Journal of General Internal Medicine

, Volume 21, Issue 8, pp 813–817 | Cite as

Impact of health literacy on longitudinal asthma outcomes


BACKGROUND: The impact of health literacy on longitudinal asthma outcomes is not known.

OBJECTIVES: To measure the association between health literacy and asthma outcomes and to assess how health literacy affects outcomes through covariates.

DESIGN: Longitudinal cohort.

PATIENTS: One hundred and seventy-five adult asthma patients.

MEASUREMENTS: Independent variables measured at enrollment included demographic and asthma characteristics, depressive symptoms, self-efficacy, and asthma knowledge. Health literacy was measured with the Test of Functional Health Literacy in Adults. Outcomes were Asthma Quality of Life Questionnaire and SF-36 scores and emergency department utilization for asthma measured every 3 to 6 months for 2 years. The effects of health literacy on outcomes and interactions between health literacy and covariates were measured with multivariable models.

RESULTS: The mean age of study participants was 42 years, and 83% were women. Less health literacy was associated with worse quality of life, worse physical function, and more emergency department utilization for asthma over 2 years (P ≤.05 for all comparisons). In multivariable analysis, health literacy did not remain statistically significant with any of the outcomes. Although the magnitude of its effect on emergency department utilization remained relatively intact, its effects on quality of life and functional status became attenuated with the sequential addition of covariates, particularly asthma knowledge.

CONCLUSIONS: Less health literacy was associated with poor longitudinal asthma outcomes. This relationship was both direct and indirect through effects on other independent variables, particularly patients’ knowledge of asthma and self-management. Efforts to improve asthma outcomes should focus on improving literacy skills that are required to learn, understand, and implement effective self-management.

Key words

health literacy asthma quality of life outcomes emergency department utilization 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Parker RM, Ratzan SC, Lurie N. Health literacy: a policy challenge for advancing high-quality health care. Health Aff. 2003;22:147–53.CrossRefGoogle 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;19:1228–39.PubMedCrossRefGoogle Scholar
  3. 3.
    Tomlinson LM. Patient and practitioner literacy and women’s health: a global view from the closing decade 1990–2000. Ethn Dis. 2003;13:248–58.PubMedGoogle Scholar
  4. 4.
    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
  5. 5.
    Schillinger D, Grumbach K, Piette J, et al. Association of health literacy with diabetes outcomes. JAMA. 2002;288:475–82.PubMedCrossRefGoogle Scholar
  6. 6.
    Gazmararian JA, Williams MV, Peel J, Baker DW. Health literacy and knowledge of chronic disease. Patient Educ Counsel. 2003;51:267–75.CrossRefGoogle Scholar
  7. 7.
    Williams MV, Baker DW, Honig EG, Lee TM, Nowlan A. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest. 1998;114:1008–15.PubMedGoogle Scholar
  8. 8.
    Mancuso CA, Rincon M, McCulloch CE, Charlson ME. Self-efficacy, depressive symptoms, and patients’ expectations predict outcomes in asthma. Med Care. 2001;39:1326–38.PubMedCrossRefGoogle Scholar
  9. 9.
    Logorreta AP, Leung KM, Berkbigler D, Evans R, Liu X. Outcomes of a population-based asthma management program: quality of life, absenteeism, and utilization. Ann Allergy Asthma Immunol. 2000;85:28–45.CrossRefGoogle Scholar
  10. 10.
    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;10:537–41.PubMedCrossRefGoogle Scholar
  11. 11.
    Juniper EF, Guyatt GH, Epstein RS, Ferrie PJ, Jaeschke R, Hiller TK. Evaluation of impairment of health-related quality of life in asthma: development of a questionnaire for use in clinical trials. Thorax. 1992;47:76–83.PubMedGoogle Scholar
  12. 12.
    Ware JE, Kosinski M, Bayliss MS, McHorney CA, Rogers WH, Raczek A. Comparison of methods for scoring and statistical analysis of SF-36 health profile and summary measures: summary of results from the Medical Outcomes Study. Med Care. 1995;33:264–79.CrossRefGoogle Scholar
  13. 13.
    Tobin DL, Wigal JK, Winder JA, Holroyd KA, Creer TL. The Asthma Self-efficacy Scale. Ann Allergy. 1987;59:273–7.PubMedGoogle Scholar
  14. 14.
    Check Your Asthma IQ. National Asthma Education Program. National Heart Lung and Blood Institute. J Allergy Clin Immunol. 1991;88:468–9.Google Scholar
  15. 15.
    Yesavage JA, Brink TL. Development and validation of a geriatric depression screening scale: a preliminary report. Psychiatr Res. 1983;17:37–49.CrossRefGoogle Scholar
  16. 16.
    Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clin Gerontol. 1986;5:165–73.CrossRefGoogle Scholar
  17. 17.
    Williams MV, Parker RM, Baker DW, et al. Inadequate functional health literacy among patients at two public hospitals. JAMA. 1995;274:1677–82.PubMedCrossRefGoogle Scholar
  18. 18.
    SAS Institute. SAS User’s Guide. Version 5. Cary, NC: SAS Institute: 1985.Google Scholar
  19. 19.
    Guidelines for the Diagnosis and Management of Asthma Expert Panel Report 2. NIH Publication No. 97-4051. Bethesda, MD: National Asthma Education and Prevention Program; April 1997.Google Scholar
  20. 20.
    Health Literacy: Report of the Council on Scientific Affairs. American Medical Association. JAMA. 1999;281:552–7.CrossRefGoogle Scholar
  21. 21.
    Bandura A. Social Learning Theory. Englewood Cliffs, NJ: Prentice-Hall; 1977.Google Scholar
  22. 22.
    Alt HL. Psychiatric aspects of asthma. Chest. 1992;101:415S-7S.PubMedCrossRefGoogle Scholar
  23. 23.
    Wolf M, Gazmararian JA, Baker DW. Health literacy and functional health status among older adults. Arch Intern Med. 2005;165:1946–52.PubMedCrossRefGoogle Scholar
  24. 24.
    DeWalt DA, Pignone MP. Reading is fundamental: the relationship between literacy and health. Arch Intern Med. 2005;165:1943–4.PubMedCrossRefGoogle Scholar
  25. 25.
    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
  26. 26.
    Gazmararian JA, Baker DW, Williams MV, et al. Health literacy among Medicare enrollees in a managed care organization. JAMA. 1999;281:545–51.PubMedCrossRefGoogle Scholar
  27. 27.
    Mancuso CA, Rincon M. Asthma patients’ assessments of health care and medical decision making: the role of health literacy. J Asthma. 2006;43:41–4.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2006

Authors and Affiliations

  1. 1.Weill Medical College of Cornell UniversityNew YorkUSA
  2. 2.Stanford School of MedicineStanfordUSA
  3. 3.Hospital for Special SurgeryNew York

Personalised recommendations