, 2012). However, two similar studies found no association ( Miller et al., 2007 and Peterson et al., 2007). One of these studies was statistically underpowered ( Peterson et al., 2007), and use of the REALM may have limited all three studies: the REALM simply measures vocabulary, while the decision to undergo FOBT screening is dependent on a broader

range of health literacy skills such as comprehension, reasoning, and judgement. Health literacy has, however, been associated with knowledge and positive attitudes toward CRC screening ( Arnold et al., 2012, Dolan et al., 2004, Miller selleck et al., 2007 and Peterson et al., 2007). The pathways between health literacy, knowledge and beliefs about CRC screening, and screening uptake remain to be elucidated in empirical research, although useful theoretical frameworks exist ( Davis et al., 2001 and von Wagner et al., 2009b). Consistent with our findings, an American study of a video intervention to communicate CRC screening information found that individuals with low health literacy were less likely to retain screening information (Wilson et al., 2010). A Gemcitabine greater burden of CRC knowledge processing effort during information seeking by those with lower health literacy has also been shown (von Wagner et al., 2009a). Communication interventions to improve CRC screening rates

must therefore be appropriate in terms of cognitive and health much literacy demands. The current written materials in the NHS screening programme are difficult for individuals to process and understand (Smith et al., 2013), while trials of general practitioner endorsement and ‘gist-based’ information materials for individuals with low literacy are underway in the UK (Damery et al., 2012 and Smith et al., 2013). This large analysis examined the role

of health literacy in CRC screening participation in the context of the publicly-available NHS screening programme. Because overall programme uptake remains low and characterised by social inequalities, our results are valuable for understanding and addressing these problems. Although our measure of health literacy was not validated as a stand-alone measure, it was developed using a framework defining literacy as a functional ability to complete goal-directed tasks (Thorn, 2009). This task represents a health management responsibility commonly faced by older adults that requires reading comprehension and judgement skills; this measure is a more comprehensive assessment of functional health literacy skills than simple vocabulary tests such as the REALM. In our statistical analysis we adjusted for important sociodemographic covariates and used population weights to increase the representativeness of our sample to the general English population.

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