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3D-brain 2.0--narrowing the gap between personal computers and high end workstations.

UNLABELLED: Recent advances in personal computer hardware and software have pushed the graphic capacity of these easier to use and, more importantly, cheaper computers to a level approximating the current standard of high end workstations. The interactivity and graphic complexity of a modern PC is rapidly approaching the current standard on Silicon Graphics (although with respect to texture mapping, the SGI is still ahead of the PCs). The modern medical student laboring under increasingly higher demands with respect to versatility, not only in basic science and traditional medical knowledge, is also faced with the requirement to learn and understand modern scientific visualization and analytical instruments. Furthermore, basic knowledge of information technology and computer literacy is expected of the next generation medical professionals. These demands forces medical schools to increasingly invest in computers and information technology for educational purposes. Due to common class sizes, these computers are most commonly Windows PCs or Apple Macintoshes. For distance education, telematics or studies at home, personal computer versions of the workstation graphics are a necessity. 3D-Brain 2.0 is an educational software package intended to run on basic personal computers and utilizing modern software technologies such as QuickTime VR 2.0 and VRML 2.0, to provide the students with insight into modern clinical and scientific visualization, focusing on the anatomy and functionality of the human brain. The aim of this paper to test the validity and usefulness of these new visualization techniques. METHODS: 3D-Brain is based on human brains sliced in 1 mm sections (NB. NOT based on NLMs Visual Human). Each slice was photographed, digitized, optimized and aligned using proprietary software. The datasets were then created by manual tracing followed by triangulation, smoothing and 3D visualization using Silicon Graphics computers. For the QuickTime VR project, 684 images with a 10 degrees angle were generated for each scene and ported to an Apple Macintosh computer for further manipulation. VRML code was generated directly from the original dataset. All interactivity was programmed on a Macintosh and subsequently ported to the Windows95 PC platform. The minimum requirements to run the software are either a PowerPC based Macintosh computer or a Pentium based Windows 95 computer with 16 Mb, 16 bit display and a 4 speed CD-ROM. RESULTS AND DISCUSSION: 3D-Brain 2.0 provides medical students at Goteborg University the means to complement traditional teaching using visualization techniques and three-dimensional models. These techniques also serve as an insight into the different clinical means of visualization the student will encounter throughout his/her continued education and professional career. For educational purposes, it has been established that among the tested new visualization techniques, CD-ROM based software utilizing QTVR is still the best methodology to use for pedagogical software. VRML shows promise in porting these software packages to the Web while Open Inventor is the preferred format for research purposes.

Brain↗

Patient literacy and the readability of written cancer educational materials.

PURPOSE/OBJECTIVES: The purpose of this study was to determine whether the reading level of educational materials for patients with cancer corresponds to the reading abilities of a sample of patients. A secondary aim was to describe what type of educational materials patients with cancer report as most helpful. DESIGN: Descriptive, cross-sectional. SETTING: Outpatient oncology clinics at an urban Veterans Affairs Medical Center. SAMPLE: A convenience sample of 63 outpatients with cancer. METHODS: Investigators used the Word Recognition Achievement Test-Revised Level (WRAT-R2) to measure patients' reading levels. They used the Flesch Index to analyze the reading levels of the booklets that the patients used (14 booklets developed by the American Cancer Society and 16 developed by the National Cancer Institute). Data were analyzed through descriptive statistics and a Wilcoxon signed rank test. MAIN RESEARCH VARIABLES: Patient and booklet reading levels. FINDINGS: The reading level of 27% of the sample was less than that of all 30 pamphlets (less than a sixth-grade reading level). Seventeen percent of the patients had a reading level between sixth and eighth grades (representing 47% of the pamphlets). Twenty-nine percent of the sample had WRAT scores between 9th and 12th grades (representing 80% of the pamphlets). Only 27% had WRAT scores of the 13th grade and above. Twenty-six percent of the patients preferred written educational materials alone, while 57% of patients desired more than one method of instruction. CONCLUSION: Written materials for the education of patients with cancer must be carefully matched to patient reading levels. Written materials may not be the only desirable mode of instruction. IMPLICATIONS FOR NURSING PRACTICE: Given the increasing complexity of cancer care, shorter hospital stays, and a shift toward busy ambulatory care centers, nurses need to develop creative, innovative, and comprehensive patient education programs that are understandable to patients and that use multiple types of instruction.

Adult↗

Training faculty in Bangladesh to use a microcomputer for public health: followup report.

In 1984 the Western Consortium for the Health Professions, Inc., under contract to the United Nations Fund for Population Activities (UNFPA), began a project to assist Bangladesh's National Institute for Preventive and Social Medicine (NIPSOM) in establishing a microcomputing capability. The project's goal was to enable NIPSOM to become self-sufficient in the analysis by microcomputer of health, population, and family planning data; program evaluation; and policy activities. Lack of a local microcomputer infrastructure demanded that a local team of experts be developed to run the system described in a previous report. Five NIPSOM faculty members--three of whom had taken the workshop held when the system was first installed--were assigned to a computer committee, which was responsible for the computer's well-being. Six months after the microcomputer system was installed, a second 2-week workshop was given. The consortium's consultant facilitated the development of a basic microcomputer course, which was taught by four members of the computer committee to an additional eight NIPSOM faculty members. Emphasis was placed on developing local self-reliance and the need to overcome obstacles imposed by the lack of local hardware and software support systems. A strategy is proposed for the successful introduction of microcomputers in developing countries.

Bangladesh↗

Learning resource needs of UK NHS support staff.

BACKGROUND: A report on the findings of research into the learning resource needs of support staff conducted at York Hospital. METHODS: A qualitative method of focus groups was used to explore the views and experiences of support staff. This provided a rich source of data and allowed an often overlooked group to give their own experiences of learning and libraries. This was supplemented by one-to-one interviews using more in-depth questions. A literacy and numeracy test gave a general picture of essential skill levels within the sample group. RESULTS: An improvement in communication to support staff needs to take place to ensure that all support staff know about the library, how and where to access training and obtain a network computer password. The project confirmed the need to expand library resources for support staff. It was found that there were no obvious essential skills resources within the Trust and a lack of awareness of essential skill issues. CONCLUSION: The learning needs of support staff need to be addressed sensitively. Many have had unfavourable experiences. Lack of access to computers and information technology (IT) training contributed to the group favouring written communication. More work needs to be done on essential skills for all staff.

Allied Health Personnel↗

AutoTutor: a tutor with dialogue in natural language.

AutoTutor is a learning environment that tutors students by holding a conversation in natural language. AutoTutor has been developed for Newtonian qualitative physics and computer literacy. Its design was inspired by explanation-based constructivist theories of learning, intelligent tutoring systems that adaptively respond to student knowledge, and empirical research on dialogue patterns in tutorial discourse. AutoTutor presents challenging problems (formulated as questions) from a curriculum script and then engages in mixed initiative dialogue that guides the student in building an answer. It provides the student with positive, neutral, or negative feedback on the student's typed responses, pumps the student for more information, prompts the student to fill in missing words, gives hints, fills in missing information with assertions, identifies and corrects erroneous ideas, answers the student's questions, and summarizes answers. AutoTutor has produced learning gains of approximately .70 sigma for deep levels of comprehension.

Algorithms↗

Literacy and body fatness are associated with underreporting of energy intake in US low-income women using the multiple-pass 24-hour recall: a doubly labeled water study.

OBJECTIVE: The accuracy of the multiple-pass 24-hour recall method for estimating energy intake in low-income women in the United States was ascertained by comparing the method with measurements of total energy expenditure. The multiple-pass 24-hour recall is designed to provide respondents with multiple cues and opportunities to report their food intake. It consists of 3 distinct passes: the quick list, detailed description, and review. Predictors of energy intake misreporting (energy intake--total energy expenditure) in the sample were determined. DESIGN: Four multiple-pass 24-hour recalls (2 in person, 2 by telephone) were obtained over a 14-day period to estimate energy intake. Total energy expenditure was measured over the same 14-day period using the doubly labeled water method. Body composition was measured using dual energy x-ray absorptiometry, and literacy was measured by the Wide Range Achievement Test (WRAT) for reading and spelling. SUBJECTS/SETTINGS: Thirty-five low-income women between the ages of 19 and 46 years were tested at the General Clinical Research Center at the University of Vermont, Burlington. Low income was defined as a household income at or below 130% of the federal poverty level. STATISTICAL ANALYSIS: Pearson product moment correlation coefficients, t tests, paired t tests, and stepwise multiple regression analysis were used to test the relationships among study variables. RESULTS: Mean energy intake was significantly lower than mean total energy expenditure (2,197 +/- 607 vs 2,644 +/- 503 kcal, P = .001) and the correlation between the 2 measures was poor (r = .22, P = .20). Percentage body fat and the combined age-adjusted reading and spelling WRAT scores were the best predictors of misreporting of energy intake (R = .52, P = .006). CONCLUSIONS: The multiple-pass 24-hour recall did not generate a group measure of energy intake that was accurate or unbiased in this sample. Underreporting was strongly associated with increased body fatness. The ability to read and spell as measured by the WRAT improved the accuracy of the women's recall of their food intake. APPLICATIONS: Dietetics professionals should take into consideration the problem of underreporting whenever conclusions are made about associations between diet and health and/or when evaluating the impact of food assistance programs on dietary intake.

Adipose Tissue↗

Socioeconomic development, health interventions and mortality decline in Costa Rica.

Costa Rica, whose life expectancy was 74 years by 1985, has reached a health level comparable to a developed country. The health achievements of this country are product of political and socioeconomic circumstances as well as of right public health policies. Until about 1970 the features of Costa Rica mortality, although somewhat better than the Latin American average, evolved in a similar way to the rest of the region. In particular, the decades of 1940s and 1950s saw dramatic improvements in life expectancy, thanks mainly to the import of low-cost, high-effectiveness health technologies. In the 1970s, however, Costa Rica departed from a regional pattern of stagnation and managed to close the gap with developed countries in terms of mortality levels. A dramatic decline in the infant mortality rate from 60 to 19 per 1,000 took place in this decade. The main determinants of this breakthrough were health interventions, notably a primary health care program, even though favorable socioeconomic conditions and a reduced fertility also played a role. Ecological data and other evidence suggest that up to three fourths of the mortality decline was accounted for contemporary improvements in public health services, with about 40 percent attributable to primary health care interventions. Furthermore, by targeting interventions on the less privileged population, these interventions had the merit of reducing geographic and socioeconomic differentials in child mortality.

Cause of Death↗

Defining the role of a PACS technologist.

As hospitals convert from conventional image processing to picture archiving and communication systems (PACS) technology, new job opportunities arose for PACS analysts, PACS system administrators, PACS operators, and PACS trainers. To support a PACS, these positions require education in computer information systems and work experience in information technology. At Texas Children's Hospital, new roles for radiologic technologists (RT) in supporting the operation of PACS were not recognized until after implementation of the filmless system. A new position entitled PACS technologis was created, but roles and responsibilities largely were undefined. The inadequate job description contributed to problems with appropriate utilization of the PACS technologist. The primary role of the technologist was nebulous, and the priority of tasks was undefined. There was an excessive volume of information and technology to be mastered. The role represented a new paradigm, so no template for the job description was available that encompassed the array of functions to be performed. The result was a "morph" of the RT and PACS analyst job descriptions that was contrived and unworkable. The role of the PACS technologist is vital to the operation of the radiology department that uses PACS. There is a well-established need for cross training of RTs in PACS. PACS technology is not taught in RT training programs. There are recurrent communications problems between RT and Information Technology (IT) personnel. The PACS technologist can participate in a number of activities that improve the overall level of proficiency in the imaging operation, such as specialized PACS training for RTs, collection and analysis of quality control data, and planning for installations of PACS acquisition modalities. RTs have acquired knowledge of medical terminology and human anatomy, imaging modalities, and workflow. These qualifications constitute a common basis for communication with other RTs, physicians, and other health care providers. In addition the appropriate candidate for PACS technologist should have computer software and hardware knowledge, interpersonal skills, oral and written communications skills, and analytical skills to troubleshoot issues. This report will describe the evolution of a more accurate job description for the PACS technologist, the relationship between the PACS technologist and the RT supervisor, and specific tasks are appropriate for the PACS technologist to perform.

Allied Health Personnel↗

Computerized databases for emergency care: what impact on patient care?

A field-based evaluation is conducted of a Clinical Computerized Information System (CCIS). Following training, the use of the CCIS database, word processing and other programs by thirteen full-time practicing emergency physicians in two urban emergency departments of a University-associated teaching hospital was studied over a one-year period. A tracking program automatically logged frequency and duration of use by the physicians, and user satisfaction was assessed by a reliable and validated questionnaire instrument. Based on utilization data and verbal reports of these physicians, CCIS database searching was not only found to be easy-to-learn but was readily accessible during emergency shifts. Individual physicians were found to perform an average of 3.5 searches per month lasting a mean search time of 8 min. Positive notes about the CCIS system included ease-of-use, accuracy of data, accessibility of system, and value of output while negative perceptions included a lack of integration with other systems, a lack of system completeness, and a high subscription cost. It was suggested that a less costly telephone link to a high-volume Centre would be desirable in actual implementation of the system.

Attitude of Health Personnel↗

Evaluation of pulse-polio immunisation in rural area of Maharashtra.

An evaluation survey on Pulse-polio Immunisation (PPI) in January 2000 was carried out in rural areas of Maharashtra to assess the immunisation coverage, the knowledge regarding pulse-polio and the routine immunisation schedule. House-to-house survey was carried out and information was collected by interviewing the parents of 778 children. It was observed that PPI coverage was excellent i.e., 98%. Majority of informants were female. Knowledge about pulse-polio had a direct relationship with literacy. But knowledge regarding routine immunisation and the polio disease was not found satisfactory. Excellent coverage of pulse-polio Immunisation was found because of an organised and extensive campaign, use of mass media like T.V., radio, and home visits of peripheral health staff (as told by the informants). The distance of approach to a polio booth was less than a kilometre in almost all cases. Behaviour of health staff was satisfactory everywhere. The time-period required for getting vaccinated after arrival at the polio booth was less than 5 minutes. Thus it was a worthwhile attempt to evaluate PPI coverage is rural areas of Maharasthra. Excellent coverage of pulse-polio immunisation gives us the picture that poliomyelitis is on the verge of being eradicated from India, if the excellent coverage of PPI is followed by effective surveillence.

Adult↗

Injury prevention education using pictorial information.

BACKGROUND: Written materials used in pediatric public health settings often exceed the reading skills of caretakers. OBJECTIVE: To compare a pictorial anticipatory guidance (PAG) sheet requiring limited reading skills to a TIPP (The Injury Prevention Program) sheet for providing injury prevention information to low-income urban families. DESIGN AND SETTING: A convenience sample of families with children treated at an urban pediatric clinic affiliated with a teaching hospital. Methods. Parents of children </=6 years old received either a PAG sheet or a TIPP sheet during a well-child care clinic visit; parents of children seen in the morning clinic received a PAG sheet and those seen during the afternoon clinic a TIPP sheet. All also received injury prevention counseling by a clinic nurse. The recall of injury prevention information was assessed by telephone questionnaire 14 to 28 days after the clinic encounter. RESULTS: We interviewed 66 parents (57% of families enrolled): 46 were in the PAG group and 20 in the TIPP group. There were no differences between groups in mean parent age, percent minority race, or percent public aid. Eighty-seven percent of PAG and 100% of TIPP parents recalled receiving an information sheet; 17% of PAG and 20% of TIPP parents could recall no specific injury topics. The mean number of topics recalled was 2.1 +/- 1.5 from parents in the PAG group and 1.6 +/- 1.1 from those in the TIPP group. No specific injury topic was recalled by more than half the parents in either group. CONCLUSIONS: Recall of injury information several weeks after a clinic visit is limited. The use of PAG sheets did not improve recall; lack of literacy is not the sole cause of poor recall. Successful injury prevention counseling in this population may require comprehensive and repetitive efforts.

Accident Prevention↗

Impact of nutrition education and mega-dose vitamin A supplementation on the health of children in Nepal.

The impact on vitamin A deficiency (VAD), wasting malnutrition, and excessive childhood mortality of two alternative approaches-nutrition education and mega-dose capsule distribution (6-12-month-olds: 100,000 IU; 1-5-year-olds: 200,000 IU)-in communities in Nepal are compared. Approximately 40,000 children from 75 locations in seven districts in two ecological settings (lowland and hills) took part in the study and were randomly allocated to intervention cohorts or a control group. At 24 months after the implementation of the project the reduction of risk for xerophthalmia was greater among children whose mothers were able to identify vitamin-A-rich foods (relative risk (RR) = 0.25; 95% confidence interval (CI) = 0.10-0.62) than among the children who received mega-dose capsules (RR = 0.59; 95% CI = 0.41-0.84). The risk of mortality at 2 years was reduced for both the nutrition education (RR = 0.64; 95% Cl = 0.48-0.86) and capsule distribution (RR = 0.57; 95% CI = 0.42-0.77) cohorts. The nutrition education programme was, however, more expensive to deliver than the capsule distribution programme. High rates of participation for children in the supplementation programme were achieved quickly. The nutrition education messages also spread rapidly throughout the study population (regardless of intervention cohort assignment). Practices, however, were slower to change. In communities where maternal literacy was low and channels of communication were limited the capsule distribution programme appeared to be more economical. However, there are economies of scale for nationwide education programmes that do not exist for capsule distribution programmes. Although nutrition education provides economies of scale and the promise of long-term sustainability, a comprehensive national programme requires both dietary supplementation and nutrition education components.

Child↗

Expectations and outcome skills of a generalist health care administrator.

The question of the degree of technical versus managerial competence to be found in future graduates from health administration programs is not easily resolved. In the HIMSS 1988 survey of CIOs the attributes needed for success are listed in descending rank order as follows: leadership ability, vision/imagination, knowledge of hospital systems, business acumen, decisiveness, and technical competence. CIOs ranked technical competence as less important than other attributes associated with general management success. The expectations for attitudes, knowledge, and skills presented in this article support the greater importance of management abilities relative to pure technical competence. However, it is vital that an appropriate level of technical knowledge and skill be maintained to enable future alumni of health administration programs to function effectively as administrators. Depending on their role in a health care organization, greater or lesser technical knowledge may be needed. Those pursuing a career path toward CIO must, of necessity, have greater technical knowledge and skill. We have discussed necessary and expected attitudes, knowledge, and skills that will be needed by the generalist health administration graduate in the future. It will be important to develop and maintain an attitude that MIS is a strategic tool, that health care technology is a corporate asset, and that information is power. Graduates must recognize the necessity of maintaining and enhancing their knowledge and skills through continuing education. The knowledge base of MIS education should focus on determining information needs to support strategic goals, understanding of general systems theory, principles of systems analysis, design, implementation and maintenance, awareness and exposure to standard application software, and an awareness of external sources of data.(ABSTRACT TRUNCATED AT 250 WORDS)

Computer Literacy↗

Use of a multi-application computer workstation in a clinical setting.

The goal of this study was to assess the usage frequency, user satisfaction, and quality of literature searchers for a multi-application computer workstation in a university-based general medicine clinic. A computer with medical literature searching, textbook searching, and a decision-support program was deployed in the workroom of the clinic and made available for routine use. Data were collected for ten months. More than three quarters of the study participants used the computer, with use increasing by level of medical training. Despite physicians' known preferences for nonjournal sources of information, literature searching was the application used most frequently, followed by textbooks and decision support. The literature searches were replicated by experienced clinician and librarian searchers using first full MEDLINE and then text-word-only searching, to compare the quantities of relevant references retrieved. Novice searchers retrieved a larger number of relevant references than did the experienced searchers, but they also retrieved more nonrelevant references. For both groups of experienced searchers, the full MEDLINE feature set conferred little benefit over searching with only text words. These searching results call into question the value of traditional searching methods for both novice and experienced physicians.

Attitude to Computers↗

Goal orientation and its relationship to academic success in a laptop-based BScN program.

This longitudinal study, conducted within a laptop-based BScN program examines the relationship of goal orientation profiles to comfort with technology and academic success. In phase 1 of this study, 101 first year nursing students completed an on line survey. The measurement tools used were Goal Orientation Assessment, Multiple Intelligences Learning Inventory and a locally developed Technology Comfort survey. Results showed that students were predominantly high in the mastery goal orientation profile. Males had a higher comfort level with technology. Age was inversely related to comfort with technology. An unexpected finding was that grade point average was inversely related to comfort with use of technology. The data did not support the commonly held belief that today's students are uniformly well-skilled and comfortable with new technologies. This study will continue over the next three years and will allow comparison of variables over time. Specific teaching interventions may be developed to accommodate varying learning and motivational styles in relation to comfort with technology.

Adult↗

[Model oriented assessment of literacy performance in children with cochlear implants].

BACKGROUND: Although most hearing-impaired children lag behind normally hearing children in literacy acquisition, this aspect has hardly been addressed in the evaluation of language acquisition after cochlear implantation. The present study investigated written language abilities in 8 school-age children with cochlear implants. Neurolinguistic dual-route-models of written language processing indicate that literacy acquisition leads to the establishment of two distinct reading and writing strategies: a lexical one for the quick processing of known words and a sublexical one for decoding unfamiliar words or nonwords letter by letter. PATIENTS: 8 school-aged children were investigated, a very heterogeneous group concerning age of onset of hearing impairment, educational placement, and competences in sign language. However, this range is typical of the group of CI-children. METHODS: The aim was to investigate if children with cochlear implants are able to establish both strategies or if they need to find a differential and individual access to written language. Performance within the Salzburger Lese-Rechtschreib-Test was evaluated. Individual performance of each subject was analysed. RESULTS: Performance varied substantially ranging from only rudimentary spoken and written language abilities in two children to age-equivalent performance in three of them. Severe qualitative differences in written language processing were shown in the remaining three subjects. Suggestions for remediation were made and a re-test was carried out after 12 months. Their individual profiles of performance are described in detail. CONCLUSIONS: The present study stresses the importance of a thorough investigation of written language performance in the evaluation of language acquisition after cochlear implantation. The results draw a very heterogeneous picture of performance. Model-oriented testing and analysis of performance prove to be sensible in at least a subpopulation of children with cochlear implants. Based on a better understanding of their acquired word-processing strategies, remediation programs meeting the needs of each individual child can be derived.

Age Factors↗

Partnership to engage St. Louis high school students in investigative genetics.

The authors describe the Modern Genetics Project, based on a successful hands-on science implementation model that was developed and field-tested in St. Louis area high schools between 1992 and 1998. The project, begun in 1991, features a curriculum enhancement unit, "Modern Genetics for All Students," that combines strong scientific content, hands-on investigations, and human health applications, with reference to developing national and state science-teaching standards for this topic. The unit provides a significantly higher level of hands-on involvement throughout the school year for students than is found in traditional biology classrooms. This project aims to enhance scientific literacy among St. Louis high school students (all grades) of all learning levels and all socioeconomic, racial, and ethnic backgrounds; many of the students using the curriculum are from underrepresented minorities. This long-term project is carried out by a strong partnership among scientists at Washington University, implementation specialists from the Mathematics and Science Education Center of the Cooperating School Districts of St. Louis, project evaluators from Southern Illinois University at Edwardsville, and biology teachers at local high schools. Funding was originally from the National Institutes of Health and is now from the Howard Hughes Medical Institute. In 1998, there were 31 teachers and approximately 3,200 students participating in the project. Both quantitative and qualitative evaluations of the project during the 1995-96 and 1996-97 school years indicate that there were significant gains in knowledge and attitudes among the students of all racial, ethnic, and socioeconomic groups represented, and among both boys and girls.

Adolescent↗

Reading skills and family planning knowledge and practices in a low-income managed-care population.

OBJECTIVE: To examine the relationship between reading ability and family planning knowledge and practices among Medicaid managed care enrollees. METHODS: A total of 406 women age 19-45 years enrolled in TennCare and members of Prudential HealthCare Community Plan in Memphis, Tennessee were interviewed to determine their methods of contraception, desire for additional information about contraceptives, and knowledge about the time in menstrual cycle they are at highest risk for pregnancy. Patient reading ability was assessed by an abbreviated version of the Test of Functional Health Literacy of Adults. The independent associations between reading ability, desire for additional contraceptive information, and knowledge about the highest risk time for pregnancy were assessed with logistic regression. RESULTS: Almost 10% of the respondents had low reading skills. Women who had used an intrauterine device, douching, rhythm, or levonorgestrel implants as methods of birth control had higher rates of low reading skills than women who used other methods of birth control. Compared with women with good reading skills, women with low reading skills were 2.2 times (95% confidence interval [CI] 1.1, 4.4) more likely to want to know more about birth control methods and 4.4 times (95% CI 2.2, 9.0) more likely to have incorrect knowledge about when they were most likely to get pregnant. These relationships were significant even after controlling for age, race, and marital status. CONCLUSION: Health providers and organizations that serve historically underserved populations must understand that some individuals have a low level of reading ability that limits family planning education.

Adult↗