 | |
Relationship of Functional Health Literacy to Patients' Knowledge of Their Chronic Disease A Study of Patients With Hypertension and Diabetes Mark V. Williams, MD; David W. Baker, MD, MPH; Ruth M. Parker, MD; Joanne R. Nurss, PhD
Arch Intern Med. 1998;158:166-172. ABSTRACT
Background Inadequate functional health literacy is common, but its impact on patients with chronic diseases is not well described. Objective To examine among patients with hypertension or diabetes the relationship between their functional health literacy level and their knowledge of their chronic disease and treatment. Methods We conducted a cross-sectional survey of patients with hypertension and diabetes presenting to the general medicine clinics at 2 urban public hospitals. Literacy was measured by the Test of Functional Health Literacy in Adults. Knowledge of their illness was assessed in patients with diabetes or hypertension using 21 hypertension and 10 diabetes questions based on key elements in educational materials used in our clinics. Results A total of 402 patients with hypertension and 114 patients with diabetes were enrolled. Mean (±SD) knowledge scores for patients with hypertension with inadequate (n=189), marginal (n=49), or adequate (n=155) literacy were 13.2±3.1, 15.3±2.2, and 16.5±2.3, respectively (range, 4-20; P<.001). A total of 92% of patients with hypertension and adequate literacy levels knew that a blood pressure reading of 160/100 mm Hg was high compared with 55% of those in the lowest reading level (P<.001). Mean (±SD) knowledge scores for patients with diabetes with inadequate (n=50), marginal (n=13), or adequate (n=51) literacy were 5.8±2.1, 6.8±1.9, and 8.1±1.6, respectively (range, 1-10; P<.001). A total of 94% of patients with diabetes and adequate functional health literacy knew the symptoms of hypoglycemia compared with 50% of those with inadequate literacy (P<.001). Conclusions Inadequate functional health literacy poses a major barrier to educating patients with chronic diseases, and current efforts to overcome this appear unsuccessful.
INTRODUCTION
CHRONIC DISEASES such as hypertension and diabetes require patient education to achieve adequate control and prevent adverse health outcomes. Patients with hypertension may need to understand how to properly take multiple medications and modify their lifestyle (eg, low salt diet, weight loss, or exercise) to achieve adequate blood pressure control.1 The intricacies of the diabetic diet, insulin injection, and home glucose level monitoring place even greater educational requirements on patients.2-3 Patient education also plays a critical role in facilitating patients' acceptance of their diagnosis and understanding behavioral changes required for active participation in treatment.4 Traditional patient education relies heavily on written material about disease processes, medical management, and self-care instructions. Despite the availability of extensive health education materials with relatively consistent content, many are written at too high a level for low-literate patients to comprehend essential points.5-9 Thus, patients with inadequate literacy may not benefit from such educational efforts. This may explain why some patient education programs have been unsuccessful.10-11 This problem may be more common than many health care providers realize; reading skills are deficient in 46% to 51% of adult US citizens according to the National Adult Literacy Survey.12 We previously documented that 35.1% of English-speaking patients and 61.7% of Spanish-speaking patients seeking care at2 public hospitals lack literacy skills adequate to function in the health care settings.13 We and others showed that lower literacy skills also correlate with poorer self-reported health status.14-15 Because of their worse health, patients with poor literacy skills are likely to have even greater educational needs. However, the impact of literacy on patients' knowledge of their own illnesses and self-management skills has not been elucidated. To examine the relationship between literacy and knowledge of chronic disease, we focused on patients with hypertension and diabetes. In addition to being prevalent, these chronic diseases require daily attention to self-care and have standard markers of disease control (levels of hemoglobin [Hb] A1c and blood pressure). In this study we measured the functional health literacy of patients with diabetes or hypertension and evaluated the relationship of patients' literacy levels to knowledge of their chronic disease and markers of disease control. Understanding the role of functional health literacy in disease management and patient education should enhance efforts to improve patients' knowledge of their disease and adherence to treatment plans.
PATIENTS AND METHODS
This study was conducted at 2 urban public hospitals. Harbor-UCLA Medical Center is a 500-bed public hospital in Torrance, Calif, operated by the Los Angeles County Department of Health Services. The hospital serves an extremely diverse patient population; approximately 40% are Latino, 30% black, 25% white, and 5% other ethnic minorities. Grady Memorial Hospital is an approximately 900-bed public hospital in Atlanta, Ga. The vast majority of its patients are black indigent residents of Fulton and DeKalb Counties. The study design, contact, and consent forms were approved by the human investigations committees at both institutions. Patients were enrolled during a 3-month period from June 1994 through August 1994. All research assistants underwent 15 hours of training explaining the rationale and study design, interviewing techniques, and procedures for knowledge and functional health literacy test administration. A project coordinator conducted ongoing quality control of the research assistants. At Harbor-UCLA Medical Center, all patients with hypertension or diabetes presenting to the General Medicine Clinic on weekdays during regular appointment hours were eligible if they were currently being treated with daily medication. Patients were identified by review of their medical chart and the diagnosis was confirmed with the nurse in the clinic. Patients with both type 1 and type 2 diabetes were included in the study; the vast majority had type 2. Exclusion criteria were prior enrollment in this study or other literacy studies, age younger than 18 years, unintelligible speech, overt psychiatric illness, lack of cooperation, police custody, and being too ill to participate. Patients were recruited after they had been registered into the clinic and were waiting to see a physician. To diminish selection bias, eligible patients were enrolled sequentially from the medical charts of patients waiting to be seen. After obtaining informed consent, we collected information about demographics and self-reported reading difficulties. Patients' functional health literacy was then measured with the Test of Functional Health Literacy in Adults (TOFHLA), an instrument that assesses the ability to perform basic reading and numerical tasks required of patients in the health care setting (eg, reading prescription bottles, appointment slips, and instructions for diagnostic tests).16 A 50-item reading comprehension section and 17-item numeracy section compose the TOFHLA. The reading comprehension section uses the modified Cloze procedure; every fifth to seventh word in a passage is omitted and 4 multiple-choice options are provided. This section measures the ability of patients to read and understand prose passages selected from instructions for preparation for an upper gastrointestinal tract radiograph series, the patient "Rights and Responsibilities" section of a Medicaid application, and a standard hospital informed consent document. Readability levels of these passages on the Gunning-Fog index are grades 4.3, 10.4, and 19.5, respectively. The numeracy section tests the ability of patients to comprehend labeled prescription vials, results of blood glucose tests, clinic appointment slips, and financial assistance information. The numeracy score is multiplied by a constant of 2.941 to create a score from 0 to 50, the same as reading comprehension, yielding a total TOFHLA score of 0 to 100. Scores on the TOFHLA are classified into the following functional health literacy categories: inadequate (score, 0-59), marginal (score, 60-75), or adequate (score, 76-100). Patients with inadequate functional health literacy often misread the simplest materials, such as prescription bottles and appointment slips; the Medicaid rights and responsibilities passage is not comprehended. Patients with marginal literacy frequently misread instructions, such as those indicating patients to take medications on an empty stomach. They can read the Medicaid passage, but the informed consent passage is not comprehended. Patients with adequate literacy successfully handle most literacy tasks in the health care setting, but still may have difficulty comprehending the most difficult numerical tasks and informed consent documents.13 Before administering the TOFHLA, visual acuity was screened using a pocket vision screener (Rosenbaum, Graham-Field Surgical Co Inc, New Hyde Park, NY). Patients with vision of 20/50 or better were given the standard print TOFHLA. A large print version (14-point font) of the TOFHLA was administered to patients with visual acuity from 20/70 to 20/100. Patients with vision worse than 20/100 were excluded. Patients whose primary language was Spanish were given a Spanish version of the TOFHLA, which has been described previously.13 Approximately 3 days after the initial interview, patients were contacted by telephone and interviewed to administer the appropriate test of knowledge of disease. Interviews were conducted in the patients' native language (English or Spanish). Blood pressure readings were abstracted from the medical record of the visit on the day of study entry. The most proximate measurement of HbA1c was recorded from the computerized laboratory record. Methods were similar in Atlanta but with 3 exceptions: (1) patients who spoke English as a second language were excluded, (2) only patients with hypertension were enrolled because most patients with diabetes were followed up in a separate clinic, and (3) patients were interviewed immediately after the physician visit because previous experience indicated follow-up via telephone would not be as successful. Presence of hypertension was determined by patient self-report and review of the medical chart with confirmation by the clinic nurse. Patients with hypertension in Atlanta and Los Angeles were combined for analyses. To determine the content of patient knowledge considered essential in any patient education program and expected to be known by our patients, we reviewed written materials from the American Diabetes Association, the American Heart Association, the Joint National Committee Fifth Report on Hypertension, and our own hospital education programs. We focused on material present in all patient education brochures that related to basic understanding of disease management. This material was then used to establish the content of our questionnaires to assess patients' knowledge of their disease. We developed 2 questionnaires: 1 containing 21 questions assessing patients' knowledge of hypertension, and 1 containing 10 questions assessing patients' knowledge of diabetes. For hypertension, we assessed patients' knowledge of normal and high blood pressure readings, duration of disease, lifestyle modifications, symptoms, and complications. For diabetes, we assessed patients' knowledge of normal blood glucose levels, symptoms, medications, lifestyle modifications, and complications. Examples of questions used are presented in the "Results" section. Pilot testing of the questionnaire to ensure patient comprehension resulted in simplification of some questions and their responses. Cronbach  reliability for these knowledge scales in the patient samples in this study with hypertension was .70 and for those with diabetes was .63, indicating adequate internal consistency.17 Categorical variables were analyzed using unadjusted  2 tests. Differences in age and hypertension knowledge scores were analyzed using 1-way analysis of variance. Because of the skewed distribution of scores for diabetes knowledge, differences were analyzed using the Kruskal-Wallis test. To adjust for confounding factors that could affect hypertension knowledge (eg, duration of hypertension), we used multiple linear regression. For diabetes knowledge, we created a dichotomous variable of "low diabetes knowledge" using a cutoff point of 5 correct answers or less of 10, and used this as the dependent variable in multivariate logistic regression. Two dummy variables for literacy were created, "marginal" (0/1) and "inadequate" (0/1), and patients with adequate literacy were used as the reference group. A final P=.05 for any variable or for any group of categorical variables was used to determine statistical significance in the models. Interactions between significant variables were also assessed, although none were significant. Data analyses were performed using Stata18 and SAS19 statistical software programs.
RESULTS
In Los Angeles, 488 patients were screened and 386 were eligible for the study. A total of 8 patients refused to participate, 14 were called to see the physician before completing the interview, and 364 (94% of eligible) completed the interview. In Atlanta, 284 patients were screened and 250 were eligible for the study. A total of 8 patients refused to participate in the initial interview, 26 could not be located or declined to complete the exit interview, and 216 completed both the initial and exit interviews (86% of eligible). Of these, 8 patients reported that they did not have high blood pressure but had a diagnosis of hypertension in their medical record and took antihypertension medications. More than two thirds (69%) of Spanish-speaking patients and 22% of English-speaking patients in Los Angeles and 57% of patients in Atlanta had inadequate functional health literacy. Characteristics of patients with hypertension and diabetes are presented according to literacy level in Table 1. Patients with marginal and inadequate literacy were older than patients with adequate literacy, among both patients with hypertension and diabetes (P<.001). The majority of participants were female and black or Latino, reflecting the populations seen in the clinics. Patients with lower literacy levels had completed fewer years of schooling. Spanish-speaking patients had poorer functional health literacy than English-speaking patients among both patients with hypertension or diabetes, even though the TOFHLA was administered in Spanish.
| | | | Table 1. Characteristics of Patients With Hypertension and Diabetes by Functional Health Literacy Level | | |
Patients' functional health literacy strongly correlated with knowledge of their illness. Table 2 shows examples of questions asked of patients with hypertension and proportions answering correctly according to level of functional health literacy. Patients with poor literacy skills were less likely to answer these knowledge questions correctly than literate patients. For example, only 42% of patients with inadequate literacy knew that a blood pressure reading of 130/80 mm Hg was normal, and 45% did not know that a blood pressure reading of 160/100 mm Hg was high. High proportions of patients with inadequate functional health literacy also lacked knowledge about the effect of lifestyle and dietary factors on blood pressure. One third of patients with inadequate literacy did not know that losing weight lowers blood pressure, more than one third did not know that canned vegetables are high in salt, and 60% did not know that exercise lowers blood pressure.
| | | | Table 2. Proportion of Patients Correctly Answering Selected Hypertension Questions According to Functional Health Literacy | | |
Among all patients with hypertension, mean scores of knowledge (range, 0-21) were strongly related to literacy (Figure 1). Patients with adequate functional health literacy had a mean (±SD) score of 16.5± 2.3, while the mean (±SD) scores for patients with marginal and inadequate literacy were 15.2± 2.2 and 13.2± 3.1, respectively, (P<.001). The majority of patients with the poorest knowledge of their disease had inadequate literacy skills. Of 59 patients who correctly answered 11 or fewer questions, 52 (88%) had inadequate functional health literacy.
| | | | Figure 1. Mean hypertension knowledge scores according to functional health literacy level. Asterisks indicate 95% confidence interval; scores ranged from 3 to 21 of 21 possible questions. | | |
In addition to literacy, duration of hypertension (P<.001), years of school completed (P<.01), and age (P<.01) were significantly associated with hypertension knowledge scores in univariate analysis. After adjusting for these factors, patient reading ability remained the strongest predictor of hypertension knowledge; the adjusted difference between patients with adequate and inadequate literacy was 1.9 (95% confidence interval, 1.2-2.6). A total of 73% of the patients with diabetes in this study had attended diabetes education classes (mean [±SD] number of classes, 5.8±7.0; median, 4). There was no relationship between literacy and the number of diabetes classes attended. Despite this, patients with diabetes and inadequate functional health literacy had significantly less knowledge of their disease. Sample questions of diabetes knowledge and the proportion of patients answering items correctly are shown in Table 3 according to functional health literacy. For example, literate patients were significantly more likely to know the symptoms associated with hypoglycemia and the proper treatment for it than patients with inadequate functional health literacy. Only 50% of patients with inadequate literacy knew that feeling shaky, sweaty, and hungry meant one's blood glucose level was low, compared with 94% of patients with diabetes with adequate functional health literacy (P<.001). Only 38% of low-literate patients knew the proper treatment for such symptoms compared with 73% of literate patients.
| | | | Table 3. Proportion of Patients With Diabetes Correctly Answering Selected Knowledge Questions According to Functional Health Literacy Levels* | | |
Mean scores of diabetes knowledge among patients with diabetes were directly correlated with literacy level (Figure 2). On the 10-question diabetes knowledge assessment test, patients with adequate functional health literacy had a mean (±SD) score of 8.1±1.6 while the mean (±SD) scores for patients with marginal and inadequate literacy were 7.1± 2.0 and 5.8±2.1, respectively (P<.001). Higher mean score of diabetes knowledge was also associated in univariate analysis with younger age (P=.04), more years of schooling (P<.001), and previous attendance in diabetes education classes (P=.02), but not the number of classes attended nor the number of years of having diabetes. However, in a multivariate analysis, literacy level was the only variable significantly associated with low score of diabetes knowledge ( 5 answers correct; odds ratio, 4.5). Changing the cutoff point for low score of diabetes knowledge to 6 or 7 did not change the results of the regression analysis.
| | | | Figure 2. Mean diabetes knowledge scores according to patients' functional health literacy. Asterisks indicate 95% confidence interval; scores ranged from 1 to 10 of 10 possible questions. | | |
Despite the consistent association of less knowledge of one's illness with lower functional health literacy levels, measures of outcome (blood pressure or HbA1clevel) were not significantly associated with literacy. Low-literate patients with hypertension had higher systolic blood pressures (155 mm Hg vs 147 mm Hg, P=.04) than patients with adequate literacy. However, after adjusting for age, a nonsignificant 6 mm Hg difference remained (P=.12). No association was found between literacy level and diastolic blood pressure (P=.79). A total of 55 patients had a HbA1c level recorded in the electronic laboratory records. Although a trend of worse blood glucose control with worse literacy level was noted, the differences between patients with inadequate and adequate functional health literacy on blood glucose levels (11.7 mmol/L [212 mg/dL] vs 10.9 mmol/L [197 mg/dL], P=.27) or hemoglobin A1c levels (8.3% vs 7.5%, P=.16) were not significant.
COMMENT
Many reports have emphasized that patients' literacy skills must be considered in the care and education of patients with chronic diseases such as hypertension or diabetes.20-24 However, this is the first study, to our knowledge, to measure the functional health literacy skills of patients with a chronic disease and evaluate the relationship of literacy to patients' knowledge of disease and self-management skills, and outcomes. Almost half (48%) of the patients with hypertension or diabetes in this study had inadequate functional health literacy, and these patients had significantly less knowledge of their disease, important lifestyle modifications, and essential self-management skills (Table 1, Table 2 and Table 3). The fact that patients with diabetes with inadequate literacy had lower scores on knowledge despite having attended formal education classes clearly shows that current educational strategies do not reach the large number of patients with poor reading skills. Despite the strong correlation between inadequate literacy skills and worse disease knowledge, we did not find a significant relationship between literacy and disease outcomes. Patients with hypertension and inadequate functional health literacy had higher systolic blood pressure readings than literate patients, and patients with diabetes and inadequate literacy had higher HbA1c levels, but the differences were P=.12 and P=.16, respectively. This may have been due to our small sample sizes. With our sample size of 352 patients with hypertension, we had a 65% chance, or power, of detecting a 6–mm Hg difference in systolic blood pressure between patients with inadequate and adequate literacy. With our sample size of 55 patients with diabetes with measured HbA1c, we had a 33% chance of detecting a 1-point difference in HbA1c levels between those with adequate vs inadequate literacy. Our finding of a lack of significant correlation between literacy and disease outcome may also be because we only looked at 2 potential outcome parameters, although other studies have also shown knowledge to be only weakly or not at all associated with disease outcomes or adherence.11, 25-26 Other factors, such as patients' health beliefs and their locus of control, may also affect adherence and disease outcomes.27 Inadequate knowledge of the effect of diet and weight on blood pressure certainly may contribute to poorer control of blood pressure, and lack of knowledge of the symptoms of hypoglycemia and its treatment may be life-threatening. Half of the patients with diabetes and inadequate literacy in this study did not recognize that feeling shaky, sweaty, and hungry meant one's blood glucose level was low, and 62% did not know the proper treatment. However, we did not find a strong correlation between knowledge of disease and the 2 outcomes we measured. Nevertheless, knowledge remains an important goal of patient education programs and our results show that many patients with inadequate functional health literacy, even those who have attended formal diabetes education programs, did not know the basics of their disease and self-management skills. Other studies support the importance of improving patients' knowledge through education and the associated benefits of improving compliance with health care appointments and medications for patients with hypertension28-29 and diabetes.30-32 Improving adherence to medical advice is an important goal of education programs; the Medical Outcomes Study showed that compliance correlated with improved outcomes in patients with diabetes and hypertension.33 Previous research at Grady Memorial Hospital34 showed that in addition to access barriers, limited self-care skills in management of diabetes was one of the primary causes of diabetic ketoacidosis. There are several potential limitations to our study. First, patients with higher functional health literacy may not be more knowledgeable, but simply better at taking tests than low-literate patients. We attempted to overcome this by administering the test orally, but direct assessment of disease management skills may be more valid. Second, we do not know the generalizability of our findings. Yet inadequate literacy pervades our society,12 especially among the elderly population, and must be considered in patient education.35 Finally, sample size may have prevented detection of a significant link between patients' literacy skills and the outcomes of blood pressure and HbA1c values in this exploratory study. Larger studies are necessary to explore the linkages between patients' literacy skills and health outcomes. The results of this study confirm that the low-literate patient cannot fully comprehend medical advice using standard patient education methods.36 Despite the difficulties involved in educating low-literate patients, widespread effort should not be considered hopeless because endeavors to decrease cardiovascular risk factors among less educated populations have shown some success.37 Successfully communicating medical advice to patients with chronic illnesses who have inadequate or marginal literacy requires providing appropriately written materials, using oral communication, and improving visual presentation.38-39 Significant effort has focused on improving the quality and appropriateness of printed materials.40 Further research needs to focus on using oral and visual communication to convey necessary medical information through one-on-one teaching, audiotapes, videotapes, and computer multimedia.41 Television represents an especially important potential communication medium among elderly patients; 97% reported it as their primary source of information in 1 study.42 The problem of educating low-literate patients cannot be ignored. The Joint Commission on Accreditation of Health Care Organizations43 mandated that hospitals and other health organizations provide instruction understandable to patients, assess patients' knowledge, and document such educational efforts. Additionally, Healthy People 200044 set goals of having at least 90% of patients with hypertension take action to control their blood pressure, and of having 75% of people with diabetes receive education on diabetes. Patients' functional health literacy must be considered when attempting to reach these goals. However, no simple method of identifying low-literate patients exists, and the significant shame associated with illiteracy often makes them hide their disability.45 Direct involvement of patients in developing educational materials may empower them to improve their health while ensuring that the content effectively educates them.4, 46 The future of patient education requires ingenuity and commitment of necessary resources to improve outcomes for low-literate patients with chronic diseases.
AUTHOR INFORMATION
Accepted for publication April 23, 1997. This work was supported by a grant from the Robert Wood Johnson Foundation, Princeton, NJ. We express our sincere thanks to Ron Hall, MA, project coordinator, Nina Parikh, MPH, assistant project coordinator, and Danni Daniels, MS, for statistical assistance. Copies of the TOFHLA may be obtained by contacting Joanne R. Nurss, PhD, Center for the Study of Adult Literacy, Georgia State University, University Plaza, Atlanta, GA 30303. Reprints: Mark V. Williams, MD, Department of Medicine, Emory University School of Medicine, 69 Butler St SE, Atlanta, GA 30303 (e-mail: mwillia@emory.edu). From the Division of General Medicine, Emory University School of Medicine, Atlanta, Ga (Drs Williams and Parker); the Department of Medicine, MetroHealth Medical Center, Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, Ohio (Dr Baker); and the Center for the Study of Adult Literacy, Georgia State University, Atlanta (Dr Nurss).
REFERENCES | |
1. Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. The Fifth Report of the Joint National Committee on detection, evaluation, and treatment of high blood pressure. Arch Intern Med. 1993;153:154-183. FULL TEXT | ISI | PUBMED 2. American Association of Diabetes Educators. AADE position statement: individualization of diabetes education and management. Diabetes Educ. 1995;21:105-106. 3. American Diabetes Association. National standards for diabetes self-management education programs and American Diabetes Association review criteria. Diabetes Care. 1996;19:S114-S118. 4. Grueninger UJ. Arterial hypertension: lessons from patient education. Patient Educ Couns. 1995;26:37-55. FULL TEXT | ISI | PUBMED 5. Leichter S, Nieman J, Moore R, Collins P, Rhodes A. Readability of self-care instructional pamphlets for diabetic patients. Diabetes Care. 1981;4:627-630. ABSTRACT 6. Boyd M, Citro K. Cardiac patient education literature: can patients read what we give them? J Card Rehab. 1983;3:513-516. 7. Meade C, Byrd J. Patient literacy and the readability of smoking education literature. Am J Public Health. 1989;79:204-206. FREE FULL TEXT 8. Davis T, Crouch M, Wills G, Miller S, Abdehou D. The gap between patient reading comprehension and the readability of patient education materials. J Fam Pract. 1990;31:533-538. ISI | PUBMED 9. Dixon E, Park R. Do patients understand written health information. Nursing Outlook. 1990;38:278-281. ISI | PUBMED 10. Mulrow C, Bailey S, Sonksen PH, Slavin B. Evaluation of an audiovisual diabetes education program: negative results of a randomized trial of patients with non-insulin–dependent diabetes mellitus. J Gen Intern Med. 1987;2:215-219. ISI | PUBMED 11. Dunn S, Beeney L, Hoskin P, Turtle J. Knowledge and attitude change as predictors of metabolic improvement in diabetes education. Soc Sci Med. 1990;31:1135-1141. 12. Kirsch I, Jungeblut A, Jenkins L, Kolstad A. Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey. Washington, DC: National Center for Education Statistics, US Dept of Education; 1993. 13. Williams MV, Parker RM, Baker DW, et al. Inadequate functional health literacy among patients at two hospitals. JAMA. 1995;274:1677-1682. ABSTRACT 14. Baker DW, Parker RM, Williams MV, Clark S, Nurss JR. The relationship of patient reading ability to self-reported health and use of services. Am J Public Health. 1997;87:1027-1030. FREE FULL TEXT 15. Weiss BD, Hart G, McGee DL, D'Estelle S. Health status of illiterate adults: relation between literacy and health status among persons with low literacy skills. J Am Board Fam Pract. 1992;5(3):257-264. 16. Parker R, Baker D, Williams M, Nurss J. The test of functional health literacy in adults (TOFHLA): a new instrument for measuring patients' literacy skills. J Gen Intern Med. 1995;10:537-541. ISI | PUBMED 17. Cronbach L. Coefficient alpha and the internal structure of tests. Psychometrika. 1951;16:297-334. FULL TEXT | ISI 18. Stata Corp. Stata Statistical Software. College Station, Tex: Stata Corp; 1995. 19. SAS Inc. Statistical Analysis System. 6th ed. Cary, NC: SAS Institute Inc; 1989. 20. Francis C. Hypertension, cardiac disease, and compliance in minority patients. Am J Med. 1991;91:29S-36S. 21. Bronner V. Session II wrap-up: community-based approaches and channels for controlling hypertension in blacks: barriers and opportunities. J Natl Med Assoc. 1995;87:652-655. PUBMED 22. Overland J, Hoskins P, McGill M, Yue D. Low literacy: a problem in diabetes education. Diabet Med. 1993;10:847-850. ISI | PUBMED 23. Hinnen D. Issues in diabetes education. Nurs Clin North Am. 1993;28:113-120. ISI | PUBMED 24. Doak CC, Doak LG. The literacy challenge in diabetes education: so that clients may understand. Diabetes Care Educ. 1993;14:9-11. 25. McCaul K, Glasgow R, Shafer L. Diabetes regimen behaviors: predicting adherence. Med Care. 1987;25:868-881. FULL TEXT | ISI | PUBMED 26. Benney L, Dunn S. Knowledge improvement and metabolic control in diabetes education: approaching the limits. Patient Educ Couns. 1990;16:217-229. FULL TEXT | ISI | PUBMED 27. Woolridge KL, Wallston KA, Graber AL, Brown AW, Davidson P. The relationship between health beliefs, adherence, and metabolic control of diabetes. Diabetes Educ. 1992;18:495-500. 28. Sclar DA, Chin A, Skaer TL, Okamoto MP, Nakahiro RK, Gill MA. Effect of health education in promoting prescription refill compliance among patients with hypertension. Clin Ther. 1991;13:489-495. ISI | PUBMED 29. Mullen P, Mains D, Velez R. A meta-analysis of controlled trials of cardiac patient education. Patient Educ Couns. 1992;19:143-162. FULL TEXT | ISI | PUBMED 30. Padgett D, Mumford E, Hynes M, Carter R. Meta-analysis of the effects of educational and psychological interventions on management of diabetes mellitus. J Clin Epidemiol. 1988;41:1007-1030. FULL TEXT | ISI | PUBMED 31. Brown S. Studies of educational interventions and outcomes in diabetic adults: a meta-analysis revisited. Patient Educ Couns. 1990;16:189-215. FULL TEXT | ISI | PUBMED 32. Brechner RJ, Cowie CC, Howie LJ, Herman WH, Will JC, Harris MI. Ophthalmic examination among adults with diagnosed diabetes mellitus. JAMA. 1993;270:1714-1718. ABSTRACT 33. Kravitz RL, Hays RD, Sherbourne CD, et al. Recall of recommendations and adherence to advice among patients with chronic medical conditions. Arch Intern Med. 1993;153:1869-1878. ABSTRACT 34. Musey VC, Lee JK, Crawford R, Klatka MA, McAdams D, Phillips LS. Diabetes in urban African-Americans, I: cessation of insulin therapy is the major precipitating cause of diabetic ketoacidosis. Diabetes Care. 1995;18:483-489. ABSTRACT 35. Mayeaux EJ, Murphy PW, Arnold C, Davis TC, Jackson RH, Sentell T. Improving patient education for patients with low literacy skills. Am Fam Physician. 1996;53:205-211. ISI | PUBMED 36. Plimpton S, Root J. Materials and strategies that work in low literacy health communication. Public Health Rep. 1994;109:86-92. ISI | PUBMED 37. Winkleby M, Fortmann S, Rockhill B. Trends in cardiovascular disease risk factors by educational level: the Stanford five-city project. Prev Med. 1992;21:592-601. FULL TEXT | ISI | PUBMED 38. Doak C, Doak L, Root J. Teaching Patients With Low Literacy Skills. Philadelphia, Pa: JB Lippincott; 1996. 39. Hussey LC. Minimizing effects of low compliance among the elderly. Clin Nurs Res. 1994;3:132-145. FREE FULL TEXT 40. Clear and Simple: Developing Effective Print Materials for Low-Literate Readers. Bethesda, Md: National Institutes of Health, National Cancer Institute; 1993. 41. Consoli SM, BenSaid M, Jean J, Menard J, Plouin P-F, Chatellier G. Benefits of a computer-assisted education program for hypertensive patients compared with standard education tools. Patient Educ Couns. 1995;26:343-347. FULL TEXT | ISI | PUBMED 42. Weiss BD, Reed RL, Kligman EW. Literacy skills and communication methods of low-income older persons. Patient Educ Couns. 1995;25:109-119. FULL TEXT | ISI | PUBMED 43. 1994 Accreditation Manual for Hospitals. Oakbrook Terrace, Ill: Joint Commission on Accreditation of Healthcare Organizations; 1993. 44. US Dept of Health and Human Services. Healthy People 2000: National Health Promotion and Disease Prevention Objectives for the Nation. Washington, DC: Public Health Service; 1991. 45. Parikh NS, Parker RM, Nurss JR, Baker DW, Williams MV. Shame and health literacy: the unspoken connection. Patient Educ Couns. 1996;27:33-39. FULL TEXT | ISI | PUBMED 46. Rudd RE, Comings JP. Learner developed materials: an empowering product. Health Educ Q. 1994;21:313-327. ISI | PUBMED
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Health Promot Pract 2006;7:331-335.
ABSTRACT Can education policy be health policy? Implications of research on the social determinants of health.
Low et al.
Journal of Health Politics, Policy and Law 2005;30:1131-1162.
ABSTRACT Quick Assessment of Literacy in Primary Care: The Newest Vital Sign
Weiss et al.
Ann Fam Med 2005;3:514-522.
ABSTRACT | FULL TEXT Health Literacy and Functional Health Status Among Older Adults
Wolf et al.
Arch Intern Med 2005;165:1946-1952.
ABSTRACT | FULL TEXT Depression in US Hispanics: Diagnostic and Management Considerations in Family Practice
Lewis-Fernandez et al.
J Am Board Fam Med 2005;18:282-296.
ABSTRACT | FULL TEXT Clinical Inertia Contributes to Poor Diabetes Control in a Primary Care Setting
Ziemer et al.
The Diabetes Educator 2005;31:564-571.
ABSTRACT | FULL TEXT Implementation and Evaluation of a Low-Literacy Diabetes Education Computer Multimedia Application
Gerber et al.
Diabetes Care 2005;28:1574-1580.
ABSTRACT | FULL TEXT Understanding health literacy: an expanded model
Zarcadoolas et al.
HEALTH PROMOT INT 2005;20:195-203.
ABSTRACT | FULL TEXT Barriers to Diabetes Education in Urban Patients: Perceptions, Patterns, and Associated Factors
Rhee et al.
The Diabetes Educator 2005;31:410-417.
ABSTRACT | FULL TEXT Completeness and Complexity of Information Available to Parents From Newborn-Screening Programs
Fant et al.
Pediatrics 2005;115:1268-1272.
ABSTRACT | FULL TEXT The Spoken Knowledge in Low Literacy in Diabetes Scale: A Diabetes Knowledge Scale for Vulnerable Patients
Rothman et al.
The Diabetes Educator 2005;31:215-224.
ABSTRACT | FULL TEXT Promoting Health Literacy
McCray
J. Am. Med. Inform. Assoc. 2005;12:152-163.
ABSTRACT | FULL TEXT Association of Health Literacy With Self-Management Behavior in Patients With Diabetes
Kim et al.
Diabetes Care 2004;27:2980-2982.
FULL TEXT Influence of Patient Literacy on the Effectiveness of a Primary Care-Based Diabetes Disease Management Program
Rothman et al.
JAMA 2004;292:1711-1716.
ABSTRACT | FULL TEXT Decision Aids for Benign Prostatic Hyperplasia: Applicability across Race and Education
Rovner et al.
Med Decis Making 2004;24:359-366.
ABSTRACT Socioeconomic Position and Health among Persons with Diabetes Mellitus: A Conceptual Framework and Review of the Literature
Brown et al.
Epidemiol Rev 2004;26:63-77.
FULL TEXT Disparities in Diabetes Management Practice Between Racial and Ethnic Groups in the United States
Thackeray et al.
The Diabetes Educator 2004;30:665-675.
Views and Preferences of Low-Literate Hispanics Regarding Diabetes Education: Results of Formative Research
Rosal et al.
Health Educ Behav 2004;31:388-405.
ABSTRACT Evaluation of Adequacy of Reading Level and Readability of Psychotropic Medication Handouts
Myers and Shepard-White
J Am Psychiatr Nurses Assoc 2004;10:55-59.
ABSTRACT The Relationship Between Literacy and Glycemic Control in a Diabetes Disease-Management Program
Rothman et al.
The Diabetes Educator 2004;30:263-273.
Health Literacy and Pregnancy Preparedness in Pregestational Diabetes
Endres et al.
Diabetes Care 2004;27:331-334.
ABSTRACT | FULL TEXT Functional Health Literacy and Medication Use: the Pharmacist's Role
Youmans and Schillinger
The Annals of Pharmacotherapy 2003;37:1726-1729.
FULL TEXT Rapid A1c Availability Improves Clinical Decision-Making in an Urban Primary Care Clinic
Miller et al.
Diabetes Care 2003;26:1158-1163.
ABSTRACT | FULL TEXT Pharmacist Led, Primary Care-Based Disease Management Improves Hemoglobin Aic in High-Risk Patients With Diabetes
Rothman et al.
American Journal of Medical Quality 2003;18:51-58.
ABSTRACT Closing the Loop: Physician Communication With Diabetic Patients Who Have Low Health Literacy
Schillinger et al.
Arch Intern Med 2003;163:83-90.
ABSTRACT | FULL TEXT Health Literacy and Diabetic Control
Rothman et al.
JAMA 2002;288:2687-2688.
FULL TEXT Functional Health Literacy and the Risk of Hospital Admission Among Medicare Managed Care Enrollees
Baker et al.
Am. J. Public Health 2002;92:1278-1283.
ABSTRACT | FULL TEXT Association of Health Literacy With Diabetes Outcomes
Schillinger et al.
JAMA 2002;288:475-482.
ABSTRACT | FULL TEXT Is Diabetes Treated as an Acute or Chronic Illness in Community Family Practice?
Yawn et al.
Diabetes Care 2001;24:1390-1396.
ABSTRACT | FULL TEXT Relation of health literacy to gonorrhoea related care
Fortenberry et al.
Sex. Transm. Infect. 2001;77:206-211.
ABSTRACT | FULL TEXT Health literacy: a challenge for American patients and their health care providers
Parker
HEALTH PROMOT INT 2000;15:277-283.
ABSTRACT | FULL TEXT Anticoagulant Patient Information Material Is Written at High Readability Levels
Estrada et al.
Stroke 2000;31:2966-2970.
ABSTRACT | FULL TEXT A Multivariate Analysis of Factors Associated With Depression: Evaluating the Role of Health Literacy as a Potential Contributor
Gazmararian et al.
Arch Intern Med 2000;160:3307-3314.
ABSTRACT | FULL TEXT Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century
Nutbeam
HEALTH PROMOT INT 2000;15:259-267.
ABSTRACT | FULL TEXT Health Literacy Among Medicare Enrollees in a Managed Care Organization
Gazmararian et al.
JAMA 1999;281:545-551.
ABSTRACT | FULL TEXT Health Literacy: Report of the Council on Scientific Affairs
Ad Hoc Committee on Health Literacy for the Counci
JAMA 1999;281:552-557.
ABSTRACT | FULL TEXT Reading Skills and Family Planning Knowledge and Practices in a Low-income Managed-care Population
GAZMARARIAN et al.
Obstet Gynecol 1999;93:239-244.
ABSTRACT | FULL TEXT Why Literacy Matters: Links Between Reading Ability and Health
Lee
Arch Ophthalmol 1999;117:100-103.
FULL TEXT Access to Health Information and Support: A Public Highway or a Private Road?
Eng et al.
JAMA 1998;280:1371-1375.
ABSTRACT | FULL TEXT PATIENT LITERACY LEVEL PREDICTS KNOWLEDGE OF CHRONIC DISEASE
JWatch General 1998;1998:7-7.
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