title: Literacy and health outcomes: a systematic review of the literature.
abstract: OBJECTIVE
  To review the relationship between literacy and health outcomes.
  
  
  METHODS
  We searched MEDLINE, Cumulative Index to Nursing and Allied Health (CINAHL), Educational Resources Information Center (ERIC), Public Affairs Information Service (PAIS), Industrial and Labor Relations Review (ILLR), PsychInfo, and Ageline from 1980 to 2003.
  
  
  METHODS
  We included observational studies that reported original data, measured literacy with any valid instrument, and measured one or more health outcomes. Two abstractors reviewed each study for inclusion and resolved disagreements by discussion.
  
  
  METHODS
  One reviewer abstracted data from each article into an evidence table; the second reviewer checked each entry. The whole study team reconciled disagreements about information in evidence tables. Both data extractors independently completed an 11-item quality scale for each article; scores were averaged to give a final measure of article quality.
  
  
  RESULTS
  We reviewed 3,015 titles and abstracts and pulled 684 articles for full review; 73 articles met inclusion criteria and, of those, 44 addressed the questions of this report. Patients with low literacy had poorer health outcomes, including knowledge, intermediate disease markers, measures of morbidity, general health status, and use of health resources. Patients with low literacy were generally 1.5 to 3 times more likely to experience a given poor outcome. The average quality of the articles was fair to good. Most studies were cross-sectional in design; many failed to address adequately confounding and the use of multiple comparisons.
  
  
  CONCLUSIONS
  Low literacy is associated with several adverse health outcomes. Future research, using more rigorous methods, will better define these relationships and guide developers of new interventions.
authors.affiliation: RTI International-University of North Carolina Evidence-based Practice Center, Research Triangle Park, NC 27599, USA. dewaltd@med.unc.edu
authors.forename: Darren A
authors.initials: DA
authors.lastname: Dewalt
authors.forename: Nancy D
authors.initials: ND
authors.lastname: Berkman
authors.forename: Stacey
authors.initials: S
authors.lastname: Sheridan
authors.forename: Kathleen N
authors.initials: KN
authors.lastname: Lohr
authors.forename: Michael P
authors.initials: MP
authors.lastname: Pignone
mesh_terms: D004522:Educational Status; D015438:Health Behavior; D007722:Health Knowledge, Attitudes, Practice; D006296:Health Services / Q000706:statistics & numerical data*; D006304:Health Status; D006801:Humans; D016247:Information Storage and Retrieval / Q000379:methods