Why literacy matters. Links between reading ability and health

Readability of cerebrovascular diseases online educational material from major cerebrovascular organizations

INTRODUCTION

The internet is an essential resource for patients and their loved ones to understand their medical conditions, and professional medical organizations have taken great strides to develop educational material targeting patients. The average American reads at a seventh to eighth grade reading level, hence it is important to understand the readability of this medical information to ensure patients comprehend what is being presented.

METHODS

In January 2023, online patient education material was downloaded from major cerebrovascular healthcare organizations and assessed using eight assessments, including Bormuth Cloze Mean, Bormuth Grade Placement, Coleman-Liau (grade levels), Coleman-Liau (predictive cloze scores), Flesch Reading Ease (FRE), and Fry.

RESULTS

A total of 32 files were extracted from six organizations and analyzed across 15 readability measures. None of the organizations met the federal government guidelines for grade-level readability. This held constant across all measured tests. Two organizations had above a postgraduate level. The FRE graphs do not identify any organizations with material below a ninth grade reading level, while the American Association of Neurological Surgeons (AANS) and the Society of Interventional Radiology (SIR) have a postgraduate readability level. The Fry graphs show similar results, with AANS/CNS Cerebrovascular Section, Society of NeuroInterventional Surgery (SNIS), SIR, and AANS having college-level readability. The lowest readability across all measures is only at an early seventh grade reading level.

CONCLUSIONS

Current health literacy content for cerebrovascular patients is far above the recommended readability level. We provide straightforward suggestions for how major professional organizations should improve their informational material on cerebrovascular diseases to improve patient understanding.

Internet Health Resources on Nocturnal Enuresis: A Readability, Quality, and Accuracy Analysis

INTRODUCTION

 Nocturnal enuresis is a common yet quality-of-life-limiting pediatric condition. There is an increasing trend for parents to obtain information on the disease's nature and treatment options via the internet. However, the quality of health-related information on the internet varies greatly and is largely uncontrolled and unregulated. With this study, a readability, quality, and accuracy evaluation of the health information regarding nocturnal enuresis is carried out.

MATERIALS AND METHODS

 A questionnaire was administered to parents and patients with nocturnal enuresis to determine their use of the internet to research their condition. The most common search terms were determined, and the first 30 websites returned by the most popular search engines were used to assess the quality of information about nocturnal enuresis. Each site was categorized by type and assessed for readability using the Gunning fog score, Simple Measure of Gobbledygook (SMOG) index, and Dale-Chall score; for quality using the DISCERN score; and for accuracy by comparison to the International Children's Continence Society guidelines by three experienced pediatric urologists and nephrologists.

RESULTS

 A total of 30 websites were assessed and classified into five categories: professional (n = 13), nonprofit (n = 8), commercial (n = 4), government (n = 3), and other (n = 2). The information was considered difficult for the public to comprehend, with mean Gunning fog, SMOG index, and Dale-Chall scores of 12.1 ± 4.3, 14.1 ± 4.3, and 8.1 ± 1.3, respectively. The mean summed DISCERN score was 41 ± 11.6 out of 75. Only seven (23%) websites were considered of good quality (DISCERN score > 50). The mean accuracy score of the websites was 3.2 ± 0.6 out of 5. Commercial websites were of the poorest quality and accuracy. Websites generally scored well in providing their aims and identifying treatment benefits and options, while they lacked references and information regarding treatment risks and mechanisms.

CONCLUSION

 Online information about nocturnal enuresis exists for parents; however, most websites are of suboptimal quality, readability, and accuracy. Pediatric surgeons should be aware of parents' health-information-seeking behavior and be proactive in guiding parents to identify high-quality resources.

Readability of Online Patient Education Materials for Glaucoma

PRCIS

We assessed the readability of online glaucoma patient education materials using seven validated instruments. Overall, glaucoma materials were written at a 10th to 11th grade level, above the recommended seventh grade reading level.

PURPOSE

Online health information is increasingly used by patients, yet previous studies show online patient education materials are often difficult to understand. As such, the American Medical Association recommends that patient education materials are written at or below a seventh grade reading level. This study aimed to assess the readability of online glaucoma patient education materials.

METHODS

Glaucoma was entered into the Google search engine, and the first 30 search results were assessed for readability using seven validated readability instruments. Scientific articles, forums, and dictionary entries were excluded. Single sample t tests were used to assess whether online glaucoma materials were written above the recommended seventh grade level.

RESULTS

Overall, glaucoma materials were written at a mean grade level of 10.33 (SD: 2.02). Across 6 grade level readability instruments, these patient education materials were written above the recommended seventh grade reading level (P<0.0001 for all). Glaucoma education materials only on the first page of Google search results were of a similar reading level: mean 10.56 (SD: 2.13). The readability instruments used in this study showed strong consistency.

CONCLUSIONS

Glaucoma patient education materials are written above the recommended reading level to promote accessibility of education materials. This may contribute to lower patient engagement, worse clinical outcomes, and greater racial and ethnic disparities in glaucoma management. There is a need for reliable, simple glaucoma information to improve patient outcomes.

Relationship between socioeconomic, demographic, health and social characteristics and ability to access reliable information on herbal and food supplements: analysis of Thai Health Literacy Survey 2019

Background

The consumption of herbal and food supplements attributing to health expenditures in Thailand has been increasing over the years. However, information on herbal and food supplement products can make it difficult for some people with limited health literacy to use. Evidence from previous studies outside Thailand shows that SES disadvantaged groups are more likely to have limited health literacy compared with their counterparts with advantaged SES. The present study adds to this body of knowledge through an exploration of health literacy competencies related to herbal and food supplement consumption to determine what competency would be most problematic among Thai people. The study also investigated the influences of demographic and socio-economic factors on the most problematic health literacy competency on herbal and food supplements.

Methods

The THL-S used a stratified three-stage-sampling to draw a sample of Thais aged 15 years and above. Participants were interviewed with a questionnaire of 34 items measuring health literacy and 8 items measuring behavioural practices. Responses to questions on accessing, understanding, communicating, and making decisions related to herbal and food supplement consumption were analysed. A logistic regression model was used to explore the association between having difficulties in accessing information and participant’s socio-economic factors.

Results

Levels of difficulties the participants experienced varied among their health literacy competencies. Accessing reliable information was found to be the most problematic health literacy competency faced by respondents (48%), followed by asking healthcare providers about herbal products and food supplements (41%). Significant differences in the ability to access reliable information on herbal and food supplements were found to be based on differences in: education, income levels, occupation, insurance scheme coverage, age, sex, reading ability, writing ability, chronic diseases, wearing eyeglasses or lenses, hearing impairment, and having a community leading role.

Conclusions

Accessing reliable information on herbal and food supplements has been found to be the most difficult health literacy competency among respondents to the survey, particularly vulnerable consumers in the society such as people with hearing impairment or having limited overall literacy competencies. Therefore, health literacy programs might be developed to build health literacy competencies and empower vulnerable consumers for reasonable use of herbal and food supplements.

Evaluation of online, publicly available cancer-related educational and self-management resources for symptom management

OBJECTIVE

The aims of this study were to evaluate the readability, suitability, and quality of publicly available online self-management (SM) resources for people with cancer.

METHODS

Resources were identified using two strategies: (1) a targeted search of 20 Canadian organizations and (2) a Google search. These were evaluated using the Suitability Assessment of Materials (SAM), the DISCERN tool for quality, and readability indices. The SM skills (e.g., problem-solving) and symptom management strategies addressed by each resource were also assessed. Descriptive and hierarchical cluster analyses were performed to identify resources of the highest suitability and quality as well as resource characteristics associated with higher quality and suitability.

RESULTS

A total of 92 resources were evaluated. The mean reading grade level for English resources was 10.29 (SD = 1.64, range of 7.05 to 15.09) and 12.62 for French resources (SD = 2.27, range of 10.12 to 15.65). The mean SAM score across the sample was 50.4% (SD = 10.6%), or 'adequate', and the mean DISCERN score was 61.1% (SD = 11.8%), or 'fair'. The cluster analysis indicated that 10 resources scored highly on both the SAM and the DISCERN. In total, 91 symptom management strategies were identified. On average, resources addressed 2.73 SM skills (SD = 1.58).

CONCLUSIONS

There is a need for plain language resources for people with lower reading ability and resources that incorporate more SM skills. Study findings will help healthcare professionals, patients, and their families identify optimal resources to address cancer-related symptoms.

Identifying predictors of reading speed and reading comprehension in Bosnian

The goal of the present study was to examine the predictors of reading speed and reading comprehension in third-grade students from Bosnia and Herzegovina (BIH). The sample consisted of 168 third-grade students (86 boys, 82 girls) attending regular schools in Canton Sarajevo, BIH. We examined the effects of phonological awareness (phoneme deletion and rhyming), rapid automatized naming (RAN) of letters and objects, semantic fluency, working memory, and processing speed, on three reading speed tasks and a reading comprehension task. For the reading speed tasks, total amount of explained variance was 33% for reading a text passage, 40% for word reading and 36% for pseudoword reading. The most important predictors of reading speed tasks were phoneme deletion task and RAN: Letters. On the other hand, the model explaining reading comprehension was much less predictive and explained about 11% of variance. Significant predictors of reading comprehension were working memory and processing speed. The results of this study are very informative in creating better models of reading. This in turn will help create better reading intervention programs and potentially reduce the number of children with reading disabilities.

Using readability software to enhance the health literacy of equine veterinary clients: An analysis of 17 American Association of Equine Practitioners' newsletter and website articles

BACKGROUND

Veterinarians often provide supplemental healthcare information to horse owners via newsletters and website articles. However, articles written above the reading level of the intended audience contributes to misunderstanding. To ensure that the text in equine healthcare articles and brochures is consistent with the literacy of clients, veterinarians can adopt guidelines set forth by the National Institutes of Health (NIH) and the American Medical Association (AMA) for a target 6th grade readability level.

OBJECTIVES

The goal of this study was to evaluate the readability levels of a sample of American Association of Equine Practitioners' (AAEP) newsletter and website articles prepared expressly for veterinarians to download and share with their clients. Examples from these handouts are used to illustrate principles and techniques veterinary professionals can use to align their writing with the literacy of their intended audience.

STUDY DESIGN

Software-based readability analysis of 17 AAEP newsletter and website articles.

METHODS

A free online readability calculator was used to generate a consensus grade level readability score for 17 downloadable AAEP veterinary newsletter and website articles.

RESULTS

Sixteen of 17 articles were written above the recommended 6th grade reading level.

MAIN LIMITATIONS

We propose that a 6th grade readability level, as set forth by the AMA, is a reasonable target for the diverse population that makes up veterinary clients; however, there is currently no research that establishes this target for veterinary clients and the American Veterinary Medical Association (AVMA) has yet to issue a consensus statement on the subject.

CONCLUSIONS

Awareness of the issue of client literacy and use of tools such as readability analysis software can help veterinarians provide clients with 'easy-to-read' written materials that deliver a message that clients can comprehend, thus improving their health literacy and empowering them as partners in the veterinary-client relationship.

Evaluating the complexity of online patient education materials about brain aneurysms published by major academic institutions

OBJECTIVE

Health care education resources are increasingly available on the Internet. A majority of people reference these resources at one point or another. A threshold literacy level is needed to comprehend the information presented within these materials. A key component of health literacy is the readability of educational resources. The National Institutes of Health (NIH) and the American Medical Association have recommended that patient education materials be written between a 4th- and a 6th-grade education level. The authors assessed the readability of online patient education materials about brain aneurysms that have been published by several academic institutions across the US.

METHODS

Online patient education materials about brain aneurysms were downloaded from the websites of 20 academic institutions. The materials were assessed via 8 readability scales using Readability Studio software (Oleander Software Solutions), and then were statistically analyzed.

RESULTS

None of the patient education materials were written at or below the NIH's recommended 6th-grade reading level. The average educational level required to comprehend the texts across all institutions, as assessed by 7 of the readability scales, was 12.4 ± 2.5 (mean ± SD). The Flesch Reading Ease Scale classified the materials as “difficult” to understand, correlating with a college-level education or higher. An ANOVA test found that there were no significant differences in readability among the materials from the institutions (p = 0.215).

CONCLUSIONS

Brain aneurysms affect 3.2% of adults 50 years or older across the world and can cause significant patient anxiety and uncertainty. Current patient education materials are not written at or below the NIH's recommended 4th- to 6th-grade education level.

Readability of clinical letters sent from a young people's department

BACKGROUND

Writing directly to patients or copying letters to them is common practice in Child and Adolescent Mental Health Services (CAMHS). If the intention is to increase young people's understanding and collaboration in their health care, then the readability of such letters is important. The aim of this study was to reassess the readability of letters sent to patients from the Young People's Department at Royal Cornhill Hospital since it adopted the choice and partnership approach (CAPA).

METHOD

Readability of clinical letters was measured using indices available in Microsoft Word. Results were compared to readability thresholds.

RESULTS

Most letters sent to patients were still not easily readable.

CONCLUSIONS

Awareness of easily accessible readability formulae has not led to acceptable levels of readability in letters. More needs to be done to investigate patients' views and improve communication.

Parental Literacy and Infant Health: An Evidence-Based Healthy Start Intervention

Syracuse Healthy Start, a federally funded infant mortality prevention project in Onondaga County, New York, has undertaken a range of interventions to address parental low literacy as a risk factor for infant mortality. A growing number of studies advocate for health-related information that is easy to read, of a low literacy level, and culturally appropriate. Creation of an evidence-based public health intervention involves analyzing local data, reviewing published studies, assessing available materials, initiating programmatic interventions, and evaluating the outcomes. Preparing health educational materials that are clear, culturally sensitive, and at appropriate reading levels follows Paulo Freire’s lead in empowering the disadvantaged to positively affect their health and the health of their infants toward the reduction of infant mortality.

Functional health literacy, chemotherapy decisions, and outcomes among a colorectal cancer cohort

BACKGROUND

Functional health literacy is essential for the self-management of chronic diseases and preventive health behaviors. Patients with cancer who have a low level of health literacy may be at greater risk for poor care and poor outcomes.

METHODS

We assessed health literacy using the Short Test of Functional Health Literacy in Adults in 347 participants with colorectal cancer who were nested within a prospective observational study of system, health care provider, and participant characteristics influencing cancer outcomes.

RESULTS

Having adequate health literacy increased the likelihood that participants with stage 3/4 disease received chemotherapy (odds ratio, 3.29; 95% confidence interval, 1.23-8.80) but had no effect on cancer stage at diagnosis or vital status at last observation during postenrollment follow-up. No difference was seen in health literacy status regarding participant beliefs and preferences about chemotherapy among those with stage 3/4 disease, nor in participant roles in deciding whether to receive chemotherapy.

CONCLUSIONS

Patients with lower levels of health literacy were less likely to receive chemotherapy compared with participants with higher levels of health literacy. Therefore, clear communication related to key health care decisions may lead to fewer disparities due to a patient's level of health literacy.

The Challenge of Cardiovascular Diseases and Diabetes to Public Health: A Study Based on Qualitative Systemic Approach

The most common modeling approaches to understanding incidence, prevalence and control of chronic diseases in populations, such as statistical regression models, are limited when it comes to dealing with the complexity of those problems. Those complex adaptive systems have characteristics such as emerging properties, self-organization and feedbacks, which structure the system stability and resistance to changes. Recently, system science approaches have been proposed to deal with the range, complexity, and multifactor nature of those public health problems. In this paper we applied a multilevel systemic approach to create an integrated, coherent, and increasingly precise conceptual framework, capable of aggregating different partial or specialized studies, based on the challenges of the Longitudinal Study of Adult Health - ELSA-Brasil. The failure to control blood pressure found in several of the study's subjects was discussed, based on the proposed model, analyzing different loops, time lags, and feedback that influence this outcome in a population with high educational level, with reasonably good health services access. We were able to identify the internal circularities and cycles that generate the system's resistance to change. We believe that this study can contribute to propose some new possibilities of the research agenda and to the discussion of integrated actions in the field of public health.

Health literacy, computer skills and quality of patient-physician communication in Chinese patients with cataract

Purpose

The aim of the study was to assess levels of health literacy and computer skills in Chinese patients with cataract, and their impact on the doctor-patient relationship.

Methods

We undertook a cross-sectional study of cataract patients scheduled for cataract extraction procedures in Guangdong Province, China. Generic health literacy was assessed using 3 established screening questions. Adequate computer skills was determined if patients had used a computer and routinely used search engines on the Internet. Socio-demographic measures (e.g., age, sex, education) were obtained from a standardized interview. Participants who indicated that they could not understand what their doctors mean were considered to have had poor patient-physician communications.

Results

Of the 211 participants, 92 (43.6%) had inadequate health literacy and 204 (96.7%) inadequate computer skills. In multivariate analysis, females were more likely to have inadequate health literacy (odds ratio = 2.5, 95% confidence intervals [CI]: 1.3 to 4.7). People with inadequately health literacy were more likely to have a poor patient-physician communication (odds ratio = 3.5, 95% CIs: 1.3 to 9.0). Similar associations were found for inadequate computer skills.

Conclusion

Chinese elderly patients with cataract have inadequate health literacy and very limited computer skills, which place them at high risk of misunderstanding and mismanaging their ocular conditions. Patient education information other than online materials may improve the eye care and outcomes of these patients.

Knowledge of and barriers to health literacy in Illinois

OBJECTIVE

To examine Illinois pharmacists' knowledge of and barriers to health literacy.

DESIGN

Cross-sectional descriptive study.

SETTING

Illinois, August to November 2009.

PARTICIPANTS

701 Illinois pharmacists.

INTERVENTION

Mail survey.

MAIN OUTCOME MEASURES

Pharmacists' knowledge (percent correct), mean barrier factors, and percent agreement of barrier items.

RESULTS

Usable responses were obtained from 701 respondents out of 1,457 pharmacists receiving surveys (48.1%). Percent correct for knowledge items ranged from 31.5% to 95.4% with only 19% to 27% of respondents answering a majority of the items correctly. Pharmacists had poor knowledge (percent correct) about prevalence of low health literacy (31.5%), its relationship to years of schooling (46.9%) and its lack of relationship to reading comprehension (48.4%). Overall process and practice-related barrier domain items were the most important barriers. In particular, the most frequently cited barriers towards low health literacy interventions were lack of adequate time (90.4%), use of mail order (83.8%), and presence of convenient delivery mechanisms (82.8%), all process barriers. Majority of respondents (57.3%) agreed that lack of knowledge about health literacy and its consequences is a barrier. Significant differences existed for barrier factors by demographics. Multivariate analysis examining the relationship between knowledge and barriers after controlling for demographics revealed no significant differences.

CONCLUSION

Pharmacists have limited knowledge of health literacy. We suggest training programs designed to address poor knowledge, interpreter services, access to written information tailored for various reading grade levels, and minimizing functional barriers such as time constraints.

Innovative use of a standardized debriefing guide to assist in the development of a research questionnaire with low literacy demands

Prevalence and impact of low literacy has resulted in greater attention to developing written materials at lower reading levels for both patient education and research. The purpose of this study was to develop and evaluate how well a research questionnaire about self-management preferences, intentionally developed as a tool for individuals with low literacy skills, performed. The investigators created a standardized debriefing guide to evaluate comprehension and ease of instrument completion to accompany the administration of the Conventional and Alternative Management for Asthma (CAMA) instrument. The use of a standardized debriefing guide following cognitive interviewing techniques, allowed for the identification of problematic words, unclear meanings and confusion over scaling despite a deliberate attempt to develop a tool with low literacy demands. Such approaches might be considered critically important to insure the accuracy of patient-reported outcomes when self-administered tools are used to collect research and clinical data.

High-risk populations for vision loss and eye care underutilization: a review of the literature and ideas on moving forward

Much work has been done to highlight and understand the significant disparities in the use of eye care services, but they continue to exist. We review the existing literature on utilization in high-risk populations to provide a context for understanding what "high-risk" means, to understand the utilization patterns among high-risk populations, and to highlight barriers to appropriate eye care utilization. We also discuss potential approaches to reduce these disparities.

Health literacy and glaucoma

PURPOSE OF REVIEW

This review discusses the concept and measurement of health literacy, with a focus on the care of patients with glaucoma.

RECENT FINDINGS

Nearly one-fourth of adults in the USA lack the skills needed to fully comprehend and act on verbal or written information in the healthcare environment. This problem, referred to as poor health literacy, is associated with worse health-related outcomes in many chronic diseases, including glaucoma. Patients with glaucoma and poor literacy skills are less likely to refill their prescribed medications and miss more scheduled appointments than their more literate peers. Moreover, ophthalmic educational materials are often written at a level of readability that surpasses the skills of many patients with glaucoma.

SUMMARY

Patients with chronic eye diseases such as glaucoma and limited health literacy skills are vulnerable to poor visual outcomes. Attention to health literacy may improve the care and outcomes of these patients.

Medicines non-adherence: adult literacy and implications for practice

Functional health literacy is defined as the level at which individuals can obtain, process and understand basic health information (Martin et al, 2009). Government statistics suggest low functional health literacy is an under-recognised and growing problem in UK health care. It is associated with high hospitalisation (Baker et al, 1998) and increased medicines non-adherence (Kalichman et al, 1999). Health professionals are poor at assessing and identifying those at risk because they have yet to acknowledge the prevalence of the problem. Initiatives attempting to address medicines non-adherence promote patient involvement in treatment decisions but remain ineffective if patients cannot read or understand written instructions. To help patients with low functional health literacy practitioners should speak slowly, repeat information, use plain, non-medical language and adopt teach-back techniques. These actions take extra time but are relatively easy to adopt and with a little thought become part of everyday practice.

Factors associated with delays in seeking treatment for stroke care in veterans

BACKGROUND

Our objective was to examine the association between delay in seeking treatment (DST) for stroke care and demographic and clinical characteristics variables in a sample of veterans.

METHODS

We used survey data from 100 veterans with a diagnosis of stroke who were receiving poststroke care at a Veterans Affairs (VA) Medical Center in the southeastern United States to evaluate the relationship between DST and key sample demographic and clinical characteristics. We used backward stepwise logistic regression models to assess the independent association between DST and demographic and clinical variables.

RESULTS

We found that stroke survivors reporting DST were more likely to be black (56.4% versus 32.8%; P = .02) and younger at the time of stroke onset (58.1 years versus 63.7 years; P = .02). In backward stepwise logistic regression models, being black was an independent predictor of DST (odds ratio [OR] 2.76; 95% confidence interval [CI], 1.04-7.30; P = .04) in this veteran population.

CONCLUSIONS

Race appears to be a key factor associated with an increased likelihood of delays in seeking urgent stroke care in veterans. Future studies need to further examine the complex sociodemographic profile of patients who are most likely to delay seeking care for stroke and to develop interventions to reduce the impact of DST.

Readability of websites containing information about prostate cancer treatment options

PURPOSE

Approximately 90 million American adults have literacy skills that test below a high school reading level. Websites written above this level can pose a challenge for those seeking online information about prostate cancer treatment options. In this study we determine the readability of selected websites using a systematic search process and validated readability formulas.

MATERIALS AND METHODS

We identified the 3 most popular keywords from 513 terms related to prostate cancer treatment options. We then systematically collected 270 websites from the top 3 search engines, and excluded from study those that were nonEnglish, not primarily text, irrelevant and/or duplicated. We used the Flesch-Kincaid grade level and Flesch Reading Ease to determine scores for each site.

RESULTS

A total of 62 unique websites were analyzed. Median Flesch-Kincaid grade level was 12.0 (range 8.0 to 12.0) and median Flesch Reading Ease score was 38.1 (range 0.0 to 65.5). Only 3 sites (4.8%) were written below a high school reading level (less than 9.0).

CONCLUSIONS

Few websites with discussions on prostate cancer treatment options are written below a high school reading level. This is problematic for a third of Americans who seek to further educate themselves using online resources. Clinicians can use this information to guide their patients to appropriate websites.

Consumer Literacy and the Readability of Health Education Materials

Written materials about communication sciences and disorders frequently are used for patient intake, prevention, community education, counseling, subject recruitment for research, therapy activities, assessment procedures, and treatment monitoring. In order to increase the effectiveness of print material, one must consider the interactive nature of the reading process between the reader and the written material. Therefore, to increase understandability, settings should consider the reading and cognitive skills of consumers, as well as the surface, deep, and design elements in materials.

Health literacy and adolescents: a framework and agenda for future research

Health literacy is an important issue in public health today, especially as patients are taking a greater role in obtaining information about their health. Health literacy is commonly defined as 'the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions'. While there is a large body of literature concerning health literacy and adults, few studies have focused on adolescents. Adolescents may have less interaction with the health care system and lower health care costs than adults, but they are increasingly involved with their health care, especially those with chronic illness. They are frequent users of mass media and other technology to access health information and are a target group for many health-related educational interventions. Adolescents are also at a crucial stage of development, learning skills they will carry with them into adulthood. The goal of this paper is to provide a summary of issues justifying the importance of studying health literacy as it relates to adolescents and to provide a framework and suggestions for future research.

Stroke awareness among low literacy Latinos living in the South Carolina low country

BACKGROUND

Little is known about stroke awareness in Latinos with low literacy and living in regions with high stroke rates.

METHODS

We surveyed a convenience sample of 60 adult Latinos living in Charleston South Carolina to examine recognition of 4 common warning signs of stroke and appropriate first action to call 9-1-1.

RESULTS

Forty-six percent of the participants recognized sudden facial, arm, or leg weakness; 39% recognized sudden vision loss; 43% recognized sudden trouble walking; 45% recognized sudden headache; 17% recognized all four warning signs. Twenty-seven percent of the participants incorrectly identified chest pain as a warning sign of stroke. Participants at the lowest literacy levels recognized three of the four warning signs more frequently than the participants at higher literacy levels.

DISCUSSION

Overall, awareness of stroke warning signs was considerably low in this high-risk population. The relationship between low-literacy and stroke awareness was unclear in this sample.

Patient literacy levels within an inner-city optometry clinic

BACKGROUND

This study compares the literacy levels of patients seeking primary optometric care at the Illinois Eye Institute, located in a Chicago inner-city neighborhood, to the literacy demands of available near point cards and patient educational materials.

METHODS

The revised large print Slosson Oral Reading Test was administered to 100 primary care patients 10 to 15 minutes after the instillation of mydriatic eye drops. In addition, the Flesch-Kincaid Grade Level was calculated using the Spelling and Grammar component of the Microsoft Word software package 2003 (Microsoft, Redmond, Washington) for available near point testing cards and patient education materials used in this clinic from the American Optometric Association and the National Eye Institute.

RESULTS

A total of 37.4% of patients read 1 standard deviation or more below their age-expected levels. A total of 46.5% of patients read at or below an eighth-grade level. The literacy demands of the tested near point cards ranged from 2nd grade to 12th grade. The literacy demands of patient education materials ranged from 7th grade to 12th grade.

CONCLUSIONS

About one third to almost one half of the 100 patients in this sample from the Illinois Eye Institute optometry clinic read below their age-expected level. Therefore, near point testing materials and patient education materials may not be written at a suitable reading level to be effective in this population. Clinicians who provide eye care for patients in inner city settings should consider communicating important information using nonwritten methods to those patients with low literacy levels.

Assessment of osteoporosis-website quality

INTRODUCTION

The Internet provides great opportunities for patient healthcare education, but poses risks that inaccurate, outdated, or harmful information will be disseminated. Osteoporosis is a topic of great interest to patients, many of whom use the Internet to obtain medical information. The aim of this study was to develop and evaluate measurement tools to determine the quality of osteoporosis websites for patients.

METHODS

Quality indicators in the categories of content, credibility, navigability, currency, and readability were incorporated into separate evaluation tools for healthcare professionals and for patients. Websites were selected from an Internet search. Interobserver reliability and validity were assessed, and a sample of osteoporosis websites was evaluated by an osteoporosis nurse educator and compared to patient evaluations.

RESULTS

For the quality indicators, there was 79% agreement between the osteoporosis nurse educators, 88% agreement between the physician osteoporosis experts, and 71% agreement comparing the osteoporosis nurse educators to the physician osteoporosis experts. Quality scores for evaluated websites ranged from 18-96 (maximum possible=100), with a mean of 66. Websites with Uniform Resource Locator (URL) suffix .com scored significantly lower compared to those with .gov (P<0.05), .edu (P<0.01), and .org (P<0.01). Healthcare professionals and patients were in agreement on the quality of the highest-rated websites, with less agreement for lower-rated websites.

CONCLUSIONS

In summary, a tool for measuring the quality of medical websites was developed and evaluated. Significant variability in osteoporosis-website quality was observed. Higher-quality scores were associated with a higher level of search engine match and specific URL suffixes. A validated tool for evaluating medical websites may have value in assisting patients to select high-quality osteoporosis educational information on the Internet, and may encourage website developers to improve the quality of information that is provided.

Injection Drug Use and Wound Care

Persons who have injected drugs present challenges to providing wound care. They tend to have multiple physical and psychosocial problems and abuse many substances. They may mistrust health care providers because of past experiences and their perceived negative attitude toward providers. Because they often self-treat abscesses and wounds before seeking care, the infection or wound can be large. A complete history and physical examination should be obtained. All aspects of the person's background will have an impact on wound healing. Wounds need careful assessment and diagnosis. Correct diagnosis of the wound is critical for the proper treatment. Treatment decisions must also include pain control, financial concerns, living arrangements, insurance, and the person's ability to perform the care. Patient education is a critical link in enhancing positive wound healing outcomes.

Promoting health literacy

This report reviews some of the extensive literature in health literacy, much of it focused on the intersection of low literacy and the understanding of basic health care information. Several articles describe methods for assessing health literacy as well as methods for assessing the readability of texts, although generally these latter have not been developed with health materials in mind. Other studies have looked more closely at the mismatch between patients' literacy levels and the readability of materials intended for use by those patients. A number of studies have investigated the phenomenon of literacy from the perspective of patients' interactions in the health care setting, the disenfranchisement of some patients because of their low literacy skills, the difficulty some patients have in navigating the health care system, the quality of the communication between doctors and their patients including the cultural overlay of such exchanges, and ultimately the effect of low literacy on health outcomes. Finally, the impact of new information technologies has been studied by a number of investigators. There remain many opportunities for conducting further research to gain a better understanding of the complex interactions between general literacy, health literacy, information technologies, and the existing health care infrastructure.

Performance of the English and Spanish S-TOFHLA among publicly insured Medicaid and Medicare patients

The objective of this study was to analyze the psychometric properties of the English and Spanish S-TOFHLA for three patient populations of interest. Despite being widely used, little is written about psychometric properties of the S-TOFHLA, particularly the Spanish version. Participants were Medicaid and Medicare patients: 936 non-Hispanic and 368 Hispanic patients completed the English S-TOFHLA; 1066 Hispanics completed the Spanish S-TOFHLA. Validity of both versions of the S-TOFHLA was supported by strong positive relationships with education and inverse relationships with age. Significant differences between scores for men and women remained after adjusting for level of education. Score differences occurred across numerous items. More research is needed on the S-TOFHLA and other health literacy instruments to determine why women score differently than men. Variability in literacy skills within subgroups of patients highlights the importance of healthcare providers being sensitive to patients' literacy levels in both spoken and written communications.

Estimates of fruit and vegetable intake in childhood and adult dietary behaviors of African American women

OBJECTIVE

This exploratory study examined how estimates of one's fruit and vegetable intake in childhood are related to 3 current dietary behaviors among African American women: intake of fruits and vegetables, exposure to and preference for fruits and vegetables, and preference for trying new foods.

DESIGN

Baseline data from a randomized dietary intervention trial.

SETTING

Ten urban public health centers in St. Louis, Missouri.

PARTICIPANTS

1227 African American women.

VARIABLES MEASURED

A 33-item fruit and vegetable food frequency questionnaire, items measuring estimates of childhood fruit and vegetable intake, adult fruit and vegetable intake, exposure to and preference for fruit and vegetable, and preference for trying new foods.

ANALYSIS

Linear regression evaluated the association between predictors and continuous measures; logistic regression determined the association between predictors and categorical measures.

RESULTS

Estimates of one's vegetable intake as a child were significantly related to exposure and preference for both fruits and vegetables, trying of new foods, and intake of both fruits and vegetables in adulthood. Estimates of eating fruit as a child were not significantly associated with these adult dietary behaviors.

CONCLUSIONS AND IMPLICATIONS

Developmental influences on adult dietary patterns may be stronger for vegetables than fruits among African American women. Additional emphasis is needed regarding exposure to and preference for vegetable intake in childhood.

Professional and patient perspectives on nutritional needs of patients with cancer

PURPOSE/OBJECTIVES

To identify and compare perceptions of RNs, registered dietitians (RDs), and patients regarding the best format and key nutrition information components that should be provided to patients during cancer treatment.

DESIGN

Cross-sectional study using an opinion-based questionnaire.

SETTING

Outpatient cancer centers.

SAMPLE

506 RNs and 367 RDs, as well as 653 patients undergoing cancer treatment.

METHODS

Two similar self-administered questionnaires were developed, one for patients and one for healthcare professionals. Face and content validity were assessed by a panel of experts. Data were analyzed using descriptive statistics, chi-square statistic, and a Spearman Correlation Coefficient to compare responses.

MAIN RESEARCH VARIABLES

Patient nutrition concerns as well as format and content of printed educational materials.

FINDINGS

Significant differences existed among groups regarding the most common nutrition concerns, the perception of importance of information frequently provided to patients with cancer, and rank order of importance for eight items typically provided to patients. The dietary information format preferred by all groups was an all-inclusive booklet; RNs (75%) were more likely than RDs (43%) or patients (50%) to prefer this format. Data also revealed that almost half of the patients (47%) received no dietary counseling, including 18% who experienced significant weight loss.

CONCLUSIONS

RNs and RDs who provide nutrition education to patients with cancer should consider the need to develop and use a variety of printed materials to meet individual needs. Because major concerns of patients and healthcare professionals were related to patients ability to consume adequate amounts of food, this should be the primary focus of any nutrition education materials.

IMPLICATIONS FOR NURSING

These findings provide information that can be applied to the development of informational materials and counseling practices.

Health literacy, social support, and health: a research agenda

Amid increased concerns about the adverse consequences of low health literacy, it remains unclear how health literacy affects health status and health service utilization. Moreover, studies have shown significant variation in individual adaptation to health literacy problems. This article proposes research hypotheses to address two questions: (1) What are the causal pathways or intermediate steps that link low health literacy to poor health status and high utilization of expensive services such as hospitalization and emergency care? (2) What impact does social support have on the relationships between health literacy and health service utilization? Empirical studies of health literacy are reviewed to indicate the limitations of current literature and to highlight the importance of the proposed research agenda. In particular, we note the individualistic premise of current literature in which individuals are treated as isolated and passive actors. Thus, low health literacy is considered simply as an individual trait independent of support and resources in an individual's social environment. To remedy this, research needs to take into account social support that people can draw on when problems arise due to their health literacy limitations. Examination of the proposed agenda will make two main contributions. First, we will gain a better understanding of the causal effects of health literacy and identify missing links in the delivery of care for patients with low health literacy. Second, if social support buffers the adverse effects of low health literacy, more effective interventions can be designed to address differences in individuals' social support system in addition to individual differences in reading and comprehension. More targeted and more cost-efficient efforts could also be taken to identify and reach those who not only have low health literacy but also lack the resources and support to bridge the unmet literacy demands of their health conditions.

Informed Consent: A Process to Facilitate Older Adults' Participation in Research

Trust is the foundation of the informed consent process. According to Kass et al., Yet only through vigilance and humility will we, as investigators, be able to live up to the trust that is placed in us; and only if that trust is deserved can the research enterprise survive (1996, p. 28). Therefore, further research should examine the effect of the informed consent process in limiting older adults' participation. Only by re-evaluating the first point of contact, implementing creative strategies to overcome barriers to the informed consent process, and validating these strategies through research will nurses facilitate the inclusion of older adults in research.

A readability analysis of Australian stroke information

The aims of this study were to document the readability of a stroke education brochure and to illustrate how the readability of this document might be improved. Readability analyses using three different formulas were conducted on a stroke education brochure from the Australian National Stroke Foundation. Consistent with previous studies of the readability of written health information, results indicated that the overall level of difficulty of the material was too complex for the average member of the public to read and understand. Revision of a randomly selected section of text using established guidelines for writing patient information, and subsequent reanalysis of this section, showed that simple revisions of health literature can dramatically improve readability. Given the importance of effective communication of preventative information about stroke, we present these results as a model of how future revisions of difficult to read stroke-related literature might be conducted to improve public education.

Readability of printed patient information for epileptic patients

BACKGROUND

Written information can be a valuable tool in patient education. Studies evaluating written information for various disease states have frequently demonstrated that the majority of literature is written at a readability level that exceeds that of the average patient, and it has been recommended that written communications for adult patients should be provided at a fifth-grade level or lower.

OBJECTIVE

To assess the readability of printed patient information available to patients with epilepsy.

METHODS

Samples of written patient information (n = 101) were obtained from various sources. The information was classified based on source, content, and intended audience, and readability was assessed using the Flesch Reading Ease Score (FRES) and Flesch-Kincaid Grade Level (FKGL) score.

RESULTS

The mean FRES and FKGL score for all samples were 50.2 and 9.4, respectively. Significant differences were observed in both the FRES and FKGL score of material obtained from different sources; however, no differences were observed when material was analyzed according to content. The mean FRES and FKGL score for materials intended for adults were 49.6 and 9.5, respectively. In comparison, mean FRES and FKGL scores for materials intended for children/adolescents were 78.9 and 5.3, respectively.

CONCLUSIONS

The majority of information tested was written at a level that exceeds the reading ability of many patients. The information intended for children is actually written at the appropriate level for an adult. Efforts should be taken to develop written teaching tools that target low-level readers, especially for a disease state that affects many children.

Research priorities in the evolving demographic landscape of Alzheimer disease and associated dementias

The rapid increase of ethnically diverse late onset dementia-affected persons is bringing a special urgency to Alzheimer disease and associated disorders research. By this decade's end, non-European heritage ethnically diverse persons will account for 25% of the dementia-affected cohort and 33% by mid-century. These populations have received some attention in both dementia-focused basic biomedical and social-behavioral research. However, studies differ greatly with regard to the constructs of culture used, the methodologies used, and representativeness of the populations sampled. Moreover, social status factors are often confounded with cultural variables. Therefore, several clarifying research approaches are suggested. In biomedical research, categorically ascribed (US census type) definitions, or assumed (self-reported) ethnic group designators will not suffice where actual biophysiological sampling precision is needed. A strategy for the phenotypic sampling of cohorts is therefore suggested for this research domain. In social-behavioral research, the acceptance of a common operational definition of culture is urged. And, with reference to a specific social status confound, namely literacy, a neuroimaging research strategy is proposed to determine whether non-literates might not be misclassified relative to the determination of their actual cognitive functioning status. Additionally, two conceptual models for addressing and are briefly presented.

Implementing a Web-based information resource at an inner-city community church: lessons learned

The objective of this project was to develop and implement electronic access to HIV/AIDS information resources at Glide Memorial Church in San Francisco, CA. This involved developing tailored Web-based access to the relevant information for the Glide Clinic patients. In addition, the project deployed workstations in 2 clinic areas and provided support to clinic patients as they learned to access the information resources. This article describes the experience with information retrieval in a clinic setting for underserved patients, including lessons learned, effective strategies, and anecdotes of effect on patients. Required nursing informatics competencies in this particular area are also addressed.