Journal of General Internal Medicine

, Volume 28, Issue 1, pp 74–81 | Cite as

Lower Health Literacy is Associated with Poorer Health Status and Outcomes in Chronic Obstructive Pulmonary Disease

  • Theodore A. Omachi
  • Urmimala Sarkar
  • Edward H. Yelin
  • Paul D. Blanc
  • Patricia P. Katz
Original Research



Limited health literacy is associated with poor outcomes in many chronic diseases, but little is known about health literacy in chronic obstructive pulmonary disease (COPD).


To examine the associations between health literacy and both outcomes and health status in COPD.


Structured interviews were administered to 277 subjects with self-report of physician-diagnosed COPD, recruited through US random-digit telephone dialing. Health literacy was measured with a validated three-item battery. Multivariable linear regression, controlling for sociodemographics including income and education, determined the cross-sectional associations between health literacy and COPD-related health status: COPD Severity Score, COPD Helplessness Index, and Airways Questionnaire-20R [measuring respiratory-specific health-related quality of life (HRQoL)]. Multivariable logistic regression estimated associations between health literacy and COPD-related hospitalizations and emergency department (ED) visits.


Taking socioeconomic status into account, poorer health literacy (lowest tertile compared to highest tertile) was associated with: worse COPD severity (+2.3 points; 95 % CI 0.3–4.4); greater COPD helplessness (+3.7 points; 95 % CI 1.6–5.8); and worse respiratory-specific HRQoL (+3.5 points; 95 % CI 1.8–4.9). Poorer health literacy, also controlling for the same covariates, was associated with higher likelihood of COPD-related hospitalizations (OR = 6.6; 95 % CI 1.3–33) and COPD-related ED visits (OR = 4.7; 95 % CI 1.5–15). Analyses for trend across health literacy tertiles were statistically significant (p < 0.05) for all above outcomes.


Independent of socioeconomic status, poor health literacy is associated with greater COPD severity, greater COPD helplessness, worse respiratory-specific HRQoL, and higher odds of COPD-related emergency health-care utilization. These results underscore that COPD patients with poor health literacy may be at particular risk for poor health-related outcomes.


chronic obstructive pulmonary disease health literacy health status health outcomes utilization 



Airways Questionnaire-20R


COPD Helplessness Index


confidence interval


chronic obstructive pulmonary disease


emergency department


health-related quality of life


odds ratio


minimum clinically important difference


standard deviation



Dr. Omachi was supported by K23 HL102159 from the National Heart, Lung, and Blood Institute, National Institutes of Health. Dr. Katz, Dr. Blanc, and recruitment of the cohort were supported by R01 HL067438 from the National Heart, Lung, and Blood Institute, National Institutes of Health.

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Supplementary material

11606_2012_2177_MOESM1_ESM.docx (32 kb)
ESM 1 (DOCX 31 kb)


  1. 1.
    Eisner MD, Blanc PD, Omachi TA, et al. Socioeconomic status, race and COPD health outcomes. J Epidemiol Community Health. 2011;65:26–34.PubMedCrossRefGoogle Scholar
  2. 2.
    Baker DW, Wolf MS, Feinglass J, Thompson JA, Gazmararian JA, Huang J. Health literacy and mortality among elderly persons. Arch Intern Med. 2007;167:1503–9.PubMedCrossRefGoogle Scholar
  3. 3.
    Davey Smith G, Hart C, Hole D, et al. Education and occupational social class: which is the more important indicator of mortality risk? J Epidemiol Community Health. 1998;52:153–60.PubMedCrossRefGoogle Scholar
  4. 4.
    Blane D. Commentary: explanations of the difference in mortality risk between different educational groups. Int J Epidemiol. 2003;32:355–6.PubMedCrossRefGoogle Scholar
  5. 5.
    Institute of Medicine. Health literacy: A prescription to end confusion. Washington, DC: National Academy Press, Institute of Medicine Committee on Health Literacy; 2004.Google Scholar
  6. 6.
    Paasche-Orlow MK, Parker RM, Gazmararian JA, Nielsen-Bohlman LT, Rudd RR. The prevalence of limited health literacy. J Gen Intern Med. 2005;20:175–84.PubMedCrossRefGoogle Scholar
  7. 7.
    Gazmararian JA, Williams MV, Peel J, Baker DW. Health literacy and knowledge of chronic disease. Patient Educ Couns. 2003;51:267–75.PubMedCrossRefGoogle Scholar
  8. 8.
    Scott TL, Gazmararian JA, Williams MV, Baker DW. Health literacy and preventive health care use among Medicare enrollees in a managed care organization. Med Care. 2002;40:395–404.PubMedCrossRefGoogle Scholar
  9. 9.
    Schillinger D, Grumbach K, Piette J, et al. Association of health literacy with diabetes outcomes. Jama. 2002;288:475–82.PubMedCrossRefGoogle Scholar
  10. 10.
    Peterson PN, Shetterly SM, Clarke CL, et al. Health literacy and outcomes among patients with heart failure. Jama. 2011;305:1695–701.PubMedCrossRefGoogle Scholar
  11. 11.
    Paasche-Orlow MK, Wolf MS. The causal pathways linking health literacy to health outcomes. Am J Health Behav. 2007;31(Suppl 1):S19–26.PubMedCrossRefGoogle Scholar
  12. 12.
    Roberts NJ, Ghiassi R, Partridge MR. Health literacy in COPD. Int J Chron Obstruct Pulmon Dis. 2008;3:499–507.PubMedGoogle Scholar
  13. 13.
    Trupin L, Earnest G, San Pedro M, et al. The occupational burden of chronic obstructive pulmonary disease. Eur Respir J. 2003;22:462–9.PubMedCrossRefGoogle Scholar
  14. 14.
    Eisner MD, Trupin L, Katz PP, et al. Development and validation of a survey-based COPD severity score. Chest. 2005;127:1890–7.PubMedCrossRefGoogle Scholar
  15. 15.
    Chen H, Eisner MD, Katz PP, Yelin EH, Blanc PD. Measuring disease-specific quality of life in obstructive airway disease: validation of a modified version of the airways questionnaire 20. Chest. 2006;129:1644–52.PubMedCrossRefGoogle Scholar
  16. 16.
    Blanc PD, Eisner MD, Trupin L, Yelin EH, Katz PP, Balmes JR. The association between occupational factors and adverse health outcomes in chronic obstructive pulmonary disease. Occup Environ Med. 2004;61:661–7.PubMedCrossRefGoogle Scholar
  17. 17.
    Katz PP, Gregorich S, Eisner M, et al. Disability in valued life activities among individuals with COPD and other respiratory conditions. J Cardiopulm Rehabil Prev. 2010;30:126–36.PubMedGoogle Scholar
  18. 18.
    Kim J. Atlas of respiratory disease mortality, United States: 1982–1993. Cincinnati, OH: Department of Health and Human Services, National Institute for Occupational Safety and Health; 1998.Google Scholar
  19. 19.
    Radeos MS, Cydulka RK, Rowe BH, Barr RG, Clark S, Camargo CA Jr. Validation of self-reported chronic obstructive pulmonary disease among patients in the ED. Am J Emerg Med. 2009;27:191–6.CrossRefGoogle Scholar
  20. 20.
    Tisnado DM, Adams JL, Liu H, et al. What is the concordance between the medical record and patient self-report as data sources for ambulatory care? Med Care. 2006;44:132–40.PubMedCrossRefGoogle Scholar
  21. 21.
    Straus SE, McAlister FA, Sackett DL, Deeks JJ. Accuracy of history, wheezing, and forced expiratory time in the diagnosis of chronic obstructive pulmonary disease. J Gen Intern Med. 2002;17:684–8.PubMedCrossRefGoogle Scholar
  22. 22.
    Chew LD, Bradley KA, Boyko EJ. Brief questions to identify patients with inadequate health literacy. Fam Med. 2004;36:588–94.PubMedGoogle Scholar
  23. 23.
    Chew LD, Griffin JM, Partin MR, et al. Validation of screening questions for limited health literacy in a large VA outpatient population. J Gen Intern Med. 2008;23:561–6.PubMedCrossRefGoogle Scholar
  24. 24.
    Wallace LS, Rogers ES, Roskos SE, Holiday DB, Weiss BD. Brief report: screening items to identify patients with limited health literacy skills. J Gen Intern Med. 2006;21:874–7.PubMedCrossRefGoogle Scholar
  25. 25.
    Sarkar U, Schillinger D, Lopez A, Sudore R. Validation of self-reported health literacy questions among diverse English and Spanish-speaking populations. J Gen Intern Med. 2011;26:265–71.PubMedCrossRefGoogle Scholar
  26. 26.
    Davis TC, Long SW, Jackson RH, et al. Rapid estimate of adult literacy in medicine: a shortened screening instrument. Fam Med. 1993;25:391–5.PubMedGoogle Scholar
  27. 27.
    Omachi TA, Katz PP, Yelin EH, et al. The COPD Helplessness Index: A new tool to measure factors affecting patient self-management. Chest 2010;137(4):823–30.Google Scholar
  28. 28.
    Peterson C. Learned helplessness and health psychology. Health Psychol. 1982;1:153–68.CrossRefGoogle Scholar
  29. 29.
    Hajiro T, Nishimura K, Jones PW, et al. A novel, short, and simple questionnaire to measure health-related quality of life in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1999;159:1874–8.PubMedGoogle Scholar
  30. 30.
    Alemayehu B, Aubert RE, Feifer RA, Paul LD. Comparative analysis of two quality-of-life instruments for patients with chronic obstructive pulmonary disease. Value Health. 2002;5:437–42.PubMedCrossRefGoogle Scholar
  31. 31.
    Omachi TA, Yelin EH, Katz PP, Blanc PD, Eisner MD. The COPD severity score: a dynamic prediction tool for health-care utilization. Copd. 2008;5:339–46.PubMedCrossRefGoogle Scholar
  32. 32.
    Eisner MD, Omachi TA, Katz PP, Yelin EH, Iribarren C, Blanc PD. Measurement of COPD severity using a survey-based score: validation in a clinically and physiologically characterized cohort. Chest. 2010;137:846–51.PubMedCrossRefGoogle Scholar
  33. 33.
    Miravitlles M, Llor C, de Castellar R, Izquierdo I, Baro E, Donado E. Validation of the COPD severity score for use in primary care: the NEREA study. Eur Respir J. 2009;33:519–27.PubMedCrossRefGoogle Scholar
  34. 34.
    Burge S, Wedzicha JA. COPD exacerbations: definitions and classifications. Eur Respir J Suppl. 2003;41:46s–53s.PubMedCrossRefGoogle Scholar
  35. 35.
    Pauwels R, Calverley P, Buist AS, et al. COPD exacerbations: the importance of a standard definition. Respir Med. 2004;98:99–107.PubMedCrossRefGoogle Scholar
  36. 36.
    Rodriguez-Roisin R. Toward a consensus definition for COPD exacerbations. Chest. 2000;117:398S–401S.PubMedCrossRefGoogle Scholar
  37. 37.
    Hosmer DW, Lemeshow S. Applied logistic regression. 2nd ed. Hoboken, NJ: John Wiley & Sons, Inc.; 2000.CrossRefGoogle Scholar
  38. 38.
    Vittinghoff E, Glidden DV, Shiboski SC, McCulloch CE. Regression Methods in Biostatistics: Linear, Logistic, Survivial, and Repeated Measures Models. New York: Springer Science & Business Media, Inc.; 2005.Google Scholar
  39. 39.
    Bourbeau J, Julien M, Maltais F, et al. Reduction of hospital utilization in patients with chronic obstructive pulmonary disease: a disease-specific self-management intervention. Arch Intern Med. 2003;163:585–91.PubMedCrossRefGoogle Scholar
  40. 40.
    Covinsky KE, Fortinsky RH, Palmer RM, Kresevic DM, Landefeld CS. Relation between symptoms of depression and health status outcomes in acutely ill hospitalized older persons. Ann Intern Med. 1997;126:417–25.PubMedGoogle Scholar
  41. 41.
    Ambrosino N, Bruletti G, Scala V, Porta R, Vitacca M. Cognitive and perceived health status in patient with chronic obstructive pulmonary disease surviving acute on chronic respiratory failure: a controlled study. Intensive Care Med. 2002;28:170–7.PubMedCrossRefGoogle Scholar
  42. 42.
    Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients’ knowledge of their chronic disease. A study of patients with hypertension and diabetes. Arch Intern Med. 1998;158:166–72.PubMedCrossRefGoogle Scholar
  43. 43.
    Williams MV, Parker RM, Baker DW, Coates W, Nurss J. The impact of inadequate functional health literacy on patients’ understanding of diagnosis, prescribed medications, and compliance. Acad Emerg Med. 1995;2:386.CrossRefGoogle Scholar
  44. 44.
    Press VG, Arora VM, Shah LM, et al. Misuse of respiratory inhalers in hospitalized patients with asthma or COPD. J Gen Intern Med 2011;26:635-42.PubMedCrossRefGoogle Scholar
  45. 45.
    Paasche-Orlow MK, Riekert KA, Bilderback A, et al. Tailored education may reduce health literacy disparities in asthma self-management. Am J Respir Crit Care Med 2005;172;980-6.PubMedCrossRefGoogle Scholar
  46. 46.
    Williams MV, Baker DW, Honig EG, Lee TM, Nowlan A. Inadequate literacy is a berrer to asthma knowledge and self-care. Chest 1998;114:1008-15.PubMedCrossRefGoogle Scholar
  47. 47.
    Norman GR, Sloan JA, Wyrwich KW. Interpretation of changes in health-related quality of life: the remarkable universality of half a standard deviation. Med Care. 2003;41:582–92.PubMedGoogle Scholar
  48. 48.
    Kazis LE, Anderson JJ, Meenan RF. Effect sizes for interpreting changes in health status. Med Care. 1989;27:S178–89.PubMedCrossRefGoogle Scholar
  49. 49.
    Mancuso CA, Rincon M. Impact of health literacy on longitudinal asthma outcomes. J Gen Intern Med. 2006;21:813–7.PubMedCrossRefGoogle Scholar
  50. 50.
    Bleecker ER. Similarities and differences in asthma and COPD. The Dutch hypothesis. Chest. 2004;126:93S–5S. discussion 159S–61S.PubMedCrossRefGoogle Scholar
  51. 51.
    Baker DW, Gazmararian JA, Williams MV, et al. Functional health literacy and the risk of hospital admission among Medicare managed care enrollees. Am J Public Health. 2002;92:1278–83.PubMedCrossRefGoogle Scholar
  52. 52.
    Baker DW, Parker RM, Williams MV, Clark WS. Health literacy and the risk of hospital admission. J Gen Intern Med. 1998;13:791–8.PubMedCrossRefGoogle Scholar
  53. 53.
    Baker DW, Parker RM, Williams MV, et al. The health care experience of patients with low literacy. Arch Fam Med. 1996;5:329–34.PubMedCrossRefGoogle Scholar
  54. 54.
    Quint JK, Donaldson GC, Hurst JR, Goldring JJ, Seemungal TR, Wedzicha JA. Predictive accuracy of patient-reported exacerbation frequency in COPD. Eur Respir J. 2011;37:501–7.PubMedCrossRefGoogle Scholar
  55. 55.
    Raina P, Torrance-Rynard V, Wong M, Woodward C. Agreement between self-reported and routinely collected health-care utilization data among seniors. Health Serv Res. 2002;37:751–74.PubMedCrossRefGoogle Scholar
  56. 56.
    Cleary PD, Jette AM. The validity of self-reported physician utilization measures. Med Care. 1984;22:796–803.PubMedCrossRefGoogle Scholar
  57. 57.
    Roberts RO, Bergstralh EJ, Schmidt L, Jacobsen SJ. Comparison of self-reported and medical record health care utilization measures. J Clin Epidemiol. 1996;49:989–95.PubMedCrossRefGoogle Scholar
  58. 58.
    Rothman RL, DeWalt DA, Malone R, et al. Influence of patient literacy on the effectiveness of a primary care-based diabetes disease management program. Jama. 2004;292:1711–6.PubMedCrossRefGoogle Scholar
  59. 59.
    DeWalt DA, Malone RM, Bryant ME, et al. A heart failure self-management program for patients of all literacy levels: a randomized, controlled trial [ISRCTN11535170]. BMC Health Serv Res. 2006;6:30.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2012

Authors and Affiliations

  • Theodore A. Omachi
    • 1
    • 2
  • Urmimala Sarkar
    • 3
    • 4
  • Edward H. Yelin
    • 5
    • 6
  • Paul D. Blanc
    • 2
    • 7
  • Patricia P. Katz
    • 5
    • 6
  1. 1.Division of Pulmonary, Critical Care, and Sleep Medicine, Department of MedicineUniversity of California, San FranciscoSan FranciscoUSA
  2. 2.Cardiovascular Research InstituteUniversity of California, San FranciscoSan FranciscoUSA
  3. 3.Division of General Internal Medicine, Department of MedicineUniversity of California, San FranciscoSan FranciscoUSA
  4. 4.Center for Vulnerable PopulationsSan Francisco General HospitalSan FranciscoUSA
  5. 5.Institute for Health Policy StudiesUniversity of California, San FranciscoSan FranciscoUSA
  6. 6.Division of Rheumatology, Department of MedicineUniversity of California, San FranciscoSan FranciscoUSA
  7. 7.Division of Occupational and Environmental Medicine, Department of MedicineUniversity of California, San FranciscoSan FranciscoUSA

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