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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 
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.
To evaluate health literacy skills in relation to Healthy Eating Index scores (HEI) and Sugar-Sweetened Beverage (SSB) consumption, while accounting for demographic variables.
Cross-sectional survey.
A community-based proportional sample of adults residing in the rural Lower Mississippi Delta.
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.
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.
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.
PMCID: PMC3160591  PMID: 21703379
Health literacy; diet quality; beverages; health disparities
2.  Functional health literacy and health‐promoting behaviour in a national sample of British adults 
To measure the prevalence of limited functional health literacy in the UK, and examine associations with health behaviours and self‐rated health.
Psychometric testing using a British version of the Test of Functional Health Literacy in Adults (TOFHLA) in a population sample of adults.
UK‐wide interview survey (excluding Northern Ireland and the Scottish Isles).
759 adults (439 women, 320 men) aged 18–90 years (mean age = 47.6 years) selected using random location sampling.
Main outcome measures
Functional health literacy, self‐rated health, fruit and vegetable consumption, physical exercise and smoking.
We found that 11.4% of participants had either marginal or inadequate health literacy. Multivariable logistic regression analysis indicated that the risk of having limitations in health literacy increased with age (adjusted odds ratio 1.04; 95% confidence interval 1.02 to 1.06), being male (odds ratio = 2.04; 95% confidence interval 1.16 to 3.55), low educational attainment (odds ratio = 7.46; 95% confidence interval 3.35 to 16.58) and low income (odds ratio = 5.94; 95% confidence interval 1.87 to 18.89). In a second multivariable logistic regression analysis, every point higher on the health literacy scale increased the likelihood of eating at least five portions of fruit and vegetables a day (odds ratio = 1.02; 95% confidence interval 1.003 to 1.03), being a non‐smoker (odds ratio = 1.02; 95% confidence interval 1.0003 to 1.03) and having good self‐rated health (odds ratio = 1.02; 95% confidence interval 1.01 to 1.04), independently of age, education, gender, ethnicity and income.
The results encourage efforts to monitor health literacy in the British population and examine associations with engagement with preventative health behaviours.
PMCID: PMC2465677  PMID: 18000132
health literacy; health communication; health behaviour; self‐rated health
3.  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.
PMCID: PMC3814999  PMID: 24093355
4.  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.
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).
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.
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).
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.
•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.
PMCID: PMC3969575  PMID: 24287122
Colorectal cancer screening; Early detection; Faecal occult blood test; Health equity; Organised Screening; Health literacy; Communication
5.  Beyond Reading Alone: The Relationship Between Aural Literacy And Asthma Management 
Patient education and counseling  2010;82(1):110-116.
To examine the relationship between literacy and asthma management with a focus on the oral exchange.
Study participants, all of whom reported asthma, were drawn from the New England Family Study (NEFS), an examination of links between education and health. NEFS data included reading, oral (speaking), and aural (listening) literacy measures. An additional survey was conducted with this group of study participants related to asthma issues, particularly asthma management. Data analysis focused on bivariate and multivariable logistic regression.
In bivariate logistic regression models exploring aural literacy, there was a statistically significant association between those participants with lower aural literacy skills and less successful asthma management (OR:4.37, 95%CI:1.11, 17.32). In multivariable logistic regression analyses, controlling for gender, income, and race in separate models (one-at-a-time), there remained a statistically significant association between those participants with lower aural literacy skills and less successful asthma management.
Lower aural literacy skills seem to complicate asthma management capabilities.
Practice Implications
Greater attention to the oral exchange, in particular the listening skills highlighted by aural literacy, as well as other related literacy skills may help us develop strategies for clear communication related to asthma management.
PMCID: PMC2944911  PMID: 20399060
literacy; aural literacy; asthma; asthma management; health communications; provider-patient communication; oral exchange
6.  Understanding the Health Literacy of America Results of the National Assessment of Adult Literacy 
Health literacy refers to an individual’s ability to understand healthcare information to make appropriate decisions (S. C Ratzen & R. M. Parker, 2000). Healthcare professionals are obligated to make sure that patients understand information to maximize the benefits of healthcare. The National Assessment of Adult Literacy (NAAL) provides information on the literacy/health literacy levels of the U.S. adult population. The NAAL is the only large-scale survey of health literacy. The results of the NAAL provide information on literacy/health literacy and the relationship between background variables and literacy/health literacy. Multiple variables with potential for a relationship with literacy/health literacy were chosen for the NAAL including, but not limited to, education, language, race, gender, income, overall health, seeking health information, and health insurance.
PMCID: PMC2668931  PMID: 19190475
7.  Relationship of literacy and heart failure in adults with diabetes 
Although reading ability may impact educational strategies and management of heart failure (HF), the prevalence of limited literacy in patients with HF is unknown.
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.
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).
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.
PMCID: PMC1914051  PMID: 17605784
8.  Lower Health Literacy is Associated with Poorer Health Status and Outcomes in Chronic Obstructive Pulmonary Disease 
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).
To examine the associations between health literacy and both outcomes and health status in COPD.
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.
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.
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.
PMCID: PMC3539035  PMID: 22890622
chronic obstructive pulmonary disease; health literacy; health status; health outcomes; utilization
9.  The Association among Literacy, Numeracy, HIV Knowledge and Health-Seeking Behavior: A Population-Based Survey of Women in Rural Mozambique 
PLoS ONE  2012;7(6):e39391.
Limited literacy skills are common in the United States (US) and are related to lower HIV knowledge and worse health behaviors and outcomes. The extent of these associations is unknown in countries like Mozambique, where no rigorously validated literacy and numeracy measures exist.
A validated measure of literacy and numeracy, the Wide Range Achievement Test, version 3 (WRAT-3) was translated into Portuguese, adapted for a Mozambican context, and administered to a cross-section of female heads-of-household during a provincially representative survey conducted from August 8 to September 25, 2010. Construct validity of each subscale was examined by testing associations with education, income, and possession of socioeconomic assets, stratified by Portuguese speaking ability. Multivariable regression models estimated the association among literacy/numeracy and HIV knowledge, self-reported HIV testing, and utilization of prenatal care.
Data from 3,557 women were analyzed; 1,110 (37.9%) reported speaking Portuguese. Respondents’ mean age was 31.2; 44.6% lacked formal education, and 34.3% reported no income. Illiteracy was common (50.4% of Portuguese speakers, 93.7% of non-Portuguese speakers) and the mean numeracy score (10.4) corresponded to US kindergarten-level skills. Literacy or numeracy was associated (p<0.01) with education, income, age, and other socioeconomic assets. Literacy and numeracy skills were associated with HIV knowledge in adjusted models, but not with HIV testing or receipt of clinic-based prenatal care.
The adapted literacy and numeracy subscales are valid for use with rural Mozambican women. Limited literacy and numeracy skills were common and associated with lower HIV knowledge. Further study is needed to determine the extent to which addressing literacy/numeracy will lead to improved health outcomes.
PMCID: PMC3382184  PMID: 22745747
10.  Establishing Content Validity for the Nutrition Literacy Assessment Instrument 
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).
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.
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.
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.
PMCID: PMC3702232  PMID: 23823698
11.  Health literacy, health status, and healthcare utilization of taiwanese adults: results from a national survey 
BMC Public Health  2010;10:614.
Low health literacy is considered a worldwide health threat. The purpose of this study is to assess the prevalence and socio-demographic covariates of low health literacy in Taiwanese adults and to investigate the relationships between health literacy and health status and health care utilization.
A national survey of 1493 adults was conducted in 2008. Health literacy was measured using the Mandarin Health Literacy Scale. Health status was measured based on self-rated physical and mental health. Health care utilization was measured based on self-reported outpatient clinic visits, emergency room visits, and hospitalizations.
Approximately thirty percent of adults were found to have low (inadequate or marginal) health literacy. They tended to be older, have fewer years of schooling, lower household income, and reside in less populated areas. Inadequate health literacy was associated with poorer mental health (OR, 0.57; 95% CI, 0.35-0.91). No association was found between health literacy and health care utilization even after adjusting for other covariates.
Low (inadequate and marginal) health literacy is prevalent in Taiwan. High prevalence of low health literacy is not necessarily indicative of the need for interventions. Systematic efforts to evaluate the impact of low health literacy on health outcomes in other countries would help to illuminate features of health care delivery and financing systems that may mitigate the adverse health effects of low health literacy.
PMCID: PMC2967535  PMID: 20950479
12.  Low Health Literacy, Limited English Proficiency, and Health Status in Asians, Latinos, and Other Racial/Ethnic Groups in California 
Journal of health communication  2012;17(Suppl 3):82-99.
We estimated health status by low health literacy and limited-English proficiency alone and in combination for Latinos, Chinese, Korean, Vietnamese, and Whites in a population-based sample: 48,427 adults from the 2007 California Health Interview Survey, including 3,715 with limited-English proficiency, were studied. Multivariate logistic models examined self-reported health by health literacy and English proficiency in the full sample and racial/ethnic subgroups. Overall, 44.9% with limited-English proficiency reported low health literacy versus 13.8% of English speakers. Among the limited-English proficient, Chinese respondents had the highest prevalence of low health literacy (68.3%), followed by Latinos (45.3%), Koreans (35.6%), Vietnamese (29.7%), and Whites (18.8%). In the full sample, respondents with both limited-English proficiency/low health literacy reported the highest prevalence of poor health (45.1%), followed by limited-English proficiency-only (41.1%), low health literacy-only (22.2%), and neither (13.8%), a hierarchy that remained significant in multivariate models. However, sub-analyses revealed limited-English proficient Latinos, Vietnamese, and Whites had equal or greater odds of poor health compared with low health literate/limited-English proficient respondents. Individuals with both limited-English proficiency and low health literacy are at high risk for poor health. Limited-English proficiency may carry greater health risk than low health literacy, though important racial/ethnic variations exist.
PMCID: PMC3552496  PMID: 23030563
13.  The relationship between literacy and multimorbidity in a primary care setting 
BMC Family Practice  2012;13:33.
Multimorbidity is now acknowledged as a research priority in primary care. The identification of risk factors and people most at risk is an important step in guiding prevention and intervention strategies. The aim of this study was to examine the relationship between literacy and multimorbidity while controlling for potential confounders.
Participants were adult patients attending the family medicine clinic of a regional health centre in Saguenay (Quebec), Canada. Literacy was measured with the Newest Vital Sign (NVS). Multimorbidity was measured with the Disease Burden Morbidity Assessment (DBMA) by self-report. Information on potential confounders (age, sex, education and family income) was also collected. The association between literacy (independent variable) and multimorbidity was examined in bivariate and multivariate analyses. Two operational definitions of multimorbidity were used successively as the dependent variable; confounding variables were introduced into the model as potential predictors.
One hundred three patients (36 men) 19–83 years old were recruited; 41.8% had completed 12 years of school or less. Forty-seven percent of patients provided fewer than four correct answers on the NVS (possible low literacy) whereas 53% had four correct responses or more. Literacy and multimorbidity were associated in bivariate analyses (p < 0.01) but not in multivariate analyses, including age and family income.
This study suggests that there is no relationship between literacy and multimorbidity when controlling for age and family income.
PMCID: PMC3388951  PMID: 22536833
14.  Inadequate Functional Health Literacy in Spanish as a Barrier to Cervical Cancer Screening Among Immigrant Latinas in New York City 
Preventing Chronic Disease  2004;1(4):A07.
The objective of this study was to examine the association between inadequate functional health literacy in Spanish among low-income Latinas aged 40 and older and cervical cancer screening knowledge and behavior.
Spanish-speaking Latinas aged 40–78 of various nationalities (n = 205) participated in a study that included a survey on cervical cancer knowledge and behavior administered in Spanish and the Spanish version of the Test of Functional Health Literacy in Adults.
Compared to those with adequate and marginal health literacy, women with inadequate functional health literacy in Spanish were significantly less likely to have ever had a Papanicolaou (Pap) test (odds ratio, 0.12; 95% confidence interval [CI], 0.04-0.37) or in the last three years (odds ratio, 0.35; 95% CI, 0.18-0.68) and were significantly more likely to have had their last Pap test at a local public hospital (odds ratio, 2.43; 95% CI, 1.18-4.97). Even when controlling for other factors, women with inadequate health literacy were 16.7 times less likely (adjusted odds ratio, 0.06; 95% CI, 0.01-0.55) to have ever had a Pap test.
Almost half of the population we studied will have difficulty interpreting written medical materials, even in Spanish. When developing efforts to reach women who have not been screened, programs and service providers need to be aware that the women most in need of information about screening may be more likely to be unable to read any written materials provided to them, regardless of the language or level of simplicity of the materials. Programs and strategies need to be implemented to increase screening prevalence and to minimize the identified gaps in regular screening for Latinas who have low health literacy.
PMCID: PMC1277947  PMID: 15670438
15.  Developing Predictive Models of Health Literacy 
Journal of General Internal Medicine  2009;24(11):1211-1216.
Low health literacy (LHL) remains a formidable barrier to improving health care quality and outcomes. Given the lack of precision of single demographic characteristics to predict health literacy, and the administrative burden and inability of existing health literacy measures to estimate health literacy at a population level, LHL is largely unaddressed in public health and clinical practice. To help overcome these limitations, we developed two models to estimate health literacy.
We analyzed data from the 2003 National Assessment of Adult Literacy (NAAL), using linear regression to predict mean health literacy scores and probit regression to predict the probability of an individual having ‘above basic’ proficiency. Predictors included gender, age, race/ethnicity, educational attainment, poverty status, marital status, language spoken in the home, metropolitan statistical area (MSA) and length of time in U.S.
All variables except MSA were statistically significant, with lower educational attainment being the strongest predictor. Our linear regression model and the probit model accounted for about 30% and 21% of the variance in health literacy scores, respectively, nearly twice as much as the variance accounted for by either education or poverty alone.
Multivariable models permit a more accurate estimation of health literacy than single predictors. Further, such models can be applied to readily available administrative or census data to produce estimates of average health literacy and identify communities that would benefit most from appropriate, targeted interventions in the clinical setting to address poor quality care and outcomes related to LHL.
PMCID: PMC2771237  PMID: 19760299
health literacy; estimation; multivariable model; community
16.  Management of obesity in low-income African Americans. 
The Bariatrics Clinic at Howard University Hospital was initiated to help low-income African-American adults with low literacy skills in obesity control. Fourteen African-American women and two men participated in the study. Essential components of the treatment included nutrition education, exercise, and behavior modification related to food intake. The nutrition education component involved teaching nutritional needs, taking into account low literacy skills, low economic status, and individual food preferences. A realistic diet plan was based on individual needs, economic status, availability of food, likes and dislikes, lifestyle, and family dynamics. On average, patients lost 2 lb a week on this program. On average, a 14-lb weight loss occurred in seven weeks. There has been a 10% dropout from this program as opposed to drop out rates of 40% to 50% with other treatments. The main reasons for the success of this program is that it is individualized and is sensitive to food preferences.
PMCID: PMC2608454  PMID: 10203915
17.  The Demographic Assessment for Health Literacy (DAHL): A New Tool for Estimating Associations between Health Literacy and Outcomes in National Surveys 
Journal of General Internal Medicine  2008;23(10):1561-1566.
To impute limited health literacy from commonly measured socio-demographic data and to compare it to the Short-Test of Functional Health Literacy in Adults (S-TOFHLA) for estimating the influence of limited health literacy on health status in the elderly.
The Prudential Medicare Study assesses the S-TOFHLA score, leading to a “reference standard” classification of 25% of people with inadequate literacy; the National Health Interview Survey has no such assessment. We estimated a regression of S-TOFHLA on sex, age, years of schooling, and race/ethnicity in The Prudential Medicare Study data to derive a Demographic Assessment for Health Literacy (DAHL) score, and imputed inadequate literacy to the 25% with the lowest DAHL scores. Using regression, we then examined associations between several health status measures (including hypertension, diabetes, physical and mental SF-12) and inadequate literacy (imputed or test-based).
Estimates of association using imputed inadequate literacy closely approximate those obtained using S-TOFHLA-based inadequate literacy for most outcomes examined.
As few population surveys measure health literacy, the DAHL, a readily calculated health literacy proxy score, may be useful for expanding the scope of health literacy research in national survey data.
PMCID: PMC2533384  PMID: 18618197
inadequate health literacy; health status; functional status; national surveys
18.  Health Literacy, Numeracy, and Graphical Literacy Among Veterans in Primary Care and Their Effect on Shared Decision Making and Trust in Physicians 
Journal of Health Communication  2013;18(Suppl 1):273-289.
Studies reveal high levels of inadequate health literacy and numeracy in African Americans and older veterans. The authors aimed to investigate the distribution of health literacy, numeracy, and graph literacy in these populations. They conducted a cross-sectional survey of veterans receiving outpatient care and measured health literacy, numeracy, graph literacy, shared decision making, and trust in physicians. In addition, the authors compared subgroups of veterans using analyses of covariance. Participants were 502 veterans (22–82 years). Low, marginal, and adequate health literacy were found in, respectively, 29%, 26%, and 45% of the veterans. The authors found a significant main effect of race qualified by an age and race interaction. Inadequate health literacy was more common in African Americans than in Whites. Younger African Americans had lower health literacy (p < .001), graph literacy (p < .001), and numeracy (p < .001) than did Whites, even after the authors adjusted for covariates. Older and younger participants did not differ in health literacy, objective numeracy, or graph literacy after adjustment. The authors found no health literacy or age-related differences regarding preferences for shared decision making. African Americans expressed dissatisfaction with their current role in decision making (p = .03). Older participants trusted their physicians more than younger participants (p = .01). In conclusion, African Americans may be at a disadvantage when reviewing patient education materials, potentially affecting health care outcomes.
PMCID: PMC3815195  PMID: 24093361
19.  The Impact of Functional Health Literacy and Acculturation on the Oral Health Status of Somali Refugees Living in Massachusetts 
American journal of public health  2013;103(8):1516-1523.
This study sought to determine the impact of health literacy and acculturation on oral health status of Somali refugees in Massachusetts.
Survey of 439 adult Somalis who arrived in the U.S. < 10 years ago. Subjects had an oral examination with decayed, missing, and filled teeth (DMFT) counts. STOFHLA was used to measure health literacy. Generalized linear multivariable regression models were used to assess the association between English literacy (STOFHLA) and the oral health parameters.
Participants had means of 1.4 decayed, 2.8 missing, and 1.3 filled teeth. Among subjects in the U.S. 0-4 years, subjects with low STOFHLA scores had lower mean DMFT (Mean Rate Ratio=0.78, p=0.016) compared with subjects with higher STOFHLA scores; however, among subjects in the U.S. 5-10 years, those with low STOFHLA scores had higher mean DMFT (Mean Rate Ratio=1.37, p=0.012) compared with subjects with higher STOFHLA scores. No significant association between STOFHLA and decayed teeth was detected. Participants with low STOFHLA scores had marginally lower risk of periodontal disease compared to those with high scores (OR=0.22, p=0.047)
Overall Somali oral health status is good. Oral health of Somalis with low health literacy worsens over time in the U.S. It is possible that beneficial factors linked to low literacy for newly arrived Somali refugees diminish and may be countered by less access to preventive care and less utilization of beneficial oral hygiene practices.
PMCID: PMC3640653  PMID: 23327248
20.  Literacy Education as Treatment for Depression in Patients with Limited Literacy and Depression: A Randomized Controlled Trial 
Individuals with limited literacy and those with depression share many characteristics, including low self-esteem, feelings of worthlessness, and shame.
To determine whether literacy education, provided along with standard depression treatment to adults with depression and limited literacy, would result in greater improvement in depression than would standard depression treatment alone.
Randomized clinical trial with patients assigned either to an intervention group that received standard depression treatment plus literacy education, or a control group that received only standard depression treatment.
Seventy adult patients of a community health center who tested positive for depression using the 9-question Patient Health Questionnaire (PHQ-9) and had limited literacy based on the Rapid Estimate of Adult Literacy in Medicine (REALM).
Depression severity was assessed with PHQ-9 scores at baseline and at 3 follow-up evaluations that took place up to 1 year after study enrollment. Changes in PHQ-9 scores between baseline and follow-up evaluations were compared between the intervention and control groups.
The median PHQ-9 scores were similar in both the intervention and control groups at baseline (12.5 and 14, respectively). Nine-question Patient Health Questionnaire scores improved in both groups, but the improvement was significantly larger in the intervention group. The final follow-up PHQ-9 scores declined to 6 in the intervention group but only to 10 in the control group.
There may be benefit to assessing the literacy skills of patients who are depressed, and recommending that patients with both depression and limited literacy consider enrolling in adult education classes as an adjuvant treatment for depression.
PMCID: PMC1831579  PMID: 16881941
literacy; depression; education
21.  Health Literacy, Physician Trust, and Diabetes-related Self-care Activities in Hispanics with Limited Resources 
Hispanics with diabetes often have deficits in health literacy (HL). We examined the association among HL, psychosocial factors, and diabetes-related self-care activities.
Cross-sectional analysis of 149 patients. Data included patient demographics and validated measures of HL, physician trust, self-efficacy, acculturation, self-care behaviors, and A1c.
Participants (N=60) with limited HL were older and less educated, and had more years with diabetes compared with adequate HL participants (N=89). Limited HL participants reported greater trust in their physician, greater self-efficacy, and better diet, foot care, and medication adherence. Health literacy status was not associated with acculturation or A1c. In adjusted analyses, HL status remained associated with physician trust, and we observed a notable but nonsignificant trend between HL status and medication adherence.
Lower HL was associated with greater physician trust and better medication adherence. Further research is warranted to clarify the role of HL and physician trust in optimizing self-care for Hispanics.
PMCID: PMC3916094  PMID: 24185168
Health literacy; Hispanics; diabetes; self-care; trust
22.  Impact of Health Literacy on Longitudinal Asthma Outcomes 
The impact of health literacy on longitudinal asthma outcomes is not known.
To measure the association between health literacy and asthma outcomes and to assess how health literacy affects outcomes through covariates.
Longitudinal cohort.
One hundred and seventy-five adult asthma patients.
Independent variables measured at enrollment included demographic and asthma characteristics, depressive symptoms, self-efficacy, and asthma knowledge. Health literacy was measured with the Test of Functional Health Literacy in Adults. Outcomes were Asthma Quality of Life Questionnaire and SF-36 scores and emergency department utilization for asthma measured every 3 to 6 months for 2 years. The effects of health literacy on outcomes and interactions between health literacy and covariates were measured with multivariable models.
The mean age of study participants was 42 years, and 83% were women. Less health literacy was associated with worse quality of life, worse physical function, and more emergency department utilization for asthma over 2 years (P ≤.05 for all comparisons). In multivariable analysis, health literacy did not remain statistically significant with any of the outcomes. Although the magnitude of its effect on emergency department utilization remained relatively intact, its effects on quality of life and functional status became attenuated with the sequential addition of covariates, particularly asthma knowledge.
Less health literacy was associated with poor longitudinal asthma outcomes. This relationship was both direct and indirect through effects on other independent variables, particularly patients' knowledge of asthma and self-management. Efforts to improve asthma outcomes should focus on improving literacy skills that are required to learn, understand, and implement effective self-management.
PMCID: PMC1831574  PMID: 16881939
health literacy; asthma; quality of life; outcomes; emergency department utilization
23.  Relationship between Self-Reported Racial Composition of High School and Health Literacy among Community Health Center Patients 
Intervention and policy approaches targeting the societal factors that affect health literacy (e.g., educational systems) could have promise to improve health outcomes, but little research has investigated these factors. This study examined the associations between self-reported racial composition of prior educational and neighborhood contexts and health literacy among 1061 English- and Spanish-speaking adult community health center patients. We found that self-reported racial composition of high school was a significant predictor of health literacy among those who received schooling in the US, controlling for race/ethnicity, education, age, country of birth, and survey language. Black and Hispanic patients had significantly lower health literacy than white patients within educational strata among those schooled in the US. The findings revealed substantial disparities in health literacy. Self-reported racial composition of school context was a significant predictor of health literacy. Transdisciplinary, multi-level intervention approaches are likely to be needed to address the health literacy needs of this population.
PMCID: PMC3170677  PMID: 21636703
health literacy; community health centers; health disparities; residential segregation
24.  1Applicability of a Video Intervention to Increase Informed Decision Making for Prostate Specific Antigen (PSA) Testing among African-American men with Different Levels of Health Literacy 
To evaluate the applicability of an evidence-based video intervention to promote informed decision making for prostate cancer (CaP) screening among African-American men with different levels of health literacy.
Forty nine African-American men participated in interviewer-administered, pretest-posttest interviews between January and March 2008. Health literacy status was assessed with the Test of Functional Health Literacy in Adults (TOFHLA). Repeated measures analysis of covariance (ANCOVA), McNemar or binomial distributions were computed to assess pretest/posttest differences in knowledge. Descriptive statistics were produced to describe participants’ perceptions of the information presented in the video.
Results indicated that men with functional health literacy had higher mean levels of CaP screening knowledge at baseline than men with inadequate health literacy. The between group (F2,44 = 4.84; p = .013) and within group (F1,44 = 5.16; p = .028) test results from repeated measures ANCOVA indicated that preexisting group differences in CaP knowledge had lessened after intervention exposure. Nearly all men rated the information presented in the video as credible (98%), trustworthy (96%), interesting (100%), understandable (94%), and complete (96%).
Result from this exploratory study suggests that the video intervention is suitable for use with African-American men with different health literacy characteristics in two counties in the Greater Florida Panhandle Region. More research is recommended to evaluate the impact of the intervention on mens’ intentions to undergo screening and actual screening behavior.
PMCID: PMC3711946  PMID: 20355352
Health literacy; prostate cancer education; African-American men
25.  Relationship between health literacy, health status, and healthy behaviors among older adults in Isfahan, Iran 
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.
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.
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.
PMCID: PMC3577376  PMID: 23555134
Health care utilization; health literacy; health preventive behaviors; health status; older adults

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