Index

A

AARP, 119, 292–293

ABEL. See Adult basic education and literacy system

Aboriginal people, cultural language of, 114–115

Academy for Educational Development, 153

Academy of General Dentistry, 193

Access to health care and preventive services, 179–180

See also Language access

Accreditation Council for Continuing Medical Education (ACCME), 159

Accreditation of health systems

Joint Commission on Accreditation of Healthcare Organizations, 14, 16, 55, 199, 228

National Committee for Quality Assurance, 14, 16, 55, 199–201, 228, 278

Accreditation of medical education

Accreditation Council for Continuing Medical Education, 159

Ad Hoc Committee on Health Literacy, 36

Adult Basic Education and Literacy (ABEL) system, 10, 154

Adult education system, 154–157

context of, 154–155

incorporating health content into, 156–157

strategies and opportunities in, 155–157

Adult Literacy & Lifeskills Survey (ALL), 62

Adult population groups

percentage with literacy skills at NALS levels 1, 2, or 3-4, 64

percentage with literacy skills at NALS levels 1 or 2, 294

Advertising and marketing

FDA involvement in, 194

a popular source of health information, 123–124

Advocacy organizations, 292

for African-Americans, 294–295

for the elderly, 292–293

for Hispanics, 293–294

prison systems, 296

professional associations, 296–297

social service agencies, 296

African-Americans

advocacy organizations for, 294–295

literacy proficiency among, 63

National Association for the Advancement of Colored People, 294–295



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Health Literacy: A Prescription to End Confusion Index A AARP, 119, 292–293 ABEL. See Adult basic education and literacy system Aboriginal people, cultural language of, 114–115 Academy for Educational Development, 153 Academy of General Dentistry, 193 Access to health care and preventive services, 179–180 See also Language access Accreditation Council for Continuing Medical Education (ACCME), 159 Accreditation of health systems Joint Commission on Accreditation of Healthcare Organizations, 14, 16, 55, 199, 228 National Committee for Quality Assurance, 14, 16, 55, 199–201, 228, 278 Accreditation of medical education Accreditation Council for Continuing Medical Education, 159 Ad Hoc Committee on Health Literacy, 36 Adult Basic Education and Literacy (ABEL) system, 10, 154 Adult education system, 154–157 context of, 154–155 incorporating health content into, 156–157 strategies and opportunities in, 155–157 Adult Literacy & Lifeskills Survey (ALL), 62 Adult population groups percentage with literacy skills at NALS levels 1, 2, or 3-4, 64 percentage with literacy skills at NALS levels 1 or 2, 294 Advertising and marketing FDA involvement in, 194 a popular source of health information, 123–124 Advocacy organizations, 292 for African-Americans, 294–295 for the elderly, 292–293 for Hispanics, 293–294 prison systems, 296 professional associations, 296–297 social service agencies, 296 African-Americans advocacy organizations for, 294–295 literacy proficiency among, 63 National Association for the Advancement of Colored People, 294–295

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Health Literacy: A Prescription to End Confusion National Medical Association, 295 National Urban League, 295 Agency for Healthcare Research and Quality (AHRQ), 14–15, 103, 127, 136, 183, 197, 205, 291 Agency for International Development(AID), 25 Agency roles, 191–201 AHRQ. See Agency for Healthcare Research and Quality AID. See Agency for International Development Alaska Natives, literacy proficiency among, 63 ALL. See Adult Literacy & Lifeskills Survey Alzheimer’s Association of Los Angeles, 135 AMA. See American Medical Association American Academy of Neurology, 297 American Association of Family Physicians Foundation, 26 American Cancer Society, 119 American Medical Association (AMA), 160, 193 Ad Hoc Committee on Health Literacy, 36, 109 American Public Health Association, 160 Americans with Disabilities Act, 184 n America’s health literacy advocacy organizations, 286 employers, 286 governmental and social service agencies, 286–287 insurers, 286 organizations and systems acting to improve, 286–287 Approaches to improving health literacy, 127–137 approaches to increasing language access, 136–137 collaborative programs, 134–136 community opportunities, 127, 132–133 nongovernmental organizations, 134 Asian Health Services, 133 “Ask Me 3” program, 160 Assessment Framework Matrix, 152 Assessment of health literacy, in educational settings, 151–152 Assessments of literacy and health literacy excerpts from the National Adult Literacy Survey, 308–322 excerpts from the Test of Functional Health Literacy in Adults, 304–307 Rapid Estimate of Adult Literacy in Medicine, 302–303 sample material from selected, 301–322 Association of American Colleges and Universities, 147 Associations of limited health literacy, 6–9, 59–107 associations with health knowledge, behavior, and outcomes, 82–100 financial, 7–8, 100–103 in health knowledge, behavior, and outcomes, 7, 82–100 Attaining Cultural Competency and Enriching Health Service Solutions, 133 Awareness, cultural, 112 B Background information, 250–254 Basic print literacy, 38–39 Bayer Corporation, 146 Behavior, associations of limited health literacy with, 7, 82–100 Behavioral Health Risk Factor Surveillance System (BHRFSS), 14, 53, 55 BHRFSS. See Behavioral Health Risk Factor Surveillance System Billie, Alvin, 132 Bolivia, literacy proficiency in, 83 Bridging Disciplines in the Brain: Behavioral and Clinical Sciences, 224 Building Effective AIDS Response initiative, 218 Bureau of Primary Health Care, 197, 219 C CAHL. See Coalition for Allied Health Leadership CAHPS. See Consumer Assessment of Health Plans Survey Calculating literacy, 45 California HealthCare Foundation, 26 California Literacy, Inc., 160 California Medical Association (CMA), 160

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Health Literacy: A Prescription to End Confusion California Statewide Health Initiative, 160 Canada, literacy in, 61 Capacity, individual, 32 Care delivery, 269 Carmona, Richard H., 136 Carstairs Index, of social deprivation, 88–89 Case studies. See Vignettes CDC. See Centers for Disease Control and Prevention Center for Epidemiologic Studies Depression Scale-Short Form, 96–97 Center for Health Services Research and Policy, 200 Center for Linguistic and Cultural Competence in Health Care, 114 Center for Youth Services, 134 Centers for Disease Control and Prevention (CDC), 14–15, 103, 119, 136, 153, 161, 192, 195, 267 Health Communication Division, 218 “Programs-That-Work,” 148 School Health Policies and Programs Study 2000, 143 Task Force on Guidelines for Community Preventative Services, 127 Centers for Medicare & Medicaid Services (CMS), 100n, 135, 193–194 Centro Latino de Salud, Educación y Cultura, 133 Charlson Comorbidity Index, 90–91 Children’s Partnership, 124 Chronic Care Model, 173, 268–271, 274–275, 279 shaping for patients with limited health literacy, 274–277 Chronic disease care and self-management, 171–173 chronic disease management program, 222 model for improvement of, 279 Chronic disease outcomes community and environmental factors, 274 effect of limited health literacy on, 270–274 home-based monitoring and clinical support, 272–274 office-based clinician–patient communication, 271–272 Civil Rights Act, 184n Clinician–patient communication, office-based, 271–272 Cloze procedure, 48 CMA. See California Medical Association CMS. See Centers for Medicare and Medicaid Services Coalition for Allied Health Leadership (CAHL), 159 Collaborative programs, to improve health literacy, 134–136 College and university health education, 147–148 Combined approaches, to health literacy in the health system, 220–221 Comments, from respondents to surveyors, 227 Commissioned papers and background information, 250–299 approaches to improving health literacy, 250–253 federal funding for health literacy over a 10-year period, 254 field lessons, 250–253 Committee on Comprehensive School Health Programs in Grades K-12, 146 Committee on Health Literacy, 3, 26–27, 243 First Workshop hosted by, 246 Second Workshop hosted by, 248 Third Workshop hosted by, 249 Commonwealth fund, 26 Communication techniques office-based clinician-patient, 271–272 personal, 219–220 technology-based, 215–218 Community-based interventions, published studies of, 128–133 Community factors effect on chronic disease outcomes, 274 opportunities to improve health literacy, 127, 132–133 Complexity of health information, 122–123 Components of literacy, 38 Conceptual framework for health literacy, 32–35 culture and society, 33–34 education system, 34–35

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Health Literacy: A Prescription to End Confusion health system, 35 potential points for intervention in the health literacy framework, 34 Consumer Assessment of Health Plans Survey (CAHPS), 98–99, 200 Consumer-directed health care, 182–183 Context of health systems, 168–201 emerging issues in the health system context, 171–183 health law and health literacy, 183–191 Contexts of health literacy and opportunities for intervention, 9–12 culture and society, 9–10, 108 educational systems, 10–11, 142 health systems, 11–12, 167 Continuing education approaches, to educating health professionals, 159–160 Costs. See Health expenditures Council of Chief State School Officers, State Collaborative on Assessment and Student Standards, 152 Council of State Governments, 198, 251 CRISP database, 195, 254 Crossing the Quality Chasm: A New Health System for the 21st Century, 12, 26, 177, 228 Cultural competence, 112–113 cultural awareness, 112 cultural encounter, 112 cultural knowledge, 112 cultural skill, 112 Cultural languages, traditional, 114–115 Culture dissociation of culture, meaning, and health literacy, measures for, 118–119 language and meaning, in the context of health literacy, 115–118 mass culture, 119–126 meaning and language, in the context of health literacy, 115–118 traditional culture, 110–119 Culture and society, 9–10, 108–141 health literacy in, 33–34 mass culture, 119–126 opportunities for intervention in, 9–10, 108 opportunities to improve health literacy, 126–137 traditional culture, 110–119 Curricular approaches, to educating health professionals, 158–159 Curriculum Linking Science Education and Health Literacy program, 146, 153 Cycling literacy, 44 D Data sources and methods, 243–254 commissioned papers and background information, 250–254 literature review, 243–244 public workshops, 244–249 study committee, 243 Definition of health literacy, 31–37 conceptual framework for health literacy, 32–35 scope of health literacy, 36–37 Definition of literacy, 37–40 basic print literacy, 38–39 components of literacy, 38 functionality of all literacy, 39–40 literacy for different types of text, 39 Demographic associations, with limited literacy, 62–65 Department of Cancer Control and Population Science, Portfolio Management Application software, 254 Disease registries, 269 Document literacy, and sample items from the National Adult Literacy Survey, 312–319 E “Ecology” of health service organizations, 169 Economic factors, and health, 20–21 Education for health professionals, 157–160 continuing education approaches, 159–160 curricular approaches, 158–159 Educational materials grade-level measures of, 47 tailored to health literacy in the health system, 221–224

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Health Literacy: A Prescription to End Confusion Educational Resources Information Center (ERIC), 68, 127, 244 Educational systems, 10–11, 142–166 adult education system, 154–157 education for health professionals, 157–160 health literacy in, 34–35 K-12 and university education systems, 143–154 opportunities for intervention in, 10–11, 142 recommendations, 161 strategies for health literacy instruction, 149–151 Elderly people, advocacy organizations for, 292–293 Emerging issues in the health system context, 171–183 access to health care and preventive services, 179–180 chronic disease care and self-management, 171–173 consumer-directed health care, 182–183 health expenditures, 181–182 limitations on provider time, 180–181 patient–provider communication, 173–175 patient safety and health-care quality, 176–179 Employers, 290–292 Encounters, cultural, 112 England, literacy in, 61 Environmental factors, effect on chronic disease outcomes, 274 Epidemiology of limited health literacy, 65–81 association of limited health literacy, 81–103 and health literacy skills among various populations, 70–81 studies of limited health literacy, 67–69, 80 ERIC. See Educational Resources Information Center Evidence-based approaches, to improving health literacy, 126–127 Excerpts from the National Adult Literacy Survey, 308–322 from the Test of Functional Health Literacy in Adults, 304–307 Executive Order No. 13166, “Improving Access to Services for Persons with Limited English Proficiency, August 2000,” 114n Expenditures. See Health expenditures Experiential identity, 111 Extent and associations of limited health literacy, 6–9, 59–107 the associations of limited health literacy, 81 the epidemiology of limited health literacy, 65–81 literacy in America, 60–65 mock-up prescription medication instructions in Bahasa Malaysia, the written language of Malaysia, 60 recommendation, 103 F Family and friends, a popular source of health information, 125 FDA. See Food and Drug Administration Federal government, 191–198 Agency for Healthcare Research and Quality, 197 Centers for Disease Control and Prevention, 195 Centers for Medicare and Medicaid Services, 193–194 Department of Veterans Affairs, 197–198 Food and Drug Administration, 194–195 funding for health literacy over a 10-year period, 254 Health Resources and Services Administration, 196–197 National Institutes of Health, 195–196 Office of the Secretary, Office of Disease Prevention and Health Promotion, 192–193 Field lessons, 250–253 Financial associations, of limited health literacy, 7–8, 100–103 First Workshop, hosted by the Committee on Health Literacy, 246 Flesch-Kincaid Reading Grade Level, 47

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Health Literacy: A Prescription to End Confusion Flesch Scale Analysis, 201 Florida/Caribbean AIDS Education and Training Center, 218 Food and Drug Administration (FDA), 192, 194–195 advertising, 194 labeling, 194 outreach, 194 Formulating literacy, 45 Foundation for Accountability, 183 Foundation for Informed Medical Decision Making, 217 Friends, a popular source of health information, 125 Fry Readability Scale, 47, 201 Functional literacy functionality of all literacy, 39–40 measures of, 49–50 G Gallup Organization polls, 121, 146 sources of health information reported in, 121 Gathering Place, 132 Generating literacy, 45 Georgia Academy of Family Physicians, 297 Geriatric Depression Scale, 84–85, 88–89 GEs. See Grade Equivalents Governmental and agency roles, 191–201 roles of regulatory agencies, 199–201 roles of state governments, 198–199 roles of the federal government, 191–198 Grade Equivalents (GEs), 46 for the REALM, 303 Grade-level measures of literacy, 45–47, 50 grade-level ability for individual readers, 46–47 grade-level measures of materials, 47 Gunning Fog index, 50 H Hablamos Juntos, 114–115 Harvard School of Public Health, 158 HCFA. See Health Care Financing Administration Health, social and economic factors in, 20–21 Health Assessment Questionnaire, 88–89 Health care and informed consent in research, 187–190 predicted spending on, 262 quality of, 176–179 Health Care Financing Administration (HCFA), 100, 291 See also Centers for Medicare & Medicaid Services Health-care settings, interventions in, 206–213 Health Communication Division (CDC), 218 Health content, incorporating into adult education programs, 156–157 Health contexts, literacy skill demands of, 41, 43 Health Education Assessment Project, 152 Health education programs K-12, 143–146 opportunities for, 148–149 Health expenditures, 181–182 “Health Framework for California’s Public Schools, Kindergarten through Grade Twelve,” 153 Health Information National Trends Survey (HINTS), 121 Health information sources, 123–126 advertising and marketing, 123–124 family and friends, 125 the Internet, 125–126 news media, 123 Health information use, 120–126 complexity of materials, 122–123 selected findings from Sex Matters, 122 sources of health information reported in a Gallup Poll, 121 Health Insurance Portability and Accountability Act of 1996, 192 Health Interview Survey (HIS), 53 “Health is Strength” Project, 133 Health knowledge, associations of limited health literacy with, 7, 82–100 Health law and health literacy, 183–191 doctrine of informed consent, 186–191 governmental and agency roles, 191–201 standard of reasonable care, 184–186

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Health Literacy: A Prescription to End Confusion Health literacy, 4–6, 31–58 definition of, 31–37 framework for, 33 measures used in health literacy research, 43–51 needs and opportunities, 51–55 new field of inquiry and practice, 20 opportunities to improve, 126–137 as a public concern, 25–26 sample material from selected assessments of, 301–322 Health Literacy, Let Your Patients Understand, 160 Health literacy approaches in the health system, 204–225 combined approaches, 220–221 and in-sample prediction of total costs, 263 partnerships, 224–225 personal communication and education, 219–220 provision of simplified/more attractive written materials, 214–215 tailored materials, 221–224 technology-based communication techniques, 215–218 Health Literacy Coalition, 160 Health Literacy Educational Kit, 160 Health literacy framework, potential points for intervention in, 5, 34 Health literacy instruction, strategies for, 149–151 Health literacy measures, 50–51 Health literacy-related activities, frequency of doing, 203 Health literacy skills among various populations, epidemiology of, 70–81 health-related associations of, 84–99 Health-literate America, vision for, 12–14, 240–242 Health on the Net Foundation Code of Conduct, 273 Health Professions Network, 159 Health-related associations, of health literacy skills, 84–99 Health Resources and Services Administration (HRSA), 14–15, 103, 136, 161, 196–197, 218–219, 226 Bureau of Primary Health Care, 219 Health service organizations, ecology of, 169 Health systems, 11–12, 167–239 context of, 168–201 emerging issues in, 171–183 health literacy in, 35 Joint Commission on Accreditation of Healthcare Organzations, 14, 16, 55, 199, 228 National Committee for Quality Assurance, 14, 16, 55, 199–201, 228, 278 navigating, 172 opportunities in, 11–12, 167, 201–227 Healthcare processes, rules for redesigning, 178 Healthy People 2010 program, 4, 25, 31, 36–37, 125, 149, 192–193 “Healthy Reading Kits,” 153 Helling v. Carey, 186 HHS. See U.S. Department of Health and Human Services Hidding v. Williams, 190 HINTS. See Health Information National Trends Survey HIS. See Health Interview Survey Hispanics advocacy organizations for, 293–294 cultural language of, 116–118 literacy proficiency among, 63 Mexican American Legal Defense and Educational Fund, 293 National Council of La Raza, 293 National Hispanic Medical Association, 293–294 HIV/AIDS Bureau, 197, 218 Home-based monitoring and clinical support, effect on chronic disease outcomes, 272–274 Ho’oponopono process, 175 Hospital Anxiety and Depression Scale, 88–89 Howard, David H., 8, 101, 256–266 HRSA. See Health Resources and Services Administration I IALS. See International Adult Literacy Surveys

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Health Literacy: A Prescription to End Confusion IDL. See Instrument for Diagnosis of Reading/Instrumento Para Diagnostical Lecturas “Improving Access to Services for Persons with Limited English Proficiency, August 2000,” 114n “Improving Chronic Disease Care for Populations with Limited Health Literacy,” 171n, 267–284 Chronic Care Model, 268–270 effect of limited health literacy on chronic disease outcomes, 270–274 a framework based on health literacy and related research, 271 measuring progress, 277–278 shaping the chronic care model for patients with limited health literacy, 274–277 Improving Diabetes Efforts across Language and Literacy project, 218 Improving health literacy collaborative programs, 134–136 combined approaches, 220–221 community-based interventions, 128–133 community opportunities, 127, 132–133 lessons from the field, 250–253 nongovernmental organizations, 134 promising approaches to, 127–137 Incollingo v. Ewing, 185 Increasing language access, approaches to, 136–137 Indian Health Service, 15, 136 Individual capacity, 32 Inflexxion® Incorporated, 153 Informed consent, 186–191 consent form, for participation in smoking cessation study, 216 difference between actual readability and target readability ofdocuments, 188–189 in health care and research, 187–190 legal precedents, 190–191 texts provided by institutional review boards at U.S. medical schools, 188 Institute for Healthcare Advancement, 134 Institute for Policy Innovation, 124 Institute of Medicine (IOM), 3, 9, 12–13, 20–21, 25, 101, 111, 115, 117, 168–169, 197, 224, 240, 244 Committee on Comprehensive School Health Programs in Grades K-12, 146 Institutional Review Boards, 16 Instrument for Diagnosis of Reading/Instrumento Para Diagnostical Lecturas (IDL), 47, 65, 78–79, 100 Insurers, 285–290 Medicaid, 288–290 Medicare, 285, 287–288 Tricare, 285, 290 Integrating literacy, 44 Interagency Education Research Initiative, 15, 150–151, 161 International Adult Literacy Surveys (IALS), 6, 45, 49, 52, 61 International Reading Association, 50 Internet, 119 a popular source of health information, 125–126 Intervention in the health literacy framework opportunities for, 9–12 potential points for, 5, 34 samples of published studies of, 206–213 IOM. See Institute of Medicine Iowa Medical Society, 297 Ireland, literacy in, 61 J JCAHO. See Joint Commission on Accreditation of Healthcare Organizations Joint Commission on Accreditation of Healthcare Organizations (JCAHO), 14, 16, 55, 199, 228 Joint Committee on National Health Standards, 11, 36, 144 Journal of the American Medical Association, 119 K K-12 education, 143–147 health education programs, 143–146 literacy education, 147 science education, 146 Kellogg Foundation, 26 Knowledge, cultural, 112

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Health Literacy: A Prescription to End Confusion L Labeling, FDA involvement in, 194 Language and meaning, in the context of health, 115–118 patient perspectives and, 117–118 traditional, 113–114 Language access, approaches to increasing, 136–137 “Language Access: Helping Non-English Speakers Navigate Health and Human Services,” excerpt from introduction to, 136 Legal issues doctrine of informed consent, 186–191 governmental and agency roles, 191–201 standard of reasonable care, 184–186 Legal precedents, 190–191 LEP. See Limited English proficiency Limitations of existing measures of health literacy, 49–51 functional literacy measures, 49–50 grade-level scores, 50 health literacy measures, 50–51 Limitations on provider time, 180–181 Limited English proficiency (LEP), 113–114 Limited health literacy, 6–9, 59–107 associations of, 7, 81–103 financial associations of, 7–8 studies of, 67–69, 80 Limited health literacy’s effect on chronic disease outcomes, 270–274 community and environmental factors, 274 home-based monitoring and clinical support, 272–274 office-based clinician-patient communication, 271–272 Limited literacy, demographic associations with, 62–65 Literacy components of, 38 for different types of text, 39 examples of skills needed for health, 42 in health contexts, 41–43 literacy skill demands of health contexts, 41, 43 living in a society with high demands for, 21–25 sample material from selected assessments of, 301–322 Literacy education, K-12, 147 Literacy in America, 60–65 demographic associations with limited literacy, 62–65 extent and associations of, 60–65 Literacy surveys, 43–45 calculating, 45 cycling, 44 formulating, 45 generating, 45 integrating, 44 locating, 44 Literature review, 243–244 Locating literacy, 44 M Maintenance-of-Effort (MOE) funds, 135 Managed Care Consumer Assistance Program (MCCAP), 134 Managed care contracts, state Medicaid, 200–201 Marketing health information, 123–124 Mass culture, 119–126 advertising and marketing, 123–124 family and friends, 125 Internet, 125–126 news media, 123 ways people obtain and use health information, 120–126 Materials grade-level measures of, 47 tailored to health literacy in the health system, 221–224 Maternal and Child Health Bureau, 197 MBS. See Medicare Beneficiaries Survey MCCAP. See Managed Care Consumer Assistance Program MDI. See Metered dose inhaler technique Meaning and language, in the context of health, 115–118 Measures used in health literacy research, 43–51 grade-level measures of literacy, 45–47 limitations of existing measures, 49–51 literacy surveys, 43–45 measures of health literacy, 47–49

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Health Literacy: A Prescription to End Confusion “Media Smart Youth”, 153 Medicaid, 15, 48, 65, 135, 274, 288–290 Arizona enrollees, 100 state managed care contracts, 200–201 Medicaid Health Plan Employer Data and Information Set, 277 Medical Expenditure Panel Survey(MEPS), 14, 53, 55 Medicare, 15–16, 83, 102, 228, 274, 285, 287–288 federal spending for, 285, 288 numbers of enrollees in, 287 predicted expenditures on, 289 Medicare Beneficiaries Survey (MBS), 14, 53, 55 Medline, 68, 127, 244 MEPS. See Medical Expenditure Panel Survey Metered dose inhaler (MDI) technique, 98–99 Metlife Foundation, 26 Mexican American Legal Defense and Educational Fund, 293 Migrant Health Centers, 219 Mini-Mental State Examination (MMSE), 84–85 MMSE. See Mini-Mental State Examination MOE. See Maintenance-of-Effort funds Molina Healthcare, 134 Morocco, literacy proficiency in, 83 N NAACP. See National Association for the Advancement of Colored People NAAL. See National Assessment of Adult Literacy NALS. See National Adult Literacy Survey National Adult Literacy Survey (NALS), 6, 25, 44, 49–50, 52–53, 60–67, 80, 100, 102, 120, 154, 274, 288, 297 article “Swimmer completes Manhattan marathon” used in, 309 bank deposit slip used in, 320 bus schedule used in, 318 discrimination article used in, 311 document literacy and sample items, 312–319 energy chart used in, 317 excerpts from, 308–322 home equity loan advertisement used in, 322 job application used in, 314 Korean jet article used in, 313 Level 1, 8, 10, 45, 61–65, 100, 102, 120, 123 Level 2, 8, 10, 45, 61–64, 102, 120 Level 3, 10, 45, 120 Level 4, 45, 61 Level 5, 61, 123 peanut butter label used in, 321 prose literacy and sample items, 308–312 quantitative literacy and sample items, 319–322 sales graph used in, 316 wage and tax statement used in, 315 National Assessment of Adult Literacy (NAAL), 14, 49, 53, 55, 62 National Association for the Advancement of Colored People (NAACP), 294–295 National Cancer Institute (NCI), 26, 121, 153, 215, 254 National Center for Education Statistics, 193, 292 National Center for Health Promotion and Disease Prevention (NCP), 197 National Center for Research Resources, 153 National Center for the Study of Adult Learning and Literacy (NCSALL), 155–156 National Committee for Quality Assurance (NCQA), 14, 16, 55, 199–201, 228, 278 National Conference of State Legislatures’ Children’s Policy Initiative, 136 National Council of La Raza, 293 National Council on the Aging, 160 National Health Education Standards: Achieving Health Literacy (NHES), 11, 15, 143–145, 152, 161 National Health Objectives, 148 National Hispanic Medical Association, 293–294 National Immunization Program, 195 National Institute for Literacy (NIFL), 155, 251

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Health Literacy: A Prescription to End Confusion National Institute for Occupational Safety and Health, 195 National Institute of Child Health and Human Development (NICHD), 15, 147, 161, 196 National Institute of Environmental Health Sciences, 196 National Institutes of Health (NIH), 14, 16, 52, 55, 103, 119, 195–196, 229 Department of Cancer Control and Population Science, 254 grant funding over the 1997–2002 period, 196 National Library of Medicine, 4, 31, 119 National Literacy Act of 1991, 43 National Medical Association, 112n, 295 National Network of Health Career Programs in Two Year Colleges, 159 National Research Council (NRC), 147 National Science Foundation, 15, 150–151, 161 National Science Teachers Association, 146, 150 National Standards to Protect the Privacy of Personal Health Information, 192 National Survey on Health Literacy Initiatives, 198 National Urban League, 295 National Youth Anti-Drug Media Campaign, 124 Native Americans cultural language of, 114–115 literacy proficiency among, 63 Native Hawaiians, understanding of healing, 175 NCI. See National Cancer Institute NCP. See National Center for Health Promotion and Disease Prevention NCQA. See National Committee for Quality Assurance NCSALL. See National Center for the Study of Adult Learning and Literacy News media, a popular source of health information, 123 NHES. See National Health Education Standards: Achieving Health Literacy NICHD. See National Institute of Child Health and Human Development NIFL. See National Institute for Literacy NIH. See National Institutes of Health No Child Left Behind legislation, 147 Nongovernmental organizations, opportunities to improve health literacy, 134 Northwest AIDS Education and Training Center, 218 NRC. See National Research Council Numeracy, sample items from the Test of Functional Health Literacy in Adults, 304–305 O Office-based clinician–patient communication, effect on chronic disease outcomes, 271–272 Office of Civil Rights, 135 National Standards to Protect the Privacy of Personal Health Information, 192 Office of Disease Prevention and Health Promotion (OPHP), 192–193 Office of Minority Health, 14, 136 Center for Linguistic and Cultural Competence in Health Care, 114 Office of National Drug Control Policy, National Youth Anti-Drug Media Campaign, 124 Office of the Secretary, Office of Disease Prevention and Health Promotion, 192–193 Office of Vocational and Adult Education, 15, 154–155 OPHP. See Office of Disease Prevention and Health Promotion Opportunities to improve health literacy in health systems, 201–227 approaches to health literacy in the health system, 204–225 evidence-based approaches, 126–127 other promising approaches, 127–137 overview of current efforts, 202–204 recommendations, 228–229 summary of approaches, 226–227 Organization for Economic Co-operation and Development, 61

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Health Literacy: A Prescription to End Confusion Organizations, acting to improve America’s health literacy, 286–287 Outcomes, associations of limited health literacy with, 7, 82–100 Outreach, FDA involvement in, 194 “Outside the Clinician–Patient Relationship—A Call to Action for Health Literacy,” 63n, 285–299 advocacy organizations, 292 employers, 290–292 insurers, 285–290 OVID web gateway, 68 P Pacific Islanders, literacy proficiency among, 63 Pakistan, literacy proficiency in, 83, 100 Partnership for Clear Health Communication, 160 Partnerships, for health literacy in the health system, 224–225 Patient-centered approach, 179 Patient Navigator Program, 220 Patient perspectives, and language, 117–118 Patient–provider communication, 173–175 Patient safety and health-care quality, 176–179 Peabody Individual Achievement Test-Revised, 48 People’s finding and using health information, 120–126 Percentiles, 46 Pfizer Corporation, 26, 160, 214 Pictograms for patient education, examples of, 215 “Plain Talk,” 134 Popular sources of health information, 123–126 advertising and marketing, 123–124 family and friends, 125 the Internet, 125–126 news media, 123 Portfolio Management Application software, 254 Prescription medication instructions, in Bahasa Malaysia, mock-up of, 60 Priority Areas for National Action in Quality Improvement, 13, 26, 168–169, 240 Prison systems, as advocacy organizations, 296 Private sector, national totals for enrollees and cost of hospitalization and physician service health plans for United States, 2000, 291 Professional associations, as advocacy organizations, 296–297 Program for Appropriate Technology in Health, 134 “Programs-That-Work,” 148 Progress, measuring, 277–278 Project Toolbox, description of, 223 ProLiteracy America, 296 Promoting Health: Intervention Strategies from Social and Behavioral Research, 111 Prose literacy, and sample items from the National Adult Literacy Survey, 308–312 Prudential Medicare HMO, 256 PsychInfo, 127, 244 PT Tool, 223–224 Public concern, health literacy as, 25–26 Public workshops, 244–249 Published studies of community-based interventions, examples of, 128–133 Q Quality Chasm Report. See Crossing the Quality Chasm: A New Health System for the 21st Century Quantitative literacy, and sample items from the National Adult Literacy Survey, 319–322 R Race, and literacy proficiency, 63 Rapid Estimate of Adult Literacy in Medicine (REALM)©, 47–51, 66–68, 70–73, 76–79, 81–89, 92–95, 98–100, 195, 219, 302–303 scores and grade equivalents for, 303 Readability, of informed consent documents, 189 Reading comprehension, sample items from the Test of Functional Health Literacy in Adults, 305–307

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Health Literacy: A Prescription to End Confusion REALM. See Rapid Estimate of Adult Literacy in Medicine Reasonable care, standard of, 184–186 Recommendations, 14–16 for development of conceptual frameworks, 137 for educational systems, 161 for extent and associations of limited health literacy, 103 for health literacy, 55 for opportunities in health systems, 228–229 Redesigning healthcare processes, rules for, 178 Regulatory agencies, 199–201 Joint Commission on Accreditation of Healthcare Organizations, 199 National Committee for Quality Assurance, 199–201 “Relationship Between Health Literacy and Medical Costs,” 101n, 256–266 data description, 256–259 discussion, 263–264 results, 261–263 statistical analysis, 260–261 Robert Wood Johnson Foundation, 26, 116 Roles of the federal government, 191–198 of regulatory agencies, 199–201 of state governments, 198–199 Roosevelt, Eleanor, 1 S S-TOFHLA. See Short Test of Functional Health Literacy in Adults Scandinavian countries, literacy in, 61 SCASS. See State Collaborative on Assessment and Student Standards Schillinger, Dean, 267–284 SCHIP. See State Children’s Health Insurance Program School Health Education Profiles Study, 145 School Health Policies and Programs Study 2000, 143 Science education, K-12, 146 Scores, for the REALM, 303 Second Workshop, hosted by the Committee on Health Literacy, 248 Self-management educational activities, 269 Sex Matters, 121–122 selected findings about the way people obtain and use health information, 122 SF-12. See Short Form-12 Health Survey Shaw, George Bernard, 267 “Shima Yazhi” lay health program, 132 Short Form-12 Health Survey (SF-12), 84–85, 90–91, 259–261 Short Test of Functional Health Literacy in Adults (S-TOFHLA), 49, 66, 68–69, 72–73, 76–79, 81, 83–85, 88–89, 96–99, 101, 219, 256–258, 272 Simplified Measure of Gobbledygook (SMOG), 47, 201 Simplified/more attractive written materials, to improve health literacy in the health system, 214–215 Skill cultural, 112 needed for health, 42 Slosson Oral Reading Test-Revised, 48 SMOG. See Simplified Measure of Gobbledygook Social factors, and health, 20–21 Social service agencies, as advocacy organizations, 296 Society culture and, 9–10, 108–141 health literacy framework, 5, 34 opportunities for intervention in, 9–10, 108 Sociological Abstracts, 68, 127, 244 Sources of health information, 123–126 advertising and marketing, 123–124 family and friends, 125 the Internet, 125–126 news media, 123 Speaking of Health, 20, 112, 217, 221 Standard of reasonable care, 184–186 Standard scores, 46 Stanines, 46 State Children’s Health Insurance Program (SCHIP), 135 State Collaborative on Assessment and Student Standards (SCASS), 152 Assessment Framework Matrix, 152 Health Education Assessment Project, 152

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Health Literacy: A Prescription to End Confusion State Medicaid managed care contracts, 200–201 State Officials Guide to Health Literacy, The, 152, 198 Strategies and opportunities, in the adult education system, 155–157 Strategies and opportunities in K-12 and university systems, 148–154 assessment of health literacy in educational settings, 151–152 examples of current approaches, 152–154 opportunities for health education programs, 148–149 strategies for health literacy instruction, 149–151 Substance Abuse and Mental Health Services Administration, 15, 136 Survey of Income and Program Participation, 100 Surveys representatives of the study sample, 257 respondents to survey, comments from, 227 T TANF. See Temporary Assistance for Needy Families Target readability, of informed consent documents, 189 Task Force on Guidelines for Community Preventative Services, 127, 267 Technology-based communication techniques examples of ongoing approaches using, 218 and health literacy in the health system, 215–218 Temporary Assistance for Needy Families (TANF), 135 Test of Functional Health Literacy in Adults (TOFHLA), 8, 47–51, 68–71, 74–87, 90–95, 98–99, 101 abbreviated version, 74–75 excerpts from, 304–307 numeracy, sample items, 304–305 prompts for, 304–305 reading comprehension, sample items, 305–307 See also Short Test of Functional Health Literacy in Adults TEXT study, 150–151 Third Workshop, hosted by the Committee on Health Literacy, 249 To Err Is Human: Building a Safer Health System, 25, 173, 176 TOFHLA. See Test of Functional Health Literacy in Adults Traditional culture, 110–119 cultural languages, 114–115 language, 113–114 language and meaning in the context of health, 115–118 measures able to dissociate culture, meaning, and health literacy, 118–119 Tricare, 285, 290 U Unequal Treatment, 136 University health education, 147–148 University of Colorado Medical School, 158 University of Virginia (UVA) School of Medicine, 158–159 U.S. Census, 108 U.S. Department of Defense, 14–15, 103 U.S. Department of Education, 15, 154–155, 161 National Center for Education Statistics, 193 Office of Vocational and Adult Education, 15, 154–155 U.S. Department of Health and Human Services (HHS), 2, 14, 16, 20, 25, 55, 103, 119, 149, 181, 193, 228 National Standards for Culturally and Linguistically Appropriate Services in Health Care, 109 Office for Civil Rights, 135 Office of the Actuary, 181n Task Force on Community Preventive Services, 267 U.S. Department of Labor, survey by, 44 U.S. Department of Veterans Affairs (VA), 197–198 National Center for Health Promotion and Disease Prevention, 197 U.S. Pharmacopeial Convention, Inc. (USP), 215

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Health Literacy: A Prescription to End Confusion U.S. Surgeon General, 13, 142, 240–241 Use of health information, 120–126 complexity of materials, 122–123 popular sources of health information, 123–126 selected findings from Sex Matters, 122 sources of health information reported in a Gallup Poll, 121 USP. See U.S. Pharmacopeial Convention, Inc. UVA. See University of Virginia V VA. See U.S. Department of Veterans Affairs Veterans Administration, 14–15, 49, 103 Vignettes, 1, 3, 9, 19, 22, 31, 40, 67, 101, 108, 115–116, 167–168, 175, 177, 190, 227, 240 Virginia Medical Society, 297 Visual medicine schedule (VMS), 223 VMS. See Visual medicine schedule W Wagner, Ed, 269 Web-based survey, response to, 251 Weiss, Barry D., 285–299 What to Do for Health, 134 WHO. See World Health Organization “Who’s in the Driver’s Seat? Increasing Consumer Involvement in Health Care,” 183 Wide Range Achievement Test-Revised (WRAT-R), 47–48, 72–73, 123 Women’s Health Initiative, 43 Workforce Investment Act, 154 Workshops, hosted by the Committee on Health Literacy, 246–249 World Bank, 83 World Health Organization (WHO), 25, 145 WRAT-R. See Wide Range Achievement Test-Revised Written materials, simplified/more attractive, 214–215 Y Young Adult Literacy Survey, 44

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