Journal of General Internal Medicine

, Volume 28, Issue 11, pp 1469–1476

The Impact of Health Literacy on Desire for Participation in Healthcare, Medical Visit Communication, and Patient Reported Outcomes among Patients with Hypertension

  • Hanan J. Aboumatar
  • Kathryn A. Carson
  • Mary Catherine Beach
  • Debra L. Roter
  • Lisa A. Cooper
Original Research



Low health literacy (HL) is associated with poor healthcare outcomes; mechanisms for these associations remain unclear.


To elucidate how HL influences patients’ interest in participating in healthcare, medical visit communication, and patient reported visit outcomes.


Cross-sectional study of enrollment data from a randomized controlled trial of interventions to improve patient adherence to hypertension treatments. Participants were 41 primary care physicians and 275 of their patients. Prior to the enrollment visit, physicians received a minimal intervention or communication skills training and patients received a minimal intervention or a pre-visit coaching session. This resulted in four intervention groups (minimal patient/minimal physician; minimal patient/intensive physician; intensive patient/minimal physician; and intensive patient/intensive physician).


Rapid Estimate of Adult Literacy in Medicine; patients’ desire for involvement in decision making; communication behaviors; patient ratings of participatory decision making (PDM), trust, and satisfaction.


A lower percentage of patients with low versus adequate literacy had controlled blood pressure. Both groups were similarly interested in participating in medical decision making. Communication behaviors did not differ based on HL except for medical question asking by patients, which was lower among low literacy patients. This was particularly true in the intensive patient /intensive physician group (3.85 vs. 6.42 questions; p = 0.002). Overall, ratings of care didn’t differ based on HL; however, in analyses stratified by intervention assignment, patients with low literacy in minimal physician intervention groups reported significantly lower PDM scores than adequate literacy patients.


Patients with low and adequate literacy were similarly interested in participating in medical decision making. However, low literacy patients were less likely to experience PDM in their visits. Low literacy patients in the intensive physician intervention groups asked fewer medical questions. Patients with low literacy may be less able to respond to physicians’ use of patient-centered communication approaches than adequate literacy patients.


health literacy  participatory decision making patient–physician relationship communication 


  1. 1.
    Kutner M, Greenberg E, Jin Y, et al. The health literacy of America’s adults—Results for the 2003 national assessment of adult literacy. Washington, DC: US. Department of Education; 2006:i–60. Available at Accessed April 10, 2013.
  2. 2.
    Kirsch IS, Jungeblut A, Jenkins L, Kolstadet A. A First Look at the Results of the National Adult Literacy Survey. Nat’l Center for Education Statistics, 1993. Available at April 10, 2013.
  3. 3.
    Williams MV, Baker DW, Honig EG, Lee TM, Nowlan A. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest. 1998;114:1008–1015.PubMedCrossRefGoogle Scholar
  4. 4.
    Baker DW, Parikh NS, Pitkin K, et al. Inadequate functional health literacy among patients at two public hospitals. JAMA. 1995;274(21):1677–1682.PubMedCrossRefGoogle Scholar
  5. 5.
    Baker DW, Parker RM, Williams MV, et al. The health care experience of patients with low literacy. Arch Fam Med. 1996;5(6):329–334.PubMedCrossRefGoogle Scholar
  6. 6.
    Berkman ND, DeWalt DA, Pignone MP, Sheridan SL, Lohr KN, Lux L, Sutton SF, Swinson T, Bonito AJ. Literacy and Health Outcomes. Evidence Report/Technology Assessment No. 87 (Prepared by RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-02-0016). AHRQ Publication No. 04-E007-2. Rockville, MD: Agency for Healthcare Research and Quality. January 2004. Available at Accessed April 10, 2013.
  7. 7.
    DeWalt DA, Berkman ND, Sheridan S, et al. Literacy and health outcomes. A systematic review of the literature. J Gen Intern Med. 2004;19:1228–1239.PubMedCrossRefGoogle Scholar
  8. 8.
    Weiss BD, Hart G, Pust RE. The relationship between literacy and health. J Health Care Poor Underserved. 1991;1:351–363.PubMedCrossRefGoogle Scholar
  9. 9.
    Weiss BD, Hart G, McGee DL, Estelle S. Health status of illiterate adults: relation between literacy and health status among persons with low literacy skills. J Am Board Fam Pract. 1992;5:257–264.PubMedGoogle Scholar
  10. 10.
    Berkman ND, et al. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med. 2011;155(2):97–107.PubMedCrossRefGoogle Scholar
  11. 11.
    Selden CR, Zorn M, Ratzan S, Parker RM. Health Literacy. Current Bibliographies in Medicine. Bethesda, MD: National Library of Medicine, 2000. No.2000-1. Available at: Accessed April 10, 2013.
  12. 12.
    Nielsen-Bohlman L, Panzer AM, Kindig DA. 2004 Health literacy: A prescription to end confusion. Washington, DC: Institute of Medicine: National Academies Press. Available at Accessed April 10, 2013.
  13. 13.
    Parker R, Ratzanb SC. Health literacy: a second decade of distinction for Americans. J Heal Commun. 2010;15:20–33.CrossRefGoogle Scholar
  14. 14.
    Mancuso CA, Rincon M. Asthma patients assessments of health care and medical decision making: the role of health literacy. J Asthma. 2006;43:41–44.PubMedCrossRefGoogle Scholar
  15. 15.
    Collins M, Crowley R, Karlawish JH, Casarett DJ. Are depressed patients more likely to share health care decisions with others? J Palliat Med. 2004;7:527–532.PubMedCrossRefGoogle Scholar
  16. 16.
    Barragan M, Hicks G, Williams MV, Franco-Paredes C, Duffus W, Del Rio C. Low health literacy is associated with HIV test acceptance. J Gen Intern Med. 2005;20:422–425.PubMedCrossRefGoogle Scholar
  17. 17.
    Katz MG, Jacobson TA, Veledar E, et al. Patient literacy and question-asking behavior during the medical encounter: a mixed-methods analysis. J Gen Intern Med. 2007;22:782–6.PubMedCrossRefGoogle Scholar
  18. 18.
    Cooper LA, Roter DL, Bone LR, et al. A randomized controlled trial of interventions to enhance patient-physician partnership, patient adherence and high blood pressure control among ethnic minorities and poor persons: study protocol NCT00123045. Implement Sci. 2009;4:7.PubMedCrossRefGoogle Scholar
  19. 19.
    Cooper LA, Roter DL, Carson KA, et al. A randomized trial to improve patient-centered care and hypertension control in underserved primary care patients. J Gen Intern Med. 2011;26(11):1297–304.PubMedCrossRefGoogle Scholar
  20. 20.
    Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care. 1986;24:67–74.PubMedCrossRefGoogle Scholar
  21. 21.
    Davis TC, Long SW, Jackson RH, et al. Rapid estimate of adult literacy in medicine: a shortened screening instrument. Fam Med. 1993;25(6):391–5.PubMedGoogle Scholar
  22. 22.
    Brody DS. Patient perception of involvement in medical care: relationship to illness attitudes and outcomes. J Gen Intern Med. 1989;4(6):506–11.PubMedCrossRefGoogle Scholar
  23. 23.
    Bertakis KD, Roter D, Putnam SM. The relationship of physician medical interview style to patient satisfaction. J Fam Pract. 1991;32:175–81.PubMedGoogle Scholar
  24. 24.
    Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM. Physician patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997;277:553–59.PubMedCrossRefGoogle Scholar
  25. 25.
    Roter DL. Patient participation in the patient–provider interaction: the effects of patient question asking on the quality of interaction, satisfaction and compliance. Health Educ Monogr. 1977;5:281–315.PubMedCrossRefGoogle Scholar
  26. 26.
    Wissow LS, Roter D, Bauman LJ, et al. Patient–provider communication during the emergency department care of children with asthma. The National Cooperative Inner-City Asthma Study, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD. Med Care. 1998;36:1439–50.PubMedCrossRefGoogle Scholar
  27. 27.
    Roter DL, Larson S. The relationship between residents’ and attending physicians’ communication during primary care visits: an illustrative use of the Roter Interaction Analysis System. Health Commun. 2001;13(1):33–48.PubMedCrossRefGoogle Scholar
  28. 28.
    Roter D, Larson S. The Roter interaction analysis system (RIAS): utility and flexibility for analysis of medical interactions. Patient Educ Couns. 2002;46(4):243–51.PubMedCrossRefGoogle Scholar
  29. 29.
    RIAS Works. Available at Accessed April 10, 2013.
  30. 30.
    Kaplan SH, Gandek B, Greenfield S, Rogers W, Ware JE. Patient and visit characteristics related to physicians’ participatory decision-making style. Results from the medical outcomes study. Med Care. 1995;33(12):1176–87.PubMedCrossRefGoogle Scholar
  31. 31.
    Kaplan SH, Greenfield S, Gandek B, Rogers WH, Ware JE Jr. Characteristics of physicians with participatory decision-making styles. Ann Intern Med. 1996;124(5):497–504.PubMedCrossRefGoogle Scholar
  32. 32.
    Anderson LA, Dedrick RF. Development of the trust in physician scale: a measure to assess interpersonal trust in patient-physician relationships. Psychol Rep. 1990;67(3 Pt 2):1091–100.PubMedGoogle Scholar
  33. 33.
    Cooper LA, Roter DL, Johnson RL, Ford DE, Steinwachs DM, Powe NR. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med. 2003;139(11):907–15.PubMedCrossRefGoogle Scholar
  34. 34.
    The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) Available at Accessed on April 10, 2013.
  35. 35.
    Parikh NS, Parker RM, Nurss JR, Baker DW, Williams MV. Shame and health literacy: the unspoken connection. Patient Educ Couns. 1996;27(l):33–9.PubMedCrossRefGoogle Scholar
  36. 36.
    Schillinger D, Bindman A, Wang F, Stewart A, Piette J. Functional health literacy and the quality of physician–patient communication among diabetes patients. Patient Educ Couns. 2004;52:315–323.PubMedCrossRefGoogle Scholar
  37. 37.
    Bass PF 3rd, Wilson JF, Griffith CH, Barnett DR. Residents’ ability to identify patients with poor literacy skills. Acad Med. 2002;77(10):1039–41.PubMedCrossRefGoogle Scholar
  38. 38.
    Sheridan SL, et al. Interventions for individuals with low health literacy: a systematic review. J Heal Commun. 2011;16:30–54.CrossRefGoogle Scholar
  39. 39.
    Pringle M, Stewart-Evans C. Does awareness of being video recorded affect doctors’ consultation behaviour? Br J Gen Pract. 1990;40:455–58.PubMedGoogle Scholar
  40. 40.
    Wolraich ML, Albanese M, Stone G, et al. Medical communication behavior system. An interactional analysis system for medical interactions. Med Care. 1986;24:891–903.PubMedCrossRefGoogle Scholar
  41. 41.
    Frisch A-L, Camerini L, Diviani N, Schulz PJ. Defining and measuring health literacy: how can we profit from other literacy domains? Health Promot Int. 2012;27(1):117–126.PubMedCrossRefGoogle Scholar
  42. 42.
    Nutbeam D. Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century. Heal Promot Int. 2000;15:259–267.CrossRefGoogle Scholar
  43. 43.
    Schulz PJ, Nakamoto K. Emerging themes in health literacy. Stud Commun Sci. 2005;5:1–10.Google Scholar
  44. 44.
    Jordan JE, Buchbinder R, Osborne RH. Conceptualizing health literacy from the patient perspective. Patient Educ Couns. 2010;79:36–42.PubMedCrossRefGoogle Scholar
  45. 45.
    Zarcadoolas C, Pleasant A, Greer DS. Elaborating a definition of health literacy: a - commentary. J Heal Commun. 2003;8:119–120.Google Scholar

Copyright information

© Society of General Internal Medicine 2013

Authors and Affiliations

  • Hanan J. Aboumatar
    • 1
    • 2
  • Kathryn A. Carson
    • 2
    • 3
    • 4
  • Mary Catherine Beach
    • 2
    • 3
    • 5
  • Debra L. Roter
    • 5
  • Lisa A. Cooper
    • 2
    • 3
    • 4
    • 5
  1. 1.Armstrong Institute for Safety and QualityJohns Hopkins MedicineBaltimoreUSA
  2. 2.Division of General Internal Medicine, Department of MedicineJohns Hopkins University School of MedicineBaltimoreUSA
  3. 3.Welch Center for Prevention, Epidemiology, and Clinical ResearchJohns Hopkins UniversityBaltimoreUSA
  4. 4.Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreUSA
  5. 5.Department of Health Behavior, and SocietyJohns Hopkins Bloomberg School of Public HealthBaltimoreUSA

Personalised recommendations