Approximately 80 million Americans have limited health literacy, which puts them at greater risk for poorer access to care and poorer health outcomes.
To update a 2004 systematic review and determine whether low health literacy is related to poorer use of health care, outcomes, costs, and disparities in health outcomes among persons of all ages.
English-language articles identified through MEDLINE, CINAHL, PsycINFO, ERIC, and Cochrane Library databases and hand-searching (search dates for articles on health literacy, 2003 to 22 February 2011; for articles on numeracy, 1966 to 22 February 2011).
Two reviewers independently selected studies that compared outcomes by differences in directly measured health literacy or numeracy levels.
One reviewer abstracted article information into evidence tables; a second reviewer checked information for accuracy. Two reviewers independently rated study quality by using predefined criteria, and the investigative team jointly graded the overall strength of evidence.
96 relevant good- or fair-quality studies in 111 articles were identified: 98 articles on health literacy, 22 on numeracy, and 9 on both. Low health literacy was consistently associated with more hospitalizations; greater use of emergency care; lower receipt of mammography screening and influenza vaccine; poorer ability to demonstrate taking medications appropriately; poorer ability to interpret labels and health messages; and, among elderly persons, poorer overall health status and higher mortality rates. Poor health literacy partially explains racial disparities in some outcomes. Reviewers could not reach firm conclusions about the relationship between numeracy and health outcomes because of few studies or inconsistent results among studies.
Searches were limited to articles published in English. No Medical Subject Heading terms exist for identifying relevant studies. No evidence concerning oral health literacy (speaking and listening skills) and outcomes was found.
Low health literacy is associated with poorer health outcomes and poorer use of health care services.
Primary Funding Source:
Agency for Healthcare Research and Quality.
Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Viera A, Crotty K, et al. Health Literacy Interventions and Outcomes: An Update of the Literacy and Health Outcomes Systematic Review of the Literature. Evidence Report/Technology Assessment no. 199. (Prepared by RTI International–University of North Carolina Evidence-based Practice Center under contract 290-2007-10056-I.). Rockville, MD: Agency for Healthcare Research and Quality; 2011. Google Scholar
- 2. Health literacy: report of the Council on Scientific Affairs. Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association. JAMA. 1999;281:552-7. [PMID: 10022112] Google Scholar
Baker DW. The meaning and the measure of health literacy. J Gen Intern Med. 2006;21:878-83. [PMID: 16881951] CrossrefMedlineGoogle Scholar
Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacy of America's Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006-483). Washington, DC: U.S. Department of Education, National Center For Education Statistics; 2006. Google Scholar
Institute of Medicine. Report Brief. Health Literacy: A Prescription to End Confusion. Washington, DC: National Academies Pr; 2004. Google Scholar
U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. National Action Plan to Improve Health Literacy. Washington, DC: U.S. Department of Health and Human Services; 2010. Google Scholar
Berkman ND, DeWalt DA, Pignone MP, Sheridan SL, Lohr KN, Lux L, et al. Literacy and Health Outcomes. Evidence Report Technology Assessment no. 87 (Prepared by the RTI International–University of North Carolina Evidence-based Practice Center under contract 290-02-0016.). Rockville, MD: Agency for Healthcare Research and Quality; 2004. Google Scholar
Owens DK, Lohr KN, Atkins D, Treadwell JR, Reston JT, Bass EB, et al. AHRQ series paper 5: grading the strength of a body of evidence when comparing medical interventions—agency for healthcare research and quality and the effective health-care program. J Clin Epidemiol. 2010;63:513-23. [PMID: 19595577] CrossrefMedlineGoogle Scholar
Davis TC, Long SW, Jackson RH, Mayeaux EJ, George RB, Murphy PW, et al. Rapid estimate of adult literacy in medicine: a shortened screening instrument. Fam Med. 1993;25:391-5. [PMID: 8349060] MedlineGoogle Scholar
Parker RM, Baker DW, Williams MV, Nurss JR. The test of functional health literacy in adults: a new instrument for measuring patients' literacy skills. J Gen Intern Med. 1995;10:537-41. [PMID: 8576769] CrossrefMedlineGoogle Scholar
Schwartz LM, Woloshin S, Black WC, Welch HG. The role of numeracy in understanding the benefit of screening mammography. Ann Intern Med. 1997;127:966-72. [PMID: 9412301] LinkGoogle Scholar
Jastak S, Wilkinson G. Wide Range Achievement Test-Revised (WRAT-R). San Antonio, TX: The Psychological Corporation; 1984. Google Scholar
Baker DW, Gazmararian JA, Williams MV, Scott T, Parker RM, Green D, et al. Health literacy and use of outpatient physician services by Medicare managed care enrollees. J Gen Intern Med. 2004;19:215-20. [PMID: 15009775] CrossrefMedlineGoogle Scholar
Howard DH, Gazmararian J, Parker RM. The impact of low health literacy on the medical costs of Medicare managed care enrollees. Am J Med. 2005;118:371-7. [PMID: 15808134] CrossrefMedlineGoogle Scholar
Murray MD, Tu W, Wu J, Morrow D, Smith F, Brater DC. Factors associated with exacerbation of heart failure include treatment adherence and health literacy skills. Clin Pharmacol Ther. 2009;85:651-8. [PMID: 19262464] CrossrefMedlineGoogle Scholar
Paasche-Orlow MK, Riekert KA, Bilderback A, Chanmugam A, Hill P, Rand CS, et al. Tailored education may reduce health literacy disparities in asthma self-management. Am J Respir Crit Care Med. 2005;172:980-6. [PMID: 16081544] CrossrefMedlineGoogle Scholar
DeWalt DA, Dilling MH, Rosenthal MS, Pignone MP. Low parental literacy is associated with worse asthma care measures in children. Ambul Pediatr. 2007;7:25-31. [PMID: 17261479] CrossrefMedlineGoogle Scholar
Cho YI, Lee SY, Arozullah AM, Crittenden KS. Effects of health literacy on health status and health service utilization amongst the elderly. Soc Sci Med. 2008;66:1809-16. [PMID: 18295949] CrossrefMedlineGoogle Scholar
Murphy DA, Lam P, Naar-King S, RobertHarris D, Parsons JT, Muenz LR; Adolescent Medicine Trials Network for HIV/AIDS Interventions. Health literacy and antiretroviral adherence among HIV-infected adolescents. Patient Educ Couns. 2010;79:25-9. [PMID: 19665860] CrossrefMedlineGoogle Scholar
Hope CJ, Wu J, Tu W, Young J, Murray MD. Association of medication adherence, knowledge, and skills with emergency department visits by adults 50 years or older with congestive heart failure. Am J Health Syst Pharm. 2004;61:2043-9. [PMID: 15509127] CrossrefMedlineGoogle Scholar
Shone LP, Conn KM, Sanders L, Halterman JS. The role of parent health literacy among urban children with persistent asthma. Patient Educ Couns. 2009;75:368-75. [PMID: 19233588] CrossrefMedlineGoogle Scholar
Bennett IM, Chen J, Soroui JS, White S. The contribution of health literacy to disparities in self-rated health status and preventive health behaviors in older adults. Ann Fam Med. 2009;7:204-11. [PMID: 19433837] CrossrefMedlineGoogle Scholar
White S, Chen J, Atchison R. Relationship of preventive health practices and health literacy: a national study. Am J Health Behav. 2008;32:227-42. [PMID: 18067463] CrossrefMedlineGoogle Scholar
Guerra CE, Krumholz M, Shea JA. Literacy and knowledge, attitudes and behavior about mammography in Latinas. J Health Care Poor Underserved. 2005;16:152-66. [PMID: 15741716] CrossrefMedlineGoogle Scholar
Howard DH, Sentell T, Gazmararian JA. Impact of health literacy on socioeconomic and racial differences in health in an elderly population. J Gen Intern Med. 2006;21:857-61. [PMID: 16881947] CrossrefMedlineGoogle Scholar
Sudore RL, Mehta KM, Simonsick EM, Harris TB, Newman AB, Satterfield S, et al. Limited literacy in older people and disparities in health and healthcare access. J Am Geriatr Soc. 2006;54:770-6. [PMID: 16696742] CrossrefMedlineGoogle Scholar
Kripalani S, Henderson LE, Chiu EY, Robertson R, Kolm P, Jacobson TA. Predictors of medication self-management skill in a low-literacy population. J Gen Intern Med. 2006;21:852-6. [PMID: 16881946] CrossrefMedlineGoogle Scholar
Waldrop-Valverde D, Jones DL, Jayaweera D, Gonzalez P, Romero J, Ownby RL. Gender differences in medication management capacity in HIV infection: the role of health literacy and numeracy. AIDS Behav. 2009;13:46-52. [PMID: 18618237] CrossrefMedlineGoogle Scholar
Raehl CL, Bond CA, Woods TJ, Patry RA, Sleeper RB. Screening tests for intended medication adherence among the elderly. Ann Pharmacother. 2006;40:888-93. [PMID: 16595567] CrossrefMedlineGoogle Scholar
Estrada CA, Martin-Hryniewicz M, Peek BT, Collins C, Byrd JC. Literacy and numeracy skills and anticoagulation control. Am J Med Sci. 2004;328:88-93. [PMID: 15311167] CrossrefMedlineGoogle Scholar
Yin HS, Mendelsohn AL, Wolf MS, Parker RM, Fierman A, van Schaick L, et al. Parents' medication administration errors: role of dosing instruments and health literacy. Arch Pediatr Adolesc Med. 2010;164:181-6. [PMID: 20124148] CrossrefMedlineGoogle Scholar
Yin HS, Dreyer BP, Foltin G, van Schaick L, Mendelsohn AL. Association of low caregiver health literacy with reported use of nonstandardized dosing instruments and lack of knowledge of weight-based dosing. Ambul Pediatr. 2007;7:292-8. [PMID: 17660100] CrossrefMedlineGoogle Scholar
Davis TC, Wolf MS, Bass PF, Thompson JA, Tilson HH, Neuberger M, et al. Literacy and misunderstanding prescription drug labels. Ann Intern Med. 2006;145:887-94. [PMID: 17135578] LinkGoogle Scholar
Wolf MS, Davis TC, Shrank W, Rapp DN, Bass PF, Connor UM, et al. To err is human: patient misinterpretations of prescription drug label instructions. Patient Educ Couns. 2007;67:293-300. [PMID: 17587533] CrossrefMedlineGoogle Scholar
Rothman RL, Housam R, Weiss H, Davis D, Gregory R, Gebretsadik T, et al. Patient understanding of food labels: the role of literacy and numeracy. Am J Prev Med. 2006;31:391-8. [PMID: 17046410] CrossrefMedlineGoogle Scholar
LeVine RA, LeVine SE, Rowe ML, Schnell-Anzola B. Maternal literacy and health behavior: a Nepalese case study. Soc Sci Med. 2004;58:863-77. [PMID: 14672599] CrossrefMedlineGoogle Scholar
Lincoln A, Paasche-Orlow MK, Cheng DM, Lloyd-Travaglini C, Caruso C, Saitz R, et al. Impact of health literacy on depressive symptoms and mental health-related: quality of life among adults with addiction. J Gen Intern Med. 2006;21:818-22. [PMID: 16881940] CrossrefMedlineGoogle Scholar
Nokes KM, Coleman CL, Cashen M, Dole P, Sefcik E, Hamilton MJ, et al. Health literacy and health outcomes in HIV seropositive persons. Res Nurs Health. 2007;30:620-7. [PMID: 18022832] CrossrefMedlineGoogle Scholar
Bennett IM, Culhane JF, McCollum KF, Mathew L, Elo IT. Literacy and depressive symptomatology among pregnant Latinas with limited English proficiency. Am J Orthopsychiatry. 2007;77:243-8. [PMID: 17535122] CrossrefMedlineGoogle Scholar
Kalichman SC, Pope H, White D, Cherry C, Amaral CM, Swetzes C, et al. Association between health literacy and HIV treatment adherence: further evidence from objectively measured medication adherence. J Int Assoc Physicians AIDS Care (Chic). 2008;7:317-23. [PMID: 19056866] CrossrefMedlineGoogle Scholar
Walker D, Adebajo A, Heslop P, Hill J, Firth J, Bishop P, et al. Patient education in rheumatoid arthritis: the effectiveness of the ARC booklet and the mind map. Rheumatology (Oxford). 2007;46:1593-6. [PMID: 17767002] CrossrefMedlineGoogle Scholar
Morris NS, MacLean CD, Littenberg B. Literacy and health outcomes: a cross-sectional study in 1002 adults with diabetes. BMC Fam Pract. 2006;7:49. [PMID: 16907968] CrossrefMedlineGoogle Scholar
Coffman MJ, Norton CK. Demands of immigration, health literacy, and depression in recent Latino immigrants. Home Health Care Management & Practice. 2010;22:116-22. CrossrefGoogle Scholar
Paasche-Orlow MK, Cheng DM, Palepu A, Meli S, Faber V, Samet JH. Health literacy, antiretroviral adherence, and HIV-RNA suppression: a longitudinal perspective. J Gen Intern Med. 2006;21:835-40. [PMID: 16881943] CrossrefMedlineGoogle Scholar
Mayben JK, Kramer JR, Kallen MA, Franzini L, Lairson DR, Giordano TP. Predictors of delayed HIV diagnosis in a recently diagnosed cohort. AIDS Patient Care STDS. 2007;21:195-204. [PMID: 17428187] CrossrefMedlineGoogle Scholar
Kim SH. Health literacy and functional health status in Korean older adults. J Clin Nurs. 2009;18:2337-43. [PMID: 19583664] CrossrefMedlineGoogle Scholar
Lee SY, Arozullah AM, Cho YI, Crittenden K, Vicencio D. Health literacy, social support, and health status among older adults. Educational Gerontology. 2009;35:191-201. CrossrefGoogle Scholar
Baker DW, Wolf MS, Feinglass J, Thompson JA, Gazmararian JA, Huang J. Health literacy and mortality among elderly persons. Arch Intern Med. 2007;167:1503-9. [PMID: 17646604] CrossrefMedlineGoogle Scholar
Gazmararian JA, Baker DW, Williams MV, Parker RM, Scott TL, Green DC, et al. Health literacy among Medicare enrollees in a managed care organization. JAMA. 1999;281:545-51. [PMID: 10022111] CrossrefMedlineGoogle Scholar
Baker DW, Wolf MS, Feinglass J, Thompson JA. Health literacy, cognitive abilities, and mortality among elderly persons. J Gen Intern Med. 2008;23:723-6. [PMID: 18330654] CrossrefMedlineGoogle Scholar
Sudore RL, Yaffe K, Satterfield S, Harris TB, Mehta KM, Simonsick EM, et al. Limited literacy and mortality in the elderly: the health, aging, and body composition study. J Gen Intern Med. 2006;21:806-12. [PMID: 16881938] CrossrefMedlineGoogle Scholar
Lindau ST, Basu A, Leitsch SA. Health literacy as a predictor of follow-up after an abnormal Pap smear: a prospective study. J Gen Intern Med. 2006;21:829-34. [PMID: 16881942] CrossrefMedlineGoogle Scholar
Grubbs V, Gregorich SE, Perez-Stable EJ, Hsu CY. Health literacy and access to kidney transplantation. Clin J Am Soc Nephrol. 2009;4:195-200. [PMID: 19056617] CrossrefMedlineGoogle Scholar
Hibbard JH, Peters E, Dixon A, Tusler M. Consumer competencies and the use of comparative quality information: it isn't just about literacy. Med Care Res Rev. 2007;64:379-94. [PMID: 17684108] CrossrefMedlineGoogle Scholar
Mancuso CA, Rincon M. Asthma patients' assessments of health care and medical decision making: the role of health literacy. J Asthma. 2006;43:41-4. [PMID: 16448964] CrossrefMedlineGoogle Scholar
Mancuso CA, Rincon M. Impact of health literacy on longitudinal asthma outcomes. J Gen Intern Med. 2006;21:813-7. [PMID: 16881939] CrossrefMedlineGoogle Scholar
Miller E, Lee JY, DeWalt DA, Vann WF. Impact of caregiver literacy on children's oral health outcomes. Pediatrics. 2010;126:107-14. [PMID: 20547644] CrossrefMedlineGoogle Scholar
Wolf MS, Davis TC, Osborn CY, Skripkauskas S, Bennett CL, Makoul G. Literacy, self-efficacy, and HIV medication adherence. Patient Educ Couns. 2007;65:253-60. [PMID: 17118617] CrossrefMedlineGoogle Scholar
Peterson NB, Dwyer KA, Mulvaney SA, Dietrich MS, Rothman RL. The influence of health literacy on colorectal cancer screening knowledge, beliefs and behavior. J Natl Med Assoc. 2007;99:1105-12. [PMID: 17987913] MedlineGoogle Scholar
Torres RY, Marks R. Relationships among health literacy, knowledge about hormone therapy, self-efficacy, and decision-making among postmenopausal health. J Health Commun. 2009;14:43-55. [PMID: 19180370] CrossrefMedlineGoogle Scholar
von Wagner C, Semmler C, Good A, Wardle J. Health literacy and self-efficacy for participating in colorectal cancer screening: The role of information processing. Patient Educ Couns. 2009;75:352-7. [PMID: 19386461] CrossrefMedlineGoogle Scholar
Wolf MS, Gazmararian JA, Baker DW. Health literacy and health risk behaviors among older adults. Am J Prev Med. 2007;32:19-24. [PMID: 17184964] CrossrefMedlineGoogle Scholar
von Wagner C, Knight K, Steptoe A, Wardle J. Functional health literacy and health-promoting behaviour in a national sample of British adults. J Epidemiol Community Health. 2007;61:1086-90. [PMID: 18000132] CrossrefMedlineGoogle Scholar
Sharif I, Blank AE. Relationship between child health literacy and body mass index in overweight children. Patient Educ Couns. 2010;79:43-8. [PMID: 19716255] CrossrefMedlineGoogle Scholar
Huizinga MM, Beech BM, Cavanaugh KL, Elasy TA, Rothman RL. Low numeracy skills are associated with higher BMI. Obesity (Silver Spring). 2008;16:1966-8. [PMID: 18535541] CrossrefMedlineGoogle Scholar
Paasche-Orlow MK, Clarke JG, Hebert MR, Ray MK, Stein MD. Educational attainment but not literacy is associated with HIV risk behavior among incarcerated women. J Womens Health (Larchmt). 2005;14:852-9. [PMID: 16313213] CrossrefMedlineGoogle Scholar
Marteleto L, Lam D, Ranchhod V. Sexual behavior, pregnancy, and schooling among young people in urban South Africa. Stud Fam Plann. 2008;39:351-68. [PMID: 19248720] CrossrefMedlineGoogle Scholar
Needham HE, Wiemann CM, Tortolero SR, Chacko MR. Relationship between health literacy, reading comprehension, and risk for sexually transmitted infections in young women. J Adolesc Health. 2010;46:506-8. [PMID: 20413090] CrossrefMedlineGoogle Scholar
Chang LC. Health literacy, self-reported status and health promoting behaviours for adolescents in Taiwan. J Clin Nurs. 2011;20:190-6. [PMID: 20629822] CrossrefMedlineGoogle Scholar
Janisse HC, Naar-King S, Ellis D. Brief report: parent's health literacy among high-risk adolescents with insulin dependent diabetes. J Pediatr Psychol. 2010;35:436-40. [PMID: 19755494] CrossrefMedlineGoogle Scholar
Gazmararian JA, Kripalani S, Miller MJ, Echt KV, Ren J, Rask K. Factors associated with medication refill adherence in cardiovascular-related diseases: a focus on health literacy. J Gen Intern Med. 2006;21:1215-21. [PMID: 17105519] CrossrefMedlineGoogle Scholar
Osborn CY, Paasche-Orlow MK, Davis TC, Wolf MS. Health literacy: an overlooked factor in understanding HIV health disparities. Am J Prev Med. 2007;33:374-8. [PMID: 17950402] CrossrefMedlineGoogle Scholar
Waite KR, Paasche-Orlow M, Rintamaki LS, Davis TC, Wolf MS. Literacy, social stigma, and HIV medication adherence. J Gen Intern Med. 2008;23:1367-72. [PMID: 18563494] CrossrefMedlineGoogle Scholar
Osborn CY, Davis TC, Bailey SC, Wolf MS. Health literacy in the context of HIV treatment: introducing the Brief Estimate of Health Knowledge and Action (BEHKA)-HIV version. AIDS Behav. 2010;14:181-8. [PMID: 19023653] CrossrefMedlineGoogle Scholar
Gatti ME, Jacobson KL, Gazmararian JA, Schmotzer B, Kripalani S. Relationships between beliefs about medications and adherence. Am J Health Syst Pharm. 2009;66:657-64. [PMID: 19299373] CrossrefMedlineGoogle Scholar
Johnson VR, Jacobson KL, Gazmararian JA, Blake SC. Does social support help limited-literacy patients with medication adherence? A mixed methods study of patients in the Pharmacy Intervention for Limited Literacy (PILL) study. Patient Educ Couns. 2010;79:14-24. [PMID: 19647967] CrossrefMedlineGoogle Scholar
Graham J, Bennett IM, Holmes WC, Gross R. Medication beliefs as mediators of the health literacy-antiretroviral adherence relationship in HIV-infected individuals. AIDS Behav. 2007;11:385-92. [PMID: 17053858] CrossrefMedlineGoogle Scholar
Fang MC, Machtinger EL, Wang F, Schillinger D. Health literacy and anticoagulation-related outcomes among patients taking warfarin. J Gen Intern Med. 2006;21:841-6. [PMID: 16881944] CrossrefMedlineGoogle Scholar
Chew LD, Bradley KA, Flum DR, Cornia PB, Koepsell TD. The impact of low health literacy on surgical practice. Am J Surg. 2004;188:250-3. [PMID: 15450829] CrossrefMedlineGoogle Scholar
Hironaka LK, Paasche-Orlow MK, Young RL, Bauchner H, Geltman PL. Caregiver health literacy and adherence to a daily multi-vitamin with iron regimen in infants. Patient Educ Couns. 2009;75:376-80. [PMID: 19395227] CrossrefMedlineGoogle Scholar
Gerber BS, Cho YI, Arozullah AM, Lee SY. Racial differences in medication adherence: A cross-sectional study of Medicare enrollees. Am J Geriatr Pharmacother. 2010;8:136-45. [PMID: 20439063] CrossrefMedlineGoogle Scholar
Kripalani S, Gatti ME, Jacobson TA. Association of age, health literacy, and medication management strategies with cardiovascular medication adherence. Patient Educ Couns. 2010;81:177-81. [PMID: 20684870] CrossrefMedlineGoogle Scholar
Sentell TL, Halpin HA. Importance of adult literacy in understanding health disparities. J Gen Intern Med. 2006;21:862-6. [PMID: 16881948] CrossrefMedlineGoogle Scholar
Wolf MS, Gazmararian JA, Baker DW. Health literacy and functional health status among older adults. Arch Intern Med. 2005;165:1946-52. [PMID: 16186463] CrossrefMedlineGoogle Scholar
Parker EJ, Jamieson LM. Associations between indigenous Australian oral health literacy and self-reported oral health outcomes. BMC Oral Health. 2010;10:3. [PMID: 20346124] CrossrefMedlineGoogle Scholar
Tang YH, Pang SM, Chan MF, Yeung GS, Yeung VT. Health literacy, complication awareness, and diabetic control in patients with type 2 diabetes mellitus. J Adv Nurs. 2008;62:74-83. [PMID: 18352966] CrossrefMedlineGoogle Scholar
Powell CK, Hill EG, Clancy DE. The relationship between health literacy and diabetes knowledge and readiness to take health actions. Diabetes Educ. 2007;33:144-51. [PMID: 17272800] CrossrefMedlineGoogle Scholar
Schillinger D, Barton LR, Karter AJ, Wang F, Adler N. Does literacy mediate the relationship between education and health outcomes? A study of a low-income population with diabetes. Public Health Rep. 2006;121:245-54. [PMID: 16640146] CrossrefMedlineGoogle Scholar
Mancuso JM. Impact of health literacy and patient trust on glycemic control in an urban USA population. Nurs Health Sci. 2010;12:94-104. [PMID: 20487332] CrossrefMedlineGoogle Scholar
Powers BJ, Olsen MK, Oddone EZ, Thorpe CT, Bosworth HB. Literacy and blood pressure—do healthcare systems influence this relationship? A cross-sectional study. BMC Health Serv Res. 2008;8:219. [PMID: 18947408] CrossrefMedlineGoogle Scholar
Pandit AU, Tang JW, Bailey SC, Davis TC, Bocchini MV, Persell SD, et al. Education, literacy, and health: mediating effects on hypertension knowledge and control. Patient Educ Couns. 2009;75:381-5. [PMID: 19442477] CrossrefMedlineGoogle Scholar
Muir KW, Santiago-Turla C, Stinnett SS, Herndon LW, Allingham RR, Challa P, et al. Health literacy and vision-related quality of life. Br J Ophthalmol. 2008;92:779-82. [PMID: 18460538] CrossrefMedlineGoogle Scholar
Johnston MV, Diab ME, Kim SS, Kirshblum S. Health literacy, morbidity, and quality of life among individuals with spinal cord injury. J Spinal Cord Med. 2005;28:230-40. [PMID: 16048141] CrossrefMedlineGoogle Scholar
Hahn EA, Cella D, Dobrez DG, Weiss BD, Du H, Lai JS, et al. The impact of literacy on health-related quality of life measurement and outcomes in cancer outpatients. Qual Life Res. 2007;16:495-507. [PMID: 17091362] CrossrefMedlineGoogle Scholar
Hahn EA, Du H, Garcia SF, Choi SW, Lai JS, Victorson D, et al. Literacy-fair measurement of health-related quality of life will facilitate comparative effectiveness research in Spanish-speaking cancer outpatients. Med Care. 2010;48:S75-82. [PMID: 20473208] CrossrefMedlineGoogle Scholar
Zhang XH, Li SC, Fong KY, Thumboo J. The impact of health literacy on health-related quality of life (HRQoL) and utility assessment among patients with rheumatic diseases. Value Health. 2009;12 Suppl 3S106-9. [PMID: 20586970] CrossrefMedlineGoogle Scholar
Guerra CE, Dominguez F, Shea JA. Literacy and knowledge, attitudes, and behavior about colorectal cancer screening. J Health Commun. 2005;10:651-63. [PMID: 16278201] CrossrefMedlineGoogle Scholar
Miller DP, Brownlee CD, McCoy TP, Pignone MP. The effect of health literacy on knowledge and receipt of colorectal cancer screening: a survey study. BMC Fam Pract. 2007;8:16. [PMID: 17394668] CrossrefMedlineGoogle Scholar
Garbers S, Chiasson MA. Inadequate functional health literacy in Spanish as a barrier to cervical cancer screening among immigrant Latinas in New York City. Prev Chronic Dis. 2004;1:A07. [PMID: 15670438] MedlineGoogle Scholar
Barragán M, Hicks G, Williams MV, Franco-Paredes C, Duffus W, del Rio C. Low health literacy is associated with HIV test acceptance. J Gen Intern Med. 2005;20:422-5. [PMID: 15963165] CrossrefMedlineGoogle Scholar
Yin HS, Johnson M, Mendelsohn AL, Abrams MA, Sanders LM, Dreyer BP. The health literacy of parents in the United States: a nationally representative study. Pediatrics. 2009;124 Suppl 3S289-98. [PMID: 19861483] CrossrefMedlineGoogle Scholar
Shieh C, Broome ME, Stump TE. Factors associated with health information-seeking in low-income pregnant women. Women Health. 2010;50:426-42. [PMID: 20853218] CrossrefMedlineGoogle Scholar
Hassan K, Heptulla RA. Glycemic control in pediatric type 1 diabetes: role of caregiver literacy. Pediatrics. 2010;125:1104-8. [PMID: 20368322] CrossrefMedlineGoogle Scholar
Wolf MS, Davis TC, Shrank WH, Neuberger M, Parker RM. A critical review of FDA-approved Medication Guides. Patient Educ Couns. 2006;62:316-22. [PMID: 16884888] CrossrefMedlineGoogle Scholar
Wolf MS, Knight SJ, Lyons EA, Durazo-Arvizu R, Pickard SA, Arseven A, et al. Literacy, race, and PSA level among low-income men newly diagnosed with prostate cancer. Urology. 2006;68:89-93. [PMID: 16844451] CrossrefMedlineGoogle Scholar
Smith JL, Haggerty J. Literacy in primary care populations: is it a problem? Can J Public Health. 2003;94:408-12. [PMID: 14700237] CrossrefMedlineGoogle Scholar
Weiss BD, Palmer R. Relationship between health care costs and very low literacy skills in a medically needy and indigent Medicaid population. J Am Board Fam Pract. 2004;17:44-7. [PMID: 15014052] CrossrefMedlineGoogle Scholar
Weiss BD, Blanchard JS, McGee DL, Hart G, Warren B, Burgoon M, et al. Illiteracy among Medicaid recipients and its relationship to health care costs. J Health Care Poor Underserved. 1994;5:99-111. [PMID: 8043732] CrossrefMedlineGoogle Scholar
Baron RM, Kenny DA. The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol. 1986;51:1173-82. [PMID: 3806354] CrossrefMedlineGoogle Scholar
Bailey SC, Pandit AU, Yin S, Federman A, Davis TC, Parker RM, et al. Predictors of misunderstanding pediatric liquid medication instructions. Fam Med. 2009;41:715-21. [PMID: 19882395] MedlineGoogle Scholar
Osborn CY, Cavanaugh K, Wallston KA, White RO, Rothman RL. Diabetes numeracy: an overlooked factor in understanding racial disparities in glycemic control. Diabetes Care. 2009;32:1614-9. [PMID: 19401443] CrossrefMedlineGoogle Scholar
Aggarwal A, Speckman JL, Paasche-Orlow MK, Roloff KS, Battaglia TA. The role of numeracy on cancer screening among urban women. Am J Health Behav. 2007;31 Suppl 1S57-68. [PMID: 17931137] CrossrefMedlineGoogle Scholar
Ciampa PJ, Osborn CY, Peterson NB, Rothman RL. Patient numeracy, perceptions of provider communication, and colorectal cancer screening utilization. J Health Commun. 2010;15 Suppl 3157-68. [PMID: 21154091] CrossrefMedlineGoogle Scholar
Cavanaugh K, Huizinga MM, Wallston KA, Gebretsadik T, Shintani A, Davis D, et al. Association of numeracy and diabetes control. Ann Intern Med. 2008;148:737-46. [PMID: 18490687] LinkGoogle Scholar
Apter AJ, Wang X, Bogen D, Bennett IM, Jennings RM, Garcia L, et al. Linking numeracy and asthma-related quality of life. Patient Educ Couns. 2009;75:386-91. [PMID: 19217741] CrossrefMedlineGoogle Scholar
Osborn CY, Cavanaugh K, Wallston KA, Rothman RL. Self-efficacy links health literacy and numeracy to glycemic control. J Health Commun. 2010;15 Suppl 2146-58. [PMID: 20845200] CrossrefMedlineGoogle Scholar
Sheridan SL, Pignone M. Numeracy and the medical student's ability to interpret data. Eff Clin Pract. 2002;5:35-40. [PMID: 11874195] MedlineGoogle Scholar
Sheridan SL, Pignone MP, Lewis CL. A randomized comparison of patients' understanding of number needed to treat and other common risk reduction formats. J Gen Intern Med. 2003;18:884-92. [PMID: 14687273] CrossrefMedlineGoogle Scholar
Haggstrom DA, Schapira MM. Black-white differences in risk perceptions of breast cancer survival and screening mammography benefit. J Gen Intern Med. 2006;21:371-7. [PMID: 16686816] CrossrefMedlineGoogle Scholar
Vavrus F. Girls' schooling in Tanzania: the key to HIV/AIDS prevention? AIDS Care. 2006;18:863-71. [PMID: 17012074] CrossrefMedlineGoogle Scholar
Portnoy DB, Roter D, Erby LH. The role of numeracy on client knowledge in BRCA genetic counseling. Patient Educ Couns. 2010;81:131-6. [PMID: 19854023] CrossrefMedlineGoogle Scholar
Lokker N, Sanders L, Perrin EM, Kumar D, Finkle J, Franco V, et al. Parental misinterpretations of over-the-counter pediatric cough and cold medication labels. Pediatrics. 2009;123:1464-71. [PMID: 19482755] CrossrefMedlineGoogle Scholar
Waldrop-Valverde D, Osborn CY, Rodriguez A, Rothman RL, Kumar M, Jones DL. Numeracy skills explain racial differences in HIV medication management. AIDS Behav. 2010;14:799-806. [PMID: 19669403] CrossrefMedlineGoogle Scholar
DeWalt DA, Pignone MP. Reading is fundamental: the relationship between literacy and health [Editorial]. Arch Intern Med. 2005;165:1943-4. [PMID: 16186462] CrossrefMedlineGoogle Scholar
Wolf MS, Feinglass J, Thompson J, Baker DW. In search of ‘low health literacy’: threshold vs. gradient effect of literacy on health status and mortality. Soc Sci Med. 2010;70:1335-41. [PMID: 20167411] CrossrefMedlineGoogle Scholar
Geller J, Swetter SM, Leyson J, Miller DR, Brooks K, Geller AC. Crafting a melanoma educational campaign to reach middle-aged and older men. J Cutan Med Surg. 2006;10:259-68. [PMID: 17241595] CrossrefMedlineGoogle Scholar
Sanders LM, Federico S, Klass P, Abrams MA, Dreyer B. Literacy and child health: a systematic review. Arch Pediatr Adolesc Med. 2009;163:131-40. [PMID: 19188645] CrossrefMedlineGoogle Scholar
Kelly CM, Jorm AF, Wright A. Improving mental health literacy as a strategy to facilitate early intervention for mental disorders. Med J Aust. 2007;187:S26-30. [PMID: 17908021] CrossrefMedlineGoogle Scholar
Easton P, Entwistle VA, Williams B. Health in the “hidden population” of people with low literacy. A systematic review of the literature. BMC Public Health. 2010;10:459. [PMID: 20687946] CrossrefMedlineGoogle Scholar
Eichler K, Wieser S, Brügger U. The costs of limited health literacy: a systematic review. Int J Public Health. 2009;54:313-24. [PMID: 19644651] CrossrefMedlineGoogle Scholar
DavIDs SL, Schapira MM, McAuliffe TL, Nattinger AB. Predictors of pessimistic breast cancer risk perceptions in a primary care population. J Gen Intern Med. 2004;19:310-5. [PMID: 15061739] CrossrefMedlineGoogle Scholar
Laramee AS, Morris N, Littenberg B. Relationship of literacy and heart failure in adults with diabetes. BMC Health Serv Res. 2007;7:98. [PMID: 17605784] CrossrefMedlineGoogle Scholar
Author, Article, and Disclosure Information
Nancy D. Berkman,
From RTI International, Research Triangle Park; University of North Carolina at Chapel Hill, Chapel Hill; and Duke University, Durham, North Carolina.
Disclaimer: The authors of this report are responsible for its content. Statements in this report should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
Acknowledgment: The authors thank Audrey R. Holland, Anthony J. Viera, Loraine G. Monroe, Michelle Brasure, Elizabeth Harden, Elizabeth Tant, and Ina F. Wallace for their assistance in conducting the systematic review. They also thank Kathleen N. Lohr, Meera Viswanathan, and Dan Jonas for their input on standard Agency for Healthcare Research and Quality Evidence-based Practice Center protocols. Finally, they thank Kathleen N. Lohr, Anthony J. Viera, and Jonathan M. Farber for their input on prior drafts of this manuscript and Loraine G. Monroe for her assistance in preparing the manuscript.
Financial Support: This project was funded by the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services (under contract HHSA-290-2007-10056-1).
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-0110.
Corresponding Author: Nancy D. Berkman, PhD, Program on Health Care Quality and Outcomes, Division of Health Services and Social Policy Research, RTI International, PO Box 12194, 3040 Cornwallis Road, Research Triangle Park, NC 27709-2194; e-mail: berkman@rti.
Current Author Addresses: Dr. Berkman: Program on Health Care Quality and Outcomes, Division of Health Services and Social Policy Research, RTI International, PO Box 12194, 3040 Cornwallis Road, Research Triangle Park, NC 27709-2194.
Dr. Sheridan: 5039 Old Clinic Building, CB 7110, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599.
Dr. Donahue: Department of Family Medicine, University of North Carolina at Chapel Hill, CB 7595, 590 Manning Drive, Chapel Hill, NC 27599.
Dr. Halpern: Durham Medical Center, 4220 North Roxboro Road, Durham, NC 27704.
Dr. Crotty: W228 S2406 Oriole Drive, Waukesha, WI 53186.
Author Contributions: Conception and design: N.D. Berkman, S.L. Sheridan, K.E. Donahue, D.J. Halpern.
Analysis and interpretation of the data: N.D. Berkman, S.L. Sheridan, K.E. Donahue, D.J. Halpern, K. Crotty.
Drafting of the article: N.D. Berkman, S.L. Sheridan, K.E. Donahue, D.J. Halpern.
Critical revision of the article for important intellectual content: N.D. Berkman, S.L. Sheridan, K.E. Donahue, D.J. Halpern, K. Crotty.
Final approval of the article: N.D. Berkman, S.L. Sheridan, K.E. Donahue, D.J. Halpern.
Statistical expertise: D.J. Halpern.
Obtaining of funding: N.D. Berkman, S.L. Sheridan.
Administrative, technical, or logistic support: N.D. Berkman, K. Crotty.
Collection and assembly of data: N.D. Berkman, S.L. Sheridan, K.E. Donahue, D.J. Halpern, K. Crotty.