BACKGROUND: Few evaluations of school health programs measure academic

(DH, CH, NO); and the Behavior Change Research Group, Population Sciences and Cancer Control Program (DH, JC) at the University of New Mexico, Albuquerque, New Mexico. Submitted August 14, 2007; accepted February 26, 2008. Address correspondence to Deborah Helitzer, ScD, Family and Community Medicine, University of New Mexico, MSC 09-5040, Albuquerque, NM 87131. E-mail: helitzer@salud.unm pitalization have been documented. [1][2][3] Evidence demonstrates that patients with lower health literacy incur higher health care costs, 1,4 and health literacy has been linked to lower use of preventive services such as Pap tests, mammograms, and dental care. 5,6 The Institute of Medicine and Healthy People 2010 define health literacy 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." 7 Functional health literacy requires complex, multidimensional skills, including reading, writing, listening, numeric literacy, oral and visual communication, and decision-making abilities. It also calls for an understanding of health topics (such as cervical cancer) and the ability to navigate health systems. 8,9 Written health education materials and forms, which the health system IntroductionResearch continues to reveal the association between literacy and health. Literacy is defined as "using printed and written information to function in society, to achieve one's goals, and to develop one's knowledge and potential." 1 Relationships between literacy levels and heart disease, physical health, and rates of hos- most often relies on to convey information and treatment procedures, place certain "demands" on their users or readers. These demands compel health consumers to use their functional health literacy skills to read (at different levels), interpret, comprehend, analyze, and apply the information they gain from these written materials. These demands may be substantial if materials are written at a high reading level, if text and format are too dense, or if concepts are ambiguous and nonmotivating.Thus, health literacy is not a one-sided issue, limited to the capacity or capabilities of the patient/client. Indeed, the health system itself places complex demands on health consumers. These demands include requiring people to self-manage their health care, read difficult texts, and understand their health rights, as well as obliging them to find their way (navigate) in confusing clinic/hospital settings with technical medical signs or without conveniently placed or easy to read maps. 10 National Literacy AssessmentsIn 2003, the National Assessment of Adult Literacy (NAAL) was conducted in the United States with more than 19,000 adults. The NAAL included a separate literacy component intended to measure adults' ability to use literacy skills to read and understand health-related information. The results indicated that most (53%) adults had intermediate health literacy, and 12% scored in the proficient range. The...

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Most health literacy assessments evaluate literacy skills including reading, writing; numeracy and interpretation of tables, graphs, diagrams and charts. Some assess understanding of health systems, and the ability to adequately apply one’s skills to specific health-related tasks or demands in health situations. However, to achieve functional health literacy, the ability to “obtain, process, and understand basic health information and services needed to make appropriate health decisions,” other health literacy dimensions should be assessed: a person’s knowledge and attitudes about a health issue affects his or her ability to and interest in participating in his or her own care. In patient care settings, the abilities to listen, ask questions and check one’s understanding are crucial to making appropriate decisions and carrying out instructions. Although literacy is a skill associated with educational attainment and therefore difficult to change in a short time, health education interventions can address health literacy domains such as knowledge, attitudes and oral communication skills. For this reason, an instrument that can assess these constructs is a valuable part of a health educator’s toolbox. The authors describe the development and process and outcomes of testing a novel instrument targeted to assess HPV and cervical cancer health literacy competencies, TALKDOC, including its validation with the Health Activities Literacy Scale.