Health literacy has been associated with health-related knowledge and patient comprehension. This systematic review updates a 2004 review and found 96 eligible studies that suggest that low health ...

Low Health Literacy and Health Outcomes: An Updated Systematic Review

Objectives To update a 2004 systematic review of health care service use and health outcomes related to differences in health literacy level and interventions designed to improve these outcomes for individuals with low health literacy. Disparities in health outcomes and effectiveness of interventions among different sociodemographic groups were also examined. Data sources We searched MEDLINE®, the Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, PsychINFO, and the Educational Resources Information Center. For health literacy, we searched using a variety of terms, limited to English and studies published from 2003 to May 25, 2010. For numeracy, we searched from 1966 to May 25, 2010. Review methods We used standard Evidence-based Practice Center methods of dual review of abstracts, full-text articles, abstractions, quality ratings, and strength of evidence grading. We resolved disagreements by consensus. We evaluated whether newer literature was available for answering key questions, so we broadened our definition of health literacy to include numeracy and oral (spoken) health literacy. We excluded intervention studies that did not measure health literacy directly and updated our approach to evaluate individual study risk of bias and to grade strength of evidence. Results We included good- and fair-quality studies: 81 studies addressing health outcomes (reported in 95 articles including 86 measuring health literacy and 16 measuring numeracy, of which 7 measure both) and 42 studies (reported in 45 articles) addressing interventions. Differences in health literacy level were consistently associated with increased hospitalizations, greater emergency care use, lower use of mammography, lower receipt of influenza vaccine, poorer ability to demonstrate taking medications appropriately, poorer ability to interpret labels and health messages, and, among seniors, poorer overall health status and higher mortality. Health literacy level potentially mediates disparities between blacks and whites. The strength of evidence of numeracy studies was insufficient to low, limiting conclusions about the influence of numeracy on health care service use or health outcomes. Two studies suggested numeracy may mediate the effect of disparities on health outcomes. We found no evidence concerning oral health literacy and outcomes. Among intervention studies (27 randomized controlled trials [RCTs], 2 cluster RCTs, and 13 quasi-experimental designs), the strength of evidence for specific design features was low or insufficient. However, several specific features seemed to improve comprehension in one or a few studies. The strength of evidence was moderate for the effect of mixed interventions on health care service use; the effect of intensive self-management inventions on behavior; and the effect of disease-management interventions on disease prevalence/severity. The effects of other mixed interventions on other health outcomes, including knowledge, self-efficacy, adherence, and quality of life, and costs were mixed; thus, the strength of evidence was insufficient. Conclusions The field of health literacy has advanced since the 2004 report. Future research priorities include justifying appropriate cutoffs for health literacy levels prior to conducting studies; developing tools that measure additional related skills, particularly oral (spoken) health literacy; and examining mediators and moderators of the effect of health literacy. Priorities in advancing the design features of interventions include testing novel approaches to increase motivation, techniques for delivering information orally or numerically, "work around" interventions such as patient advocates; determining the effective components of already-tested interventions; determining the cost-effectiveness of programs; and determining the effect of policy and practice interventions.

/pdf/health-literacy-interventions-and-outcomes-an-updated-chswt8nilu.pdf

Health literacy interventions and outcomes: an updated systematic review.

Health literacy has been put forward as a potential mechanism explaining the well-documented relationship between education and health. However, little empirical research has been undertaken to explore this hypothesis. The present study aims to study whether health literacy could be a pathway by which level of education affects health status. Health literacy was measured by the Health Activities and Literacy Scale, using data from a subsample of 5,136 adults between the ages of 25 and 65 years, gathered within the context of the 2007 Dutch Adult Literacy and Life Skills Survey. Linear regression analyses were used in separate models to estimate the extent to which health literacy mediates educational disparities in self-reported general health, physical health status, and mental health status as measured by the Short Form-12. Health literacy was found to partially mediate the association between low education and low self-reported health status. As such, improving health literacy may be a useful strategy for reducing disparities in health related to education, as health literacy appears to play a role in explaining the underlying mechanism driving the relationship between low level of education and poor health.

https://www.tandfonline.com/doi/pdf/10.1080/10810730.2013.825668

The relationship between health, education, and health literacy: results from the Dutch adult literacy and life skills survey.

Context Little is known about the effects of low health literacy among patients with heart failure, a condition that requires self-management and frequent interactions with the health care system. Objective To evaluate the association between low health literacy and all-cause mortality and hospitalization among outpatients with heart failure. Design, Setting, and Patients Retrospective cohort study conducted at Kaiser Permanente Colorado, an integrated managed care organization. Outpatients with heart failure were identified between January 2001 and May 2008, were surveyed by mail, and underwent follow-up for a median of 1.2 years. Health literacy was assessed using 3 established screening questions and categorized as adequate or low. Responders were excluded if they did not complete at least 1 health literacy question or if they did not have at least 1 year of enrollment prior to the survey date. Main Outcome Measures All-cause mortality and all-cause hospitalization. Results Of the 2156 patients surveyed, 1547 responded (72% response rate). Of 1494 included responders, 262 (17.5%) had low health literacy. Patients with low health literacy were older, of lower socioeconomic status, less likely to have at least a high school education, and had higher rates of coexisting illnesses. In multivariable Cox regression, low health literacy was independently associated with higher mortality (unadjusted rate, 17.6% vs 6.3%; adjusted hazard ratio, 1.97 [95% confidence interval, 1.3-2.97]; P = .001) but not hospitalization (unadjusted rate, 30.5% vs 23.2%; adjusted hazard ratio, 1.05 [95% confidence interval, 0.8-1.37]; P = .73). Conclusion Among patients with heart failure in an integrated managed care organization, low health literacy was significantly associated with higher all-cause mortality.

https://jamanetwork.com/journals/jama/articlepdf/899405/joc15035_1695_1701.pdf

Health literacy and outcomes among patients with heart failure.

Medication adherence: a call for action.

Inability to read the labels on prescription medication containers is a possible reason for poor medication adherence. In this study of patients in community health centers, many were unable to und...

http://krhis.kdhe.state.ks.us/olrh/Notices.nsf/bf25ab0f47ba5dd785256499006b15a4/7505f589436f625486257237006890bb/$FILE/Perscription%20Litercracy.pdf

Literacy and Misunderstanding Prescription Drug Labels

A critical review of FDA-approved Medication Guides.

Background: Health literacy has increasingly been viewed as a patient safety issue and may contribute to medication errors. Objective: To examine patients' abilities to understand and demonstrate instructions found on container labels of common prescription medications. Design: Cross-sectional study using in-person, structured interviews. Setting: 3 primary care clinics serving mostly indigent populations in Shreveport, Louisiana; Jackson, Michigan; and Chicago, Illinois. Patients: 395 English-speaking adults waiting to see their providers. Measurement: Correct understanding of instructions on 5 container labels; demonstration of 1 label's dosage instructions. Results: Correct understanding of the 5 labels ranged from 67.1 % to 91.1%. Patients reading at or below the sixth-grade level (low literacy) were less able to understand all 5 label instructions. Although 70.7% of patients with low literacy correctly stated the instructions, "Take two tablets by mouth twice daily," only 34.7% could demonstrate the number of pills to be taken daily. After potential confounding variables were controlled for, low (adjusted relative risk, 2.32 [95% Cl, 1.26 to 4.28]) and marginal (adjusted relative risk, 1.94 [Cl, 1.14 to 3.27]) literacy were significantly associated with misunderstanding. Taking a greater number of prescription medications was also statistically significantly associated with misunderstanding (adjusted relative risk, 2.98 [Cl, 1.40 to 6.34] for ≥5 medications). Limitations: The study sample was at high risk for poor health literacy and outcomes. Most participants were women, and all spoke English. The authors did not examine the association between misunderstanding and medication error or evaluate patients' actual prescription drug-taking behaviors. Conclusions: Lower literacy and a greater number of prescription medications were independently associated with misunderstanding the instructions on prescription medication labels.

Marolee Neuberger

Papers

Literacy and Misunderstanding Prescription Drug Labels

A critical review of FDA-approved Medication Guides.

Literacy and misunderstanding prescription drug labels. Commentary