International Journal of Clinical Pharmacy

, Volume 36, Issue 1, pp 36–44 | Cite as

Investigating the association between health literacy and non-adherence

  • Remo OstiniEmail author
  • Therese Kairuz
Review Article


Background Low health literacy is expected to be associated with medication non-adherence and early research indicated that this might be the case. Further research suggested that the relationship may be more equivocal. Aim of the review The goal of this paper is initially to clarify whether there is a clear relationship between health literacy and non-adherence. Additionally, this review aims to identify factors that may influence that relationship and ultimately to better understand the mechanisms that may be at work in the relationship. Method English language original research or published reviews of health literacy and non-adherence to orally administered medications in adults were identified through a search of four bibliographic databases (PubMed, EMBASE, CINAHL, and EBSCO Health). Results The search protocol produced 78 potentially relevant articles, of which 16 articles addressed factors that contribute to non-adherence and 24 articles reported on the results of research into the relationship between non-adherence and health literacy. Factors that contribute to non-adherence can be categorised into patient related factors, including patient beliefs; medication related factors; logistical factors; and factors around the patient-provider relationship. Of the 23 original research articles that investigated the relationship between non-adherence and health literacy, only five reported finding clear evidence of a relationship, four reported mixed results and 15 articles reported not finding the expected relationship. Research on possible mechanisms relating health literacy to non-adherence suggest that disease and medication knowledge are not sufficient for addressing non-adherence while self-efficacy is an important factor. Other findings suggest a possible U-shaped relationship between non-adherence and health literacy where people with low health literacy are more often non-adherent, largely unintentionally; people with moderate health literacy are most adherent; and people with high health literacy are somewhat non-adherent, sometimes due to intentional non-adherence. Conclusion It is clear that relevant research generally fails to find a significant relationship between non-adherence and health literacy. A U-shaped relationship between these two conditions would explain why linear statistical tests fail to identify a relationship across all three levels of health literacy. It can also account for the conditions under which both positive and negative relationships may be found.


Health literacy Knowledge Non-adherence Non-linear relationship Patient adherence Self-efficacy 




Conflicts of interest



  1. 1.
    Bush RA, Boyle F, Ostini R, Ozolins I, Brabant M, Soto EJ, et al. Advancing health literacy through primary health care systems. Canberra: Australian Primary Health Care Research Institute; 2009.Google Scholar
  2. 2.
    Dewalt DA, Berkman ND, Sheridan S, Lohr KN, Pignone MP. Literacy and health outcomes: a systematic review of the literature. J Gen Intern Med. 2004;19(12):1228–39.PubMedCentralPubMedCrossRefGoogle Scholar
  3. 3.
    Keller DL, Wright J, Pace HA. Impact of health literacy on health outcomes in ambulatory care patients: a systematic review. Ann of Pharmacother. 2008;42(9):1272–81.CrossRefGoogle Scholar
  4. 4.
    Pignone MP, DeWalt DA. Literacy and health outcomes: is adherence the missing link? J Gen Intern Med. 2006;21(8):896–7.PubMedCentralPubMedCrossRefGoogle Scholar
  5. 5.
    Ratzan SC, Parker RM. Introduction. In: Selden CR, Zorn M, Ratzan SC, Parker RM, editors. National library of medicine current bibliographies in medicine: health literacy. NLM Pub. No. CBM 2000-1. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services; 2000.Google Scholar
  6. 6.
    Parker RM, Baker DW, Williams MV, Nurss JR. The test of functional health literacy in adults: a new instrument for measuring patients’ literacy skills. J Gen Intern Med. 1995;10(10):537–41.PubMedCrossRefGoogle Scholar
  7. 7.
    Davis TC, Crouch MA, Long SW, Jackson RH, Bates P, George RB, et al. Rapid assessment of literacy levels of adult primary care patients. Fam Med. 1991;23(6):433–5.PubMedGoogle Scholar
  8. 8.
    Davis TC, Long SW, Jackson RH, Mayeaux EJ, George RB, Murphy PW, et al. Rapid estimate of adult literacy in medicine: a shortened screening instrument. Fam Med. 1993;25(6):391–5.PubMedGoogle Scholar
  9. 9.
    Nutbeam D. The evolving concept of health literacy. Soc Sci Med. 2008;67(12):2072–8.PubMedCrossRefGoogle Scholar
  10. 10.
    World Health Organization. Adherence to long-term therapies: evidence for action; 2003. Cited 2013 August 17. Available from:
  11. 11.
    Nutbeam D. Health promotion glossary. Health Promot Int. 1998;13(4):349–64.CrossRefGoogle Scholar
  12. 12.
    Balkrishnan R. Predictors of medication adherence in the elderly. Clin Thera. 1998;20(4):764–71.CrossRefGoogle Scholar
  13. 13.
    Vrijens B, Geest SD, Hughes DA, Przemyslaw K, Demonceau J, Ruppar T, et al. A new taxonomy for describing and defining adherence to medications. B J Clin Pharmacol. 2012;73(5):691–705.CrossRefGoogle Scholar
  14. 14.
    Gerth WC. Compliance and Persistence with Newer Antihypertensive Agents. Curr Hypertens Rep. 2002;4:424–33.PubMedCrossRefGoogle Scholar
  15. 15.
    Wride N, Finch T, Rapley T, Moreira T, May C, Fraser S. What’s in a name? Medication terms: what they mean and when to use them. B J Opthalmol. 2007;91:1422–4.CrossRefGoogle Scholar
  16. 16.
    Blackwell B. Compliance. Psychother Psychosom. 1992;58:161–9.PubMedCrossRefGoogle Scholar
  17. 17.
    U.S. National Library of Medicine. MEDLINE/PubMed search and health literacy information. Bethesda, MD2011 [cited 2013 April 26]; Available from:
  18. 18.
    Ngoh LN. Health literacy: a barrier to pharmacist-patient communication and medication adherence. J Am Pharm Assoc. 2009;49(5):e132–46.CrossRefGoogle Scholar
  19. 19.
    Gellad WF, Grenard JL, Marcum ZA. A systematic review of barriers to medication adherence in the elderly: looking beyond cost and regimen complexity. Am J Geriatr Pharmacother. 2011;9(1):11–23.PubMedCentralPubMedCrossRefGoogle Scholar
  20. 20.
    Campbell NL, Boustani MA, Skopelja EN, Gao S, Unverzagt FW, Murray MD. Medication adherence in older adults with cognitive impairment: a systematic evidence-based review. Am J Geriatr Pharmacother. 2012;10(3):165–77.PubMedCrossRefGoogle Scholar
  21. 21.
    Mosher HJ, Lund BC, Kripalani S, Kaboli PJ. Association of health literacy with medication knowledge, adherence, and adverse drug events among elderly veterans. J Health Commun. 2012;17(Suppl 3):241–51.PubMedCrossRefGoogle Scholar
  22. 22.
    Mohan AV, Riley MB, Boyington DR, Kripalani S. Illustrated medication instructions as a strategy to improve medication management among Latinos: a qualitative analysis. J Health Psychol. 2013;18(2):187–97.PubMedCrossRefGoogle Scholar
  23. 23.
    Elliott RA, Marriott JL. Standardised assessment of patients’ capacity to manage medications: a systematic review of published instruments. BMC Geriatr. 2009;9:27.PubMedCentralPubMedCrossRefGoogle Scholar
  24. 24.
    Johnson VR, Jacobson KL, Gazmararian JA, Blake SC. Does social support help limited-literacy patients with medication adherence? A mixed methods study of patients in the pharmacy intervention for limited literacy (PILL) study. Patient Educ Couns. 2010;79(1):14–24.PubMedCrossRefGoogle Scholar
  25. 25.
    Kalichman SC, Ramachandran B, Catz S. Adherence to combination antiretroviral therapies in HIV patients of low health literacy. J Gen Intern Med. 1999;14(5):267–73.PubMedCentralPubMedCrossRefGoogle Scholar
  26. 26.
    Kalichman SC, Pope H, White D, Cherry C, Amaral CM, Swetzes C, et al. Association between health literacy and HIV treatment adherence: further evidence from objectively measured medication adherence. J Int Assoc Physicians AIDS Care (Chic). 2008;7(6):317–23.PubMedCentralCrossRefGoogle Scholar
  27. 27.
    Osborn CY, Cavanaugh K, Wallston KA, Kripalani S, Elasy TA, Rothman RL, et al. Health literacy explains racial disparities in diabetes medication adherence. J Health Commun. 2011;16(Suppl 3):268–78.PubMedCentralPubMedCrossRefGoogle Scholar
  28. 28.
    Paasche-Orlow MK, Cheng DM, Palepu A, Meli S, Faber V, Samet JH. Health literacy, antiretroviral adherence, and HIV-RNA suppression: a longitudinal perspective. J Gen Intern Med. 2006;21(8):835–40.PubMedCentralPubMedCrossRefGoogle Scholar
  29. 29.
    Kalichman SC, Grebler T. Stress and poverty predictors of treatment adherence among people with low-literacy living with HIV/AIDS. Psychosom Med. 2010;72(8):810–6.PubMedCentralPubMedCrossRefGoogle Scholar
  30. 30.
    Moisan J, Gaudet M, Gregoire JP, Bouchard R. Non-compliance with drug treatment and reading difficulties with regard to prescription labelling among seniors. Gerontology. 2002;48(1):44–51.PubMedCrossRefGoogle Scholar
  31. 31.
    Colbert AM, Sereika SM, Erlen JA. Functional health literacy, medication-taking self-efficacy and adherence to antiretroviral therapy. J Adv Nurs. 2013;69(2):295–304.PubMedCrossRefGoogle Scholar
  32. 32.
    Bhor M, Plake KS, Chen JT. Relationship between health literacy, outcome expectations, efficacy expectations and medication adherence. Value in Health. 2009;12(3):A155.CrossRefGoogle Scholar
  33. 33.
    Gatti ME, Jacobson KL, Gazmararian JA, Schmotzer B, Kripalani S. Relationships between beliefs about medications and adherence. Am J Health Syst Pharm. 2009;66(7):657–64.PubMedCrossRefGoogle Scholar
  34. 34.
    Rust C, Davis C. Health literacy and medication adherence in underserved African-american breast cancer survivors: a qualitative study. Soc Work Health Care. 2011;50(9):739–61.PubMedCrossRefGoogle Scholar
  35. 35.
    Navarra AM, Neu N, Toussi S, Nelson J, Larson EL. Health literacy and adherence to antiretroviral therapy among hiv-infected youth. J Assoc Nurses AIDS Care. 2013; 1–11.Google Scholar
  36. 36.
    Graham J, Bennett IM, Holmes WC, Gross R. Medication beliefs as mediators of the health literacy-antiretroviral adherence relationship in HIV-infected individuals. AIDS Behav. 2007;11(3):385–92.PubMedCrossRefGoogle Scholar
  37. 37.
    Joyner-Grantham J, Mount DL, McCorkle OD, Simmons DR, Ferrario CM, Cline DM. Self-reported influences of hopelessness, health literacy, lifestyle action, and patient inertia on blood pressure control in a hypertensive emergency department population. Am J Med Sci. 2009;338(5):368–72.PubMedCrossRefGoogle Scholar
  38. 38.
    Loke YK, Hinz I, Wang X, Salter C. Systematic review of consistency between adherence to cardiovascular or diabetes medication and health literacy in older adults. Ann Pharmacother. 2012;46(6):863–72.PubMedCrossRefGoogle Scholar
  39. 39.
    Bauer AM, Schillinger D, Parker MM, Katon W, Adler N, Adams AS, et al. Health literacy and antidepressant medication adherence among adults with diabetes: the diabetes study of Northern California (DISTANCE). J Gen Intern Med. 2013; 1181–7.Google Scholar
  40. 40.
    Waite KR, Paasche-Orlow M, Rintamaki LS, Davis TC, Wolf MS. Literacy, social stigma, and HIV medication adherence. J Gen Intern Med. 2008;23(9):1367–72.PubMedCentralPubMedCrossRefGoogle Scholar
  41. 41.
    Waldrop-Valverde D, Jones DL, Jayaweera D, Gonzalez P, Romero J, Ownby RL. Gender differences in medication management capacity in HIV infection: the role of health literacy and numeracy. AIDS Behav. 2009;13(1):46–52.PubMedCentralPubMedCrossRefGoogle Scholar
  42. 42.
    Noureldin M, Plake KS, Morrow DG, Tu W, Wu J, Murray MD. Effect of health literacy on drug adherence in patients with heart failure. Pharmacother. 2012;32(9):819–26.CrossRefGoogle Scholar
  43. 43.
    Waldrop-Valverde D, Jones DL, Weiss S, Kumar M, Metsch L. The effects of low literacy and cognitive impairment on medication adherence in HIV-positive injecting drug users. AIDS Care. 2008;20(10):1202–10.PubMedCrossRefGoogle Scholar
  44. 44.
    Kripalani S, Gatti ME, Jacobson TA. Association of age, health literacy, and medication management strategies with cardiovascular medication adherence. Patient Educ Couns. 2010;81(2):177–81.PubMedCrossRefGoogle Scholar
  45. 45.
    Kripalani S, Schmotzer B, Jacobson T. Improving medication adherence through graphically enhanced interventions in coronary heart disease (IMAGE-CHD): a randomized controlled trial. JGIM. 2012;27(12):1609–17.PubMedCrossRefGoogle Scholar
  46. 46.
    Holzemer WL, Bakken S, Portillo CJ, Grimes R, Welch J, Wantland D, et al. Testing a nurse-tailored HIV medication adherence intervention. Nurs Res. 2006;55(3):189–97.PubMedCrossRefGoogle Scholar
  47. 47.
    Murphy DA, Lam P, Naar-King S, Robert Harris D, Parsons JT, Muenz LR. Health literacy and antiretroviral adherence among HIV-infected adolescents. Patient Educ Couns. 2010;79(1):25–9.PubMedCentralPubMedCrossRefGoogle Scholar
  48. 48.
    Bains SS, Egede LE. Associations between health literacy, diabetes knowledge, self-care behaviours, and glycemic control in a low income population with type 2 diabetes. Diabetes Technol Ther. 2011;13(3):335–41.PubMedCrossRefGoogle Scholar
  49. 49.
    Fang MC, Machtinger EL, Wang F, Schillinger D. Health literacy and anticoagulation-related outcomes among patients taking warfarin. J Gen Intern Med. 2006;21(8):841–6.PubMedCentralPubMedCrossRefGoogle Scholar
  50. 50.
    Gazmararian JA, Kripalani S, Miller MJ, Echt KV, Ren J, Rask K. Factors associated with medication refill adherence in cardiovascular-related diseases: a focus on health literacy. J Gen Intern Med. 2006;21(12):1215–21.PubMedCentralPubMedCrossRefGoogle Scholar
  51. 51.
    Powers BJ, Bosworth HB. Revisiting literacy and adherence: future clinical and research directions. J Gen Intern Med. 2006;21(12):1341–2.PubMedCentralPubMedCrossRefGoogle Scholar
  52. 52.
    Lindquist LA, Go L, Fleisher J, Jain N, Friesema E, Baker DW. Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications. J Gen Intern Med. 2012;27(2):173–8.PubMedCentralPubMedCrossRefGoogle Scholar
  53. 53.
    Orford J. Excessive appetites: a psychological view of addictions. 2nd ed. Chichester: John Wiley and Sons; 2001.Google Scholar
  54. 54.
    Ostini R, Jackson C, Hegney D, Tett SE. How is medication prescribing ceased? A systematic review. Med Care. 2011;49(1):24–36.PubMedCrossRefGoogle Scholar
  55. 55.
    Ostini R, Hegney D, Jackson C, Tett SE. Knowing how to stop: ceasing prescribing when the medicine is no longer required. J Manag Care Pharm. 2012;8(1):68–72.Google Scholar

Copyright information

© Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2013

Authors and Affiliations

  1. 1.School of Population HealthThe University of QueenslandIpswichAustralia
  2. 2.School of PharmacySt LuciaAustralia

Personalised recommendations