes how the American Cancer Society (ACS) has followed the advice offered in an article by Davis, et al. that explained it is easier to change the communication skills of the health care provider than those of the patient. Recently there has been an increased emphasis on the development of easier-to-read materials and national health organizations such as the National Cancer Institute, and the Centers for Disease Control and Prevention are developing materials at lower reading grade levels. Information about all of the major cancer sites distributed by ACS National Cancer Information Center is available in a condensed plain language (eighth grade reading level) brochure. And, following the Davis et al. message that written materials (at any grade level) are not always the most effective means of communications, ACS is developing other communication programs, such as ACS Tell-A-Friend program for promoting mammography, and other peer-counseling programs. 

Nicoll LH. (2002) Patient education in the Internet era. CIN: Computers, Informatics, Nursing, Vol. 2C(6): 215-216.

Written by a nurse, this editorial provides data to show how widespread Internet use is by Americans in seeking health information. She believes because so many people turn to the internet for health information that the role of the nurse as patient educator needs to expand to include helping patients understand and analyze information they find on web sites, and even teach critical-thinking skills to enable patients to maximize the benefits of the web.

Weiss R. (2002). Literacy issues in patient care. Health Progress, 83(6):10, 58.

Advocates for the use of plain language in health care communication. The author comments that getting health information to patients is only half the battle and that it is critical for providers to ensure that the information accomplishes what it’s designed to do. To this end, the author suggests eight steps to help accomplish this goal: (1) Produce communications at the third to fifth grade reading level; (2) Talk to your audience before writing copy; (3) Once you know the audience and what you want to communicate, determine how to say it; (4) Use line drawings, photographs, cartoons, and other art; (5) Pre-test your materials; (6) Ensure that your staff understands the information and is trained to use it effectively; (7) Explain each page of the materials to patients; and (8) Verify the message has been received.

Materials Assessment

Alexander K. (2002). A selected list of Spanish language and low literacy patient education Web sites. Journal of Pediatric Health Care, 16(3): 151-5.

Itemizes what the author deems as the best and most reliable Internet resources for Spanish speakers who read English at a basic level; Spanish speakers who read Spanish only; and English speakers who read English at a basic level. The article does not describe the criteria used for selection. 

Cox K. (2002). Informed consent and decision-making: patients' experiences of the process of recruitment to phases I and II anti-cancer drug trials. Patient Education and Counseling, 46(1): 31-8.

Points out that one of the major factors involved in patients' abilities to make informed decisions about their participation in a clinical trial involves the patients' abilities to understand the written information given to them. Readability of consent forms used in the study presented in this article were calculated using the Flesch-Kincaid reading ease test. For the nine clinical trials, the readability of the forms ranged from 76.4 (fairly easy) to 50.58 (difficult) with the majority scoring in the fairly difficult range. All 55 of the patients who received the written material felt that some of the information was too hard to understand. Half of the surveyed population thought that written information was useful because they could refer back to it and the other half thought that is was useless because it was too hard to understand. 

Croft DR., Peterson MW. (2002). An evaluation of the quality and contents of asthma education on the World Wide Web. Chest, 121(4): 1301-1307. 

Examines 145 web sites from four different search engines to measure the accessibility and quality of currently available asthma education materials on the World Wide Web. The educational material found on these sites required a mean reading level of 10.3 according to the Flesch-Kincaid scale. Twenty-seven of the sites had a reading grade level of 12th grade or higher. Only nine sites contained multilingual asthma education material. Information quality was measured based on inclusion of core educational concepts and compliance with Health On the Net (HON) principles. The mean number of HON principles followed in these web sites was 6.3 (8 principles total). Authors did not endorse any particular web sites, but provide a table of addresses of web sites that conform to all HON criteria and are below a 9th grade reading level.

Endres J, Montgomery J, Welch P. (2002). Lead poison prevention: a comparative review of brochures. Journal of Environmental Health, 64(6): 20-5; quiz 35-6.

Evaluated the readability of 20 lead poisoning prevention brochures from 11 different states. The brochures were assessed using the Fry Graph Reading Level Index. The average readability of the sample brochures was slightly above the sixth grade level (6.15) and the scores ranged from third grade through ninth grade. Forty percent of the brochures (8 of 20) achieved the investigator's established targeted goal of fourth through sixth grade readability range.

Eysenbach G, Powell JP, Kuss O, Sa E. (2002). Empirical studies assessing the quality of health information for consumers on the World Wide Web. Journal of the American Medical Association, 287(20): 2691-2700.

Uses a variety of data sources to find published and unpublished empirical studies in any language in which investigators searched the web systematically for specific health information, or evaluated the quality of web sites, and reported quantitative results. The data was synthesized and results show that the most frequently used criteria to evaluate a web site include accuracy and completeness of information, readability, design, disclosure, and references provided. 

Eysenbach G, Kohler C. (2002). How do consumers search for and appraise health information on the world wide web? Qualitative study using focus groups, usability tests, and in-depth interviews. British Medical Journal, 321: 573-577.

Investigates techniques for retrieval and appraisal used by consumers when they search for health information on the internet. Multiple methods, including focus groups, observations and in-depth interviews were used with a group of 21 volunteers ranging in age from 19-71 years of age. The study found that users of the Internet explore only the first few links on general search engines when seeking health information, and that they do not generally verify or try to find out information regarding the authors or owners of the site. Also, when assessing the credibility of a site the most important criteria for viewing a web site identified among the group in this study include a professional design, understandable and professional writing, and citation of scientific references.

Forbis SG, Aligne CA. (2002). Poor readability of written asthma management plans found in national guidelines. Pediatrics, 109(4). URL http://www.pediatrics.org/cgi/content/full/109/4/e52.

Assessed whether written asthma management plans (WAMPs) presented in national asthma guidelines are written at or below a fifth-grade reading level. They examined 10 WAMPs, seven from the national guidelines, one from the World Health Organization and two local ones. The grade levels of the WAMPs ranged from 4.9 to 9.2. None of the national plans achieved a grade level to or below fifth grade. The mean grade level for the national plans was 8.1. Mean grade level for the other three was 5.5. Results indicate that it is possible to achieve fifth grade readability level. 

Foster DR, Rhoney DH. (2002). Readability of printed patient information for epileptic patients. The Annals of Pharmacotherapy, 36(12): 1856-61.

Assessed 101 samples of written patient information materials related to epilepsy based on source, content, intended audience and readability. Source was classified as either state, national, pharmaceutical, university, hospital, or lay press. The materials were also divided between printed and Internet based. Content was classified as either general disease information or drug-specific while intended audience was divided into adults and children. Readability levels were assessed using the Flesch Reading Ease Score (FRES) and the Flesch-Kincaid Grade Level (FKGL). The national and hospital printed materials were written at lower readability levels (FKGL ~9). In contrast, state printed material, general Internet-based material and material from university websites were the most complex (FKGL ~11). The mean FKGL score was 9.4. Researchers also report that 66% of the samples contained general disease information and all but two of the samples were intended for adults.

Gannon W, Hildebrant E. (2002). A winning combination: women, literacy, and participation in health care. Health Care for Women International, 23(6-7): 754-60.

Compares the reading ability of clients who use a women’s health center and the readability of that clinic’s health information materials. Women in the study were over 18, spoke English, used the clinic as their primary source of gynecological health care, and were able to complete the basic clinic forms (n=50). Patients’ literacy abilities were assessed with the REALM and the clinic’s health materials were assessed using the Flesch-Kincaid computer formula. The researchers report that 14% of the patients read at the 7th to 8th grade level and 2% at the 4th to 6th grade level. Four of the brochures were written at the grade school level, three at the high school level, and three at above the 12th grade (n=10). Consent forms and contractual and legal forms were also assessed by the researchers and were written above the 11th grade level. Given this information, 16% of the women could not be expected to be able to read the patient education materials and most of the women could not be expected to understand the legal documents. Authors suggest that the TOFHLA be used in future studies so that pronunciation as well as comprehension can be evaluated.

Graber MA, D’Alessandro DM, Johnson-West J. (2002) Reading level or privacy policies on Internet health web sites. The Journal of Family Practice, 51(7): 642-645.

Examines the readability of privacy statements for eighty Internet health web sites to determine whether these statements can inform users of their rights. Found that 30% of the sites had no privacy policy posted. The average readability level of those sites with privacy statements (as measured by the Flesch, Fry and SMOG) required two years of college level education. Authors concluded that no website had a privacy policy that could be comprehended by most English-speaking people in the U.S. and therefore that privacy statements do not inform users of their rights. Authors suggest that privacy policies be rewritten in plain language. 

Hochhauser M. (2002) Patient education and the web: what you see on the computer screen isn’t always what you get in print. Patient Care Management, 17(11): 10-12.

Author highlights research to date that suggests the average patient will have difficulty understanding health information on the web because it is often written at very high reading levels (10th grade and higher). He offers tips for writing for the web, noting that health information on the web is not just a copy of health information from paper, but it must be written and designed in ways that are consistent with web standards.

Hochhauser M. (2002) Which prescription for the illegible and unreadable DTC brief summary – major surgery or euthanasia? Managed Care Quarterly, 10(3): 6-10.

Reports that the FDA requires pharmaceutical companies to produce brief summaries in direct-to-consumer (DTC) drug ads. The author argues that these summaries are ineffective because they are often illegible and packed with too much information (too many words on a line, very small font, no paragraph breaks, etc.), and they are unreadable and require very high literacy skills (written at too high a grade level for the average reader, include lengthy medical jargon, etc.) He suggests that the FDA provide document design templates and plain language examples for pharmaceutical companies to follow, noting that there is “no point in giving patients information they can’t read or understand just to satisfy government regulations.” 

Mathew J, McGrath J. (2002) Readability of consent forms in schizophrenia research. The Australian and New Zealand Journal of Psychiatry, 36(4): 564-565.

Assesses the readability of 23 consent forms used in schizophrenia research. Measures of readability used included Word count and Flesch scores. They found that six of the 23 required between 8th and 9th grade education levels, and nine of the 23 required at least a university level of education. Findings suggest that many consent forms are written in a way that people with schizophrenia will not understand, and suggests that more work is needed to encourage researchers to provide a readability grade with consent forms.

Wong SSM, Bekker HL, Thornton JG, Gbolade BA. (2002). Assessing the quality of information leaflets about abortion methods in England and Wales. The Journal of Family Planning and Reproductive Health Care, 28(4), 214-215.

Assesses the readability and content of a random sample of leaflets providing information about abortion methods available in 44 clinics in England and Wales. Application of the Flesch Readability Formula indicate that 46% of leaflets were of a “standard ease or lower,” as defined by the Daily Mail readability ease accessible by 83% of the British population. Content analysis of leaflets suggest that information about treatment options, procedural benefits and risks, and after care was insufficient. The report concluded that quality of written information is inadequate to support informed decision-making about abortion in this population.

Health Promotion

Andrus MR, Roth MT. (2002) Health Literacy: A Review. Pharmacotherapy, 22(3): 282-302.

Presents a review of health literacy. Provides an explanation of key definitions and measures of literacy and health literacy, and discusses the prevalence of illiteracy and inadequate health literacy in the U.S. The article also offers evidence from a number of research studies that illustrate the discrepancy between patient literacy levels and readability, and the numerous consequences of inadequate health literacy including lack of use of preventive services, poorer self-reported health, poorer compliance rates, increased hospitalization, and increased health care costs. Specific suggestions on ways to improve patient education, ensure patient understanding, advance research and promote health literacy are also included.

Davis TC, Williams MV, Marin E, Parker RM, Glass J. (2002). Health literacy and cancer communication. CA: A Cancer Journal for Clinicians, 52(3): 134-49. 

Authors searched the MEDLINE database for English-language articles published between October 1996 and January 2001 on health literacy and cancer communication and reported results from that search and previously conducted literacy searches. They reported on the prevalence of inadequate health literacy in the United States; the identification of patients with low literacy; the impact of low health literacy on cancer screening, stage at diagnosis, risk communication, provider/patient communication, informed consent; and low literacy and cancer communication on the Web. They concluded that research to date indicates that patients want practical, concise information focused on action and motivation. They also make research recommendations, suggest practical guidelines for patient education, and offer health literacy communication tips for individuals and organizations who work in the health field.

Diogo SJ. (2002). Academy backs amalgam, oral health literacy. General Dentistry, 50(5): 394-6.

Reports that the Academy of General Dentistry House of Delegates passed a measure in July 2002 at the Academy’s 50th Annual Meeting to promote oral health literacy.

Elkind PD, Pitts K, Ybarra SL. (2002). Theater as a mechanism for increasing farm health and safety knowledge. American Journal of Industrial Medicine Supplement 2, 28-35.

Describes an intervention that used theater to educate Hispanic farm workers in Eastern Washington about farm health and safety. Community needs assessment identified relevant health and safety needs of the community, followed by development of culturally and literacy-appropriate scripts by growers, farm workers, healthcare providers, advocates, and two independent playwrights. To test effectiveness of the one-act plays in increasing knowledge, 185 farm workers and 115 local community members completed pre- and post-test questionnaires. Questions had been pre-tested with farm workers and were read aloud to subjects. Of 17 questions designed to measure knowledge gains, 13 showed positive change. Two-month follow-up interviews suggest some retention of health and safety messages.

Finan N. (2002). Visual literacy in images used for medical education and health promotion. Journal of Audiovisual Media in Medicine, 22(1): 16-23.

Evaluates three health promotion campaigns, first in relation to semiotic principles and second in how well they achieved their objectives of gaining and retaining attention as well as delivering their intended message. Only nine out of the twenty images in the three campaigns adequately conveyed the correct message to the intended audience, based on nine different semiotic principles and focus group data. 

Katz LW, Osborne H. (2002). Simplicity is the best medicine for compliance information: Eight basic steps help improve employee comprehension. Patient Care Management, 17(9), 7-9.

Provides guidance on how to simplify employee compliance plans. Specifically, guidelines address issues that pertain to the use of multisyllabic words, industry-specific language, explicit writing, sentence length, active vs. passive voice, tone, organization, and literacy level of audience. 

Kelleher J. (2002). Cultural literacy and health. Epidemiology, 13(5), 497-500.

Presents a short commentary on the theory of cultural literacy and how this concept may affect health. Author proposes that cultural literacy is part of the basic communication structure of a diverse, modern, knowledge-based society and that people’s individual levels of cultural literacy may affect their ability to understand the requirements of good health, as well as impact their access to health care. The author believes that epidemiologists need to gather more empirical data on whether there is an association between cultural literacy and good health.

Pennington JAT, Hubbard VS. (2002). Nutrition education materials from the National Institutes of Health: development, review and availability. Journal of Nutrition Education and Behavior, 34: 53-58.

Describes how the materials developed by the National Institutes of Health (NIH) for the general public go through a two tiered process. The NIH National Coordinating Committee and a joint DHHS/USDA team review materials to ensure scientific and technical accuracy and consistency with the Dietary Guidelines for Americans. Authors note that efforts are made to assess the reading level and to make sure that the reading level is appropriate for the targeted audience. They also look at content, style, and layout. Materials are tested on a case-by-case basis and include peer review processes or focus group testing.

Meade CD, Calvo A, Rivera M. (2002). Screening and community outreach programs for priority populations: Considerations for oncology managers. The Journal of Oncology Management, September/October, 20-28.

Describes a partnership between a Cancer Center in South Florida and a rural Hispanic farm worker community to improve breast health. Provides a model for effective community partnership which includes attention to partnership building, development of literacy and culturally relevant outreach strategies, utilization of community strengths, financial considerations, evaluation, and sustainability.

Shire N. (2002). Effects of race, ethnicity, gender, culture, literacy, and social marketing on public health. Journal of Gender Specific Medicine, 5(2): 48-54.

Provides historical examples and recent evidence to illustrate that race and ethnicity, gender, culture, and illiteracy are linked to health risks and discrepancies. 

Other

Flannery MA. (2002). The early botanical medical movement as a reflection of life, liberty, and literacy in Jacksonian America. Journal of the Medical Library Association, 90(4), 442-454.

Explores the grassroots Thomsonian botanical medical movement of the early 1800s as an exemplification of the contradiction between the democratic and anti-intellectual ideals of the Jacksonian era and the dramatic rise of literacy during the same period. The Thomsonian botanical medical movement, while preaching common sense over schooling and experiential, accessible knowledge over trust in the elitist medical profession, owed its proliferation and institutionalization to a highly literate public. The movement also urged uneducated laypeople to take charge of their own health care while requiring fairly advanced literacy to utilize its pamphlets, books, and journals. 

 

 

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