Eighty-seven million American adults have low health literacy (LHL), costing up to $238 billion annually in inefficiencies (Vernon, Trujillo, Rosenbaum, & DeBuono, 2007). Yet, the highly complex United States health care and health insurance systems require advanced health literacy for effective navigation (Kindig, Panzer, & Nielsen-Bohlman, 2004; Quincy, 2012; Somers & Mahadevan, 2010; Villaire & Mayer, 2009). For instance, health information is often written at or above a high school level; hence, inaccessible to people with LHL (Rudd, 2007). With respect to health insurance, consumers must navigate technical guides, understand cost-sharing terms, determine whether their provider is in- or out-of-network, and calculate co-pays, deductibles, and co-insurance (Quincy, 2012). Ultimately, LHL prevents optimal health system and insurance navigation, affecting health care access and health outcomes (Ingram, 2012; Long et al., 2014; Parker, 2012; Quincy, 2012; Volandes & Paasche-Orlow, 2007).
Older adults, adolescents, people with low income and educational levels, and racial and ethnic minorities are disproportionately affected by LHL (Ingram, 2012; Kutner, Greenburg, Jin, & Paulsen, 2006; Prins & Mooney, 2014; Rudd, 2007; Volandes & Paasche-Orlow, 2007). The 2003 National Assessment of Adult Literacy revealed that 58% of African Americans had basic or below basic health literacy, compared with 28% of non-Hispanic Whites (Kutner et al., 2006). LHL is an independent predictor of racial/ethnic disparities in health behaviors (e.g., smoking, adherence to HIV treatment), access to health care resources, and health outcomes (Al Sayah, Majumdar, Egede, & Johnson, 2015; Berkman et al., 2011; Hossain, Ehtesham, Salzman, Jenson, & Calkins, 2013; Lanning & Doyle, 2010; Mantwill, Monestel-Umaña, & Schulz, 2015; Sentell & Halpin, 2006; Stewart et al., 2015).
Despite the disproportionate LHL among African Americans, there is limited evidence on its determinants and on effective health literacy interventions in African-American populations (Weekes, 2012). This article explores health literacy barriers and strategies among African Americans, drawing from the literature and the authors' experiences with community-engaged research in African-American communities.
Health Literacy Barriers
The disproportionate LHL among African Americans is rooted in historically unjust power structures (Estacio, 2013; Gee & Ford, 2011; Noonan, Velasco-Mondragon, & Wagner, 2016; Volandes & Paasche-Orlow, 2007). Discriminatory policies and practices have systematically limited African Americans' access to the resources and skills needed to obtain, understand, and apply health information (Foulk, Carroll, & Wood, 2001; Prins & Mooney, 2014; Rajaram & Bockrath, 2014; Smith, 2003; Wallace, 2015). Systemic factors such as limited educational opportunities, racism, health system mistrust, and a lack of culturally tailored health information and services are health literacy barriers for this population (Bhattacharya, 2013; Goodman et al., 2012; Kutner et al., 2006; Ownby et al., 2014; Politi et al., 2014; Prins & Mooney, 2014).
Education is positively correlated with health literacy (Lee et al., 2014; Ownby et al., 2014; Rudd, 2007) and differences in educational opportunities mediate the relationship between race/ethnicity and health literacy (Ownby et al., 2014). Racial residential segregation and discrimination perpetuate inequities by limiting access to quality education among African Americans (Goodman et al., 2012; Kutner et al., 2006; Ownby et al., 2014; Prins & Mooney, 2014; Rudd, 2007; Wallace, 2015).
Additionally, African Americans are less likely than other racial/ethnic groups to trust the health care system due to negative past experiences including abuse by health researchers (Bhattacharya et al., 2013; Politi et al., 2014; Prins & Mooney, 2014). One of the most egregious examples was the Tuskegee Study of Untreated Syphilis in the Negro Male from 1932 to 1972, wherein a curative treatment (penicillin) was withheld from hundreds of Black men to examine the effects of untreated syphilis (Tuskegee University, n.d.). Mistrust interferes with health literacy development as it affects interactions with the health care system, access to health-related resources, and health-related decision-making (Bhattacharya, 2013; Politi et al., 2014). The health care system has played a role in creating disparities in health literacy by historically failing to accommodate racial and ethnic minority populations' needs and preferences in the delivery of services and health information (Saha, Beach, & Cooper, 2008).
Moreover, health care providers may not recognize the extent of this health literacy gap. One study reported that physicians overestimated the health literacy scores of 54% of African-American patients, compared with 11% of non-Hispanic White and 36% of patients of another race/ethnicity (Kelly & Haidet, 2007). The failure to identify people with LHL is a missed opportunity to tailor patient-provider communications, thus affecting patients' understanding and application of recommendations (Kelly & Haidet, 2007).
Health Literacy Strategies
While adopting universal precautions of health literacy simplifies health communication and information processing for all consumers (DeWalt et al, 2010; 2011), studies suggest that reaching African Americans with LHL more effectively also relies on adopting culturally tailored, interactive, and community-engaged health literacy approaches (Bertera, 2014; Broussard, Radkins, & Compton, 2014; Rikard, Thompson, Head, McNeil, & White., 2012; Ross, Ashford, Bleechington, Dark, & Erwin, 2010). This is based on the premise that health information is processed through multiple lenses; thus, the interpretation of health-related concepts and images varies across cultures and other social markers (e.g., language, generations) (Kindig et al., 2004; Scrimshaw, 2019).
Culturally tailored and interactive approaches such as storytelling and culturally appropriate graphics have been reported to improve health literacy related to diverse health conditions in African-American samples (Bertera, 2014; Broussard et al., 2014; Rikard et al., 2012; Ross et al., 2010). For instance, oral storytelling slideshows on diabetes and hypertension that featured community members' voices and photographs were developed and administered to a group of predominantly older African-American women (Bertera, 2014). Exposure to these slideshows produced significant pre-post increases in diabetes (8.8%, p < .000) and hypertension (5.6 %, p < .001) knowledge and self-efficacy (11.3% and 13.2% respectively; p < .000) in the intervention group, with the greatest effects among those with LHL (measured by a Veteran's Administration instrument) (Bertera, 2014). Print materials containing real-life stories, culturally appropriate concepts and images, and practical, action-oriented steps have also been well received in African-American samples with LHL (Broussard et al., 2014; Rikard et al, 2012).
In addition, interactive and user-friendly digital platforms such as mobile health applications present considerable opportunities for reaching African Americans with LHL more effectively (Anderson, 2015; Fox and Duggan, 2012; Krebs & Duncan, 2015; Perrin, 2017; Pew Research Center, 2018). Although there is a dearth of literature on the use of digital health literacy interventions among African Americans with LHL, reports suggest that the ownership and use of mobile technology for accessing online health information has increased among racial/ethnic minorities, particularly African Americans (Anderson, 2015; Choi & Dinitto, 2013; Fox & Duggan, 2012; Krebs & Duncan, 2015; Perrin, 2017; Pew Research Center, 2018). However, these reports do not stratify mobile technology or internet use by health literacy levels, yet online health information is often written at higher reading levels and the ability to effectively process and use such information varies by health literacy levels (Meppelink, Smit, Diviani, & Van Weert, 2016). For instance, African Americans with LHL are less likely to use computers or the internet for health information (McCleary-Jones et al., 2013). Thus, to reach a large number of people with LHL, online or digital health literacy interventions should incorporate features that tailor health information to individuals' health literacy needs, technical skills, health needs, as well as personal and cultural values (Bickmore & Paasche-Orlow, 2012; Hur, Lee, & Schmidt, 2015).
On the other hand, some traditional health communication channels have received support in African-American samples of varying age groups (Ali, Combs, Muvuka, & Ayangeakaa, 2018; Lariscy, Reber, & Paek, 2010). For instance, along with the internet, television and radio were identified as preferred health communication channels in a sample of African-American youth (Lariscy et al., 2010). Furthermore, a qualitative study by our research team examined health insurance literacy among 87 residents (young, middle-aged, and senior adults) of a predominantly African-American community and found that participants preferred in-person health insurance navigation delivered by culturally competent community health workers who are from or familiar with the community, trustworthy, nonjudgmental, and knowledgeable about health insurance (Ali et al., 2018).
Engaging African-American community members in developing health literacy interventions has shown promise in ensuring their cultural and linguistic suitability, acceptability, usability, and effectiveness (Bhattacharya et al., 2013; Mullen, 2013; Rikard et al., 2012; Smith, 2003). Participatory approaches help capture diverse and shared cultural values, beliefs, and experiences in African-American communities (Rikard et al., 2012). In addition, such approaches can mobilize collective action to improve health literacy policies and practices (Bhattacharya, 2013; Estacio, 2013; Freire, 1970; Gillis, 2004; Mullins, Blatt, Gbarayor, Yang, & Baquet, 2005; Rikard et al., 2012).
There are several promising examples of community-engaged health literacy interventions. A group comprising African-American community members, university researchers, and a community-based organization developed a culturally tailored HIV/AIDS toolkit with culturally appropriate images and skill-based information in plain language to improve HIV-related health literacy in an African-American community (Rikard et al., 2012). Community members perceived the toolkit as acceptable, easy to use, and effective in raising awareness and dialogue on HIV (Rikard et al., 2012). In another study, two interactive low-literacy educational workbooks were developed for African Americans with psychotic disorders in collaboration with service users, providers, and graphic designers (Broussard et al., 2014). These workbooks were written at the fifth-grade level and contained storylines with comic-strip illustrations featuring African-American characters, which service users and providers found useful and understandable (Broussard et al., 2014). Similarly, over a 2-year period, our team used Boot Camp Translation, a novel community-based participatory research (CBPR) tool, to engage community members, academics, and health professionals in a predominantly African-American community facing extensive health and social inequities. Through facilitated group discussions and consensus building, we developed and disseminated culturally targeted health communication campaigns to improve health literacy on depression (“Depression is Real”), HIV (“We're in Control Now!”), and childhood asthma (“Every Child with Asthma Needs an Asthma Action Plan”) (Community Research Louisville, n.d.; Muvuka, Combs, Ali, Scott, & Williams, 2020). The CBPR examples also highlight that health literacy needs can be more effectively addressed by multidisciplinary teams comprising community stake-holders, diverse health professionals, and academics, among several others.
In African-American communities, the Black church is a powerful resource for health literacy initiatives. Using CBPR, Tucker et al. (2019) trained church leaders and selected church goers from 21 Black churches to deliver a 6-week church-based health promotion intervention comprising individual coaching, group discussions, and physical activity. At post-test, this initiative significantly increased nutritional health literacy (measured using the Newest Vital Sign; mean difference = 1.20, p < .001) and health behaviors (e.g., nutrition and physical activity) in the intervention group (mean difference = 0.76, p < .001) (Tucker et al., 2019). Similarly, Dulchavsky, Riffin, Johnson, Cogan, and Joseph (2014) installed health information touchscreen kiosks in four Black churches to improve health literacy and found self-reported changes in at least one behavior in more than 85% of users 1 to 2 years later.
There are significant gaps in the literature concerning health literacy barriers and interventions in African-American communities. We conclude, as do D'Eath, Barry, and Sixsmith, (2012), that research on effective approaches for improving health literacy in populations that experience health disparities should be prioritized. Specifically, the health information delivery preferences of African Americans in diverse settings warrants further exploration (D'Eath et al., 2012; Spruill et al., 2015). Of particular interest would be examining the role of technology or digital platforms in reaching African Americans with LHL. Additionally, because many health literacy interventions are health system-focused, more research on community-based health literacy interventions is needed (Logan et al., 2015). Furthermore, we need to examine the determinants of LHL, particularly in racial/ethnic minority populations, and the mechanisms through which they interfere with health literacy development.
Given the multidimensional and multifactorial nature of health literacy, collaborative and multipronged solutions are necessary to ensure sustainable improvements. Health literacy barriers should be addressed on both supply (i.e., health system) and demand side (i.e., consumers). Examples of supply-side interventions include establishing user-friendly and culturally sensitive health system navigation processes, engaging consumers in developing interventions, and tailoring health communication approaches. In addition, health care providers and organizations should be trained to identify and accommodate consumers with unique health literacy, cultural, and linguistic needs.
Ultimately, achieving sustainable improvements in health literacy among African Americans requires tackling broader systemic barriers. This requires developing supportive institutions and policies to eliminate systemic racism and reduce inequities in access to quality education, employment, income, and health-related resources (Wallace, 2015). Considering that health literacy “crosses multiple boundaries, professions and jurisdictions” (Mitic & Rootman, 2012), there is a need for multisectoral and participatory health literacy approaches that engage diverse stakeholders such as community members, faith leaders, the health care sector, nonhealth sectors, policymakers, and academic institutions (Mitic & Rootman, 2012; US Department of Health and Human Services, 2010). Improving health literacy among African Americans should be a critical component of strategies to achieve health equity (Logan et al., 2015).
- Ali, N.M., Combs, R.M., Muvuka, B. & Ayangeakaa, S.D. (2018). Addressing health insurance literacy gaps in an urban African American population: A qualitative study. American Journal of Community Health, 43, 1208–1216 doi:10.1007/s10900-018-0541-x [CrossRef].
- Al Sayah, F., Majumdar, S. R., Egede, L. E. & Johnson, J. A. (2015). Associations between health literacy and health outcomes in a predominantly low-income African American population with type 2 diabetes. Journal of Health Communication, 20(5), 581–588 doi:10.1080/10810730.2015.1012235 [CrossRef] PMID:25826448
- Anderson, M. (2015). Racial and ethnic differences in how people use mobile technology. Pew Internet and American Life Project. https://www.pewresearch.org/fact-tank/2015/04/30/racial-and-ethnic-differences-in-how-people-use-mobile-technology/
- Berkman, N. D., Sheridan, S. L., Donahue, K. E., Halpern, D. J. & Crotty, K. (2011). Low health literacy and health outcomes: An updated systematic review. Annals of Internal Medicine, 155(2), 97–107 doi:10.7326/0003-4819-155-2-201107190-00005 [CrossRef] PMID:21768583
- Bertera, E. M. (2014). Storytelling slide shows to improve diabetes and high blood pressure knowledge and self-efficacy: Three-year results among community dwelling older African Americans. Educational Gerontology, 40(11), 785–800 doi:10.1080/03601277.2014.894381 [CrossRef]
- Bhattacharya, G. (2013). Contextualizing disparity reduction in rural health care: A call to action. Journal of Family Social Work, 16(1), 86–100 doi:10.1080/10522158.2012.736079 [CrossRef]
- Bickmore, T. W. & Paasche-Orlow, M. K. (2012). The role of information technology in health literacy research. Journal of Health Communication, 17(Suppl. 3), 23–29 doi:10.1080/10810730.2012.712626 [CrossRef] PMID:23030559
- Broussard, B., Radkins, J. B. & Compton, M. T. (2014). Developing visually based, low-literacy health education to ols for African Americans with psychotic disorders and their families. Community Mental Health Journal, 50(6), 629–636 doi:10.1007/s10597-013-9666-7 [CrossRef] PMID:24633539
- Community Research Louisville. (n.d.). About us. https://communityresearchlouisville.com
- Choi, N. G. & Dinitto, D. M. (2013). The digital divide among low-income homebound older adults: Internet use patterns, eHealth literacy, and attitudes toward computer/Internet use. Journal of Medical Internet Research, 15(5), e93 doi:10.2196/jmir.2645 [CrossRef] PMID:23639979
- D'Eath, M., Barry, M. & Sixsmith, J. (2012). Rapid evidence review of interventions for improving health literacy. European Centers for Disease Prevention and Control. https://ecdc.europa.eu/sites/portal/files/media/en/publications/Publications/1205-TER-Improving-Health-Literacy.pdf
- DeWalt, D. A., Callahan, L. F., Hawk, V. H., Broucksou, K. A., Hink, A., Rudd, R. & Brach, C. (2010). Health literacy universal precautions toolkit. Agency for Healthcare Research and Quality. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/healthliteracytoolkit.pdf
- DeWalt, D. A., Broucksou, K. A., Hawk, V., Brach, C., Hink, A., Rudd, R. & Callahan, L. (2011). Developing and testing the health literacy universal precautions toolkit. Nursing Outlook, 59(2), 85–94 doi:10.1016/j.outlook.2010.12.002 [CrossRef] PMID:21402204
- Dulchavsky, S. A., Ruffin, W. J., Johnson, D. A., Cogan, C. & Joseph, C. L. (2014). Use of an interactive, faith-based kiosk by congregants of four predominantly, African-American churches in a metropolitan area. Frontiers in Public Health, 2, 106 doi:10.3389/fpubh.2014.00106 [CrossRef] PMID:25140296
- Estacio, E. V. (2013). Health literacy and community empowerment: It is more than just reading, writing and counting. Journal of Health Psychology, 18(8), 1056–1068 doi:10.1177/1359105312470126 [CrossRef] PMID:23349398
- Foulk, D., Carroll, P. & Wood, S. N. (2001). Addressing health literacy: A description of the intersection of functional literacy and health. American Journal of Health Studies, 17(1), 7–14 http://www.nald.ca/library/research/gillis/community/community.pdf
- Fox, S. & Duggan, M. (2012). Mobile health 2012. Pew Internet and American Life Project. http://www.pewinternet.org/2012/11/08/mobile-health-2012/
- Freire, P. (1970). Pedagogy of the oppressed. Herder and Herder.
- Gee, G. C. & Ford, C. L. (2011). Structural racism and health inequities: Old issues, new directions. Du Bois Review, 8(1), 115–132 doi:10.1017/S1742058X11000130 [CrossRef] PMID:25632292
- Gillis, D. E. (2004). A community-based approach to health literacy using participatory research. Adult Learning, 15(1–2), 14–17 doi:10.1177/104515950401500104 [CrossRef]
- Goodman, M. S., Gaskin, D. J., Si, X., Stafford, J. D., Lachance, C. & Kaphingst, K. A. (2012). Self-reported segregation experience throughout the life course and its association with adequate health literacy. Health & Place, 18(5), 1115–1121 doi:10.1016/j.healthplace.2012.04.010 [CrossRef] PMID:22658579
- Hossain, W. A., Ehtesham, M. W., Salzman, G. A., Jenson, R. & Calkins, C. F. (2013). Healthcare access and disparities in chronic medical conditions in urban populations. Southern Medical Journal, 106(4), 246–254 doi:10.1097/SMJ.0b013e31828aef37 [CrossRef] PMID:23558412
- Hur, I., Lee, R. & Schmidt, J. J. (2015). How healthcare technology shapes health literacy? A systematic review. 21st Americas Conference on Information Systems. https://pdfs.semanticscholar.org/0b8d/92a0b60e49157886384e07eccf4efe824b52.pdf
- Ingram, R.R. (2012). Using Campinha-Bacote's process of cultural competence model to examine the relationship between health literacy and cultural competence. Journal of Advanced Nursing, 68(3), 695–704. doi:10.1111/j.1365-2648.2011.05822.x [CrossRef]
- Kelly, P. A. & Haidet, P. (2007). Physician overestimation of patient literacy: A potential source of health care disparities. Patient Counselling and Health Education, 66(1), 119–122 doi:10.1016/j.pec.2006.10.007 [CrossRef] PMID:17140758
- Kindig, D. A., Panzer, A. M. & Nielsen-Bohlman, L (Eds.). (2004). Health literacy: A prescription to end confusion. National Academies Press. https://www.nap.edu/catalog/10883/health-literacy-a-prescription-to-end-confusion
- Krebs, P. & Duncan, D. T. (2015). Health app use among US mobile phone owners: A national survey. JMIR mHealth and uHealth, 3(4), e101 doi:10.2196/mhealth.4924 [CrossRef] PMID:26537656
- Kutner, M., Greenburg, E., Jin, Y. & Paulsen, C. (2006). The health literacy of America's adults: Results from the 2003 National Assessment of Adult lLteracy. National Center for Education Statistics. http://nces.ed.gov/pubs2006/2006483.pdf
- Lanning, B. A. & Doyle, E. I. (2010). Health literacy: Developing a practical framework for effective health communication. American Medical Writers Association Journal. https://cdn.ymaws.com/www.amwa.org/resource/resmgr/journal/Issues/2010/2010v25n4_online.pdf
- Lariscy, R., Reber, B. & Paek, H. (2010). Examination of media channels and types as health information sources for adolescents: Comparisons for black/white, male/female, urban/rural. Journal of Broadcasting & Electronic Media, 54(1), 102–120 doi:10.1080/08838150903550444 [CrossRef]
- Lee, J. Y., Divaris, K., DeWalt, D. A., Baker, A. D., Gizlice, Z., Rozier, R. G. & Vann, W. F. Jr. . (2014). Caregivers' health literacy and gaps in children's Medicaid enrollment: Findings from the Carolina Oral Health Literacy Study. PLoS One, 9(10), e110178 doi:10.1371/journal.pone.0110178 [CrossRef] PMID:25303271
- Logan, R. A., Wong, W. F., Villaire, M., Daus, G., Parnell, T. A., Willis, E. & Paasche-Orlow, M. K.2015. Health literacy: A necessary element for achieving health equity. National Academy of Medicine Perspectives. https://nam.edu/perspectives-2015-health-literacy-a-necessary-element-for-achieving-health-equity/
- Long, S. K., Kenney, G. M., Zuckerman, S., Goin, D. E., Wissoker, D., Blavin, F. & Hempstead, K. (2014). The health reform monitoring survey: Addressing data gaps to provide timely insights into the affordable care act. Health Affairs, 33(1), 161–167 doi:10.1377/hlthaff.2013.0934 [CrossRef] PMID:24352654
- Mantwill, S., Monestel-Umaña, S. & Schulz, P. J. (2015). The relationship between health literacy and health disparities: A systematic review. PLoS One, 10(12), e0145455 doi:10.1371/journal.pone.0145455 [CrossRef] PMID:26698310
- McCleary-Jones, V., Scheideman-Miller, C., Rev Dorn, J. A. Jr.. , Johnson, B., Overall, M. & Dwyer, K. (2013). Health information technology use and health literacy among community-dwelling African Americans. Association of Black Nursing Faculty Journal, 24(1), 10–16 PMID: 23589966
- Meppelink, C. S., Smit, E. G., Diviani, N. & Van Weert, J. C. (2016). Health literacy and online health information processing: unraveling the underlying mechanisms. Journal of Health Communication, 21(Suppl. 2), 109–120 doi:10.1080/10810730.2016.1193920 [CrossRef]
- Mitic, W. & Rootman, I. (2012). An inter-sectoral approach for improving health literacy for Canadians: A discussion paper. Public Health Association of British Columbia. http://phabc.org/wp-content/uploads/2015/09/IntersectoralApproachforHealthLiteracy-FINAL.pdf
- Mullen, E. (2013). Health literacy challenges in the aging population. Nursing Forum, 48(4), 248–255 doi:10.1111/nuf.12038 [CrossRef] PMID:24188436
- Mullins, C. D., Blatt, L., Gbarayor, C. M., Yang, H.-W. K. & Baquet, C. (2005). Health disparities: A barrier to high-quality care. American Journal of Health-System Pharmacy, 62(18), 1873–1882 doi:10.2146/ajhp050064 [CrossRef] PMID:16141106
- Muvuka, B., Combs, R.M., Ali, N.M., Scott, H. & Williams, M.T. (2020). Depression is real: Developing a health communication campaign in an urban African American community. Progress in Community Health Partnerships: Research, Education, and Action, 14(2), 161–172 doi:10.1353/cpr.2020.0029 [CrossRef]
- Noonan, A. S., Velasco-Mondragon, H. E. & Wagner, F. A. (2016). Improving the health of African Americans in the USA: An overdue opportunity for social justice. Public Health Reviews, 37, 12 doi:10.1186/s40985-016-0025-4 [CrossRef] PMID:29450054
- Ownby, R. L., Acevedo, A., Waldrop-Valverde, D., Jacobs, R. J. & Cabal-lero, J. (2014). Abilities, skills and knowledge in measures of health literacy. Patient Education and Counseling, 95(2), 211–217 doi:10.1016/j.pec.2014.02.002 [CrossRef] PMID:24637163
- Parker, R. M. (2012). Health literate practices can facilitate state health insurance exchange communication. Journal of Health Communication, 17(3), 372–375 doi:10.1080/10810730.2012.670020 [CrossRef] PMID:22439691
- Perrin, A. (2017). Smartphones help blacks, Hispanics bridge some – but not all – digital gaps with whites. Pew Internet and American Life Project. https://www.pewresearch.org/fact-tank/2017/08/31/smart-phones-help-blacks-hispanics-bridge-some-but-not-all-digital-gaps-with-whites/
- Pew Research Center. (2018). Mobile fact sheet. Pew Internet and American Life Project. http://www.pewinternet.org/fact-sheet/mobile/
- Politi, M. C., Kaphingst, K. A., Kreuter, M., Shacham, E., Lovell, M. C. & McBride, T. (2014). Knowledge of health insurance terminology and details among the uninsured. Medical Care Research and Review: MCRR, 71(1), 85–98 doi:10.1177/1077558713505327 [CrossRef] PMID:24163306
- Prins, E. & Mooney, A. (2014). Literacy and health disparities. New Directions for Adult and Continuing Education, 2014(142), 25–35 doi:10.1002/ace.20092 [CrossRef]
- Quincy, L. (2012). Measuring health insurance literacy: A call to action. Consumers Union, University of Maryland, & American Institute of Research. http://consumersunion.org/pub/Health_Insurance_Literacy_Roundtable_rpt.pdf
- Rajaram, S. S. & Bockrath, S. (2014). Cultural competence: New conceptual insights into its limits and potential for addressing health disparities. Journal of Health Disparities Research and Practice, 7(5), 82–89.
- Rikard, R. V., Thompson, M. S., Head, R., McNeil, C. & White, C. (2012). Problem posing and cultural tailoring: Developing an HIV/AIDS health literacy toolkit with the African American community. Health Promotion Practice, 13(5), 626–636 doi:10.1177/1524839911416649 [CrossRef] PMID:22102601
- Ross, L., Ashford, A. D., Bleechington, S. J., Dark, T. & Erwin, D. O. (2010). Applicability of a video intervention to increase informed decision making for prostate-specific antigen testing. Journal of the National Medical Association, 102(3), 228–236 doi:10.1016/S0027-9684(15)30529-0 [CrossRef] PMID:20355352
- Rudd, R. E. (2007). Health literacy skills of U.S. adults. American Journal of Health Behavior, 31(1, Suppl. 1), S8–S18 doi:10.5993/AJHB.31.s1.3 [CrossRef] PMID:17931141
- Saha, S., Beach, M. C. & Cooper, L. A. (2008). Patient centeredness, cultural competence and healthcare quality. Journal of the National Medical Association, 100(11), 1275–1285 doi:10.1016/S0027-9684(15)31505-4 [CrossRef] PMID:19024223
- Scrimshaw, S. C. (2019). Science, health, and cultural literacy in a rapidly changing communications landscape. Proceedings of the National Academy of Sciences of the United States of America, 116(16), 7650–7655 doi:10.1073/pnas.1807218116 [CrossRef]
- Sentell, T. L. & Halpin, H. A. (2006). Importance of adult literacy in understanding health disparities. Journal of General Internal Medicine, 21(8), 862–866 doi:10.1111/j.1525-1497.2006.00538.x [CrossRef] PMID:16881948
- Smith, A. L. (2003). Health policy and the coloring of an American male crisis: A perspective on community-based health services. American Journal of Public Health, 93(5), 749–752 doi:10.2105/AJPH.93.5.749 [CrossRef] PMID:12721136
- Somers, S. A. & Mahadevan, R. (2010). Health literacy implications of the Affordable Care Act. http://www.chcs.org/media/Health_Literacy_Implications_of_the_Affordable_Care_Act.pdf
- Spruill, I., Pope, C., Garrett-Mayer, E., Zapka, J., Davis, B., Stubbs, A. & Freeman, M. ( 2015, November 2. ). Ethno-cultural barriers to health literacy and Disease Management among African Americans in South Carolina [Paper presentation]. 7th Annual Health Literacy Research Conference. , Bethesda, MD, United States. . https://www.bumc.bu.edu/healthliteracyconference/files/2015/09/Spruill-health-literacy-oral-presentation3-r-final.pdf
- Stewart, D. W., Vidrine, J. I., Shete, S., Spears, C. A., Cano, M. A., Correa-Fernández, V. & McNeill, L. H. (2015). Health literacy, smoking, and health indicators in African American adults. Journal of Health Communication, 20(0 2), 24–33. doi:10.1080/10810730.2015.1066465 [CrossRef]. PMID: 26513028
- Tucker, C. M., Kang, S., Ukonu, N. A., Linn, G. S., DiSangro, C. S., Arthur, T. M. & Ralston, P. A. (2019). A culturally sensitive church-based health-smart intervention for increasing health literacy and health-promoting behaviors among black adult churchgoers. Journal of Health Care for the Poor and Underserved, 30(1), 80–101 doi:10.1353/hpu.2019.0009 [CrossRef]
- Tuskegee University. (n.d.). USPHS syphilis study. https://www.tuskegee.edu/about-us/centers-of-excellence/bioethics-center/about-theusphs-syphilis-study
- U.S. Department of Health and Human Services. (2010). National action plan to improve health literacy. https://health.gov/communication/HLActionPlan/pdf/Health_Literacy_Action_Plan.pdf
- Vernon, J. A., Trujillo, A., Rosenbaum, S. & DeBuono, B. (2007). Low health literacy: Implications for national health policy. Department of Health Policy, School of Public Health and Health Services, The George Washington University. https://publichealth.gwu.edu/departments/healthpolicy/CHPR/downloads/LowHealthLiteracyRe-port10_4_07.pdf
- Villaire, M. & Mayer, G. (2009). Health literacy: The low-hanging fruit in health care reform. Journal of Health Care Finance, 36(2), 55–59 https://www.ncbi.nlm.nih.gov/pubmed/20499721 PMID:20499721
- Volandes, A. E. & Paasche-Orlow, M. K. (2007). Health literacy, health inequality and a just healthcare system. The American Journal of Bio-ethics, 7(11), 5–10 doi:10.1080/15265160701638520 [CrossRef] PMID:18027287
- Wallace, S. P. (2015). Equity and social determinants of health among older adults. Generations, 38(4), 6–11 http://www.ingentaconnect.com/contentone/asag/gen/2014/00000038/00000004/art00002
- Weekes, C. V. (2012). African Americans and health literacy: A systematic review. Association of Black Nursing Faculty Journal, 23(4), 76–80 PMID: 23311265