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1.  Health Literacy is associated with Healthy Eating Index Scores and Sugar-Sweetened Beverage Intake: Findings from the Rural Lower Mississippi Delta 
Background
Although health literacy has been a public health priority area for over a decade, the relationship between health literacy and dietary quality has not been thoroughly explored.
Objective
To evaluate health literacy skills in relation to Healthy Eating Index scores (HEI) and Sugar-Sweetened Beverage (SSB) consumption, while accounting for demographic variables.
Design
Cross-sectional survey.
Participants/setting
A community-based proportional sample of adults residing in the rural Lower Mississippi Delta.
Methods
Instruments included a validated 158-item regional food frequency questionnaire and the Newest Vital Sign (scores range 0–6) to assess health literacy.
Statistical analyses performed
Descriptive statistics, ANOVA, and multivariate linear regression.
Results
Of 376 participants, the majority were African American (67.6%), without a college degree (71.5%), and household income level <$20,000/year (55.0%). Most participants (73.9%) scored in the two lowest health literacy categories. The multivariate linear regression model to predict total HEI scores was significant (R2=0.24; F=18.8; p<0.01), such that every 1 point increase in health literacy was associated with a 1.21 point increase in healthy eating index scores, while controlling for all other variables. Other significant predictors of HEI scores included age, gender, and SNAP participation. Health literacy also significantly predicted sugar-sweetened beverages consumption (R2=0.15; F=6.3; p<0.01), while accounting for demographic variables. Every 1 point in health literacy scores was associated with 34 fewer SSB kilocalories/day. Age was the only significant covariate in the SSB model.
Conclusion
While health literacy has been linked to numerous poor health outcomes, to our knowledge this is the first investigation to establish a relationship between health literacy and HEI scores and SSB consumption. Our study suggests that understanding the causes and consequences of limited health literacy is an important factor in promoting compliance to the Dietary Guidelines for Americans.
doi:10.1016/j.jada.2011.04.010
PMCID: PMC3160591  PMID: 21703379
Health literacy; diet quality; beverages; health disparities
2.  Limited health literacy is a barrier to colorectal cancer screening in England: Evidence from the English Longitudinal Study of Ageing☆ 
Preventive Medicine  2014;61(100):100-105.
Objective
To determine the association between health literacy and participation in publicly available colorectal cancer (CRC) screening in England using data from the English Longitudinal Study of Ageing (ELSA).
Methods
ELSA is a population-based study of English adults aged ≥ 50 years. Health literacy, participation in the national CRC screening programme, and covariates were interview-assessed in 2010–11. All those age-eligible for screening from 2006 to 11 were included in the present analysis (n = 3087). The association between health literacy and screening was estimated using multivariable-adjusted logistic regression.
Results
73% of participants had adequate health literacy skills. Screening uptake was 58% among those with adequate and 48% among those with limited health literacy skills. Having adequate health literacy was associated with greater odds of CRC screening (multivariable adjusted OR = 1.20; 95% CI: 1.00–1.44), independent of other predictors of screening: age (OR = 0.92; 95% CI: 0.91–0.94 per one year increase), female sex (OR = 1.31; 95% CI: 1.11–1.54), and being in a higher wealth quintile (OR = 1.88; 95% CI: 1.43–2.49).
Conclusions
Limited health literacy is a barrier to participation in England's national, publicly available CRC screening programme. Interventions should include appropriate design of information materials, provision of alternative support, and increased one-on-one interaction with health care professionals.
Highlights
•We examine the role of health literacy in colorectal cancer screening in England.•Almost one in three English adults aged 60–75 have limited health literacy skills.•Low literacy is a barrier to colorectal cancer screening participation in England.•Interventions are needed to reduce literacy-based screening inequalities.
doi:10.1016/j.ypmed.2013.11.012
PMCID: PMC3969575  PMID: 24287122
Colorectal cancer screening; Early detection; Faecal occult blood test; Health equity; Organised Screening; Health literacy; Communication
3.  Establishing Content Validity for the Nutrition Literacy Assessment Instrument 
Introduction
Identification of low levels of health literacy is important for effective communication between providers and clients. Assessment instruments for general health literacy are inadequate for use in nutrition education encounters because they do not identify nutrition literacy. The primary objective of this 2-part study was to assess content validity for the Nutrition Literacy Assessment Instrument (NLAI).
Methods
This study included a 35-item online survey of registered dietitians (134 of whom answered all questions) and a pilot study in which 5 registered dietitians used the NLAI among 26 clients during nutrition education consultations. To assess agreement with the NLAI by survey participants, we used the following scale: “necessary” (70% agreement), “adequate” (80% agreement), or “good” (90% agreement); comments were analyzed by using content analysis. For the pilot, we made comparisons between subjective assessments, the Rapid Estimate of Adult Literacy in Medicine (REALM), and the NLAI. Registered dietitians also completed a postpilot–study survey.
Results
For the online survey, we found good agreement (average, 89.7%) for including each section of the NLAI. All sections accomplished their purpose (average, 81.5%). For the pilot, REALM and NLAI correlation (r = 0.38) was not significant; the subjective assessment of clients by dietitians and NLAI lacked agreement 44% of the time, and registered dietitians provided instruction on deficient knowledge and skills identified by the NLAI 90% of the time.
Conclusion
The NLAI is a content-valid measure of nutrition literacy. Additional validation of the NLAI is important because an objective instrument is needed for identifying nutrition literacy, a construct that appears to be different from health literacy.
doi:10.5888/pcd10.120267
PMCID: PMC3702232  PMID: 23823698
4.  Health literacy among refugees in Sweden – a cross-sectional study 
BMC Public Health  2014;14(1):1030.
Background
Refugees have poorer health compared to indigenous populations, which may be explained by lower health literacy, i.e. not being able to access, understand, appraise or apply health information. This study aims to determine levels of functional and comprehensive health literacy, and factors associated with inadequate health literacy, in refugees coming to Sweden.
Method
A cross-sectional study was performed among 455 adult refugees speaking Arabic, Dari, Somali or English. Participants in 16 strategically selected language schools for immigrants responded to a questionnaire. Health literacy was measured using the Swedish Functional Health Literacy Scale and the HLS-EU-Q16 questionnaire. Uni- and multivariate statistical methods were used to investigate group differences.
Results
The majority of the participating refugees had inadequate or limited functional health literacy and comprehensive health literacy. About 60% of them had inadequate functional health literacy and 27% had inadequate comprehensive health literacy. Low education and/or being born in Somalia were factors associated with an increased risk of having inadequate functional health literacy. Having inadequate functional health literacy was associated with an increased risk of having inadequate comprehensive health literacy.
Conclusions
The majority of refugees in the language schools had limited or poor health literacy. Health literacy should be taken into consideration in contexts and in activities addressing migrants. More research is needed to better understand health literacy among refugees and to develop strategies and methods to increase health literacy and make life easier for those with low health literacy.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2458-14-1030) contains supplementary material, which is available to authorized users.
doi:10.1186/1471-2458-14-1030
PMCID: PMC4195944  PMID: 25278109
Health literacy; Refugees; Health promotion; Sweden; S-FHL; HLS-EU-Q16
5.  Association of Health Literacy with Complementary and Alternative Medicine Use: A Cross-Sectional Study in Adult Primary Care Patients 
Background
In the United States, it is estimated that 40% of adults utilize complementary and alternative medicine (CAM) therapies. Recently, national surveys report that over 90 million adults have inadequate health literacy. To date, no study has assessed health literacy and its effect on CAM use. The primary objective of this study was to assess the relationship between health literacy and CAM use independent of educational attainment. Second objective was to evaluate the differential effect of health literacy on CAM use by race.
Methods
351 patients were recruited from an outpatient primary care clinic. Validated surveys assessed CAM use (I-CAM-Q), health literacy (REALM-R), and demographic information. We compared demographics by health literacy (adequate vs. inadequate) and overall and individual CAM categories by health literacy using chi square statistics. We found a race by health literacy interaction and ran sequential logistic regression models stratified by race to test the association between health literacy and overall CAM use (Model 1), Model 1 + education (Model 2), and Model 2 + other demographic characteristics (Model 3). We reported the adjusted effect of health literacy on CAM use for both whites and African Americans separately.
Results
75% of the participants had adequate literacy and 80% used CAM. CAM use differed by CAM category. Among whites, adequate health literacy was significantly associated with increased CAM use in both unadjusted (Model 1, OR 7.68; p = 0.001) and models adjusted for education (Model 2, OR 7.70; p = 0.002) and other sociodemographics (Model 3, OR 9.42; p = 0.01). Among African Americans, adequate health literacy was not associated with CAM use in any of the models.
Conclusions
We found a race by literacy interaction suggesting that the relationship between health literacy and CAM use differed significantly by race. Adequate health literacy among whites is associated with increased CAM use, but not associated with CAM use in African Americans.
doi:10.1186/1472-6882-11-138
PMCID: PMC3276434  PMID: 22208873
6.  Parental Health Literacy, Knowledge and Beliefs Regarding Upper Respiratory Infections (URI) in an Urban Latino Immigrant Population 
Parents who are recent immigrants and/or non-native English speakers are at increased risk for poor health literacy. For example, misconceptions regarding treatment for upper respiratory infections (URIs), including nonjudicious use of antibiotics, have been described among Latinos. We sought to assess the influence of health literacy on knowledge and beliefs surrounding URI care and to explore the correlation between two health literacy measures among Latino parents in northern Manhattan. A descriptive survey design was used, and a total of 154 Latino parents were enrolled from four early head start programs between September 2009 and December 2009. Health literacy was measured using the Short Test of Functional Health Literacy in Adults (S-TOFHLA) and Newest Vital Sign (NVS); parental knowledge and beliefs regarding antibiotic treatment for URIs were also assessed. Analyses were conducted in 2010 with multivariable logistic regression performed to examine predictors of health literacy. Inadequate health literacy was observed in 83.8 % of respondents using NVS and 35.7 % with the S-TOFHLA. College education was significantly associated with adequate health literacy using either the NVS or S-TOFHLA; however, other results varied between measures. Using NVS, there was a greater likelihood of adequate health literacy with US birth status (AOR 13.8; 95 % CI, 1.99–95.1), >5 years US residency (AOR 7.6; 95 % CI, 1.3–43.1) and higher antibiotic knowledge scores (AOR 1.7; 95 % CI, 1.2–2.4). Using S-TOFHLA, the odds of adequate health literacy increased with access to a regular care provider (AOR 2.6; 95 % CI, 1.2–5.6). Scores consistent with adequate health literacy on the NVS, but not the S-TOFHLA, were associated with correct beliefs regarding antibiotic use for URIs in comparison to scores of participants with inadequate health literacy. Since health literacy levels were low in this population and the risk of viral URI was high during the first few years of life, targeted education to improve health literacy, knowledge, and beliefs about URI and related antibiotic treatment is needed.
doi:10.1007/s11524-012-9692-8
PMCID: PMC3462826  PMID: 22707307
Health literacy; Upper respiratory infection (URI); Knowledge of antibiotics; Latinos; Parents
7.  Assessing the Impact of Health Literacy on Education Retention of Stroke Patients 
Introduction
Inadequate health literacy is a pervasive problem with major implications for reduced health status and health disparities. Despite the role of focused education in both primary and secondary prevention of stroke, the effect of health literacy on stroke education retention has not been reported. We examined the relationship of health literacy to the retention of knowledge after recommended stroke education.
Methods
This prospective cross-sectional study was conducted at an urban safety-net hospital. Study subjects were patients older than 18 admitted to the hospital stroke unit with a diagnosis of acute ischemic stroke who were able to provide informed consent to participate (N = 100). Health literacy levels were measured by using the short form of Test of Functional Health Literacy in Adults. Patient education was provided to patients at an inpatient stroke unit by using standardized protocols, in compliance with Joint Commission specifications. The education outcomes for poststroke care education, knowledge retention, was assessed for each subject. The effect of health literacy on the Stroke Patient Education Retention scores was assessed by using univariate and multivariate analyses.
Results
Of the 100 participating patients, 59% had inadequate to marginal health literacy. Stroke patients who had marginal health literacy (mean score, 7.45; standard deviation [SD], 1.9) or adequate health literacy (mean score, 7.31; SD, 1.76) had statistically higher education outcome scores than those identified as having inadequate health literacy (mean score, 5.58; SD, 2.06). Results from multivariate analysis indicated that adequate health literacy was most predictive of education outcome retention.
Conclusions
This study demonstrated a clear relationship between health literacy and stroke education outcomes. Studies are needed to better understand the relationship of health literacy to key educational outcomes for primary or secondary prevention of stroke and to refine stroke education for literacy levels of high-risk populations.
doi:10.5888/pcd11.130259
PMCID: PMC3984940  PMID: 24721215
8.  The Impact of Health and Financial Literacy on Decision Making in Community-Based Older Adults 
Gerontology  2012;58(6):531-539.
Background
Health and financial literacy have been linked to the health and well-being of older adults, yet there are few data on how health and financial literacy actually impact decision making regarding healthcare and economic choices in advanced age.
Objective
To examine the association of health and financial literacy with decision making in older adults.
Method
Data came from 525 community-dwelling older persons without dementia from the Rush Memory and Aging Project, an ongoing longitudinal study of aging. Health and financial literacy were assessed via a series of questions designed to measure comprehension of health and financial information and concepts. The two scores were averaged to yield a total literacy score. A modified, 12-item version of the Decision-Making Competence Assessment Tool was used to measure financial and healthcare decision making (6 items each), using materials designed to approximate those used in real world settings. All 12 items were summed to yield a total decision-making score. Associations were tested via linear regression models adjusted for age, sex and education. Secondary models adjusted for global cognitive function, income, depression and chronic medical conditions.
Results
On average, participants correctly answered 67% of the literacy questions (health literacy = 61.6%, SD = 18.8% and financial literacy = 72.5%, SD = 16.0%). After adjustment for cognitive function, the total literacy score was positively associated with the decision-making total score (estimate = 0.64, SE = 0.08, p < 0.001), as well as healthcare (estimate = 0.37, SE = 0.5, p < 0.001) and financial decision making (estimate = 0.28, SE = 0.05, p < 0.001). Further, total literacy, health and financial literacy all were independently associated with decision making in models adjusted for covariates including income, depression, and chronic medical conditions (all p values < 0.001). Finally, there was evidence of effect modification such that the beneficial association between literacy and healthcare decision making was stronger among older persons, poorer persons and persons at the lower ranges of cognitive ability.
Conclusion
Among community based older persons without dementia, higher levels of health and financial literacy were associated with better decision making, suggesting that improvements in literacy could facilitate better decision making and lead to better health and quality of life in later years.
doi:10.1159/000339094
PMCID: PMC3491105  PMID: 22739454
Financial literacy; Health literacy; Decision making
9.  Relationship between health literacy, health status, and healthy behaviors among older adults in Isfahan, Iran 
Background:
Health literacy is a measure of an individual's ability to read, comprehend, and act on medical instructions. Limited health literacy can reduce the adults’ ability to comprehend and use basic health-related materials, such as prescription, food labels, health education pamphlets, articles, appointment slips, and health insurance plans, which can affect their ability to take appropriate and timely health care action. Nowadays, low health literacy is considered a worldwide health threat. So, the purpose of this study was to assess health literacy level in older adults and to investigate the relationships between health literacy and health status, health care utilization, and health preventive behaviors.
Materials and Methods:
A cross-sectional survey of 354 older adults was conducted in Isfahan. The method of sampling was clustering. Health literacy was measured using the Test of Functional Health Literacy in Adults (TOFHLA). Data were collected using home interviewing. Health status was measured based on self-rated general health. Health care utilization was measured based on self-reported outpatient clinic visits, emergency room visits, and hospitalizations, and health preventive behaviors were measured based on self-reported preventive health services use.
Results:
Approximately 79.6% of adults were found to have inadequate health literacy. They tended to be older, had fewer years of schooling, lower household income, and were females. Inadequate health literacy was associated with poorer general health (P < 0.001). Health literacy level was negatively associated with outpatient visits (P = 0.003) and hospitalization (P = 0.01). No significant association was found between health literacy level and emergency room utilization. Self-reported lack of PSA (Prostate-Specific Antigen) test (P < 0.001) and fecal occult blood test (FOBT; P = 0.003) was higher among individuals with inadequate health literacy than those with adequate health literacy. No significant association was found between health literacy level and mammogram in the last 2 years.
Conclusion:
Low health literacy is more prevalent in older adults. It indicates the importance of health literacy issue in health promotion. So, with simple educational materials and effective interventions for low health literacy group, we can improve health promotion in the society and mitigate the adverse health effects of low health literacy.
doi:10.4103/2277-9531.100160
PMCID: PMC3577376  PMID: 23555134
Health care utilization; health literacy; health preventive behaviors; health status; older adults
10.  Correlates of health and financial literacy in older adults without dementia 
BMC Geriatrics  2012;12:30.
Background
Recent research has begun to recognize the important influence of literacy levels and how they affect health and wellbeing, especially in older adults. Our study focuses on health and financial literacy, two domains of literacy which previous research has suggested may be significantly related to health and wellbeing. Our study examines the relation of health and financial literacy with health promoting behaviors and health status among community-based older persons.
Methods
We conducted a cross-sectional study using data from the Rush Memory and Aging Project, a community-based cohort study of aging in northeastern Illinois. The study consisted of 556 older persons without dementia, each determined by a clinical evaluation. Health and financial literacy were measured using a series of questions designed to assess the ability to understand and process health and financial information, concepts, and numeracy; the two scores were averaged to yield a total literacy score. Health promoting behaviors, including engagement in cognitive, physical, and social activities, were assessed using self report measures. Indicators of heath status, including cognition (global cognition and five specific cognitive abilities), functional status (basic and instrumental activities of daily living, mobility disability), and mental health (depressive symptoms, loneliness) were assessed.
Results
In a series of regression models adjusted for age, sex, and education, higher total literacy scores were associated with more frequent participation in health promoting behaviors, including cognitive, physical and social activities (all p values <0.05). Higher total literacy scores were associated with higher cognitive function, less disability, and better mental health (all p values < 0.05). Literacy remained associated with health promoting behaviors and health status in fully adjusted models that also controlled for income and the number of chronic medical conditions. Most of the findings were similar for health and financial literacy except that health literacy was more strongly associated with health promoting behaviors whereas financial literacy was more strongly associated with mental health.
Conclusions
Health and financial literacy are associated with more frequent engagement in health promoting behaviors and better health status in older persons without dementia.
doi:10.1186/1471-2318-12-30
PMCID: PMC3459814  PMID: 22691341
Health literacy; Financial literacy; Older adults; Dementia
11.  The Effect of Individual Factors on Health Behaviors Among College Students: The Mediating Effects of eHealth Literacy 
Background
College students’ health behavior is a topic that deserves attention. Individual factors and eHealth literacy may affect an individual’s health behaviors. The integrative model of eHealth use (IMeHU) provides a parsimonious account of the connections among the digital divide, health care disparities, and the unequal distribution and use of communication technologies. However, few studies have explored the associations among individual factors, eHealth literacy, and health behaviors, and IMeHU has not been empirically investigated.
Objective
This study examines the associations among individual factors, eHealth literacy, and health behaviors using IMeHU.
Methods
The Health Behavior Scale is a 12-item instrument developed to measure college students’ eating, exercise, and sleep behaviors. The eHealth Literacy Scale is a 12-item instrument designed to measure college students’ functional, interactive, and critical eHealth literacy. A nationally representative sample of 525 valid college students in Taiwan was surveyed. A questionnaire was administered to collect background information about participants’ health status, degree of health concern, major, and the frequency with which they engaged in health-related discussions. This study used Amos 6.0 to conduct a confirmatory factor analysis to identify the best measurement models for the eHealth Literacy Scale and the Health Behavior Scale. We then conducted a multiple regression analysis to examine the associations among individual factors, eHealth literacy, and health behaviors. Additionally, causal steps approach was used to explore indirect (mediating) effects and Sobel tests were used to test the significance of the mediating effects.
Results
The study found that perceptions of better health status (t520=2.14-6.12, P<.001-.03) and greater concern for health (t520=2.58-6.95, P<.001-.003) influenced college students’ development of 3 dimensions of eHealth literacy and adoption of healthy eating, exercise, and sleep behaviors. Moreover, eHealth literacy played an intermediary role in the association between individual factors and health behaviors (Sobel test=2.09-2.72, P<.001-.03). Specifically, higher levels of critical eHealth literacy promoted students’ health status and their practice of multiple positive health behaviors, including eating, exercise, and sleep behaviors.
Conclusions
Because this study showed that eHealth literacy mediates the association between individual factors and health behaviors, schools should aim to enhance students’ eHealth literacy and promote their health behaviors to help them achieve high levels of critical eHealth literacy. Although some of the study’s hypotheses were not supported in this study, the factors that influence health behaviors are complex and interdependent. Therefore, a follow-up study should be conducted to further explore how these factors influence one another.
doi:10.2196/jmir.3542
PMCID: PMC4275503  PMID: 25499086
demographic; health behavior; mediation; eHealth literacy; quantitative evaluation
12.  Health Literacy and Antidepressant Medication Adherence Among Adults with Diabetes: The Diabetes Study of Northern California (DISTANCE) 
Journal of General Internal Medicine  2013;28(9):1181-1187.
ABSTRACT
BACKGROUND
Previous studies have reported that health literacy limitations are associated with poorer disease control for chronic conditions, but have not evaluated potential associations with medication adherence.
OBJECTIVE
To determine whether health literacy limitations are associated with poorer antidepressant medication adherence.
DESIGN
Observational new prescription cohort follow-up study.
PARTICIPANTS
Adults with type 2 diabetes who completed a survey in 2006 and received a new antidepressant prescription during 2006–2010 (N = 1,366) at Kaiser Permanente Northern California.
MAIN MEASURES
Validated three-item self-report scale measured health literacy. Discrete indices of adherence based on pharmacy dispensing data according to validated methods: primary non-adherence (medication never dispensed); early non-persistence (dispensed once, never refilled); non-persistence at 180 and 365 days; and new prescription medication gap (NPMG; proportion of time that the person is without medication during 12 months after the prescription date).
KEY RESULTS
Seventy-two percent of patients were classified as having health literacy limitations. After adjusting for sociodemographic and clinical covariates, patients with health literacy limitations had significantly poorer adherence compared to patients with no limitations, whether measured as early non-persistence (46 % versus 38 %, p < 0.05), non-persistence at 180 days (55 % versus 46 %, p < 0.05), or NPMG (41 % versus 36%, p < 0.01). There were no significant associations with primary adherence or non-persistence at 365 days.
CONCLUSIONS
Poorer antidepressant adherence among adults with diabetes and health literacy limitations may jeopardize the continuation and maintenance phases of depression pharmacotherapy. Findings underscore the importance of national efforts to address health literacy, simplify health communications regarding treatment options, improve public understanding of depression treatment, and monitor antidepressant adherence.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-013-2402-8) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-013-2402-8
PMCID: PMC3744297  PMID: 23512335
health literacy; medication adherence; antidepressive agents; diabetes mellitus; healthcare disparities
13.  Accuracy in self-reported health literacy screening: a difference between men and women in Taiwan 
BMJ Open  2013;3(11):e002928.
Objective
Self-reported screening questions are considered as an effective way to identify patients with limited health literacy. Yet research has shown that individuals tend to over-report their reading level. Moreover, the likelihood of over-reporting may differ between gender groups. This study examined if systematic differences exist between men and women in their response to self-reported screening questions.
Design
A national survey in Taiwan with participants selected using a multistage stratified, probability-proportional-to-size sampling strategy.
Participants
A total of 5682 Taiwanese adults aged 18 and older were sampled and recruited. Of those adults, 3491 participated in the survey, resulting in a 62.1% response rate. Both gender groups were equally represented in the final study sample.
Main measures
Self-reported health literacy was assessed using two sets of questions that asked how difficult it was for the respondent to understand written health materials and how often the participant needed assistance from others to understand written health materials. The objective level of health literacy was measured using the Mandarin Health Literacy Scale (MHLS).
Results
A significant gender difference was observed among participants who had inadequate health literacy: while women's self-report was in line with the MHLS test result, men had a significant tendency to over-report their comprehension of health information.
Conclusions
In Taiwan, screening questions are prone to socially desirable response and may underidentify male patients with inadequate health literacy. Development of a brief and easy-to-use health literacy test may be a more effective approach to health literacy screening in clinical settings. Alternatively, clinicians can verify patient comprehension of health information via the ‘teach back’ or ‘show me’ technique in order to improve communication and patient care. Research is needed to examine if gender differences in self-report of health literacy exist in other countries.
doi:10.1136/bmjopen-2013-002928
PMCID: PMC3840358  PMID: 24259386
health literacy; screening; self-report; gender difference
14.  How the stigma of low literacy can impair patient-professional spoken interactions and affect health: insights from a qualitative investigation 
Background
Low literacy is a significant problem across the developed world. A considerable body of research has reported associations between low literacy and less appropriate access to healthcare services, lower likelihood of self-managing health conditions well, and poorer health outcomes. There is a need to explore the previously neglected perspectives of people with low literacy to help explain how low literacy can lead to poor health, and to consider how to improve the ability of health services to meet their needs.
Methods
Two stage qualitative study. In-depth individual interviews followed by focus groups to confirm analysis and develop suggestions for service improvements. A purposive sample of 29 adults with English as their first language who had sought help with literacy was recruited from an Adult Learning Centre in the UK.
Results
Over and above the well-documented difficulties that people with low literacy can have with the written information and complex explanations and instructions they encounter as they use health services, the stigma of low literacy had significant negative implications for participants’ spoken interactions with healthcare professionals.
Participants described various difficulties in consultations, some of which had impacted negatively on their broader healthcare experiences and abilities to self-manage health conditions. Some communication difficulties were apparently perpetuated or exacerbated because participants limited their conversational engagement and used a variety of strategies to cover up their low literacy that could send misleading signals to health professionals.
Participants’ biographical narratives revealed that the ways in which they managed their low literacy in healthcare settings, as in other social contexts, stemmed from highly negative experiences with literacy-related stigma, usually from their schooldays onwards. They also suggest that literacy-related stigma can significantly undermine mental wellbeing by prompting self-exclusion from social participation and generating a persistent anxiety about revealing literacy difficulties.
Conclusion
Low-literacy-related stigma can seriously impair people’s spoken interactions with health professionals and their potential to benefit from health services. As policies increasingly emphasise the need for patients’ participation, services need to simplify the literacy requirements of service use and health professionals need to offer non-judgemental (universal) literacy-sensitive support to promote positive healthcare experiences and outcomes.
doi:10.1186/1472-6963-13-319
PMCID: PMC3751726  PMID: 23958036
Low literacy; Patient-provider communication; Patient-provider relationships; Person-centred care; Qualitative
15.  The effect of health literacy on knowledge and receipt of colorectal cancer screening: a survey study 
BMC Family Practice  2007;8:16.
Background
An estimated one-half of Americans have limited health literacy skills. Low literacy has been associated with less receipt of preventive services, but its impact on colorectal cancer (CRC) screening is unclear. We sought to determine whether low literacy affects patients' knowledge or receipt of CRC screening.
Methods
Pilot survey study of patients aged 50 years and older at a large, university-affiliated internal medicine practice. We assessed patients' knowledge and receipt of CRC screening, basic sociodemographic information, and health literacy level. We defined limited literacy as reading below the ninth grade level as determined by the Rapid Estimate of Adult Literacy in Medicine. Bivariate analyses and exact logistic regression were used to determine the association of limited health literacy with knowledge and receipt of CRC screening.
Results
We approached 105 patients to yield our target sample of 50 completing the survey (recruitment rate 48%). Most subjects were female (72%), African-American (58%), and had household incomes less than $25,000 (87%). Overall, 48% of patients had limited literacy skills (95% CI 35% to 61%). Limited literacy patients were less likely than adequate literacy patients to be able to name or describe any CRC screening test (50% vs. 96%, p < 0.01). In the multivariable model, limited literacy patients were 44% less likely to be knowledgeable of CRC screening (RR 0.56, p < 0.01). Self-reported screening rates were similar (54% vs. 58%, p = 0.88).
Conclusion
Patients with limited literacy skills are less likely to be knowledgeable of CRC screening compared to adequate literacy patients. Primary care providers should ensure patients' understanding of CRC screening when discussing screening options. Further research is needed to determine if educating low literacy patients about CRC screening can increase screening rates.
doi:10.1186/1471-2296-8-16
PMCID: PMC1852801  PMID: 17394668
16.  Low Health Literacy Is Associated with HIV Test Acceptance 
Background
The Centers for Disease Control and Prevention has proposed increasing the proportion of people who learn their HIV serostatus. The health care setting represents a logical site to accomplish this goal. However, little is known about factors that determine acceptability of HIV testing in health care settings, particularly patients' health literacy.
Objective
To evaluate the association between patients' health literacy and acceptance of HIV testing among individuals at an urgent care center (UCC).
Methods
As part of a prospective study that sought to increase HIV testing at a UCC located in an inner-city hospital serving an indigent population, we surveyed patients who had been offered an HIV test by their providers and had accepted or refused testing. Pretest counseling was provided using a low-literacy brochure given to patients upon registration into the clinic. We measured health literacy level using the Rapid Estimate of Adult Literacy in Medicine (REALM) scale.
Results
Three hundred seventy-two patients were enrolled in the study. In univariate analysis, no statistically significant difference between HIV test acceptors or refusers was found for gender, race/ethnicity, marital status, income, type of health insurance, educational level, or type of test offered. Acceptors were more likely to have a low literacy level (odds ratio [OR], 1.763; 95% confidence interval [CI], 1.084 to 2.866) and be less than 40 years old (OR, 1.639; 95% CI, 1.085 to 2.475). In multivariate analysis, low health literacy was shown to be a predictor of HIV test acceptance controlling for age and education (OR, 2.017; 95% CI, 1.190 to 3.418).
Conclusions
Low health literacy was shown to be a predictor of HIV test acceptance. Patients presenting to a UCC with poorer health literacy appear more willing to comply with health care providers' recommendations to undergo HIV testing than those with adequate health literacy when an “opt-out” strategy combined with a low-literacy brochure is used.
doi:10.1111/j.1525-1497.2005.40128.x
PMCID: PMC1490105  PMID: 15963165
health literacy; HIV testing and counseling
17.  Oral Health Literacy among Clients Visiting a Rural Dental College in North India-A Cross-Sectional Study 
Background
Limited health literacy among adults is one of the many barriers to better oral health outcomes. It is not uncommon to find people who consider understanding oral health information a challenge. Therefore, the present study assessed oral health literacy among clients visiting Gian Sagar Dental College and Hospital, Rajpura.
Materials and Methods
A cross-sectional study was conducted on 450participants who visited the Out Patient Department (OPD) of Gian Sagar Dental College and Hospital for a period of two months (Nov–Dec, 2013). A questionnaire was given to each of the participants. Oral health literacy was graded on a 12-point Likert scale based on the total score. Oral Health Literacy of the participants was assessed as low, medium and high on the basis of responses. Statistical analysis was done using SPSS-15 statistical package. ANOVA and Student t-test were used to do comparisons between groups.
Results
Low oral health literacy scores were reported in 60.2% (271) participants. More than 60% of the study participants had knowledge about dental terms such as ‘dental caries,’ and ‘oral cancer.’ Only 22% of the graduates had a high literacy score. Mean oral health literacy score according to educational qualification was statistically significant (p<0.05), whereas there was no significant difference in terms of age and gender (p>0.05).
Conclusion
The majority of the participants had low literacy scores. There is a need to address these problems especially among rural population by health care providers and the government.
PMCID: PMC4141230  PMID: 25183933
Oral health; literacy; clients; knowledge; education
18.  The relationship between functional health literacy and health promoting behaviors among older adults 
Background:
Health literacy is a measure of individual's ability to read, comprehend, and act on medical instructions. Older adults are one of the most important at risk groups affected by the impact of inadequate health literacy. Health promoting behaviors in older adults have potential impact on their health and quality of life and reduce the costs incurred to health care. Given the paucity of information health literacy and health promoting behavior, the purpose of this study was to examine health literacy level in older adults and the relationship between health literacy and health promoting behaviors.
Materials and Method:
A cross-sectional survey of 354 older adults was conducted in Isfahan. The method of sampling was clustering. Health literacy was measured using the Test of Functional Health Literacy in Adults (TOFHLA). Data were collected via home interviewing. Health promoting behaviors were measured based on self-reported smoking status, exercise, and consumption of fruit and vegetables. The collected data were analyzed using descriptive statistics and one-way ANOVA and χ2 tests under SPSS 18 software.
Results:
The sample group averaged 67 ± 6.97 years in age. Approximately 79.6% of adults were found to have inadequate health literacy. They tended to be older, have fewer years of schooling, lower household income, and being female Individuals with inadequate health literacy were more likely to report limitations in activity and lower consumption of fruit and vegetables (P < 0.001). No significant association was found between health literacy and smoking status.
Conclusion:
Considering high prevalence of inadequate health literacy among older adults, and its inverse relationship with some health promoting behaviors. Simple educational materials and effective interventions for low health literacy people can improve health promotion in society and mitigate the adverse health effects of low health literacy.
doi:10.4103/2277-9531.145925
PMCID: PMC4275619  PMID: 25540792
Health literacy; health promoting behaviors; older adults
19.  Determinants of health literacy and health behavior regarding infectious respiratory diseases: a pathway model 
BMC Public Health  2013;13:261.
Background
Health literacy has been defined as the degree to which individuals have the capacity to obtain, process, and understand the basic health information and services needed to make appropriate health decisions. Currently, few studies have validated the causal pathways of determinants of health literacy through the use of statistical modeling. The purpose of the present study was to develop and validate a health literacy model at an individual level that could best explain the determinants of health literacy and the associations between health literacy and health behaviors even health status.
Methods
Skill-based health literacy test and a self-administrated questionnaire survey were conducted among 3222 Chinese adult residents. Path analysis was applied to validate the model.
Results
The model explained 38.6% of variance for health literacy, 11.7% for health behavior and 2.3% for health status: (GFI = 0.9990; RMR = 0.0521; χ2 = 10.2151, P = 0.1159). Education has positive and direct effect on prior knowledge (β = 0.324) and health literacy (β = 0.346). Health literacy is also affected by prior knowledge (β = 0.245) and age (β = -0.361). Health literacy is a direct influencing factor of health behavior (β = 0.101). The most important factor of health status is age (β = 0.107). Health behavior and health status have a positive interaction effect.
Conclusion
This model explains the determinants of health literacy and the associations between health literacy and health behaviors well. It could be applied to develop intervention strategies to increase individual health literacy, and then to promote health behavior and health status.
doi:10.1186/1471-2458-13-261
PMCID: PMC3621712  PMID: 23521806
Health literacy; Health behavior; Determinants; Causal pathways
20.  Health Literacy and Cognitive Performance among Older Adults 
Objectives
Specific cognitive abilities may explain the association of health literacy with health status. We studied the relationship between health literacy and memory and verbal fluency in older adults.
Design
Cross-sectional cohort.
Setting
Twenty senior centers and apartment buildings in New York City, NY.
Participants
Independently living, English and Spanish-speaking adults ages 60 and older (n=414).
Measurements
Health literacy was measured using the Short Test of Functional Health Literacy in Adults (S-TOFHLA). The associations of S-TOFHLA scores with immediate and delayed recall (Wechsler Memory Scale II), verbal fluency (Animal Naming), and global cognitive function (Mini Mental Status Exam, MMSE), were modeled with multivariable logistic and linear regression.
Results
Health literacy was inadequate in 24.3%. Impairment of immediate recall occurred in 20.4%; delayed recall, 15.0%; verbal fluency, 9.9%; and MMSE, 17.4%. Abnormal cognitive function was strongly associated with inadequate health literacy: immediate recall (AOR 3.44, 95% CI 1.71 to 6.94, p<.0001); delayed recall (AOR 3.48, 95% CI 1.58 to 7.67, p = .002); and verbal fluency (AOR 3.47, 95% CI 1.44 to 8.38, p=.006). These associations persisted in subgroups that excluded individuals with normal age-adjusted MMSE scores.
Conclusion
Memory and verbal fluency are strongly associated with health literacy, independently of education and health status, even among those with subtle cognitive dysfunction. Reducing the cognitive burden of health information might mitigate the detrimental effects of limited health literacy in older adults. Research that examines the impact of materials tailored to older adults' cognitive limitations on health literacy and health outcomes is needed.
doi:10.1111/j.1532-5415.2009.02347.x
PMCID: PMC2754116  PMID: 19515101
Health literacy; cognitionl; older adults
21.  Investigating the relationship between information literacy and academic performance among students 
Background:
Nowadays, no student can ever pursue the ends of his studies unless he makes use of his information literacy skills. To become lifelong learners, they do need these skills. Information literacy is a set of information needed for searching, retrieval, evaluating, and making best use of information. This study uncovers the relationship between information literacy and academic performance among students at Isfahan University of Medical Sciences.
Materials and Methods:
This is a practical study using a survey method. All MA students in Isfahan University of Medical Sciences make the statistical population for this study, according to the sample size determined by using Cochran formula 265 samples that were selected by stratified random sampling. Data collection was through information literacy questionnaires designed by Davarpanah and Siamak, verified by Library and Information Sciences experts; and finally, gave a Cronbach's alpha of 0.83. To determine academic performance, the average scores of the students in previous semesters were considered.
Results:
The information literacy of all other students was significantly higher than medium except for students at Nursing and Nutrition faculties. The students of Management and Information Sciences faculty had the highest level of information literacy and students of nutrition faculty were attributed with the least level. There was no significant difference between male and female students’ information literacy. We also found out that there was a significant positive relationship between information literacy and students’ academic performance in Isfahan University of Medical Sciences.
Conclusion:
Information literacy is one of the most important factors that leads to educational success. As there is a significant positive relationship between information literacy and students’ academic performance, we should necessarily provide them with relative skills dealing with information literacy to improve their academic performance.
doi:10.4103/2277-9531.139677
PMCID: PMC4165104  PMID: 25250361
Academic performance; information literacy; students; Isfahan University of Medical Sciences
22.  Associations Between Smoking and Media Literacy in College Students 
Journal of health communication  2009;14(6):541-555.
Organizations recommend media literacy to reduce tobacco use, and higher media literacy has been associated with lower smoking among high school students. The relationship between smoking media literacy and tobacco use, however, has not been systematically studied among college students. The purpose of this study was to determine the association between smoking and smoking media literacy among college students. We conducted the National College Health Assessment (NCHA) at a large, urban university, adding six items measuring smoking media literacy. A total of 657 students responded to this random sample e-mail survey. We used multiple logistic regression to determine independent associations between smoking media literacy items and current smoking. The media literacy scale was internally consistent (α = 0.79). Of the respondents, 21.5% reported smoking cigarettes over the past 30 days. In a fully adjusted multivariate model, participants with medium media literacy had an odds ratio (OR) for current smoking of 0.45 (95% CI = 0.29, 0.70), and those with high media literacy had an OR for current smoking of 0.38 (95% CI = 0.20, 0.70). High smoking media literacy is independently associated with lower odds of smoking. Smoking media literacy may be a valuable construct to address in college populations.
doi:10.1080/10810730903089598
PMCID: PMC3008588  PMID: 19731126
23.  Understanding Health Literacy Measurement Through Eye Tracking 
Journal of Health Communication  2013;18(Suppl 1):185-196.
This study used eye-tracking technology to explore how individuals with different levels of health literacy visualize health-related information. The authors recruited 25 university administrative staff (more likely to have adequate health literacy skills) and 25 adults enrolled in an adult literacy program (more likely to have limited health literacy skills). The authors administered the Newest Vital Sign (NVS) health literacy assessment to each participant. The assessment involves having individuals answer questions about a nutrition label while viewing the label. The authors used computerized eye-tracking technology to measure the amount of time each participant spent fixing their view at nutrition label information that was relevant to the questions being asked and the amount of time they spent viewing nonrelevant information. Results showed that lower NVS scores were significantly associated with more time spent on information not relevant for answering the NVS items. This finding suggests that efforts to improve health literacy measurement should include the ability to differentiate not just between individuals who have difficulty interpreting and using health information, but also between those who have difficulty finding relevant information. In addition, this finding suggests that health education material should minimize the inclusion of nonrelevant information.
doi:10.1080/10810730.2013.825666
PMCID: PMC3814999  PMID: 24093355
24.  Lower Health Literacy is Associated with Poorer Health Status and Outcomes in Chronic Obstructive Pulmonary Disease 
ABSTRACT
BACKGROUND
Limited health literacy is associated with poor outcomes in many chronic diseases, but little is known about health literacy in chronic obstructive pulmonary disease (COPD).
OBJECTIVE
To examine the associations between health literacy and both outcomes and health status in COPD.
PARTICIPANTS, DESIGN AND MAIN MEASURES
Structured interviews were administered to 277 subjects with self-report of physician-diagnosed COPD, recruited through US random-digit telephone dialing. Health literacy was measured with a validated three-item battery. Multivariable linear regression, controlling for sociodemographics including income and education, determined the cross-sectional associations between health literacy and COPD-related health status: COPD Severity Score, COPD Helplessness Index, and Airways Questionnaire-20R [measuring respiratory-specific health-related quality of life (HRQoL)]. Multivariable logistic regression estimated associations between health literacy and COPD-related hospitalizations and emergency department (ED) visits.
KEY RESULTS
Taking socioeconomic status into account, poorer health literacy (lowest tertile compared to highest tertile) was associated with: worse COPD severity (+2.3 points; 95 % CI 0.3–4.4); greater COPD helplessness (+3.7 points; 95 % CI 1.6–5.8); and worse respiratory-specific HRQoL (+3.5 points; 95 % CI 1.8–4.9). Poorer health literacy, also controlling for the same covariates, was associated with higher likelihood of COPD-related hospitalizations (OR = 6.6; 95 % CI 1.3–33) and COPD-related ED visits (OR = 4.7; 95 % CI 1.5–15). Analyses for trend across health literacy tertiles were statistically significant (p < 0.05) for all above outcomes.
CONCLUSIONS
Independent of socioeconomic status, poor health literacy is associated with greater COPD severity, greater COPD helplessness, worse respiratory-specific HRQoL, and higher odds of COPD-related emergency health-care utilization. These results underscore that COPD patients with poor health literacy may be at particular risk for poor health-related outcomes.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-2177-3) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-012-2177-3
PMCID: PMC3539035  PMID: 22890622
chronic obstructive pulmonary disease; health literacy; health status; health outcomes; utilization
25.  Relationship of literacy and heart failure in adults with diabetes 
Background
Although reading ability may impact educational strategies and management of heart failure (HF), the prevalence of limited literacy in patients with HF is unknown.
Methods
Subjects were drawn from the Vermont Diabetes Information System Field Survey, a cross-sectional study of adults with diabetes in primary care. Participants' self-reported characteristics were subjected to logistic regression to estimate the association of heart failure and literacy while controlling for social and economic factors. The Short Test of Functional Health Literacy was used to measure literacy.
Results
Of 172 subjects with HF and diabetes, 27% had limited literacy compared to 15% of 826 subjects without HF (OR 2.05; 95% CI 1.39, 3.02; P < 0.001). Adjusting for age, sex, race, income, marital status and health insurance, HF continued to be significantly associated with limited literacy (OR 1.55, 95% CI 1.00, 2.41, P = .05).
After adjusting for education, however, HF was no longer independently associated with literacy (OR 1.31; 95% CI 0.82 – 2.08; P = 0.26).
Conclusion
Over one quarter of diabetic adults with HF have limited literacy. Although this association is no longer statistically significant when adjusted for education, clinicians should be aware that many of their patients have important limitations in dealing with written materials.
doi:10.1186/1472-6963-7-98
PMCID: PMC1914051  PMID: 17605784

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