Hypertension Education to Enhance Health Literacy

Practice Problem: The health of patients suffers greatly when their health literacy is not addressed through evidence-based education material. PICOT: The PICOT question that guided this project was, in adult patients with hypertension (P), how does evidence-based education material (I) compared to the current state of verbal instructions provided (C) affect health literacy rates based on the high blood pressure health literacy scale (O) within 12-weeks (T)? Evidence: The literature evidence revealed three strong themes, which included information on who is most at risk for low health literacy levels, education delivery methods, and specific education to be used. Intervention: This virtual intervention included a hypertension education format from the American Heart Association in both English and Spanish, when appropriate. The educational intervention was completed by the director at the clinic. Outcome: The results demonstrated a change in health literacy following education delivery. The two-tailed Wilcoxon signed rank test was not significant based on an alpha value of .05, V = 0.00, z = -1.83, p = .068 for the full high blood pressure-health literacy assessment for the four participants; however, the clinical significance was meaningful. Conclusion: The project was conducted in a free clinic for those who are marginalized. Four patients qualified based on the inclusion criteria, and each participant was given the health literacy assessment before and after receiving the evidence-based education material specific to hypertension.


Hypertension Education to Enhance Health Literacy
Health literacy can be considered an important vital sign to assess in healthcare.
The concept of health literacy is often overlooked but is highly important for patient education and adherence to a treatment or medication regimen. Poor health literacy directly correlates with poor patient outcomes and adverse events (Berkman et al., 2011). The inverse of this is also true; high health literacy rates correlate with better patient outcomes and adverse events (Berkman et al., 2011). For this reason, the purpose of this project was to determine if evidence-based practice discharge material about hypertension can improve health literacy rates of hypertensive patients at a small free clinic in Florida that serves both sheltered and unsheltered patients.

Significance of the Practice Problem
Health literacy empowers patients to be active participants in their healthcare, and without it, patients are left as bystanders to their own healthcare. Low health literacy rates can have a significant impact on patient outcomes, which is impacted by their understanding of the care and instructions. Not addressing a patient's health literacy level is an ethical and safety issue that could lead to a legal issue (Nairn, 2014). Boslaugh (2022) explains that health literacy is essentially one's healthcare knowledge, which includes the ability to find information and understand what the information means. The National Library of Medicine (2021) indicates that nearly 90% of adults struggle with some aspect of health literacy. The initial health literacy rates of the clinic in Florida are unknown, as health literacy rates have never been addressed within the clinic. It is important to understand that low health literacy rates do not necessarily mean low general literacy rates. A person can have a high literacy level and still have a low health literacy level because they do not understand the medical terminology being used when their health status is being conveyed to them (National Library of Medicine, 2021). Hickey et al. (2018) detailed that an astonishing number of American adults, 80 million, had limited or low health literacy. The Health Resources and Services Administration (2019) showed that those who were marginalized due to low socioeconomical status, those who were older, minorities, and those who were medically underserved had even lower health literacy rates. These individuals experienced a higher than usual use of emergency services compared to primary care. MacLeod and colleagues (2017) found that factors such as being older or a minority could predict lower health literacy rates, and poor health literacy rates can predict poor health status.
The health system as a whole and society can suffer greatly when there are low health literacy rates. Low health literacy rates result in unnecessary repeated care, higher mortality, and greater prevalence of disease burden. All of this combined comes at a significant cost to the health system and society; a report in 2020 by the UnitedHealth Group showed that in the United States alone, improvements in health literacy rates could result in healthcare cost savings of over 25 billion dollars and prevent nearly 1 million hospital visits in a year. This indicates that efforts to improve health literacy can help improve healthcare in general.

PICOT Question
The PICOT question used to guide the project was, in adult patients with hypertension (P), how does evidence-based education material (I) compared to the current state of verbal instructions provided (C) affect health literacy rates based on the high blood pressure health literacy scale (O) within 12-weeks (T)?

Population
The participants included in the project were all adult patients within the clinic who had a diagnosis of hypertension. The clinic sees a mix of male and female patients 18 years of age and older; therefore, the participants were both male and female patients 18 years of age or older. The patients were of varying ethnicity and race. The clinic also saw a percentage of unsheltered or homeless individuals; however, both sheltered and unsheltered participants were included. The project also included patients of any educational level and employment status. The evidence-based discharge material was only given to patients with a diagnosis of hypertension, as this is the top international classification of disease (ICD-10) code for the clinic, which was all the time frame for the project would allow.

Intervention
The intervention for the project was to implement evidence-based discharge material specific to hypertension patients for providers to disseminate. A study by Hesselink and team (2014) reported that inadequate discharge material results in adverse events. DeSal et al. (2021) showed that limited or no discharge material hinders patients' treatment compliance due to decreased health literacy. For this reason, the researcher used robust evidence-based discharge material from the American Heart Association (AHA) and made it readily available for providers. The evidence-based discharge material contained a description of the condition, an explanation of potential warning signs and symptoms of hypertension, medication education, and lifestyle modifications.

Comparison
The comparison for the project was standard practice. Prior to the project at the clinic, there was no distribution of formal consistent discharge materials, except for the current state of simple verbal instruction from the provider.

Outcome
The desired outcome for this project was increased health literacy rates of patients. The Centers for Disease Control and Prevention (2022) uniquely defined health literacy as "the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others" (para. 4). Health literacy rates correspond with patient compliance levels; the higher the health literacy rate, the greater the compliance. The instrument used to measure health literacy outcomes was the high blood pressure health literacy scale (HBP-HLS). This was first published in 2012 by Kim and colleagues. The primary author granted permission to use the instrument. The instrument is a four-part health literacy evaluation. This was given to participants before the hypertension discharge teaching and then administered again during their follow-up visit. During the initial development and testing, the instrument was concluded to be both valid and reliable. The reliability was measured using the Kuder-Richardson 20 . A KR-20 greater than 0.90 indicates good reliability (Zach, 2022). The KR-20 for the HBP-HLS is 0.98. The content validity index was used to measure validity. This was  0.8, which to be considered valid; the index should be greater than 0.78 (Polit & Beck, 2006). The literacy rates of the participants were analyzed using the demographic information and the Two-Tailed Wilcoxon Signed Rank Test.

Timing
The length of the study was 12-weeks. Patients were initially recruited over a two-week period. Those who needed a follow-up appointment per their provider's instructions within the 12-weeks were addressed during the first two weeks and given the evidence-based discharge material. The health literacy assessment was administered during the initial appointment and again at the follow-up appointment.

Evidence-Based Practice Framework & Change Theory
The Johns Hopkin's evidence-based practice (JHEBP) framework was used throughout the project. With permission, the JHEBP framework was used to guide the development and implementation of this project. The framework is a robust work plan that uses the practice question, evidence, and translation process, or PET process, to ensure that all aspects are included in a project and visualized in a Gantt chart layout (Dang et al., 2022). Each PET section has guided steps with additional appendices that were all applied to this project. The framework ensured that the practice question was pertinent, and the most current evidence regarding hypertension education and health literacy was appraised and used to select the appropriate discharge teaching for the clinic. The most beneficial component of the PET process for this project, translation, ensured that the project was properly conducted given the project manager's inability to physically be at the clinic.

Havelock's Change Theory
The project focused on changing health knowledge of hypertension to enhance health literacy and positively impact patient outcomes. Havelock's change theory was used as the foundation for the implementation of the project. Havelock's built upon Lewin's unfreezing/refreezing theory. He emphasized the importance of unfreezing but created his own steps which included first building a relationship and then assessing for change (Udod & Wagner, 2018). The next steps are to acquire resources, choose the solution, gain acceptance, and lastly, maintain and separate.
Havelock's change theory was most fitting for the project because the delivery of the evidence-based discharge material was individually reviewed with participants. The unfreezing part of the project was the lack of attention to administering evidence-based hypertension discharge material to patients. Havelock's change theory promotes a more individualized approach to change and recognizes resistance to change. Havelock's steps of building a relationship and gaining acceptance was important for this project to ensure that the participants were willing to accept the hypertension discharge material.
This was done by utilizing the staff at the clinic who the participants were already familiar with. Havelock's change theory was also important for ongoing needs assessments during the follow-up assessments. The theory emphasizes the need for knowledge building, which allowed for the healthcare provider at the clinic to continue to expand on the discharge teaching to further enhance the participants' health literacy.

Evidence Search Strategy
The evidence search strategy focused on using PubMed, CINAHL Complete, and Medline. The keywords used in CINAHL Complete, and Medline were hypertension or HTN or high blood pressure or elevated blood pressure AND health literacy or health education or health knowledge or health information or health understanding. Boolean operators were used to exclude coronavirus or COVID or COVID-19, as this topic has saturated evidence in the last two years but was not the focus of this project. The search was limited to academic journals only. The search was further limited to research written in English and published within the last three years to ensure the latest evidence was appraised. The geography was limited to only include the United States, as hypertensive management and health literacy can vary from country to country. The phrase hypertension education to enhance health literacy was used to search within PubMed. The search within PubMed was limited to the last 10 years, English, and adults for the same reasons noted earlier. Results that focus on electronic health education were all excluded, as the project setting and dissemination of hypertension education is in person.

Evidence Search Results
The initial search in all databases at University of St. Augustine resulted in 33,870 articles and 20 articles in PubMed. From there, the search criteria was applied, and this resulted in 253 articles to review for inclusion. Of the 253 articles, only seven were selected for the evidence synthesis. The articles that were excluded primarily fell into three categories that did not provide support for the project. The three main exclusion categories were articles discussing the health literacy of the providers rather than the patients, articles focused on electronic health (eHealth) or telehealth, and articles focused on homebased hypertension monitoring. Other articles were excluded if they discussed literacy of irrelevant topics or if the article was a discussion of education only. Only one systematic review and meta-analysis was retained for inclusion.
Although hypertension was not one of the non-communicable diseases included in the systematic review and meta-analysis that was retained, the statistical and clinical significance found in the study was important to include because it further supported the design of this project (See Figure 1 for the PRISMA flowchart).
The researcher used the JHEBP model to appraise each of the seven articles for the level of evidence and quality of evidence. Four articles were level III, quality A/B; two articles were level I, quality A; and one article was level II, quality A.  Dang et al. (2022) to be considered quality A/B, most of the following criteria needs to be evident: good transparency about the data process, diligence in data interpretation, clear verification process, self-reflection, participant-driven inquiry, and an insightful interpretation. The cross-sectional surveys all have some amount of the criteria present.
The two level I, quality A articles by Delavar et al. (2020) and Kurt and Gurdogan (2020) are both robust randomized control trials. In the JHEBP model, randomized control trials are considered the best and level I (Dang et al., 2022). For an article to be considered quality A, it needs to have "consistent, generalizable results; sufficient sample size for the study design; adequate control; definitive conclusions; consistent recommendations based on comprehensive literature review that includes thorough reference to scientific evidence" (Dang et al., 2022, p.5). The two randomized control trials met this criteria well. The fifth article to be included for the evidence synthesis was a systematic review and meta-analysis that was level II evidence and quality A by Heine et al. (2021). The JHEBP model indicates that a systematic review of a combination of study designs with or without a meta-analysis is considered level II evidence (Dang et al., 2022). The quality criteria was the same as described for the other four articles (See Figure 2 for evidence search result).

Themes with Practice Recommendations
Health literacy is an important component of a patient's health. The way it is delivered, the content that is delivered, and who it is delivered by were all important aspects to consider when the ultimate goal was improved outcomes for patients through enhanced health literacy. Further, it was important to understand those who had a greater need for education to enhance health literacy. Education delivery and education content were two strong themes throughout the literature as well as who is most at risk for low health literacy levels.

Education Delivery
Disease-specific, evidence-based education to enhance health literacy is necessary; however, who provides that education often varies. Education can be delivered by any member of the healthcare team, including but not limited to the primary care provider, the nursing staff, the pharmacists, or other staff such as therapists or a nutritionist. When it comes to education delivery, patients prefer to receive hypertension education directly from their primary care provider and are more likely to adopt healthy behaviors because of the education from their primary care provider (Chapman et al., 2022;Heine et al., 2021;and Kim et al., 2022). In healthcare, it is the responsibility of the healthcare providers, most importantly the primary provider, to appropriately educate patients.

Education Content
The type of education provided to patients to improve health literacy is also important. Lifestyle education seems to be preferred by patients and has the most impact on the patients' overall knowledge, attitudes, and behaviors, thus improving their health literacy. When it comes to managing hypertension, patients want education about lifestyle management more often than medication education (Chapman et al., 2022;Delavar et al., 2020;Heine et al, 2021;Whelton et al., 2018). Lifestyle education is in line with the American Heart Association (AHA) and the American College of Cardiology (ACC) hypertension management guidelines (Whelton et al., 2018). In a systematic review by Heine et al. (2021), it was discovered that lifestyle management education had a significant impact on overall health literacy among a variety of non-communicable diseases. It can be inferred that the same would be true for hypertension, as it is one of the leading non-communicable diseases. Based on the evidence, lifestyle education should be provided to patients on a routine basis to enhance health literacy.
The literature provides substantial evidence that lifestyle education is equally as important as pharmacological education. Nevertheless, the areas of focus with lifestyle education vary. The AHA/ACC guidelines suggest education focused on diet modifications, exercise, and alcohol intake in addition to medication education (Whelton et al., 2018). When it comes to medication compliance as a component of health literacy, patients need lifestyle modification education in addition to medication education as evidenced by two level I, high-quality randomized control trials (RCT) (Delavar et al., 2020 andKurt &Gurdogan, 2020).

Education Need
In healthcare, all patients need to receive education regarding their health. Some patients have high health literacy rates, and education is provided to build upon their knowledge. However, for other patients with low health literacy rates, simplified education is essential to ensure clarity and introduce the health topic to the patient.
When it comes to low health literacy rates, those who are impacted by other social determinants of health such as low income, unsheltered, and minority status are most vulnerable and need simplified and focused disease-specific education (Hickey et al., 2019 andOdoh et al., 2021). This finding is clinically significant for the project since the clinic is a free clinic serving those who fall below the 200% Federal Poverty Guidelines, and the majority of patients are unsheltered and/or Hispanic.

Practice Recommendation
It is evident that some form of evidence-based education material provided to patients can have a significant impact on their health literacy and therefore their overall health. Each article was considered to be high quality and to provide unique conclusions for practice recommendations. A systematic review and meta-analysis by Heine et al. (2021) offered validation that lifestyle education enhances health literacy throughout a variety of non-communicable diseases. The RCT listed in appendix A showed that the same is true for patients diagnosed with hypertension. Further, the cross-sectional surveys in appendix A confirmed that education promotes healthy behaviors, thus enhancing health literacy and the understanding that patients prefer to receive hypertension management education from their primary provider in a simplistic form.
Based on these findings, it was recommended that an evidence-based hypertension summary be provided to patients by their primary provider with detailed sections on medication treatment and lifestyle management with specific emphasis on diet and activity. This practice change answered the PICOT question "in adult patients with hypertension (P), how does evidence-based education material (I) compared to the current state of verbal instructions provided (C) affect health literacy rates based on the high blood pressure health literacy scale (O) within 12-weeks (T)?"

Setting, Stakeholders, and Systems Change
The project setting was a small free clinic for the uninsured that also functions as a day shelter for unsheltered individuals in the area. The clinic is the only free clinic in the area that provides primary care. To qualify as a patient at the clinic, patients must be a resident of the county and fall below the 200% Federal Poverty Guidelines. There were between 200-250 established patients at the clinic; many were Hispanic and Spanish speaking. The vision and mission of the clinic are to provide quality and compassionate healthcare to uninsured and medically underserved patients. The need for this project was established through the medical director.
The medical director, the nurse practitioner, and the director of the clinic were the primary organizational supports for this project; together, they are the primary decisionmakers. The stakeholders involved in the project were the patients, the nurse practitioner, the director, and the interim medical director. The patients were the stakeholders most impacted by the project. The nursing students were going to be the most crucial stakeholder in the project as they often act as medical assistants at the clinic. At the time of the project, there were no nursing students in rotation at the clinic; therefore, the director of the clinic became the most crucial stakeholder and the person who administered the HBP-HLS assessment and education. This will continue as long as the director is available and remains engaged. There was a need for continued interprofessional collaboration between the nurse practitioner, the director, and the project manager. The clinic had been struggling finically and subsequently underwent changes that left the clinic short staffed and with limited leadership. This was foreseen as having a significant impact on the project but ultimately had no impact. Table 1 outlines the full strengths, weakness, opportunities, and threats (SWOT) analysis. The strengths of the clinic included the dedication and compassion of the current staff along with the partnerships with various other organizations. These partnerships allow the clinic to function as a primary care clinic. The weakness of the clinic included recent reduction in force of staff, language barriers, and disorganization throughout the clinic. There were minimal opportunities for service at the clinic, however, one opportunity would have been the ability to leverage the nursing students who rotate through the clinic to assist with the project. The students ended up not taking part in the project. The largest threat was the potential for closure of the clinic due to financial constraints. Beard and colleagues (2012) explained that any change that occurs at the point where providers interact with the patients is considered micro-level system change; meso-level system change is related to changes to programs and clinic services, and macro-level system change occur at the system level or broader organizational level.
The system change level for the project was primarily at the micro level. The clinic was small and a single entity, therefore, the change did not impact a larger whole directly.
There was a minor change in workflow for the nurse practitioner who was responsible for giving the patients the evidence-based hypertension education (see Appendix E).
This did not happen due to time constraints, so the nursing director became the one who administered the education.

Implementation Plan with Timeline and Budget
The implementation plan for the project was guided by four main objectives. The main objective for the project was to improve health literacy as a social determinant of health among underserved populations by 80% by utilizing EBP education and evaluation using the high blood pressure health literacy scale. The second objective of the project was to build the EBP skills of the provider to improve outcomes for patients by utilizing EBP hypertension education 100% of the time. The third objective was to improve the quality of life and self-care among hypertension patients by reducing medication titrations by 10% during the follow-up visit. The fourth objective was that patients would be able to accurately read 80% of words from the HBP-HLS assessment whether they read in English or Spanish.
The workflow of the nurse practitioner was initially thought to be most affected by the change, therefore, her involvement as the change champion was critical. However, the change champion changed to the nursing director right before implementation started. There was excellent interprofessional collaboration throughout the project between the project manager (PM), the nurse practitioner, and the clinic director. The The timeline (Appendix C) and budget (Table 2) for the project was the most difficult aspect of the project due to several factors. The timeline started with frequent meetings with the preceptor and mentor for guidance while composing the proposal.
After the proposal was complete, the project was conducted over a 12-week period with week one starting with emails and Zoom calls to provide training on the use of the tool using clear communication. Weeks two through eleven consisted of continued emails.
The first phase of the project was to administer the HBP-HLS (Appendix D) to all participants during their appointment. The nurse practitioner originally identified the nursing students who rotate through the clinic as the provider who would have administered the HBP-HLS assessment to the patients when they were there. The nursing students ended up not taking part in the project and the nursing director became the provider who administered the education. Once the HBP-HLS was performed, the director administered the EBP hypertension education (Appendix E) to all participants. This phase continued until all possible participants were reached. Phase two began during week four of the 12-week period.
Phase two was to readminister the HBP-HLS to patients who were scheduled for follow-up appointments during the project timeline. Data collection began in week two and continued through week eleven. Data analysis began once the first post-education on HBP-HLS follow-up assessment was performed. Havelock's change theory was crucial during phase one. This was where the usual verbal education was replaced with the EBP education, and the nursing director's workflow was most impacted and accounted for the building a relationship and diagnosing the problem stages. The acquire resources for change and choose the solution stages of Havelock's change theory was ongoing starting in week two when the EBP education was given to patients.
Gaining acceptance and maintain and separate were the last stages of Havelock's change theory, which were evident as the nursing director routinely gave the education.
The budget for the project was limited. The clinic did not have the financial means to support a tremendous amount of printing, so printing was kept to a minimum.
The salary of the nurse practitioner and the clinic director was already covered by the clinic.

Results
All patients at the clinic were recruited as participants in the project. However, only those who had a planned follow-up appointment during the project time were included. This resulted in only four total participants. The implementation of the project was approved by the Evidence-Based Practice Review Council (EPRC) at University of St. Augustine Health Science and the nursing director at the clinic.

Data Collection
The data collected during the project was collected at two different points. The demographic information including age, gender, education level, sex, housing status, and hypertension diagnosis was answered using a paper survey handed to participants in the waiting room upon arrival (Appendix F). The demographic survey was important to gather information to better understand the HBP-HLS assessment and analyze the data. The HBP-HLS assessment was administered by the clinic nursing director in paper form. The HBP-HLS was administered during an appointment and before the hypertension education was given and then again when the participant followed up within the project time frame. The data was stored and maintained by the clinic nursing director in a locked room throughout the project and later sent to the PM via e-mail to be analyzed. The integrity of data collection was maintained as only one individual administered the tool. A potential risk to patients was loss of confidentiality. However, all efforts were made to ensure there was no loss of confidentiality by not using patient identifying information in the data collection. Clinical significance is just as important to evaluate as statistical significance because it is the clinical significance that indicates how meaningful the results were to patient care (Kim & Mallory, 2013. p. 152). The clinical significance was determined by the impact the study had on the setting. Therefore, clinical significance was determined by evaluating if there was any increase in HBP-HLS score for the intervention group

Impact
This project was needed in order to bring awareness to low health literacy and the impact it can have on patient outcomes. The implementation of disease specific education to enhance health literacy at the clinic has helped to address the issue of low health literacy and the need for education from a trusted individual. The sustainability of the project at the clinic is limited due to uncertainty of the future of the clinic. However, the education used for the project is standardized education from the American Heart Association. By utilizing education that is reviewed and kept up to date by a reputable organization, the accessibility and delivery of the education will be more sustainable for the clinic and other healthcare organizations.
Low health literacy is a common finding and is not specific to one disease. For this reason, expanding the education beyond hypertension will be highly beneficial. The long-term effectiveness of the intervention can be evaluated by further monitoring the patients who participated in the study and seeing if their outcomes improve. This could be evaluated by looking at their blood pressure trends, medication dose, and their verbal statements of improved eating habits and increased activity.
There were many limitations to this project. The first limitation was due to the geographical location of the clinic in relation to the project manager. The PM was not able to be physically present at the clinic and had to rely on effective communication skills through email. This limitation likely had the biggest impact on the low number of participants. The next limitation of the project was the time constraint the nurse practitioner at the clinic faced. This resulted in the director of nursing being the one to collect the health literacy assessment and administer the education. Although this was not ideal, this likely did not have any effect on the results since the director of nursing is a familiar and trusted person to the individuals at the clinic. The last main limitation to the project was low number of participants. Only four individuals were able to participate because all other possible patients did not need a scheduled follow up appointment within the project time frame. Overall, any increase in health literacy is clinically significant. Therefore, even with the limitations, the impact was meaningful.

Dissemination
The project results were disseminated in four main ways. First, at the conclusion of the data analysis, an executive summary was provided to the project site. The project was then presented virtually as an oral poster presentation to leaders and students at the University. Third, the project was shared with local providers who work closely with unsheltered individuals in the PMs hometown. Lastly, the full manuscript was submitted to the university's Scholarship and Open Access Repository (SOAR).

Conclusion
The intention of the proposed project aimed to enhance health literacy of patients diagnosed with hypertension at a free clinic using evidence-based practice hypertension discharge teaching material. Health literacy is often overlooked by providers but needs to be a priority to improve patient outcomes. The literature showed that there is an educational need and further that the education delivery and content is highly important.
By gaining support of the clinics key stakeholders and optimizing the strengths and opportunities, the objectives of the project were achieved. The data was obtained and stored in a secure manner to ensure confidentiality of the participants. Statistical analysis before and after the hypertension material was provided to patients by administering the High Blood Pressure-Health Literacy Scale assessment was achieved. There was a small increase in the printed health literacy subscale (PHL) portion of the HBP-HLS. The results of the project were disseminated to pertinent and appropriate sources.    Take medication on empty stomach one hour before or two to three hours after a meal unless otherwise directed by your doctor.

3-4. Appointment slip
The following questions are about appointment slip.

Instructions for the HBP-HLS
In the first section, participants are asked to pronounce words, arranged in columns of increasing complexity. In this section, the administrator should provide the participant with a laminated copy of the word list from which subjects will read. Using the participant's paper copy of the HBP-HLS, the administrator will mark if a word was correctly or incorrectly pronounced. The administrator should have a clipboard and pencil when testing participants. This procedure is used to help reduce shame, and to improve the objectivity of the scoring.
The test is to be administered one-on-one, rather than in a group setting. The examiner should be familiar with the pronunciation of words before administering the test. The examiner's copy should not be visible to the subject. Should the subject be curious about the correct pronunciation of words, this should be deferred until after the test is completed.
For sections 2-4, please read ONLY the questions to the participant. Have them to read and interpret the LABELS themselves.
Many low-or non-literate subjects are very sensitive about their inability to read and should be treated at all times with courtesy and respect. Their inability to read should not be treated as blameworthy. Before beginning testing, make sure that those subjects who need eyeglasses or contact lenses are wearing them for the test.
*The HBP-HLS is an open access instrument and permission has been granted for use by the author