Agency for Healthcare Research and Quality, National Healthcare Disparities Report. 2005. Retreived August 24, 2007 fromhttp://www.ahrq.gov/qual/nhdr05/fullreport/Index.htm

The 2005 NHDR uses the same measures of quality as its companion National Healthcare Quality Report (NHQR) to monitor the Nation's annual progress toward eliminating disparities in health care. This year's report focuses on the same group of 46 "core" measures of quality tracked in the NHQR; additionally, the NHDR includes 13 core measures of access to care.

Berkman ND, DeWalt DA, Pignone MP, Sheridan SL, Lohr KN, Lux L, Sutton SF, Swinson T, Bonito AJ. Literacy and Health Outcomes. Evidence Report/Technology Assessment No. 87 (Prepared by RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-02-0016). AHRQ Publication No. 04-E007-2. Rockville, MD: Agency for Healthcare Research and Quality. January 2004. Retrieved June 19, 2007, from http://www.ahrq.gov/downloads/pub/evidence/pdf/literacy/literacy.pdf

Research has examined the effect of low literacy on a wide variety of health outcomes, but we are unaware of any published systematic reviews that have analyzed these relationships or examined interventions to mitigate the health effects of low literacy. To evaluate the existing research, we performed a systematic review to address two four-part key questions based on questions initially posed by the American Medical Association and the Agency for Healthcare Research and Quality and put into final form in cooperation with our Technical Expert Advisory Group. The questions are as follows: · Key Question 1: Are literacy skills related to: (a) Use of health care services? (b) Health outcomes? (c) Costs of health care? (d) Disparities in health outcomes or health care service use according to race, ethnicity, culture, or age? · Key Question 2: For individuals with low literacy skills, what are effective interventions to: (a) Improve use of health care services? (b) Improve health outcomes? (c) Affect the costs of health care? (d) Improve health outcomes and/or health care service use among different racial, ethnic, cultural, or age groups?

The California Health Literacy Initiative, (2003, October). Low Literacy, High Risk: The Hidden Challenge Facing Health Care in California. Retrieved June 19, 2007, from The California Health Literacy Initiative Web site: http://cahealthliteracy.org/pdffiles/healthliteracylongreport012704_3.pdf

The California Health Literacy Pilot Study reveals that for low literate adults in California, obtaining health care can be a process that is confusing, humiliating, dangerous and sometimes deadly. Based on suggestions from participants in the pilot study, there are multiple recommendations that we propose to lessen the problem of low health literacy in California. Some of these recommendations include allocating more resources to adult literacy organizations to provide health literacy instruction, developing effective interventions to avoid medical errors due to low literacy, forming partnerships between literacy- and languageaccess advocates, and creating quality standards and measures around health literacy which are accepted by the medical community at large.

Canadian Public Health Association, (2002). Directory of Plain Language Health Information. Ottawa, Ontario: Canadian Public Health Association. This publication is available to buy. See http://www.pls.cpha.ca/english/start.htm

In response to the need for easy-to-read health information, many health centres, government departments and health organizations, including the Canadian Public Health Association’s National Literacy and Health Program, have adopted a plain language approach. This directory helps you get your hands on plain language health information so you or your organization would not have to write and produce information.

The Centre for Literacy of Quebec, (2001). Background Document on Literacy and Health. Retrieved June 19, 2007, from The Centre for Literacy Web site: http://www.centreforliteracy.qc.ca/health/finalsum/bd/backdoc.pdf

The purpose of this document is to establish the rationale for conducting a Needs Assessment the information and education needs of hard-to-reach patients at the Montreal General Hospital, the McGill University Health Centre (MUHC). These hard-to-reach patients include those literacy, those who face language and cultural barriers, and those who cannot process health information because of physical or cognitive learning disabilities. The overall purpose is health information given to and health education process of hard-to-reach patients, as well ways to improve how health care professionals communicate with such patients. The findings Needs Assessment will be used in planning a Health Literacy Centre at the hospital.

Davis, Terry C. et al. (2005, May/June). Health Literacy and Cancer Communication. CA: A Cancer Journal for Clinicians, 52, Retrieved June 18, 2007, from http://www.ncbi.nlm.nih.gov/sites/entrez?cmd= Retrieve&db=PubMed&list_uids=12018928&dopt=Abstract

Health literacy is increasingly recognized as a critical factor affecting communication across the continuum of cancer care. We reviewed research on health literacy and examined its impact on cancer outcomes and communication.

Kim, Sarang, MD et al. . "Association of Health Literacy With Self-Management Behavior in Patients With Diabetes." Diabetes Care 27(2004): 2980-2982. Retreived August 24, 2007 from http://care.diabetesjournals.org/cgi/content/full/27/12/2980

Limited health literacy, common in patients with diabetes, has been associated with worse diabetes outcomes. While patients with limited health literacy have worse diabetes knowledge, knowledge does not necessarily predict outcomes. Because diabetes requires extensive self-care, differences in self-management behaviors may be a key contributor to the disparity in outcomes. In fact, low health literacy has been associated with poor self-care in other chronic illnesses. The objectives of our study were to examine the association of health literacy with self-management behaviors in patients with diabetes and to determine whether diabetes education improves self-management behaviors in patients with limited compared with adequate health literacy.

Kutner, Mark et al. (2006, September). The Health Literacy of America's Adults: Results from the 2003 National Assessment of Adult Literacy. Retrieved June 20, 2007, from National Center for Education Statistics Web site: http://nces.ed.gov/pubs2006 /2006483.pdf

The Health Literacy of America’s Adults is the first release of the National Assessment of Adult Literacy (NAAL) health literacy results. The results are based on assessment tasks designed specifically to measure the health literacy of adults living in the United States. Health literacy was reported using four performance levels: Below Basic, Basic, Intermediate, and Proficient. The majority of adults (53 percent) had Intermediate health literacy.

Massachusetts Department of Education Adult and Community Learning Services, (2001, October). Massachusetts Adult Basic Education Curriculum Framework For Health. Retrieved June 18, 2007, from the Massachussetts Department of Education Web site: http://www.doe.mass.edu/acls/frameworks/health.pdf

This Framework is designed to promote an understanding of the significance and potential of health education while offering guiding principles, standards, and integration strategies for teaching and developing curricula.Since health issues often undermine the persistence and success of adult learners, it is in our best interest to integrate health education in the classroom. By integrating health, we are not adding “one more thing” into an already full curriculum, but instead we use health topics as a vehicle for development of social and academic skills.

The Joint Commission, (2007). “What Did the Doctor Say?:' Improving Health Literacy to Protect Patient Safety." Retrieved June 19, 2007, from The Joint Commission Web site: http://www.jointcommission.org/NR/rdonlyres/D5248B2E-E7E6-4121-8874- 99C7B4888301/0/improving_health_literacy.pdf

This white paper emanates from the Joint Commission’s Public Policy Initiative. Launched in 2001, this initiative seeks to address broad issues that have the potential to seriously undermine the provision of safe, high-quality health care and, indeed, the health of the American people. These are issues that demand the attention and engagement of multiple publics if successful resolution is to be achieved.

Matthews, Trudi L. and Jenny C. Sewell (2002). The Council of State Governments. Retrieved June 19, 2007, from State Official’s Guide to Health Literacy Web site: http://www.csg.org/pubs/Documents/SOG02HealthLiteracy.PDF

This State Official’s Guide to Health Literacy—the first of CSG’s new series on critical policy issues relevant to state officials—reports the results of this survey, supporting and expanding on these results using data from academic research and private-sector initiatives. Readers will gain an understanding of the problem, what can be done to improve health literacy and how to make the current system more accessible to someone with low health literacy.

MAXIMUS, (2005, October ). The Health Literacy Style Manual. Retrieved June 18, 2007, from Covering Kids & Families Web site: http://coveringkidsandfamilies.org/resources/docs/stylemanual.pdf

This little book is filled with hints and suggestions for developing and improving applications, notices, and other print materials related to government programs. In it are some tried and true strategies for writing and formatting specifically for clients, many of whom have limited literacy skills. Most of these strategies are not new, but we’ve collected them here, added some of our own, and illustrated them with (mostly) real-life examples. They’ll help you develop easy-to-read materials for skilled readers as well as for those who struggle to read.

Meade, PhD, RN, Cathy D. et al.(1994, January). Educating Patients with Limited Literacy Skills: The Effectiveness of Printed and Videotaped Materials about Colon Cancer. American Journal of Public Health , 84, Retrieved June 18, 2007, from http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1614927&blobtype=pdf

We investigated whether printed or videotaped information is more effective in enhancing colon cancer knowledge. Subjects (n = 1100) were randomized into three groups: to receive a booklet, view a videotape, or receive no intervention. Subjects receiving the intervention showed increased knowledge compared with control subjects (booklet = 23% and videotape = 26% vs no intervention = 3%). Findings suggest that personalized educational materials are effective in enhancing colon cancer knowledge.

McCray, Alexa T., PhD. Promoting Health Literacy. Journal of the American Medical Informatics Association 12(2005): 152-163. Retrieved ($) August 24, 2007, from http://www.jamia.org/cgi/content/abstract/12/2/152?ck=nck

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. 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.

Rootman, Irving et al. National Literacy and Health Research Program Needs assessment and Environmental scan. The National Literacy and Health Program (Canada), Retrieved June 18, 2007, from the National Literacy and Health Program Web site: http://www.nlhp.cpha.ca/clhrp/needs_e/needs_e.pdf

This study is a component of a Literacy and Health Research Program funded in April, 2002 by the Social Sciences and Humanities Research Council through the National Literacy Secretariat. Its objectives are to identify: gaps in knowledge in literacy and health research in Canada; current and proposed initiatives in literacy and health in Canada; and resources and opportunities for research in literacy and health in Canada.

Rudd, Rima E. et al. (2002, January). An Overview of Medical and Public Health Literature Addressing Literacy Issues: An Annotated Bibliography. Retrieved June 19, 2007, from: http://eric.ed.gov/ERICDocs/data/ericdocs2/ content_storage_01/0000000b/80/10/d4/50.pdf

Zobel, Emily (2002, March). An Updated Overview of Medical and Public Health Literature Addressing Literacy Issues: An Annotated Bibliography of Articles Published in 2001. Retrieved June 19, 2007, from Health Literacy Studies, Harvard School of Public Health Web site: http://www.hsph.harvard.edu/healthliteracy/lit_2001.html

In January 2000, Rudd et al. published an annotated bibliography of medical and public health literature addressing literacy issues published between 1990 and 1999. Their search of the literature indicated a growing recognition of literacy issues and communication barriers within the health fields. Zobel's bibliography serves to augment the initial two searches with more recent literature from 2001.

Sarkar, Urmimala. Is self-efficacy associated with diabetes self-management across race/ethnicity and health literacy?. Diabetes Care 29(2006): 823-829. Retrieved August 24, 2007, http://care.diabetesjournals.org/cgi/reprint/29/4/823.pdf

Self-efficacy was associated with self-management behaviors in this vulnerable population, across both race/ethnicity and health literacy levels. However, the magnitude of the associations suggests that, among diverse populations, further study of the determinants of and barriers to self-management is warranted. Policy efforts should be focused on expanding the reach of self-management interventions to include ethnically diverse populations across the spectrum of health literacy.

Schillinger, Dean (2004). Functional health literacy and the quality of physician–patient communication among diabetes patients. Patient Education and Counseling, 52, Retrieved June 19, 2007, from http://www.ucsf.edu/aetcnec/evaluation/Schillinger. Health.Literacy.04.pdf

While patients with poor functional health literacy (FHL) have difficulties reading and comprehending written medical instructions, it is not known whether these patients also experience problems with other modes of communication, such as face-to-face encounters with primary care physicians.We enrolled 408 English- and Spanish-speaking diabetes patients to examine whether patients with inadequateFHL report worse communication than patients with adequate FHL.We assessed patients’ experiences of communication using sub-scales from the Interpersonal Processes of Care in Diverse Populations instrument. In multivariate models, patients with inadequate FHL, compared to patients with adequate FHL, were more likely to report worse communication in the domains of general clarity (adjusted odds ratio [AOR] 6.29, P < 0.01), explanation of condition (AOR 4.85, P = 0.03), and explanation of processes of care (AOR 2.70, P = 0.03). Poor FHL appears to be a marker for oral communication problems, particularly in the technical, explanatory domains of clinician–patient dialogue. Research is needed to identify strategies to improve communication for this group of patients.

Sherow, Sheila and JoAnn Weinberger (2002). The Pennsylvania Adult Basic and Literacy Education Interagency Coordinating Council. Retrieved June 19, 2007, from A Report on Health Literacy Web site: http://www.able.state.pa.us/able/lib/able/pubs/ HEALTHLIT_2002.pdf

This report is a follow-up to the ABLE ICC’s health literacy forum and is intended to serve as the beginning of a statewide, interdepartmental health literacy initiative. The health literacy topics discussed during the forum are presented in this document, each with priority issues and a brief review of current research findings.

Shrank, William and Jerry Avorn. "Educating Patients About Their Medications: The Potential And Limitations Of Written Drug Information." Health Affairs 26(2007): 731-741. Retreived ($) August 24, 2007 from http://content.healthaffairs.org/cgi/content/abstract/26/3/731

Drug information on labels and inserts is a major source of knowledge for patients as they attempt to balance the risks and benefits of drugs and administer them safely. Yet this information is often inconsistent, incomplete, and difficult for patients to read and understand. We reviewed the numerous sources of written prescription drug information, the regulations that govern their content and format and the lack of oversight in the process, and the history that led to this system. We suggest that oversight and standards are needed so that written drug information can serve as a coherent and organized system to educate patients.

Sihota, Saranjit and Linda Lennard (2004, June). Health literacy: being able to make the most of health. Retrieved June 19, 2007, from National Consumer Council Web site: http://www.ncc.org.uk/health/health_literacy.pdf

This report is a broad first look at the topic of health literacy, to gauge what we know and what we still need to find out.The subject is vast: it contains innumerable issues and complexities both in understanding its impact on people in varying social, economic and health circumstances, and in defining the appropriate solutions.

U.S. Department of Health and Human Services Office of Disease Prevention and Health Promotion, Quick Guide to Health Literacy. Retrieved June 19, 2007, from www.health.gov Web site: http://www.health.gov/communication/literacy/quickguide/Quickguide.pdf

The Quick Guide to Health Literacy is for government employees, grantees and contractors, and community partners working in healthcare and public health fields. It contains: a basic overview of key health literacy concepts, techniques for improving health literacy through communication, navigation, knowledge-building, and advocacy, examples of health literacy best practices, and suggestions for addressing health literacy in your organization.

Weiner, Janet, MPH (2004). Designing an Illustrated Patient Satisfaction Instrument for Low-literacy Populations. American Journal of Managed Care , 10, Retrieved June 19, 2007, from http://www.ajmc.com/Article.cfm?Menu=1&ID=2766

Up to 25% of adults in the United States have difficulty with everyday reading tasks. As patients, adults with low literacy may not be able to complete many self-administered written questionnaires, which often are used to obtain information from patients and to gauge their satisfaction with care. We developed an illustrated version of a patient satisfaction instrument used by the Veterans Health Administration. This paper describes the extensive design process used to develop, pilot-test, and revise this 63-item illustrated instrument. A total of 438 patients were interviewed over a 1-year period to obtain feedback on illustrations, with at least 15 people viewing and commenting on each picture and revision. All pictures were revised, with the majority revised at least 4 times. We report on this iterative design process as well as on lessons we learned in illustrating questions for low-literacy populations.

Weiss, MD, Barry D. (2003). Health Literacy : A Manual for Clinicians. Retrieved June 18, 2007, from the American Medical Association Web site: http://www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf

This manual will discuss the problem of limited health literacy, its consequences for the healthcare system, and the likelihood that a clinician’s practice includes patients with limited health literacy. The manual will then provide practical tips for clinicians to use in making their office practices more “user-friendly” to patients with limited health literacy, and give suggestions for improving interpersonal communication between clinicians and patients. Finally, the manual concludes with several case discussions based on vignettes in the accompanying videotape.

Yonger, Elizabeth et al.(2001, April) Immunization and Child Health Materials Development Guide. Retrieved June 18, 2007, from http://www.path.org/vaccineresources/files/CVP-Materials-Development-Guide.pdf

This Guide is based on a popular and widely used book produced by PATH in 1989 and revised in 1996: Developing Health and Family Planning Materials for Low-Literate Audiences: A Guide. We have expanded that Guide to include information on developing radio, video, and computer-based materials and shifted the focus to immunization and child health. We have also expanded the scope beyond low-literate audiences to include writing for policy-makers, providers, fieldworkers, and others targeted for training or advocacy efforts. We hope you will find the expanded topics and resources in this guide useful and relevant.

Zimmerman, M ( 2002). Developing Materials on HIV/AIDS/STIs for Low-Literate Audiences: A Guide: Section 1. Retrieved June 19, 2007, from PATH: A Catalyst for Global Health Web site: http://www.path.org/files/HIV_low-lit_section_1_of_5.pdf

The specific focus of this 5 section publication is on developing print materials for programs to use to reduce the incidence of STIs, including HIV/AIDS. Section 1 includes the Table of Contents.

Zimmerman, M ( 2002). Developing Materials on HIV/AIDS/STIs for Low-Literate Audiences: A Guide: Section 2. Retrieved June 19, 2007, from PATH: A Catalyst for Global Health Web site: http://www.path.org/files/HIV_low-lit_section_2_of_5.pdf

Section 2 includes information on defining behavior change communication, the role of print materials in behavior change communication, and how to use the guide.

Zimmerman, M ( 2002). Developing Materials on HIV/AIDS/STIs for Low-Literate Audiences: A Guide: Section 3. Retrieved June 19, 2007, from PATH: A Catalyst for Global Health Web site: http://www.path.org/files/HIV_low-lit_section_3_of_5.pdf

Section 3 includes examples of how others have used visual images to communicate key HIV/AIDS/STI-related concepts and messages.

Zimmerman, M ( 2002). Developing Materials on HIV/AIDS/STIs for Low-Literate Audiences: A Guide: Section 4. Retrieved June 19, 2007, from PATH: A Catalyst for Global Health Web site: http://www.path.org/files/HIV_low-lit_section_4_of_5.pdf

Section 4 includes tips for working with the printer who will be printing your materials.

Zimmerman, M ( 2002). Developing Materials on HIV/AIDS/STIs for Low-Literate Audiences: A Guide: Section 5. Retrieved June 19, 2007, from PATH: A Catalyst for Global Health Web site: http://www.path.org/files/HIV_low-lit_section_5_of_5.pdf

Section 5 includes the Appendices.