Low Functional Health Literacy Research Articles

Health literacy: varying relations with control over care and number of GP visits

Introduction In chronic care, patients are expected to exert a certain degree of control over the care for their condition, for instance by fulfilling care tasks in their home environment. Health literacy is considered relevant in this regard, especially critical health literacy. The aim of this study was to examine to what extent functional, interactive and critical health literacy are associated with patients’ perceived control over care and with the frequency of GP visits. Methods Data from the Dutch ‘National Panel of people with Chronic illness or Disability’ were used (N = 2508). Functional, interactive and critical health literacy was assessed by the Functional, Communicative and Critical Health Literacy measure (FCCHL). Perceived control over care was indicated by perceived ability to: organize care, interact with providers and perform self-care. By stepwise linear regression analyses, associations between health literacy and ability to organize care, interact with providers and perform self-care were studied. By stepwise logistic regression analysis, associations between health literacy and frequency of GP visits was studied. Analyses were adjusted for sex, disease knowledge, cognitive functioning, age, level of education, and health status. Results Lower functional and interactive health literacy were significantly associated with a lower perceived ability to organize care and to perform self-care. Only lower interactive health literacy was significantly associated with a lower perceived ability to interact with healthcare providers. Only lower functional health literacy was significantly associated with a higher frequency of GP visits. Conclusions The results imply that functional, interactive and critical health literacy vary in their relevance for patients’ ability to exert control over care. Initiatives to strengthen patients’ role in healthcare may be improved by attention for patients’ health literacy, especially functional and interactive. Key messages Attention for functional and interactive health literacy skills may help chronically ill people to exert control over their care. Chronically ill people with lower functional health literacy seem to need more support from general practitioners than those with higher functional health literacy. (aut. ref.)

Effects of Health Literacy and Social Capital on Health Information Behavior

This study aimed to examine whether social capital (bonding and bridging social capital) attenuate the effect of low functional health literacy on health information resources, efficacy, and behaviors. In-person interviews were conducted with 1,000 residents in Seoul, Korea, in 2011. The authors found that respondents’ functional health literacy had positive effects on the scope of health information sources and health information self-efficacy but not health information-seeking intention. Respondents’ social capital had positive effects on the scope of health information sources, health information efficacy, and health information-seeking intention. The authors found (a) a significant moderation effect of bridging social capital on the relation between health literacy and health information self-efficacy and (b) a moderation effect of bonding social capital on the relation between health literacy and health information-seeking intention.

Prescription and over‐the‐counter pain medication in arthritis: awareness of active ingredients and attitudes to medication borrowing and sharing

AbstractBackgroundMany Australians with arthritis self‐manage their pain with prescription and/or over‐the‐counter pain medications, containing paracetamol. If taken appropriately, these medications are relatively safe; however, if mismanaged through patients’ inability to understand medication labels and instructions, these medications may cause adverse drug events and/or toxicities.AimThis study explored the prescription and over‐the‐counter pain medications most commonly used by people with arthritis and the ability of these patients to correctly identify paracetamol as an active ingredient in commonly available preparations. The study also investigated the functional health literacy of these patients and their inclination to borrow and/or share pain medications.MethodAdult participants diagnosed with arthritis were invited to complete an anonymous survey which included questions about their prescription and over‐the‐counter pain medications; their medication borrowing and sharing behaviours; their functional health literacy; and their knowledge about preparations containing paracetamol as an active ingredient.ResultsMost of the 254 participants used analgesic agents containing paracetamol, as combination tablets (paracetamol 500 mg and codeine 30 mg) or paracetamol‐only tablets (paracetamol 665 mg) to self‐manage their pain. Respondents with low functional health literacy scores were significantly less likely to identify paracetamol as an active ingredient in both combination and paracetamol‐only pharmaceutical products, and were more likely to guess or did not know how to identify that paracetamol was an active ingredient in these products. Almost 30% of the respondents indicated that they had and/or intended to borrow/share their over‐the‐counter pain medications whereas less than 10% suggested that they had and/or intended to borrow/share their prescription pain medication.ConclusionAustralians with arthritis, especially those with low functional health literacy scores, self‐managing their pain with paracetamol‐containing products, do not always recognise paracetamol as an active ingredient in combination products, and may risk potential paracetamol‐related adverse effects and/or toxicities.

Functional health literacy and glycaemic control in older adults with type 2 diabetes: a cross-sectional study

ObjectivesTo investigate the relationship between functional health literacy and glycaemic control in a sample of older patients with type 2 diabetes.DesignCross-sectional study.SettingA government-financed outpatient geriatric clinic in São Paulo, Brazil.Participants129...

An Innovative Fever Management Education Program for Parents, Caregivers, and Emergency Nurses

Parents frequently present to the emergency department (ED) concerned about their child's fever. Fever management education programs have been found to improve parents' knowledge of managing fever, although no education program was identified that specifically considered parents with lower functional health literacy. This article describes the development of an easily understood children's fever management education program for parents with varying levels of health literacy. A review of existing literature and guidelines was conducted. Pictorial images and written material constrained to fifth-grade level of readability were used. Academics and ED experts confirmed the content of this evidence-based program. The education program, a combination of Digital Video Disc (DVD) and a brochure in relation to child fever management, is currently being trailed at an ED in Sydney and is appropriate for EDs or primary care settings. Tailoring education programs with plain and simple language is potentially beneficial to all parents (or caregivers) presenting to the ED with children experiencing fever. This program will provide nurses with a simple and clear fever management brochure or DVD to give to parents or caregivers with varying levels of health literacy. We envisage that this program will be continuously televised within local EDs and available for parents or caregivers to view online.

The relationship between functional health literacy and the use of the health system by diabetics in Switzerland.

Background: Observational studies from the USA have suggested that patients with low health literacy (HL) have higher health care costs and use an inefficient mix of health care services. To date, there were no studies from Europe that investigated the impact of HL on the use of the health system. The purpose of this study was to measure functional HL among persons having type 2 diabetes and to investigate the relationship between functional HL and health care costs and utilization. Methods: The study population were insured persons of the basic health insurance plan of the largest health insurer in Switzerland. Persons selected for participation had been reimbursed for diabetes medications in 2010–11, were aged 35–70 years and did not live in a long-term care institution. The level of functional HL was measured by one screening question. The following dependent variables were used: total costs, outpatient costs, inpatient costs, days admitted and number of physician visits attended. All multiple regression analyses were adjusted for age, gender, education, duration of diabetes, treatment with insulin (yes/no) and other chronic disease (yes/no). Results: High levels of functional HL were associated with lower total costs (P = 0.007), lower outpatient costs (P = 0.004) and less physician visits (P = 0.001). In the standard insurance plan with free access to all health professionals subgroup, the effects found were more pronounced. Conclusions: Persons with low functional HL need extra medical support, and therefore have higher health care costs.

The Role of Health Literacy and Numeracy in Contraceptive Decision-Making for Urban Chicago Women

Low functional health literacy and numeracy have known associations with poor health outcomes, yet little work has investigated these markers of health disparity in a family planning population. We used an in-depth qualitative process and 2 literacy and numeracy assessment tools, the REALM-7 and the Schwartz numeracy scale, to assess the role of literacy and numeracy in contraceptive decision-making in an urban Chicago population. Brief surveys and semi-structured interviews were conducted with 30 postpartum women who had received Medicaid-funded care at an obstetrics clinic in an academic medical center. In-person one-on-one interviews were then reviewed for themes using an iterative process. Qualitative analysis techniques identifying emergent themes were applied to interview data. Literacy and numeracy were assessed using REALM-7 and a validated 3-question numeracy scale. In this cohort of African American (63 %) and Hispanic (37 %) women (median age 26), 73 % had unplanned pregnancies. Although health literacy rates on the REALM-7 were adequate, numeracy scores were low. Low literacy and numeracy scores were associated with interview reports of poor contraceptive knowledge and difficulty with contraceptive use. Low health literacy and numeracy may play an important role in contraception decision-making in this low-income, minority population of women. We recommend further study of literacy and numeracy in a family planning population. Comprehensive contraception education and communication around the contraceptive decision-making process should take place at literacy and numeracy levels appropriate to each individual.

Medicines non-adherence: adult literacy and implications for practice

Functional health literacy is defined as the level at which individuals can obtain, process and understand basic health information (Martin et al, 2009). Government statistics suggest low functional health literacy is an under-recognised and growing problem in UK health care. It is associated with high hospitalisation (Baker et al, 1998) and increased medicines non-adherence (Kalichman et al, 1999). Health professionals are poor at assessing and identifying those at risk because they have yet to acknowledge the prevalence of the problem. Initiatives attempting to address medicines non-adherence promote patient involvement in treatment decisions but remain ineffective if patients cannot read or understand written instructions. To help patients with low functional health literacy practitioners should speak slowly, repeat information, use plain, non-medical language and adopt teach-back techniques. These actions take extra time but are relatively easy to adopt and with a little thought become part of everyday practice.

Association between low functional health literacy and mortality in older adults: longitudinal cohort study

Objective To investigate the association between low functional health literacy (ability to read and understand basic health related information) and mortality in older adults.Design Population based longitudinal cohort study based...

Risks associated with low functional health literacy in an Australian population

Medical Journal of AustraliaVolume 192, Issue 8 p. 478-479 Letter Risks associated with low functional health literacy in an Australian population Robert A Bush, Corresponding Author Robert A Bush Professor and Director, Healthy Communities Research Centre r.bush@uq.edu.au University of Queensland, Brisbane, QLD.Correspondence: r.bush@uq.edu.auSearch for more papers by this authorFrances M Boyle, Frances M Boyle AssociateProfessor and Head, Health Systems and Policy Group University of Queensland, Brisbane, QLD.Search for more papers by this authorRemo Ostini, Remo Ostini Research Fellow, Healthy Communities Research Centre University of Queensland, Brisbane, QLD.Search for more papers by this author Robert A Bush, Corresponding Author Robert A Bush Professor and Director, Healthy Communities Research Centre r.bush@uq.edu.au University of Queensland, Brisbane, QLD.Correspondence: r.bush@uq.edu.auSearch for more papers by this authorFrances M Boyle, Frances M Boyle AssociateProfessor and Head, Health Systems and Policy Group University of Queensland, Brisbane, QLD.Search for more papers by this authorRemo Ostini, Remo Ostini Research Fellow, Healthy Communities Research Centre University of Queensland, Brisbane, QLD.Search for more papers by this author First published: 19 April 2010 https://doi.org/10.5694/j.1326-5377.2010.tb03597.xCitations: 2Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume192, Issue8April 2010Pages 478-479 RelatedInformation

Risks associated with low functional health literacy in an Australian population

Despite attention given to health literacy bythe National Health and Hospitals ReformCommission, current discussions remain wor-ryingly limited.In the 1990s, Nutbeam was prominentamong those who recognised both the indi-vidual and the larger environmental settingsof health literacy, as well as its relevance toprevention. “Health literacy and health skills”was included as a category in a landmarkhealth goals and targets framework, as “per-sonal health knowledge and positive attitudestowards changing behaviour demonstrablyinfluence people’s ability to adopt healthylifestyles”.

Risks associated with low functional health literacy in an Australian population

To measure the level of functional health literacy (FHL) in an Australian population, and to explore the level of risk associated with level of FHL. Cross-sectional, random population survey administered to 2824 South Australians aged>or=15 years, September-October 2008. Newest Vital Sign as a measure of FHL, self-reported general health status, and use of health services. 24% of respondents were at risk of limited FHL, and 21% had a high likelihood of inadequate FHL; this increased with age (>or=65 years, 50% v 25-44 years, 11%). In multiple logistic regression models, a high likelihood of inadequate FHL was significantly more common among those with lower education (left school<or=15 years of age, odds ratio [OR], 8.1; 95% CI, 4.8-13.6); with lower annual income (<$20 000, OR, 4.1; 95% CI, 2.3-7.4); who were born in countries other than Australia, New Zealand, the United Kingdom and Ireland; and with poorer health status (OR, 1.6; 95% CI, 1.2-2.2). Inadequate FHL was significantly less common among females (OR, 0.6; 95% CI, 0.5-0.8). People with inadequate or at-risk FHL were significantly more likely to report having diabetes, cardiac disease or stroke, and significantly less likely to have recently attended a doctor. Respondents aged>or=65 years with inadequate FHL were more likely to have been admitted to hospital (OR, 2.2; 95% CI, 1.1-4.5). Many Australians are likely to have limited health literacy, and this is a risk to effective health care delivery and health improvement across the community.

Development and evaluation of an oral health literacy instrument for adults

To develop and validate an instrument to measure the functional oral health literacy of adults. For the generation of items different dental patient educational materials and text types were selected that had reading levels similar to materials used for the Test of Functional Health Literacy in Adults (TOFHLA) which was the model for our Oral Health Literacy Instrument (OHLI). The OHLI contains reading comprehension and numeracy sections. The reading comprehension section is a 38-item test with words omitted from one passage on dental caries and another on periodontal disease. The numeracy section has 19 items to test comprehension of directions for taking common prescriptions associated with dental treatment, postextraction instructions and dental appointments. We also developed a 17-item oral health knowledge test. The OHLI, the TOFHLA, the oral health knowledge test and a brief questionnaire were administered to a convenience sample of 100 patients. Internal reliability of OHLI was assessed with Cronbach's alpha. Test-retest reliability was examined by intra-class correlation coefficient (ICC). Concurrent validity was tested by comparing OHLI scores across categories of education level and frequency of dental visits. Construct validity was assessed by correlating OHLI scores with TOFHLA scores and with the oral health knowledge scores using Spearman's rho (rho) and multiple linear regression. Participants averaged 39 years (SD = 12.4); 73% were female; 64% had college/university education; 40% visited a dentist every 3-6 months. Total OHLI and TOFHLA weighted mean scores were 87.2 and 91.7, respectively (possible range 0-100). The Cronbach's alpha values were high (>0.7) for OHLI and its components. The ICC values indicated good agreement between the test and retest results for OHLI and the oral health knowledge test. Patients visiting a dentist every 3-6 months had significantly higher levels of oral health literacy than those visiting only when they felt pain. The association between OHLI and education level was not significant. OHLI scores were significantly correlated with the scores on the TOFHLA (rho = 0.613) and the test of oral health knowledge (rho = 0.573). These associations remained significant in multiple regression models. Initial testing of OHLI suggested that it is a valid and reliable instrument to evaluate oral health literacy among adults, although additional work is needed to investigate the instrument's predictive validity and sensitivity to change using oral health outcomes with population groups known to be at high risk of low functional oral health literacy.

Making health literacy real: adult literacy and medical students teach each other

This paper reports a pilot project at Harvard Medical School (HMS) that taught medical students the importance of plain language communication by collaborating with adult literacy students. Classes provided students with patient-doctor communication experience and health information. After a lecture on health literacy and cross-cultural care, a librarian taught students where to find high-quality, easy-to-read, and non-English health information. Adult learners identified health topics of interest. Medical students then created presentations on these topics and received critical feedback from the adult students. HMS students improved their use of plain language communication and their understanding of health disparities. Everyone expressed a desire to learn more. The project demonstrated that health literacy competencies can be integrated into medical school instruction using a combination of didactic and experiential methods. Medical schools and their librarians are in a unique position to work with future providers to ameliorate the problem of low health literacy. The profound consequences of poor health literacy have been well documented and indicate that vast amounts of health information are incomprehensible to millions of people [1–4]. People with low functional health literacy have more difficulty navigating the health care system and obtaining services. They are less likely to comprehend the written and oral information given to them by providers. They are also more likely to suffer higher health care costs and disproportionately have poorer health outcomes than those with high levels of health literacy. Older people, nonwhites, immigrants, and low-income people constitute a large segment of people with low health literacy [3]. Issues of culture, language, and learning are interrelated, and to be effective, health information must be provided in both culturally and linguistically appropriate formats to address the increasingly diverse multicultural and multilingual population [4]. The Liaison Committee on Medical Education of the American Association of Medical Colleges (AAMC), the American Medical Association (AMA), and the Institute of Medicine (IOM) all emphasize the need to address these issues in medical education [5–8]. While other medical education efforts focused on health literacy are described in the literature, their methodology relies on role-playing between medical students and faculty [8,9]. To the authors' knowledge, this class was different because it offered an opportunity to work with adult literacy students. The creation and implementation of this educational opportunity by the coauthors, a community service program manager and a librarian, illustrates a novel pathway for medical librarians to share their knowledge of health literacy with both adult learners and medical students. Medical librarians are active in the health literacy movement, participating as both consumer health information specialists and educators for health care professionals. The Medical Library Association's Health Information Literacy (HIL) web page—with links to projects, presentations, and information sources created by librarians—provides evidence of this involvement [10]. The Countway Library at HMS has hosted displays to raise awareness of health literacy issues both at the library and in the medical education building.

Assessing Adult Health Literacy in Urban Healthcare Settings

To determine if health literacy is lower among those using the emergency department as compared to those using community health clinics. A comparison was done of the health literacy level of patients at a level-I adult and pediatric emergency department and 3 community health clinics. The second purpose of the study was to identify and assess predictors of low or adequate health literacy in order to better accommodate the communication needs of these patients. The study used a convenience, cross-sectional design. The settings for the study were varied. The emergency department was a level-I inner-city pediatric and adult trauma center with 45,000 annual visits. The 3 outpatient clinics were all members of a 44-clinic network of private, community health centers that serve 175,000 underserved patients annually. Overall, 536 patients were approached to complete an in-person survey that included a 15-item written questionnaire and the Short Test of Functional Health Literacy in Adults (S-TOFHLA), a English- and Spanish-validated health literacy measure. Based on language spoken with healthcare providers, patients were given either the Spanish or English S-TOFHLA. The refusal rate was 25.7%, with 536 patients approached and 398 completing the survey. Three of the four sites had a refusal rate of 8% per site. The fourth site had a higher refusal rate at 38%. Overall, 20% of subjects had marginal or inadequate functional health literacy. There was a significant difference at p=18.42, df=3, p=0.001 among sites. Three of the sites had > or =78% of the participants scoring at the adequate level. The fourth site, however, only had 66% who scored at the adequate level, with 34% of the scores in the inadequate functioning level as compared with 14% for the emergency department and its adjacent clinic and 3% for the clinic located at the city's edge. Using logistical regression, there was an association between literacy level and education (t=2.653, sig 0.008) and age (t=-6.451, sig 0.001). Less-than-adequate functional health literacy was seen at 20% of all sites. The location of healthcare access was not as predictive of low functional health literacy as were demographic indicators, such as age and education levels.

The Influence of Functional Literacy on Perceived Health Status in Korean Older Adults

The purpose of this study was to understand the level of functional health literacy and its influence on perceived health status in Korean older adults. A cross-sectional survey was conducted in Daegu, Kyungpook and Busan province. A total of 103 older adults aged 65 yr or older were interviewed in person between July 1 to August 30, 2007. A high proportion of older adults were unable to read and understand written basic medical instructions. Only 40-50% were able to comprehend directions for taking medication four times a day or on an empty stomach. Only 11-38% were able to understand information regarding treatment procedure, informed consent, or educational material for elderly fall prevention. Individuals who were older, single, and had less education and income were more likely to have lower functional health literacy. After adjusting for sociodemographic variables, individuals with lower health literacy had poorly perceived health status. Many Korean older adults have a very low level of functional literacy. Low health literacy was independently associated with poorly perceived health status.

Literacy and Knowledge, Attitudes and Behavior About Mammography in Latinas

This cross-sectional study explored the association between functional health literacy and the knowledge, beliefs, attitudes, and behavior about mammography and self-breast examination in a sample of Latinas attending community health clinics in Philadelphia. The results show that 70% of Latinas had inadequate or marginal functional health literacy. In Latinas, functional health literacy is only weakly associated with knowledge and not associated with beliefs and attitudes about screening mammography, but is significantly associated with having ever had a mammogram. After adjusting for demographic characteristics, functional health literacy was significantly associated with having ever had a mammogram (odds ratio [OR] 1.14, 95% confidence interval [CI] 1.02-1.27). These findings suggest that Latinas with poor functional health literacy are less likely to undergo mammography. Future research should target increasing the knowledge about and rates of screening mammography in patients with low functional health literacy.

Health Literacy and Pregnancy Preparedness in Pregestational Diabetes

The 19,000 women with pregestational diabetes who deliver infants each year in the United States are at increased risk of adverse outcomes, including spontaneous abortion, stillbirth, and congenital anomalies. The risk could be limited by preconceptional planning that ensures good glycemic control as well as folic acid supplementation. This pilot study was done to examine the association, if any, between low functional health literacy in women with pregestational diabetes and markers of adverse pregnancy outcomes. Seventy-four pregnant women with type 1 or type 2 pregestational diabetes were prospectively entered into the study. They completed the short form of the Test of Functional Health Literacy in Adults (TOFHLA) as well as a demographic and medical questionnaire. Sixteen of the 74 women (22%) had low functional health literacy based on a TOFHLA score of 30 or lower. Women with adequate health literacy came earlier for prenatal care. There was no intergroup difference in gestational age at the time of evaluation. The adequate-literacy women were more often white and had had diabetes for a longer time. Fewer women in the low-literacy group had a high school education, and these women also had lower socioeconomic status. Unplanned pregnancies were more frequent in the low-literacy group, and women were less likely to have discussed becoming pregnant with a physician. In addition, low-literacy women were less likely to have taken folic acid before pregnancy or in the first trimester. Low-literacy women were likelier to be hospitalized during pregnancy, chiefly because of inadequate glycemic control. There was no group difference in gestational age at delivery, but birth weights were significantly greater in the low-literacy group. These women also were likelier to have an infant weighing more than 4000 g. In women with pregestational diabetes, low functional health literacy is associated with several factors that could negatively affect birth outcomes.

An application of health literacy research

Finding methods to improve the delivery of educational materials by the practicing nurse is imperative in the current health care arena. Time, energy, and effectiveness are all aspects that are critical as the health care provider attempts to meet the growing needs of the compromised client. Low functional health literacy is one public health problem that impacts the nurse’s ability to effectively provide health instruction in a timely, organized manner. This article presents a pilot research project used to investigate the mastery of educational information by clients in a West Texas area. The research project is used as the foundation for discussion of several interesting facets resulting from the initial research. Ideas are presented as a direction for implementation for practice within the health care community. Low health literacy is a grave challenge, which currently is not understood nor considered by the nurse at the bedside. Practicing health care providers need the opportunity to carefully and specifically investigate the role of health care literacy in producing positive client outcomes.

Health literacy and pregnancy preparedness in pregestational diabetes.

We investigated the association between functional health literacy and markers of pregnancy preparedness in women with pregestational diabetes. English- and Spanish-speaking pregnant women with pregestational diabetes were recruited. Women completed the Test of Functional Health Literacy in Adults (TOFHLA) short form and a questionnaire. A TOFHLA score of < or =30 was defined as low functional health literacy. Of 74 women participating in the study, 16 (22%) were classified as having low functional health literacy. Compared with women with adequate health literacy, those with low health literacy were significantly more likely to have an unplanned pregnancy (P = 0.02) and significantly less likely to have either discussed pregnancy ahead of time with an endocrinologist or obstetrician (P = 0.01) or taken folic acid (P = 0.001). The results of this study suggest that low functional health literacy among women with pregestational diabetes is associated with several factors that may adversely impact birth outcomes.