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PubMed2002

Developing linguistic literacy: a comprehensive model.

This is a position paper modelling the domain of linguistic literacy and its development through the life span. It aims to provide a framework for the analysis of language development in the school years, integrating sociolinguistic and psycholinguistic notions of variation, language awareness, and literacy in a comprehensive model. The paper focuses on those aspects of literacy competence that are expressed in language as well as aspects of linguistic knowledge that are affected by literacy competence, tracing the route that children take in appropriating linguistic literacy as part of their cognitive abilities and examining the effect of literacy on language across development. Our view of linguistic literacy consists of one defining feature: control over linguistic variation from both a user-dependent ('lectal') and a context-dependent (modality, genre, and register) perspective; of one concomitant process: metalanguage and its role in language development; and of one condition: familiarity with writing and written language from two aspects: written language as discourse style--the recognition that the kind of language used for writing is essentially different from the one used for speech; and written language as a notational system--the perception and growing command of the representational system that is used in the written modality. Linguistic literacy is viewed as a constituent of language knowledge characterized by the availability of multiple linguistic resources and by the ability to consciously access one's own linguistic knowledge and to view language from various perspectives.

Awareness↗
PubMed2002

The association of health literacy with cervical cancer prevention knowledge and health behaviors in a multiethnic cohort of women.

OBJECTIVE: Our purpose was to describe the relationship between health literacy, ethnicity, and cervical cancer screening practices and to evaluate physician recognition of low literacy. STUDY DESIGN: We studied a prospective cohort of English-speaking patients > or =18 years (n = 529) in ambulatory women's clinics. Univariate and multivariate analyses were used to evaluate demographics, health practices and beliefs, and knowledge regarding cervical cancer screening and prevention. Physicians' assessments of patient reading skills were obtained. RESULTS: Low health literacy (<9th grade) was found among 40% of participants. Minority women were half as likely to know the purpose of the Papanicolaou test (9% vs 21%; P <.03) and were significantly more likely to have low literacy levels compared with white women (46% vs 15%; P <.05). Literacy was the only factor independently associated with knowledge related to cervical cancer screening (adjusted odds ratio, 2.25; 95% CI, 1.05-4.80). Physicians detected only 20% of the lowest readers. CONCLUSION: Poor health literacy was a better predictor of cervical cancer screening knowledge than ethnicity or education, yet physicians infrequently recognized low literacy. Improved physician awareness and development of low literacy interventions may improve cervical cancer screening, particularly for the most vulnerable women.

Adult↗
PubMed2005

Health literacy, morbidity, and quality of life among individuals with spinal cord injury.

OBJECTIVES: Health literacy has been related to indicators of health outcomes in a number of populations, but not in spinal cord injury (SCI). The current study aimed to describe levels of health literacy in SCI and to investigate its possible associations with morbidity, health-related quality of life, functional independence, community participation, and life satisfaction. DESIGN: Cross-sectional survey of 107 community-living people with SCI recruited in a New Jersey outpatient SCI center. Primary measures were the Test of Functional Health Literacy in Adults (TOFHLA), standard questions about morbidity from the Behavioral Risk Factors Surveillance Study, the Craig Handicap Assessment and Reporting Technique (CHART), Short Form-12 (SF-12), and Diener's Satisfaction with Life Scale. RESULTS: Health literacy was marginal or inadequate (TOFHLA = 0-74) in only 14% of the sample. TOFHLA scores correlated significantly with physical health morbidity, even after control for severity of motor paralysis and education. American Spinal Injury Association (ASIA) Motor Scores were correlated with physical morbidity and CHART Physical Independence scores; and education was related to community Mobility, Occupation, and Economic Independence, and Satisfaction with Life scores, independent of other factors. Rasch analysis identified ceiling measurement limitations in the TOFHLA. CONCLUSIONS: Health literacy levels in this sample were higher than those found in other groups. Health literacy was independently related to physical health morbidity, but its associations with other outcomes were limited, entwined with education, and affected by severity of injury. Future research might examine higher-level aspects of health literacy to overcome ceiling measurement problems. Mediators of the association between health literacy and morbidity, such as health self-care behaviors, should also be examined.

Adult↗
PubMed2003

Health literacy in low-income Latino men and women receiving antiretroviral therapy in community-based treatment centers.

Health literacy is an important and well known predictor of health-seeking behaviors and health status. Some populations of persons living with HIV/AIDS (PLHA) are reported to have low levels of health literacy. Factors contributing to low levels of health literacy in traditionally underserved ethnic minority groups seeking community-based treatment services are many and include individual level predisposing and enabling factors as well as system enabling factors. The purpose of this study was to describe deficits in health literacy in a sample of 90 low-income HIV-infected Latino men and women reported to have problems with treatment adherence. Additionally, correlates of health literacy were examined to identify the relative impact of these factors in predicting lower levels of health literacy in this at-risk population. Results of the study indicated that years of education was associated with understanding HIV terms and accurately reading and understanding instructions on prescription bottles. In a multivariate context, individual predisposing and system enabling factors accounted for 22% of the variance in patients' understanding HIV terms. Individual predisposing and individual enabling factors accounted for 17% of the variance in reading and understanding instructions on prescription bottles. Further research is needed to examine the role of treatment programs in mediating relationships between individual predisposing factors and health literacy and the linkages between health literacy, health promotion behaviors, and subsequent health status in at-risk populations.

Adult↗
PubMed1993

Age, education, and literacy skills of adult Mississippians.

This study examined the literacy skills of 1791 black and white Mississippi residents aged 16 to 75, with varying levels of education. Using a new literacy test developed by the Educational Testing Service (ETS), three kinds of literacy were assessed: prose literacy, document literacy, and quantitative literacy. Results revealed that very few Mississippians were totally illiterate, but that the level of literacy was associated with education, age, and race. Within age groups, educated persons scored higher than less educated persons. However, both highly-educated and little-educated older persons scored lower on all three measures of literacy than equally educated younger persons.

Adolescent↗
PubMed2005

Understanding health literacy: an expanded model.

A long and yet unfinished history of investigating how individual capabilities and social processes explain or predict health indicates that poor education, low literacy, poor health and early death are strongly linked around the world. However, the complexity of those relationships is not fully understood. In this article, we propose an expanded model of health literacy characterized by four domains: fundamental literacy (reading, writing, speaking and numeracy), science literacy, civic literacy and cultural literacy. To explore the utility of this model, we examine selected pieces of the public discourse about terrorism and bioterrorism that dominated the mass media during the anthrax threat in the United States during 2001. We conclude that this model of health literacy is useful to analyze health communication, to aid in constructing more understandable and appropriate health communication, and ultimately can lead to the development of a new measure to assess health literacy skills in individuals.

Anthrax↗
PubMed2004

Literacy and numeracy skills and anticoagulation control.

BACKGROUND: The ability to use printed material to function in society (literacy) and to handle basic numerical concepts (numeracy) may have implications in patients' ability to follow dosing schedules. We examined literacy and numeracy skills among patients on warfarin and explored their association with anticoagulation control. METHODS AND RESULTS: Patients older than 50 years attending two anticoagulation management units were prospectively enrolled. We measured literacy, numeracy, and international normalized ratio (INR). During a 3-month follow-up period, we calculated the variability of the INR and the amount of time a patient's INR was within his or her therapeutic range, variables associated with bleeding and effectiveness. Among 143 patients, only 75 (52.4%) were able to read health-related words at the eighth grade level or less. Patients' self-reported grade completed was higher than the measured literacy grade level (kappa = 0.21). While 79.0% had completed at least eight grades, only 47.6% had a score at that grade level. Sixty-nine patients answered none or correctly answered fewer than two of the six numeracy questions (48.3%). The INR variability was higher among patients with lower literacy (P = 0.009) and lower numeracy skills (P = 0.004). The time in range was similar among patients at different literacy levels (P = 0.9). Patients with lower numeracy level spent more time above their therapeutic range (P = 0.04) and had a trend of less time spent in range (P = 0.10). CONCLUSIONS: Low literacy was prevalent among study patients taking warfarin. Low literacy and numeracy were associated with measures of poor anticoagulation control.

Aged↗
PubMed2002

Health literacy and preventive health care use among Medicare enrollees in a managed care organization.

BACKGROUND: Many older adults in Medicare managed care programs have low health literacy, and this may affect use of preventive services. OBJECTIVES: To determine whether older adults with inadequate health literacy were less likely to report receiving influenza and pneumococcal vaccinations, mammograms, and Papanicolaou smears than individuals with adequate health literacy after adjusting for other covariates. RESEARCH DESIGN: Cross-sectional survey; home interviews with community dwelling enrollees. SUBJECTS: Medicare managed care enrollees 65 to 79 years old in four US cities (n = 2722). MEASURES: Short Test of Functional Health Literacy in Adults and self-reported preventive service use. RESULTS: In bivariate analyses, self-reported lack of preventive services was higher among individuals with inadequate health literacy than those with adequate health literacy: never had an influenza vaccination: 29% versus 19% (P = 0.000); never had a pneumococcal vaccination: 65% versus 54% (P = 0.000); no mammogram in the last 2 years: 24% versus 17% (P = 0.017); never had a Papanicolaou smear: 10% versus 5% (P = 0.002). After adjusting for demographics, years of school completed, income, number of physician visits, and health status, people with inadequate health literacy were more likely to report they had never received the influenza (OR, 1.4; 95% CI, 1.1-1.9) or pneumococcal vaccination (OR, 1.3; 95% CI, 1.1-1.7), and women were less likely to have received a mammogram (OR, 1.5; 95% CI, 1.0-2.2) or Papanicolaou smear (OR, 1.7; 95% CI, 1.0-3.1). CONCLUSIONS: Among Medicare managed care enrollees, inadequate health literacy is independently associated with lower use of preventive health services.

Aged↗
PubMed2006

Low literacy impairs comprehension of prescription drug warning labels.

BACKGROUND: Adverse events resulting from medication error are a serious concern. Patients' literacy and their ability to understand medication information are increasingly seen as a safety issue. OBJECTIVE: To examine whether adult patients receiving primary care services at a public hospital clinic were able to correctly interpret commonly used prescription medication warning labels. DESIGN: In-person structured interviews with literacy assessment. SETTING: Public hospital, primary care clinic. PARTICIPANTS: A total of 251 adult patients waiting for an appointment at the Louisiana State University Health Sciences Center in Shreveport (LSUHSC-S) Primary Care Clinic. MEASUREMENTS: Correct interpretation, as determined by expert panel review of patients' verbatim responses, for each of 8 commonly used prescription medication warning labels. RESULTS: Approximately one-third of patients (n=74) were reading at or below the 6th-grade level (low literacy). Patient comprehension of warning labels was associated with one's literacy level. Multistep instructions proved difficult for patients across all literacy levels. After controlling for relevant potential confounding variables, patients with low literacy were 3.4 times less likely to interpret prescription medication warning labels correctly (95% confidence interval: 2.3 to 4.9). CONCLUSIONS: Patients with low literacy had difficulty understanding prescription medication warning labels. Patients of all literacy levels had better understanding of warning labels that contained single-step versus multiple-step instructions. Warning labels should be developed with consumer participation, especially with lower literate populations, to ensure comprehension of short, concise messages created with familiar words and recognizable icons.

Adolescent↗
PubMed2006

Brief report: screening items to identify patients with limited health literacy skills.

BACKGROUND: Patients with limited literacy skills are routinely encountered in clinical practice, but they are not always identified by clinicians. OBJECTIVE: To evaluate 3 candidate questions to determine their accuracy in identifying patients with limited or marginal health literacy skills. METHODS: We studied 305 English-speaking adults attending a university-based primary care clinic. Demographic items, health literacy screening questions, and the Rapid Estimate of Adult Literacy in Medicine (REALM) were administered to patients. To determine the accuracy of the candidate questions for identifying limited or marginal health literacy skills, we plotted area under the receiver operating characteristic (AUROC) curves for each item, using REALM scores as a reference standard. RESULTS: The mean age of subjects was 49.5; 67.5% were female, 85.2% Caucasian, and 81.3% insured by TennCare and/or Medicare. Fifty-four (17.7%) had limited and 52 (17.0%) had marginal health literacy skills. One screening question, "How confident are you filling out medical forms by yourself?" was accurate in detecting limited (AUROC of 0.82; 95% confidence interval [CI]=0.77 to 0.86) and limited/marginal (AUROC of 0.79; 95% CI=0.74 to 0.83) health literacy skills. This question had significantly greater AUROC than either of the other questions (P<.01) and also a greater AUROC than questions based on demographic characteristics. CONCLUSIONS: One screening question may be sufficient for detecting limited and marginal health literacy skills in clinic populations.

Adolescent↗
PubMed2006

Predictors of medication self-management skill in a low-literacy population.

BACKGROUND: Patients' ability to manage medications is critical to chronic disease control. Also known as medication management capacity (MMC), it includes the ability to correctly identify medications and describe how they should be taken. OBJECTIVE: To evaluate the effects of low literacy, medication regimen complexity, and sociodemographic characteristics on MMC. DESIGN: Cross-sectional analysis of enrollment data from participants in a randomized trial. PARTICIPANTS: Patients with coronary heart disease in an inner-city clinic. MEASUREMENTS: Medication management capacity was measured with the Drug Regimen Unassisted Grading Scale (DRUGS), which scores subjects' ability to identify, open, describe the dose, and describe the timing of their medications. DRUGS overall and component scores were compared by literacy, Mini Mental State Exam score, regimen complexity (number of prescription medications), and sociodemographic characteristics. RESULTS: Most of the 152 participants were elderly (mean age 65.4 years), women (54.6%), and African American (94.1%). Approximately half (50.7%) had inadequate literacy skills, and 28.9% had marginal skills. In univariate analysis, MMC was significantly associated with literacy (P<.001), and this effect was driven by the ability to identify medications. In multivariable models, patients with inadequate literacy skills had 10 to 18 times the odds of being unable to identify all of their medications, compared with those with adequate literacy skills (P<.05). CONCLUSIONS: Adults with inadequate literacy skills have less ability to identify their medications. Techniques are needed to better educate low-literacy patients about their medications, as a potential strategy to enhance adherence.

Aged↗
PubMed2005

Tailored education may reduce health literacy disparities in asthma self-management.

RATIONALE: Although inadequate health literacy has been associated with lower asthma medication knowledge and worse metered-dose inhaler (MDI) technique, the relationship between health literacy and the capacity to learn asthma self-management skills is unknown. OBJECTIVES: In this prospective cohort study of adults hospitalized for severe asthma exacerbations at two inner-city hospitals, we examined the relationship between inadequate health literacy and difficulties learning and retaining instructions about discharge medications and appropriate MDI technique. METHODS: At hospital discharge, participants received one-on-one, 30-min, guideline-based, written and oral instruction about their asthma discharge regimen as well as appropriate MDI technique. MEASUREMENTS AND MAIN RESULTS: Seventy-three patients were enrolled. Inadequate health literacy was identified in 16 (22%) participants. Before instruction, inadequate health literacy was associated with lower asthma medication knowledge (5.2/10 vs. 7.2/10, p < 0.001) and worse MDI technique (3.2/6 vs. 3.9/6, p = 0.03). However, inadequate health literacy was not associated with difficulty learning (p = 0.33) or retaining (p = 0.35) instructions about the discharge regimen. Similarly, inadequate health literacy was not associated with difficulty learning (p = 0.26) or retaining (p = 0.97) appropriate MDI technique. Results were similar in multivariable models adjusted for demographic characteristics and asthma severity indicators. CONCLUSIONS: These findings suggest that inadequate health literacy is a surmountable barrier to learning and remembering key asthma self-management skills.

Academic Medical Centers↗
PubMed2006

Misperceptions of medical understanding in low-literacy patients: implications for cancer prevention.

BACKGROUND: Patients with limited literacy skills often have difficulty understanding medical information, are less likely to undergo cancer screening, and present with cancer at later stages than patients with better literacy skills. Since primary care physicians are responsible for performing or initiating the majority of cancer screening in the United States, they need to be able to not only identify patients who might not understand medical information but also communicate effectively with them about cancer prevention and screening. METHODS: To determine whether family medicine residents could identify patients who might have difficulty understanding medical information because of limited literacy, we measured the literacy skills of patients in a university-based family medicine clinic using the short form of the Test of Functional Health Literacy in Adults (S-TOFHLA). After the patients completed their office visits with a physician, we asked family medicine residents to rate the patients' ability to understand medical information. RESULTS: Among 140 patients who met with 18 family medicine resident physicians, 24% had limited literacy skills based on testing with the S-TOFHLA. Residents identified only about half of these patients as having poor or below average understanding of medical information. CONCLUSIONS: IN many cases, family medicine residents are unable to identify patients who, based on assessment of their literacy skills, are likely to have difficulty understanding medical information. When working with residents, medical educators should promote the habit of taking poor literacy into account when communicating with patients.

Communication↗
PubMed2006

Literacy and health outcomes: a cross-sectional study in 1002 adults with diabetes.

BACKGROUND: Inconsistent findings reported in the literature contribute to the lack of complete understanding of the association of literacy with health outcomes. We evaluated the association between literacy, physiologic control and diabetes complications among adults with diabetes. METHODS: A cross-sectional study of 1,002 English speaking adults with diabetes, randomly selected from the Vermont Diabetes Information System, a cluster-randomized trial of a diabetes decision support system in a region-wide sample of primary care practices was conducted between July 2003 and March 2005. Literacy was assessed by the Short-Test of Functional Health Literacy in Adults. Outcome measures included glycated hemoglobin, low density lipoprotein, blood pressure and self-reported complications. RESULTS: After adjusting for sociodemographic characteristics, duration of diabetes, diabetes education, depression, alcohol use, and medication use we did not find a significant association between literacy and glycemic control (beta coefficent,+ 0.001; 95% confidence interval [CI], -0.01 to +0.01; P = .88), systolic blood pressure (beta coefficent, +0.08; 95% CI, -0.10 to +0.26; P = .39), diastolic blood pressure (beta coefficent, -0.03; 95% CI, -0.12 to +0.07, P = .59), or low density lipoprotein (beta coefficent, +0.04; 95% CI, -0.27 to +0.36, P = .77. We found no association between literacy and report of diabetes complications. CONCLUSION: These findings suggest that literacy, as measured by the S-TOFHLA, is not associated with glycated hemoglobin, blood pressure, lipid levels or self-reported diabetes complications in a cross-sectional study of older adults with diabetes under relatively good glycemic control. Additional studies to examine the optimal measurement of health literacy and its relationship to health outcomes over time are needed.

Aged↗
PubMedDate not supplied

'Breaking it down': patient-clinician communication and prenatal care among African American women of low and higher literacy.

PURPOSE: Low literacy has been associated with poor medical adherence, but its role in maternal care utilization has not been explored. METHODS: We undertook a concurrent mixed methods study among 202 African American women of low (< or = 6th grade) and higher literacy receiving Medicaid. Poor use of prenatal care was defined by (1) starting care after the first trimester and (2) inadequate care utilization according to the Adequacy of Prenatal Care Utilization Index (APNCU). Participant-derived themes regarding prenatal care and care utilization were identified and explored through individual interviews (free listing and cultural consensus analysis; n = 40), and 4 confirmatory focus groups stratified by literacy. RESULTS: Thirty-three women (16%) had low-literacy levels, 120 (61%) women started prenatal care after the first trimester, and 101 (50%) had inadequate utilization of prenatal care. Neither measure varied by literacy (P >.05). Cultural consensus analysis identified a single prenatal care factor that was comprised of 9 items, shared by women of low and higher literacy (eigenvalue 0.881, SD 0.058). Focus groups confirmed these items among participants from both literacy groups. Communication with clinicians was a central theme linking all of the factor items. Effective communication, exemplified by "breaking it down," was described as encouraging, whereas ineffective communication discouraged use of care. CONCLUSION: Women who had both low- and higher-literacy skills had high rates of poor prenatal care utilization and reported that communication with clinicians influenced their use of prenatal care. Improving the clarity of communication by breaking down information into simple parts should be a priority for prenatal clinicians.

Adolescent↗
PubMed2025

Financial Literacy Skills Instruction Among Autistic Individuals: A Systematic Review.

PURPOSE: Financial literacy skills are crucial for an independent life in modern societies. However, it does not appear that researchers have examined financial literacy skills among autistic individuals. This manuscript uses a systematic review to identify existing research which examines financial literacy skill instruction for autistic individuals. METHOD: We used a systematic review strategy to identify approximately 9500 articles. These articles proceeded through abstract and full-text screening for relevance. RESULTS: We identified two studies which directly taught financial literacy skills, and ten more which taught more basic money skills (such as calculating change). Neither of the two studies which taught financial literacy skills did so as an exclusive focus; both taught these skills alongside other objectives, as part of a larger intervention. CONCLUSIONS: Research on financial literacy skill instruction among autistic individuals is lacking, though there is a foundation of research examining money skills and related life skills to build upon. We recommend additional research on financial literacy skill instruction, ideally designed with the unique skills and needs of autistic individuals in mind, and with their input.

Humans↗
PubMed2026

Evaluating A Patient-Led Health Literacy Program for People Living With Metastatic Breast Cancer.

IntroductionLow cancer health literacy undermines patients' ability to interpret complex information and participate in shared decision making, and is associated with worse outcomes. Evidence for effective health literacy interventions in metastatic breast cancer (MBC) remains limited. We evaluated a patient-led, virtual health literacy program designed to strengthen MBC-specific knowledge and self-efficacy.MethodsWe conducted a mixed-methods, pre-post evaluation across two program iterations (Fall 2023; Spring 2024) delivered by a national, patient-led-MBC organization, Project Life. The five-week synchronous course called Spinning Science covered breast cancer subtyping, genetic/genomic testing, clinical trials, circulating tumor DNA, and information literacy, with small-group activities and polling. Program participants were adults living with MBC. De-identified pre/post surveys assessed (1) self-efficacy for engaging in health decisions, and (2) knowledge using items adapted from the Cancer Health Literacy Test aligned to course content. Paired two-sample t-tests examined pre-post changes (&#x3b1;=0.05). Open-ended responses were analyzed thematically.ResultsFifty-four people with MBC were enrolled (cohort 1, n=17; cohort 2, n=37); 46 provided matched pre- and post-surveys (14 and 32, respectively). Agreement with "I don't know enough to make my own medical decisions" declined from 43% pre to 13% post (p<0.05), indicating improved self-efficacy. Baseline knowledge scores were high, and knowledge item gains were not statistically significant, consistent with ceiling effects. Post-program items showed >80% agreement for increased confidence in self-advocacy, improved health literacy, and sense of community. Qualitative feedback highlighted strengths like digestible content, approachable patient facilitators and flexible scheduling, as well as priorities for refinement such as continued access to materials, and more MBC-specific and numeracy content.ConclusionsA patient-developed, virtual health literacy program for people living with MBC showed meaningful improvements in self-efficacy, with actionable, participant-driven refinements between cohorts. This model offers a practical, scalable pathway for advancing self-efficacy within and beyond MBC.

Humans↗
PubMed2000

A multivariate analysis of factors associated with depression: evaluating the role of health literacy as a potential contributor.

BACKGROUND: High rates of low health literacy among elderly populations along with a high prevalence of chronic conditions may lead to increased levels of depression symptomatology. We sought to determine whether older adults with inadequate health literacy were more likely to report depressive symptoms and whether health literacy was an independent predictor of depression symptomatology. METHODS: A total of 3260 new Medicare enrollees 65 years or older were interviewed in person between June and December 1997 from 4 managed care plans (853 in Cleveland, Ohio, 498 in Houston, Tex, 975 in South Florida, and 934 in Tampa, Fla). Depression symptoms were measured by the Geriatric Depression Scale. RESULTS: Overall, 13% of respondents were classified as depressed. Individuals with inadequate health literacy had 2.7 times the odds (95% confidence interval, 2.2-3.4) of being depressed compared with individuals with adequate health literacy skills. However, after controlling for health status with multiple logistic regression, individuals with inadequate health literacy were not more likely to be depressed (adjusted odds ratio, 1.2; 95% confidence interval, 0.9-1.7). Individuals who had less social support, exercised less than twice a week, drank alcohol heavily, or had poor health status (at least 3 health conditions, physical limitations, or fair or poor self-rated health) had significantly higher odds of depression symptomatology. CONCLUSIONS: Although individuals with inadequate health literacy were more than twice as likely to report depressive symptoms, this was mostly explained by their worse health status. The strong relation between depression symptoms and poor health status suggests the need to research interventions to improve mental and physical health concurrently. The influence of particular interventions on depression, such as referral to community support contacts and recommendations for an exercise program, needs to be further evaluated. Arch Intern Med. 2000;160:3307-3314.

Activities of Daily Living↗