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THUNDER BAY - HEALTH - There's a term that doctors, nurses, public health educators, and even schools have been using a lot lately: 'HPV'. However it seems that there is a lot of confusion about what it is, what it does, who can get it and how it can affect your health. Read the information below, and get the right facts about HPV.

HPV is short form for Human papillomavirus which is a common type of virus. Viruses are microscopic organisms that can infect healthy cells and cause them to grow differently.

HPV is spread during sexual activity with skin-to-skin contact. It is very important for you to know that HPV infects both women and men. There's a common myth that men can't get HPV, but they can. The virus does not discriminate based on sex or sexual orientation. In fact, 75 percent of Canadians will be infected with HPV in their lifetime.

There are more than 100 types of HPV, with at least 40 types that can cause genital warts or cancer. HPV types 6 and 11 cause genital warts. Genital warts are small bumps on the skin, in the genital area, that can have a cauliflower appearance. While genital warts are gross and embarrassing, cancers caused by HPV can be life-threatening if they aren't found early.

HPV types 16 and 18 cause 70% of all cervical cancers - a preventable cancer if it is caught early by a Pap test. The cervix is the lower part of the uterus in a female's reproductive system. Women ages 21 years and older, who have ever been sexually active, should go for a Pap test to screen for abnormal cervical cells that could lead to cancer. Having a regular Pap test every 3 years is one way to help prevent infections from becoming cancer. HPV can also cause cancer of the anus, penis, and mouth.

Often, HPV infections have no signs or symptoms, so you won't know if you are infected. This is why it is important to protect yourself. There are a few ways that you can do this:

If you are sexually active, practice safe sex and use condoms. However, you can still get HPV from skin that isn't covered by the condom.

Complete your cancer screening Pap test regularly (every 3 years).

Get the HPV vaccine. The HPV vaccine is a safe way to protect against harmful types of HPV (types 6, 11, 16, and 18) infection.

Another common myth around HPV is that if you get the HPV vaccine you don't have to get a Pap test. That is false. If you get the HPV vaccine, you still need to get a Pap test. Furthermore, the vaccine does not protect against pregnancy or other sexually transmitted infections, so you should continue to practice safe sex.

If you have more questions about HPV or the HPV vaccine, visit: www.hpvinfo.ca.

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NetNewsLedger - Thunder Bay News - Get the correct facts about HPV

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THUNDER BAY - HEALTH - There's a term that doctors, nurses, public health educators, and even schools have been using a lot lately: 'HPV'. However it seems that there is a lot of confusion about what it is, what it does, who can get it and how it can affect your health.

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Find a Health Center Near you and call to schedule a screening!

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Find a Health Center Near you and call to schedule a screening!

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Pap tests find abnormal cell changes in your cervix. How often you get a Pap test depends on your age, medical history, and the results of your last Pap or HPV tests.

What happens during a Pap test?

Pap tests, sometimes called Pap smears, are very important tests for finding abnormal cells on your cervix that could lead to cervical cancer. Pap tests find cell changes caused by HPV, but they don't detect HPV itself.

Pap tests may be part of your regular check up, pelvic exam or well-woman exam. During a Pap test, your doctor or nurse puts a metal or plastic speculum into your vagina. The speculum opens up to separate the walls of your vagina so that they can get to your cervix. Then they use a small sampler - a tiny spatula or brush - to gently collect cells from your cervix. The cells are sent to a lab to be tested.

Pap tests only take a few minutes. They shouldn't hurt, but you might feel some discomfort or pressure when your doctor or nurse opens the speculum inside you. You might also feel a light scratching when they take cells from your cervix.

Do I need a Pap test?

You should start getting regular Pap tests age 21. How often you get tested after that depends on your age, medical history, and the results of your last Pap or HPV tests. In general:

If you're 21-29 years old, get a Pap test once every 3 years (starting at age 25, your doctor may switch to an HPV test - either one is fine).

If you're 30-65 years old, get a Pap test and HPV test (co-testing) once every 5 years, or just a Pap test or HPV test every 3 years.

If you're older than 65, you may not need Pap tests anymore.

You may need to get tested more often if you've had problems with your cervix before, have a weak immune system, or if your mother took a medicine called DES while she was pregnant with you. Your doctor or nurse will tell you which tests you need and how often you should get them.

What if I have an abnormal Pap test?

If your Pap test results are abnormal, don't panic. It's pretty common to have unclear or abnormal Pap test results. Most of the time, it doesn't mean that you have cervical cancer.

An unclear test result means that your cervical cells look like they could be abnormal. But it isn't clear if it's related to HPV or something else. Unclear results are also called equivocal, inconclusive, or ASC-US.

An abnormal Pap test result means that there are abnormal cell changes on your cervix. This doesn't mean that you definitely have cervical cancer. The changes may be minor (low-grade) or serious (high-grade). The more serious changes are often called precancerous because they aren't cancer yet but can turn into it over time.

If you have an unclear or abnormal Pap test result, you made need further tests and/or treatment including:

If your doctor finds abnormal cells during your colposcopy, you'll probably need treatment. Common treatments include cryotherapy and LEEP.

Where can I go for a Pap test?

You can get a Pap test at your doctor or nurse's office, a community health clinic, the health department, or your local Planned Parenthood health center.

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Pap Smear Test | How Much Does a Pap Smear Cost?

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Pap tests find abnormal cell changes in your cervix. How often you get a Pap test depends on your age, medical history, and the results of your last Pap or HPV tests. Pap tests, sometimes called Pap smears, are very important tests for finding abnormal cells on your cervix that could lead to cervical cancer.

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Health Literacy Education for Health Care Professionals

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Health Literacy Education for Health Care Professionals

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A Health Literacy Assessment Tool for Patient Care and Research

The Newest Vital Sign (NVS) is a valid and reliable screening tool available in English and Spanish that identifies patients at risk for low health literacy. It is easy and quick to administer, requiring just three minutes. In clinical settings, the test allows providers to appropriately adapt their communication practices to the patient's health literacy level. Researchers have used the instrument to measure health literacy and evaluate the impact of low health literacy on a variety of health outcomes.

The Newest Vital Sign is one of Pfizer Inc.'s most important contributions to the health literacy movement and has been researched extensively by health literacy experts. In a recent systematic review ¹, the NVS performed moderately well in identifying patients with limited literacy.

How Does the Newest Vital Sign Work?

The Newest Vital Sign is based on a nutrition label from an ice cream container. Patients are given the label and then asked 6 questions about it. Patients can and should refer to the label while answering questions. The questions are asked orally and the responses recorded by a health care provider or researcher on a special score sheet, which contains the correct answers. Based on the number of correct responses, the health care provider or researcher can assess the patient's health literacy level.

What Can Providers Do to Improve Patient Understanding?

If the Newest Vital Sign results indicate a patient has limited health literacy skills, providers can use clear health communication techniques to help patients better understand their medical issues and follow instructions. More information about these techniques can be found here.

What Research Supports the Newest Vital Sign?

Since the Newest Vital Sign was published in the Annals of Family Medicine (December 2005), it has appeared in more than 25 peer-reviewed studies. The NVS has been used to assess health literacy in populations ranging from parents of young children to older adults, among racial/ethnic minorities, and applied to a wide variety of health conditions.

Newest Vital Sign - English

Newest Vital Sign - Spanish

¹ Powers BJ, et al. Can this patient read and understand written health information? JAMA 2010 Jul 7;304(1):76-84

Newest Vital Sign - English

Newest Vital Sign - Spanish

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The Newest Vital Sign | Pfizer: One of the world's premier biopharmaceutical companies

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A Health Literacy Assessment Tool for Patient Care and Research The Newest Vital Sign (NVS) is a valid and reliable screening tool available in English and Spanish that identifies patients at risk for low health literacy. It is easy and quick to administer, requiring just three minutes.

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No, Not My Body! --HPV Prevention Education

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This is an education video designed to inform participants in the No, Not My Body! HPV Prevention Education Program the facts and statistics about HPV.-- Created using PowToon -- Free sign up at http://www.powtoon.com/ . Make your own animated videos and animated presentations for free.

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provides quick, reader-friendly snapshots of interesting people, news, and current research related to cancer and its management. These 5-point profiles take only about 5 minutes to read and often feature audio or video.
Oncology Nursing Society 36th Annual Congress Dionne Walker, BSN, RN; Linda Bracks-Madison, MSN, RN; Judith Payne, PhD, RN, AOCN
Poster/ abstract 1052135-Bridging the Information Gap: An HPV Education Project

At the time that the HPV education project was developed, Ms. Walker was Clinical Care Coordinator for the Cord Blood Bank Program, Ms. Bracks-Madison was (and still is) working in the Division of Internal Medicine, and Dr. Payne was Associate Director of Nursing Research at The University of Texas M.D. Anderson Cancer Center, Houston, TX. Dr. Payne is currently Associate Director, Nursing Research, Duke University School of Nursing, Durham, NC.

Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States, with approximately 20 million people currently infected and an additional 6.2 million infected each year, despite increased media attention to HPV as a cause of cervical cancer and the availability of a vaccination to reduce HPV-associated cervical cancer.

Nurses are in a key position to participate in a community-based education project that will help sexually active women at risk for HPV to reduce their lifestyle risk factors for HPV, make informed health decisions regarding screening and, if needed, receive treatment for HPV infection.

The investigators evaluated the medical literature, searching the databases EBSCOHost and CINAHL Plus, using the following key words: "human papillomavirus (HPV)," "HPV-cancer," "HPV-counseling," "HPV-education," and womens' knowledge HPV," retrieving 40 articles.

* They uncovered a lack of simple, easy-to-understand information about HPV that healthcare providers can use to inform patients about risks and how to protect themselves, and management of cervical infections with HPV.

* Based on their findings, a nurse-led community-based education project will be developed in community centers, with educational training across nursing specialties, to teach women about HPV risk factors, genotype testing, and recommended screening and treatment modalities. Information about the psychosocial aspects of HPV infection (eg, the stigma associated with sexually transmitted disease, particularly among older women, and the finding that older physicians may be inconsistent in communicating to patients about HPV risk) will inform the healthcare provider approach to patient communication.

* Efficacy of the community-based project in increasing public awareness about HPV-related cervical cancers will be assessed via surveys conducted before and after the educational intervention.

An ideal time for nurses to initiate individual patient assessments and provide education about the risk of HPV transmission and ways that women can prevent HPV infection is during wellness visits/checkups, though patient education for this project will occur at other times also.

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Take 5-Bridging the Information Gap: An HPV Education Project

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Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States, with approximately 20 million people currently infected and an additional 6.2 million infected each year, despite increased media attention to HPV as a cause of cervical cancer and the availability of a vaccination to reduce HPV-associated cervical cancer.

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Understanding the relationship between how population groups experience "place" and the impact of "place" on health is fundamental to the social determinants of health-including both social and physical determinants.

Examples of social determinants include:

Availability of resources to meet daily needs (e.g., safe housing and local food markets)

Access to educational, economic, and job opportunities

Access to health care services

Quality of education and job training

Availability of community-based resources in support of community living and opportunities for recreational and leisure-time activities

Transportation options

Public safety

Social support

Social norms and attitudes (e.g., discrimination, racism, and distrust of government)

Exposure to crime, violence, and social disorder (e.g., presence of trash and lack of cooperation in a community)

Socioeconomic conditions (e.g., concentrated poverty and the stressful conditions that accompany it)

Residential segregation

Language/Literacy

Access to mass media and emerging technologies (e.g., cell phones, the Internet, and social media)

Culture

Examples of physical determinants include:

Natural environment, such as green space (e.g., trees and grass) or weather (e.g., climate change)

Built environment, such as buildings, sidewalks, bike lanes, and roads

Worksites, schools, and recreational settings

Housing and community design

Exposure to toxic substances and other physical hazards

Physical barriers, especially for people with disabilities

Aesthetic elements (e.g., good lighting, trees, and benches)

By working to establish policies that positively influence social and economic conditions and those that support changes in individual behavior, we can improve health for large numbers of people in ways that can be sustained over time. Improving the conditions in which we live, learn, work, and play and the quality of our relationships will create a healthier population, society, and workforce.

Healthy People 2020 Approach to Social Determinants of Health

A "place-based" organizing framework, reflecting five (5) key areas of social determinants of health (SDOH), was developed by Healthy People 2020.

These five key areas (determinants) include:

Economic Stability

Education

Social and Community Context

Health and Health Care

Neighborhood and Built Environment

Each of these five determinant areas reflects a number of key issues that make up the underlying factors in the arena of SDOH.

Health and Health Care

Access to Health Care

Access to Primary Care

Health Literacy

This organizing framework has been used to establish an initial set of objectives for the topic area as well as to identify existing Healthy People objectives (i.e., in other topic areas) that are complementary and highly relevant to social determinants. It is anticipated that additional objectives will continue to be developed throughout the decade.

In addition, the organizing framework has been used to identify an initial set of evidence-based resources and other examples of how a social determinants approach is or may be implemented at a state and local level.

Emerging Strategies To Address Social Determinants of Health

A number of tools and strategies are emerging to address the social determinants of health, including:

Use of Health Impact Assessments to review needed, proposed, and existing social policies for their likely impact on health6

Application of a "health in all policies" strategy, which introduces improved health for all and the closing of health gaps as goals to be shared across all areas of government4, 7

References

1Secretary's Advisory Committee on Health Promotion and Disease Prevention Objectives for 2020. Healthy People 2020: An Opportunity to Address the Societal Determinants of Health in the United States. July 26, 2010. Available from: http://www.healthypeople.gov/2010/hp2020/advisory/SocietalDeterminantsHealth.htm

2World Health Organization, Commission on Social Determinants of Health. Closing the Gap in a Generation: Health equity through action on the social determinants of health. Available from: http://www.who.int/social_determinants/en

3National Partnership for Action: HHS Action Plan to Reduce Racial and Ethnic Health Disparities, 2011; and The National Stakeholder Strategy for Achieving Health Equity, 2011. Available from: http://minorityhealth.hhs.gov/npa

4The National Prevention and Health Promotion Strategy. The National Prevention Strategy: America's Plan for Better Health and Wellness, June 2011. Available from: https://www.surgeongeneral.gov/priorities/prevention/strategy/index.html

5The Institute of Medicine. Disparities in Health Care: Methods for Studying the Effects of Race, Ethnicity, and SES on Access, Use, and Quality of Health Care, 2002.

6Health Impact Assessment: A Tool to Help Policy Makers Understand Health Beyond Health Care. Annual Review of Public Health 2007;28:393-412. Retrieved October 26, 2010. Available from: http://www.annualreviews.org/doi/abs/10.1146/annurev.publhealth.28.083006.131942

7European Observatory on Health Systems and Policies. Health in All Policies: Prospects and potentials, 2006. Accessed on June 16, 2011. Available from: http://www.euro.who.int/__data/assets/pdf_file/0003/109146/E89260.pdf [PDF - 1.23 MB]

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Understanding the relationship between how population groups experience "place" and the impact of "place" on health is fundamental to the social determinants of health-including both social and physical determinants.

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Health Literacy is defined in the Institute of Medicine report, Health Literacy: A Prescription to End Confusion, as "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions."

Health literacy requires a complex group of reading, listening, analytical, and decision-making skills, as well as the ability to apply these skills to health situations. For example, it includes the ability to understand instructions on prescription drug bottles, appointment slips, medical education brochures, doctor's directions and consent forms, and the ability to negotiate complex health care systems.

More recent definitions focus on specific skills needed to navigate the health care system and the importance of clear communication between health care providers and their patients. Both health care providers and patients play important roles in health literacy. The number of different definitions for health literacy demonstrate how the field has evolved.

Definitions of Health Literacy

"Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions."
( Healthy People)

"The term 'health literacy' means the degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services in order to make appropriate health decisions."
( Patient and Affordable Care Act of 2010, Title V)

Health literacy is the use of a wide range of skills that improve the ability of people to act on information in order to live healthier lives. These skills include reading, writing, listening, speaking, numeracy, and critical analysis, as well as communication and interaction skills."
( Calgary Charter)

Health Literacy in a Cultural Context

Recognizing that culture plays an important role in communication helps us better understand health literacy. For people from different cultural backgrounds, health literacy is affected by belief systems, communication styles, and understanding and response to health information. Even though culture is only one part of health literacy, it is a very important piece of the complicated topic of health literacy. The United States Department of Health and Human Services (HHS) recognizes that "culture affects how people communicate, understand and respond to health information."

There is a move toward "patient-centered" health care as part of an overall effort to improve the quality of health care and to reduce costs. Individual patients and providers need to work together to ensure effective communication. Patients need to take an active role in health related decisions and develop strong health information skills. Healthcare providers need to utilize effective health communication skills. Health educators need to write printed and Web-based information using plain language.

Skills Needed for Health Literacy

Patients are often faced with complex information and treatment decisions. Patients need to:

Access health care services

Analyze relative risks and benefits

Calculate dosages

Communicate with health care providers

Evaluate information for credibility and quality

Interpret test results

Locate health information

In order to accomplish these tasks, individuals may need to be:

Visually literate (able to understand graphs or other visual information)

Computer literate (able to operate a computer)

Information literate (able to obtain and apply relevant information)

Numerically or computationally literate (able to calculate or reason numerically)

Oral language skills are important as well. Patients need to articulate their health concerns and describe their symptoms accurately. They need to ask pertinent questions, and they need to understand spoken medical advice or treatment directions. In an age of shared responsibility between physician and patient for health care, patients need strong decision-making skills. With the development of the Internet as a source of health information, health literacy may also include the ability to search the Internet and evaluate Web sites.

Prevalence of Low Health Literacy

According to the Agency for Health Care Research and Quality Report, Health Literacy Interventions and Outcomes: an Update of the Literacy and Health Outcomes Systematic Review of the Literature, low health literacy is linked to higher risk of death and more emergency room visits and hospitalizations. Health literacy may not be related to years of education or general reading ability. A person who functions adequately at home or work may have marginal or inadequate literacy in a health care environment.

People with low health literacy use more health care services, have a greater risk for hospitalization, and have a higher utilization of expensive services, such as emergency care and inpatient admissions. ( IOM, 2004)
Vulnerable populations include older adults, immigrant populations, minority populations, and low income populations.

Reasons for limited literacy skills include:

Lack of educational opportunity -people with a high school education or lower

Learning disabilities

Cognitive decline in older adults

"Use it or lose it." Reading abilities are typically three to five grade levels below the last year of school completed. As a result, people with a high school diploma, typically read at a seventh or eighth grade reading level.

The relationship between literacy and health is complex. Literacy impacts health knowledge, health status, and access to health services. Several socioeconomic factors impact health status. Literacy impacts income level, occupation, education, housing, and access to medical care. Poor and illiterate people are more likely to work under hazardous conditions or be exposed to environmental toxins.

Economic Impact of Low Health Literacy

In addition to the effects of low health literacy on the individual patient, there are economic consequences of low health literacy to society. According to the report Low Health Literacy: Implications for National Health Policy "Low health literacy is a major source of economic inefficiency in the U.S. health care system." The report estimates that the cost of low health literacy to the U.S. economy is between $106 billion to $238 billion annually. This represents between 7 percent and 17 percent of all personal health care expenditures. To put this in perspective, the cost represents an amount equal to the cost of insuring every one of the more than 47 million people who lacked coverage in the United States in 2006. Improving health communication reduces health care costs and increases the quality of health care.

Initiatives to Improve Patient Communication

Low health literacy was once viewed as an individual patient's deficit-that is, a patient's lack of knowledge and skills regarding health issues. We now recognize that health literacy is a "systems issue" (Rudd, 2010), reflecting the complexity of both the presentation of health information and navigation of the health care system. (Parker, Ratzan, 2010)

The Joint Commission, the group that accredits and certifies health care organizations and programs in the United States, stresses the importance of health literacy, health communication, and cultural competencies as an element of quality health care. In their report, What Did the Doctor Say?: Improving Health Literacy to Protect Patient Safety, the Commission states:

Health literacy issues and ineffective communications place patients at greater risk of preventable adverse events. If a patient does not understand the implications of her or his diagnosis and the importance of prevention and treatment plans, or cannot access health care services because of communications problems, an untoward event may occur. The same is true if the treating physician does not understand the patient or the cultural context within which the patient receives critical information... The Joint Commission's accreditation standards underscore the fundamental right and need for patients to receive information - both orally and written - about their care in a way in which they can understand this information.

These landmark reports helped move health literacy from an "under-recognized silent epidemic to an issue of health policy and reform".

Research Findings on the Impact of Low Health Literacy

Below are just a few of the conclusions from studies on health literacy and outcomes.

People with low health literacy have a lower likelihood of getting flu shots, understanding medical labels and instructions, and a greater likelihood of taking medicines incorrectly compared with adults with higher health literacy. (Bennett, 2008)

Individuals with limited health literacy reported poorer health status and were less likely to use preventative care. (Nielson-Bohlman, 2004)

Individuals with low levels of health literacy are more likely to be hospitalized and have bad disease outcomes. (Baker, 2002) and (Schillinger, 2002)

Inpatient spending increases by approximately $993 for patients with limited health literacy. (Howard, 2004)

After controlling for relevant covariates, lower health literacy scores were associated with high mortality rates within a Medicare managed care setting. (Baker, 2007)

The annual cost of low health literacy to the U.S. economy was $106 billion to $238 billion. (Vernon, 2007)

Low literacy adversely impacts cancer incidence, mortality, and quality of life. For example:

Cancer screening information may be ineffective; as a result, patients may be diagnosed at a later stage.

Treatment options may not be fully understood; therefore, some patients may not receive treatments that best meet their needs.

Informed consent documents may be too complex for many patients and consequently, patients may make suboptimal decisions about accepting or rejecting interventions. (Merriman, Betty, CA: A Cancer Journal for Physicians, May/June 2002)

Among primary care patients with Type 2 diabetes, inadequate health literacy is independently associated with worse glycemic control and higher rates of retinopathy. Inadequate health literacy may contribute to the disproportionate burden of diabetes related problems among disadvantaged populations. (Schillinger, 2002)

Role of the Consumer Health Librarian

Many consumer health initiatives are geared towards technological access to health information or rewriting existing health materials at a simpler language level. Both of these approaches are important, but limited. Easy-to-read materials and access to technology are only pieces of a process that must be placed in a larger community context.
This may take the form of providing space for meetings, providing health literacy materials, or actively developing health literacy programs. Consumer health librarians can promote awareness of health literacy among health professionals by creating clearinghouses of health literacy information, sponsoring health literacy seminars, and encouraging multi-organizational collaborations.
The National Action Plan for Health Literacy identifies the following strategies for health information and library professionals to contribute to health literacy:

Help to train all health care staff in the principles of health literacy and plain language.

Create collections or repositories of materials (e.g. insurance forms and instructions, informed consent and other legal documents, aftercare and medication instruction, and patient education materials) in several languages and review the materials with members of the target population.

Help to disseminate existing communication tools and resources for patients.

Consumer health librarians can also support the direct needs of health information consumers by providing materials that are multilingual, culturally appropriate and easy-to-read, and by developing methods and materials to teach consumers how to evaluate health information resources, especially those found on the Internet.

References

Agency for Health Care Research and Quality (AHRQ). 2011. Health Literacy Interventions and Outcomes: an Update of the Literacy and Health Outcomes Systematic Review of Literature, 2011

American Medical News. Gerontologists outline how doctors can bridge communication gap with older patients

Bennett IM, Chen J, Soroui JS, et al. The contribution of health literacy to disparities in self-rated health status and preventive health behaviors in older adults. Annals of Family Medicine, 2009, May-Jun;7(3):204-11.

Centers for Disease Control and Prevention. Older Adults: Why Is Health Literacy Important?

Davis, T. C., Williams, M. V., Marin, E., Parker, R. M., & Glass, J. (January 01, 2002). Health literacy and cancer communication. Ca: a Cancer Journal for Clinicians, 52, 3.)

Howard DH, Sentell T, Gazmararian JA. Impact of health literacy on socioeconomic and racial differences in health in an elderly population. Journal of General Internal Medicine, 2006, Aug;21(8):857-61.

Institute of Medicine and Nielsen-Bohlman, L., Panzer, A. M., Kindig, D. A., Health Literacy: A Prescription to End Confusion

Joint Commission. (2007). What did the doctor say?: Improving health literacy to protect patient safety. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations.

Kutner, M., Greenberg, E., Jin,Y., and Paulsen, C. (2006). The Health Literacy of America's Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006-483).U.S.Department of Education.Washington, DC: National Center for Education Statistics.

Paasche-Orlow, M. K., Riekert, K. A., Bilderback, A., Chanmugam, A., Hill, P., Rand, C. S., Brancati, F. L., Krishnan, J. A. (January 01, 2005). Tailored education may reduce health literacy disparities in asthma self-management. American Journal of Respiratory and Critical Care Medicine, 172, 8, 980-6.

Parker R, Ratzan SC. Health Literacy: a second decade of distinction for Americans. Journal of Health Communication, 2010:15(Suppl 2)20-33.

Rudd, R. Improving Americans' health literacy. New England Journal of Medicine, 2010; 363(24):2283-85.

Schillinger D, Grumbach K, Piette J, et al. Association of Health Literacy With Diabetes Outcomes. Journal of the American Medical Association. 2002;288(4):475-482. doi:10.1001/jama.288.4.475.

United States Department of Health and Human Services.Office of Disease Prevention and Health Promotion. Quick Guide to Health Literacy Fact Sheet: Health Literacy Basics. Retrieved December 29, 2016.

Vernon, J. A., Trujillo, A, Rosenbaum, S, (2007). Low health literacy: Implications for national health policy.

Weiss, B. D., American Medical Association., & AMA Foundation. (2007). Health literacy and patient safety: Help patients understand. Chicago, Ill: AMA Foundation.

Williams, M. V., Baker, D. W., Honig, E. G., Lee, T. M., & Nowlan, A. (January 01, 1998). Inadequate literacy is a barrier to asthma knowledge and self-care. Chest, 114, 4, 1008-15.

White S, Chen J, Atchison R. Relationship of preventive health practices and health literacy: a national study. American Journal of Health Behavior, 2008 May-Jun;32(3):227-42.

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Definition Health Literacy is defined in the Institute of Medicine report, Health Literacy: A Prescription to End Confusion, as "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions."

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National Action Plan to Improve Health Literacy | Healthy People 2020

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The National Action Plan to Improve Health Literacy is a strategy document for organizations and individuals to use to improve health literacy. The plan includes 7 goals and multiple action steps to engage organizations, professionals, policymakers, communities, individuals, and families in a linked, multisector effort.

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CDC flyer for revision