Low Health Literacy and Health Outcomes: An Updated Systematic Review
Abstract
BACKGROUND: Approximately 80 million Americans have limited health literacy, which puts them at greater risk for poorer access to care and poorer health outcomes. PURPOSE: 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. DATA SOURCES: 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). STUDY SELECTION: Two reviewers independently selected studies that compared outcomes by differences in directly measured health literacy or numeracy levels. DATA EXTRACTION: 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. DATA SYNTHESIS: 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. LIMITATIONS: 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. CONCLUSION: Low health literacy is associated with poorer health outcomes and poorer use of health care services. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.
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The literature recommends using bullet points, bolded keywords, headings, and signposting for developing visualizations for people with communication difficulties.
“We also prioritized using bullet points, bolded keywords, headings, and signposting, as recommended in the literature [3, 7, 56] for developing visualizations for people with communication difficulties in our designs.”
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- Authors
- Berkman, N. D., Sheridan, S. L., Donahue, K. E., Halpern, D. J., & Crotty, K.
- Affiliations
- University of North Carolina at Chapel Hill (US)
- Venue
- Annals of Internal Medicine
- Publisher
- American College of Physicians
- Published
- 2011-07-19
- Volume
- 155
- Issue
- 2
- Pages
- 97-107
- ISSN
- 0003-4819 (ISSN-L)
- 1539-3704
- OpenAlex
- W2045241688
- Cited by
- 5,505
- References
- 5
- Citations by year
- 2026: 591 · 2025: 572 · 2024: 523 · 2023: 488 · 2022: 488 · 2021: 494 · 2020: 434 · 2019: 383 · 2018: 344 · 2017: 243 · 2016: 261 · 2015: 259 · 2014: 181 · 2013: 151 · 2012: 76
- FWCI
- 22.39
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Annals of Internal Medicine (publishedVersion)
- PubMed (publishedVersion)
- Funders
- U.S. Public Health Service (HHSA-290-2007-10056-1)
- Topics
- Health Sciences › Health Professions › General Health Professions › Health Literacy and Information Accessibility
- Health Sciences › Health Professions › General Health Professions › Patient-Provider Communication in Healthcare
- Health Sciences › Health Professions › General Health Professions › Interpreting and Communication in Healthcare
- Keywords
- health literacy, numeracy, health outcomes, health care utilization, racial disparities, hospitalization, emergency department utilization, mammography screening, influenza vaccination, medication adherence, health disparities, older adults, mortality
- MeSH terms
- Educational Status, Health Services, Health Services Accessibility, Hospitalization, Humans, Health Knowledge, Attitudes, Practice, United States, Health Care Costs, Outcome Assessment, Health Care, Healthcare Disparities, Health Literacy
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