Health Literacy Level Essay Assignment.
Health literacy skills are cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways which promote and maintain good health’. Patients use these literacy skills to critically analyze information; to allow them to exert greater control over life events and situations. An understanding of health literacy is also important for those developing and delivering healthcare programmes, especially vaccination programmes, as both the information and the actions required to use the information are complex requiring sophisticated health literacy skills beyond the capacity of a significant proportion of the population. Health Literacy Level Essay Assignment.There are simple steps which can be taken to make the information in vaccination materials easier to understand and use. The complex concepts of reading and numeracy skills in relation to health will be discussed and strategies described which can improve access to healthcare information for all patients, whatever their literacy level.

Keywords: health literacy, health information, vaccination

Introduction
Health literacy skills are ‘the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways which promote and maintain good health’1. Health literacy skills can be conceptualized at various levels of complexity; however the most fundamental skills can be defined as ‘those basic skills in reading needed to be able to function in everyday (health) situations to access and use information’ i.e., functional health literacy.1 To become and remain healthy citizens need a wide range of literacy and numeracy skills to promote health, protect personal and public safety, prevent disease, manage illness and navigate the health service. Health Literacy Level Essay Assignment.
Low health literacy is a public health problem; it reduces health and/or increases the levels and impact of illness while simultaneously affecting a significant proportion of the population. Lower functional health literacy skills are associated with lower levels of self-reported health3 and higher prevalence of long-term health conditions,3 higher mortality in older people,4-6 greater use of medical services such as increased hospitalization and greater emergency care use,7 poorer ability to interpret labels and health messages and demonstrate taking medications appropriately,6,8 and poorer ability to manage long-term illnesses such as heart failure and asthma. Health Literacy Level Essay Assignment.9,10 Health literacy also impacts on a persons’ ability to engage in preventative activities; there is evidence of lower involvement in cancer screening (colorectal,11,12 cervical13 and breast screening Health Literacy Level Essay Assignment.12,14 and reduced uptake of influenza vaccination.12,14 Low health literacy is known to be a problem for a large proportion of the population. Reported levels of low health literacy vary according to the measures used, but in industrialized nations reported prevalence of low or ‘problematic’ health literacy is around 50%.3,15-17 The situation is similar in England; when a range of health materials in common circulation were rated for the level of literacy and numeracy skills required to fully understand and use them, the literacy (text) component difficulty of the majority of materials was at the skills level expected to be achieved by English school students at age 14–16 y (National Qualifications Framework level 2: see Table 1), while the numeracy component was at the skills level expected to be achieved by English school students at age 11–14 y (National Qualifications Framework level 1, Table 1). Analysis of the most recent English national skills survey, undertaken on the English working age (16 – 65 y) population,18 shows that 43% of working age adults do not have the literacy skills to fully understand and use the written (text) element of health materials in common circulation, this figure rises to 61% when text is combined with numerical concepts or calculations. Health Literacy Level Essay Assignment.19 There is significant regional variation in the proportion of the population below these ‘health literacy thresholds’, with those in London and the North-East being at higher risk of low health literacy.
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Health literacy is associated with other social determinants of health; in particular older people and those from Black and Minority Ethnic Groups (with a first language other than English), in low grade employment (with low income) and living in more socio-economically deprived areas are at higher risk of being below the ‘health literacy threshold’19. These groups are already at higher risk of poor health20 therefore understanding the issues raised by low health literacy can help to reduce health inequalities. Health Literacy Level Essay Assignment.

Table 1. English National Qualifications Framework (NQF)18

Level
English National Qualifications Framework age equivalent
Literacy
An adult classified at the level understands
Numeracy
An adult classified at the level understands
Examples of typical skills

Entry 1
5–7 y
Short texts with repeated language patterns on familiar topics. Health Literacy Level Essay Assignment.
Information from common signs and symbols
Information given by numbers and symbols in simple graphical, numerical and written material
Write short messages.
Select floor numbers in lifts

Entry 2
7–9 y
Short straightforward texts on familiar topics.
Information from short documents, familiar sources, signs and symbols.
Information given by numbers, symbols, simple diagrams and charts in graphical, numerical and written material
Describe health symptoms.
Use a cashpoint machine

Entry 3
9–11 y
Short
straightforward texts on familiar topics accurately and independently.
Information from everyday sources.
Information given by numbers, symbols, diagrams and charts used for different purposes and in different ways in graphical, numerical and written material.
Understand price labels.
Pay household bills

Level 1
Matriculation examinations (GSCE) grade D-G
Short
straightforward texts of varying length on a variety of topics accurately and independently.
Information from different sources
Straightforward mathematical information used for different purposes. Independently select relevant information from given graphical, numerical and written material
GCSE grades D-G

Level 2 or above
GCSE grades A* to C or higher qualifications
A range of texts of varying complexity accurately and independently.
Can obtain information of varying length and detail from different sources.
Mathematical information used for different purposes and can independently select and compare relevant information from a variety of graphical, numerical and written material. Health Literacy Level Essay Assignment.
5 grades A* to C GCSE

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Why health literacy is important in vaccination programmes

The complexity of vaccine information
Information about vaccination is inherently complex and consequently challenging to communicate to patients, particularly those with low literacy and numeracy. Patients need to have information about the disease or illness, the risks of contracting the condition, the risks of having the vaccination, and the potential risk of vaccination failure resulting in the patient contracting the condition anyway. There are three important elements to consider as vaccination information is developed and communicated; what are the overall literacy and numeracy skills of the patient, do they have marked variation in literacy and numeracy sub-skills (known as ‘spiky profiles’) and what cognitive skills are required for the patient to respond to the information?

Targeting resources toward patients with low health literacy and numeracy
When thinking about approaches to tailoring health information to patient health literacy and numeracy skills there are several approaches. The strongest predictor of functional health literacy and numeracy skills is the patient education level (in England this has a sensitivity of 59% and a specificity of 78%.21 One option is thus to routinely collect data on qualification level at patient registration and tailor information to health literacy levels. Such questions are routinely asked for and so this approach is likely to be acceptable to patients. A second option is to ‘test’ patient health literacy levels, either before or during consultation. The Newest Vital Sign22 and the REALM23 are quick measures which can be applied in clinical settings and have been validated for use in the UK.24,25 However, such an approach has the potential to distress patients particularly those with low literacy and numeracy due to the stigma attached.26 Such approaches place the onus for successful communication of information on the patient rather than on the doctor or nurse. A better more inclusive approach is that of universal precautions, where information and services are developed to be accessible and understandable by people with low health literacy and numeracy.27 Table 2shows the proportion of the English working age population at or above different literacy and numeracy levels; from this table it can be seen that producing information presented more simply greatly increases the proportion of the population able to understand and use it. Obviously a proportion of the population have more sophisticated language and numeracy skills, therefore simple and accessible materials can be supported by more complex information available to those who request it.

Table 2. Percentage of the English working age population at or above different literacy and numeracy skills levels

% Literacy
% Numeracy

Entry level 2
95
93

Entry level 3
93
76

Level 1
85
51

Level 2 or above
57
22

‘Spiky profiles’ and learning preferences
Literacy and numeracy skills are made up of ‘sub-skills’ using different cognitive processes. For literacy the sub-skills are reading comprehension, vocabulary, word recognition, comprehension and writing. For numeracy the sub-skills are numbers, shapes and space and data handling. Everyone has skills that are better in some areas than others and corresponding learning preferences (‘spiky profiles’18, for people at lower skill levels these are more marked. People with higher skills levels will generally be able to adapt to understand and use information presented in a non-preferred format, whereas people with lower skills will find this difficult or impossible to do.

Cognitive processing of information
Skills levels also impact on the extent of cognitive processing applied to information, as shown in Bloom’s Taxonomy of Learning28 (Fig. 1). At the lowest skill level people may know, but not understand information. More sophisticated skills are required to apply knowledge in various settings and to be able to analyze the information ‘de novo’ rather than having to rely on pre-analyzed data. Being able to deconstruct and reconstruct information and to evaluate the relevance of information to oneself, one’s life and work environments requires the highest level cognitive skills. This is of importance in vaccination information, which requires cognitive processing at all these levels as patients must not just understand but evaluate and act upon vaccination information.

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Figure 1. Bloom’s taxonomy of learning28

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Making vaccine information easier to understand
For vaccine information to be accessible and useful for as many people as possible those producing vaccine information should take account of the literacy and numeracy level required to understand and use the materials. This should include the design and layout of the material, whether materials can be produced in varying formats to suit learning preferences and whether additional support is required in understanding and applying the information thus enabling patients to make decisions that are right for them.
Simple steps can be taken to reduce the literacy and numeracy difficulty of vaccine information. For text (literacy) information, the SMOG (simplified measure of gobbledygook) is a useful tool. Developed in the US.29 It has now been applied to UK English.30 The two major factors impacting on the readability are the number of syllables in each word, specifically the number of words with three or more syllables, and the sentence length. Short sentences and short words greatly increase the accessibility of information to people with lower skills levels. The SMOG test is available online (http://www.niace.org.uk/misc/SMOG-calculator/smogcalc.php#top) meaning that documents can be written, rewritten and simplified easily. The SMOG is however only a tool; it does not analyze the quality of the content – completely incorrect information can be written at a highly accessible level – but it is helpful when used well. In addition factors such as document layout, font size and word spacing can have a large impact on readability.30Communicating complex medical information in mono- and bi-syllabic words can be very challenging; how can one explain about illnesses such as meningococcal septicaemia without using these very complex words? Such ‘medical metalanguage’ is best managed by using the term once or twice early in a text, next to a simplified explanation, then referring back to the term with simpler language. In longer texts this can be repeated to refresh recognition of essential medical terms. (Table 3.)

Table 3. Making the literacy (text) element of materials easier to read

Harder to read
Easier to read

Text density
High density of text
Lots of white space, short chunks of text, spaces between chunks of text

Line spacing
Less than double
Double or greater

Font
Gothic, italic
Size less than 12
Distinct, clear e.g., Calibri, Arial, Helvetica. Size 12–14

Casing
ALL CAPITALS
Mixture upper and lower case

Highlighting methods
CAPITALS
Bold or boxed

Separated from relevant text, used as background
Next to relevant text, at end of paragraphs

Illustrations
Separated from relevant text, used as background
Next to relevant text, at end of paragraphs

Layout
Headings scattered throughout pages, sentences running over ages, no page numbering.
Headings and new sections at top of pages. Sentences and paragraphs not running over pages. Pages numbered.

SMOG
Long sentences, long words, multiple clauses, many points per sentence
Short sentences, short words, one point per sentence, one or two clauses

Voice
Passive
Active

Complex medical language
Used frequently
Used once or twice only with everyday language explanation

Unfortunately, no tools like the SMOG exist to assess and simplify the numeracy content of materials. There are, however, simple steps that can be taken to make the numeracy content of materials easier to understand. This is particularly important for vaccine information because of the need to convey complex numerical constructs such as risk. These difficulties are augmented by the fact that for 60% of people numeracy skills levels are lower than literacy skills.18 Generally an individual’s numeracy skills decline faster than literacy skills as many people do not routinely use numeracy skills in everyday life. Finally, large numbers (over 1,000) are difficult for people to conceptualize. Steps to increasing the accessibility of the numeracy components of materials are shown in Table 4. Key points are to avoid numbers wherever possible, to reduce the number of calculations required to zero or 1 by using absolute values (i.e., avoiding decimals and fractions) and giving real-life examples rather than abstract concepts. As with the text component of materials, using larger clearer fonts, spacing and increasing the amount of white space may help to keep numerical information clear. Following these suggestions will mean that understanding will be improved for many people, enabling them to undertake more sophisticated cognitive processing such as applying the information to their situation and evaluating different sources and types of information. Having information available in different formats (such as graphs, pictographs, video and audio formats) may be helpful for people with lower numeracy skills, who can then choose the format they find most helpful.

Table 4. Making the numeracy element of materials easier to understand

Harder to understand
Easier to understand

Calculations
Raw figures
Example calculations, simple descriptions, avoid ambiguity

Terminology
Maths: maximum or majority / minimum or minority / mean / median / diameter
Literacy: most / least or fewer / average / commonest / width or size

Fractions / ratios etc
Ratios / proportions / fractions / percentages
Absolute values, consider pictorial respresentation

Number size and complexity
Large numbers, decimal points
Small numbers, whole numbers

Figures vs words
Words (e.g., Eighty-eight)
Numbers (e.g., 88)

Concepts
Abstract maths concepts
Real-life examples

Number of calculation steps
Multiple steps
None, or single steps with examples. If multiple steps are required consider tables

Layout
Lots of numbers, small font, distracting information
Few numbers next to simple explanatory text, lots of white space, tables may help

Finally, written information should always be supported by the practitioner checking the patients’ understanding. The ‘teach back’ technique is a good example31; the practitioner uses a phrase such as ‘let me see if I’ve explained this clearly enough. Can you tell me the benefits to you if you have this injection?’ The emphasis should always be that teach back tests the practitioner communication skills, not the patient health literacy skills.

Building public health literacy skills
Teaching basic skills to adults is a highly specialized field outside both the skill-sets and time constraints of health professionals. However health professionals aware of the issues of health literacy may, through their clinical work, be able to identify patients with low literacy and numeracy skills who would benefit from opportunities to build their health literacy skills. Good health is important to everyone and thus is an excellent ‘hook’ to get people engaged in learning literacy and numeracy. Furthermore, the skills learned are likely to be highly transferable to other areas of life such as management of personal finances. Learning outcomes from such programmes include increased health knowledge, improved health behaviors, and engagement in further learning, including studying for qualifications.32 In vaccination clinics, sensitivity to the issues involved, and engagement with local education services, means that patients who might benefit from developing health, and wider, literacy and numeracy skills can be supportively referred to appropriate education courses.

Potential impact on participation in vaccination programmes
The known association between low health literacy and low rates of involvement in vaccination programmes implies that simplifying vaccine information and building patient health literacy skills should lead to higher vaccination rates, but such interventions may have unexpected outcomes. There has been little high quality research published in this area,6 however a well-designed Australian randomized controlled trial looked at the effect of a carefully designed decision aid focusing on the benefits and risks of Colorectal Cancer (CRC) Screening, when this was sent out with the CRC screening kit it increased knowledge and informed choice but decreased participation in screening.33 Decisions about participation in preventative health actions are complex and will reflect not only the extent to which individuals can understand the information, but also issues of self-efficacy, locus of control, previous experiences (personally or of family and friends) and cultural influences. Interventions designed to improve participation may need to look different to interventions designed to improve knowledge and inform choice. A potential solution to this could be the theoretical construct ‘critical health literacy’, defined by Nutbeam as ‘more advanced cognitive skills that, together with social skills, can be applied to critically analyze information, and to use this information to exert greater control over life events and situations’34. Nutbeam goes on to postulate that developing higher-level health literacy skills will have social benefits and the development of social capital. It could be that by clearly outlining the benefits and risks to the individual, their friends, families and communities (i.e., the risk of infectious disease outbreaks if immunization rates (herd immunity) drop below critical levels) about the benefits of immunization, may lead to more informed decisions, resulting in higher participation rates.

Conclusion
Health literacy is a complex concept, ranging from basic skills in reading and numeracy through to advanced cognitive skills needed to critically analyze information, and to use this to exert greater control over life events and situations. Health literacy is important for those developing and delivering vaccination programmes, as both the information and the actions required to use the information are complex requiring sophisticated health literacy skills beyond the capacity of a significant proportion of the population. However, simple steps can be taken to make the information in vaccination materials easier to understand and use. Materials should be produced at as simple literacy and numeracy level as possible, with more detailed and sophisticated material available for those wanting more detailed information. Those with lower skills should be offered alternative information formats or longer 1:1 consultation time. Techniques such as ‘teach-back’ can be used to check that information has been successfully communicated and understood.
In the course of their work, those administering vaccines will identify patients with low health literacy skills. Such health professionals are in an ideal position to inform patients about local opportunities to develop literacy and numeracy skills for health and multiple other areas in life. Developing partnerships between health professionals and adult learning tutors can lead to fruitful partnerships for both.
Finally, while developing and using health information which is easier to use and understand must be best for patients, and will improve informed consent, it may have unintended consequences on participation rates. Widening information and discussions beyond individual benefits and risks, to include consequences to families, communities and the wider society may help to redress this.

Glossary

Abbreviations:

CRC
Colorectal Cancer

NQF
National Qualifications Framework

SMOG
simplified measure of gobbledygook

The concept of health literacy evolved from a history of defining, redefining, and quantifying the functional literacy needs of the adult population. Along with these
changes has come the recognition that sophisticated literacy skills are increasingly
needed to function in society and that low literacy may have an effect on health
and health care. We present a brief history of literacy in the United States, followed
by a discussion of the origins and conceptualization of health literacy. Increased
attention to this important issue suggests the need to review existing definitions of
the term ”health literacy,” because despite the growing interest in this field, one
question that persists is, ”What is health literacy?”
In 2006, David Baker offered a perspective about the meaning and the measure of
health literacy (Baker, 2006). He astutely acknowledged that there was a lack of
shared meaning of the term ”health literacy,” noting, ”Ironically, as the field of
health literacy has expanded in scope and depth, the term ‘health literacy’ itself
has come to mean different things to various audiences and has become a source
of confusion and debate” (p. 878). It seems that Baker’s goal of adopting a shared
terminology of ”health literacy” among researchers and other experts—which was
also recommended by the Institute of Medicine (2004)—has not yet been realized.
In this commentary, we assess the status of the meaning of the term ”health
literacy”—looking both retrospectively and prospectively for wisdom and for direction. We begin with a historical review of the evolution of the definition and
measurement of literacy in the United States. This reflection provides useful context
and demonstrates the massive transformation that has occurred with literacy. The
historical view will help to inform ideas about future directions in defining and
measuring health literacy and supports an expectation that conceptualizations(and definitions) of health literacy will continue to evolve in response to rapid advancement in science and technology, as well as changes in delivery of health care

and public health services, coupled with increasing expectations and responsibility on individuals and groups to be able to understand and act on the information.
Next, we look systematically at the variety of published definitions of health
literacy and how they enhance our understanding of the evolution of the term and
the overall construct. We offer suggestions for minor modifications to the most
commonly used definition of health literacy which more directly incorporates
expectations of the current health care system and the changing nature of the patient=clinician relationship. We note how the rapid expansion in the field of health
literacy has influenced and expanded its definition and framework.
The Changing Definition of Literacy in the United States
In early U.S. history, definitions and measurement of literacy were crude. Before the
Civil War, an individuals’ ability to sign his name on a legal document (rather than
mark with an X) was an indication of literacy (Lockridge, 1974). In the mid 1800s
through the mid 1930s, the U.S. Census Bureau merely asked individuals (white
males initially) if they could read and write in any language. Using this approach,
20% of the population was deemed illiterate in the 1870s, but a century later
(1979) only 0.6% of adults reported they could not read or write (Kaestle,
Damon-Moore, Stedman, & Tinsley, 1991). Though inexactly measured, this trend
indicated that complete illiteracy became rare in the United States.
In the twentieth century, more sophisticated definitions, conceptualizations,
and measurement began to evolve in large part because military and labor experts
were interested in determining what individuals needed to function on the job. The
Civilian Conservation Corps coined the term ”functional literacy,” and defined it
as having three or more years of schooling. For the next thirty years, literacy was
defined in relation to increasing levels of school achievement, corresponding to the
greater demands in the labor market and society overall. In the 1940s, a fourth
grade education was considered the literacy level needed for various army jobs
(Comings & Kirsch, 2005; Sticht, 1975). By the 1950s, the U.S. Census Bureau
defined functional literacy as having at least a 6th grade education and by the
1960s, as part of the War on Poverty, the Department of Education set a national
standard of functional literacy as an 8th grade education and expanded adult basic
education programs to help achieve that goal (Kirsch & Jungeblut, 1986). In the
late 1970s, it was thought that individuals needed at least a high school diploma
(Kaestle et al., 1991). Today, postsecondary training is often considered necessary
for individuals to compete in the labor market (Snow & Biancarosa, 2003;
Spellings, 2006).
Public policy was influenced in the 1980s by publication of ”Toward a Literate
Society,” a report by reading researchers Carroll and Chall which stated that, while
illiteracy levels were declining, many individuals in the U.S. continued to have severe
reading problems. Low literacy was identified as a national policy concern that
would limit our economic, social, and defense competiveness and ”risk the very
security of the nation” (Kaestle et al., 1991). This National Academy of Education
report stated that any national program to improve literacy needed accurate and
detailed data about the number of individuals with limited skills, the severity of their
problems and their sociodemographic characteristics (Carroll & Chall, 1975; Kirsch
10 N. D. Berkman et al.
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et al., 1993). Health Literacy Level Essay Assignment.Subsequent Congressional hearings found it difficult to examine the
magnitude of the problem or trends because of inconsistencies in the ways literacy
was defined and measured. In 1988, Congress asked the Department of Education
to define literacy and address the need for information on the nature and extent
of adult literacy. The resulting National Literacy Act defined literacy in 1991 as
”an individual’s ability to read, write and speak in English, and compute and
solve problems at a level of proficiency necessary to function on the job and in
society, to achieve one’s goals, and develop one’s knowledge and potential” (Kirsch
et al., 1993).
Accompanying increasing attention to defining and improving literacy was a
focus on population measurement. While testing of children focused on achievement
in school (Kaestle et al., 1991; Snow, 2003), testing of adults was conceptualized as
functional literacy or skills practiced outside of schools to accomplish practical tasks
in work, leisure and citizenship (Kaestle et al., 1991).Health Literacy Level Essay Assignment. The more expansive concept of
functional competency goes beyond basic functional literacy and includes higher
order cognitive activities such as information processing, working memory, problem
solving and quantitative skills (Kaestle et al., 1991; Kirsch & Jungeblut, 1986).
The first major efforts to measure literacy in the adult population focused on
real world tasks but were limited to particular segments of the population. The
Department of Education’s 1985 National Assessment of Educational Progress
(NAEP) tested young adults 21 to 25 years of age (Kirsch & Jungeblut, 1986) and
in 1990, the Department of Labor commissioned the Literacy Proficiencies of Job
Seekers (Kirsch et al., 1993). Finally, the Department of Education commissioned
the 1993 National Adult Literacy Survey (NALS) to assess the breadth and
depth of adult literacy in the entire population (Kirsh et al., 1993; Committee on
Performance Levels for Adult Literacy, 2005). Based on the results of the previous
two tests, literacy was viewed as an ordered set of skills and was characterized into
three domains: prose, document, and quantitative skills. The results indicated that
21–23% of the adult population was in the lowest of 5 literacy levels and another
25–28% was in Level 2; the related conclusion that 90 million Americans lacked
adequate literacy skills received widespread media attention. Health Literacy Level Essay Assignment.
The Department of Education’s subsequent 2003 National Assessment of Adult
Literacy Survey (NAAL) was commissioned in part to identify how many indivi-
duals had ”below basic skills” and needed basic adult education (Kutner et al.,
2007). At the request of Healthy People 2010 and health services researchers, health
items were included the survey. The NAAL was the first large scale national literacy
assessment to contain a component specifically designed to measure health literacy in
U.S. adults (Kutner et al., 2007). An oral reading fluency section was added to better
understand reading difficulty and a supplement was designed for adults with very
low literacy to gather information on how they understood and navigated literacy
and health literacy demands in their daily lives (Baer et al., 2009). Health tasks
were characterized into three types: clinical, preventive and navigation of the health
system. Scores were divided into four categories: below basic, basic, intermediate and
proficient. Results of the three literacy scales differed slightly from the health literacy
scale; 12–33% scored below basic and 22–33% scored in the basic category on the
three functional literacy scales, compared to 14% scoring below basic and 22% scor-
ing in the basic category on the health literacy scale. Several key conceptual features
of literacy were found to affect performance on any given literacy or health literacy
task: the task demand, test characteristic and the individual’s skill (White, 2010).
Definitions of Health Literacy 11
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This brief history of literacy in the United States aligns with the country’s shift
from an agricultural to an industrial economy and now to an information-based
economy. The definitions and measurement of literacy have also changed, becoming
more representative of the skills needed to function successfully in the current
society. In the last twenty years, the relationship between low literacy, health status
and health outcomes have been documented (Berkman et al., 2004; IOM, 2004). This
growing body of research has led to the formation of a new field of study referred to
as health literacy.
The Origins of the Conceptualization of Health Literacy
Multiple Definitions of Health Literacy
As a relatively new construct, the definition of health literacy is evolving and has not
been consistently applied (Berkman et al., 2004). Health Literacy Level Essay Assignment.Because individuals with similar
educational attainment can differ substantially in their reading and mathematical skills,
educational attainment was recognized as an inconsistent indicator of skill level
(Berkman et al., 2004; Kirsch et al., 1993; Kutner et al., 2007). Thus, it can be an
inaccurate proxy measure of individuals’ baseline skills when evaluating differences in
health outcomes or the effectiveness of health related interventions. This recognition
led to an appreciation for the need to more directly conceptualize health related literacy.
Reaching a consensus on a definition of health literacy is complicated by the
multiple skill categories and applications that are increasingly identified as necessary
to be ”literate” in relation to one’s health. Table 1 presents a summary of definitions
of health literacy found in the literature. While an early definition focused on the
ability to apply basic reading and mathematical (numeracy) skills in a health care
context (AMA Ad Hoc Committee, 1999), a widely cited subsequent definition
focuses on the goals of being health literate, ”the capacity to obtain, process, and
understand” in a health related context, rather than the specific skills required to
achieve those goals (Ratzan and Parker, 2000). Several later definitions, with varying
levels of specificity, detail a constellation of abilities that would be needed for an
individual to be health literate; these include, in addition to literacy and numeracy,
rhetorical discourse (effective speaking, listening, and writing), the ability to use
technology (particularly the Web), motivation, cognitive ability, and networking
and social skills (Nutbeam 2006; Bernhardt, Brownfield, & Parker, 2005). Health Literacy Level Essay Assignment.
Further distinctions across definitions include differences in several important
domains including whether the focus is on the individual or at a broader level,
and whether health literacy level is considered static or can be expected to change
over time through experience, and changes in the health care system and society,
including changes in technology. We discuss these issues in greater detail below.
Is Health Literacy an Individual or a Broader Construct?
Health literacy is commonly considered an individual-level construct and refers to a
person’s ability or capacity (see Table 1). Some definitions imply, while others
specifically refer to specific skills an individual would need to perform health care
related tasks. Across definitions, outcomes are related to the health of the individual,
but vary in nuance, e.g., making health decisions, functioning in the health care
environment, or promoting and maintaining good health. A recent definition of

Table 1. Various definitions of health literacy
Definitions Source
Individual static definitions
The constellation of skills, including the
ability to perform basic reading and
numerical tasks required to function in
the health care environment, such as the
ability to read and comprehend
prescription bottles, appointment slips,
and other essential health-related
materials. Health Literacy Level Essay Assignment.
AMA Ad Hoc Committee on
Health Literacy (1999)
The degree to which individuals have the
capacity to obtain, process, and
understand basic health information
and services needed to make
appropriate health decisions.
Ratzan & Parker (2000), in
Institute of Medicine (2004)
and Healthy People 2010,
DHHS (2000)
The capacity of individuals to obtain,
process, and understand the basic
information and services needed tomake appropriate health decisions. Lee et al. (2004) note that moderators of  health literacy include disease and
self-care knowledge, health risk
behavior, preventive health, and
physician visits, and compliance with
medications. Social support is a
moderator for the relationship of health
literacy with health status and health
service use. Health Literacy Level Essay Assignment.
Selden, Zorn, Ratzan, & Parker
(2000) in Lee, Arozullah, &
Cho (2004)
The cognitive and social skills that
determine the motivation and ability of
individuals to gain access to,
understand, and use information in
ways that promote and maintain good
health. Ratzan (2001) conceptualizes
health literacy as a framework for
health promotion activities and a link
between knowledge and practice. Health Literacy Level Essay Assignment.
Nutbeam (2000) in Ratzan (2001)
Personal, cognitive, and social skills that
determine the ability of individuals to
gain access to, understand, and use
information to promote and maintain
good health. These include such
outcomes as improved knowledge and
understanding of health determinants,
and changed attitudes and motivations
Nutbeam (2006)
(Continued )
Definitions of Health Literacy 13
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Table 1. Continued
Definitions Source
in relation to health behavior, as well as improved self-sufficiency in relation to defined tasks. Typically these are outcomes related to health education activities. Health literacy is conceptualized as one domain in a conceptual model of health promotion.
An individual-level construct composed of
a combination of attributes that can
explain and predict one’s ability to
access, understand, and apply health
information in a manner necessary to
successfully function in daily life and
within the health care system. Health Literacy Level Essay Assignment.
Functional health literacy: the skills and
ability to successfully function and
successfully complete health related
tasks. Individual-level attributes include
abilities in prose, document, and
quantitative literacy; ability to engage
in two-way communication; skills in
media literacy and computer literacy;
motivation to receive health
information; and freedom from
impairments and=or communicative assistance from others.
Bernhardt, Brownfield, & Parker in Schwartzberg et al. (Ed.) (2005)
Health numeracy is the degree to which
individuals have the capacity to access,
process, interpret, communicate, and act on numerical, quantitative, graphical, biostatistic, and probabilistic
health information needed to make
effective health decisions. Health
numeracy is considered to be not simply
about understanding (processing and
interpreting), but also about
functioning (communicating and
acting) on numeric concepts in terms of health.
Goldbeck, Ahlers-Schmidt,
Paschal, & Dismuke (2005)
The degree to which individuals can
obtain, process, understand, and
communicate about health-related
information needed to make informed
health decisions. Health Literacy Level Essay Assignment.

health literacy expands the emphasis beyond individuals to also include groups.
Termed ”public health literacy” this conceptualization concerns the knowledge,
skills and engagement that groups of individuals have to address the public health
of their community (Freedman et al., 2009). Public health literacy is complementary
to individual health literacy and outcomes include a community’s understanding of
public health messages as well as having the skills to evaluate and participate in civic
action related to health care issues.
Table 1. Continued
Definitions Source
Individual dynamic definition
The wide range of skills and competencies that people develop to seek out, comprehend, evaluate, and use health
information and concepts to make informed choices, reduce health risks, and increase quality of life. Zarcadoolas (2005)
Varies by context and setting and is not necessarily related to years of education or general reading ability.
The National Network of
Libraries of Medicine (2009) Individual=system definition
The ability to function in the health care environment and depends on characteristics of both the individual and the health care system. An individual’s health literacy is context specific (dynamic) and may vary depending upon the medical problem being treated, the health care provider, and the system providing care. The definition includes health knowledge. Baker (2006)
Dependent on individual and system factors, including communication skills of lay persons and professionals, lay and professional knowledge of health topics, culture, the demands of the healthcare and public health systems, and the demands of the situation= context. Health Literacy Level Essay Assignment.
Healthy People 2010
Public health definition
Public health literacy is the degree to which individuals and groups can obtain, process, understand, evaluate, and act upon information needed to make public health decisions that benefit the community.

A New Definition of Health Literacy
The Ratzan and Parker (2000) definition that was included in the Institute of
Medicine (IOM) report Health Literacy: A Prescription to End Confusion (2004)
and Healthy People 2010 has been widely used. They define health literacy as being,
”The degree to which individuals have the capacity to obtain, process, and under-
stand basic health information and services needed to make appropriate health
decisions.” Based on a review of the definitions found in the literature (Table 1)
and consultation with an expert panel, we offer some suggestions for minor
modifications to the definition: The degree to which individuals can obtain, process,
understand, and communicate about health-related information needed to make
informed health decisions.
We substituted the phrase ”have the capacity to” to ”can” to emphasize that we
are measuring ”know how” or ability that can be put to use. This more clearly
separates health literacy from intelligence. We added the skill ”communicate about”
to obtain, process, and understand health-related information since we consider oral
communication skills (listening and speaking) to be a critical component of health
literacy. We eliminated the term ”basic” in relation to the health information needed
to make decisions. Each health care decision requires using a different quantity and
complexity of information. Limiting the expectation of the health information and
services individuals have the capacity to use to ”basic” may be misconstrued as there
being a ceiling on the difficulty of decisions. As stated in Healthy People 2010, health
literacy is not simply a function of basic literacy skills, but is ”dependent on individual and system factors, including communication skills of lay persons and professionals, lay and professional knowledge of health topics, culture, the demands of
the healthcare and public health systems, and the demands of the situation=context.”
Also, the term ”basic” focuses attention in the definition on distinguishing between
low and a higher level of health literacy, which is better left to measurement.
We eliminated health services from the definition because health-related
information encompasses information about services. We substituted the word
”informed” for ”appropriate.” Cultural background may influence the manner in
which individuals interact with the health care system, clinicians, as well as their
health related goals. The term ”appropriate” risks being misinterpreted to mean
that there is one best decision for a particular person or situation.
The Influence of the Health Care System on the Definition of Health Literacy
Some definitions characterize health literacy as a product of both an individual’s
capabilities and the demands of the health care system (Baker, 2006; U.S. Depart-
ment of Health and Human Services, 2000). At issue is whether individuals’ level
of health literacy would be considered higher or lower based on variation in the com-
plexity of the information they encounter. One could argue that the population’s
health literacy would be higher if health-related materials and communication more
universally integrated principals of clear language, making them easier to understand
and a closer match to individuals’ skill level.
Definitions of health literacy have begun to embrace a more ecologically framed
conceptual model with an appreciation for the role of language, culture, and social
capitol (Zarcadoolas, Pleasant, & Greer, 2006; Nutbeam, 2008). This more robust
perspective should also recognize the role that health information technology is
16 N. D. Berkman et al. Health Literacy Level Essay Assignment.
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beginning to play in society and the need for considering the ability to use this tech-
nology as a component of health literacy skills. Technology will continue to impact
both our understanding and measurement of literacy and health literacy, as it
increasingly becomes an accepted mode for communicating health information.
We agree that an ecologically framed perspective is appropriate and useful; however,
we believe that caution is warranted to ensure that the conceptualization of health
literacy does not become immeasurable and blur with other concepts, such as
patient-centered communication.
Is Being Health Literate Static or Dynamic?
Whether health literacy is considered a fixed or dynamic concept will impact not
only its definition but its measurement as well. Consistent with a definition of liter-
acy more generally, an individual’s health literacy would be considered relatively
fixed. People can improve their literacy skills only through intensive interventions
such as adult education classes so that generally an individual’s literacy level would
not be likely to change markedly in adulthood, absent such interventions. Corre-
sponding to this conceptualization, an individual’s health literacy level would gener-
ally only need to be measured once. However, some experts consider health literacy
to be dynamic. Zarcadoolas et al. (2005) state that health literacy is ”the wide range
of skills …. that people develop to use health information.” This implies that indivi-
duals’ health literacy can change as they gain experience with the various health
circumstances and choices that they face and therefore their health literacy level
would need to measured and reevaluated repeatedly. We believe that conceptualizing
health literacy as dynamic is inevitable. Viewing health literacy as static was prim-
arily an artifact of its origins in prose literacy ability and related to limitations in
existing measurement tools. We expect future movement to be toward the dynamic
viewpoint, corresponding to increased sophistication in the field.
Is There One Correct Definition?
Through our review, we have gained a greater appreciation for the complex nature of
the construct of health literacy. It can be viewed using a variety of lenses, resulting in
a differently nuanced interpretation. In the end, the definition of health literacy that
one selects may depend on one’s goals. Health Literacy Level Essay Assignment.
Measuring Health Literacy
The development of instruments that go beyond static measures of literacy and
numeracy has lagged behind the attention more recently paid to defining and
conceptualizing health literacy. A few instruments have been commonly used in
studies to directly measure an individual’s literacy or health literacy in relation to
health outcomes. These include the Rapid Estimate of Adult Literacy in Medicine
(REALM) (Davis et al., 1993) and the Test of Functional Health Literacy in Adults
(TOFHLA) (Parker et al., 1995). The REALM and the TOFLHA focus primarily on
reading-related skills (Berkman et al., 2004) and thus, are not considered compre-
hensive measures of the skills needed by individuals in the health care environment.
The National Assessment of Adult Literacy (NAAL) is considered the most
comprehensive tool; however, it is not publically available and thus cannot be used

in research or intervention studies. It seems that health literacy has been in large part
limited by progress in developing measurement tools, more so than definitions and
conceptualizations. Health Literacy Level Essay Assignment.
Conclusions
The terms ”literacy” and ”health literacy” have been defined, refined, and measured
in a variety of ways over the years, responding to changing demands in an increas-
ingly complex society. During the recent period of growing interest in health literacy
as an integral component of health communication, advancements have been made
in defining the term. Lack of consensus about the definition of health literacy could
potentially handicap progress in its measurement or delay solutions to significant
problems. On the other hand, the range of definitions reflects an appreciation for
the complexity of the construct, and the possibility that different definitions may
be needed depending on one’s goals. The field of health literacy is growing rapidly,
broadening to involve a larger and more interdisciplinary audience, and with that,
there is a greater recognition of its complex and multifaceted nature.
References
Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American
Medical Association. (1999). Health literacy report of the Council on Scientific Affairs.
Journal of the American Medical Association,281, 552–557.
Baer, J., Kutner, M., & Sabatini, J. (2009). Basic reading skills and the literacy of America’s
least literate adults: Results from the 2003 National Assessment of Adult Literacy (NAAL)
Supplemental Studies (NCES-2009-481). Washington, DC: U.S. Department of
Education, Institute of Education Sciences, National Center for Education Statistics.
Baker, D. (2006). The meaning and measure of health literacy. Journal of General Internal
Medicine,21, 878–883.
Berkman, N. D., DeWalt, D. A., Pignone, M. P., Sheridan, S. L., Lohr, K. N., Lux, L., et al.
(2004). Literacy and health outcomes. Evidence report=technology assessment No. 87
(AHRQ Publication No.04-E007-2). Rockville, MD: Agency for Healthcare Research
and Quality. Health Literacy Level Essay Assignment.
Carroll, J. B., & Chall, J. S. (1975). Toward a literate society. New York: McGraw-Hill.
Comings, J., & Kirsch, I. (2005). Literacy skills of US adults. In J. G. Schwartzberg, J. B.
VanGeest, & C. C. Wang (Eds.), Understanding health literacy: Implications for medicine
and public health (pp. 43–53). Chicago: American Medical Association Press.
Committee on Performance Levels for Adult Literacy. (2005). Measuring literacy. Perfor-
mance levels for adults. Washington, DC: The National Academies Press.
Davis, T. C., Lon, S. W., Jackson, R. H., Mayeaux, E. J., George, R. B., Murphy, P. W., &
Crouch, M. A. (1993). Rapid estimate of adult literacy in medicine: A shortened screening
instrument. Family Medicine,25(6), 391–395.
Freedman, D. A., Bess, K. D., Tucker, H. A., Boyd, D. L., Tuchman, A. M., & Wallston, K. A.
(2009). Public health literacy defined. Am erican Journal of Preventive Medicine,36(5), 446–451.
Golbeck, A. L., Ahlers-Schmidt, C. R., Paschal, A. M., & Dismuke, S. E. (2005). A definition
and operational framework for health literacy. American Journal of Preventive Medicine,
29(4), 375–376.
Institute of Medicine. (2004). Health literacy: A prescription to end confusion. Washington,
DC: The National Academy Press. Washington, DC. http://www.iom.edu/Reports/
2004/Health-Literacy-A-Prescription-to-End-Confusion.aspx
18 N. D. Berkman et al.
Downloaded by [200.98.139.205] at 15:17 28 January 2016

ORDER A CUSTOM-WRITTEN PAPER HERE

Institute of Medicine. (2009). Measures of health literacy: Workshop summary. Washington,
DC: The National Academy Press. http://www.iom.edu/Reports/2009/Measures-of-
Health-Literacy.aspx
Kaestle, C. F., Damon-Moore, H., Stedman, L. C., & Tinsley, K. (1991). Literacy in the Uni-
ted States. New Haven, CT: Yale University Press.
Kirsch, I., & Jungeblut, A. (1986). Literacy: Profiles of America’s young adults. Princeton, NJ:
Educational Testing Service.
Kirsch, I., Jungeblut, A., Jenkins, L., & Kolstad, A. (1993, September). Adult literacy in
America: A first look at the results of the National Adult Literacy Survey. Washington,
DC: National Center for Education Statistics, U.S. Department of Education.
Kutner, M., Greenberg, E., Jin, Y., & Paulsen, C. (2006). The health literacy of America’s
adults: Results from the 2003 National Assessment of Adult Literacy (NCES 2006–483).
Washington, DC: National Center for Education Statistics.
Kutner, M., Greenberg, E., Jin, Y., et al. (2007). Literacy in everyday life: Results from 2003
National Assessment of Adult Literacy. Washington, DC: U.S. Department of Education.
Lee, S. Y. D., Arozullah, A. M., & Cho, Y. I. (2004). Health literacy, social support, & health:
A research agenda. Social Science and Medicine,58, 1309–1321.
Lockridge, K. A. (1974). Literacy in colonial New England: An enquiry into the social context of
literacy in the early modern West (1st ed.). New York: W. W. Norton & Company.
National Network of Libraries of Medicine. (2009). Health literacy. http://nnlm.gov/
outreach/consumer/hlthlit.html
Nutbeam, D. (2008). The evolving concept of health literacy. Social Science and Medicine,
67(12), 2072–2078.
Nutbeam, D., & Bauman, A. (2006). Evaluation in a nutshell: A practical guide to the evaluation
of health promotion programs. New York: McGraw-Hill.
Parker, R. M., Baker, D. W., Williams, M. V., & Nurss, J. R. (1995). The test of functional
health literacy in adults: A new instrument for measuring patients’ literacy skills. Journal
of General Internal Medicine,10, 537–541.
Ratzan, S. C. (2001). Health literacy: Communication for the public good. Health Promotion
International,16, 207–214.
Schwartzberg, J. G. (Ed.). (2005). Understanding health literacy: Implications for medicine and
public health. Chicago: American Medical Association Press.
Snow, C., & Biancarosa, G. (2003). Adolescent literacy and the achievement gap: What do we
know and where do we go from here? New York: Carnegie Corporation of New York.
Spellings, M. A. (2006). Test of leadership: Charting the future of U.S. higher education. Jessup,
MD: U.S. Department of Education–Education Publications Center. Health Literacy Level Essay Assignment.
Sticht, T. (Ed.). (1975). Reading for working: A functional literacy anthology. Alexandria, VA:
Human Resources Research Organization.
U.S. Department of Health and Human Services. (2000). Healthy People 2010 (2nd ed.).
Washington, DC: Department of Health and Human Services, National Networks of
Libraries of Medicine.
White, S. (2010). Understanding functional literacy: Connecting text features, task demands,
respondent skills. New York: Routledge.
Wide Range Inc. (1993). Wide Range Achievement Test (WRAT 3). Wilmington, DE: Wide
Range Inc.
Zarcadoolas, C., Pleasant, A., & Greer, D. (2005). Understanding health literacy: An
expanded model. Health Promotion International,20(2), 195–203.
Zarcadoolas, C., Pleasant, A., & Greer, D. (2006). Advancing health literacy. San Francisco:
Jossey-Bass

 Nutbeam D. Health Promotion Glossary. Health Promot Int 1999; 13:349 – 64 [Google Scholar]
Rudd R, Kirsch I, Yamamoto K. Literacy and Health in America. Princeton, NJ: Education Testing Service 2004. Accessed at: http://www.ets.org/Media/Research/pdf/PICHEATH.pdf
HLS-EU Consortium. Comparative report of health literacy in eight EU member states. The European Health Literacy Survey (HLS-EU). 2012. Accessed at: http://ec.europa.eu/eahc/documents/news/Comparative_report_on_health_literacy_in_eight_EU_member_states.pdf
. Bostock S, Steptoe A. Association between low functional health literacy and mortality in older adults: longitudinal cohort study. BMJ 2012; 344:e1602; http://dx.doi.org/10.1136/bmj.e1602; PMID:[PMC free article] [PubMed] [CrossRef] [Google Scholar]
 Baker DW, Wolf MS, Feinglass J, Thompson JA, Gazmararian JA, Huang J. Health literacy and mortality among elderly persons. Arch Intern Med 2007; 167:1503 – 9; http://dx.doi.org/10.1001/archinte.167.14.1503; PMID: [PubMed] [CrossRef] [Google Scholar]
. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Viera A, Crotty K, et al. Health Literacy Interventions and Outcomes: An Updated Systematic Review. Rockville (MD): Agency for Healthcare Research and Quality (US); 2011 Mar. (Evidence Reports/Technology Assessments, No. 199.) Available from: http://www.ncbi.nlm.nih.gov/books/NBK82434/ [PMC free article] [PubMed]
 Howard DH, Gazmararian J, Parker RM. The impact of low health literacy on the medical costs of Medicare managed care enrollees. Am J Med 2005; 118:371 – 7; http://dx.doi.org/10.1016/j.amjmed.2005.01.010; PMID: [PubMed] [CrossRef] [Google Scholar]
 Zhang NJ, Terry A, McHorney CA. Impact of health literacy on medication adherence: a systematic review and meta-analysis. Ann Pharmacother 2014; 48:741 – 51; http://dx.doi.org/10.1177/1060028014526562; PMID: [PubMed] [CrossRef] [Google Scholar]
 Murray MD, Tu W, Wu J, Morrow D, Smith F, Brater DC. Factors associated with exacerbation of heart failure include treatment adherence and health literacy skills. Clin Pharmacol Ther 2009; 85:651 – 8; http://dx.doi.org/10.1038/clpt.2009.7; PMID: [PMC free article] [PubMed] [CrossRef] [Google Scholar]
 DeWalt DA, Dilling MH, Rosenthal MS, Pignone MP. Low parental literacy is associated with worse asthma care measures in children. Ambul Pediatr 2007; 7:25 – 31; http://dx.doi.org/10.1016/j.ambp.2006.10.001; PMID: [PMC free article] [PubMed] [CrossRef] [Google Scholar]
\ Cho YI, Lee SY, Arozullah AM, Crittenden KS. Effects of health literacy on health status and health service utilization amongst the elderly. Soc Sci Med 2008; 66:1809 – 16; http://dx.doi.org/10.1016/j.socscimed.2008.01.003; PMID: [PubMed] [CrossRef] [Google Scholar]
 White S, Chen J, Atchison R. Relationship of preventive health practices and health literacy: a national study. Am J Health Behav 2008; 32:227 – 42; http://dx.doi.org/10.5993/AJHB.32.3.1; PMID: [PubMed] [CrossRef] [Google Scholar]
 Garbers S, Chiasson MA. Inadequate functional health literacy in Spanish as a barrier to cervical cancer screening among immigrant Latinas in New York City. Prev Chronic Dis 2004; 1:A07; PMID:[PMC free article] [PubMed] [Google Scholar]
14. Bennett IM, Chen J, Soroui JS, White S. The contribution of health literacy to disparities in self-rated health status and preventive health behaviors in older adults. Ann Fam Med 2009; 7:204 – 11; http://dx.doi.org/10.1370/afm.940; PMID: [PMC free article] [PubMed] [CrossRef] [Google Scholar]
15. Rudd RE. Health literacy skills of U.S. adults. Am J Health Behav 2007; 31:Suppl 1S8 – 18; http://dx.doi.org/10.5993/AJHB.31.s1.3; PMID: [PubMed] [CrossRef] [Google Scholar]
16. Health Literacy in Canada. A Healthy Understanding. Canadian Council on Learning, 2008. Accessed at: http://www.ccl-cca.ca/pdfs/HealthLiteracy/HealthLiteracyReportFeb2008E.pdf
17. Literacy H. Australia. Canberra: Australian Bureau of Statistics, 2006. Accessed at: http://www.abs.gov.au/AUSSTATS/abs@.nsf/Latestproducts/4233.0Main%20Features22006
18. The 2011 Skills for Life Survey: A Survey of Literacy, Numeracy and ICT Levels in England. London: Department for Business Innovation and Skills 2012. BIS Research paper number 81. Accessed at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/36000/12-p168-2011-skills-for-life-survey.pdf
19. Rowlands G, Protheroe J, Richardson M, Seed P, Winkley J, Rudd R. Defining and describing the mismatch between population health literacy and numeracy and health system complexity. In progress; data on file at King’s College London. [Google Scholar]
20. Fair Society. Healthy Lives: A Strategic Review of Health Inequalities in England Post-2010 (The Marmot Review), February 2010. Accessed at: http://www.ncb.org.uk/media/42195/marmotreview_vssbriefing.pdf
21. Rosenkilde KL, Protheroe J, Seed P, Wolf MS, Rowlands G. Estimating Health Literacy levels from National Surveys. In progress. 2014. [Google Scholar] Health Literacy Level Essay Assignment.
22. Weiss BD, Mays MZ, Martz W, Castro KM, DeWalt DA, Pignone MP, Mockbee J, Hale FA. Quick assessment of literacy in primary care: the newest vital sign. Ann Fam Med 2005; 3:514 – 22; http://dx.doi.org/10.1370/afm.405; PMID: [PMC free article] [PubMed] [CrossRef] [Google Scholar]
23. Davis TC, Long SW, Jackson RH, Mayeaux EJ, George RB, Murphy PW, Crouch MA. Rapid estimate of adult literacy in medicine: a shortened screening instrument. Fam Med 1993; 25:391 – 5; PMID: [PubMed] [Google Scholar]
24. Rowlands G, Khazaezadeh N, Oteng-Ntim E, Seed P, Barr S, Weiss BD. Development and validation of a measure of health literacy in the UK: the newest vital sign. BMC Public Health 2013; 13:116; http://dx.doi.org/10.1186/1471-2458-13-116; PMID: [PMC free article] [PubMed] [CrossRef] [Google Scholar]
25. Ibrahim SY, Reid F, Shaw A, Rowlands G, Gomez GB, Chesnokov M, Ussher M. Validation of a health literacy screening tool (REALM) in a UK population with coronary heart disease. J Public Health (Oxf)2008; 30:449 – 55; http://dx.doi.org/10.1093/pubmed/fdn059; PMID: [PubMed] [CrossRef] [Google Scholar]
26. Parikh NS, Parker RM, Nurss JR, Baker DW, Williams MV. Shame and health literacy: the unspoken connection. Patient Educ Couns 1996; 27:33 – 9; http://dx.doi.org/10.1016/0738-3991(95)00787-3; PMID: [PubMed] [CrossRef] [Google Scholar]
27. DeWalt DA, Callahan LF, Hawk VH, Broucksou KA, Hink A, Rudd R, et al. Health Literacy Universal Precautions Toolkit. Rockville MD: Agency for Healthcare Research and Quality, 2010. [Google Scholar]
28. Bloom B. Taxonomy of Educational Objectives: Cognitive and Affective Domains. New York: David McKay Company Inc; 1956 & 1964. [Google Scholar]
29. McLaughlin GH. SMOG Grading–a New Readability Formula. J Read 1969; 12:639 – 46 [Google Scholar]
30. Readability: how to produce clear written materials for a range of readers. Leicester, UK: NIACE; 2009. [Google Scholar]
31. Schillinger D, Piette J, Grumbach K, Wang F, Wilson C, Daher C, Leong-Grotz K, Castro C, Bindman AB. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med 2003; 163:83 – 90; http://dx.doi.org/10.1001/archinte.163.1.83; PMID: [PubMed] [CrossRef] [Google Scholar]
32. Evaluation of the second phase of the Skilled for Health Programme. London: The Tavistock Institute and Shared Intelligence, 2009. Accessed at: http://www.chlfoundation.org.uk/pdf/Skilled_for_health_evaluation.pdf.
 Smith SK, Trevena L, Simpson JM, Barratt A, Nutbeam D, McCaffery KJ. A decision aid to support informed choices about bowel cancer screening among adults with low education: randomised controlled trial. BMJ 2010; 341:c5370; http://dx.doi.org/10.1136/bmj.c5370; PMID: [PMC free article] [PubMed] [CrossRef] [Google Scholar]
. Nutbeam D. Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century. Health Promot Int 2000; 15:259 – 67; http://dx.doi.org/10.1093/heapro/15.3.259 [CrossRef] [Google Scholar] Health Literacy Level Essay Assignment.