Health literacy

The ability to read and understand medication instructions is a form of health literacy.

Health literacy is the ability to obtain, read, understand, and use healthcare information in order to make appropriate health decisions and follow instructions for treatment.[1] There are multiple definitions of health literacy,[2] in part, because health literacy involves both the context (or setting) in which health literacy demands are made (e.g., health care, media, internet or fitness facility) and the skills that people bring to that situation (Rudd, Moeykens, & Colton, 1999). Studies reveal that only 12 percent of the adults in the U.S. have proficient health literacy. This means 77 million adults have basic or below basic health literacy. These individuals have difficulty with common health tasks including reading the label of a prescribed drug.[3] Low health literacy reduces the success of treatment and increases the risk of medical error. Health literacy is essential to promote healthy individuals and communities.

Various interventions, such as simplifying information and illustrations, avoiding jargon, using "teach-back" methods, and encouraging patients' questions, have improved health behaviors in persons with low health literacy. Since health literacy is a primary contributing factor to health disparities, it is a continued and increasing concern for health professionals. The proportion of adults aged 18 and over in the U.S., in the year 2010, who reported that their health care providers always explained things so they could understand them was about 60.6%.[4] This number increased 1% from 2007 to 2010.[4] The Healthy People 2020 initiative of the United States Department of Health and Human Services has included health literacy as a pressing new topic, with objectives for improving it in the decade to come.[5]

Society as a whole is responsible for improving health literacy. Most importantly, improving health literacy is the responsibility of healthcare and public health professionals and systems.

Characteristics

Plain language

In order to have a population that understands health terms and can make proper health decisions, the language used by health professionals has to be at a level that others who are not in the medical field can understand. Health professionals must know their audience in order to better serve their patient. The language used by these professionals should be plain language. Plain language is a strategy for making written and oral information easier to understand; it is communication that users can understand the first time they read or hear it.[6]

Some key elements of plain language include:[7]

  • Organizing information so most important points come first
  • Breaking complex information into understandable chunks
  • Using simple language and defining technical terms
  • Using active voice
  • Using lists and tables to make complex material easier to understand

If health practitioners use plain language and ask their patients to teach back what they were told, individuals will be better able to take action to protect their health and wellness and the health system will have better health outcomes.

Factors

Many factors determine the health literacy level of health education materials or interventions: readability of the text, the patient's current state of health, language barriers of the patient, cultural appropriateness of the materials, format and style, sentence structure, use of illustrations, interactiveness of the intervention, and numerous other factors.

A study of 2,600 patients conducted in 1995 by two US hospitals found that between 26% and 60% of patients could not understand medication directions, a standard informed consent form, or materials about scheduling an appointment.[8]

History

The young and multidisciplinary field of health literacy emerged from two groups of experts: physicians, health providers such as nurses[9], and health educators; and Adult Basic Education (ABE) and English as a second language (ESL) practitioners in the field of education. Physicians and nurses are a source of patient comprehension and compliance studies. Adult Basic Education / English for Speakers of Languages Other Than English (ABE/ESOL) specialists study and design interventions to help people develop reading, writing, and conversation skills and increasingly infuse curricula with health information to promote better health literacy. A range of approaches to adult education brings health literacy skills to people in traditional classroom settings, as well as where they work and live.

Biomedical approach

The biomedical approach to health literacy that became dominant (in the U.S.) during the 1980s and 1990s often depicted individuals as lacking health literacy or "suffering" from low health literacy. This approach assumed that recipients are passive in their possession and reception of health literacy and believed that models of literacy and health literacy are politically neutral and universally applicable. This approach is found lacking when placed in the context of broader ecological, critical, and cultural approaches to health. This approach has produced, and continues to reproduce, numerous correlational studies.[10]

Level of health literacy is considered adequate when the population has sufficient knowledge, skills, and confidence to guide their own health, and people are able to stay healthy, recover from illness, and/or live with disability or disease.[11]

McMurray states that health literacy is important in a community because it addresses health inequities. It is no coincidence that individuals with lower levels of health literacy live, disproportionally, in communities with lower socio-economic standing. A barrier to achieving adequate health literacy for these individuals is a lack of awareness, or understanding of, information and resources relevant to improving their health. This knowledge gap arises from both patients being unable to understand information presented to them and hospitals' inadequate efforts and materials to address these literacy gaps.

A more robust view of health literacy includes the ability to understand scientific concepts, content, and health research; skills in spoken, written, and online communication; critical interpretation of mass media messages; navigating complex systems of health care and governance; knowledge and use of community capital and resources; and using cultural and indigenous knowledge in health decision making (Nutbeam, 2000; Ratzan, 2001; Zarcadoolas, Pleasant, & Greer, 2002). This integrative view sees health literacy as a social determinant of health that offers a powerful opportunity to reduce inequities in health.

This perspective defines health literacy as the wide range of skills, and competencies that people develop over their lifetimes to seek out, comprehend, evaluate, and use health information and concepts to make informed choices, reduce health risks, and increase quality of life (Zarcadoolas, Pleasant, & Greer, 2006). While various definitions vary in wording, they all fall within this conceptual framework.

Defining health literacy in that manner builds the foundation for a multi-dimensional model of health literacy built around four central domains:[12]

  • fundamental literacy,
  • scientific literacy,
  • civic literacy, and
  • cultural literacy.

There are several tests, which have verified reliability in the academic literature that can be administered in order to test one's health literacy. Some of these tests include the Medical Term Recognition Test (METER), which was developed in the United States (2 minute administration time) for the clinical setting.[13] The METER includes many words from the Rapid Estimate of Adult Literacy in Medicine (REALM) test.[13] The Short Assessment of Health Literacy in Spanish and English populations (SAHL-S&E) uses word recognition and multiple choice questions to test a person's comprehension.[13] The CHC-Test measures Critical Health Competencies and consists of 72 items designed to test a person's understanding of medical concepts, literature searching, basic statistics, and design of experiments and samples.[13]

Patient safety and outcomes

According to an Institute of Medicine (2004) report, low health literacy negatively affects the treatment outcome and safety of care delivery.[14] The lack of health literacy affects all segments of the population. However, it is disproportionate in certain demographic groups, such as the elderly, ethnic minorities, recent immigrants, and persons with low general literacy.[15] These populations have a higher risk of hospitalization, longer hospital stays, are less likely to comply with treatment, are more likely to make errors with medication,[16] and are more ill when they initially seek medical care.[17][18]

The mismatch between a clinician's communication of content and a patient's ability to understand that content can lead to medication errors and adverse medical outcomes. Health literacy skills are not only a problem in the general population. Health care professionals (doctors, nurses, public health workers) can also have poor health literacy skills, such as a reduced ability to clearly explain health issues to patients and the public.[19][20] In addition to tailoring the content of what health professionals communicate to their patients, a well arranged layout, pertinent illustrations, and intuitive format of written materials can improve the usability of health care literature. This in turn can help in effective communication between healthcare providers and their patients.[21]

Risk identification

Identifying a patient as having low health literacy is essential for a healthcare professional to conform their health intervention in a way that the patient will understand. When patients with low health literacy receive care that is tailored to their more limited medical knowledge base, results have shown that health behaviors drastically improve. This has been seen with: correct medication use and dosage, utilizing health screenings, as well as increased exercise and smoking cessation. Effective visual aids have shown to help supplement the information communicated by the doctor in the office. In particular, easily readable brochures and videos have shown to be very effective.[22] Healthcare professionals can use many methods to attain patients' health literacy. A multitude of tests used during research studies and three minute assessments commonly used in doctors offices are examples of the variety of tests healthcare professionals can use to better understand their patients' health literacy.[18][23][24]

The American Medical Association showed that asking simple single item questions, such as "How confident are you in filling out medical forms by yourself?", is a very effective and direct way to understand from a patient's point of view how they feel about interacting with their healthcare provider and understanding their health condition.[25]

Intervention

In order to be understood by patients with insufficient health literacy, health professionals must intervene to provide clear and concise information that can be more easily understood. Avoidance of medical jargon, illustrations of important concepts, and confirming information by a "teach back" method have shown to be effective tools to communicating essential health topics with health illiterate patients.[23] A program called "Ask Me 3"[24] is designed to bring public and physician attention to this issue, by letting patients know that they should ask three questions each time they talk to a doctor, nurse, or pharmacist:

  • What is my main problem?
  • What do I need to do?
  • Why is it important for me to do this?

There have also been large-scale efforts to improve health literacy. For example, a public information program by the US Department of Health and Human Services encourages patients to improve healthcare quality and avoid errors by asking questions about health conditions and treatment.[25] Additionally, the IROHLA (Intervention Research on Health Literacy of the Ageing population) project, funded by the European Union (EU), seeks to develop evidence-based guidelines for policy and practice to improve health literacy of the ageing population in EU member states.[26] The project has developed a framework and identified and validated interventions which together constitute a comprehensive approach of addressing health literacy needs of the elderly.

Diabetes is a rapidly growing health problem among immigrants—affecting approximately 10 percent of Asian-Americans. It is the fifth-leading cause of death in Asian-Americans between the ages of 45 and 64. In addition, type 2 diabetes is the most common form of the disease. Those who are diagnosed with type 2 diabetes have high levels of blood glucose because the body does not effectively respond to insulin. It is a lifelong disease with no known cure. Diabetes is a chronic, debilitating, and costly social burden—costing healthcare systems about $100 billion annually.[27]

Diabetes disproportionately affects underserved and ethnically diverse populations, such as Vietnamese-American communities. The relationship between the disease and health literacy level is in part because of an individual's ability to read English, evaluate blood glucose levels, and communicate with medical professionals. Other studies also suggest lack in knowledge of diabetes symptoms and complications.[28] According to an observational cross-sectional study conducted, many Vietnamese-American diabetic patients show signs of poor blood glucose control and adherence due to inadequate self-management knowledge and experience.[29] Diabetes health literacy research is needed to fully understand the burden of the chronic disease in Vietnamese-American communities, with respect to language and culture, health literacy, and immigrant status. Ethnic minority groups and immigrant communities have less knowledge of health promoting behavior, face considerable obstacles to health services, and experience poor communication with medical professionals.[30] According to a recent review, studies have supported an independent relationship between literacy and knowledge of diabetes management and glucose control, but its impact on patients has not been sufficiently described.[31][32] With the demand of chronic disease self-management (e.g., diabetic diet, glucose monitoring, etc.), a call for cultural-specific patient education is needed to achieve the control of diabetes and its adverse health outcomes in low- to middle-income Vietnamese-American immigrant communities.

Oral health literacy in school teachers of Mangalore, India

The problem of low oral health literacy (OHL) is often neglected which may lead to poor oral health outcomes and under utilization of oral care services. A cross-sectional survey of school teachers working in schools at Mangalore, India was undertaken. Details regarding demographics, medical, and dental history, oral hygiene practices and habits, diet history, and decay promoting the potential of school teachers were obtained using face-to-face interview method. The Rapid Estimate of Adult Literacy in Dentistry-99 (REALD-99) was used to assess their OHL.The OHL was high in the school teachers with the REALD-99 scores ranging from 45 to 95 with a mean score of 75.83 ± 9.94. Th This study found that there was a statistically significant difference between OHL and education, frequency of brushing and the filled teeth. Although this study indicated high OHL levels among school teachers in Mangalore, India the magnitude of dental caries in this population was also relatively high and very few had a healthy periodontium.[33]

eHealth literacy

eHealth literacy describes the relatively modern concept of an individual's ability to search for, successfully access, comprehend, and appraise desired health information from electronic sources and to then use such information to attempt to address a particular health problem.[34] Due to the increasing influence of the internet for information-seeking and health information distribution purposes, eHealth literacy has become an important topic of research in recent years[35]. Stellefson (2011) states, "8 out of 10 Internet users report that they have at least once looked online for health information, making it the third most popular Web activity next to checking email and using search engines in terms of activities that almost everybody has done."[36] Though in recent years, individuals may have gained access to a multitude of health information via the Internet, access alone does not ensure that proper search skills and techniques are being used to find the most relevant online and electronic resources. As the line between a reputable medical source and an amateur opinion can often be blurred, the ability to differentiate between the two is important.

Health literacy requires a combination of several different literacy skills in order to facilitate eHealth promotion and care. Six core skills are delineated by an eHealth literacy model referred to as the Lily model. The Lily Model's six literacies are organized into two central types: analytic and context-specific. Analytic type literacies are those skills that can be applied to a broad range of sources, regardless of topic or content (i.e., skills that can also be applied to shopping or researching a term paper in addition to health) whereas context-specific skills are those that are contextualized within a specific problem domain (can solely be applied to health). The six literacies are listed below, the first three of the analytic type and the latter three of the context-specific:

  • Traditional literacy
  • Media literacy
  • Information literacy
  • Computer literacy
  • Scientific literacy
  • Health literacy

According to Norman (2006), both analytical and context-specific literacy skills are "required to fully engage with electronic health resources." As the World Wide Web and technological innovations are more and more becoming a part of the healthcare environment, it is important for information technology to be properly utilized to promote health and deliver health care effectively. Furthermore, it was argued by Hayat Brainin & Neter (2017), that digital media fosters the creation of interpersonal ties, that can supplement eHealth literacy. According to Hayat Brainin & Neter (2017), individuals with low eHealth literacy who were able to recruit help when performing online activities demonstrated higher health outcomes compared to similar individuals who did not find help. Also relating to the proliferation of digital media is the fact that many individuals now can create their own ‘media content’ (user-generated content). This means that the boundary between “information” and “media” content, as proposed by Norman in 2006, now is increasingly blurred, creating additional challenges for health practitioners (Holmberg, 2016).[37]

It has also been suggested that the move towards patient-centered care and the greater use of technology for self-care and self-management requires higher health literacy on the part of the patient.[38] This has been noted in several research studies, for example among adolescent patients with obesity.[39]

Improvement

Incorporate information through the university level

The United States Department of Health and Human Services created a National Action Plan to Improve Health Literacy.[40] One of the goals of the National Action Plan is to incorporate health and science information in childcare and education through the university level. The target is to educate people at an early stage; that way individuals are raised with health literacy and will have a better quality of life. The earlier an individual is exposed to health literacy skills the better for the person and the community.

Programs such as Head Start[41] and Women, Infants, and Children (WIC)[42] have impacted our society, especially the low income population. Head Start provides low-income children and their families early childhood education, nutrition, and health screenings. Health literacy is integrated in the program for both children and parents through the education given to the individuals. WIC serves low-income pregnant women and new mothers by supplying them with food, health care referrals, and nutrition education. Programs like these help improve the health literacy of both the parent and the child, creating a more knowledgeable community with health education.

Although programs like Head Start and WIC have been working with the health literacy of a specific population, much more can be done with the education of children and young adults. Now, more and more adolescents are getting involved with their health care. It is crucial to educate these individuals in order for them to make informed decisions.

Many schools in the country incorporate a health class in their curriculum. These classes provided an excellent opportunity to facilitate and develop health literacy in today's children and adolescents. The skills of how to read food labels, the meaning of common medical terms, the structure of the human body, and education on the most prevalent diseases in the United States should be taught in both private and public schools. This way new generations will grow with health literacy and would hopefully make knowledgeable health decisions.

Framework and potential intervention points

The National Library of Medicine defines health literacy as:[43]

"The degree to which individuals have the capacity to obtain, process, and understand basic health literacy

information and services needed to make appropriate health decisions."

Based on this clinical definition, health literacy gives individuals the skills that they need to both understand and effectively communicate information and concerns. Bridging that gap between literacy skills and the ability of the individual in health contexts, the Health Literacy Framework highlights the health outcomes and costs associated with health contexts including cognitive abilities, social skills, emotional state, and physical conditions such as visual and auditory contributions.

Potential Intervention Points are illustrated in reflection of the Health Literacy Framework. While these potential intervention points include interactions such as those of individuals and the education systems that they are engaged with, their health systems, and societal factors as they relate to health literacy, these points are not components of a causal model. The three potential intervention points are culture and society, the health system, and the education system. Health outcomes and costs are the products of the health literacy developed during diversity of exposure to these three potential intervention points.

Referring to shared ideas, meanings, and values that influence an individual's beliefs and attitudes, cultural and societal influences are a significant intervention point for health literacy development. As interactions with healthcare systems often first occur at the family level, deeply rooted beliefs and values can shape the significance of the experience. Included components that reflect the development of health literacy both culturally and societally are native language, socioeconomic status, gender, race, and ethnicity, as well as mass media exposure. These are pathways to understanding American life paralleling conquests for a health literate America.

The health system is an intervention point in the Health Literacy Framework. For the purposes of this framework, health literacy refers to an individual's interaction with people performing health-related activities in settings such as hospitals, clinics, physician's offices, home health care, public health agencies, and insurers.

In the United States, the education system consists of K-12 curricula. In addition to this standard educational setting, adult education programs are also environments in which individuals can develop traditional literacy skills founded in comprehension and real-world application of knowledge via reading and writing. Tools for educational development provided by these systems impact an individual's capacity to obtain specific knowledge regarding health. Reflecting components of traditional literacy such as cultural and conceptual knowledge, oral literacy (listening and speaking,) print literacy (reading and writing,) and numeracy, education systems are also potential intervention points for health literacy development.

Development of a health literacy program

A successful health literacy program will have many goals that all work together to improve health literacy. Many people assume these goals should communicate health information to the general public, however in order to be successful the goals should not only communicate with people but also take into account social and environmental factors that influence lifestyle choices.[44] A good example of this is the movement to end smoking. When a health literacy program is put into place where only the negative side effects of smoking are told to the general public it is doomed to fail. However, when there is a larger program put in – one that includes strategies outlining how to quit smoking, raises tobacco prices, reduces access to tobacco by minors, and reflect social a social unacceptability of smoking – it will be much more effective.[44]

The U.S. Department of Health and Human Services suggests a National Action Plan to implement a comprehensive Health Literacy Program. They include 7 goals:[45]

  1. Develop and disseminate health and safety information that is accurate, accessible, and actionable
  2. Promote changes in the health care system that improve health information, communication, informed decision making, and access to health services
  3. Incorporate accurate, standards-based, and developmentally appropriate health and science information and curricula in child care and education through the university level
  4. Support and expand local efforts to provide adult education, English language instruction, and culturally and linguistically appropriate health information services in the community
  5. Build partnerships, develop guidance, and change policies
  6. Increase basic research and the development, implementation, and evaluation of practices and interventions to improve health literacy
  7. Increase the dissemination and use of evidence-based health literacy practices and interventions

These goals should be taken into account when implementing a health literacy program.

There are also goals for the outcomes of a Health Literacy Program.

Health Related Goals[43]

  • Promoting and protect health and prevent disease
  • Understand, interpret, and analyze health information
  • Apply health information over a variety of life events and situations
  • Navigate the healthcare system
  • Actively participate in encounters with healthcare professionals and workers
  • Understand and give consent
  • Understand and advocate for rights

Libraries

Libraries have increasingly recognised that they can play a role in health literacy since the 2000s, influenced by the Medical Library Association. Library initiatives have included running education programs, fostering partnerships with health organisations, and using outreach efforts.[46]

See also

Citations

  1. ↑ Roundtable on Health Literacy; Board on Population Health and Public Health Practice; Institute of the Medicine (10 February 2012). Facilitating State Health Exchange Communication Through the Use of Health Literate Practices: Workshop Summary. National Academies Press. p. 1. ISBN 978-0-309-22029-3.
  2. ↑ A. Pleasant; J. McKinney (2011). "Coming to consensus on health literacy measurement: An online discussion and consensus-gauging process". Nursing Outlook. 59 (2): 95–106.e1. doi:10.1016/j.outlook.2010.12.006. Retrieved 2013-12-26.
  3. ↑ "America's Health Literacy: Why We Need Accessible Health Information". health.gov. Retrieved 2015-11-20.
  4. 1 2 "Health Communication and Health Information Technology - Healthy People 2020".
  5. ↑ "Health Communication and Health Information Technology - Healthy People 2020".
  6. ↑ "Health Literacy - Fact Sheet: Health Literacy Basics". health.gov. Retrieved 2015-11-20.
  7. ↑ "Federal Plain Language Guidelines: Table of Contents". www.plainlanguage.gov. Retrieved 2016-03-30.
  8. ↑ M. V. Williams; et al. (1995). "Inadequate functional health literacy among patients at two public hospitals". JAMA. 274 (21): 677–82. doi:10.1001/jama.274.21.1677. PMID 7474271. Retrieved 2006-06-30.
  9. ↑ Dickens, C., and Piano, MR. (2013) "Health literacy and nursing: an update." The American Journal of Nursing. Jun;113(6):52-7. doi: 10.1097/01.NAJ.0000431271.83277.2f.
  10. ↑ Pleasant & Kuruvilla, 2008
  11. ↑ Anne McMurray (2007). Community Health and Wellness: A Sociological Approach (3rd ed.). Brisbane: Elsevier. ISBN 978-0-7295-3788-9.
  12. ↑ Zarcadoolas et al. 2005, 2006
  13. 1 2 3 4 Altin, Sibel; Finke, Isabelle; Kautz-Freimuth, Sibylle; Stock, Stephanie (2014). "The evolution of health literacy assessment tools: a systematic review". BMC Public Health. 14 (1): 1207. doi:10.1186/1471-2458-14-1207. PMC 4289240. PMID 25418011.
  14. ↑ The Institute of Medicine: Health Literacy: A Prescription to End Confusion (2004)
  15. ↑ 2003 National Assessment of Adult Literacy The Health Literacy of America's Adults Retrieved 9 September 2006
  16. ↑ Terry C. Davis; Michael S. Wolf, MPH; Pat F. Bass III, MD; Jason A. Thompson, BA; Hugh H. Tilson, MD, DrPH; Marolee Neuberger, MS; and Ruth M. Parker, MD (2006). "Literacy and Misunderstanding Prescription Drug Labels". Annals of Internal Medicine. 145 (12): 887–94. doi:10.7326/0003-4819-145-12-200612190-00144. PMID 17135578. Archived from the original on 2007-02-24. Retrieved 2006-11-30.
  17. ↑ U.S. Department of Health and Human Services: Quick Guide to Health Literacy
  18. 1 2 M. V. Williams; et al. (1995). "The test of functional health literacy in adults: a new instrument for measuring patients' literacy skills". J Gen Intern Med. 10 (1): 537–41. doi:10.1007/BF02599568. PMID 8576769.
  19. ↑ American Society of Anesthesiology abstracts (October 25, 2005), Aaron M. Fields, M.D., Kirk H. Shelley, M.D., Ph.D., Craig Freiberg, M.D. (Department of Anesthesiology, Yale University School of Medicine)Patients and Jargon: Are We Speaking the Same Language?, retrieved 2008-10-18
  20. ↑ The Center for Advancement of Health (March 2003): Talking the Talk: Improving Patient-Provider Communication Archived 2008-10-06 at the Wayback Machine., retrieved 2008-10-18
  21. ↑ Gill, P.S.; Gill, T.S.; Kamath, A.; whisnant, B. (2012). "Readability Assessment of Concussion and Traumatic Brain Injury Publications by Centers for Disease Control and Prevention". International Journal of General Medicine. 5: 923–933. doi:10.2147/IJGM.S37110.
  22. ↑ Agency for Healthcare Research and Quality: Evidence Report/Technology Assessment: Number 87 Literacy and Health Outcomes
  23. 1 2 "A Conversation on Cultural Competence With Cindy Brach, Senior Health Policy Researcher, AHRQ". Agency for Healthcare Research and Quality. 2013-04-17. Retrieved 2013-08-22.
  24. 1 2 "National Patient Safety Foundation". Archived from the original on 2008-03-08.
  25. 1 2 Agency for Healthcare Research and Quality: Questions Are the Answer, retrieved 2008-10-18
  26. ↑ "Home". Archived from the original on 2015-06-13. Retrieved 2015-06-11.
  27. ↑ Cabiglio, Josie. Diabetes on the rise among Asians. Nguoi Viet 2. Web. 7 Dec 2010. "Archived copy". Archived from the original on 2006-11-26. Retrieved 2011-12-02.
  28. ↑ Glazier R.H. (2004). "Neighborhood recent immigration and hospitalization in Toronto, Canada". Canadian Journal of Public Health. 95: 130–134.
  29. ↑ Mull Dorothy S.; et al. (2001). "Vietnamese diabetic patients and their physicians". Western Journal of Medicine. 175: 307–311. doi:10.1136/ewjm.175.5.307. PMC 1071603.
  30. ↑ Simich, Laura. "Health Literacy and Immigrant Populations." Public Health Agency of Canada and Metropolis Canada (2009): 1-18. Print.
  31. ↑ Schillinger Dean; et al. (2002). "Association of Health Literacy With Diabetes Outcomes". Journal of the American Medical Association. 288: 475–481. doi:10.1001/jama.288.4.475.
  32. ↑ Schillinger Dean; et al. (2006). "Does Literacy Mediate the Relationship Between Education and Health Outcomes? A Study of a Low-Income Population with Diabetes". Public Health Reports. 121: 245–254. doi:10.1177/003335490612100305.
  33. ↑ Simon, Arun K; Rao, Ashwini; Rajesh, GuruRaghavendran; Shenoy, Ramya; Pai, Mithun B. H. (2018-04-01). "Influence of oral health literacy on the oral health status of school teachers in Mangalore, India". Journal of Indian Association of Public Health Dentistry. 16 (2).
  34. ↑ Norman, Cameron D; Skinner, Harvey A (1 January 2006). "eHealth Literacy: Essential Skills for Consumer Health in a Networked World". Journal of Medical Internet Research. 8 (2): e9. doi:10.2196/jmir.8.2.e9.
  35. ↑ Hayat, T; Brainin, E; Neter, E (2017). "With Some Help From My Network: Supplementing eHealth Literacy With Social Ties". Journal of Medical Internet Research. 19 (3): e98. doi:10.2196/jmir.6472. PMC 5391437. PMID 28360024.
  36. ↑ Stellefson, Michael; Hanik, Bruce; Chaney, Beth; Chaney, Don; Tennant, Bethany; Chavarria, Enmanuel Antonio (1 January 2011). "eHealth Literacy Among College Students: A Systematic Review With Implications for eHealth Education". Journal of Medical Internet Research. 13 (4): e102. doi:10.2196/jmir.1703.
  37. ↑ Holmberg C (2016). "If You can't beat It-Use It: why and how clinicians need to consider social media in the treatment of adolescents with obesity". European Journal of Clinical Nutrition. 70 (9): 977–8. doi:10.1038/ejcn.2016.126.
  38. ↑ Kim, Henna; Xie, Bo (January 2017). "Health literacy in the eHealth era: A systematic review of the literature". Patient Education and Counseling. 100: 1073–1082. doi:10.1016/j.pec.2017.01.015.
  39. ↑ Holmberg, C., Berg, C., Dahlgren, J., Lissner, L., & Chaplin, J. E. (2018). Health literacy in a complex digital media landscape: Pediatric obesity patients’ experiences with online weight, food, and health information. Health Informatics Journal. Mar 1:1460458218759699. doi: 10.1177/1460458218759699
  40. ↑ "National Action Plan to Improve Health Literacy" (PDF).
  41. ↑ "Home - Office of Head Start - Administration for Children and Families".
  42. ↑ "Women, Infants, and Children (WIC) - Food and Nutrition Service".
  43. 1 2 Nielsen-Bohlmn, Lynn (2004). "Health Literacy: A Prescription to End Confustion". Institute of Medicine.
  44. 1 2 Nutbeam, D. (2000-09-01). "Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century". Health Promotion International. 15 (3): 259–267. doi:10.1093/heapro/15.3.259. ISSN 0957-4824.
  45. ↑ U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion (2010). "National Action Plan to Improve Health Literacy" (PDF).
  46. ↑ Barr-Walker, Jill (13 June 2016). "Health literacy and libraries: a literature review". Reference Services Review. 44 (2): 191–205. doi:10.1108/RSR-02-2016-0005.

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