Journal of General Internal Medicine

, Volume 19, Issue 12, pp 1228–1239 | Cite as

Literacy and health outcomes

A systematic review of the literature
  • Darren A. DeWaltEmail author
  • Nancy D. Berkman
  • Stacey Sheridan
  • Kathleen N. Lohr
  • Michael P. Pignone


OBJECTIVE: To review the relationship between literacy and health outcomes.

DATA SOURCES: We searched MEDLINE, Cumulative Index to Nursing and Allied Health (CINAHL), Educational Resources Information Center (ERIC), Public Affairs Information Service (PAIS), Industrial and Labor Relations Review (ILLR), PsychInfo, and Ageline from 1980 to 2003.

STUDY SELECTION: We included observational studies that reported original data, measured literacy with any valid instrument, and measured one or more health outcomes. Two abstractors reviewed each study for inclusion and resolved disagreements by discussion.

DATA EXTRACTION: One reviewer abstracted data from each article into an evidence table; the second reviewer checked each entry. The whole study team reconciled disagreements about information in evidence tables. Both data extractors independently completed an 11-item quality scale for each article; scores were averaged to give a final measure of article quality.

DATA SYNTHESIS: We reviewed 3,015 titles and abstracts and pulled 684 articles for full review; 73 articles met inclusion criteria and, of those, 44 addressed the questions of this report. Patients with low literacy had poorer health outcomes, including knowledge, intermediate disease markers, measures of morbidity, general health status, and use of health resources. Patients with low literacy were generally 1.5 to 3 times more likely to experience a given poor outcome. The average quality of the articles was fair to good. Most studies were cross-sectional in design; many failed to address adequately confounding and the use of multiple comparisons.

CONCLUSIONS: Low literacy is associated with several adverse health outcomes. Future research, using more rigorous methods, will better define these relationships and guide developers of new interventions.

Key words

health literacy health outcomes systematic review 


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Copyright information

© Society of General Internal Medicine 2004

Authors and Affiliations

  • Darren A. DeWalt
    • 1
    • 2
    • 4
    • 5
    Email author
  • Nancy D. Berkman
    • 1
  • Stacey Sheridan
    • 1
    • 4
  • Kathleen N. Lohr
    • 1
  • Michael P. Pignone
    • 1
    • 2
    • 3
    • 4
  1. 1.the RTI International-University of North Carolina Evidence-based Practice CenterResearch Triangle Park
  2. 2.Robert Wood Johnson Clinical Scholars ProgramUniversity of North Carolina at Chapel HillChapel Hill
  3. 3.Cecil G. Sheps Center for Health Services ResearchUniversity of North Carolina at Chapel HillChapel Hill
  4. 4.Divisions of General Internal MedicineUniversity of North Carolina School of MedicineChapel Hill
  5. 5.Community PediatricsUniversity of North Carolina School of MedicineChapel Hill

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