Health Literacy Publications

California Literacy, Inc., makes no claim as to the accuracy of the information provided in the California Health Literacy Initiative Resource Center.

     Schillinger, D. (2001). Improving the quality of chronic disease management for populations with low functional health literacy: A call to action. Disease Management, 4, 103-109.
Click here to view the PDFfile

     Schillnger, D., & Chen, A. (2004). Literacy and language: Disentangling measures of access, utilization and quality. Journal of General Internal Medicine, 288-290.
Click here to view the PDF file

     Schillinger, D. (Chapter Author and Section Editor). (In press). Health literacy and the delivery of health care: Conceptual framework for the relationship between literacy and health. In C. Wang, & J. Schwartzberg (Eds.), Health Literacy.

     Schillinger, D. (In press). Improving chronic illness care for populations with limited health literacy. Chapter. National Academy of Sciences.

Publications Available Online

Research Studies: Literacy and Health Outcomes

Bennett, D. (2003). Low literacy, high risk: the hidden challenge facing health care in California. California Literacy, Inc.
This pilot study surveyed adults with limited literacy skills, physicians and hospital administrators in California to provide a more informed and specific body research about the issue of health literacy in the state.
http://www.cahealthliteracy.org/pdffiles/
allfourpageshealthlitreport_2.pdf
(Key Findings)
http://www.cahealthliteracy.org/pdffiles/
healthliteracylongreport012704_3.pdf
(Full Report)

Davis, T.C., Williams, M.V., Marin, E., Parker, R.M., Glass, J., Health literacy and cancer communication. (2002). CA: A Cancer Journal for Clinicians, 52. 134-149.
This article helps health care providers understand the factors that contribute to miscommunication and more specifically, the impact of patients’ health literacy on cancer communication.
http://caonline.amcancersoc.org/cgi/content/full/52/3/134

Kaufman, H., Skipper, B., Small, L., Terry, T., & McGrew, M. (2001). Effect of literacy on breast-feeding outcomes. Southern Medical Journal, 94(3). 293-293.
The effect of functional health literacy on the initiation and continuance of breast-feeding in women at a public health clinic was studied. An association between functional health literacy and breast-feeding was seen, with only 23% of the women in the lower literacy group exclusively breast-feeding during the first 2 months compared with 54% of women in the higher literacy group. Many patients need simpler health education materials that encourage breastfeeding.
http://www.medscape.com/viewarticle/410734

Schillinger, D., Bindman, A., Stewart, A., Wang F., & Piette, J. (2004). Health Literacy and the Quality of Physician-Patient Interpersonal Communication. Patient Education and Counseling 3, 315-323.

Schillinger, D. (2001). Improving the quality of chronic disease management for populations with low functional health literacy: A call to action. Disease Management, 4, 103-109.

Schillnger, D., & Chen, A. (2004). Literacy and language: Disentangling measures of access, utilization and quality. Journal of General Internal Medicine.

Cultural Competence

Stevens, B. (2001). Developing culturally appropriate Medicare education materials. Center for Medicare Education, 2.
This brief explores the lessons learned from an effort to provide culturally appropriate materials to Medicare beneficiaries. CME discovered that 1) culturally appropriate Medicare education is more than translation, 2) the differences within ethnic groups are as important – and as difficult – to deal with as the differences among ethnic groups, and 3) the process through which educational materials are developed needs to be guided by cultural expectations and behaviors.
http://www.medicareed.org/content/CMEPubDocs/
V2N4(revisedMay2003).pdf

Health Literacy Policy and Programs

Hohn, M.D. (2002). Literacy, health and health literacy: State and policy considerations, Focus on Basics. Health and Literacy.
In this article, Hohn provides an overview of the five strategies worth considering when contemplating how to engage with literacy and health issues.
http://ncsall.gse.harvard.edu/fob/2002/hohn.html

Kaplan, S.A., Greene, J., Molnar, C., Bernstein, A., & Ghanbarpour, S. (2000). Educating medicaid beneficiaries about managed care: Approaches in 13 cities. The Commonwealth Fund.
This article covers a review of Medicaid managed care educational efforts that was conducted in 13 cities across the country. The intent of the study is to help policymakers develop and sustain programs that will teach beneficiaries to understand, use, and benefit from Medicaid managed care.
http://www.commonwealthfund.org/publications/ publications_show.htm?doc_id=221386

National Literacy Act. (1991).
http://www.nifl.gov/public-law.html

O’Hara, D. (2001). Pediatricians reach out and read to young patients. American Medical News.
The Reach Out and Read Program fosters literacy promotion as part of primary care.
http://www.ama-assn.org/amednews/2001/03/26/hlsa0326.htm

Rudd, R.E. (2002). A maturing partnership. Focus on Basics, 5.
The author traces the early innovations in the health literacy movement.
http://ncsall.gse.harvard.edu/fob/2002/rudd.html

Rudd, R.E., Moeykens, B.A., & Colton, T. (1999). Health and literacy: A review of medical and public health literature. In J. Comings, B. Garner & C. Smith (Eds.), The Annual Review of Adult Learning and Literacy. New York: Jossey-Bass.
This study explores the link between the literacy level of patients and health outcomes. Barriers to health communication are highlighted as well as strategies for improving communication.
http://www.hsph.harvard.edu/healthliteracy/litreview_final.pdf

Rudd, R.E., Zahner, L., & Bahn, M. (1999). Findings from a national survey of state directors of adult education. National Center for the Study of Adult Learning and Literacy, 9.
The results of a survey of State Directors of Adult Education are reported in this article. Respondents were asked to consider health within the context of adult learning. http://www.hsph.harvard.edu/healthliteracy/report9.pdf

Rudd, R.E., Colton, T., & Schacht, R. (2000). An overview of medical and public health literature addressing literacy issues: An annotated bibliography. National Center for the Study of Adult Learning and Literacy, 14.
http://www.gse.harvard.edu/~ncsall/research/report14.pdf

Patient Education and Communication Techniques

Communication breakdown. (2002). American Medical News.
This article describes how the implications of poor communication touch nearly every aspect of health care. The AMA has created a number of efforts aimed at improving doctor-patient communication.
http://www.ama-assn.org/amednews/2000/03/06/edsa0306.htm

Kerka, S. (2000). Health and adult literacy. ERIC Practice Application Brief, 7.
This educational brief discusses the role of low literacy in determining health outcomes. Four solutions were taken from the Healthy People 2010 report and discussed: the readability of health materials, improving health communications, changing individual behaviors, and using approaches that empower the patient.
http://www.cete.org/acve/docs/pab00016.pdf

Kiefer, K. (2001). Health literacy: Responding to the need for help. Center for Medicare Education.This article provides an in-depth discussion of health literacy including its impact on the Medicare enrollment process. Recommendations include assessment of health literacy skills by healthcare providers, one-on-one and group assistance, visual tools, and training programs. Funding opportunities for these types of programs are also discussed.
http://www.ncsall.net/fileadmin/resources/teach/ environ_resources.pdf

LaMachia, J., & Morrish, E. (1996). Ideas in Action: Participatory Health and Literacy Education with Adults: Discussion Guide for Adult Basic Education and Literacy Instructors, Health Educators and Others. World Education.
http://www.nelrc.org/changeagent/pdf/issue4.pdf

Osborne, H. (2004). Health Literacy from A to Z: Practical Ways to Communicate Your Health Message.
Jones and Bartlett Publishers.
This is an easy-to-use handbook designed for the busy health care professional. The link provided offers details about the publication and costs associated with purchase.
http://www.jbpub.com/catalog/0763745502

Schwartzberg, J., & Lagay, F. (2002). Health literacy: What patients know when they leave your office or clinic. Virtual Mentor.
The experiences and histories of adults with low health literacy are provided. This article discusses strategies and information to help health care providers understand the problem of low health literacy and gives them the tools to create solutions.
http://www.ama-assn.org/ama/pub/category/5154.html

Youmans, S., & Schillinger, D. (2003). Functional health literacy and medication management: The role of the pharmacist. Annals of Pharmacotherapy.
This article emphasizes the need for patients to understand their medications and the pharmacist’s role in ensuring health literacy among patients.
http://www.theannals.com/cgi/reprint/37/11/1726.pdf

Plain Language and Readability

Betterley, C., & Dobson, B. (2000). Tools for evaluating written and audiovisual nutrition education materials. Journal of Extension, 38(4).
NAL Call Number: LC45.4 J682
Iowa State University Extension and the Iowa Department of Public Health jointly developed two guides and evaluation forms to help Extension nutrition educators, public health nutritionists, and others select educational materials that best meet the needs of target audiences. http://joe.org/joe/2000august/tt3.html

Lackman, L., Nieto, R.D., & Gliem, R. (1997). Instrument development for low literacy audiences: Assessing extension program personnel teaching effectiveness. Journal of Extension, 35(1).
The specific objectives of the study were to: (a) describe the evaluation instruments and constructs used to write the low literacy instrument, (b) outline the procedures followed for establishing content and face validity of the low literacy instrument, and (c) report the reliability coefficients calculated for the instrument.
http://www.joe.org/joe/1997february/rb1.html

McGee, J. (1999). Writing and designing print materials for beneficiaries: A guide for state Medicaid agencies. United States Department of Health and Human Services, Health Care Financing Administration, 10145.
The 'Guide Checklist for Assessing Print Materials' is available online and is
focused on the development of print materials for Medicaid beneficiaries. It provides advice and tips for writing, designing, and pre-testing written materials.
http://www.hsph.harvard.edu/healthliteracy/how_to/guide_cklst.pdf

Schuster, E., & McAllister, D.W. (1993). Writing for a changing world: Reaching low literacy audiences with print material. North Central Region Extension Publication 475.
NAL Call Number: S544 N6
This brochure features writing tips and resources designed to help Cooperative Extension staff communicate health messages to audiences with limited literacy skills.
http://www.extension.umn.edu/distribution/
communications/DL6052.html

Health Literacy Publications by Topic

Electronic versions of the following articles with a NAL Call number are available on: http://www.nal.usda.gov/fnic/foodstamp/Library/search.html

Cancer

Davis, T.C., Arnold C., Berkel, H.J., Nandy, I., Jackson, R.H., & Glass, J. (1996). Knowledge and attitude on screening mammography among low-literate, low-income women. Cancer, 78.

Davis, T.C., Williams, M.V., Marin, E., Parker, R.M., Glass, J., Health literacy and cancer communication. (2002). CA: A Cancer Journal for Clinicians, 52. 134-149.
This article helps health care providers understanding the factors that contribute to miscommunication and more specifically, the impact of patients’ health literacy on cancer communication.
http://caonline.amcancersoc.org/cgi/content/full/52/3/134

Meade, C.D., Diekmann, J., & Thornhill, D.G. (1992). Readability of American Cancer Society patient education literature. Oncology Nursing Forum, 19. 51-55.
American Cancer Society (ACS) literature, commonly used to inform patients about cancer-detection methods, life-style risks, and treatment modalities, was examined for readability. Only one booklet was written at less than a grade six reading level. The nurse's role in cancer education encompasses awareness of patients' diverse reading skills and formulation of a systematic method to develop materials that meet the needs of low literate groups.

Cardiovascular Nutrition

Albright, C.L., Fortmann, S., Howard-Pitney, B., & Winkleby, M. (1997). Development of a curriculum to lower dietary fat intake in a multiethnic population with low literacy skills. Journal of Nutrition Education, 29. 215-223.
NAL Call Number: TX341 J6
The goal of the Stanford Nutrition Action Program (SNAP) was to design a curriculum that would address nutrition issues and stimulate reduction of dietary fat. The SNAP curriculum combines interactive teaching techniques and behavior change methods to successfully teach and stimulate the interest of low-literate, low-income populations to overcome barriers to reducing fat. This curriculum is available for purchase.

Ammerman, A.S., DeVellis, B.M., Haines, P.S., Keyserling, T.C., Carey, T.S., DeVellis, R.F., & Simpson R.J. (1992). Nutrition education for cardiovascular disease prevention among low-income populations- description and pilot evaluation of a physician-based model. Patient Education and Counseling, 19. 5-18.
The majority of physicians feel unprepared to help patients achieve dietary change, and few existing nutrition intervention programs address the special needs of low literate populations. The Food for Heart Program was developed to facilitate dietary counseling experienced by primary care physicians who care for low literate patients and to overcome barriers to behavior change faced by patients.

Gans, K.M., Lovell, H.J., Fortunet, R., & Lasater, T.M. (1998). Low-literacy audio intervention for lowering fat intake. Journal of Nutrition Education, 30.
NAL Call Number: TX341 J6

Glanz, K., & Rudd, J. (1990). Readability and content analysis of print cholesterol education materials. Patient Education and Counseling, 16. 109-118.
This article provides an analysis of the readability levels and content of 38 print cholesterol education materials available from government, health agencies, professional associations, universities and industry sources. Readability analysis was done using the SMOG and Fog Grading formulas and content analysis examined the presence of messages in each of nine key areas. The readability assessment revealed that the average reading grade level was close to Grade 11, which is too difficult for many adults.

Howard-Pitney, B., et al. (1997). The Stanford Nutrition Action Program: A dietary intervention for low-literacy adults. American Journal of Public Health, 87. 1971-1976.
Few comprehensive nutrition programs for cardiovascular disease risk factor reduction have been developed specifically for adults with low literacy skills despite a growing awareness of the need for such programs. The Stanford Nutrition Action Program curriculum, tailored to the cultural, economic, and learning needs of low literate, low-income adults, was found to be significantly more effective than the general nutrition curriculum in achieving fat-related nutritional changes.

Levin, S. (1996). Pilot study of a cafeteria program relying primarily on symbols to promote healthy choices. Journal of Nutrition Education, 82. 282-285.
NAL Call Number: TX341 J6

McCarthy, P.R., Lansing, D., Hartman, T.J., & Himes, J.H. (1992). What works best for worksite cholesterol education? Answers from targeted focus groups. Journal of the American Dietetic Association, 92. 978-81.
NAL Call Number: 389.8 Am34
This articles highlights the fact that focus group participants wanted information presented in a simple, easy-to-understand manner. They asked for behavioral directives rather than background information or medical jargon. We conclude that employees respond best to worksite wellness programs that are simple, practical, and relevant which allow them to participate actively in learning activity during work time.

Merritt, L., Gates, M.A., & Skiba, K. (1993). Readability levels of selected hypercholesterolemia patient education literature. Heart & Lung, 22. 415-20.
The objectives of this article are to assess the readability of selected hypercholesterolemia print materials, summarize the limitations of readability formulas, describe how expert judgment can be used to enhance readability determinations of printed materials, and discuss indirect and direct methods for assessing patient literacy levels. The results indicate that the pamphlets may not be appropriate for use with most of the adults in the United States who may be candidates for hypercholesterolemia patient education.

TenHave, T.R., et al. (1997.) Literacy assessment in a cardiovascular nutrition setting. Patient Education and Counseling, 31. 139-150.
This brief and relatively unobtrusive literacy assessment may help to identify persons who can benefit most from audiovisual approaches to cardiovascular nutrition education.

Child Care

Gould, S.M. & Anderson, J. (1996). Enhancing compliance in the child and adult care food program using digitized photographs. Journal of Nutrition Education, 28.
NAL Call Number: TX341 J6

Cultural Competence

González, V., González, J.T., Freeman, V. & Howard-Pitney, B. (1991). Health Promotion in Diverse Cultural Communities. Palo Alto, CA: Stanford University, Stanford Center for Research in Disease Prevention
This book presents practical guidelines for working more successfully in and with, diverse cultural communities, without perpetuating cultural stereotypes. It suggests some ways to learn about the cultural specifics of a community and emphasizes the importance of understanding each community's diverse cultural identity and background.

Stevens, B. (2001). Developing culturally appropriate Medicare education materials. Center for Medicare Education, 2.
This brief explores the lessons learned from an effort to provide culturally appropriate materials to Medicare beneficiaries. CME discovered that 1) culturally appropriate Medicare education is more than translation, 2) the differences within ethnic groups are as important – and as difficult – to deal with as the differences among ethnic groups, and 3) the process through which educational materials are developed needs to be guided by cultural expectations and behaviors.
http://www.medicareed.org/content/CMEPubDocs/
V2N4(revisedMay2003).pdf

Diabetes Education

Kicklighter, J.R., & Stein, M.A. (1993). Factors influencing diabetic clients’ ability to read and comprehend printed diabetic diet material. The Diabetes Educator, 19. 40-46.
NAL Call Number: RC660 A1D522
The factors related to diabetic clients' abilities to read and comprehend printed diabetic diet material were explored by collecting data on social and demographic variables, prior knowledge, reading ability (using the Nelson-Denny Test), and comprehension of the diet (using the cloze technique) from 58 outpatient diabetic clients. Analysis of cloze scores revealed that 62% of the clients scored less than 40%, indicating that the material was too difficult for them to comprehend.

McNeal, B. (1984). Comprehension assessment of diabetes education program participants. Diabetes Care, 7. 232-235.
NAL Call Number: RC660 A1D53 F&N
This article examines a study of the reading and comprehension skills of 39 diabetics participating in a diabetes education program. It revealed a significant mismatch between these literacy skills and the level of oral and printed instruction used in the program. It was determined that over 50% of the participants could not fully comprehend 5th grade material while the program's oral instructions and written materials were at 9th grade level or higher.

Schillinger, D., Bindman, A., Stewart, A., Wang F., & Piette, J. (2004). Health Literacy and the Quality of Physician-Patient Interpersonal Communication. Patient Education and Counseling, 3, 315-323.

Food and Nutrition Education

Betts, N.M., Dirkx, J., & Ruud, Jamie. (1993). Using a critical incident technique to develop nutrition information materials for adults with low literacy skills. Journal of Nutrition Education, 25. 208-212.
NAL Call Number: TX341 J6

Gould, S.M., & Anderson, J. (1999). Development and evaluation of a pictorial version of a WIC allowable foods list. Journal of the American Dietetic Association, 99. 978-980.
NAL Call Number: 389.8 Am34

Haldeman, L., Pérez-Escamilla, R., Ferris, A., Drake, L., Himmelgreen, D., Bonello, H., González, A., Segura-Millán, S., Méndez, I., Bermudez, A., & Romero-Daza, N. (2000) Development of a color-coded bilingual food label for low literacy Latino caretakers. Journal of Nutrition Education, 32. 152-160.
NAL Call Number: TX341 J6
The purpose of this study was to develop a bilingual, user-friendly food label (UFFL) for low literate audiences. A UFFL was developed that included color-coding, bilingual text, and a shaded Food Guide Pyramid. Results indicated that participants found the UFFL easy to understand. The UFFL can be used as a nutrition education tool and the methodology developed may help food policy makers to improve the nutrition education value of the FDA food label.

Hartman, T.J., McCarthy, P.R., Park, R.J., Schuster, E., & Kushi, L.H. (1994). Evaluation of the literacy level of participants in an urban expanded food and nutrition education program. Journal of Nutrition Education, 26. 37-41.
NAL Call Number: TX341 J6
The Minnesota Extension Service's Expanded Food and Nutrition Education Program (EFNEP), and the College of Education and School of Public Health at the University of Minnesota are cooperating to develop and evaluate the effectiveness of a cardiovascular disease prevention nutrition education program targeted at a population with low literacy skills. This collaborative effort, entitled the "Innovative Dietary Education Approaches" (IDEA) Project, began in September 1991.

Hartman, T.J., McCarthy, P.R., Park, R.J., Schuster, E., & Kushi, L.H. (1994). Focus group responses of potential participants in a nutrition education program for individuals with limited literacy skills. Journal of the American Dietetic Association, 94. 744-748.
NAL Call Number: 389.8 Am34
These focus groups were intended to obtain information to direct the design and development of a nutrition intervention program targeted at a low literate audience. Clients with limited literacy skills have valuable opinions and insights that program developers targeting this hard-to-reach group should hear. The EFNEP participants wanted simple, practical, and relevant information about what foods to eat and how to prepare them.

Nitzke, S. (1989). Improving the effectiveness of nutrition education materials for low literacy clients. Nutrition Today, 24. 17-23.
NAL Call Number: RA784 N8
This article addresses the challenge of communicating nutrition information in a meaningful way. Reaching low literate adults requires special skills and techniques that are addressed in this article.

Nitzke, S. (1987). Research into practice example: Reaching low-literate adults with printed nutrition materials. Journal of the American Dietetic Association, 87. 73-77.
NAL Call Number: 389.8 AM34
This article examines a receiver-assisted pamphlet that features snack information written in the language of the target audience. It was developed using the language experience approach and compared to a standard sender-produced version written by nutrition professionals. Information garnered suggests that the receiver-assisted pamphlet was more easily understood and the perception of personal relevance was improved, although content recognition and oral miscue analyses indicated that some of the wording in the receiver-assisted version tended to be more difficult.

Nutrition education opportunities: Strategies to help patients with limited reading skills. (1989). Report of the Second Ross Roundtable on Current Issues in Public Health. Columbus, OH: Ross Laboratories.
NAL Call Number: TX364 R67 1988
This report addresses how to create plain language nutrition education materials. It includes discussions on illiteracy, reading levels of existing nutrition education materials and efforts to reach low-literate audiences.

Pennington, J.A.T., & Hubbard, V.S. (2002). Nutrition education materials from the National Institutes of Health: Development, review and availability. Journal of Nutrition Education and Behavior, 34. 53-58.
NAL Call Number: TX341 J6
Many of the institutes, centers, and offices (ICOs) within the National Institutes of Health (NIH) develop and disseminate nutrition education materials for the general public. The pretesting, ICO clearance, NES review , and joint DHHS/USDA review result in materials for nutrition educators that are high in quality, low in cost or free, easily accessible, appropriate for the intended target audience, and consistent with the Dietary Guidelines for Americans.

Rudd, J., Betts, N.M., & Dirkx, J. (1993). Developing written nutrition information for adults with low literacy skills. Journal of Nutrition Education, 25. 11-16.
NAL Call Number: TX341 J6
The purpose of this project was to develop nutrition materials based on bulletins HG 232(1-11), "The Dietary Guidelines and Your Diet", for use by adults with low literacy skills. A booklet for testing at the fifth grade level was designed and tested using qualitative research methods. Findings from the interviews provide evidence of the need for nutrition information among low literate adults. Further research with low literate adults is needed to define typical dietary practices, beliefs and perceptions, and barriers to change.

Struempler, B.J., & Marshall, A.C. (1999). Using low-literacy newsletters to provide nutrition education for limited resource individuals. Journal of Nutrition Education, 31. NAL Call Number: TX341 J6

Tziraki, C., Sutton, S., et al. (1994). National Cancer Institute's Ethnic and Low Literacy Nutrition Education Project. Journal of Nutrition Education, 26. 101-106.
NAL Call Number: TX341 J6

General Nutrition

Brunt, A.R. (1997). Helping consumers with low literacy interpret the new food label. Journal of Nutrition Education, 29. 224A.
NAL Call Number: TX341 J6

Dollahite, J., Thompson, C., & McNew, R. (1996). Readability of printed sources of diet and health information. Patient Education and Counseling, 27. 123-134.
This study surveyed nutrition education materials, which are low in cost, brief, and the type most used in patient education, to determine which might be useful with low literate clients. Many of the publications reviewed can be read and understood by many Americans, but there were few that were appropriate for the millions with limited literacy skills.

Johnson, R.K., Soultanakis, R.P., & Mathews, D.E. (1998). Literacy and body fatness are associated with underreporting of energy intake in US low-income woman using the multiple-pass 24-hour recall: A doubly labeled water study. Journal of the American Dietetic Association, 98. 1136-1140.
NAL Call Number: 389.8 Am34
This study revealed that the ability to read and spell improves the ability to recall food intake. It recommends that dietetics professionals should consider the problem of underreporting whenever conclusions are made about associations between diet and health and/or when evaluating the impact of food assistance programs on dietary intake.

Macario, E., Emmons, K.M., Sorenson, G., Hunt, M.K., & Rudd, R.E. (1998). Factors influencing nutrition education for patients with low literacy skills. Journal of the American Dietetic Association, 98. 559-564.
NAL Call Number: 389.8 Am34
Results suggested that health care providers consider nutrition to be a fundamental health education topic, but that its successful inculcation in patients with limited literacy skills is hindered mostly by insufficient provider time. Effective nutrition interventions must build on patients' social networks; appear in a visually based, interactive format; and be culturally appropriate.

Nitzke, S. & Voichick. (1992). Overview of reading and literacy research and applications in nutrition education. Journal of Nutrition Education, 24. 261-266.
NAL Call Number: TX341 J6
Educational materials are more effective when they are tailored to the cognitive abilities and learning styles of the intended audience. Examples of existing plain language materials and guides are cited. Practical techniques are needed for measuring the literacy skills of target clientele and ensuring the readability of nutrition education materials.

Swanson, R.B., & Birklid, C.A. (1992). Readability of recommended nutrition sources. Home Economics Research Journal, 20. 187-197.
NAL Call Number: TX1 H63
In this study, the readability of books recommended to consumers by professional nutrition and dietetics organizations was determined. Only one recommended book was written at a level easy enough to understand for adults with low literacy skills. For many consumers, the comprehension and application of the concepts presented in these recommended books will probably require interaction with professionals.

Tagtow, A., & Amos, R. J. (2000). Extent to which dietitians evaluate nutrition education materials. Journal of Nutrition Education, 32. 161-168.
NAL Call Number: TX341 J6
This study examined the extent to which dietitians evaluated various readability, content, and format characteristics of nutrition education materials; the barriers they encountered when selecting, evaluating, or developing them; and their perceptions of how adequate the materials were in meeting clients' needs. The results of this study can enhance the delivery of nutrition services, guide professional development, and lead to further nutrition communication research.

Health Literacy Policy

Gazmararian, J.A., Baker, D.W., Williams, M.V., Parker, R.M., Scott, T.L., Green, D.C., Fehrenbach, S.N., Ren, J., Koplan, J.P. (1999). Journal of the American Medical Association, 281. 545-51.
This article reports findings of a study measuring health literacy of elderly Medicare enrollees in a managed care organization using the Short Test of Functional Health Literacy in Adults

Health literacy: report of the Council on Scientific Affairs. (1999). Journal of the American Medical Association, 281. 552-557.
This article emphasizes the importance of health literacy awareness and makes recommendations adopted as AMA policy.

Hohn, M.D. (2002). Literacy, health and health literacy: State and policy considerations, focus on basics. Health and Literacy.
In this article, Hohn provides an overview of the five strategies worth considering when contemplating how to engage with literacy and health issues.
http://ncsall.gse.harvard.edu/fob/2002/hohn.html

Kaplan, S.A., Greene, J., Molnar, C., Bernstein, A., & Ghanbarpour, S. (2000). Educating medicaid beneficiaries about managed care: Approaches in 13 cities. The Commonwealth Fund.
This article covers a review of Medicaid managed care educational efforts that was conducted in 13 cities across the country. The intent of the study is to help policymakers develop and sustain programs that will teach beneficiaries to understand, use, and benefit from Medicaid managed care. http://www.commonwealthfund.org/publications/ publications_show.htm?doc_id=221386

Kiefer, K. (2001). Health literacy: Responding to the need for help. Center for Medicare Education.
This article provides an in-depth discussion of health literacy including its impact on the Medicare enrollment process. Recommendations include assessment of health literacy skills by healthcare providers, one-on-one and group assistance, visual tools, and training programs. Funding opportunities for these types of programs are also discussed.
http://hpi.georgetown.edu/agingsociety/pdfs/CMEReport1.pdf

Kilker, K. (2000). Considering Health Literacy. Center for Medicare Education, 1.
This article provides a brief overview of health literacy, its definition, the effect of low health literacy on Medicare and Medicaid populations, and the costs associated with low health literacy. Examples of programs that address this problem are provided.

Kirsch, I.S., Jungebut, A., Jenkins L., & Kolstad, A. (1993). Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey. Washington, D.C.: National Center for Education Statistics, United States Department of Education.

Root, J., & Stableford, S. (1999). Easy-to-read consumer communications: A missing link in Medicaid managed care. Journal of Health Politics, Policy and Law, 24. 1-26.
This article highlights the Maine Area Health Education Center Health Literacy Center's efforts to educate Medicaid patients with easy-to-read materials. The center sponsored three national skills training workshops titled "Writing for the Medicaid Market."

Shutan, B. (2001). ABCs of health care: Educational campaigns are afoot to improve patient understanding and save on unnecessary care and costs. Risk & Insurance, 12.
In this article, the health literacy efforts of the various organizations such as the AMA, Pfizer Inc., risk management company FutureHealth Corp., and medical management company Intracorp are examined.

Williams, M.V., Parker, R.M., Baker, D.W., Parikh, N.S., Pitkin, K., Coates, W.C., & Nurss, J.R. (1995). Inadequate functional health literacy among patients at two public hospitals. Journal of the American Medical Association, 274. 1677 - 1682.

Patient Education

Davis, T.C., Meldrum, H., Tippy, P.K.P., Weiss, B.D., & Williams, M.V. (1996). How poor literacy leads to poor health care. Patient Care, 30. 94-127.
In this article, the scope of the literacy problem and its effect on health care is described. It includes a list of resources and tips for communicating effectively with patients.

Davis, T.C., Crouch, M.A., Wills, G., Miller, S., & Abdehou, D.M. (1990). The gap between patient reading comprehension and the readability of patient education materials. Journal of Family Practice, 31. 533-538.

Doak, C.C., Doak, L.G., & Root, J.H. (1996). Teaching Patients with Low Literacy Skills. 2nd ed. Philadelphia: J. B. Lippincott.
This is a popular text that may help people gain insight and develop solutions regarding improved patient education. It discusses teaching strategies to address low health literacy.

Health Literacy. (1999). Journal of the American Medical Association, 282. 525-7.
These are several letters discussing health literacy and the JAMA Patient Page.

Mayeaux, E. J., Jr., Murphy, P.W., Arnold, C., Davis, T.C., Jackson, R.H., & Sentell, T. (1996). Improving patient education for patients with low literacy skills. American Family Physician 53. 205-11.
This article dispels literacy myths and offers suggestions for improving information provision to patients. It offers techniques to improve oral communication with patients, sources of patient education materials, and brochures.

McCabe, B. J., Tysinger, J. W., Kreger, M., & Cockran, C. (1989). A strategy for designing effective patient education materials. Journal of the American Dietetic Association, 89. 1290-1295.
NAL Call Number: 389.8 Am34 Health care professionals have long voiced a concern about the mismatch between patients' reading skills and the readability of printed educational materials. The gap between patients' reading levels and the readability of diet education materials has not been closed in the past 20 years. This article details a strategy for developing effective printed educational materials that was used to develop and revise dietetic materials for patients at a university medical center.

National Work Group on Literacy and Health. (1998). Communicating with patients who have limited literacy skills. The Journal of Family Practice, 46. 168-76.
This article reviews literacy issues and makes several recommendations, such as providing materials at 5th grade level or lower. It includes appendices with sources of low-literacy education materials, selected word recognition tests, and guides for creating low-literacy education materials.

Perdue, B.J., Degazon, C., & Lunney, M. (1999). Case study: Diagnoses and interventions with low literacy. Nursing Diagnosis, 10.
This is a case study of the effect of low literacy on patient education. Results point to the need for nurses to be aware of cues indicating low literacy, to assess functional health literacy when appropriate, and to tailor patient education to the abilities of the patient. In this case, the home health aide also needed to assist in following the special diet and proper use of medications.

Shelton, D. (1998). Mistaking medicine. American Medical News.

Shield, J.E., & Mullen, M.C. (1992). Developing health education materials for special audiences: Low-literate adults. Chicago, IL: American Dietetic Association.
NAL Call Number: Audiocassette no. 503
This audiocassette tape and study guide review the impact of illiteracy on health care and foodservice industries, how to evaluate the readability of education materials and ways to adapt existing print materials.

Woodring, B.C. (2000). If you have taught- have the child and family learned? Pediatric Nursing, 26. 505.
This is a discussion of key concepts nurses should consider when educating the child and family. Topics include individual learning styles and readiness to learn, content of communications, and evaluation. Examples of clinically appropriate, easy-to-use assessment tools are included.

Plain Language and Readability

Baker, L.M., & Wilson, F.L. (1996). Consumer health materials recommended for public libraries: too tough to read? Public Libraries, 35. 124-30.
In this article, questions are raised regarding librarians' roles in providing readable consumer health information.

Baker, L.M., Wilson, F.L., & Kars, M. (1997). The readability of medical information on InfoTrac; does it meet the needs of people with low literacy skills?
Reference & User Services Quarterly, 37. 155-60.
This article reveals that readability scores of 250 items in the Health Reference Center on InfoTrac ranged from tenth to fourteenth grade levels, which is too high for people with low literacy skills.

Busselman, K.M., & Holcomb, C.A. (1994). Reading skill and comprehension of the Dietary Guidelines by WIC participants. Journal of the American Dietetic Association, 94. 622-625.
NAL Call Number: 389.8 Am34
WRAT-R can be used as a quick screening method for reading-skill level of individuals in WIC programs and other counseling situations. The cloze techniques may be useful for assessing comprehension of specific printed materials. Assessment of reading skill and comprehension by nutrition educators is recommended to increase the likelihood of selecting and/or developing effective materials.

Clear & simple: Developing effective print materials for low-literate readers. (1994). Bethesda, MD: National Cancer Institute, National Institutes of Health.
This guide outlines a process for developing publications for people with limited-literacy skills. It includes information on target audience research, designing and developing materials and how to pre-test publications.

Davis, T.C., Crouch, M.A., Wills, G., Miller, S., & Abdehou, D.M. (1990). The gap between patient reading comprehension and the readability of patient education materials. Journal of Family Practice, 31. 533-538.

Davis, T.C., Michielutte, R., Askov, E.N., Williams, M.V., & Weiss, B.D. (1998). Practical assessment of adult literacy in health care. Health Education & Behavior, 25. 613-24.
In this article, the several literacy assessment tools and their application in health care settings are assessed. It provides recommendations and includes an appendix on how to order literacy tests.

Davis, T.C., Crouch, M.A, Long, S.W., Jackson, R.J., Bates, P., George, R.B., & Bairnsfather, L.E. (1991). Rapid assessment of literacy levels of adult primary care patients. Family Medicine, 23. 433-435.
This describes the Rapid Estimate of Adult Literacy in Medicine (REALM) as a tool to identify patients with limited reading skills.

Doak, C., Doak, L.G., & Root, J.H. (1996). Teaching Patients with Low Literacy Skills. Philadelphia, PA: JB Lippincott Co.
NAL Call Number: RT90 D6 1996 ISBN: 0397551614
This text provides strategies for improving patient comprehension and assessing the suitability of materials (SAM method). It reviews use of the Fry Readability Graph. Also, it discusses how to teach patients using written materials, tapes, video, computer aided instruction, visuals, and graphics.
Effective patient education. (1999). In S. Weavers, & J. Marcus (Eds.), Diabetes Patient Education Manual (pp. 1-29). Gaithersburg, MD: Aspen Publishers, Inc.
NAL Call Number: RC660 D544 1999 ISBN: 0834212757
This article discusses literacy assessment using the Rapid Estimate of Adult Literacy of Medicine (REALM) instrument, readability assessment using the SMOG index, layout and design of print materials and how to teach patients with low-literacy skills.

Freda, M.C., Damus, K., & Merkatz, I.R. (1999). Evaluation of the readability of ACOG patient education pamphlets. Obstetrics & Gynecology, 93. 771-774.
The objective of this article is to evaluate whether ACOG's patient education pamphlets comply with the recommended readability level for health education materials intended for the general public. Their data suggests that most of ACOG's patient education pamphlets currently available are written at a higher readability level than recommended for the general public. The readability of those pamphlets has improved but the goal of sixth-grade readability level has not been reached.

Gaston, N. & Daniels, P. (1988). Guidelines: Writing for adults with limited reading skills. Alexandria, VA: United States Department of Agriculture, Food and Nutrition Service, Office of Information.
NAL Call Number: APE1126 A4G8
These guidelines are intended to assist writers and editors in preparation of written materials for adults with limited reading skills. Basic points in preparing informational material are as follows: know the characteristics of the audience so that the material is appropriate; clearly identify and organize the message; and present the material in a way to get and hold readers' attention long enough for them to retain the message.

Gazmararian, J.A., Baker, David W., Williams, M.V., Parker, R.M., Scott, T.L., Green, D.C., Fehrenbach, S. N., Ren, J., & Koplan, J.P. (1999). Health literacy among Medicare enrollees in a managed care organization. Journal of the American Medical Association 281. 545-51.
This article presents findings of a study measuring health literacy of elderly Medicare enrollees in a managed care organization. The Short Test of Functional Health Literacy in Adults was used and implications of the finding are discussed.

Graber, M.A., Roller, C.M., & Kaeble, B. (1999). Readability levels of patient education material on the World Wide Web. The Journal of Family Practice, 48. 58-61.
This article evaluates the readability of patient information on the Web as determined by the Flesch reading score and Flesch-Kinkaid reading level. Information sources that were evaluated include commercial, academic, government, and organizational sites. Findings show that the sampled materials were written at a 10th grade reading level, too high for a majority of patients.

Hanson-Divers, E.C. (1997). Developing a medical achievement reading test to evaluate patient literacy skills: a preliminary study. Journal of Health Care for the Poor and Underserved, 8. 56-69.
This article describes the development and use of the Medical Achievement Reading Test (MART) to determine patient literacy levels. This test is designed to be less threatening than other such tests.

Lackman, L., Nieto, R.D., & Gliem, R. (1997). Instrument development for low literacy audiences: Assessing extension program personnel teaching effectiveness. Journal of Extension, 35(1).
In this article, the development of an appropriate evaluation instrument to be used by low literacy audiences, is discussed. The instrument in intended to assess the Extension program personnel’s teaching effectiveness. Specific objectives of the study were to: (a) describe the evaluation instruments and constructs used to write the low literacy instrument, (b) outline the procedures followed for establishing content and face validity of the low literacy instrument, and (c) report the reliability coefficients calculated for the instrument.
http://www.joe.org/joe/1997february/rb1.html

LaMachia, J., & Morrish, E. (1996). Ideas in Action: Participatory Health and Literacy Education with Adults: Discussion Guide for Adult Basic Education and Literacy Instructors, Health Educators and Others. World Education.
http://www.sabes.org/resources/fieldnotes/vol10/f04conc.htm

Lasater, L., & Mehler, P.S. (1998). The illiterate patient: Screening and management. Hospital Practice, 33. 163-170.
This article debunks literacy myths, provides overview of literacy screening tests, and offers alternative means of providing information to low-literacy patients.

McGee, J. (1999). Writing and designing print materials for beneficiaries: A guide for state medicaid agencies. United States Department of Health and Human Services, Health Care Financing Administration, 10145.
The 'Guide Checklist for Assessing Print Materials' is available online and is
focused on the development of print materials for Medicaid beneficiaries. It provides advice and tips for writing, designing, and pre-testing written materials.
http://www.hsph.harvard.edu/healthliteracy/how_to/guide_cklst.pdf

McCabe, B. J., Tysinger, J. W., Kreger, M., & Cockran, C. (1989). A strategy for designing effective patient education materials. Journal of the American Dietetic Association, 89, 1290-1295.
NAL Call Number: 389.8 Am34
This article details a strategy for developing effective printed educational materials that was used to develop and revise dietetic materials for patients at a university medical center.

Meyer, J., & Rainey, J. (1994). Writing health education material for low-literacy populations. Journal of Health Education, 25. 372-374.
NAL Call Number: LB3401 A57

Meade, C.D., & Smith, C.F. (1991). Readability formulas: Cautions and criteria.
Patient Education and Counseling, 17. 153-158.
This article advocates the SMOG formula for determining reading level but acknowledges that there are factors that contribute to the readability of patient materials other than scores derived from formulas.

Murphy, P.W., & Davis, T.C. (1997). When low literacy blocks compliance.
Registered Nurse Journal, 60. 58-64.
This article includes a copy of the REALM and gives example of a pamphlet that was written at a sixth grade level because it is important to provide patients with materials they can comprehend.

Murphy, P.W., Davis, T.C., Long, S.W., Jackson, R.H., & Decker, B.C. (1993). Rapid Estimate of Adult Literacy in Medicine (REALM): A quick reading test for patients. Journal of Reading, 37. 124-130.
In this article, the development and use of the REALM instrument is discussed.

National Work Group on Literacy and Health. (1998). Communicating with patients who have limited literacy skills. The Journal of Family Practice, 46. 168-176.
This article reviews literacy issues and makes several recommendations, such as providing materials at 5th grade level or lower. Appendices with sources of plain language education materials, selected word recognition tests, and guides for creating plain language education materials are included.

Nitzke, S., Shaw, A., Pingree, S., & Voichick, S.J. Writing for reading: Guide for developing print materials in nutrition for low-literacy adults. University of Wisconsin-Madison.
NAL Call Number: LB1050.42 W7
This is a guide for targeting and developing nutrition information for adults with limited literacy skills.

Osborne, H. (2001). Overcoming communication barriers in patient education.
Gaithersburg, MD: Aspen Publishers, Inc.
NAL Call Number: R118 O83 2001 ISBN: 083422030X
In this article, general health literacy information is provided and various communication strategies including writing, graphics and pictographs, videotapes and audiotapes, are presented.

Parker, R.M., Baker, D.W., Williams, M.V., & Nurss, J.R. The test of functional health literacy in adults: A new instrument for measuring patients' literacy skills. Journal of General Internal Medicine, 10. 537-41.
In this article, the Test of Functional Health Literacy in Adults (TOFHLA) is described and compared to the WRAT-R and the REALM. The TOFHLA measures patients' ability to perform health- related tasks that require reading and computational skills. It is the "first available tool for measuring functional health literacy."

Shield, J.E. & Mullen, M.C. (1994). Developing client education materials. In R. Chernoff (Ed.), Communicating as Professionals (pp. 91-104). Chicago, IL: American Dietetic Association
NAL Call Number: R118 C6 1994 ISBN: 0880911239
This article presents information on needs assessment, learning and behavioral objectives, wording, graphics, layout, readability formulas, and pre-testing. A three-phase process for developing readable materials includes planning, development and evaluation.

Valaitis, R.K., & Shea, E. (1993). An evaluation of breastfeeding promotion literature: Does it really promote breastfeeding? Canadian Journal of PublicHealth, 84. 24-27.

Williams, M., Baker, D., Parker, R.M., & Nurss, J.R. (1998). Relationship of functional health literacy to patients’ knowledge of their chronic disease. Archives of Internal Medicine, 158. 166-172.

Winslow, E.H. (1998). Caring for patients with limited literacy. American Journal of Nursing, 98. 55-57.
This article provides a brief review of literature on literacy and shows how to calculate reading grade using the SMOG formula.

Mental Health

Sentell, T., & Ratcliff-Baird, B. (2003). Literacy and Comprehension of Beck Depression Inventory Response Alternatives. Community Mental Health Journal, 39. 323-331.

Sentell, T., & Shumway., M. (2003). Low Literacy and Mental Illness in a Nationally Representative Sample. Journal of Nervous and Mental Disease, 191. 549-552.