Nancy D. Berkman, PhD; Stacey L. Sheridan, MD, MPH; Katrina E. Donahue, MD, MPH; David J. Halpern, MD, MPH; Karen Crotty, PhD, MPH
Disclaimer: The authors of this report are responsible for its content. Statements in this report should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
Acknowledgment: The authors thank Audrey R. Holland, Anthony J. Viera, Loraine G. Monroe, Michelle Brasure, Elizabeth Harden, Elizabeth Tant, and Ina F. Wallace for their assistance in conducting the systematic review. They also thank Kathleen N. Lohr, Meera Viswanathan, and Dan Jonas for their input on standard Agency for Healthcare Research and Quality Evidence-based Practice Center protocols. Finally, they thank Kathleen N. Lohr, Anthony J. Viera, and Jonathan M. Farber for their input on prior drafts of this manuscript and Loraine G. Monroe for her assistance in preparing the manuscript.
Financial Support: This project was funded by the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services (under contract HHSA-290-2007-10056-1).
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-0110.
Requests for Single Reprints: Nancy D. Berkman, PhD, Program on Health Care Quality and Outcomes, Division of Health Services and Social Policy Research, RTI International, PO Box 12194, 3040 Cornwallis Road, Research Triangle Park, NC 27709-2194; e-mail: email@example.com.
Current Author Addresses: Dr. Berkman: Program on Health Care Quality and Outcomes, Division of Health Services and Social Policy Research, RTI International, PO Box 12194, 3040 Cornwallis Road, Research Triangle Park, NC 27709-2194.
Dr. Sheridan: 5039 Old Clinic Building, CB 7110, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599.
Dr. Donahue: Department of Family Medicine, University of North Carolina at Chapel Hill, CB 7595, 590 Manning Drive, Chapel Hill, NC 27599.
Dr. Halpern: Durham Medical Center, 4220 North Roxboro Road, Durham, NC 27704.
Dr. Crotty: W228 S2406 Oriole Drive, Waukesha, WI 53186.
Author Contributions: Conception and design: N.D. Berkman, S.L. Sheridan, K.E. Donahue, D.J. Halpern.
Analysis and interpretation of the data: N.D. Berkman, S.L. Sheridan, K.E. Donahue, D.J. Halpern, K. Crotty.
Drafting of the article: N.D. Berkman, S.L. Sheridan, K.E. Donahue, D.J. Halpern.
Critical revision of the article for important intellectual content: N.D. Berkman, S.L. Sheridan, K.E. Donahue, D.J. Halpern, K. Crotty.
Final approval of the article: N.D. Berkman, S.L. Sheridan, K.E. Donahue, D.J. Halpern.
Statistical expertise: D.J. Halpern.
Obtaining of funding: N.D. Berkman, S.L. Sheridan.
Administrative, technical, or logistic support: N.D. Berkman, K. Crotty.
Collection and assembly of data: N.D. Berkman, S.L. Sheridan, K.E. Donahue, D.J. Halpern, K. Crotty.
Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low Health Literacy and Health Outcomes: An Updated Systematic Review. Ann Intern Med. 2011;155:97-107. doi: 10.7326/0003-4819-155-2-201107190-00005
Download citation file:
Published: Ann Intern Med. 2011;155(2):97-107.
Approximately 80 million Americans have limited health literacy, which puts them at greater risk for poorer access to care and poorer health outcomes.
To update a 2004 systematic review and determine whether low health literacy is related to poorer use of health care, outcomes, costs, and disparities in health outcomes among persons of all ages.
English-language articles identified through MEDLINE, CINAHL, PsycINFO, ERIC, and Cochrane Library databases and hand-searching (search dates for articles on health literacy, 2003 to 22 February 2011; for articles on numeracy, 1966 to 22 February 2011).
Two reviewers independently selected studies that compared outcomes by differences in directly measured health literacy or numeracy levels.
One reviewer abstracted article information into evidence tables; a second reviewer checked information for accuracy. Two reviewers independently rated study quality by using predefined criteria, and the investigative team jointly graded the overall strength of evidence.
96 relevant good- or fair-quality studies in 111 articles were identified: 98 articles on health literacy, 22 on numeracy, and 9 on both. Low health literacy was consistently associated with more hospitalizations; greater use of emergency care; lower receipt of mammography screening and influenza vaccine; poorer ability to demonstrate taking medications appropriately; poorer ability to interpret labels and health messages; and, among elderly persons, poorer overall health status and higher mortality rates. Poor health literacy partially explains racial disparities in some outcomes. Reviewers could not reach firm conclusions about the relationship between numeracy and health outcomes because of few studies or inconsistent results among studies.
Searches were limited to articles published in English. No Medical Subject Heading terms exist for identifying relevant studies. No evidence concerning oral health literacy (speaking and listening skills) and outcomes was found.
Low health literacy is associated with poorer health outcomes and poorer use of health care services.
Agency for Healthcare Research and Quality.
to gain full access to the content and tools.
Learn more about subscription options.
Register Now for a free account.
Results provided by:
Copyright © 2016 American College of Physicians. All Rights Reserved.
Print ISSN: 0003-4819 | Online ISSN: 1539-3704
Conditions of Use
This PDF is available to Subscribers Only