Health Literacy

Health Literacy

We are committed to improving health literacy as part of our mission to improve health.

Health literacy is vital for health, be it living healthy, disease prevention or to achieve the best possible results from medical care. We must partner with patients to promote their understanding of their medical condition or disease, the reasons they are being treated, and the appropriate use of their medications and other treatments.

Since its inception in 1891, our company has pushed the boundaries of science with the hope and expectation that advancing scientific knowledge will lead to major advances in health.1 We believe one way to improve global health care outcomes is to make medical and health information accessible to health care professionals and patients around the world.2 Our commitment to improving patient health outcomes extends to our commitment to health literacy.

Limited health literacy costs health systems 3–5% of their budget.3

Health literacy can affect a person’s ability to access health care services, use services appropriately, adopt health-promoting behaviors, manage chronic conditions, navigate the health care system, and act on health-related news and information.4,5

Health literacy challenges can affect people of all ages, races, incomes and educational levels. Some population groups in the U.S. are more vulnerable to low health literacy. They include the elderly, people with less than a high school education, people living in poverty, racial and ethnic minorities, and people with limited English proficiency.6

Those with limited health literacy are more likely to have chronic conditions and are less able to manage them effectively.7 More than 77 million U.S. adults have basic or below basic health literacy skills.8

Health literacy is essential in efforts to:

  • Encourage use of appropriate preventive measures, e.g., health screenings, mammograms and recommended vaccinations
  • Teach patients about health benefits, risk factors and adherence to treatment plans
  • Inform and alert the public about important health recommendations9,10

KEY DEFINITION

Although the most commonly used definition in the U.S. focuses on the ability of the individual to obtain, communicate, process and understand health information,11 our company recognizes that we must strive to communicate information to patients in a way they can understand and use. A commonly used definition in the EU acknowledges the complexity of managing one’s health effectively.

Health literacy: Health literacy is linked to literacy and entails people’s knowledge, motivation and competence to access, understand, appraise and apply health information in order to make judgments 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.10

POOR HEALTH LITERACY IS A SERIOUS CHALLENGE

Health literacy challenges exist in all parts of the world. According to the WHO Regional Office for Europe (WHO/Europe), people with strong health literacy skills enjoy better health and well-being; while those with weaker skills tend to engage in riskier behavior and have poorer health.12 Health literacy also has an impact on the efficient use of health care resources. According to a systematic review, limited health literacy costs health systems three to five percent of their budget.13

According to more recent research, low health literacy has been estimated to cost the U.S. economy between $106 billion and $236 billion annually.4

Our company recognizes the potential we have to help improve millions of lives by improving how we communicate as we shepherd discoveries from the lab to the marketplace. We also know it will take a multifaceted effort focused on public policy, engaging diverse stakeholders and new ways of communicating. Consequently, we are calling for collaboration among government agencies, health care providers, patient advocacy groups and health care companies to do more together to increase patient understanding of health care and treatment plans.

At a time when patients and family members are increasingly involved in their own care, clear communication at every point along the patient journey, from researching symptoms to seeking diagnosis, to managing disease, is a crucial adjunct to the medicines we discover.

KEY HEALTH LITERACY PRIORITIES

Our company is committed to ensuring diversity in clinical trials, championing health literacy across countries and divisions, and proposing new solutions to improve health care equity around the globe. In the U.S., our goal is to create and model patient-centered innovative programs that foster health literacy.

We publicly share best practices with other pharmaceutical companies and other stakeholders, demonstrating our commitment to improving patient health outcomes. We proudly participate in both the National Academies’ Health Literacy Roundtable and the Roundtable on the Promotion of Health Equity and the Elimination of Health Disparities.

Our vision in Europe is to enable citizen- and patient-centered health systems. Health literacy is a key enabler for citizens and patients to take an active role with regard to their health. In addition, health literacy activities lead to better “readable” health systems, where patients can easily navigate and receive the care needed.14 Empowered citizens and readable health systems contribute to better health and more efficient health care.

We have been engaging in Europe with various stakeholders such as the European Commission, the European Parliament, and patient, physician, pharmacy and nurse associations toward these health literacy goals. Health literacy has also become an important component of our engagement in cancer care policies.

Policy makers across Europe have shown increased interest in health literacy. The Council of the European Parliament refers to the importance of health literacy in the context of personalized medicines.15 The “Riga Roadmap”—a joint declaration by industry, civil society and patient organizations launched during the Latvian EU Presidency—calls for a regular EU health literacy survey across all EU member states to collect comparative data, and for investing in health literacy interventions.16

Finally, many affiliates of our company have translated health literacy into programs to improve the health of citizens and patients in high-priority areas such as oncology. We highlight some of our U.S. and global health-literacy initiatives below.

U.S. Initiatives

SHAPING THE EXTERNAL ENVIRONMENT—HEALTH CARE PROVIDERS

While the skills of individual patients and caregivers are an important part of health literacy, there is also a need to reduce the complexity of the health care system. Poor health literacy and health care disparities may negatively impact quality, adherence and patient safety. Many payers, integrated health systems and large medical groups share our commitment to addressing these issues.

Individuals with limited health literacy have a lower quality of communication with health professionals.17 By taking a systematic approach to promoting health literacy, medical practices and other health care organizations may help to improve the quality of patient care.

We continue to share and update resources about health literacy for these audiences. This reflects the widespread and growing understanding across the health care system of the need to make it simpler for patients to successfully manage their own health. These resources include many actionable tips to address health literacy. We also shared information about health literacy at a clinical trials conference at a large health system (Advocate) in 2016.

SHAPING THE EXTERNAL ENVIRONMENT—PATIENTS / HEALTH CARE CONSUMERS

Patients require health literacy skills in order to understand and navigate the health care system, talk to providers, engage in self-management, exercise basic numeracy skills, adopt healthy behaviors, and act on news and information.18 Our consumer-engagement platform, available in the U.S., provides unbranded health-literate content in support of our pharmaceutical and vaccine brands. This multi-channel health and wellness program is designed to improve engagement and adherence, to help U.S. consumers strive to meet their goals for a healthy lifestyle, and to provide a platform to educate patients on real-time health-related issues.

Since 2014, we have had a leadership role in the Multi-Regional Clinical Trials Center (MRCT) aggregate Return of Results working group. This working group included representatives from patient advocacy, industry and academia, who worked collaboratively to develop a health-literate template and supporting guidance document for returning aggregate results to clinical trial participants.

In 2015, two of our employees participated in a European Medicines Agency (EMA) task force on lay summaries, in advance of an EU requirement to publish a public summary of each clinical trial beginning in 2018. Patient representatives were also part of this task force. The draft EU guidance issued in June 2016 featured health literacy principles, numeracy, readability, and templates for simple language. We completed qualitative research in 2016 and submitted for publication in early 2017.

The research highlighted the need to simplify the titles of the 10 proposed headers.

The research also demonstrated that people across a range of health literacy levels, including both limited and proficient health literacy, found the simple language and clear format acceptable.

A summary of the research was submitted during the open comment period for the draft guidance. In early 2017, the Commission indicated a willingness to consider the alternate simpler headers developed by the task force. The EMA task force and the Multi-Regional Clinical Trials (MRCT) Center of Brigham and Women’s Hospital and Harvard are aligned to create global, health-literate guidance and templates.

SHAPING THE EXTERNAL ENVIRONMENT—BEST PRACTICES FOR INDUSTRY

We continue to partner with academia to develop and test health-literate patient labeling for new molecules. This collaboration is between leaders in the field of health literacy at Northwestern University and Emory University and a cross-divisional team at our company, including labeling, legal and regulatory policy. The work is led by the Worldwide Product Labeling Group in our research laboratories.

The purpose of the collaboration is to demonstrate improved patient understanding and use, by optimizing the development and testing process.

Best practices from the field of health literacy and patient feedback are incorporated throughout the development of patient labeling for new molecules. Patient input is given in focus groups during the initial development, and again later to confirm comprehension of the draft label for FDA submission.

Notably, our past approach included conducting market research across a broad range of education levels; however, few of the respondents who presented had limited health literacy. Such candidates are harder to locate, are less likely to participate and have not been represented adequately in the databases of market research agencies serving the pharmaceutical industry.

Northwestern University and Emory University helped us apply best practices from the field of health literacy to secure these respondents. Notably, in 2016, we worked with a large national recruiter of participants for market research to add health literacy screening questions, enabling us to more easily include respondents with low health literacy in future research. This may also aid other pharmaceutical companies in including respondents across a range of health literacy levels.

This process has consistently achieved strong comprehension in respondents with both limited and adequate health literacy (90 percent or better in both groups in qualitative research). In March 2016, we published this innovative approach in Quirks, a magazine for market researchers. This was the first article ever in Quirks about health literacy, and it generated significant interest. Our commitment to health literacy in patient labeling was also highlighted on the National Academies’ Health Literacy Roundtable website.

We received the 2016 health literacy research award from the Institute for Health Advancement for our patient labeling work.

We have had three health-literate patient labels approved by the FDA, a key milestone both for patients and the work that we believe is a model for others in the industry. This work was presented twice at the FDA in 2016 and we were invited to highlight the inclusion of respondents with low health literacy at the November 2016 meeting of the National Academies’ Health Literacy Roundtable.

In 2016, our manufacturing division began to apply a similar process (partnership with Northwestern and Emory; iterative patient input) to the development of an “instructions for use” guide. The sample medicine kit tested was complex, with 60 medicine packets and three different size syringes for caretakers to mix and measure the medicine for their children, based on weight. Eye-tracking technology was used to time how long people read each instruction, and to follow gaze patterns to make sure they read the instructions in the correct order. Two rounds of eye-tracking research in 2016 demonstrated great improvement in the ability of people to follow the directions in order, and to mix and measure the medicine correctly.

CHANGING OUR CULTURE: COMMITMENT ACROSS THE ENTERPRISE

Health literacy is about the ability to deliver patient communications in an understandable and actionable way. We work to integrate health literacy principles into our patient-education materials. We have an online training program, providing clear instructions to the creators of materials on how to implement health-literacy best practices. These best practices are derived from research in the field of health literacy, as well as from feedback we have received from health care providers and patients themselves.

This training was rolled out to several creative agencies in 2016, with broader dissemination planned in 2017. Employees within several groups attended in-person health literacy training in 2016, including informed consent, clinical trial materials, labeling and patient education materials.

We lead the industry in our commitment of resources to health literacy, with a full-time position dedicated to health literacy since 2012, a health literacy reviewer for patient education and a market researcher. There are many other champions across the company who have embraced health literacy and lead efforts within their own functional areas, including manufacturing, research and compliance.

DEMONSTRATING SCIENTIFIC EXCELLENCE

A committee within our company’s Investigator Studies Program (MISP) is focused on patient engagement, diversity and health literacy. Six studies were funded in 2016, with plans to fund additional studies in 2017.

In 2013, we partnered with Northwestern Medicine, Walgreens and Alliance of Chicago community health centers to collaborate on a study with a simple goal: to provide clear instructions on prescription medicine labels so patients don’t make mistakes or overcomplicate taking their daily medications.

In 2014, the electronic health record (EHR) and pharmacy systems were designed to support the study, and pharmacists and prescribers were trained. Patient enrollment began in 2015 and continued into 2016. The primary outcomes include self-management knowledge, prescription adherence, and measures of blood sugar control and blood pressure. The results were analyzed in late 2016, and will be presented at conferences and submitted for publication beginning in 2017.

To advance key discussions in health literacy, our company was part of a small group of National Academies’ Health Literacy Roundtable members who authored two perspective papers in early 2016, “Strategies to Enhance Numeracy Skills” and “Considerations for a New Definition of Health Literacy” The National Academy of Medicine announced the Top 10 Perspectives of 2016, and the “Considerations” perspective was #5 on the list.

Global Initiatives

 

We collaborate with various stakeholders in policy development for health literacy and support programs that improve the health literacy levels of citizens and patients.

In the EU, we do so together with European associations of physicians, patients, universities and policy makers from the European Parliament and other EU institutions. Our vision in Europe is to enable citizen- and patient-centered health systems.

Health literacy is a fundamental requirement for citizens and patients to take an active role with regard to their health.19 In addition, health literacy activities lead to better “readable” health systems where patients can easily navigate and receive the care needed. Empowered citizens and readable health systems contribute to better health and more efficient health care.20

In 2016 we expanded our engagement to also encompass cancer literacy. Patients with higher health literacy levels are better able to navigate and access the health system, understand the importance of cancer prevention, seek earlier diagnosis and adhere better to treatment.21 To that end, we supported a survey of the European Cancer Patient Coalition (ECPC) that assessed patients’ knowledge about biomarkers22 and developed infographics showing the importance of health literacy in the context of biomarker testing for cancer therapy. Health literacy was also recognized as an important component to improved cancer care by All.Can, a multi-stakeholder platform to foster sustainable cancer care, of which our company is a member.23

We have been engaging in Europe with the European Commission, the European Parliament, patients, physicians, and pharmacy and nurse associations. Together, with the European Patients’ Forum (EPF), the Standing Committee of European Doctors (CPME) and Health Literacy Europe, we participated in the consultation mid-term evaluation of the Third Health Programme (2014-2020), calling for the development of an action plan on health literacy.24 This action plan recognizes that citizens and patients are at the center of health, health policies and health systems.

Health literacy has gained attention among policy makers across Europe. Both the conclusions of the Council of the European Union and the “Riga Roadmap”—a joint declaration by industry, civil society and patient organizations—refer to the importance of health literacy.15, 16

BELGIUM

Well Done—MSD Health Literacy Awards 2016

In 2016, MSD in Belgium, together with 14 key stakeholders, organized the fourth edition of the Well Done—MSD Health Literacy Awards, to recognize and reward Belgian and Luxembourgian projects that made a significant contribution to the health literacy of citizens. This project involves close collaboration between MSD and key stakeholders, including patients and HCP associations, Sickness Funds, members of parliament, and the National Institute for Health and Disability Insurance.

The 2016 edition resulted in 54 health literacy projects. Three of these projects were selected for the First Line, Specialty Care and Community Award of €3,000 each. Our engagement gave us many new opportunities to collaborate with important stakeholders and testified to our commitment to health literacy.

Health literacy has also gathered interest at the Belgian health care department of the NIHDI. The ambition for 2017 is to support the national health literacy policy objectives and to increase the mobilization of projects through social media.

Further analysis of the Belgian Health Literacy Survey

In addition, further analysis of the data of the Belgian Health Literacy Survey 2015 was conducted. The survey was originally initiated by MSD in Belgium with the aim to assess the health literacy level of chronic patients with hypertension, diabetes or asthma.

The Université Catholique de Louvain interviewed 450 patients and 360 health care practitioners. Among these patients, 12 percent had insufficient health literacy, 15.8 percent had limited health literacy, and 72.3 percent had a sufficient level of health literacy. Low health literacy was relatively more common among hypertensive patients versus diabetes-type 2 patients. One out of three hypertensive patients versus one out of five diabetes-type 2 patients showed insufficient or limited health literacy levels.

When looking at the health literacy by professional situation, the study showed a trend for lower health literacy levels with chronic patients who are unemployed or do not work outside the home. Patients with a better health literacy level had fewer problems following instructions from their physician.

HUNGARY

“It speaks to me!”

Health literacy research supported by the Hungarian industry association in 2015 showed that one out of two Hungarians had insufficient health literacy levels. As a consequence, the Association of Innovative Pharmaceutical Manufacturers (AIPM) created a separate working group on health literacy under the leadership of MSD in Hungary with the aim to initiate programs to improve health literacy in Hungary. Two main projects were executed in 2016, a health literacy award and an academy of patient organizations.

In order to highlight the problem of low health literacy in Hungary and partly to improve health literacy in the country, AIPM launched a project called “It speaks to me! Health Literacy Award 2016.”

The program aimed to reward the best programs and practices for improving health literacy and health awareness, but also to gather the attention of the public. Applications were received with projects aimed at increasing people’s medical knowledge in four categories: health care institutions, health care professionals, patient organizations and information to the public. Almost every segment of the Hungarian health care system — patient organizations, institutions, physicians and health care professionals — has participated, with 103 applications submitted in the four categories.

In addition to the award, AIPM has launched the Academy of Patient Organizations with the goal of compiling educational lecture series and online materials to help Hungarian patient organizations improve their health literacy.

The Academy also helped to build a bridge between patients and doctors and develop a network of patient organizations. More than 60 organizations have joined the program so far, which is a clear indicator of the need, interest and educational value of the program.

IRELAND

“My Health Care, My Future”

With the Irish government focused on a long-term strategy for the health care system, in 2016 MSD in Ireland published research carried out by Ipsos MRBI, a global independent market research company. The first-of-its-kind report involved interviews with almost 1,000 members of the public, as well as key stakeholders, to understand the key values for a future health care system in Ireland.

Clear communication became a key theme throughout the research. The interviews showed the strong correlation between patient understanding of their condition and treatment plan, and their likelihood of medication adherence. Eighty-six percent of respondents said it is very important that their illness or condition be clearly explained in language they understand.

The National Adult Literacy Agency (NALA) was involved at all stages of the research and believes the report emphasizes the need for clear communication from health professionals. It is, they argue, something that benefits everyone and yet requires minimal investment.

The final report from the “My Health Care, My Future” research was launched by the Minister for Health at an event with 100 stakeholders. The findings and themes within the report have contributed to the work of a Parliamentary Committee on the Future of Health Care, which has been tasked with publishing a 10-year strategy for improving Ireland’s health care system. Published in April 2017, this strategy forms the cornerstone of health policy in Ireland for the coming years.

ITALY

Volere Non Basta (“Asking for Something Is Not Enough”)

Since 2013, the Fondazione MSD, in partnership with Rome Sapienza University and Milan Engineering School, has been promoting the Patient Academy, a program that supports patient empowerment. The 2016 edition of the Patient Academy involved the Italian Observatory of Narrative Medicine (OMNI) and the Center for Digital Health Humanities, under the aegis of National Institute of Health. The 2016 theme was “digital narrative medicine” and aimed at exploiting digital technologies to improve patient-physician communication and to reach better health results.

SITA Campaign on antimicrobial resistance (AMR)

This large awareness campaign on antimicrobial resistance (AMR) reached over 62 million people. It was conducted by the Italian Society of Anti-infective Therapy with the endorsement of the Ministry of Health, and as institutional testimonial, the President of the Social Affairs Commission at Parliament level. The campaign underlined the importance of the alliance among citizens, physicians and institutions and to fight AMR and promote the correct use of antibiotics. The main tools/communication channels included a website, to inform citizens of AMR and the need for appropriate use of antibiotics, and a short movie, “Vampiri,” mainly diffused through the web, to reach the general public.

Il Sole per Amico (“The Sun as a Friend”) and Meglio Smettere (“Stop smoking is better”)

In collaboration with scientific society and patient associations, we supported two awareness campaigns to promote primary prevention against cancer. The Italian Melanoma Intergroup, under the patronage of the Ministries of Health and Education, focused on melanoma’s primary prevention. It involved 50,000 children and their families, 4,500 teachers, 300 schools and more than 100 physicians throughout Italy. It also included a major event at the parliamentary level, two national press conferences and 11 regional press conferences, resulting in significant media coverage.

The second campaign focused on risk awareness of smoking, targeting the younger population. It was conducted in partnership with the Italian Association of Medical Oncology (AIOM) under the aegis of the Ministries of Health. The campaign featured two famous testimonials from the 2015 U.S. Open winner Flavia Pennetta and Italian Juventus football club manager Massimiliano Allegri.

Ora Che Mi Ci Fai Pensare (“Now That You’ve Got Me Thinking”)

“Ora Che Mi Ci Fai Pensare” is a campaign focused on the impact of therapy on patients suffering from inflammatory bowel disease (IBD) and their quality of life. The campaign, which launched in February 2015, was developed by Italian and European patients’ associations, the Italian Scientific Society for Gastroenterology (IG-IBD) and MSD in Italy. The campaign consists of a series of patient-shot videos available on YouTube/Vimeo and Facebook. These include the short movie, “Now That You’ve Got Me Thinking,” which was presented in several short-movie festivals throughout Italy in 2016.

“LOVE IT”

Education through information was the objective of “LOVE IT,” a 360-degree cross-media campaign with the Italian Society of Gynecology and Obstetrics (SIGO), leveraging Italian “The Pill without a Pill” campaign actions and aimed at creating a cultural movement on contraception.

ROMANIA

“Protect Her Wings”— Educating about cervical cancer

Nearly 12 percent of cervical cancers diagnosed in the European Union each year occur in Romania, and close to 15 percent of the women who lose the fight against cervical cancer each year in the European Union are from Romania.

Together with the National Institute of Public Health, MSD in Romania developed a campaign called “Protect Her Wings.” The campaign aims to inform and educate women about cervical cancer and HPV infection, and to increase primary and secondary prevention of cervical cancer.

The campaign rallies scientific and NGO institutions, and will encourage inter-institutional work and host a series of events and roundtables. Clear and comprehensive educational materials and a website were developed to support the campaign’s objectives. These provide information for media and other stakeholders, including a 24-page brochure and a leaflet containing key information about cervical cancer and HPV infection, targeting the general public.

SWITZERLAND

Swiss Health Literacy Survey

Based on the European Health Literacy Survey, the Federal Office of Public Health (FOPH) in Switzerland conducted a survey about the health literacy of the Swiss population.

The results, published in June 2016, showed that health literacy of 54 percent of the participants was insufficient or problematic. The main deficits were identified in the areas of prevention and choosing the right treatment in case of illness. The Health Literacy Alliance, of which MSD is a cofounder, advocated for creating better data on health literacy in Switzerland.

The survey results demonstrate a clear need to further strengthen health literacy and encourage the Alliance in its efforts in Switzerland. The Alliance will work closely with the FOPH to address the identified health literacy gaps.

1. Merck & Co., Inc., Kenilworth, N.J., U.S.A. Corporate videos. Accessed June 22, 2016.
2. Merck & Co., Inc., Kenilworth, N.J., U.S.A. Helping the World Be Well. Corporate presentation. Accessed June 22, 2016.
3. Eichler K, Wieser S, Bruegger U. The costs of limited health literacy: a systematic review. Int J Public Health. 2009;54(5):313-24. doi: 10.1007/s00038-009-0058-2. Epub 2009 Jul 31. Accessed October 13, 2017.
4. U.S. Department of Health and Human Services (HHS). Quick Guide to Health Literacy. http://health.gov/communication/literacy/quickguide/Quickguide.pdf. Accessed June 22, 2016.
5. Ibid.
6. HHS. Office of Disease Prevention and Health Promotion. National Action Plan to Improve Health Literacy. Washington, D.C.: 2010. https://health.gov/communication/hlactionplan/pdf/Health_Literacy_Action_Plan.pdf. Accessed October 13, 2017.
7. HHS. Quick Guide to Health Literacy and Older Adults. http://health.gov/communication/literacy/olderadults/literacy.htm. Accessed June 22, 2016.
8. Kutner M, Greenberg E, Jin Y, Paulsen C. The health literacy of America’s adults: Results from the 2003 National Assessment of Adult Literacy (NCES 2006–483). U.S. Department of Education. Washington, D.C.: National Center for Education Statistics, 2006. https://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2006483. Accessed October 13, 2017.
9. Berkman ND, Sheridan SL, Donahue KE, et al. Health Literacy Interventions and Outcomes: An Updated Systematic Review. Evidence Report/Technology Assessment No.199. AHRQ Publication Number 11-E006. Rockville, MD. Agency for Healthcare Research and Quality. March 2011.
https://www.ahrq.gov/downloads/pub/evidence/pdf/literacy/literacyup.pdf. Accessed October 13, 2017.
10. Sorensen K, Van den Broucke S, Fullam J, et al. Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health. 2012:12:80. https://doi.org/10.1186/1471-2458-12-80. Accessed October 13, 2017.
11. Office of Disease Prevention and Health Promotion. U.S. Department of Health and Human Services. Healthy People 2010. Washington, D.C.: U.S. Government Printing Office. 2000. https://www.healthypeople.gov/2020/About-Healthy-People/Development-Healthy-People-2030. Accessed October 13, 2017. Originally developed for Ratzan SC, Parker RM. Introduction. In: National Library of Medicine Current Bibliographies in Medicine: Health Literacy. Selden CR, Zorn M, Ratzan SC, Parker RM, eds. NLM Pub. No. CBM 2000–1. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services; 2000.
12. World Health Organization (WHO) Europe. Health literacy: The solid facts. Kickbusch I, Pelikan JM, Apfel F, Tsouros AD, eds. 2013. http://www.euro.who.int/en/publications/abstracts/health-literacy.-the-solid-facts. Accessed December 31, 2015.
13. Eichler K, Wieser S, Bruegger U. The costs of limited health literacy: A systematic review. Int J Public Health. 2009;54(5):313. https://doi.org/10.1007/s00038-009-0058-2. Epub 2009 Jul 31.
14. The Riga Roadmap: Investing in Health and Wellbeing for All. 2015. http://rigahealthconference2015.eu/wp-content/uploads/2015/08/Riga-Roadmap-download-FINAL.pdf. Accessed May 13, 2016.
15. Council of the European Union (2015/C 421/03). Council conclusions on personalised medicine for patients. Official Journal of the European Union, C 421/2. http://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX%3A52015XG1217(01). Accessed October 13, 2017.
16. The Riga Roadmap. Investing in Health and Wellbeing for All. 2015. http://rigahealthconference2015.eu/wp-content/uploads/2015/08/Riga-Roadmap-download-FINAL.pdf. Accessed May 13, 2016.
17. Koh HK, Berwick DM, Clancy CM, et al. New federal policy initiatives to boost health literacy can help the nation move beyond the cycle of costly “crisis care”. Health Affairs. 2012;31(2):434–443. http://content.healthaffairs.org/content/31/2/434.full. Accessed October 13, 2017.
18. HHS. Quick Guide to Health Literacy. Fact Sheet. Health Literacy Basics. https://health.gov/communication/literacy/quickguide/factsbasic.htm. Accessed: June 1, 2013.
19. WHO Europe. Health literacy: The solid facts. Kickbusch I, Pelikan JM, Apfel F, Tsouros AD, eds. 2013. http://www.euro.who.int/en/publications/abstracts/health-literacy.-the-solid-facts. Accessed December 31, 2015.
20. Eichler K, Wieser S, Bruegger U. The costs of limited health literacy: A systematic review. Int J Public Health. 2009;54(5):313-24. doi: 10.1007/s00038-009-0058-2. Epub 2009 Jul 31.
21. WHO Europe. Health literacy: The solid facts. Kickbusch I, Pelikan JM, Apfel F, Tsouros AD, eds. 2013. http://www.euro.who.int/en/publications/abstracts/health-literacy.-the-solid-facts. Accessed December 31, 2015.
22. European Cancer Patient Coalition. Survey: How much do you know about biomarkers? http://www.ecpc.org/news-categories/policy-and-advocacy/421-survey-how-much-do-you-know-about-biomarkers. Accessed March 14, 2017.
23. Wait S, Han D, Muthu V, et al. Towards sustainable cancer care: Reducing inefficiencies, improving outcomes—A policy report from the All.Can initiative. J Cancer Policy. 2017;13:47–64. https://doi.org/10.1016/j.jcpo.2017.05.004. Accessed March 14, 2017.