World Journal of Surgery

, Volume 43, Issue 1, pp 96–106 | Cite as

Health Literacy Among Surgical Patients: A Systematic Review and Meta-analysis

  • Mélissa RoyEmail author
  • Joseph P. Corkum
  • David R. Urbach
  • Christine B. Novak
  • Herbert P. von Schroeder
  • Steven J. McCabe
  • Karen Okrainec
Scientific Review


Health literacy is the extent to which patients are able to understand and act upon health information. This concept is important for surgeons as their patients have to comprehend the nature, risks and benefits of surgical procedures, adhere to perioperative instructions, and make complex care decisions about interventions. Our review aimed to determine the prevalence of limited health literacy of the surgical patient population. A search of MEDLINE and EMBASE was performed from inception until January 14th 2017 for experimental and observational studies reporting surgical patients’ health literacy measurement. Overall pooled proportion of surgical patients with limited health literacy was calculated using a random-effects model and methodologic quality was assessed. A total of 40 studies representing 18,895 surgical patients were included in our quantitative synthesis. Pooled estimate of limited health literacy was 31.7% (95%CI 24.7–39.2%, I2 99.0%). There was low risk of bias among the majority of the 51 studies included in the qualitative synthesis. Statistical heterogeneity could not be fully accounted for by methodologic quality or patient and surgical characteristics. However, some of the heterogeneity was accounted by measurement tool [combined proportions with the REALM and NVS of 35.6 (95%CI 31.5–39.9, I2 73.0%)]. A number of different health literacy measurement tools were used (19 overall). Our review demonstrates a high prevalence of limited health literacy among surgical patients with considerable heterogeneity. Our findings suggest the importance of recognizing and addressing surgical patients with limited health literacy and the need for standardization in measurement tools.



The contents of this article were developed under a grant from the Canadian Institute of Health Research (CIHR), the Frederick Banting and Charles Best Canada Graduate Scholarship, awarded to support Mélissa Roy’s graduate degree.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interests.

Supplementary material

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  1. 1.
    Koh HK, Rudd RE (2015) The arc of health literacy. JAMA 314:1225–1226CrossRefGoogle Scholar
  2. 2.
    Institute of Medicine (US) Committee on Health Literacy, Nielsen-Bohlman L, Panzer AM, Kindig DA (2004) Health literacy: a prescription to end confusion. National Academies Press (US), Washington, DCGoogle Scholar
  3. 3.
    JAMA Evidence (2017) The rational clinical examination: evidence-based clinical diagnosis. Health literacy. Accessed 2 Oct 2017
  4. 4.
    Berkman ND, Sheridan SL, Donahue KE et al (2011) Health literacy interventions and outcomes: an updated systematic review. Evid Rep Technol Assess 199:1–941Google Scholar
  5. 5.
    Baker DW, Gazmararian JA, Williams MV et al (2002) Functional health literacy and the risk of hospital admission among medicare managed care enrollees. Am J Public Health 92:1278–1283CrossRefGoogle Scholar
  6. 6.
    Herndon JB, Chaney M, Carden D (2011) Health literacy and emergency department outcomes: a systematic review. Ann Emerg Med 57:334–345CrossRefGoogle Scholar
  7. 7.
    Mitchell SE, Sadikova E, Jack BW et al (2012) Health literacy and 30-day postdischarge hospital utilization. J Health Commun 17(Suppl 3):325–338CrossRefGoogle Scholar
  8. 8.
    Eichler K, Wieser S, Brügger U (2009) The costs of limited health literacy: a systematic review. Int J Public Health 54:313–324CrossRefGoogle Scholar
  9. 9.
    Komenaka IK, Nodora JN, Machado L et al (2014) Health literacy assessment and patient satisfaction in surgical practice. Surgery 155:374–383CrossRefGoogle Scholar
  10. 10.
    McCaffery KJ, Smith SK, Wolf M (2010) The challenge of shared decision making among patients with lower literacy: a framework for research and development. Med Decis Making 30:35–44CrossRefGoogle Scholar
  11. 11.
    National Center for Education Statistics (NCES) (2017) The health literacy of America’s adults: results from the 2003 national assessment of adult literacy. Accessed 12 Nov 2017
  12. 12.
    De Oliveira GS, Jr McCarthy RJ, Wolf MS et al (2015) The impact of health literacy in the care of surgical patients: a qualitative systematic review. BMC Surg 15:86CrossRefGoogle Scholar
  13. 13.
    Paasche-Orlow MK, Parker RM, Gazmararian JA et al (2005) The prevalence of limited health literacy. J Gen Intern Med 20:175–184CrossRefGoogle Scholar
  14. 14.
    Moher D, Liberati A, Tetzlaff J et al (2010) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg 8:336–341CrossRefGoogle Scholar
  15. 15.
    Sampson M, McGowan J, Cogo E et al (2009) An evidence-based practice guideline for the peer review of electronic search strategies. J Clin Epidemiol 62:944–952CrossRefGoogle Scholar
  16. 16.
    The Ottawa Hospital Research Institute. The Newcastle–Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Accessed 7 Mar 2017
  17. 17.
    Higgins JP, Thompson SG, Deeks JJ et al (2003) Measuring inconsistency in meta-analyses. BMJ 327:557–560CrossRefGoogle Scholar
  18. 18.
    DerSimonian R, Laird N (1986) Meta-analysis in clinical trials. Control Clin Trials 7:177–188CrossRefGoogle Scholar
  19. 19.
    Freeman MF, Tukey JW (1950) Transformations related to the angular and the square root. Ann Math Stat 21:607–611CrossRefGoogle Scholar
  20. 20.
    Heckman JJ, LaFontaine PA (2010) The American high school graduation rate: trends and levels. Rev Econ Stat 92:244–262CrossRefGoogle Scholar
  21. 21.
    Sterne JA, Egger M (2001) Funnel plots for detecting bias in meta-analysis: guidelines on choice of axis. J Clin Epidemiol 54:1046–1055CrossRefGoogle Scholar
  22. 22.
    Livaudais JC, Franco R, Fei K et al (2013) Breast cancer treatment decision-making: are we asking too much of patients? J Gen Intern Med 28:630–636CrossRefGoogle Scholar
  23. 23.
    Roh YH, Lee BK, Park MH et al (2016) Effects of health literacy on treatment outcome and satisfaction in patients with mallet finger injury. J Hand Ther 29:459–464CrossRefGoogle Scholar
  24. 24.
    Dageforde LA, Petersen AW, Feurer ID et al (2014) Health literacy of living kidney donors and kidney transplant recipients. Transplantation 98:88–93CrossRefGoogle Scholar
  25. 25.
    Scarpato KR, Kappa SF, Goggins KM et al (2016) The impact of health literacy on surgical outcomes following radical cystectomy. J Health Commun 21(sup2):99–104CrossRefGoogle Scholar
  26. 26.
    Zite NB, Wallace LS (2011) Use of a low-literacy informed consent form to improve women’s understanding of tubal sterilization: a randomized controlled trial. Obstet Gynecol 117:1160–1166CrossRefGoogle Scholar
  27. 27.
    Halbach SM, Ernstmann N, Kowalski C et al (2016) Unmet information needs and limited health literacy in newly diagnosed breast cancer patients over the course of cancer treatment. Patient Educ Couns 99:1511–1518CrossRefGoogle Scholar
  28. 28.
    Rosenbaum AJ, Phillips N, Patel N et al (2013) Assessment of orthopaedic literacy in an urban emergency department: pilot results of the literacy in musculoskeletal problems (LiMP) project. Curr Orthop Pract 24:400–405CrossRefGoogle Scholar
  29. 29.
    Kazley AS, Jordan J, Simpson KN et al (2014) Development and testing of a disease-specific health literacy measure in kidney transplant patients. Prog Transplant 24:263–270CrossRefGoogle Scholar
  30. 30.
    Lin X, Wang M, Zuo Y et al (2014) Health literacy, computer skills and quality of patient–physician communication in Chinese patients with cataract. PLoS ONE 9:e107615CrossRefGoogle Scholar
  31. 31.
    Menendez ME, Mudgal CS, Jupiter JB et al (2015) Health literacy in hand surgery patients: a cross-sectional survey. J Hand Surg Am 40:798.e2–804.e2Google Scholar
  32. 32.
    Wallace LS, Ergen WF, Cassada DC et al (2009) Development and validation of the rapid estimate of adult literacy in vascular surgery (REAL_VS). Ann Vasc Surg 23:446–452CrossRefGoogle Scholar
  33. 33.
    Escobedo W, Weismuller P (2013) Assessing health literacy in renal failure and kidney transplant patients. Prog Transplant 23:47–54CrossRefGoogle Scholar
  34. 34.
    Wallace LS, Cassada DC, Rogers ES et al (2007) Can screening items identify surgery patients at risk of limited health literacy? J Surg Res 140:208–213CrossRefGoogle Scholar
  35. 35.
    Beitler JJ, Chen AY, Jacobson K et al (2010) Health literacy and health care in an inner-city, total laryngectomy population. Am J Otolaryngol 31:29–31CrossRefGoogle Scholar
  36. 36.
    Koster ES, Schmidt A, Philbert D et al (2017) Health literacy of patients admitted for elective surgery. Z Gesundh Wiss 25:181–186CrossRefGoogle Scholar
  37. 37.
    Song L, Mishel M, Bensen JT et al (2012) How does health literacy affect quality of life among men with newly diagnosed clinically localized prostate cancer? Findings from the North Carolina–Louisiana Prostate Cancer Project (PCaP). Cancer 118:3842–3851CrossRefGoogle Scholar
  38. 38.
    Hawley ST, Janz NK, Hamilton A et al (2008) Latina patient perspectives about informed treatment decision making for breast cancer. Patient Educ Couns 73:363–370CrossRefGoogle Scholar
  39. 39.
    Rosenbaum AJ, Dunkman A, Goldberg D et al (2016) Cross-sectional study of musculoskeletal health literacy in patients with carpal tunnel syndrome. HAND (N Y) 11:330–335CrossRefGoogle Scholar
  40. 40.
    Cajita MI, Denhaerynck K, Dobbels F et al (2017) Health literacy in heart transplantation: prevalence, correlates and associations with health behaviors-Findings from the international BRIGHT study. J Heart Lung Transplant 36:272–279CrossRefGoogle Scholar
  41. 41.
    Grubbs V, Gregorich SE, Perez-Stable EJ et al (2009) Health literacy and access to kidney transplantation. Clin J Am Soc Nephrol 4:195–200CrossRefGoogle Scholar
  42. 42.
    Mikhail D, Visscher KL, Chen N et al (2015) Patient-appropriate health literacy educational materials in ophthalmology. Can J Ophthalmol 50:19–25CrossRefGoogle Scholar
  43. 43.
    Menendez ME, Parrish RC, Ring D (2016) Health literacy and time spent with a hand surgeon. J Hand Surg Am 41:e59–e69CrossRefGoogle Scholar
  44. 44.
    Otal D, Wizowski L, Pemberton J et al (2012) Parent health literacy and satisfaction with plain language education materials in a pediatric surgery outpatient clinic: a pilot study. J Pediatr Surg 47:964–969CrossRefGoogle Scholar
  45. 45.
    Miller-Matero LR, Hyde-Nolan ME, Eshelman A et al (2015) Health literacy in patients referred for transplant: do patients have the capacity to understand? Clin Transplant 29:336–342CrossRefGoogle Scholar
  46. 46.
    Menendez ME, van Hoorn BT, Mackert M et al (2017) Patients with limited health literacy ask fewer questions during office visits with hand surgeons. Clin Orthop Relat Res 475:1291–1297CrossRefGoogle Scholar
  47. 47.
    Haghighi ST, Lamyian M, Granpaye L (2015) Assessment of the level of health literacy among fertile Iranian women with breast cancer. Electron Physician 7:1359–1364Google Scholar
  48. 48.
    Patzer RE, Serper M, Reese PP et al (2016) Medication understanding, non-adherence, and clinical outcomes among adult kidney transplant recipients. Clin Transplant 30:1294–1305CrossRefGoogle Scholar
  49. 49.
    Lillie SE, Brewer NT, O’Neill SC et al (2007) Retention and use of breast cancer recurrence risk information from genomic tests: the role of health literacy. Cancer Epidemiol Biomarkers Prev 16:249–255CrossRefGoogle Scholar
  50. 50.
    Dageforde LA, Box A, Feurer ID et al (2015) Understanding patient barriers to kidney transplant evaluation. Transplantation 99:1463–1469CrossRefGoogle Scholar
  51. 51.
    Wilson FL, McLemore R (1997) Patient literacy levels: a consideration when designing patient education programs. Rehabil Nurs 22:311–317CrossRefGoogle Scholar
  52. 52.
    Conlin KK, Schumann L (2002) Literacy in the health care system: a study on open heart surgery patients. J Am Acad Nurse Pract 14:38–42CrossRefGoogle Scholar
  53. 53.
    Garcia-Marcinkiewicz AG, Long TR, Danielson DR et al (2014) Health literacy and anesthesia: patients’ knowledge of anesthesiologist roles and information desired in the preoperative visit. J Clin Anesth 26:375–382CrossRefGoogle Scholar
  54. 54.
    Taylor DM, Bradley JA, Bradley C et al (2016) Limited health literacy in advanced kidney disease. Kidney Int 90:685–695CrossRefGoogle Scholar
  55. 55.
    Serper M, Patzer RE, Reese PP et al (2015) Medication misuse, nonadherence, and clinical outcomes among liver transplant recipients. Liver Transplant 21:22–28CrossRefGoogle Scholar
  56. 56.
    Chew LD, Bradley KA, Flum DR et al (2004) The impact of low health literacy on surgical practice. Am J Surg 188:250–253CrossRefGoogle Scholar
  57. 57.
    Megwalu UC, Lee JY (2016) Health literacy assessment in an otolaryngology clinic population. Otolaryngol Head Neck Surg 155:969–973CrossRefGoogle Scholar
  58. 58.
    Gordon EJ, Wolf MS (2009) Health literacy skills of kidney transplant recipients. Prog Transplant 19:25–34CrossRefGoogle Scholar
  59. 59.
    Jones J, Rosaasen N, Taylor J et al (2016) Health literacy, knowledge, and patient satisfaction before kidney transplantation. Transplant Proc 48:2608–2614CrossRefGoogle Scholar
  60. 60.
    Anger JT, Lee UJ, Mittal BM et al (2012) Health literacy and disease understanding among aging women with pelvic floor disorders. Female Pelvic Med Reconstr Surg 18:340–343CrossRefGoogle Scholar
  61. 61.
    Schmidt A, Kowalski C, Pfaff H et al (2015) The influence of health literacy on information needs among women newly diagnosed with breast cancer, with special reference to employment status. J Health Commun 20:1177–1184CrossRefGoogle Scholar
  62. 62.
    Groeneveld PW, Kwoh CK, Mor MK et al (2008) Racial differences in expectations of joint replacement surgery outcomes. Arthritis Rheum 59:730–737CrossRefGoogle Scholar
  63. 63.
    Tait AR, Voepel-Lewis T, Zikmund-Fisher BJ et al (2010) Presenting research risks and benefits to parents: does format matter? Anesth Analg 111:718–723CrossRefGoogle Scholar
  64. 64.
    Lambert K, Mullan J, Mansfield K et al (2015) A cross-sectional comparison of health literacy deficits among patients with chronic kidney disease. J Health Commun 20(Suppl 2):16–23CrossRefGoogle Scholar
  65. 65.
    Kadakia RJ, Tsahakis JM, Issar NM et al (2013) Health literacy in an orthopedic trauma patient population: a cross-sectional survey of patient comprehension. J Orthop Trauma 27:467–471CrossRefGoogle Scholar
  66. 66.
    Chu CI, Tseng CC (2013) A survey of how patient-perceived empathy affects the relationship between health literacy and the understanding of information by orthopedic patients? BMC Public Health 13:155CrossRefGoogle Scholar
  67. 67.
    Hendren S, Chin N, Fisher S et al (2011) Patients’ barriers to receipt of cancer care, and factors associated with needing more assistance from a patient navigator. J Natl Med Assoc 103:701–710CrossRefGoogle Scholar
  68. 68.
    Cegala DJ, Chisolm DJ, Nwomeh BC (2013) A communication skills intervention for parents of pediatric surgery patients. Patient Educ Couns 93:34–39CrossRefGoogle Scholar
  69. 69.
    Kasparian NA, Lieu N, Winlaw DS et al (2017) eHealth literacy and preferences for eHealth resources in parents of children with complex CHD. Cardiol Young 27:722–730CrossRefGoogle Scholar
  70. 70.
    Cnossen IC, van Uden-Kraan CF, Eerenstein SE et al (2016) An online self-care education program to support patients after total laryngectomy: feasibility and satisfaction. Support Care Cancer 24:1261–1268CrossRefGoogle Scholar
  71. 71.
    Kiyosaki K, Ackerman AL, Histed S et al (2012) Patients’ understanding of pelvic floor disorders: what women want to know. Female Pelvic Med Reconstr Surg 18:137–142CrossRefGoogle Scholar
  72. 72.
    Osborn CY, Weiss BD, Davis TC et al (2007) Measuring adult literacy in health care: performance of the newest vital sign. Am J Health Behav 31(Suppl 1):S36–S46CrossRefGoogle Scholar
  73. 73.
    Baker DW (2006) The meaning and the measure of health literacy. J Gen Intern Med 21:878–883CrossRefGoogle Scholar
  74. 74.
    Wright JP, Edwards GC, Goggins K et al (2018) Association of health literacy with postoperative outcomes in patients undergoing major abdominal surgery. JAMA Surg 153:137–142CrossRefGoogle Scholar
  75. 75.
    Scarpato KR, Kappa SF, Goggins KM et al (2016) The impact of health literacy on surgical outcomes following radical cystectomy. J Health Commun 21:99–104CrossRefGoogle Scholar
  76. 76.
    Altin SV, Finke I, Kautz-Freimuth S et al (2014) The evolution of health literacy assessment tools: a systematic review. BMC Public Health 14:1207CrossRefGoogle Scholar
  77. 77.
    Abel T (2008) Measuring health literacy: moving towards a health—promotion perspective. Int J Public Health 53:169–170CrossRefGoogle Scholar
  78. 78.
    Williams MV, Davis T, Parker RM et al (2002) The role of health literacy in patient–physician communication. Fam Med 34:383–389Google Scholar
  79. 79.
    Kronzer VL (2016) Screening for health literacy is not the answer. BMJ 354:i3699CrossRefGoogle Scholar
  80. 80.
    Paasche-Orlow MK, Schillinger D, Greene SM et al (2006) How health care systems can begin to address the challenge of limited literacy. J Gen Intern Med 21:884–887CrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2018

Authors and Affiliations

  1. 1.Division of Plastic and Reconstructive Surgery, Department of SurgeryUniversity of TorontoTorontoCanada
  2. 2.Division of Plastic and Reconstructive Surgery, Department of SurgeryDalhousie UniversityHalifaxCanada
  3. 3.Division of General Surgery, Department of SurgeryUniversity of TorontoTorontoCanada
  4. 4.Division of Internal Medicine, Department of MedicineUniversity of TorontoTorontoCanada

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