Effectiveness of a Just-In-Time Adaptive App to Increase Daily Steps: An RCT.

INTRODUCTION: Addressing the public health problem of physical inactivity, this study evaluates "SNapp", a just-in-time adaptive app intervention to promote walking through dynamically tailored coaching content. It assesses SNapp's impact on daily steps and how users' perceptions regarding ease of use and usefulness moderated its effectiveness. STUDY DESIGN: SNapp was evaluated in an RCT from February 2021 to May 2022. Analyses were conducted in November 2022. SETTING/PARTICIPANTS: 176 adults (76% female, mean age of 56 years) were randomized to a control group receiving a step counter app (n = 89) or an intervention group receiving the app plus coaching content (n = 87). INTERVENTION: SNapp's coaching content encompasses individually tailored feedback on step counts and advice to engage in more walking, taking preferences regarding behavior change techniques into account. Additionally, SNapp provides contextualized content calling attention to suitable walking locations in the user's environment. MAIN OUTCOME MEASURES: The primary outcome was daily step count as recorded by the step counter app. User perceptions regarding ease of use and usefulness were assessed via survey at 3-month follow-up. RESULTS: Mixed models indicated that the intervention did not significantly impact step counts on average over time (B = -202.30, 95% CI = -889.7, 485.1), with the coefficient indicating that the intervention group walked fewer steps per day on average, though this difference was not statistically significant. Perceived ease of use did not moderate the intervention effect (B group x perceived ease of use = 38.60, 90% CI = -276.5, 353.7). Perceived usefulness significantly moderated the intervention effect (B group x perceived usefulness = 344.38, 90% CI = 40.4, 648.3). CONCLUSIONS: SNapp increased steps only in users who deemed the app useful, underscoring the importance of user perceptions in app-based interventions. TRIAL REGISTRATION: This trial was preregistered in the Dutch Trial Register (NL7064).

Real-world nudging, pricing, and mobile physical activity coaching was insufficient to improve lifestyle behaviours and cardiometabolic health: the Supreme Nudge parallel cluster-randomised controlled supermarket trial.

BACKGROUND: Context-specific interventions may contribute to sustained behaviour change and improved health outcomes. We evaluated the real-world effects of supermarket nudging and pricing strategies and mobile physical activity coaching on diet quality, food-purchasing behaviour, walking behaviour, and cardiometabolic risk markers. METHODS: This parallel cluster-randomised controlled trial included supermarkets in socially disadvantaged neighbourhoods across the Netherlands with regular shoppers aged 30-80 years. Supermarkets were randomised to receive co-created nudging and pricing strategies promoting healthier purchasing (N = 6) or not (N = 6). Nudges targeted 9% of supermarket products and pricing strategies 3%. Subsequently, participants were individually randomised to a control (step counter app) or intervention arm (step counter and mobile coaching app) to promote walking. The primary outcome was the average change in diet quality (low (0) to high (150)) over all follow-up time points measured with a validated 40-item food frequency questionnaire at baseline and 3, 6, and 12 months. Secondary outcomes included healthier food purchasing (loyalty card-derived), daily step count (step counter app), cardiometabolic risk markers (lipid profile and HbA1c via finger prick, and waist circumference via measuring tape), and supermarket customer satisfaction (questionnaire-based: very unsatisfied (1) to very satisfied (7)), evaluated using linear mixed-models. Healthy supermarket sales (an exploratory outcome) were analysed via controlled interrupted time series analyses. RESULTS: Of 361 participants (162 intervention, 199 control), 73% were female, the average age was 58 (SD 11) years, and 42% were highly educated. Compared to the control arm, the intervention arm showed no statistically significant average changes over time in diet quality (ߠ- 1.1 (95% CI - 3.8 to 1.7)), percentage healthy purchasing (ß 0.7 ( - 2.7 to 4.0)), step count (ߠ- 124.0 (- 723.1 to 475.1), or any of the cardiometabolic risk markers. Participants in the intervention arm scored 0.3 points (0.1 to 0.5) higher on customer satisfaction on average over time. Supermarket-level sales were unaffected (ß - 0.0 (- 0.0 to 0.0)). CONCLUSIONS: Co-created nudging and pricing strategies that predominantly targeted healthy products via nudges were unable to increase healthier food purchases and intake nor improve cardiometabolic health. The mobile coaching intervention did not affect step count. Governmental policy measures are needed to ensure more impactful supermarket modifications that promote healthier purchases. TRIAL REGISTRATION: Dutch Trial Register ID NL7064, 30 May 2018, https://www.onderzoekmetmensen.nl/en/trial/20990.

SNapp, a Tailored Smartphone App Intervention to Promote Walking in Adults of Low Socioeconomic Position: Development and Qualitative Pilot Study.

BACKGROUND: Adults of low socioeconomic position (SEP) are generally less physically active than those who are more socioeconomically advantaged, which increases their cardiovascular disease incidence risk. Moreover, individuals of low SEP are often less easily reached with physical activity (PA) interventions than individuals of higher SEP. Smartphone apps have been presented as a promising platform for delivering PA interventions to difficult-to-reach individuals of low SEP. Although PA apps are widely available, they are rarely based on health behavior theories and most predominantly offer generic PA advice. Consequently, it is unlikely that available apps are the most effective PA intervention tools. OBJECTIVE: To respond to these areas for improvement, we developed SNapp, an app-based intervention encouraging adults of low SEP to increase PA by providing tailored coaching messages targeting walking behavior. This study aimed to describe SNapp's stepwise development and pilot evaluation process. METHODS: We applied a stepwise approach: analyzing the health problem, developing a program framework, developing tailoring assessments, writing tailored messages, automating the tailoring process, and implementing and evaluating the program in a qualitative pilot study (11 participants). RESULTS: SNapp consisted of several elements. First, an app was developed to collect step count and geolocation data using smartphone sensor functionalities. In addition, a survey measure was created to assess users' behavior change technique (BCT) preferences. These 3 data types were used to tailor SNapp's coaching messages to stimulate walking. This allows SNapp to offer feedback on performance levels, contextually tailored prompts when users are near green spaces, and coaching content that aligns with individual BCT preferences. Finally, a server-based Python program that interacts with databases containing user data and tailored messages was built using Microsoft Azure to select and automatically send messages to users through Telegram messenger. Pilot study findings indicated that SNapp was rated positively, with participants reporting that its design, technical functioning, and message content were acceptable. Participants suggested additional functionalities that are worth considering for future updates. CONCLUSIONS: SNapp is an app-based intervention that aims to promote walking in adults of low SEP by offering tailored coaching messages. Its development is theory based, and it is among the first to incorporate contextualized feedback and content tailored to individual BCT preferences. The effectiveness of SNapp will be evaluated in a 12-month real-life parallel cluster-randomized controlled trial.

Participant recruitment, baseline characteristics and at-home-measurements of cardiometabolic risk markers: insights from the Supreme Nudge parallel cluster-randomised controlled supermarket trial.

BACKGROUND: Recruiting participants for lifestyle programmes is known to be challenging. Insights into recruitment strategies, enrolment rates and costs are valuable but rarely reported. We provide insight into the costs and results of used recruitment strategies, baseline characteristics and feasibility of at-home cardiometabolic measurements as part of the Supreme Nudge trial investigating healthy lifestyle behaviours. This trial was conducted during the COVID-19 pandemic, requiring a largely remote data collection approach. Potential sociodemographic differences were explored between participants recruited through various strategies and for at-home measurement completion rates. METHODS: Participants were recruited from socially disadvantaged areas around participating study supermarkets (n = 12 supermarkets) across the Netherlands, aged 30-80 years, and regular shoppers of the participating supermarkets. Recruitment strategies, costs and yields were logged, together with completion rates of at-home measurements of cardiometabolic markers. Descriptive statistics are reported on recruitment yield per used method and baseline characteristics. We used linear and logistic multilevel models to assess the potential sociodemographic differences. RESULTS: Of 783 recruited, 602 were eligible to participate, and 421 completed informed consent. Most included participants were recruited via letters/flyers at home (75%), but this strategy was very costly per included participant (89 Euros). Of paid strategies, supermarket flyers were the cheapest (12 Euros) and the least time-invasive (< 1 h). Participants who completed baseline measurements (n = 391) were on average 57.6 (SD 11.0) years, 72% were female and 41% had high educational attainment, and they often completed the at-home measurements successfully (lipid profile 88%, HbA1c 94%, waist circumference 99%). Multilevel models suggested that males tended to be recruited more often via word-of-mouth (ORfemales 0.51 (95%CI 0.22; 1.21)). Those who failed the first attempt at completing the at-home blood measurement were older (ß 3.89 years (95% CI 1.28; 6.49), whilst the non-completers of the HbA1c (ß - 8.92 years (95% CI - 13.62; - 4.28)) and LDL (ß - 3.19 years (95% CI - 6.53; 0.09)) were younger. CONCLUSIONS: Supermarket flyers were the most cost-effective paid strategy, whereas mailings to home addresses recruited the most participants but were very costly. At-home cardiometabolic measurements were feasible and may be useful in geographically widespread groups or when face to face contact is not possible. TRIAL REGISTRATION: Dutch Trial Register ID NL7064, 30 May 2018, https://trialsearch.who.int/Trial2.aspx?TrialID=NTR7302.

Cancer patients' needs for support in expressing instrumental concerns and emotions.

INTRODUCTION: The aim of our study was to provide an overview of intervention guidelines on how to address patients' practical needs for support in expressing instrumental concerns and emotions regarding medical, psychosocial and practical topics. METHODS: Six focus groups of cancer patients and survivors (N = 39) were organised. An interview guide was created that consisted of three topics: (a) concerns, (b) needs for support, and (c) a Concern Prompt List. Using the framework method, the transcripts were coded and analysed in Atlas T.I. RESULTS: Patients prefer to receive practical and emotional support, help with preparation, prompts/cues, instructions on how to perform the behaviour (i.e., express their concerns or emotions), feedback, a different structure for the consultation and tailoring. Most of these techniques should preferably be delivered via interpersonal communication. Needs sometimes differ for instrumental concerns and emotions. Only some needs for support were exclusively related to instrumental concerns or emotions. The typical needs for support were not solely linked to the medical, psychosocial and practical topics. CONCLUSION: Different needs to express instrumental concerns and emotions throughout the disease trajectory are categorised. These needs provide input for developing interventions to support concern expression.

"I was Right about Vaccination": Confirmation Bias and Health Literacy in Online Health Information Seeking.

When looking for health information, many people turn to the Internet. Searching for online health information (OHI), however, also involves the risk of confirmation bias by means of selective exposure to information that confirms one's existing beliefs and a biased evaluation of this information. This study tests whether biased selection and biased evaluation of OHI occur in the context of early-childhood vaccination and whether people's health literacy (HL) level either prevents or facilitates these processes. Vaccination beliefs were measured for 480 parents of young children (aged 0-4 years) using an online survey, after which they were exposed to a list of ten vaccine-related message headers. People were asked to select those headers that interested them most. They also had to evaluate two texts which discussed vaccination positively and negatively for credibility, usefulness, and convincingness. The results showed that people select more belief-consistent information compared to belief-inconsistent information and perceived belief-confirming information as being more credible, useful, and convincing. Biased selection and biased perceptions of message convincingness were more prevalent among people with higher HL, and health communication professionals should be aware of this finding in their practice.

The effects of persuasive messages on cancer patients' attitudes, norms and intention to express concerns.

OBJECTIVE: To examine whether the use of persuasive messages in which cancer patients' attitudes and perceived social norms were either simultaneously or exclusively targeted can positively change patients' attitudes, perceived social norms and the intention to express concerns in consultations. METHODS: Two online experiments were conducted. The first experiment had a pre-test and post-test measurements design with 4 conditions (attitudes message, social norms message, combined message, control message). The second experiment had a pre-test and post-test measurements design with 2 conditions (message and no message group). RESULTS: The results of the first study showed small positive changes for patients who could potentially change, but there were no differences in effects between conditions. A second study was conducted to determine whether these effects could be attributed to exposure to the message or to the pre-test questionnaire. There were no differences between the conditions. CONCLUSION: The results indicate that paying attention to the expression of concerns by patients might increase patients' intention to express further concerns. PRACTICE IMPLICATIONS: Providers might be able to support patients' in their sharing of concerns through simple communication strategies such as explicitly mentioning that the expression of concerns is possible during a consultation.

Patients' Online Information-Seeking Behavior Throughout Treatment: The Impact on Medication Beliefs and Medication Adherence.

Research on the longitudinal impact of using the internet as an information source on patients' beliefs and medication adherence is scarce. Chronic patients (N = 107) from six hospitals were surveyed to longitudinally explore their online information seeking behavior throughout treatment (i.e., before the consultation about their newly prescribed medication in the initiation phase and after six months in the implementation phase) and how this affects their medication beliefs (concerns and necessity) and medication adherence after three weeks (T1) and six months (T2). Most patients (79%) used the internet. Patients who used the internet before the consultation reported to have more concerns about their medication at T1 and T2 compared to those who did not. Moreover, patients who used the internet throughout treatment valued their concerns higher than the necessity after six months (T2). Patients who used the internet after the consultation reported to be more non-adherent after three weeks (T1) compared to those who did not. Because of the longitudinal nature of this study, we were able to pinpoint in which treatment phase patients' online information seeking behavior is particular relevant in affecting patients' beliefs and medication adherence.

Creating a synergy effect: A cluster randomized controlled trial testing the effect of a tailored multimedia intervention on patient outcomes.

OBJECTIVE: Improving adherence is a challenge and multiple barriers are likely to explain non-adherence. These barriers differ per patient and over course of the regimen. Hence, personalized interventions tailored to the specific barriers are needed. In a theoretical and evidence-based Tailored Multimedia Intervention, technology (online preparatory assessment, text messaging) was used as an add-on to a tailored counseling session (learned during a communication skills training), with the expectation of synergistic effects. METHODS: A cluster randomized controlled trial was conducted in six hospitals, eight nurses and 160 chronic patients. Patient satisfaction with communication, beliefs about medication, self-efficacy and medication adherence were assessed at initiation of the treatment and after six months. RESULTS: Intervention effects were found for patient satisfaction with nurses' affective communication and self-efficacy at the initiation of treatment. The effect on self-efficacy remained after six months. CONCLUSION: By combining tailored counseling with technology, this intervention resulted in positive changes in important prerequisites of medication adherence. PRACTICAL IMPLICATIONS: Technology can contribute significantly to health care providers' ability to tailor information to the patients' needs.

Dutch health websites and their ability to inform people with low health literacy.

OBJECTIVE: To evaluate whether Dutch online health information (OHI) generally reflects message elements that support information processing and understanding among people with low health literacy. METHODS: We content-analyzed one hundred Dutch webpages about Ebola, fibromyalgia, ALS, losing weight, borderline personality disorder, hemorrhoids, ADD, bladder infection, shingles, and chicken pox. The codebook covered the following domains: images and videos, readability level, Suitability Assessment of Materials (SAM), advertising, interactive features, and reliability cues. RESULTS: Thirty-seven webpages contained informative images that visualized the text. Twelve webpages incorporated videos, six of which were animations. Readability varied widely, but 79.2% of the texts exceeded the recommended B1 level. Half of the webpages had inadequate SAM scores; five were classified as superior. Interactive features were infrequently used. Many webpages included only a few elements that help users evaluate the reliability of OHI. Four presented a quality label. CONCLUSION: Over a wide range of health-related topics, Dutch OHI does not generally contain message elements that improve information processing among people with low health literacy. PRACTICE IMPLICATIONS: Communication professionals should make better use of digital message features. Videos, narration, and interactivity are scarcely used but can be valuable for people with low health literacy.

Understanding the interplay of cancer patients' instrumental concerns and emotions.

OBJECTIVE: 1) to assess patients' descriptions of concerns, and 2) to inform a conceptual framework in which the impact of the nature of concerns on doctor-patient communication is specified. METHODS: Six focus groups were conducted with 39 cancer patients and survivors. In these focus groups participants were asked to describe their concerns during and after their illness. RESULTS: Concerns were described as instrumental concerns (e.g., receiving insufficient information) and emotions (e.g., sadness). Patients frequently explained their concerns as an interplay of instrumental concerns and emotions. Examples of the interplay were "receiving incorrect information" and "frustration", and "difficulties with searching, finding and judging of information" and "fear". CONCLUSION: Instrumental concerns need to be taken into account in the operationalization of concerns in research. Based on the interplay, the conceptual framework suggests that patients can express instrumental concerns as emotions and emotions as instrumental concerns. Consequently, providers can respond with instrumental and emotional communication when patients express an interplay of concerns. PRACTICE IMPLICATIONS: The results of this study can be used to support providers in recognizing concerns that are expressed by patients in consultations.

Signalling product healthiness through symbolic package cues: Effects of package shape and goal congruence on consumer behaviour.

Three studies show that product packaging shape serves as a cue that communicates healthiness of food products. Inspired by embodiment accounts, we show that packaging that simulates a slim body shape acts as a symbolic cue for product healthiness (e.g., low in calories), as opposed to packaging that simulates a wide body shape. Furthermore, we show that the effect of slim package shape on consumer behaviour is goal dependent. Whereas simulation of a slim (vs. wide) body shape increases choice likelihood and product attitude when consumers have a health-relevant shopping goal, packaging shape does not affect these outcomes when consumers have a hedonic shopping goal. In Study 3, we adopt a realistic shopping paradigm using a shelf with authentic products, and find that a slim (as opposed to wide) package shape increases on-shelf product recognition and increases product attitude for healthy products. We discuss results and implications regarding product positioning and the packaging design process.

Framing in Entertainment-Education: Effects on Processes of Narrative Persuasion.

Nowadays, entertainment-education (E-E) is often used as a persuasive strategy to stimulate prosocial behavior. Although E-E is mostly regarded as a persuasive strategy in itself, in an increasing number of E-E programs several persuasive strategies are used to communicate the educational message to the audience. This study investigates the effects of a strategy widely used in health communication, but not previously studied in the field of E-E: framing. To this means we examined the effect of two different ways an E-E message can be framed: by emphasizing either the losses of not performing the behavior in question or the gains of performing this behavior. A serial multiple mediation model showed that framing affected intention to refrain from drunk cycling via counterarguing and attitude toward drunk cycling; the use of a gain frame decreased counterarguing, which decreased the attitude toward drunk cycling. This subsequently resulted in a higher intention to refrain from this behavior. Implications of these results are discussed.

Health Literacy and Online Health Information Processing: Unraveling the Underlying Mechanisms.

The usefulness of the Internet as a health information source largely depends on the receiver's health literacy. This study investigates the mechanisms through which health literacy affects information recall and website attitudes. Using 2 independent surveys addressing different Dutch health websites (N = 423 and N = 395), we tested the mediating role of cognitive load, imagination ease, and website involvement. The results showed that the influence of health literacy on information recall and website attitudes was mediated by cognitive load and imagination ease but only marginally by website involvement. Thus, to improve recall and attitudes among people with lower health literacy, online health communication should consist of information that is not cognitively demanding and that is easy to imagine.

Unraveling the Determinants of Cancer Patients' Intention to Express Concerns.

Little is known about the behavioral determinants that underlie cancer patients' intention to express concerns during a consultation. This information can be relevant to developing effective interventions for cancer patients. In this study, the integrative model of behavioral prediction (IMBP) is used as a framework to unravel the determinants of patients' intention to express concerns. The objectives of this study are to examine which of the IMBP determinants (attitude, perceived social norm, and/or self-efficacy) are significantly related to intention and what content of these determinants can be targeted to effect a change in patients' intention. An online survey based on the IMBP determinants was distributed. A total of 236 cancer patients and cancer survivors participated. The results of the survey showed that patients' attitudes and perceived social norm were the most important determinants of their intention to express concerns. The largest change in patients' intention might be achieved by targeting the affective attitude, referring to the extent to which patients believe that expressing concerns is (un)pleasant, and the social norm, referring to the extent to which patients feel (un)supported by significant others in expressing concerns.

The value of nurses' tailored communication when discussing medicines: Exploring the relationship between satisfaction, beliefs and adherence.

Numerous studies of various populations and settings link patient-provider communication or beliefs to medication adherence. A better understanding of this interplay may help to improve patient-centred communication. To predict adherence, this study used the Beliefs about Medicines Questionnaire and indications of the quality of the nurse's communication in terms of patient satisfaction. Patient satisfaction with the information provided and the degree to which the information was tailored to them were related to adherence via the patient's beliefs. This study supports the argument that tailoring is an effective strategy for improving adherence via beliefs and can contribute to medical education and to adherence interventions.

Should We Be Afraid of Simple Messages? The Effects of Text Difficulty and Illustrations in People With Low or High Health Literacy.

It is often recommended that health information should be simplified for people with low health literacy. However, little is known about whether messages adapted to low health literacy audiences are also effective for people with high health literacy, or whether simple messages are counterproductive in this group. Using a two (illustrated vs. text-only) by two (nondifficult vs. difficult text) between-subjects design, we test whether older adults with low (n = 279) versus high health literacy (n = 280) respond differently to colorectal cancer screening messages. Results showed that both health literacy groups recalled information best when the text was nondifficult. Reduced text difficulty did not lead to negative attitudes or less intention to have screening among people with high health literacy. Benefits of illustrations, in terms of improved recall and attitudes, were only found in people with low health literacy who were exposed to difficult texts. This was not found for people with high health literacy. In terms of informed decisions, nondifficult and illustrated messages resulted in the best informed decisions in the low health literacy group, whereas the high health literacy group benefited from nondifficult text in general, regardless of illustrations. Our findings imply that materials adapted to lower health literacy groups can also be used for a more general audience, as they do not deter people with high health literacy.

Strategies and motives for resistance to persuasion: an integrative framework.

Persuasion is an important element of human communication. But in many situations, we resist rather than embrace persuasive attempts. Resistance to persuasion has been studied in many different disciplines, including communication science, psychology, and marketing. The present paper reviews and connects these diverse literatures, and provides an organizing framework for understanding and studying resistance. Four clusters of resistance strategies are defined (avoidance, contesting, biased processing, and empowerment), and these clusters are related to different motivations for resisting persuasion (threat to freedom, reluctance to change, and concerns of deception). We propose that, while avoidance strategies may be triggered by any of these motivations, contesting strategies are linked primarily to concerns of deception, while empowerment and biased processing strategies are most common when people are reluctant to change.

Does Media Use Result in More Active Communicators? Differences Between Native Dutch and Turkish-Dutch Patients in Information-Seeking Behavior and Participation During Consultations With General Practitioners.

This study investigates differences between native Dutch and Turkish-Dutch patients with respect to media usage before and patient participation during medical consultations with general practitioners. In addition, the authors assessed the relation between patient participation and communication outcomes. The patients were recruited in the waiting rooms of general practitioners, and 191 patients (117 native Dutch, 74 Turkish-Dutch) completed pre- and postconsultation questionnaires. Of this sample, 120 patients (62.8%; 82 native Dutch, 38 Turkish-Dutch) agreed to have their consultations recorded to measure patient participation. Compared with Turkish-Dutch patients of similar educational levels, results showed that native Dutch patients used different media to search for information, participated to a greater extent during their consultations and were more responsive to their general practitioner. With respect to the Turkish-Dutch patients, media usage was related to increased patient participation, which was correlated with having fewer unfulfilled information needs; however, these relations were not found in the native Dutch patient sample. In conclusion, interventions that enhance participation among ethnic minority patients will better fulfill informational needs when such interventions stimulate information-seeking behavior in that group before a medical consultation.

The effectiveness of health animations in audiences with different health literacy levels: an experimental study.

BACKGROUND: Processing Web-based health information can be difficult, especially for people with low health literacy. Presenting health information in an audiovisual format, such as animation, is expected to improve understanding among low health literate audiences. OBJECTIVE: The aim of this paper is to investigate what features of spoken health animations improve information recall and attitudes and whether there are differences between health literacy groups. METHODS: We conducted an online experiment among 231 participants aged 55 years or older with either low or high health literacy. A 2 (spoken vs written text) x 2 (illustration vs animation) design was used. Participants were randomly exposed to one of the four experimental messages, all providing the same information on colorectal cancer screening. RESULTS: The results showed that, among people with low health literacy, spoken messages about colorectal cancer screening improved recall (P=.03) and attitudes (P=.02) compared to written messages. Animations alone did not improve recall, but when combined with spoken text, they significantly improved recall in this group (P=.02). When exposed to spoken animations, people with low health literacy recalled the same amount of information as their high health literate counterparts (P=.12), whereas in all other conditions people with high health literacy recalled more information compared to low health literate individuals. For people with low health literacy, positive attitudes mediated the relationship between spoken text and the intention to have a colorectal cancer screening (b=.12; 95% CI 0.02-0.25). CONCLUSIONS: We conclude that spoken animation is the best way to communicate complex health information to people with low health literacy. This format can even bridge the information processing gap between audiences with low and high health literacy as the recall differences between the two groups are eliminated. As animations do not negatively influence high health literate audiences, it is concluded that information adapted to audiences with low health literacy suits people with high health literacy as well.