Human Vaccines & Immunotherapeutics
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Health literacy Gillian Rowlands To cite this article: Gillian Rowlands (2014) Health literacy, Human Vaccines & Immunotherapeutics, 10:7, 2130-2135, DOI: 10.4161/hv.29603 To link to this article: http://dx.doi.org/10.4161/hv.29603
Published online: 11 Jul 2014.
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ReviewReview Human Vaccines & Immunotherapeutics 10:7, 2130–2135; July 2014; © 2014 Landes Bioscience
Health literacy
Ways to maximise the impact and effectiveness of vaccination information Gillian Rowlands
Keywords: health literacy, health information, vaccination
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Abbreviations: CRC, Colorectal Cancer; NQF, National Qualifications Framework; SMOG, simplified measure of gobbledygook
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. 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.
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.2 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 *Correspondence to: Gillian Rowlands; Email: [email protected] Published Online: 07/11/2014 http://dx.doi.org/10.4161/hv.29603 2130
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.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 screening12,14 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%.3,1517 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.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. 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 health 20 therefore understanding the issues raised by low health literacy can help to reduce health inequalities.
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King’s College London; London, UK
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
5–7 y
Short texts with repeated language patterns on familiar topics. 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
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
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
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
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
5 grades A* to C GCSE
Entry 1
Entry 2
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Entry 3
Level 1
Level 2 or above
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
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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 Sign 22 and the REALM 23 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 2 shows 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.
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Table 1. English National Qualifications Framework (NQF)18
% 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.
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
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Figure 1. Bloom’s taxonomy of learning28
of information to people with lower skills levels. The SMOG test is available online (http://www.niace.org.uk/misc/SMOGcalculator/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.30 Communicating 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.) 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.
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Table 2. Percentage of the English working age population at or above different literacy and numeracy skills levels
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
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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
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
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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
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Table 3. Making the literacy (text) element of materials easier to read
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
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. References 1. Nutbeam D. Health Promotion Glossary. Health Promot Int 1999; 13:349-64 2. 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 3. 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 4. Bostock S, Steptoe A. Association between low functional health literacy and mortality in older adults: longitudinal cohort study. BMJ 2012; 344:e1602; PMID:22422872; http://dx.doi.org/10.1136/bmj. e1602 5. 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; PMID:17646604; http://dx.doi. org/10.1001/archinte.167.14.1503 6. 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/
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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.
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; 118:3717; PMID:15808134; http://dx.doi.org/10.1016/j. amjmed.2005.01.010 8. 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; PMID:24619949; http://dx.doi. org/10.1177/1060028014526562 9. 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; 85:6518; PMID:19262464; http://dx.doi.org/10.1038/ clpt.2009.7 10. 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; PMID:17261479; http://dx.doi. org/10.1016/j.ambp.2006.10.001 11. 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; PMID:18295949; http://dx.doi. org/10.1016/j.socscimed.2008.01.003 12. White S, Chen J, Atchison R. Relationship of preventive health practices and health literacy: a national study. Am J Health Behav 2008; 32:22742; PMID:18067463; http://dx.doi.org/10.5993/ AJHB.32.3.1 7.
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13. 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:15670438 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; PMID:19433837; http://dx.doi.org/10.1370/afm.940 15. Rudd RE. Health literacy skills of U.S. adults. Am J Health Behav 2007; 31(Suppl 1):S8-18; PMID:17931141; http://dx.doi.org/10.5993/ AJHB.31.s1.3 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:// w w w. a b s . g o v. a u / AU S S TAT S / a b s @. n s f / 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-skillsfor-life-survey.pdf
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Table 4. Making the numeracy element of materials easier to understand
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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; PMID:18660507; http://dx.doi. org/10.1093/pubmed/fdn059 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; PMID:8788747; http://dx.doi. org/10.1016/0738-3991(95)00787-3 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. 28. Bloom B. Taxonomy of Educational Objectives: Cognitive and Affective Domains. New York: David McKay Company Inc; 1956 & 1964. 29. McLaughlin GH. SMOG Grading–a New Readability Formula. J Read 1969; 12:639-46 30. Readability: how to produce clear written materials for a range of readers. Leicester, UK: NIACE; 2009. 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; PMID:12523921; http://dx.doi.org/10.1001/archinte.163.1.83
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. 33. 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; PMID:20978060; http://dx.doi.org/10.1136/bmj.c5370 34. 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
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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. 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. 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; PMID:16338915; http://dx.doi.org/10.1370/afm.405 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:8349060 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; PMID:23391329; http://dx.doi. org/10.1186/1471-2458-13-116
ISSN: 2164-5515 (Print) 2164-554X (Online) Journal homepage: http://www.tandfonline.com/loi/khvi20
Health literacy Gillian Rowlands To cite this article: Gillian Rowlands (2014) Health literacy, Human Vaccines & Immunotherapeutics, 10:7, 2130-2135, DOI: 10.4161/hv.29603 To link to this article: http://dx.doi.org/10.4161/hv.29603
Published online: 11 Jul 2014.
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Date: 05 November 2015, At: 16:20
ReviewReview Human Vaccines & Immunotherapeutics 10:7, 2130–2135; July 2014; © 2014 Landes Bioscience
Health literacy
Ways to maximise the impact and effectiveness of vaccination information Gillian Rowlands
Keywords: health literacy, health information, vaccination
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Abbreviations: CRC, Colorectal Cancer; NQF, National Qualifications Framework; SMOG, simplified measure of gobbledygook
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. 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.
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.2 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 *Correspondence to: Gillian Rowlands; Email: [email protected] Published Online: 07/11/2014 http://dx.doi.org/10.4161/hv.29603 2130
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.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 screening12,14 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%.3,1517 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.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. 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 health 20 therefore understanding the issues raised by low health literacy can help to reduce health inequalities.
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King’s College London; London, UK
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
5–7 y
Short texts with repeated language patterns on familiar topics. 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
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
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
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
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
5 grades A* to C GCSE
Entry 1
Entry 2
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Entry 3
Level 1
Level 2 or above
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
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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 Sign 22 and the REALM 23 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 2 shows 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.
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Table 1. English National Qualifications Framework (NQF)18
% 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.
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
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Figure 1. Bloom’s taxonomy of learning28
of information to people with lower skills levels. The SMOG test is available online (http://www.niace.org.uk/misc/SMOGcalculator/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.30 Communicating 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.) 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.
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Table 2. Percentage of the English working age population at or above different literacy and numeracy skills levels
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
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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
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
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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
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Table 3. Making the literacy (text) element of materials easier to read
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
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. References 1. Nutbeam D. Health Promotion Glossary. Health Promot Int 1999; 13:349-64 2. 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 3. 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 4. Bostock S, Steptoe A. Association between low functional health literacy and mortality in older adults: longitudinal cohort study. BMJ 2012; 344:e1602; PMID:22422872; http://dx.doi.org/10.1136/bmj. e1602 5. 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; PMID:17646604; http://dx.doi. org/10.1001/archinte.167.14.1503 6. 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/
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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.
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; 118:3717; PMID:15808134; http://dx.doi.org/10.1016/j. amjmed.2005.01.010 8. 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; PMID:24619949; http://dx.doi. org/10.1177/1060028014526562 9. 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; 85:6518; PMID:19262464; http://dx.doi.org/10.1038/ clpt.2009.7 10. 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; PMID:17261479; http://dx.doi. org/10.1016/j.ambp.2006.10.001 11. 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; PMID:18295949; http://dx.doi. org/10.1016/j.socscimed.2008.01.003 12. White S, Chen J, Atchison R. Relationship of preventive health practices and health literacy: a national study. Am J Health Behav 2008; 32:22742; PMID:18067463; http://dx.doi.org/10.5993/ AJHB.32.3.1 7.
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13. 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:15670438 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; PMID:19433837; http://dx.doi.org/10.1370/afm.940 15. Rudd RE. Health literacy skills of U.S. adults. Am J Health Behav 2007; 31(Suppl 1):S8-18; PMID:17931141; http://dx.doi.org/10.5993/ AJHB.31.s1.3 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:// w w w. a b s . g o v. a u / AU S S TAT S / a b s @. n s f / 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-skillsfor-life-survey.pdf
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Table 4. Making the numeracy element of materials easier to understand
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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; PMID:18660507; http://dx.doi. org/10.1093/pubmed/fdn059 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; PMID:8788747; http://dx.doi. org/10.1016/0738-3991(95)00787-3 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. 28. Bloom B. Taxonomy of Educational Objectives: Cognitive and Affective Domains. New York: David McKay Company Inc; 1956 & 1964. 29. McLaughlin GH. SMOG Grading–a New Readability Formula. J Read 1969; 12:639-46 30. Readability: how to produce clear written materials for a range of readers. Leicester, UK: NIACE; 2009. 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; PMID:12523921; http://dx.doi.org/10.1001/archinte.163.1.83
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. 33. 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; PMID:20978060; http://dx.doi.org/10.1136/bmj.c5370 34. 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
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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. 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. 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; PMID:16338915; http://dx.doi.org/10.1370/afm.405 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:8349060 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; PMID:23391329; http://dx.doi. org/10.1186/1471-2458-13-116
