title: Addressing health literacy in patient decision aids.
abstract: BACKGROUND
  Effective use of a patient decision aid (PtDA) can be affected by the user's health literacy and the PtDA's characteristics. Systematic reviews of the relevant literature can guide PtDA developers to attend to the health literacy needs of patients. The reviews reported here aimed to assess:
  
  
  METHODS
  We reviewed literature for evidence relevant to these two aims. When high-quality systematic reviews existed, we summarized their evidence. When reviews were unavailable, we conducted our own systematic reviews.
  
  
  RESULTS
  Aim 1: In an existing systematic review of PtDA trials, lower health literacy was associated with lower patient health knowledge (14 of 16 eligible studies). Fourteen studies reported practical design strategies to improve knowledge for lower health literacy patients. In our own systematic review, no studies reported on values clarity per se, but in 2 lower health literacy was related to higher decisional uncertainty and regret. Lower health literacy was associated with less desire for involvement in 3 studies, less question-asking in 2, and less patient-centered communication in 4 studies; its effects on other measures of patient involvement were mixed. Only one study assessed the effects of a health literacy intervention on outcomes; it showed that using video to improve the salience of health states reduced decisional uncertainty. Aim 2: In our review of 97 trials, only 3 PtDAs overtly addressed the needs of lower health literacy users. In 90% of trials, user health literacy and readability of the PtDA were not reported. However, increases in knowledge and informed choice were reported in those studies in which health literacy needs were addressed.
  
  
  CONCLUSIONS
  Lower health literacy affects key decision-making outcomes, but few existing PtDAs have addressed the needs of lower health literacy users. The specific effects of PtDAs designed to mitigate the influence of low health literacy are unknown. More attention to the needs of patients with lower health literacy is indicated, to ensure that PtDAs are appropriate for lower as well as higher health literacy patients.
authors.forename: Kirsten J
authors.initials: KJ
authors.lastname: McCaffery
authors.forename: Margaret
authors.initials: M
authors.lastname: Holmes-Rovner
authors.forename: Sian K
authors.initials: SK
authors.lastname: Smith
authors.forename: David
authors.initials: D
authors.lastname: Rovner
authors.forename: Don
authors.initials: D
authors.lastname: Nutbeam
authors.forename: Marla L
authors.initials: ML
authors.lastname: Clayman
authors.forename: Karen
authors.initials: K
authors.lastname: Kelly-Blake
authors.forename: Michael S
authors.initials: MS
authors.lastname: Wolf
authors.forename: Stacey L
authors.initials: SL
authors.lastname: Sheridan
mesh_terms: D003142:Communication; D003657:Decision Making; D003661:Decision Support Techniques; D057220:Health Literacy; D006801:Humans; D019359:Knowledge; D010358:Patient Participation