Low Health Literacy Skills Research Articles

How is health literacy addressed in primary care? Strategies that general practitioners use to support patients

ABSTRACTBackground: Low health literacy is associated with adverse health outcomes and raises healthcare costs. General practitioners (GPs) are the first point of access to health care services and play a key role in building patients’ health literacy level. This study aimed to explore: (1) GPs’ understanding of health literacy, (2) their perceived challenges to addressing health literacy, and (3) the strategies they used to support patients with health literacy difficulties.Method: This qualitative study was conducted in South Western Sydney, New South Wales, Australia. Semi-structured interviews were audio-recorded and transcribed verbatim. Interview data were analyzed using the Framework method, a matrix-based approach to thematic analysis.Results: Eighteen participants took part in the study. Four key themes were identified: (1) identifying patients with health literacy difficulties; (2) perceived consequences of low health literacy; (3) being sensitive to developing health literacy skills; and (4) strategies used to build health literacy. Intuitive skills were used to identify the patient’s health literacy skills through recurring encounters with patients over time. A range of communication techniques were used to build health literacy. The value of a long-term relationship with patients and support from relatives were reported (Please eliminate this comma and the one right before this) to be important in helping patients build their health literacy skills.Conclusions: A number of challenges in health literacy exist in general practice. General practitioners can play a role in overcoming these challenges by placing an increased focus on health literacy, including self-education on this topic, identification of patients with low health literacy skills and helping build patients' level of health literacy.

Patient education and health literacy

IntroductionPatient education is a relatively new science within the field of health care. In the past it consisted mainly of the transfer of knowledge and mostly biomedically based advice. Research has shown this to not be effective and sometimes counterproductive. As health care has moved away from applying a traditional paternalistic approach of ‘doctor knows best’ to a patient-centred care approach, patient education must be tailored to meet persons' individual needs. PurposeThe purpose of this master paper is to increase awareness of patients' health literacy levels. Health literacy is linked to literacy and entails people's knowledge, motivation and competences to access, understand, appraise and apply health information in order to make judgements and take decisions in everyday life concerning health care, disease prevention and health promotion to maintain or improve quality of life during the life course. Many patients have low health literacy skills, and have difficulty with reading, writing, numeracy, communication, and, increasingly, the use of electronic technology, which impede access to and understanding of health care information. ImplicationsMultiple professional organizations recommend using universal health literacy precautions to provide understandable and accessible information to all patients, regardless of their literacy or education levels. This includes avoiding medical jargon, breaking down information or instructions into small concrete steps, limiting the focus of a visit to three key points or tasks, and assessing for comprehension by using the teach back cycle. Printed information should be written at or below sixth-grade reading level. Visual aids can enhance patient understanding.

Perceptions of low income HIV+ persons about finding accurate web-based health information

AimTo explore perceptions of low income persons living with HIV/AIDS and history of substance abuse about how they decide whether an internet site is a credible source of health-related information. BackgroundIt is hard for any consumer to determine whether the information that is available on the internet is trustworthy and even more challenging for consumers with low health literacy and insufficient computer literacy skills. MethodsMixed methods with sequential explanatory design. Electronic health literacy was measured with eHEALS and a new instrument to measure confidence in choosing a credible internet site for health-related information was developed. Qualitative data were collected during three focus groups held in high prevalence neighborhoods in New York City and after participants watched a 16-minute video produced by the United States National Library of Medicine. ResultsParticipants had low electronic health literacy and there was no relationship between electronic health literacy and confidence in identifying a credible internet site. Six themes emerged: I haven’t learned enough from the Medline video; I am not computer literate; the Internet has too many scams; the Internet piques interest in learning health-related information; prefer 1:1 interactions with trusted source for health information; and you don’t have to expose HIV status to get information. ConclusionLow income persons are interested in using the internet for health information but reluctant to do so due to multiple complex barriers. Follow-up interventions would include skills training in which persons are taught how to identify credible sites.

Cooperative Extension and Health Literacy: A National Focus

Health literacy is often defined as the degree to which an individual has the capacity to obtain, communicate, process and understand basic health information and services to make appropriate health decisions. Research shows that 30 million Americans have Below Basic health literacy skills. People with low health literacy skills contribute to higher utilization of health care services. This equates to an excess of $230 billion a year in health care costs linked to low literacy in the United States. The primary responsibility for improving health literacy lies with public health professionals and the health care and public health systems. However, studies find that interventions using principles of health literacy, applied in community-based settings, can result in improved outcomes at the population level. In this article, the Health Literacy Action Team members consider the role of Extension in this important area, and suggest practices in incorporating health literacy into existing Extension programs and educational materials, and future resources for Extension and community partners.

Assessment of health literacy skills in family doctors' patients by two brief, self-administered Italian measures.

Health Literacy (HL) is an important health determinant: low HL skills result in less healthy choices, riskier behavior, poorer health, less self-management and more hospitalization. An observational study was conducted in a selected population, attending the waiting rooms of family general practitioners, with the aim of assessing HL capabilities through the administration of two HL screeners (IMETER and SILS-IT), and comparing the two measures. An anonymous questionnaire was administered, consisting of the Italian versions of the two tests on a single sheet. Demographic data, as well as concomitant chronic diseases and vaccines received, were also collected. HL skills were measured by the scores observed at both tests, and by the frequency of subjects with low HL levels according to the respective cut-off values. Overall, 305 questionnaires were collected and analyzed. Regarding IMETER, the observed frequency of subjects with low HL skills was 25.2% and the mean score and mean adjusted-score (26.3 ± 8.8 and 23.2 ± 9.4, respectively) were lower than those observed in previous studies. Similarly, at SILS-IT the percentage of subjects with low skills (49.9%) was higher than observed previously. IMETER showed high internal consistency (Cronbach's alpha > 0.9). The two measures were significantly correlated, although with a low Spearman's coefficient, and IMETER did not provide significant information about the probability to predict low HL according to SILS-IT. These results are explainable by the differences in assessment and domains between the two tests, both reliable and suitable to screen patients with low functional HL.

Rapid Estimate of Adult Literacy in Medicine and Dentistry-20 and oral health status among adolescents, India: A cross-sectional study.

INTRODUCTION:Health literacy is an important issue in public health. Individuals with low health literacy skills often have poorer health knowledge and health status than those with higher literacy level. Research documented on the assessment of oral health literacy in health settings and its association with oral health outcomes for adolescents was scarce.AIMS AND OBJECTIVES:The aim of this study is to assess oral health literacy about oral health status among adolescents attending pre-university colleges in Mysore, India.MATERIALS AND METHODS:A cross-sectional study was conducted over a period of 2 months among 401 adolescents attending pre-university colleges. Rapid Estimate of Adult Literacy in Medicine and Dentistry-20 (REALMD-20) and the WHO oral health assessment pro forma for adults (2013) were used. Data were analyzed using SPSS version 22 and tests employed were Chi-square test, ANOVA, and multiple linear regression.RESULTS:Mean REALMD-20 score was 10.31 ± 5.7. The study participants belonging to science course (12.69 ± 5.0) and private pre-university colleges (11.76 ± 5.8) had significantly higher REALMD-20 scores. Mean decayed, missing, and filled teeth among the study participants was (0.42 ± 0.9). Type of college, course, dental history, and number of dental visits was significantly associated with oral health literacy while oral health parameters were not significantly associated.CONCLUSION:Oral health literacy was not significantly associated with oral health status. However, long-term studies are recommended to validate the results of the present study.

A Qualitative Study to Determine Barriers for Prostate Cancer Screening in Rural African-American Men.

African-American men have higher rates of prostate cancer and more advanced cancer when diagnosed than men of other ethnicities. To explore the perspectives and shared experiences of rural African-American men when it comes to interactions with healthcare providers, shared decision-making, and information on prostate cancer and screening. A convenience sample of African-American men in four rural counties in the southeastern United States agreed to participate. Semi-structured interviews of 43 men were conducted in patients' homes, classrooms, offices, and local churches. Lincoln and Guba's (1985) naturalistic approach was used. Analysis of the rich, in-depth narratives gleaned from these African-American men revealed three themes: 1) limitations in knowledge of prostate cancer, 2) poor patient/provider communication, and 3) deficient health literacy skills. Participants' perspectives about limited knowledge regarding PCa, variation in provider-patient communication and the finding of low health literacy skills expand knowledge, inform clinical practice, and provide evidence for further investigation to better provider communication and patient education concerning PCa and decision making in this population.

A Culturally Appropriate Self-Management Program for Hispanic Adults With Type 2 Diabetes and Low Health Literacy Skills.

This study assessed the feasibility of adapting a patient-centered educational intervention for type 2 diabetes (T2D) self-management for a Hispanic population with low health literacy skills. A descriptive qualitative study design and phenomenological analyses were used. Nine Hispanic adults with T2D recruited from a rural community health center participated in an educational program that instructed on low glycemic food choices, meaningful glucose self-monitoring, and physical activity to decrease blood glucose spikes. Participants' feedback was recorded during four 2-hour focus group sessions. Findings/Results: Participants' feedback clustered around four themes: information and knowledge, motivation and barriers to change, experiences with new behaviors, and personal responsibility. Data support the feasibility of adapting an established health-enhancing approach for promoting self-management of T2D to a low health literacy Spanish-speaking population. The findings may help in further development of tools and strategies for improved T2D self-management in the study population.

Assessment of the Readability of Genetic Counseling Patient Letters.

Patient letters are a powerful tool that genetic counselors use to communicate with their patients. Patient letters are often sent to provide information on a new diagnosis, reiterate test results, and to serve as a permanent record of the visit. Patient letters, however, are only helpful if the patients can understand them. More than 50% of the US population reads below a 9th grade reading level and over one-third of the population has low health literacy skills. In this study we evaluate the readability of genetic counseling patient letters by assessing reading level, image use, and terminology use. One hundred forty-nine genetic counselors participated in the survey and of these, 79 submitted a sample patient letter. Analyses of the letters revealed a mean reading level of 10.93. On average, 6 genetic terms were included in each letter, and only 25% of these terms were defined. Analyses of survey responses revealed over 75% of the genetic counselors did not include images in their patient letters. These results indicate there is room for improvement in order to make genetic counseling patient letters more accessible to the general population.

High PSA anxiety and low health literacy skills: drivers of early use of salvage ADT among men with biochemically recurrent prostate cancer after radiotherapy?

Although commonly used, early initiation of salvage androgen deprivation therapy (ADT) has not been proven to enhance survival. We evaluated whether prostate-specific antigen (PSA) anxiety or health literacy are associated with use of early salvage ADT among men with recurrent prostate cancer after radiotherapy. The prospective Comprehensive, Observational, Multicenter, Prostate Adenocarcinoma Registry was used to study 375 men with biochemically recurrent prostate cancer after external beam radiation or brachytherapy. Multivariable logistic regression was used to determine whether PSA anxiety and health literacy are associated with salvage ADT as initial management after biochemical recurrence. Sixty-eight men (18.1%) received salvage ADT as initial management for PSA recurrence. Men with high PSA anxiety were twice as likely to receive salvage ADT compared with men who did not have high PSA anxiety on both univariable [28.8% versus 13.1%; odds ratio (OR) 2.15; 95% confidence interval (CI) 1.16-4.00; P = 0.015] and multivariable analysis [adjusted OR (AOR) 2.36; 95% CI 1.21-4.62; P = 0.012]. Furthermore, men who had higher levels of health literacy were nearly half as likely to undergo salvage ADT compared with men who had lower levels of health literacy on univariable analysis (15.2% versus 26.3%; OR 0.50; 95% CI 0.29-0.88; P = 0.016), with a trend toward this association on multivariable analysis (AOR 0.58; 95% CI 0.32-1.05; P = 0.07). Among men with PSA recurrence after radiotherapy, odds of use of salvage ADT were nearly twice as great among men with high PSA anxiety or low health literacy, suggesting that these men are receiving higher rates of unproven treatment. Given that early salvage ADT is costly, worsens quality of life, and has not been shown to improve survival, quality improvement strategies are needed for these individuals.

Development of the Health Literacy Assessment Scale for Adolescents (HAS-A)

Background: Health literacy has been found to be a crucial component of successful communication and navigation in health care. Various tools have been developed to measure health literacy skills, but few have been developed specifically for adolescents, and most require in-person administration. This study sought to develop a self-report health literacy scale for adolescents to assess four key health literacy domains: the ability to obtain, communicate, understand, and process health information.Methods: We collected data from 272 youth aged 12–19 recruited from a pediatrics clinic (37%) and the community (63%). We administered the Rapid Estimate of Adolescent Literacy in Medicine-Teen, Newest Vital Sign, and three surveys, and used factor analysis to identify scale items.Results: Using multiple health literacy assessments, it was clear that many teens struggle with low health literacy skills. When identifying items that can be used as self-report items in future research, factor analysis identified three subscales; a 5-item communication scale (alpha = 0.77), a 4-item confusion scale (alpha = 0.73), and a 6-item functional health literacy scale (alpha = 0.76). The scales performed reasonably well when compared with validation items.Conclusions: Self-report items can be used to assess health literacy skills for adolescents when in-person administration is not possible or feasible. Such items will allow for greater study of how health literacy impacts communication in not only health care settings, but for all levels of health communication. The tool will also allow researchers to better understand how adolescent health literacy is related to a variety of health outcomes. Further testing of these scales with different populations is warranted.

Health literacy and informed decision making regarding colorectal cancer screening: a systematic review

Making an informed decision about participation in colorectal cancer (CRC) screening may be challenging for invitees with lower health literacy skills. The aim of this systematic review is to explore to what extent the level of a person's health literacy is related to their informed decision making concerning CRC screening. We searched for peer-reviewed studies published between 1950 and May 2013 in MEDLINE, EMBASE, SciSearch and PsycINFO. Studies were included when health literacy was studied in relation to concepts underpinning informed decision making (awareness, risk perception, perceived barriers and benefits, knowledge, attitude, deliberation). The quality of the studies was determined and related to the study results. The search returned 2254 papers. Eight studies in total were included, among which seven focused on knowledge, four focused on attitudes or beliefs concerning CRC screening, and one focused on risk perception. The studies found either no association or a positive association between health literacy and concepts underpinning informed decision making. Some studies showed that higher health literacy was associated with more CRC screening knowledge and a more positive attitude toward CRC screening. The results of studies that obtained a lower quality score were no different than studies that obtained a higher quality score. In order to obtain more insight into the association between health literacy and informed decision making in CRC cancer screening, future research should study the multiple aspects of informed decision making in conjunction instead of single aspects.

The Association of Health Literacy With Time in Therapeutic Range for Patients on Warfarin Therapy

Patients on warfarin therapy need to achieve and maintain anticoagulation control in order to experience the benefits of treatment while minimizing bleeding risk. Low health literacy skills may hinder patients' ability to use and adhere to warfarin in a safe and effective manner. The authors conducted this study to evaluate the relationship between health literacy and anticoagulation control among patients on chronic warfarin therapy. Participants were recruited from 2 diverse anticoagulation clinics in North Carolina. Time in therapeutic range (TTR) for warfarin therapy was used as a measure of anticoagulation control. Health literacy was assessed using the short form of the Test of Functional Health Literacy in Adults (S-TOFHLA). Of the 198 study participants, 51% had limited health literacy (S-TOFHLA score of 0–90) and 33% had poor anticoagulation control (TTR <50%). Participants with limited health literacy were less likely to correctly answer warfarin-related knowledge questions. Limited health literacy was significantly associated with TTR <50% (adjusted odds ratio = 2.34, 95% CI [1.01, 5.46]). Findings indicate that limited health literacy is associated with poor anticoagulation control for patients on warfarin therapy. Lack of medication understanding may hinder the safe and effective use of this narrow therapeutic index drug.

Text4baby Program: An Opportunity to Reach Underserved Pregnant and Postpartum Women?

Text4baby was launched in 2010 to promote healthy pregnancies and babies by the use of text messaging. The primary objective of this study was to assess factors related to the enrollment process and reception of text4baby. A prospective cohort study was conducted in two Women, Infant and Children clinics in Atlanta (April 2010-July 2011). Randomly selected pregnant and postpartum women (n=468) were queried on cell phone use and instructed on text4baby enrollment. Self-enrollment issues were assessed at one-week follow-up (n=351, 75.0%), and message reception and reading patterns at two-month follow-up (n=209, 44.7%). Forty-two percent of the women had some college education and 82% had household income<=$20,000. About half attempted text4baby self-enrollment (162/351), with enrollment success more likely among women with more education (80% with some college vs. 62% with less education), with household income above $10,000 (61%<$10,000 vs. 83% $10,001-$20,000 and 76%>$20,000), and among women living in smaller households (77% 1-3 members vs. 58%>3 members) (all p<0.001). Among the 209 participants in the final follow-up contact, >90% reported uninterrupted reception and regular reading of messages, and 88% planned to continue using text4baby. Results also suggested that respondents who were younger (<26 year), less educated and had lower health literacy skills were more likely to have interrupted messages. Despite substantial interest in the text4baby program in an underserved population, innovative ways to help women with significant disadvantages enroll and receive uninterrupted messages are needed.

Randomized Clinical Trial of HIV Treatment Adherence Counseling Interventions for People Living With HIV and Limited Health Literacy

Limited health literacy is a known barrier to medication adherence among people living with HIV. Adherence improvement interventions are urgently needed for this vulnerable population. This study tested the efficacy of a pictograph-guided adherence skills-building counseling intervention for limited literacy adults living with HIV. Men and women living with HIV and receiving antiretroviral therapy (N = 446) who scored <90% correct on a test of functional health literacy were partitioned into marginal and lower literacy groups and randomly allocated to 1 of 3 adherence-counseling conditions: (1) pictograph-guided adherence counseling, (2) standard adherence counseling, or (3) general health improvement counseling. Participants were followed for 9 months postintervention with unannounced pill count adherence and blood plasma viral load as primary end points. Preliminary analyses demonstrated the integrity of the trial and >90% of participants were retained. Generalized estimating equations showed significant interactions between counseling conditions and levels of participant health literacy across outcomes. Participants with marginal health literacy in the pictograph-guided and standard-counseling conditions demonstrated greater adherence and undetectable HIV viral loads compared with general health counseling. In contrast and contrary to hypotheses, participants with lower health literacy skills in the general health improvement counseling demonstrated greater adherence compared with the 2 adherence counseling conditions. Patients with marginal literacy skills benefit from adherence counseling regardless of pictographic tailoring, and patients with lower literacy skills may require more intensive or provider-directed interventions.

Mixed methods evaluation of a randomized control pilot trial targeting sugar-sweetened beverage behaviors

This Excessive sugar-sweetened beverage (SSB) consumption and low health literacy skills have emerged as two public health concerns in the United States (US); however, there is limited research on how to effectively address these issues among adults. As guided by health literacy concepts and the Theory of Planned Behavior (TPB), this randomized controlled pilot trial applied the RE-AIM framework and a mixed methods approach to examine a sugar-sweetened beverage (SSB) intervention (SipSmartER), as compared to a matched-contact control intervention targeting physical activity (MoveMore). Both 5-week interventions included two interactive group sessions and three support telephone calls. Executing a patient-centered developmental process, the primary aim of this paper was to evaluate patient feedback on intervention content and structure. The secondary aim was to understand the potential reach (i.e., proportion enrolled, representativeness) and effectiveness (i.e. health behaviors, theorized mediating variables, quality of life) of SipSmartER. Twenty-five participants were randomized to SipSmartER (n=14) or MoveMore (n=11). Participants' intervention feedback was positive, ranging from 4.2-5.0 on a 5-point scale. Qualitative assessments reavealed several opportunties to improve clarity of learning materials, enhance instructions and communication, and refine research protocols. Although SSB consumption decreased more among the SipSmartER participants (-256.9 ± 622.6 kcals), there were no significant group differences when compared to control participants (-199.7 ± 404.6 kcals). Across both groups, there were significant improvements for SSB attitudes, SSB behavioral intentions, and two media literacy constructs. The value of using a patient-centered approach in the developmental phases of this intervention was apparent, and pilot findings suggest decreased SSB may be achieved through targeted health literacy and TPB strategies. Future efforts are needed to examine the potential public health impact of a large-scale trial to address health literacy and reduce SSB.

Effective Intervention Strategies to Improve Health Outcomes for Cardiovascular Disease Patients with Low Health Literacy Skills: A Systematic Review

Systematic studies on the relationship between health literacy and health outcomes demonstrate that as health literacy declines, patients engage in fewer preventive health and self-care behaviors and have worse disease-related knowledge. The purpose of this study was to identify effective intervention strategies to improve health outcomes in patients with cardiovascular disease and low literacy skills. This study employs the following criteria recommended by Khan Kunz, Keijnen, and Antes (2003) for systematic review: framing question, identifying relevant literature, assessing quality of the literature, summarizing the evidence, and interpreting the finding. A total of 235 articles were reviewed by the research team, and 9 articles met inclusion criteria. Although nine studies were reviewed for their health outcomes, only six studies, which had a positive quality grade evaluation were used to recommend effective intervention strategies. Interventions were categorized into three groups: tailored counseling, self-monitoring, and periodic reminder. The main strategies used to improve health outcomes of low literacy patients included tailored counseling, improved provider-patient interactions, organizing information by patient preference, self-care algorithms, and self-directed learning. Specific strategies included written materials tailored to appropriate reading levels, materials using plain language, emphasizing key points with large font size, and using visual items such as icons or color codes. With evidence-driven strategies, health care professionals can use tailored interventions to provide better health education and counseling that meets patient needs and improves health outcomes.

Successful Enrollment in Text4Baby More Likely With Higher Health Literacy

Adequate health literacy is vital for understanding and using health information. The authors assessed the health literacy of pregnant women and mothers of children under the age of 1 year and their success in self-enrolling in the Text4Baby health message program: 468 pregnant women and mothers of children under the age of 1 year completed an in-person baseline survey, including the Newest Vital Sign health literacy assessment, at 2 Metro-Atlanta Women, Infants, and Children clinics. They were asked to self-enroll in the Text4Baby message program and were later contacted by phone to see whether they had attempted to enroll in the program and whether they were successful. Of the 333 women contacted by phone to assess enrollment efforts, 21% had a high likelihood of limited literacy (a score of 0–1 on the Newest Vital Sign assessment), 48% had a chance of limited literacy (a score of 2–3), and 31% had adequate literacy (a score of 4–6). Attempting to self-enroll was not associated with health literacy (p = .70), but successful enrollment was more likely with higher literacy (p = .01). Results suggested a positive association between health literacy skills and successful self-enrollment in the Text4Baby program, which suggests the need for additional outreach efforts to assure enrollment by women with low health literacy skills.

Validation of the Dutch functional, communicative and critical health literacy scales

ObjectiveWhile most existing health literacy (HL) measures focus primarily on reading comprehension, the functional, communicative and critical HL scales from Ishikawa et al. [19] aim to measure a broader HL spectrum. The objective of this study was to evaluate the validity of the Dutch translation of this instrument. MethodsTwo survey studies (n=79 and n=209) and one cognitive interview study (n=18) were performed among samples of breast cancer patients and patients with rheumatic diseases. ResultsAnalyses showed the scales measured three distinct factors and convergent validity was satisfactory for communicative and critical HL. Nevertheless, the comprehension of the items and the suitability of the response options raised some problems. ConclusionThe HL scales seem promising to measure a broad definition of HL. By revising some of the items and response options as proposed in this article, the scale will become more understandable for people with low HL skills, which might increase the content validity and the distributional properties of the scale. Practice implicationsThe scale should be revised and revalidated. An improved version should be used in practice to gain insight into HL levels of patients. This will help to develop suitable education programs for people with low HL skills.

Improved understanding and satisfaction with a modified informed consent document: a randomized study

Correspondence: Peter C Raich University of Colorado Denver, Division of Hematology/Oncology, Denver Health Medical Center, 777 Bannock Street, MC 4001, Denver, CO 80204, USA Tel +1 303 602 6062 Fax +1 303 602 6067 Email peter.raich@dhha.org Background: Informed consent documents need to convey crucial information to prospective study participants. We assessed the impact of an informed consent process designed to be understood by persons with low health literacy skills. Methods: We conducted a randomized controlled trial with ethnically and racially diverse male veterans. Participants were randomly assigned to receive and read the standard consent document for the Selenium and Vitamin E Cancer Prevention Trial prostate cancer prevention trial or a culturally tailored, easy-to-read consent document. Telephone interviews were conducted 2 weeks following consent, assessing comprehension, satisfaction, consent anxiety, state anxiety, decisional conflict, and cultural sensitivity. Results: Of 162 male veterans completing the initial telephone interview, 49.7% were African American, 44.1% were Caucasian, and 6.2% were Hispanic. The mean comprehension score for the consent document and process was significantly increased in the intervention arm participants (17.08) versus the standard consent arm (15.06, P , 0.0001). The satisfaction score with the consent information was higher in participants in the intervention arm (3.67 vs 3.42, P = 0.0009), while the consent anxiety score was reduced (1.31 vs 1.56, P = 0.0067). Conclusion: Modifications in the reading level, format, appearance, interactivity, and cultural sensitivity of an informed consent document in the cancer prevention setting significantly improved comprehension of and satisfaction with the consent document, while decreasing consent anxiety.