Understanding disadvantaged adolescents’ perception of health literacy through a systematic development of peer vignettes

Abstract Background Adolescence represents a crucial phase of life where health behaviours, attitudes and social determinants can have lasting impacts on health quality across the life course. Unhealthy behaviour in young people is generally more common in low socioeconomic groups. Nevertheless, all adolescents should have a fair opportunity to attain their full health potential. Health literacy is positioned as a potential mediating factor to improve health, but research regarding health literacy in adolescents and socially disadvantaged populations is limited. As part of Phase one of the Ophelia (OPtimising HEalth LIterAcy) framework, The purpose of this study was to explore the perceptions of socially disadvantaged Irish adolescents in relation to health literacy and related behaviours, and utilise this data to develop relevant vignettes. Methods A convergent mixed method design was used to co-create the vignettes. Questionnaires were completed by 962 adolescents (males n = 553, females n = 409, Mean age = 13.97 ± 0.96 years) from five participating disadvantaged schools in Leinster, Ireland. Focus groups were also conducted in each school (n = 31). Results were synthesised using cluster and thematic analysis, to develop nine vignettes that represented typical male and female subgroups across the schools with varying health literacy profiles. These vignettes were then validated through triangular consensus with students, teachers, and researchers. Discussion The co-creation process was a participatory methodology which promoted the engagement and autonomy of the young people involved in the project. The vignettes themselves provide an authentic and tangible description of the health issues and health literacy profiles of adolescents in this context. Application of these vignettes in workshops involving students and teachers, will enable meaningful engagement in the discussion of health literacy and health-related behaviours in Irish young people, and the potential co-designing of strategies to address health literacy in youth. Conclusion As guided by the Ophelia framework, the use of authentic, interactive and participatory research methods, such as the co-creation of vignettes, is particularly important in groups that are underserved by traditional research methods. The approach used in this study could be adapted to other contexts to represent and understand stakeholders’ perceptions of health, with a view to explore, and ultimately improve, health literacy.

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Komunikasi Efektif dalam Meningkatkan Literasi Kesehatan Mental

Jurnal Komunikasi ◽

10.24912/jk.v12i2.5948 ◽

2020 ◽

Vol 12 (2) ◽

pp. 191

Author(s):

Sarah Bryna Grace ◽

Ade Gandha Kurnia Tandra ◽

Mary Mary

Keyword(s):

Mental Health ◽

Health Literacy ◽

Young People ◽

Mental Health Literacy ◽

Effective Communication ◽

Communication Strategy ◽

Community Activities ◽

Significant Difference ◽

Health Related ◽

Audience Awareness

This article is the result of a communication study research on effective communication conducted by the Into The Light Indonesia community on improving the mental health literacy of young people in Jabodetabek. Mental health in Indonesia has not received enough attention, unlike physical health, so it is necessary to increase understanding of mental health. Since 2013, the Into The Light Indonesia community has been present as a community of young people working as a center for advocacy, study and education on suicide prevention and working on mental health issues in Indonesia. This study aims to reveal differences in mental health literacy levels between young people in Jabodetabek who participate and those who do not participate in Into The Light Indonesia community’s activities, reveal the relationship of effective communication with the delivery of mental health literacy related materials, and to evaluate the communication strategy of Into The Light Indonesia community. For this reason, the research method used is a convergent parallel mixed method, in which a quantitative approach by taking two independent samples (???? = 120) to fill out a questionnaire to compare the level of mental health literacy and measure the effectiveness of communication carried out, as well as a qualitative approach through interviews to identify and evaluate the activities carried out by the Into The Light Indonesia community. The results of this study indicate that statistically, there is no significant difference between the mental health literacy levels of participants and non-participants in the Into The Light Indonesia community activities. However, the results of the study show that effective communication significantly increases the level of mental health literacy. Into The Light participants also showed awareness and interest in finding out more mental health related information. In this study it can also be found that a communication strategy approach is needed by adopting local ways to increase audience awareness and interest, as well as quantitative evaluation with clear measurements to measure the achievement of the communication strategy objectives. Artikel ini merupakan hasil penelitian studi komunikasi mengenai komunikasi efektif yang dilakukan oleh komunitas Into The Light Indonesia dalam meningkatkan literasi kesehatan mental anak muda di Jabodetabek. Kesehatan mental di Indonesia masih belum mendapat cukup perhatian layaknya kesehatan fisik, sehingga diperlukan peningkatan pemahaman mengenai kesehatan mental. Sejak tahun 2013, komunitas Into The Light Indonesia hadir sebagai sebuah komunitas orang muda yang bergerak sebagai pusat advokasi, kajian, dan edukasi pencegahan bunuh diri dan berkecimpung pada isu kesehatan mental di Indonesia. Penelitian ini bertujuan untuk mengungkap perbedaan tingkat literasi kesehatan mental antara orang muda di Jabodetabek yang berpartisipasi dengan yang tidak berpartisipasi dalam kegiatan komunitas Into The Light Indonesia, mengungkap hubungan komunikasi efektif dalam penyampaian materi terhadap literasi kesehatan mental, dan mengevaluasi strategi komunikasi komunitas Into The Light Indonesia. Untuk itu, metode penelitian yang digunakan adalah metode campuran paralel konvergen, dimana pendekatan kuantitatif dengan mengambil dua sampel independen (???? = 120) untuk mengisi kuesioner untuk membandingkan tingkat literasi kesehatan mental dan mengukur efektivitas komunikasi yang dilakukan, serta pendekatan kualitatif melalui wawancara untuk mengidentifikasi serta mengevaluasi kegiatan-kegiatan yang dilakukan komunitas Into The Light Indonesia. Hasil penelitian ini menunjukkan bahwa secara statistik, tidak ada perbedaan yang signifikan antara tingkat literasi kesehatan mental partisipan dan nonpartisipan kegiatan komunitas Into The Light Indonesia. Namun, hasil penelitian menunjukkan bahwa komunikasi efektif meningkatkan tingkat literasi kesehatan mental secara signifikan. Terlihat juga adanya awareness dan interest untuk mencari informasi lebih banyak mengenai kesehatan mental pada partisipan kegiatan Into The Light Indonesia. Dalam penelitian ini juga dapat ditemukan bahwa diperlukan pendekatan strategi komunikasi dengan mengadopsi cara-cara lokal untuk meningkatkan awareness dan minat audience, serta evaluasi kuantitatif dengan measurement yang jelas untuk mengukur ketercapaiannya tujuan strategi komunikasi.

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Health Literacy Co-Design in a Low Resource Setting: Harnessing Local Wisdom to Inform Interventions across Fishing Villages in Egypt to Improve Health and Equity

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph18094518 ◽

2021 ◽

Vol 18 (9) ◽

pp. 4518

Author(s):

Wagida A. Anwar ◽

Nayera S. Mostafa ◽

Sally Adel Hakim ◽

Dalia G. Sos ◽

Christina Cheng ◽

...

Keyword(s):

Health Literacy ◽

Health Services ◽

Design Process ◽

Fishing Communities ◽

Low Resource ◽

Resource Setting ◽

Low Resource Setting ◽

Wide Range ◽

Literacy Profiles ◽

Improve Health

Fishermen in low resource settings have limited access to health services and may have a range of health literacy-related difficulties that may lead to poor health outcomes. To provide solutions and interventions based on their needs, co-design is considered best practice in such settings. This study aimed to implement a co-design process as a step towards developing health literacy interventions to improve health and equity in the Borollos Lake region of northern Egypt, a low resource setting with a high prevalence of chronic diseases. This study was guided by the Ophelia (Optimising Health Literacy and Access) process, a widely used and flexible co-design process that seeks to create local and fit-for-purpose health literacy solutions through genuine engagement and participation of community members and relevant stakeholders. Following a health literacy survey using the Health Literacy Questionnaire (HLQ), cluster analysis was conducted to identify the diverse health literacy profiles among the fishing communities. Seven health literacy profiles were identified. Vignettes, representing these profiles, were presented and discussed in ideas generation/co-design workshops with fishermen and health workers to develop intervention ideas. Seventeen fishermen, 22 wives of fishermen, and 20 nurses participated in four workshops. Fifteen key strategies across five themes, including ‘Enhancing education among fishing communities’, ‘Provide good quality health services’, ‘Financial support for health’, ‘Social support for health’, and ‘Promote better health-related quality of life among fishermen’, were generated. The ideas did not only target the individuals but also required actions from the government, non-government organizations, and fishermen syndicates. By harnessing local wisdom, the Ophelia process has created meaningful engagement with the local communities, leading to a wide range of practical and feasible solutions that match the special needs and environment of a low resource setting.

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1258Development of a valid evaluation tool assessing health behaviours among Māori & Pasifika young people

International Journal of Epidemiology ◽

10.1093/ije/dyab168.263 ◽

2021 ◽

Vol 50 (Supplement_1) ◽

Author(s):

Jessica Hardt ◽

Ellen Cooper ◽

Freya MacMillan ◽

Sebastien Brignano ◽

Kirstine Kira ◽

...

Keyword(s):

Young People ◽

Health Outcomes ◽

Cultural Values ◽

Health Behaviours ◽

Health Inequity ◽

Cognitive Interviewing ◽

Evaluation Tool ◽

Future Health ◽

Validated Questionnaire ◽

Improve Health

Abstract Background The Māori & Pasifika population experience high rates of health inequity, with a greater prevalence of obesity and the associated, life diminishing comorbidities. This is in part attributable to higher socioeconomic disadvantage, low health literacy and a lack of culturally tailored health services. Currently no validated tool exists to assess health behaviour change among Māori & Pasifika populations or success of tailored health interventions to tackle chronic disease. Methods The project incorporates a comprehensive validation and pilot testing process, including 1) cognitive interviewing and 2) test-retest reproducibility. Participants will include a representative sample of Māori & Pasifika young people and their parents/guardians. All research methodology is guided by cultural experts, specific to the Māori & Pasifika population. Results Qualitative data collected via cognitive interviewing will provide feedback regarding the readability, comprehension and content validity of the questionnaire items. Thematic analysis will inform improvements, optimising participant understandability. Cronbach’s alpha will be used to assess internal consistency and Pearson’s r will determine questionnaire test-retest reproducibility. Conclusions A validated questionnaire articulating with cultural values will provide meaningful data to researchers, health practitioners and government bodies regarding the lifestyle decisions of Māori & Pasifika peoples. Enhanced monitoring will determine the success of health initiatives to improve health outcomes of a priority population, across Australia and internationally. Key messages Lifestyle programs aiming to improve health outcomes are increasingly adapted to incorporate and acknowledge cultural values. Reliable measurement tools, including questionnaires, are fundamental to advancing future health research and tackling health inequity among priority populations.

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Development of a Core Online Health Literacy Course in Canada

Pedagogy in Health Promotion ◽

10.1177/2373379916662481 ◽

2016 ◽

Vol 3 (2) ◽

pp. 90-99 ◽

Cited By ~ 2

Author(s):

Sandra Vamos ◽

Paul Yeung

Keyword(s):

Public Health ◽

Health Literacy ◽

Core Competencies ◽

Critical Role ◽

Degree Programs ◽

Health Initiatives ◽

Health Related ◽

Literacy Course ◽

Systematic Development ◽

Improve Health

Health literacy has implications for people’s ability to make healthy decisions and manage their own health. To improve health literacy, we need to improve the knowledge and skills of those who receive and those who provide health information and services, while paying attention to demands of the environment that shape people’s skills and abilities. Higher education can play a critical role in nurturing a health literate population. This article articulates the need to integrate health literacy courses into health-related degree programs through the integration of Bandura’s work and Core Competencies for Public Health put forward by Canada. Offering such courses in varying formats will help prepare learners to better understand the growing demand for a health literate workforce and will contribute to the ongoing public health initiatives in improving health-related settings by removing health-related barriers. This article outlines the need for a systematic development of health literacy courses based on the integration of instructional and health literacy principles. An example of a core online undergraduate health literacy course in Canada is presented. Insights are offered into how educators can develop and modify their own health literacy courses, which aim to help learners explore ideologies, practices, tools, and policies guiding health literacy efforts for diverse people across settings.

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Investigating Health Literacy of Teachers in Asaluyeh

Social Behavior Research & Health ◽

10.18502/sbrh.v2i2.284 ◽

2019 ◽

Author(s):

Ali Asadian ◽

Ahmad Sotoudeh ◽

Mojgan Zarei Venovel ◽

Roghaieh Moosai

Keyword(s):

Health Literacy ◽

Pearson Correlation ◽

Moderate Level ◽

Literacy Teachers ◽

Internet Resources ◽

Gender And Age ◽

Health Related ◽

Information Comprehension ◽

Academic Year ◽

Improve Health

Background: Health literacy is defined as the ability of individuals to read, understand, and act on health-related concepts in order to make healthy decisions. This study was conducted to determine the level of health literacy of teachers in Asaluyeh city, Iran. Methods: This descriptive study was conducted on 200 teachers who were selected using stratified random sampling method in Asaluyeh in the academic year 2015 - 2016. Health Literacy for Iranian Adults questionnaire (HELIA) was used to measure their health literacy. Data were analyzed by SPSS20 and by using descriptive statistics, one way ANOVA, independent- samples T test, and Pearson correlation coefficient. Results: The mean age of participants was 30.56 years (SD = 4.5(, 59% of them were male (n = 118) and 41% were female (n = 82). Teachers' health literacy status was in moderate level for 9.6% of participants (n = 99) regarding access to information, for 44.6% of participants (n = 89) regarding information comprehension in, for 68.4% of participants (n = 136) regarding judgment and assessment, and for 68.4% of participants (n = 136) regarding information use. We found that health literacy had a significant relationship with gender and age. Conclusion: In this study, teachers' health literacy was at moderate level. So, it is necessary to provide effective internet resources and useful sites. We should also conduct health education programs in media such as radio and television to improve health literacy in teachers, especially in more experienced teachers. Keywords: Health Literacy, Teachers, Asaluyeh city

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Improving health literacy among older people through primary health care units in Brazil: feasibility study

Health Promotion International ◽

10.1093/heapro/daz121 ◽

2019 ◽

Vol 35 (6) ◽

pp. 1256-1266

Author(s):

Andreivna Serbim ◽

Lisiane Paskulin ◽

Don Nutbeam

Keyword(s):

Health Care ◽

Primary Health Care ◽

Health Literacy ◽

Older People ◽

Intervention Group ◽

Health Behaviours ◽

Intervention Programme ◽

Primary Health ◽

Reported Health ◽

Improve Health

Abstract There are only a small number of reported intervention studies to improve health literacy among older populations. This paper reports on a study designed to investigate the feasibility and potential impact on health literacy and health practices of embedding an intervention programme to improve health literacy with older people through established primary health care units (PHCUs) in a disadvantaged urban community in Brazil. This investigation utilized a quasi-experimental design, with 42 participants recruited for the intervention group and comparison group. The Alfa-Health Program was offered by a nurse in a PHCU as part of the public universal health system over a period of 5 months, and was compared for its impact on a range of health literacy and self-reported health outcomes with routine health care available for older people. The intervention achieved relatively high levels of participation, and positive feedback from participants. Some improvements in vaccination rates, health literacy and reported health behaviours related to food choices and physical activity were observed. The intervention made good use of existing facilities; the content and methods were well received by the participants. However, there were some difficulties in recruitment and in retention of participants. The study has demonstrated the practical feasibility of delivering a comprehensive health education programme designed to improve health literacy in a PHCU in Brazil.

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Establishing the efficacy of interventions to improve health literacy and health behaviours: a systematic review

BMC Public Health ◽

10.1186/s12889-020-08991-0 ◽

2020 ◽

Vol 20 (1) ◽

Cited By ~ 4

Author(s):

Ronie Walters ◽

Stephen J. Leslie ◽

Rob Polson ◽

Tara Cusack ◽

Trish Gorely

Keyword(s):

Systematic Review ◽

Health Literacy ◽

Health Behaviours ◽

Improve Health

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Development and validity testing of the Adolescent Health Literacy Questionnaire (AHLQ): Protocol for a mixed methods study within the Irish school setting

BMJ Open ◽

10.1136/bmjopen-2020-039920 ◽

2020 ◽

Vol 10 (11) ◽

pp. e039920

Author(s):

Ailbhe Spillane ◽

Sarahjane Belton ◽

Clare McDermott ◽

Johann Issartel ◽

Richard H Osborne ◽

...

Keyword(s):

Mixed Methods ◽

Health Literacy ◽

Young People ◽

Adolescent Health ◽

Pearson Correlation ◽

Adult Population ◽

School Setting ◽

Mixed Methods Study ◽

Advisory Panel ◽

Validity Testing

IntroductionHealth literacy research has focused predominantly on the adult population, and much less is understood about this concept from an adolescent perspective. The tools currently available to measure adolescent health literacy have been adapted from adult versions. This limits their applicability to young people because of the developmental characteristics that impact on adolescents’ behaviour, including impulse control and judgement skills. This protocol describes the intended development and validity testing of a questionnaire to measure health literacy in adolescents.Methods and analysisThis protocol describes this mixed methods study that has three phases: the first phase will involve grounded research with adolescents using qualitative group interviews, co-design and concept mapping workshops to understand what health and healthy behaviours mean to adolescents and to explore their health literacy needs and the potential domains for the questionnaire. The draft health literacy domains identified will be presented to the youth advisory panel, and the questionnaire will be altered based on their feedback. Cognitive pretesting of the questionnaire items will also be conducted. Phase 2 will involve piloting the questionnaire to a two-stage random sample of young people in five urban and rural schools in Ireland. Test–retest reliability will be conducted using Pearson correlation coefficient. Confirmatory factor analysis will also be conducted to analyse the psychometric properties of the questionnaire. Phase 3 will involve the questionnaire being rolled out to a nationally representative sample of adolescents (n=6052) in Ireland to assess their levels of health literacy.Ethics and disseminationEthical approval to conduct this study has been granted from the University College Dublin Human Research Ethics Committee – Sciences (LS-20–08). Informed assent from adolescents and informed consent from parents/guardians will be sought. The findings of this research will be disseminated at national and international conferences, as well as through publication in peer-reviewed journals.

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OP0257-PARE USING PATIENT HEALTH LITERACY PROFILES TO IDENTIFY SOLUTIONS TO CHALLENGES FACED IN RHEUMATOLOGY CARE

Annals of the Rheumatic Diseases ◽

10.1136/annrheumdis-2020-eular.877 ◽

2020 ◽

Vol 79 (Suppl 1) ◽

pp. 162.2-162

Author(s):

M. Bakker ◽

P. Putrik ◽

J. Rademakers ◽

M. Van de Laar ◽

H. Vonkeman ◽

...

Keyword(s):

Health Literacy ◽

The Netherlands ◽

Health System ◽

Demographic Data ◽

Family Doctor ◽

List Type ◽

Research Support ◽

Score Distribution ◽

Patient Health ◽

Literacy Profiles

Background:The prevalence of limited health literacy (i.e. cognitive and social resources of individuals to access, understand and apply health information to promote and maintain good health) in the Netherlands is estimated to be over 36% [1]. Access to and outcomes of rheumatological care may be compromised by limited patient health literacy, yet little is known about how to address this, thus action is required. As influencing individual patients’ health literacy in the rheumatology context is often unrealistic, it is paramount for the health system to be tailored to the health literacy needs of its patients. The OPtimising HEalth LIteracy and Access (Ophelia) process offers a method to inform system change [2].Objectives:Following the Ophelia approach:a. Identify health literacy profiles reflecting strengths and weaknesses of outpatients with RA, SpA and gout.b. Use the health literacy profiles to facilitate discussions on challenges for patients and professionals in rheumatological care and identify possible solutions the health system could offer to address these challenges.Methods:Patients with RA, SpA and gout attending outpatient clinics in three centres in the Netherlands completed the Health Literacy Questionnaire (HLQ) and questions on socio-demographic and health-related characteristics. Hierarchical cluster analysis using Ward’s method identified clusters based on the nine HLQ domains. Three researchers jointly examined 24 cluster solutions for meaningfulness by interpreting HLQ domain scores and patient characteristics. Meaningful clusters were translated into health literacy profiles using HLQ patterns and demographic data. A patient research partner confirmed the identified profiles. Patient vignettes were designed by combining cluster analyses results with qualitative patient interviews. The vignettes were used in two two-hour co-design workshops with rheumatologists and nurses to discuss their perspective on health literacy-related challenges for patients and professionals, and generate ideas on how to address these challenges.Results:In total, 895 patients participated: 49% female, mean age 61 years (±13.0), 25% lived alone, 18% had a migrant background, 6.6% did not speak Dutch at home and 51% had low levels of education. Figure 1 shows a heat map of identified health literacy profiles, displaying the score distribution per profile across nine health literacy domains. Figure 2 shows an excerpt of a patient vignette, describing challenges for a patient with profile number 9. The workshops were attended by 7 and 14 nurses and rheumatologists. Proposed solutions included health literacy communication training for professionals, developing and improving (visual) patient information materials, peer support for patients through patient associations or group consultations, a clear referral system for patients who need additional guidance by a nurse, social worker, lifestyle coach, pharmacist or family doctor, and more time with rheumatology nurses for target populations. Moreover, several system adaptations to the clinic, such as a central desk for all patient appointments, were proposed.Conclusion:This study identified several distinct health literacy profiles of patients with rheumatic conditions. Engaging with health professionals in co-design workshops led to numerous bottom-up ideas to improve care. Next steps include co-design workshops with patients, followed by prioritising and testing proposed interventions.References:[1]Heijmans M. et al. Health Literacy in the Netherlands. Utrecht: Nivel 2018[2]Batterham R. et al. BMC Public Health 2014, 14:694Disclosure of Interests:Mark Bakker: None declared, Polina Putrik: None declared, Jany Rademakers Speakers bureau: In March 2017, Prof. Dr. Rademakers was invited to speak about health literacy at the “Heuvellanddagen” Conference, hosted by Janssen-Cilag., Mart van de Laar Consultant of: Sanofi Genzyme, Speakers bureau: Sanofi Genzyme, Harald Vonkeman: None declared, Marc R Kok Grant/research support from: BMS and Novartis, Consultant of: Novartis and Galapagos, Hanneke Voorneveld: None declared, Sofia Ramiro Grant/research support from: MSD, Consultant of: Abbvie, Lilly, Novartis, Sanofi Genzyme, Speakers bureau: Lilly, MSD, Novartis, Maarten de Wit Grant/research support from: Dr. de Wit reports personal fees from Ely Lilly, 2019, personal fees from Celgene, 2019, personal fees from Pfizer, 2019, personal fees from Janssen-Cilag, 2017, outside the submitted work., Consultant of: Dr. de Wit reports personal fees from Ely Lilly, 2019, personal fees from Celgene, 2019, personal fees from Pfizer, 2019, personal fees from Janssen-Cilag, 2017, outside the submitted work., Speakers bureau: Dr. de Wit reports personal fees from Ely Lilly, 2019, personal fees from Celgene, 2019, personal fees from Pfizer, 2019, personal fees from Janssen-Cilag, 2017, outside the submitted work., Richard Osborne Consultant of: Prof. Osborne is a paid consultant for pharma in the field of influenza and related infectious diseases., Roy Batterham: None declared, Rachelle Buchbinder: None declared, Annelies Boonen Grant/research support from: AbbVie, Consultant of: Galapagos, Lilly (all paid to the department)

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Using the Brief Health Literacy Screen in Chronic Care in French Hospital Settings: Content Validity of Patient and Healthcare Professional Reports

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph18010096 ◽

2020 ◽

Vol 18 (1) ◽

pp. 96

Author(s):

Adèle Perrin ◽

Luiza Siqueira do Prado ◽

Amélie Duché ◽

Anne-Marie Schott ◽

Alexandra L. Dima ◽

...

Keyword(s):

Health Literacy ◽

Content Validity ◽

Chronic Care ◽

Routine Care ◽

Related Information ◽

Concept Of Health ◽

Patient Reported ◽

Centered Care ◽

Health Related ◽

French Hospital

Person-centered care has led healthcare professionals (HCPs) to be more attentive to patients’ ability to understand and apply health-related information, especially those with chronic conditions. The concept of health literacy (HL) is essential in understanding patients’ needs in routine care, but its measurement is still controversial, and few tools are validated in French. We therefore considered the brief health literacy screen (BHLS) for assessing patient-reported HL in chronic care settings, and also developed an HCP-reported version of the BHLS with the aim of using it as a research instrument to assess HCPs’ evaluation of patients’ HL levels. We assessed the content validity of the French translation of both the patient-reported and HCP-reported BHLS in chronic care within hospital settings, through cognitive interviews with patients and HCPs. We performed qualitative analysis on interview data using the survey response Tourangeau model. Our results show that the BHLS is easy and quick to administer, but some terms need to be adapted to the French chronic care settings. Health-related information was observed to be mainly communicated orally, hence a useful direction for future literacy measures would be to also address verbal HL.

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