"Flush tissue with stool": the problem of low health literacy in Canada

All Canadians must have the tools to take responsibility for their own health and the health of their loved ones. This includes access to up-to-date and accurate health-related information as well as the tools required to understand and use this information. ~ How low literacy can affect your health (Canadian Council on Learning)

Last January I wrote about a particularly atrocious example of patient information, a poop test brochure, which, among other things, advised the reader to "flush tissue with stool." Have you ever tried flushing a toilet using a stool, let alone trying to repeat the step "on the next two subsequent bowel movements?" It's not easy, let me tell you.

Every time some hapless patient is forced to struggle through the opaque vocabulary and convoluted syntax of the Coloscreen brochure published by Helena Laboratories in Beaumont, Texas, you can almost see the illiteracy ratio and mortality rate starting to rise on the charts. Whoever wielded the applicator stick that smeared this rank prose specimen into print has a lot to answer for, as has the Winnipeg health clinic that decided it was appropriate to give to patients [1]. For we have become a country of the reading challenged, where even Robert Service's unpretentious, galumphing strophes, which my Grade 4 class once recited with pleasure, are becoming artifacts of another age. For school kids hooked on Halo and Twitter, The Cremation of Sam McGee will soon be as obscure as Horace's Alcaics; although I see that someone has posted a video of McGee on YouTube. Perhaps this will become a trend: literary works preserved for the print-allergic population as YouTube presentations — bardic recitation in the digital realm. An abomination like the poop test brochure is not the kind of challenge we really want. A health brochure's business is to communicate important facts that will help guide a person to make good health decisions. How did we reach such an impasse: that we can produce neither texts that communicate nor readers who comprehend them?

A vision for a health literate Canada
This month another study is bringing bad news about Canadians' ability to read. "Low health literacy is a serious and costly problem," says a recent report from the Canadian Public Health Association. A vision for a health literate Canada was released on March 3, 2008. A CPHA Expert Panel found that a majority (more than 55%) of Canadian adults do not have the skills to understand information about their own health or to make daily health-related decisions. The low levels of health literacy in Canada are "critical" and a countrywide strategy is needed to solve the problem.

The panel's findings were drawn from a 2003 analysis of 23,000 Canadians by the Canadian Council on Learning, which offers its own take on the problem in a March 6 report on its website, How low literacy can affect your health. See also another CCL report dated February 28, 2008, Health literacy in Canada: a healthy understanding.

Videosphere vs. Graphosphere
What is the nature of this literacy problem, which is certainly not unique to Canada? It seems likely that Fahrenheit 451's flame throwers will never be required. As young people's desire to read is assiduously burned off in what Régis Debray calls the era of the videosphere, and as cultural and political discourse becomes increasingly infused by and confused with the ruminant world of the cartoon or the video game, elites will not crease their linen worrying about proletarian revolution. In a typically quirky but thought-provoking essay published in the New Left Review [2], Debray laments the loss of the graphosphere, the era of printing that made possible the Enlightenment and progressive social change. In his schema this passing age is being replaced by the era of the image, the videosphere, in which the book is knocked off its pedestal and replaced by widescreen, gridlinked digital culture. Debray offers an arresting image of the possible political consequences of the drift from the printed word to digital prattle:

A practical example: to find out what is going on one has to watch TV, and so stay at home. A bourgeois house arrest, for beneath "a man’s home is his castle" there always lurks, "every man for himself." The demobilization of the citizen begins with the physical immobilization of the spectator.

Very much like Ray Bradbury's dystopia. And today's video-capable mobile devices could act like a digital equivalent of ankle bracelets to keep our minds virtually immobilized. According to Debray, the Internet, its access devices, and the jet plane are good for internationalization, but they are lethal for progressive politics and international solidarity. They enlarge the sphere of individual relations but privatize them at the same time; they particularize even as they globalize. And it is the isolated, atomized individual who makes the ideal consumer and the credulously passive subject of the state.

A digression: lexemes and publishing extremes
Strange, then, that even as some thinkers mourn the loss of literacy and the end of solidarity, consumers at all levels of the literacy scale are buying extraordinary amounts of reading material, some of it even subversive of the ruling order. I find it difficult to reconcile the massive size of the English-language publishing industry and the continuing problem of low literacy. To illustrate, a brief note by Daniel Soar in the London Review of Books for 7 Feb 2008 cites the annual turnover of the British publishing industry as £2.8 billion. That's 900,000 books flying off British bookshop shelves every day, or one book for every nine loaves of bread sold in the UK. A lot of bread, however you look at it. In Canada book sales are healthy as well. The overall value for Canadian consumer book sales for 2006 was $1.59 billion. The Association of American Publishers reported that U.S. publishers had net sales of $25 billion in 2007. Book sales were up 3.2% over 2006, with a compound growth rate of 2.5% per year since 2002.

The average person has never been so well educated. Look at the size of an adult's working vocabulary today. According to the linguist David Crystal [3] it's 50,000 words. That represents the average adult's active vocabulary in present-day Britain. The estimate of passive vocabulary (words that can be recognized but would not be used in speech or writing) is roughly 25 per cent larger. Modern vocabularies are simply enormous. There are approximately 400,000 lexemes (actually differing words, not including various forms of the same word) in the Oxford English Dictionary which make up Modern English vocabulary. A reasonably well-educated person with a working vocabulary of about 50,000 words is thus actively employing about 12 per cent of the word stock of the language. By comparison, Shakespeare was working with a word stock of 150,000 lexemes. The size of his vocabulary is approximately 20,000 lexemes. This means that Shakespeare was using something over 13 per cent of the total word stock available to him. That total was probably much higher than his contemporaries, and it was certainly well ahead of the linguistically conservative King James Bible, which has only 8,000 lexemes. But it's extraordinary to think that the average educated working person in most English-speaking countries has a larger active vocabulary than the Bard himself. Obviously social status plays an important role here, something that Crystal does not discuss. Those buyers of books and users of dictionaries are less likely to be from the low-income strata of society.

Health literacy facts
But let's get back to the facts about health literacy. Whatever we may think of Debray's lofty theorizing and the remarkable vocabularies of the average adult, the fact remains that four out of ten Canadians still struggle with low literacy. And we have solid research to show how this affects the health of Canadians. What do we now know about the state of health literacy in this country?

• 11.7 million working age residents of Canada (55%) are estimated to lack the minimum level of health literacy needed to effectively manage their health information needs. (CCL, 2007)
  
  
• When seniors are added, an estimated 14.8 million may be without adequate health literacy skills. An estimated 88% of respondents 65+ fell below Level 3 on the Health Literacy Scale, which is considered the minimum level of proficiency required to meet the demands of modern day life including those posed by health information. (CCL, 2007).
  

• Canadians aged 16 to 65 who rate their health as excellent or very good have the highest levels of proficiency in health literacy. People who rate their health as fair or poor have the lowest levels of proficiency. People with the lowest health literacy skills are more than three times as likely to report fair or poor health. (Outcomes from the National Symposium on Health Literacy, CPHA, 2008)

• A recent American study examined mortality rates of a group of 3,260 adults over age 56 in four metropolitan areas and found that those with inadequate and marginal health literacy levels had a 50% higher mortality rate over a five-year period than those with adequate skills. Low health literacy was the top predictor of mortality after smoking, and was a more powerful variable than both income and years of education. (Outcomes from the National Symposium on Health Literacy, CPHA, 2008)

Dr. Irving Rootman, chair of CCL's Health and Learning Knowledge Centre and co-chair of the expert panel, provides the following grim statistics in his PowerPoint presentation: Health Literacy and Public Health [PPT]:

• Over 800 studies have found that health-related material for patient education far exceeds the reading levels of the average adult.
  

• A recent study of health information websites in Canada, the U.K. and Australia found that the content of all sites was written at a higher level than recommended by literacy organizations. The lowest level was grade 11.
  
  
• Low health literacy is a barrier to effective self-management of chronic disease. A review of randomized control trial studies found that 62% of patients with lower reading skill levels were unable or unwilling to engage in self-management.
  
  

Gimcrackery
Despite the excellent work of CPHA and CCL, I'm afraid I don't have much hope that our literacy rates will greatly improve without serious social change. After all, quickly sending their own clear message about the depth of their commitment to such change, the Conservative government wasted no time in cutting nearly $20 million from adult literacy programs back in 2006. The unerringly empathetic John Baird, the minister overseeing the cut, explained at the time: "I think if we're spending $20 million and we have one out of seven folks in the country that are functionally illiterate, we've got to fix the ground floor problem and not be trying to do repair work after the fact." Funny, but I thought doing gimcrack repairs was the government's answer to most of Canada's social problems — either that or just cutting costs and programs outright, at least the type that don't get noticed at a G8 summit. One of Harper and Co.'s bright ideas for fixing the ground floor problem of health literacy has been to cut the Canadian Health Network website, which specializes in plain-language consumer health information. By the way, CHN has a good article on Canadian health literacy: Beyond words: the health-literacy connection. But you'd better look now, because whether you can read or not, it won't be available from CHN come April Fool's Day.

The role of the media
The media aren't much help either. For all their health beats, ambulance chasing, and obesity scares, by excluding or marginalizing other perspectives — notably, a more explicitly political analysis of the origins of illness — the media play a significant part in actually narrowing public debate about health, illness and medicine, and they are not helping to fix Mr. Baird's ground floor problem either. A Social Science and Medicine article [4] that looks specifically at Canadian newspapers goes on to conclude:

The absence of any discussion about social gradients in health indicates that newspapers do not find the central observation driving the population health perspective in public policy newsworthy. Even the stories that we have classified as being concerned with the social environment largely fail to discuss broad issues of the welfare state in relation to health—housing and housing policy, child development and related issues of education and child care, the social relations of work environments (as opposed to exposures to physical hazards), community design and urban infrastructure, etc. Implicit in the obsession with issues of health care is the notion that this aspect of the welfare state is singularly important to maintaining and improving human health. Debates as to whether investments in the health care sector come at the expense of investments elsewhere within the welfare state (in education, housing, income supplementation, etc.) rarely appear in Canadian newspapers. Newspapers appear to do little to advance levels of critical health literacy on broad determinants of health in Canada.

A tissue of equivocations
If we are to avoid the bourgeois house arrest of Régis Debray's isolated, passive consumers of the videosphere, we must not approach the issue of health literacy in passive isolation. It is well known that the determinants of literacy include: education, early childhood development, aging, living and working conditions, personal capacity/genetics, gender and culture [5]. These are basically the same as the social determinants of health. Literacy should be framed within an empowering paradigm that highlights opportunities and choices for people. Unfortunately, the way the media deal with the issue has been devoid of empowerment. The blatant fostering of disease-laden imagery (e.g., “stamping out the epidemic of illiteracy”) is one such counterproductive example. It is not helpful either when literacy is promoted — wittingly or unwittingly — as the predominant solution to Canada’s economic woes. What the public often gets from journalists and politicians is a tissue of equivocations.

Literacy or the lack of it should not be separated off from its social context. Nor can the solution to poor literacy be found in some bureaucratic, gimcrack program. Perhaps John Baird was right. We should stop throwing money into programs that are not truly connected to broader efforts to change the determinants of health. But he is wrong to think that anything will change without a radical program to reduce social and economic inequity in Canada.

Like the problem of homelessness in Canada, the baleful reality of illiteracy has been studied very thoroughly. As many experts familiar with the facts will admit, we have known for years what the reports are telling us over and over again. Is it any surprise, for example, to be told that "daily reading appears to be a strong determinant of health literacy?" Good heavens, Francis Bacon was saying that "reading maketh a full man" four centuries ago.

The recommendations of the most recent report are what one might expect: we need a comprehensive, coordinated, cooperative, and integrated pan-Canadian strategy on health literacy, involving all levels of government. We also need educators, bureaucrats, and health professionals who are able to communicate in plain language [6]. And, as always, more research is required. There is nothing new here. Rather than more paper, Canadians need leadership that is truly responsive to people's needs, with the political will to increase social inclusion, reduce income disparities, and uphold everyone's right to equitable health care, housing, education, and employment opportunity. As the Expert Panel conclude, "The question is: are we willing as a country to make the investment that is required to create a health literate Canada?"

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Test your health literacy (from the Canadian Council on Learning website)

Can you correctly answer this example question?

Imagine your child is 11 years old and weighs 85 pounds. According to the chart below, how many 80 mg tablets of Tempra can you administer to your child in a 24-hour period and in what dosage?

References:

1. Rootman I. Health literacy: where are the Canadian doctors? CMAJ. 2006 Sep 12;175(6):606.

2. Debray R. Socialism: a life-cycle. New Left Review. 2007 Jul-Aug;46:5-28.

3. Crystal D. The stories of English. London: Penguin; 2004.

4. Hayes M, Ross IE, Gasher M, Gutstein D, Dunn JR, Hackett RA. Telling stories: news media, health literacy and public policy in Canada. Soc Sci Med. 2007 May;64(9):1842-52.

5. Rootman I, Ronson B. Literacy and health research in Canada: where have we been and where should we go? Can J Public Health. 2005 Mar-Apr;96 Suppl 2:S62-77.

6. Stableford S, Mettger W. Plain language: a strategic response to the health literacy challenge. J Public Health Policy. 2007;28(1):71-93.

Health literacy reports

Canadian Council on Learning.

Health literacy in Canada: A healthy understanding, February 2008. This report reveals that daily reading outside of work is associated with higher health literacy scores.

Health Literacy in Canada: Initial Results from the International Adult Literacy and Skills Survey (IALSS), September 2007. Provides Canadians with a country-wide snapshot of health literacy.

Canadian Public Health Association.

A Vision for a Health Literate Canada, February 2008. The CPHA Expert Panel on Health Literacy found a majority of Canadian adults do not have the skills needed to respond to daily health information demands. Low health literacy is associated with poor health and the Panel estimates that the situation in Canada is critical.

The Ontario Health Promotion E-Bulletin of 20 March 2008 provides an excellent list of Canadian resources on health literacy.


Recent articles in mainstream media on health literacy
The Toronto Star, March 4, 2008 Alarm raised on health literacy, by Meghan Ogilvie, http://www.thestar.com/living/article/309115

CBC March 4, 2008 Canadians illiterate about health, report says, http://www.cbc.ca/health/story/2008/03/04/health-literate.html



I like to think that when I fall,
A rain-drop in Death's shoreless sea,
This shelf of books along the wall,
Beside my bed, will mourn for me.

Robert Service, Bookshelf

The Scarers in Print: analyzing a poop test brochure for readability

Now, it's too late for me to begin shovelling and sifting at alphabeds and grammar-books. I'm getting to be a old bird, and I want to take it easy. But I want some reading—some fine bold reading, some splendid book in a gorging Lord-Mayor's-Show of wollumes. ~ Charles Dickens, Our Mutual Friend, Chapt. 5

Those of us who take our ability to read for granted, who live and breathe letters as dogs do feces and effluvia, are sometimes forgetful of the difficulties experienced by so many in the face of nothing more formidable than the back of a cereal box, let alone a "chapter book." In Our Mutual Friend the illiterate dustman Mr. Boffin hires that "ligneous sharper," the peg-legged Silas Wegg, to read to him his newly acquired and highly treasured book Decline-And-Fall-Off-The
-Rooshan-Empire ("Eight wollumes. Red and gold. Purple ribbon in every wollume, to keep the place where you leave off.") Because all print is shut to them, he and Mrs. Boffin are willing to endure night after night of Mr. Wegg's garbled delivery of Gibbon's prose, just for the feeling of participating in what they consider proper culture. They want some fine bold reading, in some splendid book. Instead they have to put up with the malapropisms, mispronunciations and petulant malingering of the scheming Silas Wegg.

In 21st century Canada there are still many Mr. and Mrs. Boffins. According to ABC Canada:

• Four out of 10 adults, age 16 to 65 — representing 9 million Canadians — struggle with low literacy. (Adult Literacy and Life Skills (ALL) Survey, Statistics Canada and the Organization for Economic Co-operation and Development, 2005)
• Nearly 15 per cent of Canadians can't understand the writing on simple medicine labels such as on an Aspirin bottle.
• An additional 27 per cent can't figure out simple information like the warnings on a hazardous materials sheet.
• In total, 42 per cent of Canadians are semi-illiterate. The proportion is even worse for those in middle age. And even when new immigrants are excluded, the numbers remain pretty much the same.

The statistics for our neighbours to the south are roughly the same, nor has there has been much improvement over the last generation in either country. This surprises me, for reading is ostensibly such a popular pastime and a prominent feature of our popular culture — certainly much more so than in that now distant, pre-postmodern period when there were few book clubs, no lit blogs, no Chapters-Indigo, no Amazon, no Oprah, no Harry Potter. In the United States, a 2004 NEA report on Reading at Risk lamented the sharp decline in the reading of books of "literature." Some hapless bloke's complaint is recorded there for posterity: "I just get sleepy when I read." To which Ursula Le Guin, in a feature article in the February Harper's, replies resignedly, yes, but there are actually many people who read wide awake. Le Guin thinks books are here to stay. "It’s just that not all that many people ever did read them. Why should we think everybody ought to now?" (Warning: the Harper's website only provides a teaser version of the article to non-subscribers.)

I have to agree. Books are not a threatened species. However, when it comes to health information, the large ranks of the functionally illiterate, possessing a merely nodding acquaintance with the printed word, face a very real threat. In English-speaking North America, as more than 300 studies indicate, health-related materials cannot be understood by most of the intended audience [1]. Now that two thirds to three quarters of our populations are seeking out consumer health information on the Internet, one wonders how this massive group of so-so readers is dealing with the often challenging vocabulary and syntax to be found on sites like MedlinePlus and the Canadian Health Network, not to mention the huckstering puffery of Health 2.0.

'Why, truly, sir,' Mr Wegg admitted, with modesty; 'I believe you couldn't show me the piece of English print, that I wouldn't be equal to collaring and throwing.' 'On the spot?' said Mr Boffin. 'On the spot.' 'I know'd it! Then consider this. Here am I, a man without a wooden leg, and yet all print is shut to me.'

Trying to digest the ColoScreen brochure
My own recent experience with "patient information" has convinced me that the literate need to learn how to write as badly as the illiterate need to learn how to read. Not long ago I had occasion to do some stooping and scooping — for my own, not my Retriever's. A lab test was required, and for the first time in my life I was introduced to the mysteries of ColoScreen. My doctor gave me a package including a special envelope, three sample collection areas with fold-over flaps, and three small wooden "applicator sticks" with which to provide "specimen" smears. The ColoScreen kit came with a 600-word set of instructions: everything I needed to know about the poop test. To this extraordinary work they give the title ColoScreen: a test for fecal occult blood. Now there was some fine bold reading!

Talk about occult. Here is a representative selection of the kind of prose some committee probably laboured over for hours in order to ensure I would make no error in carrying out what any two-year-old can do with the greatest of ease all over the nursery wallpaper:

Two days prior to, and including the test period, a red-meat free, high-residue diet should be followed ... Do not ingest high doses of aspirin or other anti-inflammatory drugs, for 7 days prior to and during testing ... However, consult a medical professional before discontinuing any prescribed medication ... Discontinue the use of toilet tank/bowl cleaners or deodorizers throughout the test period to avoid interference ... Flush tissue with stool, and discard stick in waste container ... On the next two subsequent bowel movements, repeat above steps ...

What possible excuse could there be for this laughable effort? Precision? There certainly is lots of that. Ass-covering? No one can say they weren't told in excessive detail how to scrape their own excrement into an envelope. Just who was this written for? The patients, their health care professionals, the government, or the lawyers? The strenuous, stilted syntax, the jargon, the Latinisms, the pathological avoidance of common idiom — all this adds up in my mind to a truly deplorable effort at communication. What were the authors thinking? Half their potential readership is left to puzzle at expressions like "discontinuing any prescribed medication" and "subsequent bowel movements." And couldn't they have found a simpler way to say "waste container?" Do any of us use such language in our daily lives? "That's alright, Junior. Just make sure you throw any of Fido's subsequent evacuations into the waste container."

Helena Laboratories in Beaumont, Texas, is the manufacturer of the fecal occult blood test package, and, I assume, responsible for the accompanying patient instruction. Their website advertises a number of educational brochures, and I shudder to think of the squinting and squirming and cocking of heads going on right at this moment as millions of helpless Boffins decline and fall under these heavy catapults of English prose.

Different versions of the ColoScreen brochure may be found on the Helena.com website. I checked to see how they compare to the print version I received. Sad to say, they are even more prolix and impenetrable. Here is a not untypical excerpt (perhaps it reads more easily in the Spanish version):

Because of the nonhomogeneity of the stool, it is recommended that the test be performed on three (3) consecutive evacuations, or as close together as possible.

Testing for readability
In the face of such a frontal assault one can do little else but evacuate the wounded and regroup. I wanted to find out just how bad the ColoScreen brochure really was. I needed to see some data that would allow me to compare it against a benchmark. So I resolved to analyze the text using a number of standard readability measures: Coleman Liau, Flesch Kincaid, ARI, SMOG, Gunning Fog, and Lexile. Microsoft Word does a basic readability test as part of its word count feature, and I started there.

According to Word's word count my printed ColoScreen brochure scored 57.2 in the Flesch Reading Ease measure, and 8.8 in the Flesch-Kincaid Grade Level. Not satisfied to rely on a single test, I used a number of freely available online readability analyzers. The sites I used are stored under my readability tag on del.icio.us.

Running my brochure through these online tools produced slightly varying readability results, but they averaged out at roughly Grade 9 or higher. Testing against the Lexile measure returned a Grade 10 (1100L to 1200L). By way of comparison, the Harry Potter series measure between 880L and 950L; Don Quixote (in English translation presumably) rates a fairly high 1410L.

The scores were much too high. For consumer health information, the literature is full of admonitions to employ plain language at the fifth grade level or lower to accommodate differing literacy levels [2,3,4]. The ColoScreen instructions fail to inform patients in an appropriate manner. Not only is this preposterous brochure well-nigh impenetrable to the semi-literate, it is prudish and officious to boot. In fact, it stinks.

Everyone advocates health literacy. Library shelves sag with literature on the subject and the web does the same digitally. Barbara Nail-Chiwetalu reviews the issue of health literacy in a way I found useful [5]:

Health literacy may be defined as the ability to obtain, read, comprehend, and use health information to make appropriate health decisions. The development of appropriate and effective health communication is an initiative recognized in Healthy People 2010. To this end, improving health communication may call for use of a variety of approaches, which may include:

• Improving the accessibility of appropriate health materials in communities [6]
• Emphasizing readability and comprehension of health communication materials (e.g., pamphlets, instruction guides, package inserts, books, Web sites) by

o acquiring materials that are written in conversational style (active voice) [2]
o using short sentences of ten to fifteen words [2]
o translating complex medical terms [3]
o using plain language at the fifth grade level or lower to accommodate differing literacy levels [3]
o using caution with medical textbooks written for physicians or other health professions with consumer due to the high readability level and comprehension of terms [2]
o considering use of nonwritten materials (e.g., charts, diagrams, photographs , picture books, videotapes, audiotapes, multimedia presentations) with persons having limited literacy [3,4]

• Showing sensitivity to language and cultural needs by

o providing materials that are culturally relevant [3]
o translating materials into different languages [3]
o using interpreter services to provide direct translations of what is said [4]

• Adjusting oral communication of health information by

o slowing down the rate of speech when delivering health information [3]
o using a “teach back” or “show me” approach to ensure understanding [3]
o including important family members or close friends in discussions including “surrogate” readers [3]

I don't claim expertise in health literacy, and I realize that simple readability scores are not the last word in assessing the quality of consumer health information [7,8,9]. A recent study by Rosemblat et al. [10] enlightened me as to the importance of the "main point" for readability measurement, while at the same time admitting the difficulty of measuring it:

Only two features, "Vocabulary" and "Main Point," significantly predict whether the annotators rated consumer health texts as readable for general audiences. Traditional readability formulas incorporate syntactic (words per sentence) and semantic (vocabulary) features to predict readability. While the annotators verified familiarity with vocabulary as a predictor, they also found that effective communication of the main point is a significant attribute. These results may contribute to understanding consumer seeking and browsing health information online. For example, eye-tracking studies indicate that users typically scan a Web page for the "take-home" message and move on to another page if not found in a few seconds. However, "ability to communicate the main point" is difficult to define operationally and measure.

So with all this theory and the outstanding efforts of experts and advocates, how did I end up with the ColoScreen atrocity? What applicator stick smeared this rank specimen of English prose onto my slide? Here is the take-home message I extract from my experience. We all must work a little harder at communicating to the system that it must serve real people by promoting reading and assisting the non-readers among us. That is a professional and a political commitment. If the main goals of a system of public health are to increase quality and years of health life and to eliminate health disparities, then we health librarians must re-dedicate ourselves to the dissemination of health information and the promotion of healthy lifestyles, not just for the educated and comfortable, but for everyone who would not be able to read this sentence. More simply put, let's get rid of the Scarers in Print.

'... upon-my-soul to a old bird like myself these are scarers. And even now that Commodious is strangled, I don't see a way to our bettering ourselves. ... I didn't think this morning there was half so many Scarers in Print. But I'm in for it now!' ~ Mr. Boffin, after an evening of "declining and falling" with Mr. Wegg (Our Mutual Friend, Chap. 5)

References:

1. Nielsen-Bohlman L, Panzer AM, Kindig DA, editors. Health literacy: a prescription to end confusion. Washington: National Academies Press; 2004.

2. Baker LM, Gollop CJ. Medical textbooks: can lay people read and understand them? Library trends. 2004;53(2):336-347.

3. Parker R, Kreps GL. Library outreach: overcoming health literacy challenges. J Med Lib Assoc. 2005;93(Suppl. 4):S81-S85.

4. Allen M, Matthew S, Boland MJ. Working with immigrant and refugee populations: issues and Hmong case study. Library trends. 2004;53(2): 301-328.

5. Nail-Chiwetalu, B. Libraries meeting community health needs: trends and issues (Revised January 18, 2006) [monograph on the Internet]. Washington: NCLIS, 2006 [cited 2008 Jan 24]. Available from: http://www.nclis.gov/award/NCLIS-TrendsinLibrariesReport.pdf

6. Burnham E, Peterson EB. Health information literacy: a library case study. Library trends. 2005;53(3):422-433.

7. Gemoets D, Rosemblat G, Tse T, Logan R. Assessing readability of consumer health information: an exploratory study. Medinfo. 2004;11(Pt 2):869-73.

8. Keselman A, Tse T, Crowell J, Browne A, Ngo L, Zeng, Q. Assessing consumer health vocabulary familiarity: an exploratory study. J Med Internet Res 2007;9(1):e5. doi:10.2196/jmir.9.1.e5

9. Wang, Y. Automatic recognition of text difficulty from consumers health information. 19th IEEE International Symposium on Computer-Based Medical Systems (CBMS '06). 2006:131 - 36. doi:10.1109/CBMS.2006.58

10. Rosemblat G, Logan R, Tse T, Graham L. How do text features affect readability?: expert evaluations on consumer health web site text [article on the Internet]. Mednet Congress 2006 [cited 2008 Jan 24]. Available from: http://www.mednetcongress.org/fullpapers/MEDNET-192_RosemblatGracielaA_e.pdf