Skip to main content

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

Journal of General Internal Medicine volume 28, pages 74–81 (2013)Cite this article

ABSTRACT

BACKGROUND

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).

OBJECTIVE

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

PARTICIPANTS, DESIGN AND MAIN MEASURES

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.

KEY RESULTS

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.

CONCLUSIONS

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.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

USD 39.95

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Figure 1.
Figure 2.

Abbreviations

AQ-20R:

Airways Questionnaire-20R

CHI:

COPD Helplessness Index

CI:

confidence interval

COPD:

chronic obstructive pulmonary disease

ED:

emergency department

HRQoL:

health-related quality of life

OR:

odds ratio

MCID:

minimum clinically important difference

SD:

standard deviation

REFERENCES

  1. Eisner MD, Blanc PD, Omachi TA, et al. Socioeconomic status, race and COPD health outcomes. J Epidemiol Community Health. 2011;65:26–34.

    PubMed  Article  CAS  Google Scholar 

  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.

    PubMed  Article  Google Scholar 

  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.

    PubMed  Article  CAS  Google Scholar 

  4. Blane D. Commentary: explanations of the difference in mortality risk between different educational groups. Int J Epidemiol. 2003;32:355–6.

    PubMed  Article  Google Scholar 

  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. 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.

    PubMed  Article  Google Scholar 

  7. Gazmararian JA, Williams MV, Peel J, Baker DW. Health literacy and knowledge of chronic disease. Patient Educ Couns. 2003;51:267–75.

    PubMed  Article  Google Scholar 

  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.

    PubMed  Article  Google Scholar 

  9. Schillinger D, Grumbach K, Piette J, et al. Association of health literacy with diabetes outcomes. Jama. 2002;288:475–82.

    PubMed  Article  Google Scholar 

  10. Peterson PN, Shetterly SM, Clarke CL, et al. Health literacy and outcomes among patients with heart failure. Jama. 2011;305:1695–701.

    PubMed  Article  CAS  Google Scholar 

  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.

    PubMed  Article  Google Scholar 

  12. Roberts NJ, Ghiassi R, Partridge MR. Health literacy in COPD. Int J Chron Obstruct Pulmon Dis. 2008;3:499–507.

    PubMed  Google Scholar 

  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.

    PubMed  Article  CAS  Google Scholar 

  14. Eisner MD, Trupin L, Katz PP, et al. Development and validation of a survey-based COPD severity score. Chest. 2005;127:1890–7.

    PubMed  Article  Google Scholar 

  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.

    PubMed  Article  Google Scholar 

  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.

    PubMed  Article  CAS  Google Scholar 

  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.

    PubMed  Google Scholar 

  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. 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.

    Article  Google Scholar 

  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.

    PubMed  Article  Google Scholar 

  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.

    PubMed  Article  Google Scholar 

  22. Chew LD, Bradley KA, Boyko EJ. Brief questions to identify patients with inadequate health literacy. Fam Med. 2004;36:588–94.

    PubMed  Google Scholar 

  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.

    PubMed  Article  Google Scholar 

  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.

    PubMed  Article  Google Scholar 

  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.

    PubMed  Article  Google Scholar 

  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.

    PubMed  CAS  Google Scholar 

  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.

  28. Peterson C. Learned helplessness and health psychology. Health Psychol. 1982;1:153–68.

    Article  Google Scholar 

  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.

    PubMed  CAS  Google Scholar 

  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.

    PubMed  Article  Google Scholar 

  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.

    PubMed  Article  Google Scholar 

  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.

    PubMed  Article  Google Scholar 

  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.

    PubMed  Article  CAS  Google Scholar 

  34. Burge S, Wedzicha JA. COPD exacerbations: definitions and classifications. Eur Respir J Suppl. 2003;41:46s–53s.

    PubMed  Article  CAS  Google Scholar 

  35. Pauwels R, Calverley P, Buist AS, et al. COPD exacerbations: the importance of a standard definition. Respir Med. 2004;98:99–107.

    PubMed  Article  CAS  Google Scholar 

  36. Rodriguez-Roisin R. Toward a consensus definition for COPD exacerbations. Chest. 2000;117:398S–401S.

    PubMed  Article  CAS  Google Scholar 

  37. Hosmer DW, Lemeshow S. Applied logistic regression. 2nd ed. Hoboken, NJ: John Wiley & Sons, Inc.; 2000.

    Book  Google Scholar 

  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. 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.

    PubMed  Article  Google Scholar 

  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.

    PubMed  CAS  Google Scholar 

  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.

    PubMed  Article  Google Scholar 

  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.

    PubMed  Article  CAS  Google Scholar 

  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.

    Article  Google Scholar 

  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.

    PubMed  Article  Google Scholar 

  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.

    PubMed  Article  Google Scholar 

  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.

    PubMed  Article  CAS  Google Scholar 

  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.

    PubMed  Google Scholar 

  48. Kazis LE, Anderson JJ, Meenan RF. Effect sizes for interpreting changes in health status. Med Care. 1989;27:S178–89.

    PubMed  Article  CAS  Google Scholar 

  49. Mancuso CA, Rincon M. Impact of health literacy on longitudinal asthma outcomes. J Gen Intern Med. 2006;21:813–7.

    PubMed  Article  Google Scholar 

  50. Bleecker ER. Similarities and differences in asthma and COPD. The Dutch hypothesis. Chest. 2004;126:93S–5S. discussion 159S–61S.

    PubMed  Article  Google Scholar 

  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.

    PubMed  Article  Google Scholar 

  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.

    PubMed  Article  CAS  Google Scholar 

  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.

    PubMed  Article  CAS  Google Scholar 

  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.

    PubMed  Article  CAS  Google Scholar 

  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.

    PubMed  Article  Google Scholar 

  56. Cleary PD, Jette AM. The validity of self-reported physician utilization measures. Med Care. 1984;22:796–803.

    PubMed  Article  CAS  Google Scholar 

  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.

    PubMed  Article  CAS  Google Scholar 

  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.

    PubMed  Article  CAS  Google Scholar 

  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.

    PubMed  Article  Google Scholar 

Download references

Acknowledgments

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.

Author information

Authors and Affiliations

  1. Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, 94118, USA

    Theodore A. Omachi MD, MBA

  2. Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA, 94118, USA

    Theodore A. Omachi MD, MBA & Paul D. Blanc MD, MSPH

  3. Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, 94118, USA

    Urmimala Sarkar MD, MPH

  4. Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, CA, 94118, USA

    Urmimala Sarkar MD, MPH

  5. Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, 94118, USA

    Edward H. Yelin PhD & Patricia P. Katz PhD

  6. Division of Rheumatology, Department of Medicine, University of California, San Francisco, San Francisco, CA, 94118, USA

    Edward H. Yelin PhD & Patricia P. Katz PhD

  7. Division of Occupational and Environmental Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, 94118, USA

    Paul D. Blanc MD, MSPH

Authors
  1. Theodore A. Omachi MD, MBA
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Urmimala Sarkar MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Edward H. Yelin PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Paul D. Blanc MD, MSPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Patricia P. Katz PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Theodore A. Omachi MD, MBA.

Electronic supplementary material

Below is the link to the electronic supplementary material.

ESM 1

(DOCX 31 kb)

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Omachi, T.A., Sarkar, U., Yelin, E.H. et al. Lower Health Literacy is Associated with Poorer Health Status and Outcomes in Chronic Obstructive Pulmonary Disease. J GEN INTERN MED 28, 74–81 (2013). https://doi.org/10.1007/s11606-012-2177-3

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11606-012-2177-3

KEY WORDS

  • chronic obstructive pulmonary disease
  • health literacy
  • health status
  • health outcomes
  • utilization