Health Literacy in Pediatrics - McMaster Pediatrics Residency Program

Health Literacy in Pediatrics 2012Who is most at risk?• born outside Canada• limited proficiency in English/French• low education• low income, unemployed• older adults (over 65 yrs)Canadian Council on Learning, 2008; Rootman & Gordon-El-Bihbety, 2008Canadian Council on Learning: Health Literacy Map www.ccl-cca.caWhy does health literacy matter?Low health literacy is associated with:• poorer health• chronic disease• medication errors• less preventative care• more emergency care• increased hospitalization• higher mortality (seniors)Health literacy impacts• Access to care• Patient safety• Quality of care• Health outcomesAHRQ, 2011; Canadian Council on Learning, 2008It’s a ‘silent epidemic’People with low health literacy:• Tend not to ask questions• Rely on other sources of information• Use effective coping skills• Don’t want you to know!Patients who nod and don’t ask questions are being polite.It doesn’t mean that they understand.What affects health literacy?Health literacy emerges from theinteraction among these factorsPersonProvidersProductsPlacesLindsay Wizowski, ext 46624Patient Education Services 2

Health Literacy in Pediatrics 2012PersonHow do parents feel?• anxious• tired• stressed• frustratedHow literate are parents?Percent of Canadians 16 to 35 years of agewith below proficiency literacy skillsStatistics Canada (2005) Building on our competenciesProviders• What is the strongestpersonal factor inpredicting higher levelsof health literacy?You have acutesinusitisThat’s Why, thankgood,right?you!Canadian Council on Learning, 2008Daily readingCommon mistakesDelivering too much information, too fast.Using jargon and difficult language.Not checking for understanding.ProductsPrint and online informationis complexSay what?Health information is everywhere.Much of it is conflicting or confusing.I understand that therationale for undertakingthis procedure includesrestoration ofbiomechanical alignmentof affected segments inpreparation for continued,and more comfortable,deformity managementwith othoses.Over 1000 studies: Mismatch between reading level of materials and reading skills of adultsLindsay Wizowski, ext 46624Patient Education Services 3

Health Literacy in Pediatrics 2012PlacesHospital environmentMost peoplesuffer hearing losswhen naked.• unfamiliar, scary• busy, noisy• distractions, interruptions• confusing signageHealth care system’s expectationsLow health literacyWe expect patients and families to be:• informed• activated• computer literate• self-managing• partners in carePerson’scapacitySystem’sdemandsWhat can you do?Health LiteracyUniversalPrecautions1Create a shame-free experience1. Create a shame-free experience2. Use clear language3. Use resources to make teachingmore effective4. Use teach-back to check forunderstanding• Anticipate that patients and parents mayhave trouble understanding healthinformation.• Convey an attitude of helpfulness, caringand respect.• Welcome a support person.• Encourage questions, listen.• Provide help with forms.Lindsay Wizowski, ext 46624Patient Education Services 4

Health Literacy in Pediatrics 20122 Use clear languageFind a simpler way to say it• A way of speaking and writing that iseasy for most people to understand.• Uses familiar, everyday (non-medical)language and a conversational style.• per• onset• elevated• hand hygiene• monitor the site• practice social distancing3Use resources• Blood tests should be drawn 4 hourspost injection.• Surgery may be required afterexhausting all non-operative treatments.• Ensure your child wears appropriateage/activity related protectiveequipment during physical activities.• A combination of methodsmakes teaching moreeffective.• Choose or developmaterials that are easy toread and understand.• Mark them up!Indicate key points(underline, circle).Individualized and InteractiveClear language benefits everyonePatient Education LibraryIn the MCH study,parents were satisfiedwith clear languagematerials, regardlessof their health literacyskills.Grade 5.7Hospital guidelines for developingpatient education materialsSearch for clearlanguage materialsLindsay Wizowski, ext 46624Patient Education Services 5

Health Literacy in Pediatrics 20124Check for understandingIneffective AmbiguousOK?All right?• The responsibility for communicatingclearly is yours.LesseffectiveClosedendedDo you understand?Do you have any questions?Does this make sense?• How do you know if a patientunderstands and knows what to do?EffectiveOpenendedWhat questions do you have?What parts of this are hard tounderstand?MosteffectiveTeach backTo make sure I explained thisclearly, could you tell/show mewhat you are going to do?Teach backOne of the top patientsafety practicesTeach back• Ask patients to repeat in their ownwords what they need to know or do.Teach• Not a test of the patient, but of howwell YOU explained a concept.Check• A chance to check for understandingand, if necessary to re-teach theinformation in a different way.“Closing the loop”ClarifyUnderstandingNational Quality Forum, 2010Schillinger et al, 2003Americal Academy of PediatricsSummaryAny patient or parent in your practice can havedifficulty understanding health information.Low health literacy affects their health and safety,as well as the quality of their care and experienceat the hospital.You can help by:1. Creating a shame free experience2. Using clear language3. Using resources to reinforce teaching4. Using teach back to check for understandingLindsay Wizowski, ext 46624Patient Education Services 6

Health Literacy in Pediatrics 2012Lindsay Wizowski BScN MEdPatient Education SpecialistHamilton Health SciencesExt. 46624wizowski@hhsc.caLindsay Wizowski, ext 46624Patient Education Services 7

Activity 1: Assessing health literacyThe Newest Vital Sign is a screening tool to identify patients at risk for lowhealth literacy. The NVS consists of a nutrition label accompanied by six questionsthat assess the patient’s reading and numeracy skills. The tool can be administeredin a clinical setting in just three minutes.Scoring:0 to 1 = Low health literacy is likely (greater than 50% chance that patienthas marginal or inadequate health literacy and is at significant riskfor poor health outcomes)2 to 3 = Low health literacy is possible4 to 6 = Adequate health literacyThe score provides information about the patient that will allow health careproviders to adapt their communication practices in an effort to achieve betterhealth outcomes.1. Simulation: In your group, choose one person to play the role of a parent andanother person to be the pediatric resident. The setting is a hospital pediatricoutpatient clinic. This is the child’s first visit. At this clinic, a health literacy test isadministered to a parent/caregiver as part of the family’s initial assessment.2. Assess the parent’s health literacy:The resident gives the parent the nutrition label. The parent can refer to it whileanswering questions. It is not necessary to give parents time to review the labelbefore asking the questions. Rather, they will review the label as they are askedand answer the questions.The resident asks the questions and records the patient’s responses on thescoring sheet, which contains the correct answers. Repeat questions as needed.Based on the number of correct responses, the physiotherapist estimates thepatient's health literacy level.3. After the simulated assessment, discuss the experience of “health literacy screening”from the perspective of the parent and the resident.4. What health literacy skills does the NVS measure? What health literacy skills are notmeasured?5. Discuss the advantages and disadvantages of assessing patients’ health literacy inthe clinical setting. What is your group’s recommendation regarding routine healthliteracy screening?

Newest Vital Sign – Ice cream label

Activity 2: Assessing the quality of patient education materialsThe Clear Language Checklist is an abbreviated list of criteria for the quality ofhealth information. It can be applied to printed information or webpages, toidentify aspects of writing and design that make the material hard to read orunderstand. In practice, a checklist can help you determine whether materials aresuitable for patient and family education.Instructions:1. Your group is planning education for parents of children having ear surgery(otoplasty). You want to provide parents with clear post-op instructions.2. There are two resources to review. Half of your group will review the handout“Caring for your child after ear surgery” and the other half will review thewebpage “Otoplasty” from www.medicinenet.com3. Use the “Clear Language Checklist” to assess the writing, design and overallquality of these resources.4. Compare the checklist results.5. Discuss the role of the pediatric resident in selecting or developing “clearlanguage” patient education materials.

OverallDesignWritingClear Language ChecklistDescribe the target audienceIs the purpose clearly stated at the start?YesNoNotsureN/AIs it written in familiar, everyday language?Are unfamiliar words & acronyms defined?Are sentences less than 20 words?Is it written in active voice?Is it written in a conversational style?Is it organized in short sections (paragraphs 6-8 lines)?Do sections have useful headings or questions?Is it organized in a logical way and easy to follow?Does it clearly tell readers what they need to do?Does it tell readers how to get more information or help?Are there only 1 or 2 styles of type (fonts)?YesNoNotsureN/AIs the size of the type easy to read?Are subheadings and headings in larger type?Are upper and lower case letters used throughout?Do paragraphs line up at the left margin only?Does the most important information stand out?Is there white space at margins and between sections?Are bullets used to present lists?Do pictures or colour help find or explain information?Are pictures realistic and appropriate for the audience?How suitable is the material for the audience?VerygoodGood Fair PoorHow likely is the material to achieve its purpose?How would you rate the quality of the communication?

Sample handout (page 1 of 2)Caring for your child after ear surgery(Otoplasty)What happens after surgery?Your child will go the Post Anesthetic Care Unit (PACU) to be closelymonitored until he or she is fully awake. As soon as possible, the nurse willbring one parent into the PACU to be with your child.When your child is fully awake, you and your child will go to the Same DaySurgery Unit or to the children’s ward, if your child needs to stay inhospital. The nurses will continue to check your child until you go home.How do I care for my child after surgery?Your child’s head will be wrapped in a bulky bandage. The bandage stays onfor 1 to 3 weeks to protect the new shape of the ears and prevent infection.Do not wash your child’s hair during this time.The stitches under the dressing will be taken out at your child’s follow-upappointment.Pain reliefDietAfter surgery, the amount and type of pain is different for each child.Your child’s ears may throb or ache for a few days.Your doctor may give you a prescription for pain medication. If you do nothave a prescription, you can give your child acetaminophen (Tylenol ).Follow the directions on package for your child’s age and weight.To prevent nausea and vomiting after surgery, we will start by giving yourchild clear fluids (water, apple juice or popsicles). Your child should be ableto eat and drink as usual within 12 hours of surgery.Please turn over

Caring for your child after ear surgery, page 2 of 2ActivityMost children are usually up and about within a few hours of surgery.Your child may return to school after 7 days, if he or she can be careful orsupervised during playground activities.For 4 weeks after surgery, your child should not go swimming or do anyactivity in which the ear might be bent, such as wearing a hat or helmet.When does my child need a follow-up visit?Your child needs to see the surgeon in 1 to 2 weeks. Make this appointmentbefore you go home.When should I call the doctor?Call the surgeon if your child has any of the following problems:your child feels ill or has a fever (temperature higher than 38.5°C (101.3°F)bleeding or drainage (discharge) through the bandage or dressingredness or swelling around the incisionspain that does not go away or seems to be getting worseunable to eat or drink as usualnausea or vomitingSurgeon: _______________________ Phone: _______________________After hours or on the weekend, call the hospital and ask to speak to the PlasticSurgeon or the Ear, Nose and Throat (ENT) Surgeon on-call.If you are not able to reach the doctor, bring your child to the nearest hospitalemergency room.For questions that are not urgent, please callyour family doctor or pediatrician.

Webpage downloaded from www.medicine.net Dec 22, 2012

Text from webpage downloaded from www.medicine.net Dec 22, 2012What happens after surgery?After surgery, you will be taken to the recovery room where a nurse will monitor you. You will beable to go home the same day as the surgery once you have fully recovered from theanesthetic. This usually takes several hours. You will need a friend or family member to pick youup from the surgical facility and to take you home. He or she should spend the first night aftersurgery with you. When you arrive home from the surgical facility, you should go to bed and restwith your head elevated on 2-3 pillows. By keeping your head elevated above your heart, youcan minimize edema and swelling. You may get out of bed with assistance to use the bathroom.It is best to eat a light, soft, and cool diet as tolerated once you have recovered fully from theanesthetic. Avoid hot liquids for several days. Even though you may be hungry immediatelyafter surgery, it is best to go slowly to prevent postoperative nausea and vomiting. Occasionally,you may vomit one or two times immediately after surgery; if it persists, your doctor mayprescribe medication to settle the stomach. It is important to remember that a good overall dietwith ample rest promotes healing.You will be prescribed antibiotics after surgery, and should finish all the pills that have beenordered. Some form of a narcotic will also be prescribed (typically hydrocodone/Vicodin), and isto be taken as needed. If you require narcotics you are cautioned not to drive. In somesituations your doctor may give you steroids to be taken either preoperatively and/or postoperatively.It is very important that you take this medication as prescribed, and not discontinueit prematurely. If you have nausea or vomiting post-operatively, you may be prescribedmedications for nausea (anti-emesis), such as phenergan. If you have any questions or you feelthat you are developing a reaction to any of these medications, you should consult your doctor.You should not take any other medication, either prescribed or over-the-counter, unless youhave discussed it with your doctor.

Activity 3: Writing in clear language (optional, take-home assignment)Clear language: Is a way of writing that is easy to understand Uses familiar language and a conversational style to convey information clearly Makes health information accessible to a wide audience Is recommended for printed and web-based health informationInstructions1. Review the sample of health information “What is adolescent medicine?”.This is an excerpt from a pamphlet that is being developed for teens who arereferred to an adolescent medicine clinic.2. Consider what information teens need to know, and the language you use withteens. Revise this part of the pamphlet to make it more suitable for teens.What is adolescent medicine?Adolescent medicine physicians are pediatricians with a specialty in working withand understanding the unique medical needs of teenagers. Adolescence is a transitionperiod between childhood and adulthood. It is a normal developmental period filledwith major changes in physical maturity and sexuality, cognitive processes (ways ofthinking and thought content), emotions or feelings, and relationships with others.Adolescence is a special stage of development that requires the support of healthprofessionals who can assist young people as they gradually accept increasingresponsibility for their own health and transition from childhood to adulthood.Adolescents require more than routine check ups. They have diverse health needs –including those related to their physical development, body image, nutrition,sexuality, mental health, use of substances and other risk behaviours. Difficultieswithin the family, school, or peer group often emerge or manifest as health concernsduring the adolescent years. Adolescent medicine physicians provide healtheducation to ensure understanding and encourage compliance. They provide holisticmedical care and pay particular attention to coordinating medical, mental health,social and other services. They provide adolescents with confidential care whileencouraging family involvement.Flesch-Kincaid Grade 14.5

Health Literacy in PediatricsReferencesAbrams, M. & Dreyer, B. (2009). Plain language pediatrics. Elk Grove Village, IL: AmericanAcademy of Pediatrics.Abrams, M., Klass, P. & Dreyer, B. (2009). Health literacy and children: Recommendations foraction. Pediatrics. 124 (suppl 3): S327‐S331Agency for Healthcare Research and Quality. (2011). Health literacy interventions andoutcomes: An updated systematic review. Evidence Report/Technology Assessment #199. www.ahrq.gov/clinic/tp/lituptp.htmAgency for Healthcare Research and Quality. (2010). Health Literacy Universal PrecautionsToolkit. Rockville MD: U.S. Department of Health and Human Services.www.nchealthliteracy.org/toolkit/toolkit_w_appendix.pdfAmerican Medical Association Foundation and American Medical Association. (2007). Healthliteracy and patient safety: Help patients understand. Chicago, IL: AMA Press.Apter, A., Wang, X., Bogen, D., Bennett, I., Jennings, R., Garcia, L., Sharpe, T., Frazier, C. &Have, T. (2009). Linking numeracy and asthma‐related quality of life. Patient Educationand Counseling. 75(3): 386‐391.Arozullah, A., Yarnold, P., Bennett, C., Soltysik, R., Wolf, M., Ferreira, R., Lee, S., Costello, S.,Shakir, A., Denwood, C., Bryant, F. & Davis, T. (2007). Development and validation of ashort‐form, rapid estimate of adult literacy in medicine. Medical Care. 45(11): 1026‐1033.Baker, D. (2006). The meaning and measure of health literacy. Journal of General InternalMedicine. 21, 878‐883.Baker, D., Parker, R., Williams, M., Pitkin, K., Parikh, N., Coates, W. & Imara, M. (1996). Thehealth care experiences of patients with low literacy. Archives of Family Medicine. 5(6),329‐334.Baker, D., Wolf, M., Feinglass, J. & Thompson, J. (2008). Health literacy, cognitive abilities, andmortality among elderly persons. Journal of General Internal Medicine. 23(6), 723‐726.Patient Education Services – Clinical Practice & Education – Dec 2011

Baker, D., Wolf, M., Feinglass, J., Thompson, J., Gazmararian, J. & Huang, J. (2007). Healthliteracy and mortality among elderly persons. Archives of Internal Medicine. 167(14),1503‐1509.Bass, P., Wilson, J., Griffith, C., & Barnett, D. (2002). Residents’ ability to identify patients withpoor literacy skills. Academic Medicine. 77, 1039‐1041.Baur, C. (2010). New directions in research on public health and health literacy. Journal ofHealth Communication. 15: 42‐50.Berkman, N., Davis, T. & McCormack, L. (2010). Health literacy: What is it? Journal of HealthCommunication. 15: 9‐19.Berkman, N., Sheridan, S., Donahue, K., Halpern, D. & Crotty, K. (2011). Low health literacyand health outcomes: An updated systematic review. Annals of Internal Medicine.155(2): 97‐107.Betz, C., Ruccione, K., Meesks, K., Smith, K. & Chang, N. (2008). Health literacy: A pediatricnursing concern. Pediatric nursing. 34(3): 231‐239.Brewer, N., Tzeng, J., Lillie, S., Edwards, A., Peppercorn, J. & Rimer, B. Health literacy andcancer risk perception: Implications for genomic risk communication. Medical DecisionMaking. 29(2): 157‐166.Bryan, C. (2008). Provider and policy response to reverse the consequences of low healthliteracy. Journal of Healthcare Management. 54(4): 230‐241.Bunge, M., Muhlhauser, I. & Steckelberg, A. (2010). What constitutes evidence‐based patientinformation? Overview of discussed criteria. Patient Education and Counseling. 78: 316‐328.Burkell, J. (2004). What are the chances? Evaluating risk and benefit information in consumerhealth materials. Journal of the Medical Library Association. 92(2), 200‐208.Calgary Charter on Health Literacy: Rationale and Core Principles for the Development ofHealth Literacy Curricula (2009).www.centreforliteracy.qc.ca/whatsnew/Healthlitinst/Calgary_Charter.htmCanadian Council on Learning. (2008). Health Literacy in Canada: A Healthy Understanding.Ottawa, ON: Canadian Council on Learning. http://search.ccl‐cca.ca/NR/rdonlyres/266E0889‐8B9B‐45DB‐B615‐33E146E31B06/0/HealthLiteracyReportFeb2008E.pdfPatient Education Services – Clinical Practice & Education – Dec 2011 2

Canadian Council on Learning (2008). Reading the future: Planning to meet Canada’s futureliteracy needs. http://www.ccl‐cca.ca/NR/rdonlyres/7234398B‐60DB‐4A4C‐A7C5‐ED69B0307863/0/LiteracyReadingFutureReportE.PDFCanadian Public Health Association. Health Literacy Portal. www.cpha.ca/en/portals/h‐l.aspxCanadian Public Health Association. (2006). Health literacy interventions.www.cpha.ca/uploads/portals/h‐l/interventions_e.pdfCanadian Public Health Association. (2006). Low health literacy and chronic disease preventionand control ‐ perspectives from the health and public health sectors.www.cpha.ca/uploads/portals/h‐l/kl_summary_e.pdfCancer Care Ontario, Program in Evidence‐based Care. (2009). Effective teaching strategies andmethods of delivery for patient education: Guideline recommendations. Evidence‐basedSeries # 20‐2: Section 1.www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=60063Castro, C. M. , Wilson, C., Wang, F. & Schillinger, D. (2007). Babel babble: physicians’ use ofun‐clarified medical jargon with patients. American Journal of Health Behavior 31, 85–95.Chew, L., Bradley, K. & Boyko, E. (2004). Brief questions to identify patients with inadequatehealth literacy. Family Medicine. 36, 588‐594.Chew, L., Griffin, J., Partin, M., Noorbaloochi, S., Grill, J., Snyder, A., Bradley, K., Nugent, S.,Baines A. & VanRyn, M. (2008). Validation of screening questions for limited healthliteracy in a larger VA outpatient population. Journal of General Internal Medicine.23(5), 561‐566.Cho, Y., Lee, S., Arozullah, A. & Crittenden, K. (2008). Effects of health literacy on health statusand health service utilization amongst the elderly. Social Science & Medicine. 66, 1809‐1816.Clement, S., Ibrahim, S., Crichton, N., Wolf, M. & Rowlands, G. (2009). Complex interventionsto improve the health of people with limited literacy: A systematic review. PatientEducation and Counseling. 75(3): 40‐351.Coulter, A. & Ellins, J. (2007). Effectiveness of strategies for informing , educating, andinvolving patients. BMJ. 335: 24‐27.Patient Education Services – Clinical Practice & Education – Dec 2011 3

Davis, T., Long, S., Jackson, R., Mayeaux, E., George, R., Murphy, P. & Crouch, M. (1993). Rapidestimate of adult literacy in medicine: A shortened screening instrument. FamilyMedicine. 25, 391–395.Davis, T., Wolf, M., Arnold, C., Byrd, R., Long, S., Springer, T., Kennen, E. & Bocchini, J. (2006).Development and validation of the Rapid Estimate of Adolescent Literacy in Medicine(REALM – Teen): A tool to screen adolescents for below‐grade reading in health caresettings. Pediatrics. 118(6), e1707‐ e1714.Davis, T., Wolf, M., Bass, P., Middlebrooks, M., Kennen, E., Baker, D., Bennett, C., Durazo‐Arvizu, R., Bocchini, A., Savory, S. & Parker, R. (2006). Low literacy impairscomprehension of prescription drug warning labels. Journal of General InternalMedicine. 21: 847‐851.Denham, C., Dingman, J., Foley, M., Ford, D., Martins, B., O’Regan, P. & Salamendra, A. (2008).Are you listening…are you really listening? Journal of Patient Satisfaction. 4(3): 148‐161.DeWalt, D., Broucksou, K., Hawk, V., Brach, C., Hink, A., Rudd, R. and Callahan, L. (2011).Developing and testing the health literacy universal precautions toolkit. NursingOutlook. 59(2): 85‐94.DeWalt, D., Berkman, N., Sheridan, S., Lohr, K. & Pignone, M. (2004). Literacy and healthoutcomes: A systematic review of the literature. Journal of General Internal Medicine.19, 1228‐1239.DeWalt, D. & Hink, A. (2009). Health literacy and child health outcomes: A systematic review ofthe literature. Pediatrics. 124(Suppl 3): S265‐S274.DeWalt, D. & Pignone, M. (2007). Literacy and its relationship with self‐efficacy, trust andparticipation in medical decision making. American Journal of Health Behavior.31(Suppl 1), S27‐S35.Doak, C., Doak, L. & Root, J. (1996). Teaching patients with low literacy skills. 2nd ed.Philadelphia, PA: Lippincott.Donelle, L., Arocha, J. & Hoffman‐Goetz, L. (2008). Health literacy and numeracy: Key factors incancer risk comprehension. Chronic Diseases in Canada. 29(1): 1‐8.Eggertson, L. (2011). Health Literacy: More than just the three Rs. Canadian Nurse. 107(1): 18‐23.Eichler, K., Wieser, S. & Brügger, U. (2009). The costs of limited health literacy: A systematicreview. International Journal of Public Health. 54(5):313‐24.Patient Education Services – Clinical Practice & Education – Dec 2011 4

Jeppesen, K., Coyle, J. & Miser, W. (2009). Screening questions to predict limited health literacy:A cross sectional study of patients with diabetes mellitus. Annals of Family Medicine.7(1): 24‐31.Johnson, K. & Weiss, B. (2008). How long does it take to assess literacy skills in clinical practice?Journal of the American Board of Family Medicine. 21, 211‐214.Jordan, J., Buchbinder, R. & Osborne, R. (2010). Conceptualising health literacy from the patientperspective. Patient Education and Counseling. 79(1): 36‐42.Jordan, J., Osborne, R. & Buchbinder, R. (2010). Critical appraisal of health literacy indicesrevealed variable underlying constructs, narrow content and psychometric weaknesses.Journal of Clinical Epidemiology. 64(4): 366‐379.Katz, M., Jacobson, T., Veledar, E. & Kripalani, S. (2007). Patient literacy and question‐askingbehavior during the medical encounter: a mixed‐methods analysis. Journal of GeneralInternal Medicine. 22(6): 782‐6.Keller, D., Wright, J. & Pace, H. (2008). Impact of health literacy on health outcomes inambulatory care patients: A systematic review. Annals of Pharmacotherapy. 42: 1272‐1281.Keller, P.A. & Lehman, D.R. (2008). Designing effective health communications: A metaanalysis.Journal of Public Policy & Marketing 27(2) 1‐26.Kelly, P. & Haidet, P. (2007). Physician overestimation of patient literacy: A potential source ofhealth care disparities. Patient Education and Counseling. 66, 119‐122.Kessels. R. (2003). Patients’ memory for medical information. Journal of the Royal Society ofMedicine. 96(5), 217‐222.Kickbusch, I. (2009). Health literacy: Engaging in a political debate. International Journal ofPublic Health. 54: 1‐2.Koch‐Weser, S., Rudd, R. & DeJong, W. (2010). Quantifying word use to study health literacy indoctor‐patient communication. Journal of Health Communication. 15: 590‐602.Kripalani, S. , Robertson, R. , Love‐Ghaffari, M. H. , Rodriguez, M. & Wu, S. (2007).Development of an illustrated medication schedule as a low‐literacy patient educationtool. Patient Education and Counseling 66, 368–377.Kreps, G. & Sparks, L. (2008). Meeting the health literacy needs of immigrant populations.Patient Education and Counseling. 71, 328‐332.Patient Education Services – Clinical Practice & Education – Dec 2011 7

Kumar, D., Sanders, L., Perrin, E., Lokker, N., Patterson, B., Gunn, V., Finkle, J., Franco, V.,Choi, L. & Rothman, R. (2010). Parental understanding of infant health information:Health literacy, numeracy , and the Parental Health Literacy Activities Test (PHLAT).Academic Pediatrics. 10(5): 309‐316.Lipkus, I. & Hollands, J. (1999). The visual communication of risk. Journal of the NationalCancer Institute: Monographs 25, 149‐163.Lorenzen, B., Melby, C. & Earles, B. (2008). Using principles of health literacy to enhance theinformed consent process. AORN. 88(1): 23‐29.Lui, C., Kemper, S. & McDowd, J. (2009). The use of illustration to improve older adults’comprehension of health‐related information: Is it helpful? Patient Education andCounseling. 76(2): 283-288.Machtinger, E., Wang, F., Chen, L., Rodriguez, M., Wu, S. & Schillinger, D. (2007). A visualmedication schedule to improve anticoagulation control: A randomized, controlled trial.The Joint Commission Journal of Quality and Patient Safety. 33(10), 625‐635.Mancuso, J. (2009). Assessment and measurement of health literacy: An integrative review ofthe literature. Nursing and Health Sciences. 11: 77‐89.Mancuso, C. & Rincon, M. (2006). Impact of health literacy on longitudinal asthma outcomes.Journal of General Internal Medicine. 21, 813‐817.Maniaci, M., Heckman, M. & Dawson, N. (2008). Functional health literacy and understandingof medications at discharge. Mayo Clinic Proceedings. 83(5): 554‐558.Martin, L., Ruder, T., Escarce, J., Ghosh‐Dastidar, B., Sherman, D., Elliot, M., Bird, C., Fremont,A., Gasper, C., Culbert, A., & Lurie, N. (2009). Developing predictive models of healthliteracy. Journal of General Internal Medicine. 24(11): 1211‐1216..Mazor, K., Baril, J., Dugan, E., Spencer, F., Burgwinkle, P. & Gurwitz, J. (2007). Patient educationabout anticoagulant medication: Is narrative evidence or statistical evidence moreeffective? Patient Education and Counseling. 69, 145‐157.McCray, A. (2005). Promoting health literacy. Journal of American Medical InformaticsAssociation. 12(2): 152‐163.Miller, M., Allison, J., Schmitt, M. Ray, M. & Funkhouser, E. (2010). Using single‐item healthliteracy screening to identify patients who read written nonsteroidal anti‐inflammatorymedicine information provided at pharmacies. Journal of Health Communication. 15:413‐427.Patient Education Services – Clinical Practice & Education – Dec 2011 8

Nagel, K., Wizowski, L., Duckworth, JoAnn, Cassano, J., Hahn, S. & Neal, M. (2008). Using plainlanguage skills to create an educational brochure about sperm banking for adolescentsand young adult males with cancer. Journal of Pediatric Oncology Nursing. 25(20): 220‐226.Nagel, K., Cassano, J., Wizowski, L., & Neal, M. (2009). Collaborative multidisciplinary teamapproach to fertility issues among adolescent and young adult cancer patients.International Journal of Nursing Practice. 15(4): 311‐317National Institutes of Health. (2008). Clear communication: a NIH Health Literacy Initiative.www.nih.gov/clearcommunication/index.htmNeaville, E. (2005). Making websites more accessible for users who are older and/or have adisability. Aging and Disability Resource Center. Technical Assistance Exchange IssueBrief. www.adrc‐tae.org/tiki‐download_file.php?fileId=2834Neuhauser, L. & Kreps, G. (2008). Online cancer communication: Meeting the literacy, culturaland linguistic needs of diverse audiences. Patient Education and Counseling. 71(3): 365‐377.Nielsen‐Bohlman, L., Panzer, A. & Kindig, D. (Eds.) (2004). Health Literacy:A prescription to end confusion. Washington, DC: The National Academies Press. fromwww.nap.edu/books/0309091179/html/Nutbeam, D. (2000). Health literacy as a public health goal: A challenge for contemporary healtheducation and communication strategies into the 21 st century. Health PromotionInternational. 15(3), 259‐267.Nutbeam, D. (2008). The evolving concept of health literacy. Social Science & Medicine. 67(12):2072‐2078.Nutbeam, D. (2009). Defining and measuring health literacy: What can we learn from literacystudies? International Journal of Public Health. 54(5):303‐5.Oates, D., Paasche‐Orlow, M. (2009). Health literacy: Communication strategies to improvepatient comprehension of cardiovascular health. Circulation. 119(7): 1049‐1051.Ontario Medical Association. (2009). OMA Background Paper: Patient health literacy:Implications for physician practice and health system planning. Ontario MedicalReview. Nov: 29‐35.www.oma.org/Resources/Documents/2009OMAHealthLiteracyImplications.pdfPatient Education Services – Clinical Practice & Education – Dec 2011 9

Osborn, C., Weiss, B., Davis, T., Skripkauskas, S., Rodriguez, C., Bass, P. & Wolf, M. (2007).Measuring adult literacy in health care: Performance of the Newest Vital Sign. AmericanJournal of Health Behavior. 31(Suppl3), S36‐S46.Osborn, C., Cavanaugh, K., Wallston, K. & Rothman, R. (2010). Self‐efficacy links health literacyand numeracy to glycemic control. Journal of Health Communication. 15: 146‐158.Osborn, C., Paasche‐Orlow, M., Bailey, S. & Wolf, M. (2010). The mechanisms linking healthliteracy to behavior and health status. American Journal of Health Behavior. 35(1): 118‐128.Parikh, N., Parker, R., Nurss, J., Baker, D. & Williams, M. (1996). Shame and health literacy: Theunspoken connection. Patient Education and Counseling. 27, 33‐39.Parker, R., Baker, D., Williams, M. & Nurss, J. (1995). The test of functional health literacy inadults (TOFHLA): A new instrument for measuring patients’ literacy skills. Journal ofGeneral Internal Medicine. 10, 537–545.Parker, R., Wolf, M. & Kirsch, I. (2008). Preparing for an epidemic of limited health literacy:Weathering the Perfect Storm. Journal of General Internal Medicine. 23(8), 1273‐1276.Paasche‐Orlow, M., Schillinger, D., Greene, S. & Wagner, E. (2006). How health care systems canbegin to address the challenge of limited health literacy. Journal of General InternalMedicine. 2121: 884‐887.Paasche‐Orlow, M. & Wolf, M. (2007). The causal pathways linking health literacy to healthoutcomes. American Journal of Health Behavior. 31(Suppl 1), S19‐S26.Paasche‐Orlow, M. & Wolf, M. (2007). Evidence does not support clinical screening of literacy.Journal of General Internal Medicine. 23(1), 100‐102.Paasche‐Orlow, M. & Wolf, M. (2010). Promoting health literacy research to reduce healthdisparities. Journal of Health Communication. 15: 34‐41.Paasche‐Orlow, M. (2011). Caring for Patients with limited health literacy. JAMA. 306 (10): 1122‐1129.Peerson, A. & Saunders, M. (2009). Health literacy revisited: What do we mean and why does itmatter? Health Promotion International. 24 (3), 285‐296.Peregrin, T. (2010). Picture this: Visual cues enhance health education messages for people withlow literacy skills. Journal of the American Dietetic Association. 110(4): 500‐505.Patient Education Services – Clinical Practice & Education – Dec 2011 10

Persell, S., Osborn, C., Richard, R., Skripkauskas, S. & Wolf, M. (2007). Limited health literacy isa barrier to medication reconciliation in ambulatory care. Journal of General InternalMedicine. 22(11), 1523‐1526.Peters, E., Hibbard, J., Slovic, P. & Dieckmann, N. (2007). Numeracy skill and thecommunication, comprehension, and use of risk‐benefit information. Health Affairs.26(3), 741‐748.Pfizer Clear Health Communication Initiative. (2006). The Newest Vital Sign:A new health literacy assessment tool for health care providers.www.pfizerhealthliteracy.com/physicians‐providers/newest‐vital‐sign.htmlPignone, M., DeWalt, D., Sheridan, S., Berkman, N. & Lohr, K. (2005). Interventions to improvehealth outcomes for patients with low literacy: A systematic review. Journal of GeneralInternal Medicine. 20: 185‐192.Pleasant, A & Kuruvilla, S. (2008). A tale of two health literacies: Public health and clinicalapproaches to health literacy. Health promotion International. 23(2): 152‐159.Pleasant, A. & McKinney, J. (2011). Coming to consensus on health literacy measurement: Anonline discussion and consensus‐gaging process. Nursing Outlook. 59(2): 96‐106.Porter, S., Guo, C., Bacic, J. & Chan, E. (2011). Health literacy and task environment influenceparentsʹ burden for data entry on child‐specific health information: Randomizedcontrolled trial. Journal of Medical Internet Research. 13(1): e13.www.jmir.org/2011/1/e13/Poureslami, I., Rootman, I., Balka, E., Devarakonda, R., Hatch, J. & Fitzgerald, M. (2007). Asystematic review of asthma and health literacy: A cultural‐ethnic perspective inCanada. Medscape General Medicine. 9(3): 40.Powers, B., Trinh, J. & Bosworth, H. (2010). Can this patient read and understand written healthinformation? JAMA. 304(1): 76‐84.Price, M., Cameron, R. & Butow, P. (2007). Communicating risk information: The influence ofgraphical display format on quantitative information perception: Accuracy,comprehension and preferences. Patient Education and Counseling. 69, 121‐128.Primack, B., Bui, T. & Fertman, C. (2007). Social marketing meets health literacy: Innovativeimprovement of health care providers’ comfort with patient interaction. PatientEducation and Counseling. 68(1): 3‐9.Patient Education Services – Clinical Practice & Education – Dec 2011 11

Public Health Agency of Canada. How does literacy affect the health of Canadians? www.phacaspc.gc.ca/ph‐sp/literacy‐alphabetisme/literacy‐eng.phpRatzan, S. (2001). Health literacy: Communication for the public good. Health PromotionInternational. 16(2):207‐14.Ratzan, S. (2010). The National Health Literacy Action Plan: The time has come for action.Journal of Health Communication. 15: 575‐577.Rogers, E.S., Wallace, L.S. & Weiss, B.D. (2006). Misperceptions of medical understanding inlow‐literacy patients: Implications for cancer prevention. Cancer Control. 13(3), 225‐229.Rootman, I. (2006). Health literacy: Where are the Canadian doctors? Canadian MedicalAssociation Journal. 175(6): 606‐607.Rootman, I. & Gordon‐El‐Bihbety, D. (2008). A vision for a health literate Canada: Report on theExpert Panel on Health Literacy. Ottawa, ON: Canadian Public Health Association.www.cpha.ca/en/portals/h‐l/panel.aspxRoter, D. (2011). Oral literacy demand of health care communication: Challenges and solutions.Nursing Outlook. 59(2): 79‐84.Rothman, R., Yin, S., Mulvaney, S., Co, J., Horner, C. & Lannon, C. (2009). Health literacy andquality: Focus on chronic illness care and patient safety. Pediatrics. 124(Suppl 3): 315‐326.Rubinelli, S., Schultz, P.J., & Nakamoto, K., (2009). Health literacy beyond knowledge andbehaviour: letting the patient be a patient. International Journal of Public Health. 54: 307‐311.Rudd, R., Blanch, D., Gall, V., Chibnik, L., Wright, E., Reichman, W. Liang, M. & Katz, J. (2009).A randomized controlled trial of an intervention to reduce low literacy barriers ininflammatory arthritis management. Patient Education and Counseling. 75(3):334‐9.Rudd, R. (2007). Health literacy skills of U.S. adults. American Journal of Health Behavior.31(Suppl 1), S8‐S18.Rudd, R., Kirsch, I. & Yamamoto, K. (2004). Literacy and Health in America. Princeton NJ:Educational Testing Service. www.ets.org/Media/Research/pdf/PICHEATH.pdfRudd, R. & Anderson, J. (2006). The health literacy environment of hospitals and health centers.Boston, MA: National Center for the Study of Adult Learning and Literacy, Health andAdult Learning Initiative, Harvard School of Public Health. www.ncsall.net/?id=1163Patient Education Services – Clinical Practice & Education – Dec 2011 12

Rudd, R., Soricone, L., Santos, M., Zobel, E. & Smith, J. (2005). Health Literacy Study Circles+:Introduction. www.ncsall.net/fileadmin/resources/teach/nav_ch1.pdfRyan, J., Leguen, F., Weiss, B., Albury, S., Jennings, T., Velez, F. & Salibi, N. (2007). Will patientsagree to have their literacy skills assessed in clinical practice? Health EducationResearch. 23(4), 603‐611.Sarkar, U., Karter, A., Liu, J., Adler, N., Nguyen, R. Lopez, A. & Schillinger, D. (2010). Theliteracy divide: Health literacy and the use of an internet‐based patient portal in anintegrated health system ‐ Results from the Diabetes Study of Northern California(DISTANCE). Journal of Health Communication. 15: 183‐196.Sakar, U., Schillinger, D., Lopez, A. & Sudore, R. (2011). Validation of self‐reported healthliteracy questions among diverse English and Spanish‐speaking populations. Journal ofGeneral Internal Medicine. 26(3): 265‐271.Sanders, L., Federico, S., Klass, P., Abrams, M. & Dreyer, B. (2009). Literacy and child health.Archives of Pediatric and Adolescent Medicine. 163(2): 131‐140.Sanders, L., Zacur, G., Haecker, T. & Klass, P. Number of children’s books in the home: anindicator of parent health literacy. Ambulatory Pediatrics. 4(5): 424‐428.Schillinger, D. (2007). Literacy and health communication: Reversing the “Inverse Care Law”.American Journal of Bioethics. 7(11), 15‐18.Schillinger, D., Machtinger, E., Wang, F., Chen, L., Win, K., Palacios, J., Rodriguez, M. &Bindman, A. (2006). Language, literacy and communication regarding medication in ananticoagulation clinic: Are pictures better than words? Journal of HealthCommunication. 11(7), 651‐664.Schillinger, D., Piette, J., Grumbach, K., Wang, F., Wilson, C., Daher, C., Leong‐Grotz, K., Castro,C. & Bindman, A. (2003). Closing the loop: Physician communication with diabeticpatients who have low health literacy. Archives of Internal Medicine. 163, 83‐90.Schonlau, M., Martin, L., Haas, A., Derose, K. & Rudd, R. (2011). Patients’ literacy skills: Morethan just reading ability. Journal of Health Communication. 16(10): 1046‐1954.Schwartzberg, J., Cowett, A., VanGeest, J. & Wolf, M. (2007). Communication techniques forpatients with low health literacy: A survey of physicians, nurses, and pharmacists.American Journal of Health Behavior. 31(Suppl 1): S96‐S104.Schwartzberg, J., VanGeest, J. & Wang, C. (2005). Understanding Health Literacy. Atlanta, GA:American Medical Association Press.Patient Education Services – Clinical Practice & Education – Dec 2011 13

Seligman, H., Wallace, A., DeWalt, D., Schillinger, D., Arnold, C., Bryant Shilliday, B.,Delgadillo, A., Bengal, N. & Davis, T. (2007). Facilitating behavior change with lowliteracypatient education materials. American Journal of Health Behavior. 31(Suppl 1),S69‐S78.Shaw, S., Huebner, C., Armin, J., Orzech, K. & Vivian, J. (2009). The role of culture in healthliteracy and chronic disease screening and management. Journal of Immigrant andMinority Health. 11(6): 460‐467.Shieh, C. & Halstead, J. (2009). Understanding the impact of health literacy on womenʹs health.JOGNN. 38(5):601‐612.Shohet, L. & Renaud, L. (2006). Critical analysis on best practices in health literacy. CanadianJournal of Public Health. 97 (Suppl 2): S10 – S13.Shone, L., Conn, K., Sanders, L. & Halterman, J. (2009). The role of parent health literacy amongurban children with persistent asthma. Patient Education and Counseling. 75(3): 368‐375.Simon, M., Dong, X., Nonzee, N. & Bennett, C. (2009). Heeding our words: Complexities ofresearch among low‐literacy populations. Journal of Clinical Oncology. 27(12): 1938‐1940.Sparks, L. & Nussbaum, J. (2008). Health literacy and cancer communication with older adults.Patient Education and Counseling. 71(3): 345‐350.Stableford, S. & Mettger, W. (2007). Plain language: A strategic response to the health literacychallenge. Journal of Public Health Policy. 28, 71‐93.Statistics Canada. (2005). Building on our competencies: The Canadian results of theInternational Adult Literacy and Skills Survey.www.statcan.ca/bsolc/english/bsolc?catno=89‐617‐XIESudore, R., Landefeld, S., Barnes, D., Lindquist, K., Williams, B., Brody, R. & Schillinger, D.(2007). An advance directive redesigned to meet the literacy level of most adults: Arandomized trial. Patient Education and Counseling. 69, 165‐195.Sudore, R., Landefeld, S., Williams, B., Barnes, D., Lindquist, K. & Schillinger, D. (2006). Use of amodified informed consent process among vulnerable patients: A descriptive study.Journal of General Internal medicine. 21(8): 867‐873.Sudore, R. & Schillinger, D. (2009). Interventions to improve care for patients with limitedhealth literacy. Journal of Clinical Outcomes Management. 16(1): 20‐29.www.ncbi.nlm.nih.gov/pmc/Patient Education Services – Clinical Practice & Education – Dec 2011 14

Sudore, R., Yaffe, K., Satterfield, S., Harris, T., Mehta, K., Simonsick, E., Newman, A., Rosano,C., Rooks, R., Rubin, S., Ayonayon, H. & Schillinger, D. (2006). Limited literacy andmortality in the elderly. Journal of General Internal Medicine. 21, 806‐812.Tait, A., Voepel‐Lewis, T., Zikmund‐Fisher, B. & Fagerlin, A. (2010). The effect of format onparentsʹ understanding of the risks and benefits of clinical research: A comparisonbetween text, tables, and graphics. Journal of Health Communication. 15: 487‐501.The Joint Commission. (2007). “What did the doctor say?” Improving health literacy to protectpatient safety. www.jointcommission.org/NewsRoom/PressKits/Health_Literacy/Thompson, A., Goldszmidt, M., Schwatrz, A. & Bashook, P. (2010). A randomized trial ofpictorial versus pose‐based medication information pamphlets. Patient Education andCounseling. 78: 389‐393.Tran, TP., Robinson, L., Keebler, J., Walker, R. & Wadman, M. (2008). Health literacy amongparents of pediatric patients. Western Journal of Emergency Medicine. 9(3): 130‐134.Triffiletti, L., Shields, W., McDonald, E., Walker, A. & Gielen, A. Development of injuryprevention materials for people with low literacy skills. Patient Education andCounseling. 64(1‐3): 119‐27.Turner, T., Cull, W., Bayldon, B., Klass, P., Sanders, L., Frintner, M., Abrams, M. & Dreyer, B.(2009). Pediatricians and health literacy: Descriptive results from a national survey.Pediatrics. 124(Suppl 3): S299‐S305.United Nations Economic and Social Council (ECOSOC). (2010). Health literacy and theMillennium Development Goals: United Nations Economic and Social Council(ECOSOC) regional meeting background paper (abstracted). Journal of HealthCommunication. 15: 211‐233.U.S. Department of Health and Human Services. (2006). Research‐based web design andusability guidelines. Washington, DC: U.S. General Services Administration.www.usability.gov/pdfs/guidelines.htmlU.S. Department of Health and Human Services. (2007). Plain language: A promising strategyfor clearly communicating health information and improving health literacy.Washington, DC: Office of Disease Prevention and Health Promotion.www.health.gov/communication/literacy/plainlanguage/IssueBrief.pdfUS Department of Health and Human Services. (2007). Quick guide to health literacy and olderadults. Washington, DC: Office of Disease Prevention and HealthPromotion.http://www.health.gov/communication/literacy/olderadults/literacy.htmPatient Education Services – Clinical Practice & Education – Dec 2011 15

US Department of Health and Human Services. (2009). Improving health literacy for olderadults: Expert panel report. Atlanta GA: Centers for Disease Control and Prevention.www.cdc.gov/healthmarketing/healthliteracy/reports/olderadults.pdfUS Department of Health and Human Services. (2010). National action plan to improve healthliteracy. Washington, DC: Office of Disease Prevention and Health Promotion.http://www.health.gov/communication/HLActionPlan/pdf/Health_Literacy_Action_Plan.pdfUS Department of Health and Human Services. (2010). Health literacy online: A guide towriting and designing easy‐to‐use health web sites. Washington, DC: Office for DiseasePrevention and Health Promotion.http://www.health.gov/healthliteracyonline/Web_Guide_Health_Lit_Online.pdfUS Department of Health and Human Services. (2010). Toolkit for making written material clearand effective. Washington, DC: Centers for Medicare and Medicaid Services.https://www.cms.gov/WrittenMaterialsToolkit/Vangeest, J., Welch, V. & Weiner, S. (2010). Patientsʹ perceptions of screening for health literacy:Reactions to the Newest Vital Sign. Journal of Health Communication. 15: 402‐412.Vernon, J., Trujillo, A., Rosenbaum, S. &DeBuono, B. (n.d.). Low Health Literacy: Implicationsfor National Health Policy.www.gwumc.edu/sphhs/departments/healthpolicy/chsrp/downloads/LowHealthLiteracyReport10_4_07.pdfVillaire, M. & Mayer, G. (2007). Low health literacy: The impact on chronic illness management.Professional Case Management. 12(4): 213‐216.Volandes, A. & Paasche‐Orlow, M. (2007). Health literacy, health inequality and a justhealthcare system. American Journal of Bioethics. 7(11), 5‐10.von Wagner, C., Steptoe, A., Wolf, M. & Wardle, J. (2009). Health literacy and health actions: Areview and a framework from health psychology. Health Education & Behavior. 36(5):860‐877.Waite, K., Paasche‐Orlow, M., Rintamaki, L., Davis, T. & Wolf, M. (2008). Literacy, social stigma,and HIV medication adherence. Journal of General Internal Medicine. 23(9): 1367‐1372.Wallace, A., Seligman, H., Davis, T., Schillinger, D., Arnold, C., Bryant‐Shilliday, Freburger, J. &DeWalt, D. (2009). Literacy‐appropriate educational materials and brief counselingimprove diabetes self‐management. Patient Education and Counseling. 75(3):328‐33.Patient Education Services – Clinical Practice & Education – Dec 2011 16

Wallace, L., Rogers, E., Roskos, S., Holiday, D. & Weiss, B. (2006). Brief report: Screening itemsto identify patients with limited health literacy skills. Journal of General InternalMedicine. 21, 874‐877.Weinman, J., Yusuf, G., Berks, R., Rayner, S. & Petrie, K. (2009). How accurate is patients’anatomical knowledge: a cross‐sectional, questionnaire study of six patient groups and ageneral public sample. BMC Family Practice. 12, 10:43.Weiss, B. & Griffith, M. (2010). Health literacy and the older adult. University of ArizonaCollege of Medicine. http://healthlit.fcm.arizona.edu/Weiss, B. (2003). Health Literacy: A manual for clinicians. Chicago, IL: American MedicalAssociation and American Medical Association Foundation.http://www.ama‐assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdfWeiss, B., Francis, L., Senf, J., Heist, K. & Hargraves, R. (2006). Literacy education as treatmentfor depression in patients with limited literacy and depression. Journal of GeneralInternal Medicine. 21: 823‐828.Weiss, B., Mays, M., Martz, W., Castro, K., DeWalt, D., Pignone, M., Mockbee, J. & Hale, F.(2005). Quick assessment of literacy in primary care: The Newest Vital Sign. Annals ofFamily Medicine. 3(6), 514‐522.White, R., Wolff, K., Cavanaugh, K. and Rothman, R. (2010). Addressing health literacy andnumeracy to improve diabetes education and care. Diabetes Spectrum. 23(4): 238‐243.www.ncbi.nlm.nih.gov/pmc/articles/PMC3032499/?tool=pubmedWilson, E. & Wolf, M. (2008). Working memory and the design of health materials: A cognitivefactors perspective. Patient Education and Counseling. 74(3): 318 ‐ 322.Wilson, E., Wolf, M., Curtis, L., Clayman, M., Cameron, K., Vom Eigen, K. & Makoul, G. (2010).Literacy, cognitive ability, and the retention of health‐related information aboutcolorectal cancer screening. Journal of Health Communication. 15: 116‐125.Wilson, J.F. (2003). The crucial link between literacy and health. Annals of Internal Medicine.139(10), 875‐878.Wizowski, L., Harper, T. & Hutchings, T. (2008). Writing health information for patients andfamilies. 3 rd edition. Hamilton, ON: Hamilton Health Sciences.Wolf, M., Curtis, L., Waite, K., Bailey, S., Hedlund, L., Davis, T., Shrank, W., Parker, R. andWood, A. (2011). Helping patients simplify and safely use complex prescriptionregimens. Archives of Internal Medicine, 171(4): 300‐305.Patient Education Services – Clinical Practice & Education – Dec 2011 17

Wolf, M., Davis, T., Shrank, W., Rapp, D., Bass, P., Connor, U., Clayman, M. & Parker, R. (2007).To err is human: Patient misinterpretations of prescription drug label instructions.Patient Education and Counseling. 67: 293‐300.Wolf, M., Davis, T., Tilson, H., Bass, P. & Parker, R. (2006). Misunderstanding of prescriptiondrug warning labels among patients with low literacy. American Journal of Health‐System Pharmacists. 63: 1048‐1055.Wolf, M., Gazmararian, J. & Baker, D. (2007). Health literacy and health risk behaviors amongolder adults. American Journal of Preventive Medicine. 32(1): 19‐24.Wolf, M., Williams, M., Parker, R., Parikh, N., Nolan, A. & Baker, D. (2007). Patients’ shame andattitudes towards discussing the results of literacy screening. Journal of HealthCommunication. 12: 721‐732.Wolf, M., Wilson, E., Rapp, D., Waite, K., Bocchini, M., Davis, T. & Rudd, R. (2009). Literacy andlearning in health care. Pediatrics. 124(Suppl 3): S275‐S281.Yin, H. S., Johnson, M., Mendelsohn, A., Abrams, M., Sanders, L. & Dreyer, B. (2009). The healthliteracy of parents in the United States: A nationally representative study. Pediatrics.124(S3): S289‐S298.Zamora, H. & Clingerman, E. (2011). Health literacy among older adults: A systematic literaturereview. Journal of Gerontological Nursing. 37(10): 41‐51.Patient Education Services – Clinical Practice & Education – Dec 2011 18