title: Effects of patient health literacy, patient engagement and a system-level health literacy attribute on patient-reported outcomes: a representative statewide survey.
abstract: BACKGROUND
  The effects of health literacy are thought to be based on interactions between patients' skill levels and health care system demands. Little health literacy research has focused on attributes of health care organizations. We examined whether the attribute of individuals' experiences with front desk staff, patient engagement through bringing questions to a doctor visit, and health literacy skills were related to two patient-reported outcomes.
  
  
  METHODS
  We administered a telephone survey with two sampling frames (i.e., household landline, cell phone numbers) to a randomly selected statewide sample of 3358 English-speaking adult residents of Missouri. We examined two patient-reported outcomes - whether or not respondents reported knowing more about their health and made better choices about their health following their last doctor visit. Multivariable logistic regression models were used to examine the independent contributions of predictor variables (i.e., front desk staff, bringing questions to a doctor visit, health literacy skills).
  
  
  RESULTS
  Controlling for self-reported health, having a personal doctor, time since last visit, number of chronic conditions, health insurance, and sociodemographic characteristics, respondents who had a good front desk experience were 2.65 times as likely (95% confidence interval [CI]: 2.13, 3.30) and those who brought questions were 1.73 times as likely (95% CI: 1.32, 2.27) to report knowing more about their health after seeing a doctor. In a second model, respondents who had a good front desk experience were 1.57 times as likely (95% CI: 1.26, 1.95) and those who brought questions were 1.66 times as likely (95% CI: 1.29, 2.14) to report making better choices about their health after seeing a doctor. Patients' health literacy skills were not associated with either outcome.
  
  
  CONCLUSIONS
  Results from this representative statewide survey may indicate that one attribute of a health care organization (i.e., having a respectful workforce) and patient engagement through question asking may be more important to patient knowledge and health behaviors than patients' health literacy skills. Findings support focused research to examine the effects of organizational attributes on patient health outcomes and system-level interventions that might enhance patient health.
authors.affiliation: Health Communication Research Laboratory, Washington University, St, Louis, MO, USA. kaphingstk@wudosis.wustl.edu.
authors.forename: Kimberly A
authors.initials: KA
authors.lastname: Kaphingst
authors.forename: Nancy L
authors.initials: NL
authors.lastname: Weaver
authors.forename: Ricardo J
authors.initials: RJ
authors.lastname: Wray
authors.forename: Melissa L R
authors.initials: ML
authors.lastname: Brown
authors.forename: Trent
authors.initials: T
authors.lastname: Buskirk
authors.forename: Matthew W
authors.initials: MW
authors.lastname: Kreuter
mesh_terms: D001294:Attitude to Health; D003710:Demography; D005260:Female; D057220:Health Literacy; D006801:Humans; D008297:Male; D008875:Middle Aged; D008923:Missouri; D063868:Patient Outcome Assessment; D010358:Patient Participation; D011795:Surveys and Questionnaires