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e21HLRP: Health Literacy Research and Practice • Vol. 4, No. 1, 2020
Systematic Review
Empirically Tested Health Literacy FrameworksJoycelyn Cudjoe, PhD, RN; Sabianca Delva, BSN, RN; Mia Cajita, PhD, RN-BC; and Hae-Ra Han, PhD, RN, FAAN
ABSTRACT
Background: Health literacy is a significant determinant of health behaviors, but the pathways through which health literacy influences health behaviors are not completely clear nor consistent. The purpose of this systematic review is to critically appraise studies that have empirically tested the potential pathways linking health literacy to health behavior. Methods: We performed searches of the electronic databases PubMed, Em-base, and CINAHL to identify studies that proposed a conceptual framework and empirically tested the pro-posed mechanism through which health literacy influences certain health behaviors. Twenty eligible studies were included for analysis. Key Results: The 20 studies addressed various health behaviors: chronic disease self-management (n = 8), medication adherence (n = 2), overall health status (n = 4), oral care (n = 1), cancer screening (n = 1), shared decision-making (n = 1), health information sharing (n = 1), physical activity and eat-ing behaviors (n = 1), and emergency department visits (n = 1). Most studies were conducted in the United States (n = 13) and used a cross-sectional design (n = 15). The Short Test of Functional Health Literacy in Adults was commonly used to assess health literacy levels. Selection of variables and their operationalization were informed by a theoretical model in 12 studies. Age, gender, race/ethnicity, and insurance status were reported antecedents to health literacy. The most commonly tested mediators were self-efficacy (n = 8) and disease knowledge (n = 4). Fit indices reported in the studies ranged from acceptable to excellent. Discussion: Current evidence supports self-efficacy as a mediator between health literacy and health behavior. Further research is needed to identify how health literacy interplays with known psychosocial factors to inform people’s use of preventive care services. Future studies should include more disadvantaged populations such as immigrants with high disease burden and those with low health literacy. Theory-based, empirically tested health literacy models can serve as the conceptual basis for developing effective health interventions to improve health be-haviors and ultimately decrease the burden of disease in such vulnerable populations. [HLRP: Health Literacy Research and Practice. 2020;4(1):e21-e44.]
Plain Language Summary: This review systemically compiles, and critically appraises 20 existing studies that test conceptual frameworks that propose potential pathways through which health literacy affects health behaviors. The findings from this review can help inform the development of health literacy-focused interven-tions to improve the health behaviors of populations with disease burdens.
Health literacy (HL) is a multidimensional concept that ad-dresses a range of skills people need to effectively and efficiently function in a health care environment (Baker, 2006; Guzys, Kenny, Dickson-Swift, & Threlkeld, 2015; Kindig, Panzer, & Nielsen-Bohlman, 2004). People of older age and those who be-long to low-income, low-education, immigrant, and ethnic/racial
minority groups often have low HL levels and have been found to have poor health outcomes (Crook, Stephens, Pastorek, Mackert, & Donovan, 2016; Diviani, van den Putte, Giani, & van Weert, 2015; Feinberg, Greenberg, & Frijters, 2015).
There has been a proliferation of studies on the impact of HL on health behavior (e.g., self-care, chronic disease management)
e22 HLRP: Health Literacy Research and Practice • Vol. 4, No. 1, 2020
and overall health outcomes (Guzys et al., 2015; Kim & Han, 2016; Oldach & Katz, 2014). These studies discuss the direct re-lationship between HL and health behaviors or health outcomes at the bivariate level. Recently, a growing body of research has revealed comprehensive pathways related to HL and health be-haviors or outcomes. For example, psychosocial factors such as disease knowledge, self-efficacy, and decisional balance, which are known determinants of health behaviors, were affected by HL levels, and some studies have identified these psychoso-cial factors as potential mediators to the relationship between HL and health behavior (Harvey, Vegesna, Mass, Clarke, & Skoufalos, 2014; Hui et al., 2014; Kaufman, Mirkovic, & Chan, 2017; Kim & Han, 2016; Oldach & Katz, 2014; Tanaka, Strong, Lee, & Juon, 2013). However, what remains unclear is how the-ory informs the development of HL conceptual frameworks and the methods used to empirically assess the proposed pathways through which HL influences health behavior (Alper, 2018; Kim & Han, 2016; Oldach & Katz, 2014; Sørensen et al., 2012).
It is important to gain a comprehensive understanding of the theories that guide the systematic application and evalua-tion of variables used in addressing HL and health behaviors (Alper, 2018). The purpose of this systematic review is to crit-ically appraise studies that tested a theory-based HL concep-tual framework. In addition, we were interested in discussing mechanisms through which HL influences health behavior and/or health outcome to build on empirical evidence.
METHODS Search Strategy
In October 2017 we performed searches on the elec-tronic databases PubMed, Embase, and CINAHL to find studies that identify and empirically test a HL conceptual
framework. Searches were not limited to a specific year. With the assistance of a health science librarian, we identi-fied and used the following keywords and medical subject headings in searching the electronic databases for relevant studies: “health literacy,” “theoretical models,” and “concep-tual frameworks” (see Table A for specific search terms that were used). Search terms were also truncated and explod-ed (i.e., search terms were used to retrieved all references indexed to that term), and other relevant Boolean opera-tors were used to make the search as sensitive as possible. Electronic searches were also supplemented by a search on Google Scholar, and the reference lists of relevant articles were examined for articles that were not indexed by the electronic databases. In March 2019, we performed an ad-ditional database search using the same strategies we used in the initial search.
Study EligibilityAll studies were analyzed for their relevance for the pur-
pose of our review. Studies that addressed the impact of HL on a health behavior or health outcome, described and em-pirically tested a conceptual framework, and were written in English were included in this review. Studies were excluded if they addressed HL as a study concept but did not empiri-cally test a conceptual framework, did not address the impact of HL on health behavior, and were not published in Eng-lish. Case studies, qualitative studies, conference abstracts, and study protocols and non–peer-reviewed editorial works were also excluded. For the purposes of this article, we define conceptual framework as a product that “graphically or nar-ratively explains study variables and the presumed relation-ships among them” (Maxwell, 2013).
Joycelyn Cudjoe, PhD, RN, is a Nurse Research Scientist, Inova Health System. Sabianca Delva, BSN, RN, is a Doctoral Candidate, The Johns Hopkins
University School of Nursing. Mia Cajita, PhD, RN-BC, is an Assistant Professor, University of Illinois at Chicago. Hae-Ra Han, PhD, RN, FAAN, is a Professor,
The Johns Hopkins University School of Nursing.
©2020 Cudjoe, Delva, Cajita, et al.; licensee SLACK Incorporated. This is an Open Access article distributed under the terms of the Creative Commons At-
tribution 4.0 International (https://creativecommons.org/licenses/by/4.0). This license allows users to copy and distribute, to remix, transform, and build
upon the article, for any purpose, even commercially, provided the author is attributed and is not represented as endorsing the use made of the work.
Address correspondence to Joycelyn Cudjoe, PhD, RN, Inova Health System, 8110 Gatehouse Road, Suite 200W, Falls Church, VA 22042; email: joycelyn.
Grant: This research was supported by a National Cancer Institute predoctoral training grant (F31CA221096) to J.C.
Disclaimer: The content is solely the responsibility of the authors.
Acknowledgment: The authors thank Stella Seal, medical librarian (Welch Medical Library, Johns Hopkins University), for her assistance with the
literature search.
Disclosure: The authors have no relevant financial relationships to disclose.
Received: October 15, 2018; Accepted: March 20, 2019.
doi:10.3928/24748307-20191025-01
e23HLRP: Health Literacy Research and Practice • Vol. 4, No. 1, 2020
Study Selection and Data Extraction Covidence, an Internet-based software platform that
streamlines the production of systematic reviews, was used in the study selection and data extraction process. Our initial database search yielded a total of 900 studies, of which 169 duplicates were removed. To enhance the rigor of the system-atic review process, two authors (J.C. and S.D.) independently screened all abstracts and titles for relevance to empirical testing of HL models and frameworks. All conflicts and dis-crepancies were discussed and resolved through face-to-face group discussions. A total of 676 articles were excluded for nonrelevance to our study’s purpose. The full texts of 55 rele-vant abstracts were then reviewed independently by the study authors (J.C., S.D., M.C., and H.H.) using the study’s inclu-sion and exclusion criteria. We excluded 39 studies for the following reasons: (a) studies did not include or propose an HL framework (n = 27); (b) no empirical data were presented (n = 6); (c) studies did not address the impact of HL on health behavior (n = 3); (d) studies do not include HL as a study vari-able (n = 1), (e) no full text was available (n = 1); and (f) it was a podium presentation (n = 1). Using the same search terms (Table A), an additional database search was conducted in March 2019 for studies published since November 2018. Af-ter removing duplicates, 90 titles with abstracts were reviewed for relevance. Two study authors (J.C. and S.D.) independently reviewed 17 full texts using the study’s inclusion and exclusion criteria. A total of 13 articles were excluded for the following reasons: (a) studies did not propose a HL framework (n = 9); (b); studies did not address the impact of HL on health be-havior (n = 2); (c) studies were not written in English (n = 1); and (d) no empirical data were presented (n = 1). Figure 1 provides a detailed description of the selection process. Two study authors (J.C. and S.D.) extracted data from a total of 20 studies for this systematic review. To enhance interrater reli-ability and the accuracy of information presented, the authors compared key findings and other relevant data, and discrep-ancies were resolved.
Quality AssessmentThe Joanna Briggs Checklist was the appraisal tool used in
the quality assessment of all studies included in this review (Joanna Briggs Institute, 2018). The checklist is a series of questions that authors of observational studies are expected to answer to enhance a study’s methodological rigor. Spe-cifically, each study’s quality was assessed using seven items addressing selection bias, measurement bias, confounding variables, and appropriate use of statistical analyses (Joanna Briggs Institute, 2018). Studies were assigned a score of 1 for items that were adequately described, and a score of 0 for
items that were not addressed by the authors. Total scores for each study ranged from 0 to 7, with a higher total score at-tributed to higher quality rating. Studies with a total score less than 3 were rated as low quality, studies with total scores ranging from 3 to 4 were rated as medium quality, and stud-ies with total scores of 5 or higher were rated as high quality. Findings from the quality assessments were used to critique the overall methodological strengths and weaknesses of the studies
Results of the quality assessment process are shown in Table 1. All of the studies adequately described inclusion cri-teria and the characteristics of study participants. There was adequate discussion of items addressing selection bias in most studies included in the review: description of inclusion crite-ria (n = 19), and description of study characteristics (n = 15). Most studies included in the review inadequately addressed measurement bias: identification of confounders (n = 8), use of valid and reliable measurement of outcome (n = 6), and strategy addressing confounders (n = 8). The measurement of outcomes in more than 75% (n = 15) of studies was based on self-reports. Overall, most studies had high (n = 10) to medium (n = 6) quality ratings. Only four studies received a low-quality rating.
RESULTS Overview of Studies Included
The characteristics of all 20 studies included in this review are detailed in Table 2. Most of the studies were published in the United States (n = 13) (Brega et al., 2012; Chen, 2014; Cho, Lee, Arozullah, & Crittenden, 2008; Como, 2018; Crook et al., 2016; Guo et al., 2014; Hickman, Clochesy, & Alaamri, 2016; Jin, Lee, & Dia, 2019; Osborn, Cavanaugh, et al., 2011; Osborn, Cavanaugh, Wallston, & Rothman, 2010; Osborn, Paasche-Orlow, Bailey, & Wolf, 2011; Schillinger, Barton, Kar-ter, Wang, & Adler, 2006; Soones et al., 2017), with the remain-ing studies published in China (n = 2) (Sun et al., 2013; Zou, Chen, Fang, Zhang, & Fan, 2017), Taiwan (n = 2) (Hou et al., 2018; Y. J. Lee et al., 2016), Thailand (n = 2) (Intarakamhang & Intarakamhang, 2017; Photharos, Wacharasin, & Duongpaeng, 2018), and South Korea (n = 1) (E. H. Lee, Lee, & Moon, 2016). Study designs included cross-sectional (n = 19) (Brega et al., 2012; Chen, 2014; Cho et al., 2008; Como, 2018; Crook et al., 2016; Guo et al., 2014; Hickman et al., 2016; Hou et al., 2018; Jin et al., 2019; E. H. Lee et al., 2016; Y. J. Lee et al., 2016; Osborn, Cavanaugh, et al., 2011; Osborn et al., 2010; Osborn, Paasche-Orlow, et al., 2011; Photharos et al., 2018; Schillinger et al., 2006; Soones et al., 2017; Sun et al., 2013; Zou et al., 2017) and mixed methods (n = 1) (Intarakamhang & Intarakamhang, 2017). Sample sizes ranged from 62 to 2,594,
e24 HLRP: Health Literacy Research and Practice • Vol. 4, No. 1, 2020
with only seven studies calculating sample sizes a priori (Chen, 2014; Como, 2018; Hou et al., 2018; Intarakamhang & Intarakamhang, 2017; E. H. Lee et al., 2016; Y. J. Lee et al., 2016; Photharos et al., 2018).
Study participants in all the U.S.-based studies were pre-dominately female, urban dwellers, adults (age range, 18-75 years) with less than a high school education. In addition, the samples in U.S.-based studies were more than 50% ethnic/ra-cial minority groups (i.e., Black, Hispanic, Native American/Alaska Native) except for three studies that included more than 60% White participants (Chen, 2014; Guo et al., 2014; Osborn, Cavanaugh, et al., 2011). One U.S.-based study (Crook et al., 2016), however, did not report the race or ethnicity of study participants. All studies in this systematic review included adult participants (age >18 years) except for one study in Thai-land that used national data from school-age children between ages 9 and 14 years (Intarakamhang & Intarakamhang, 2017).
All studies measured one or more subdimensions of HL. Eight studies measured print literacy (Brega et al., 2012; Chen, 2014; Cho et al., 2008; Como, 2018; Jin et al., 2019; Osborn,
Cavanaugh, et al., 2011; Osborn et al., 2010; Sun et al., 2013), four studies measured numeracy (Brega et al., 2012; Como, 2018; Crook et al., 2016; Soones et al., 2017), and four stud-ies measured functional literacy (Hou et al., 2018; Osborn, Paasche-Orlow, et al., 2011; Photharos et al., 2018; Schillinger et al., 2006). Three studies addressed disease-specific HL: dia-betes (Osborn, Cavanaugh, et al., 2011; Osborn et al., 2010) and heart failure (Zou et al., 2017). All studies used an exist-ing and well-validated HL measure except one study in Thai-land that developed and validated the Health Literacy Scale for Thai overweight children (Chronbach’s alpha: 0.70) (Inta-rakamhang & Intarakamhang, 2017). The most common HL measures were the Rapid Estimate of Adult Literacy in Medi-cine (REALM) (Osborn, Cavanaugh, et al., 2011; Osborn et al., 2010), Short Test of Functional Health Literacy in Adults (S-TOFHLA) (Cho et al., 2008; Como, 2018; Soones et al., 2017), and Test of Functional Health Literacy in Adults (TOF-HLA) (Osborn, Paasche-Orlow, et al., 2011; Schillinger et al., 2006). Additional measures included the Health Literacy Scale, Brief Health Literacy Tool, the Mandarin version of
Figure 1. Study selection process. HL = health literacy.
e25HLRP: Health Literacy Research and Practice • Vol. 4, No. 1, 2020
TAB
LE 1
Qua
lity
Ass
essm
ents
of S
tudi
es
Refe
renc
eDe
scrip
tion o
f In
clusio
n Crit
eria
Desc
riptio
n of
Stud
y Ch
arac
teris
tic
Stan
dard
Cr
iteria
Use
d for
M
easu
rem
ent o
f th
e Con
ditio
nId
entifi
catio
n of
Conf
ound
ers
Stra
tegi
es fo
r Ad
dres
sing
Conf
ound
ing
Fact
ors
Valid
and R
elia
ble
Mea
sure
men
t of
Outco
me
Stat
istica
l An
alys
esOv
eral
l Qu
ality
Breg
a et
al.
(201
2)
11
11
11
1H
igh
Chen
et a
l. (2
014)
1
11
00
01
Med
ium
Cho,
Lee
, Aro
zulla
h, &
Crit
tend
en (2
008)
1
10
00
01
Med
ium
Com
o (2
018)
11
11
11
0H
igh
Croo
k, S
teph
ens,
Past
orek
, M
acke
rt, &
D
onov
an (2
016)
1
00
00
01
Low
Hou
et a
l. (2
014)
1
00
11
01
Med
ium
Hic
kman
, Clo
ches
y, &
Ala
amri
(201
6)1
11
00
00
Med
ium
Huo
et a
l. (2
018)
11
10
01
1H
igh
Inta
raka
mha
ng &
Inta
raka
mha
ng (2
017)
1
00
00
01
Low
Jin,
Lee
, & D
ia (2
019)
11
01
10
1H
igh
E.H
. Lee
, Lee
, & M
oon
(201
6)
11
00
00
1M
ediu
m
Y.J.
Lee
et a
l. (2
016)
11
10
01
1H
igh
Osb
orn,
Cav
anau
gh, e
t al.
(201
1)
00
00
00
1Lo
w
Osb
orn,
Cav
anau
gh, W
alls
ton,
&
Roth
man
(201
0)
11
10
01
1H
igh
Osb
orn,
Paa
sche
-Orlo
w, B
aile
y, &
Wol
f (2
011)
1
10
00
01
Med
ium
Phot
haro
s, W
acha
rasi
n, &
Duo
ngpa
eng
(201
8)1
01
00
00
Low
Schi
lling
er, B
arto
n, K
arte
r, W
ang,
& A
dler
(2
006)
1
11
11
11
Hig
h
Soon
es e
t al.
(201
7)
11
11
10
0H
igh
Sun
et a
l. (2
013)
1
10
11
01
Hig
h
Zou,
Che
n, F
ang,
Zha
ng, &
Fan
(201
7)
11
01
10
1H
igh
Not
e. 1
= cl
early
disc
usse
d; 0
= n
ot d
iscus
sed.
e26 HLRP: Health Literacy Research and Practice • Vol. 4, No. 1, 2020
TAB
LE 2
Stud
y Ch
arac
teri
stic
s an
d M
ain
Find
ings
Refe
renc
eSt
udy P
urpo
seSe
tting
/Sam
ple
HL D
omai
ns (H
L Mea
sure
)M
ain R
esul
tsBr
ega
et a
l. (2
012)
To d
evel
op a
theo
retic
al fr
amew
ork
and
test
the
mec
hani
sms
thro
ugh
whi
ch H
L is
ass
ocia
ted
with
out
com
es,
focu
sing
on
the
rela
tions
hip
betw
een
HL
and
glyc
emic
con
trol
am
ong
Nat
ive
Am
eric
ans
and
Ala
ska
Nat
ives
w
ith d
iabe
tes
2,59
4 ru
ral-d
wel
ling
adul
ts w
ith d
iabe
tes
Coun
try:
Uni
ted
Stat
es
Age:
18-
65 y
; Inc
ome:
<$1
0,00
0; 9
3% le
ss
than
col
lege
gra
duat
es
Ethn
icity
: 100
% N
ativ
e A
mer
ican
and
A
lask
a N
ativ
e
HL
leve
ls: n
ot s
tate
d
Prin
t lite
racy
(TO
HFL
A)
Num
erac
y (n
ot s
tate
d)
Hig
h H
L as
soci
ated
with
dec
reas
ed H
bA1c
le
vels
(B =
–0.
070,
p <
.05)
. Sig
nific
ant a
ssoc
ia-
tion
betw
een
high
HL
and
heal
thy
beha
vior
s (fr
eque
nt h
ealth
y di
et, m
onito
r blo
od s
ugar
). Se
lf-m
onito
ring
of b
lood
sug
ar m
edia
tes
HL
and
glyc
emic
con
trol
(B =
–0.
028,
p <
.05)
. Dia
bete
s kn
owle
dge
is a
sig
nific
ant m
edia
tor b
etw
een
HL
and
glyc
emic
con
trol
(b
eta
= –0
.134
, p <
.05)
Chen
et a
l. (2
014)
Te
st a
mod
el to
exp
lain
the
rela
tion-
ship
s be
twee
n H
L, h
eart
failu
re k
now
l-ed
ge, s
elf-
effica
cy, a
nd s
elf-
care
63 u
rban
-dw
ellin
g ad
ults
with
hea
rt fa
ilure
Coun
try:
Uni
ted
Stat
es
Mea
n ag
e: 6
2.1
y; m
ean
year
s of
edu
ca-
tion:
13.
7 y;
fem
ale:
47.
6%
Ethn
icity
: 86%
Whi
te; 1
1% B
lack
, 2%
H
ispa
nic/
Latin
o, 2
% N
ativ
e A
mer
ican
/A
lask
a N
ativ
e
HL
leve
ls: i
nade
quat
e 16
%, m
argi
nal 1
6%,
adeq
uate
, 68%
Prin
t lite
racy
(s-T
OH
FLA
)D
irect
rela
tions
hip
betw
een
HL
and
hear
t fai
lure
kn
owle
dge
(bet
a =
0.46
, p <
.05)
. Hea
rt fa
ilure
kn
owle
dge
and
self-
effica
cy d
o no
t med
iate
th
e re
latio
nshi
p be
twee
n H
L an
d he
art f
ailu
re
self-
care
Cho,
Lee
, Aro
zulla
h,
& C
ritte
nden
(200
8)Ex
plor
e in
term
edia
te fa
ctor
s th
at li
nk
HL
to h
ealth
sta
tus
and
use
of h
ealth
se
rvic
es (E
D v
isit,
hos
pita
lizat
ion)
489
urba
n-dw
ellin
g ad
ults
with
Med
icar
e
Coun
try:
Uni
ted
Stat
es
Age:
>65
y
Aver
age
educ
atio
n le
vel:
HS
grad
uate
; fe
mal
e: 7
8.7%
Ethn
icity
: 59.
1% B
lack
HL
leve
ls: i
nade
quat
e 51
%
Prin
t lite
racy
/com
pre-
hens
ion
(s-T
OFH
LA)
Posit
ive,
dire
ct re
latio
nshi
ps b
etw
een
HL,
hea
lth
stat
us (b
eta
= 0.
48, p
< .0
5); d
irect
neg
ativ
e re
latio
nshi
p be
twee
n H
L an
d ho
spita
lizat
ion
and
ED v
isits
resp
ectiv
ely
(bet
a =
–0.2
4 an
d be
ta =
–0
.35)
. Com
plia
nce
and
dise
ase
know
ledg
e ar
e no
t sig
nific
ant m
edia
tors
bet
wee
n H
L an
d ou
t-co
mes
(hea
lth st
atus
, hos
pita
lizat
ions
, ED
visi
t). H
L m
edia
tes e
duca
tiona
l att
ainm
ent a
nd o
utco
mes
(h
ealth
stat
us, h
ospi
taliz
atio
n an
d ED
visi
ts)
e27HLRP: Health Literacy Research and Practice • Vol. 4, No. 1, 2020
TAB
LE 2
(con
tinue
d)
Stud
y Ch
arac
teri
stic
s an
d M
ain
Find
ings
Refe
renc
eSt
udy P
urpo
seSe
tting
/Sam
ple
HL D
omai
ns (H
L Mea
sure
)M
ain R
esul
tsCo
mo
(201
8)In
vest
igat
e w
heth
er H
L, s
elf-
effica
cy,
and
med
icat
ion
adhe
renc
e ca
n ex
-pl
ain
or p
redi
ct th
e va
rianc
e in
hea
lth
outc
omes
(per
ceiv
ed p
hysi
cal o
r m
enta
l hea
lth s
tatu
s) in
per
sons
with
ch
roni
c he
art f
ailu
re
175
urba
n-dw
ellin
g ad
ults
dia
gnos
ed w
ith
hear
t fai
lure
and
att
endi
ng c
ardi
olog
y he
alth
cen
ters
in N
ew Y
ork,
NY
Coun
try:
Uni
ted
Stat
es
Mea
n ag
e: 7
3 y;
mal
e: 6
6.9%
Ethn
icity
: 11.
4% B
lack
, 83.
4% W
hite
, 4%
H
ispa
nic/
Latin
o, 0
.6%
Asi
an, 0
.6%
Nat
ive
Am
eric
an
HL
leve
ls: i
nade
quat
e 38
.3%
, ad
equa
te: 4
5.7%
Prin
t lite
racy
/com
pre-
hens
ion
(s-T
OFH
LA)
Num
erac
y (s
-TO
FHLA
)
Self-
effica
cy is
ass
ocia
ted
with
phy
sica
l hea
lth
stat
us (p
= .0
02).
Educ
atio
n, in
com
e, m
arita
l sta
-tu
s (w
idow
), ill
ness
sev
erity
indi
cato
rs (n
umbe
r of
med
icat
ion/
days
, fre
quen
cy/d
ay) a
re s
igni
fi-ca
nt p
redi
ctor
s of
phy
sica
l hea
lth s
tatu
s
(p <
.001
). N
o as
soci
atio
ns b
etw
een
HL,
med
ica-
tion
adhe
renc
e, a
nd p
hysi
cal h
ealth
sta
tus.
Med
icat
ion
adhe
renc
e do
es n
ot m
edia
te th
e re
latio
nshi
p be
twee
n H
L an
d ph
ysic
al h
ealth
sta
-tu
s. M
edic
atio
n ad
here
nce
(p <
.001
), nu
mer
acy
(p
= .0
29),
and
read
ing
com
preh
ensi
on (p
= .0
49)
are
asso
ciat
ed w
ith m
enta
l hea
lth s
tatu
s. M
edi-
catio
n ad
here
nce
does
not
med
iate
the
rela
tion-
ship
bet
wee
n H
L an
d m
enta
l hea
lth s
tatu
s
Croo
k, S
teph
ens,
Past
orek
, M
acke
rt,
& D
onov
an (2
016)
Expl
ain
the
asso
ciat
ions
am
ong
per-
ceiv
ed h
ealth
kno
wle
dge,
info
rmat
ion
shar
ing,
att
itude
s, be
havi
ors,
and
HL
180
Engl
ish-
spea
king
adu
lts re
crui
ted
from
a c
entr
al Te
xas
acut
e an
d pr
even
tive
care
cen
ter
Coun
try:
Uni
ted
Stat
es
Age:
18-
75 y
; mea
n ag
e 38
.7 y
+13
.2;
fem
ale:
69%
Educ
atio
n: n
ot re
port
ed
Ethn
icity
: not
repo
rted
HL
leve
ls: n
ot s
tate
d
Num
erac
y (N
ewes
t Vita
l Si
gn)
Inte
rnet
use
pos
itive
ly a
ssoc
iate
d w
ith H
L le
vel (
beta
= 0
.55,
p <
.001
). A
ttitu
de to
war
d in
form
atio
n m
edia
tes
rela
tions
hip
betw
een
HL
and
beha
vior
al in
tent
ion
(p <
.001
) as
wel
l as
the
rela
tions
hip
betw
een
HL
and
info
rmat
ion
shar
ing
(p <
.001
). N
o si
gnifi
cant
ass
ocia
tion
be-
twee
n pe
rcei
ved
heal
thy
hear
t kno
wle
dge
and
HL
(bet
a =
0.14
, p =
.14)
. Hig
h pe
rcei
ved
heal
thy
hear
t kno
wle
dge
asso
ciat
ed w
ith p
ositi
ve a
t-tit
udes
tow
ard
heal
th in
form
atio
n (b
eta
= 0.
13,
p =
.03)
and
low
er p
erce
ptio
n of
info
rmat
ion
over
load
(bet
a =
–0.1
4, p
= .0
1)
Guo
et a
l. (2
014)
Ex
amin
e eff
ects
of H
L, p
atie
nt-d
entis
t co
mm
unic
atio
n, d
enta
l car
e pa
tter
ns
on s
elf-r
ated
ora
l hea
lth s
tatu
s
1,79
9 ru
ral-d
wel
ling
adul
ts in
Flo
rida
Coun
try:
Uni
ted
Stat
es
Mea
n ag
e: 5
2.9
y; H
S gr
adua
te o
r low
er:
53%
; fem
ale:
53%
; Et
hnic
ity: 3
4% B
lack
, 66
% W
hite
HL
leve
ls: l
ow 3
1%, h
igh
69%
Nav
igat
ion
(Che
w’s
3-Ite
m H
L sc
ale)
Sign
ifica
nt d
irect
ass
ocia
tion
betw
een
HL
and
self-
rate
d or
al h
ealth
(bet
a =
0.09
1, p
< .0
01).
Patie
nt-d
entis
t com
mun
icat
ion
and
dent
al c
are
patt
erns
med
iate
the
rela
tions
hip
betw
een
HL
and
self-
rate
d or
al h
ealth
(bet
a =
0.00
3, p
= .0
1)
e28 HLRP: Health Literacy Research and Practice • Vol. 4, No. 1, 2020
TAB
LE 2
(con
tinue
d)
Stud
y Ch
arac
teri
stic
s an
d M
ain
Find
ings
Refe
renc
eSt
udy P
urpo
seSe
tting
/Sam
ple
HL D
omai
ns (H
L Mea
sure
)M
ain R
esul
tsH
ickm
an, C
loch
esy,
&
Ala
amri
(201
6)Ex
amin
e pr
edic
tive
asso
ciat
ions
am
ong
HL,
qua
lity
of th
e pr
ovid
er
inte
ract
ion,
per
ceiv
ed c
omm
unic
atio
n sk
ills,
and
beha
vior
al a
ctiv
atio
n on
bl
ood
pres
sure
con
trol
109
Engl
ish-
spea
king
, urb
an-d
wel
ling
adul
ts w
ith h
yper
tens
ion
in N
orth
east
O
hio
Coun
try:
Uni
ted
Stat
es
Mea
n ag
e: 5
2 y
(±11
); ed
ucat
ion:
not
re
port
ed; F
emal
e: 5
9%; I
ncom
e: n
ot
repo
rted
Ethn
icity
: 68%
Bla
ck, 2
4% W
hite
, 5%
H
ispa
nic,
3%
Mul
tirac
ial
HL
leve
ls: n
ot s
tate
d
Func
tiona
l (Ch
ew’s
1-ite
m s
cale
)H
L (b
eta
= 0.
15, p
< .1
0), q
ualit
y of
pro
vide
r in
tera
ctio
n (b
eta
= 0.
38, p
< .0
1), p
erce
ived
com
-m
unic
atio
n sk
ills
(bet
a =
0.22
, p <
.05)
dire
ctly
as
soci
ated
with
beh
avio
ral a
ctiv
atio
n. P
rovi
der
inte
ract
ion
(bet
a =
0.27
, p <
.001
) and
beh
avio
ral
activ
atio
n (b
eta
= –0
.29,
p <
.001
) are
dire
ctly
as
soci
ated
with
blo
od p
ress
ure
cont
rol
Hou
et a
l. (2
018)
To e
xam
ine
the
mec
hani
sms
and
com
plet
enes
s of
the
Inte
grat
ed M
odel
of
HL
511
adul
ts d
iagn
osed
with
bre
ast c
ance
r an
d at
tend
ing
brea
st s
urge
ry c
linic
s an
d te
achi
ng h
ospi
tals
Coun
try:
Tai
wan
Mea
n ag
e: 5
7.9
y; <
HS
grad
uate
: 31.
7%;
Mar
ried:
71.
6%; r
esid
ence
: 75%
urb
an
dwel
lers
; em
ploy
men
t: 44
% u
nem
ploy
ed;
aver
age
dura
tion
of c
ance
r dia
gnos
is: 4
3 m
onth
s
HL
leve
ls: i
nade
quat
e: 3
7.5%
; ade
quat
e:
62.5
%
Func
tiona
l, co
mpr
ehen
-si
on
(Man
darin
ver
sion
of
HLS
-EU
-Q)
Age
and
canc
er s
tage
are
inve
rsel
y re
late
d to
HL
(p <
.05)
. Ed
ucat
ion
(bet
a =
0.41
, p <
.05)
, can
cer
dura
tion
(bet
a =
0.27
, p <
.05)
sig
nific
antly
as-
soci
ated
with
HL
Sign
ifica
nt a
ssoc
iati
ons
amon
g pa
tien
ts’ p
ar-
tici
pati
on in
sha
red
deci
sion
-mak
ing
(b
eta
= 0
.46,
p <
.05)
, sel
f-ra
ted
heal
th s
tatu
s
(bet
a =
0.2
7, p
< .0
5) a
nd H
L
No
asso
ciat
ions
am
ong
mar
ital s
tatu
s, pl
ace
of
resi
denc
e, o
ccup
atio
n, a
nd H
L
Inta
raka
mha
ng &
In
tara
kam
hang
(2
017)
Dev
elop
a s
cale
for e
valu
atin
g H
L le
vel
of o
verw
eigh
t chi
ldre
n in
Tha
iland
an
d de
velo
p a
mod
el o
f hea
lth b
ehav
-io
r to
prev
ent o
besi
ty
2,00
0 po
pula
tion-
base
d sa
mpl
e of
urb
an
and
prov
inci
al T
hai s
tude
nts
Coun
try:
Tha
iland
Age:
9-1
4 y;
edu
catio
n: n
ot re
port
ed; s
ex:
not r
epor
ted;
inco
me:
not
repo
rted
Ethn
icity
: 100
% A
sian
HL
leve
ls: n
ot s
tate
d
Med
ia, f
unct
iona
l, na
vi-
gatio
n (H
L sc
ale
for o
ver-
wei
ght T
hai c
hild
rena
)
Dire
ct e
ffect
of c
ritic
al s
kills
(med
ia li
tera
cy a
nd
mak
ing
appr
opria
te h
ealth
-rel
ated
dec
isio
n) o
n ob
esity
pre
vent
ive
beha
vior
s (e
atin
g, e
xerc
ise
and
emot
iona
l beh
avio
rs) (
beta
= 0
.55,
p <
.05)
Basi
c in
telli
genc
e sk
ills
(hea
lth k
now
ledg
e,
acce
ssin
g in
form
atio
n an
d se
rvic
es) d
irect
ly
rela
ted
to in
tera
ctiv
e sk
ills
(com
mun
icat
ion
and
man
agin
g he
alth
con
ditio
ns) (
beta
= 0
.76,
p
< .0
5)
Dire
ct re
latio
nshi
p be
twee
n in
tera
ctiv
e sk
ills
and
criti
cal s
kills
(bet
a =
0.97
, p <
.05)
e29HLRP: Health Literacy Research and Practice • Vol. 4, No. 1, 2020
TAB
LE 2
(con
tinue
d)
Stud
y Ch
arac
teri
stic
s an
d M
ain
Find
ings
Refe
renc
eSt
udy P
urpo
seSe
tting
/Sam
ple
HL D
omai
ns (H
L Mea
sure
)M
ain R
esul
tsJi
n, L
ee, &
Dia
(201
9)Ex
amin
e hy
poth
etic
al p
athw
ays
thro
ugh
whi
ch o
nlin
e he
alth
in
form
atio
n-se
ekin
g be
havi
ors
(usi
ng
emai
ls to
com
mun
icat
e w
ith p
rovi
d-er
s, vi
sit s
ocia
l net
wor
king
site
to re
ad
and
shar
e m
edic
al to
pics
) infl
uenc
e H
L, w
hich
, in
turn
, lea
ds to
col
orec
tal
canc
er s
cree
ning
am
ong
Kore
an
Am
eric
ans
433
Kore
an A
mer
ican
adu
lts li
ving
in th
e so
uthe
aste
rn U
nite
d St
ates
Coun
try:
Uni
ted
Stat
es
Mea
n ag
e: 5
7.6
y, fe
mal
e: 6
0.8%
; fam
ily
hist
ory
of c
ance
r: 54
.6%
; no
pers
onal
hi
stor
y of
can
cer:
85.4
%; e
duca
tion:
not
re
port
ed
HL
leve
ls: n
ot s
tate
d
Prin
t lite
racy
, com
pre-
hens
ion
(Brie
f HL
Scre
en-
ing
Tool
)
Onl
ine
heal
th in
form
atio
n se
ekin
g be
havi
ors
asso
ciat
ed w
ith H
L (b
eta
= 0.
146,
p <
.001
) and
in
form
atio
n ov
erlo
ad (b
eta
= 0.
179,
p <
.01)
Info
rmat
ion
over
load
inve
rsel
y as
soci
ated
with
H
L (b
eta
= –0
.242
, p <
.001
). D
ecis
iona
l bal
ance
as
soci
ated
with
HL
(bet
a =
0.12
4, p
< .0
5), f
ecal
oc
cult
bloo
d te
st (b
eta
= 0.
161,
p <
.05)
and
si
gmoi
dosc
opy
upta
ke (b
eta
= 0.
169,
p <
.01)
HL
not s
igni
fican
tly a
ssoc
iate
d w
ith fe
cal o
ccul
t bl
ood
test
, sig
moi
dosc
opy,
and
col
onos
copy
up
take
HL
does
not
med
iate
the
rela
tions
hip
betw
een
onlin
e in
form
atio
n se
ekin
g an
d co
lore
ctal
ca
ncer
scr
eeni
ng
E.H
. Lee
, Lee
, &
Moo
n (2
016)
Expl
ore
the
rela
tions
hips
am
ong
HL,
se
lf-effi
cacy
, sel
f-ca
re a
ctiv
ities
, and
H
RQO
L
459
Kore
an-s
peak
ing
adul
ts d
iagn
osed
w
ith ty
pe 2
dia
bete
s, re
crui
ted
from
uni
-ve
rsity
hos
pita
ls in
Sou
th K
orea
bet
wee
n 20
14 a
nd 2
015
Coun
try:
Sou
th K
orea
Age:
20-
70 y
; mea
n ag
e 59
.6 y
(±10
.57)
; fe
mal
e: 6
0%; l
ess
than
HS
grad
uate
: 32%
; in
com
e: n
ot re
port
ed
HL
leve
ls: n
ot s
tate
d
Func
tiona
l (co
mm
unic
a-tio
n) (H
ealth
Lite
racy
Sc
ale)
Dire
ct e
ffect
of H
L on
sel
f-effi
cacy
(bet
a =
0.45
, p
< .0
01) a
nd s
elf-
care
act
iviti
es (b
eta
= .2
09,
p <
.001
). Se
lf-effi
cacy
med
iate
s re
latio
nshi
p be
twee
n H
L an
d se
lf-ca
re a
ctiv
ities
(bet
a =
0.29
9, p
= .0
05).
Self-
care
act
iviti
es a
re d
irect
ly
rela
ted
to H
RQO
L (b
eta
= 0.
399,
p <
.001
). N
o di
rect
effe
ct o
f HL
on H
RQO
L. S
elf-
care
act
iviti
es
med
iate
rela
tions
hip
betw
een
HL
and
HRQ
OL
(bet
a =
0.20
3, p
= .0
02).
Self-
care
act
iviti
es
med
iate
rela
tions
hip
betw
een
self-
effica
cy a
nd
HRQ
OL
(bet
a =
0.26
5, p
= 0
.004
)
Y.J.
Lee
et a
l. (2
016)
Valid
ate
a hy
poth
esiz
ed m
odel
ex
plor
ing
the
influ
enci
ng p
athw
ays
of
empo
wer
men
t per
cept
ions
, HL,
sel
f-effi
cacy
, and
sel
f-ca
re to
HbA
1c le
vels
am
ong
patie
nts
with
type
2 d
iabe
tes
295
pers
on c
onve
nien
ce s
ampl
e of
adu
lt pa
tient
s di
agno
sed
with
type
2 d
iabe
tes
>6 m
onth
s an
d at
tend
ing
endo
crin
e ou
t-pa
tient
clin
ics
in s
outh
ern
Taiw
an
Coun
try:
Tai
wan
Age:
20-
80 y
; mea
n ag
e: 5
8.2
y;
fem
ale:
42%
; les
s th
an H
S gr
adua
te: 3
7.3%
; In
com
e: 6
8% lo
w S
ES
HL
leve
ls: n
ot s
tate
d
Func
tiona
l (co
mm
unic
a-tio
n) (H
ealth
Lite
racy
Sc
ale)
Non
sign
ifica
nt a
ssoc
iatio
n be
twee
n ag
e an
d H
L, H
L an
d se
lf-ca
re b
ehav
iors
, em
pow
erm
ent
and
self-
effica
cy, e
mpo
wer
men
t and
sel
f-ca
re
beha
vior
s.
HL
med
iate
s re
latio
nshi
p be
twee
n em
pow
er-
men
t and
sel
f-effi
cacy
(bet
a =
0.39
, p <
.001
). Se
lf-effi
cacy
and
HL
also
med
iate
the
rela
tion-
ship
bet
wee
n se
lf-ca
re b
ehav
iors
and
em
pow
er-
men
t (be
ta =
0.2
6, p
< .0
01).
Self-
care
beh
avio
rs m
edia
tes
self-
effica
cy a
nd
glyc
emic
con
trol
(bet
a =
–.14
; p <
.05)
e30 HLRP: Health Literacy Research and Practice • Vol. 4, No. 1, 2020
TAB
LE 2
(con
tinue
d)
Stud
y Ch
arac
teri
stic
s an
d M
ain
Find
ings
Refe
renc
eSt
udy P
urpo
seSe
tting
/Sam
ple
HL D
omai
ns (H
L Mea
sure
)M
ain R
esul
tsO
sbor
n, C
avan
augh
, et
al.
(201
1)
Test
whe
ther
HL
and/
or n
umer
acy
are
rela
ted
to d
iabe
tes
med
icat
ion
adhe
renc
e an
d w
heth
er e
ither
fact
or
expl
aine
d ra
cial
diff
eren
ces
in a
dher
-en
ce to
dia
bete
s m
edic
atio
ns
383
Engl
ish
-pea
king
urb
an, r
ural
, and
su
burb
an d
wel
ling
adul
ts li
ving
in N
orth
Ca
rolin
a an
d Te
nnes
see
diag
nose
d w
ith
type
s 1
and
2 di
abet
es
Coun
try:
Uni
ted
Stat
es
Age:
18-
85 y
; Mea
n ag
e: 5
4 y;
fem
ale:
50%
; <H
S gr
adua
te: 4
4%; i
ncom
e >$
20,0
00:
56%
Et
hnic
ity: 3
5% B
lack
HL
leve
ls: n
ot s
tate
d
Dia
bete
s-re
late
d nu
mer
acy
(Dia
bete
s N
umer
acy
Test
)
Prin
t lite
racy
(REA
LM)
HL
does
not
med
iate
rela
tions
hip
betw
een
Blac
k ra
ce a
nd d
iabe
tes
med
icat
ion
adhe
renc
e. D
irect
ne
gativ
e as
soci
atio
n be
twee
n Bl
ack
race
and
HL
(bet
a =
–0.2
8, p
< .0
01).
Non
-sig
nific
ant a
ssoc
ia-
tion
betw
een
HL
and
med
icat
ion
adhe
renc
e (p
= .0
6). D
irect
ass
ocia
tion
betw
een
dura
tion
of d
iabe
tes
and
med
icat
ion
adhe
renc
e (b
eta
= 0.
13, p
< .0
1)
Osb
orn,
Cav
anau
gh,
Wal
lsto
n, &
Ro
thm
an (2
010)
Exam
ine
the
pred
icte
d pa
thw
ay
linki
ng H
L, n
umer
acy,
and
dia
bete
s se
lf-effi
cacy
to g
lyce
mic
con
trol
383
Engl
ish-
spea
king
urb
an, r
ural
, and
su
burb
an d
wel
ling
adul
ts li
ving
in N
orth
Ca
rolin
a an
d Te
nnes
see
diag
nose
d w
ith
Type
s 1
and
2 di
abet
es
Coun
try:
Uni
ted
Stat
es
Age:
18-
85 y
; mea
n ag
e: 5
4 y;
fem
ale:
50%
; >H
S ed
ucat
ion:
56%
; inc
ome
>$20
,000
: 56
%
Ethn
icity
: 35%
Bla
ck
HL
leve
ls: n
ot s
tate
d
Dia
bete
s-re
late
d nu
mer
acy
(Dia
bete
s N
umer
acy
Test
)
Prin
t lite
racy
(REA
LM)
Youn
ger a
ge (p
< .0
01),
insu
lin u
se (p
< .0
01),
incr
ease
d du
ratio
n of
dia
bete
s dia
gnos
is (p
< .0
1),
Blac
k ra
ce (p
< .0
1) a
re d
irect
ly a
ssoc
iate
d w
ith
high
er H
bA1c
leve
ls. G
reat
er se
lf-effi
cacy
ass
oci-
ated
with
low
er H
bA1c
leve
ls (r
= –0
.25,
p <
.001
). M
odel
acc
ount
ed fo
r 21%
var
iabi
lity
in H
bA1c
. N
o di
rect
rela
tions
hip
betw
een
HL
and
glyc
emic
co
ntro
l (H
bA1c
). Se
lf-effi
cacy
med
iate
s rel
atio
nshi
p be
twee
n ge
nera
l num
erac
y an
d gl
ycem
ic c
ontro
l (p
< 0
.05)
Osb
orn,
Paa
sche
-O
rlow
, Bai
ley,
& W
olf
(201
1)
Valid
ate
the
Paas
che-
Orlo
w a
nd W
olf
mod
el e
xam
inin
g m
echa
nism
s lin
king
H
L to
phy
sica
l act
ivity
and
sel
f- re
port
ed h
ealth
sta
tus
330
Engl
ish-
spea
king
adu
lts w
ith h
yper
-te
nsio
n re
crui
ted
from
clin
ics
acro
ss th
e U
nite
d St
ates
.
Coun
try:
Uni
ted
Stat
es
Mea
n ag
e: 5
3.6
y; fe
mal
e: 6
8%; <
HS
educ
a-tio
n: 7
0.7%
; une
mpl
oyed
: 66
%; u
nins
ured
: 44
%
Ethn
icity
: 79%
Bla
ck
HL
leve
ls: n
ot s
tate
d
Func
tiona
l lite
racy
(s
-TO
FHLA
)Lo
w e
duca
tion
(bet
a =
0.56
, p<
.001
), Bl
ack
race
(b
eta
= 0.
51, p
< .0
01),
olde
r age
(bet
a =
0.36
, p
< .0
01) d
irect
ly a
ssoc
iate
d w
ith lo
w H
L. H
igh
HL
asso
ciat
ed w
ith h
igh
know
ledg
e (b
eta
= 0.
22,
p <
.001
). Se
lf-effi
cacy
dire
ctly
rela
ted
with
he
alth
stat
us (b
eta
= 0.
17, p
< .0
1). N
o as
so-
ciat
ion
betw
een
self-
care
beh
avio
r and
hea
lth
stat
us. N
onsi
gnifi
cant
rela
tions
hip
betw
een
race
and
self-
effica
cy (b
eta
= 0.
10).
Kno
wle
dge
med
iate
s rel
atio
nshi
p be
twee
n H
L an
d se
lf-effi
cacy
(B =
0.0
45, p
< .0
01)
e31HLRP: Health Literacy Research and Practice • Vol. 4, No. 1, 2020
TAB
LE 2
(con
tinue
d)
Stud
y Ch
arac
teri
stic
s an
d M
ain
Find
ings
Refe
renc
eSt
udy P
urpo
seSe
tting
/Sam
ple
HL D
omai
ns (H
L Mea
sure
)M
ain R
esul
tsPh
otha
ros,
Wac
hara
-si
n, &
Duo
ngpa
eng
(201
8)
Dev
elop
and
test
the
caus
al re
latio
n-sh
ips
amon
g fa
mily
func
tioni
ng, H
L,
chro
nic
kidn
ey d
isea
se s
elf-
effica
cy,
illne
ss p
erce
ptio
ns, s
ocia
l sup
port
,and
se
lf-m
anag
emen
t beh
avio
rs a
mon
g pe
rson
s ex
perie
ncin
g ea
rly s
tage
s of
ch
roni
c ki
dney
dis
ease
275
adul
ts e
xper
ienc
ing
early
sta
ge
chro
nic
kidn
ey d
isea
se a
nd re
ceiv
ing
med
ical
trea
tmen
t
Coun
try:
Tha
iland
60%
mal
e; c
olle
ge e
duca
ted:
<68
%; f
amily
hi
stor
y of
chr
onic
kid
ney
dise
ase:
19%
; hi
stor
y of
hyp
erte
nsio
n: 3
6.7%
; his
tory
of
diab
etes
and
hyp
erte
nsio
n: 2
9.5%
HL
leve
ls: n
ot s
tate
d
Func
tiona
l, co
mm
uni-
catio
n, c
ritic
al li
tera
cy
(Hea
lth L
itera
cy S
cale
)
HL
(bet
a =
0.31
, p <
.0),
fam
ily fu
nctio
ning
(b
eta
= 0.
53, p
< .0
5) d
irect
ly a
ssoc
iate
d w
ith
chro
nic
kidn
ey d
iseas
e se
lf-effi
cacy
HL
(bet
a =
0.37
, p <
.05)
, soc
ial s
uppo
rt
(bet
a =
0.24
, p <
0.0
5) d
irect
ly a
ssoc
iate
d w
ith
self-
man
agem
ent b
ehav
iors
Fam
ily fu
nctio
ning
is re
late
d to
self-
man
agem
ent
beha
vior
s thr
ough
soci
al su
ppor
t (be
ta =
0.1
5,
p <
.05)
Chro
nic
kidn
ey d
isea
se s
elf-
effica
cy d
oes
not
med
iate
the
rela
tions
hips
am
ong
HL,
fam
ily
func
tioni
ng, a
nd s
elf-m
anag
emen
t beh
avio
rs
Schi
lling
er, B
arto
n,
Kart
er, W
ang,
&
Adle
r (20
06)
Expl
ore
the
path
way
link
ing
HL,
edu
-ca
tion,
and
gly
cem
ic c
ontr
ol39
5 ad
ults
with
dia
bete
s re
crui
ted
from
pr
imar
y ca
re c
linic
s be
twee
n Ju
ne a
nd
Dec
embe
r 200
0 in
San
Fra
ncis
co, C
A
Coun
try:
Uni
ted
Stat
es
Mea
n ag
e: 5
7.9
y; u
nins
ured
: 30.
6%; p
rima-
ry E
nglis
h sp
eake
rs: 5
1.7%
; <H
S gr
adua
te:
46.8
%; I
ncom
e <$
10,0
00: 6
8.8%
Ethn
icity
: 18.
5% A
sian
/Pac
ific
Isla
nder
, 25
.3%
Bla
ck, 1
3.9%
Whi
te, 4
2.3%
His
pani
c
HL
leve
ls: n
ot s
tate
d
Func
tiona
l lite
racy
(s
-TO
FHLA
)D
irect
rela
tions
hip
betw
een
educ
atio
nal a
ttai
n-m
ent a
nd H
L: H
S (b
eta
= 0.
24, p
< .0
5), s
ome
colle
ge (b
eta
= 0.
51, p
< .0
5). D
irect
ass
ocia
tion
betw
een
educ
atio
nal a
ttai
nmen
t and
gly
cem
ic
cont
rol:
HS
(bet
a =
–0.1
1, p
< .0
5), s
ome
colle
ge
(bet
a =
–0.0
6, p
< .0
5). H
L m
edia
tes
rela
tions
hip
betw
een
educ
atio
nal a
ttai
nmen
t (H
S ed
ucat
ion
(bet
a =
–0.0
4, p
< .0
5) a
nd s
ome
colle
ge e
duca
-tio
n (b
eta
= –0
.08,
p <
.05)
and
gly
cem
ic c
ontr
ol
Soon
es e
t al.
(201
7)
Des
crib
e ca
usal
pat
hway
link
ing
HL
to
med
icat
ion
adhe
renc
e43
3 ol
der a
dults
with
ast
hma
recr
uite
d fr
om h
ospi
tal a
nd c
omm
unity
pra
ctic
es in
N
ew Y
ork
and
Chic
ago
Coun
try:
Uni
ted
Stat
es
Age:
60-
70 y
; mea
n ag
e: 6
7 y;
fe
mal
e: 8
4%, <
HS
grad
uate
: 32.
6%; I
ncom
e <$
1,35
0/m
onth
: 54%
Ethn
icity
: 31%
Bla
ck, 3
9% H
ispa
nic
HL
leve
ls: a
dequ
ate:
64%
; lim
ited:
36%
Com
preh
ensi
on a
nd
num
erac
y (s
-TO
FHLA
)Co
ncer
ns a
bout
med
icat
ion
asso
ciat
ed w
ith lo
w
HL
(bet
a =
–0.1
54, p
<.0
01) a
nd lo
wer
med
ica-
tion
adhe
renc
e (b
eta
= –0
.2, p
< .0
04).
Low
HL
asso
ciat
ed w
ith lo
w m
edic
atio
n ad
here
nce
thro
ugh
med
icat
ion
conc
erns
(bet
a =
0.03
3,
p =
.002
). D
irect
rela
tions
hip
betw
een
HL
and
med
icat
ion
adhe
renc
e (b
eta
= 0.
123,
p <
.001
). Co
gniti
on d
irect
ly a
ssoc
iate
d w
ith H
L
(bet
a =
–0.7
67, p
< .0
01).
Non
sign
ifica
nt re
latio
n-sh
ips
betw
een
HL
and
med
icat
ion
nece
ssity
and
ill
ness
bel
iefs
and
med
icat
ion
adhe
renc
e
e32 HLRP: Health Literacy Research and Practice • Vol. 4, No. 1, 2020
TAB
LE 2
(con
tinue
d)
Stud
y Ch
arac
teri
stic
s an
d M
ain
Find
ings
Refe
renc
eSt
udy P
urpo
seSe
tting
/Sam
ple
HL D
omai
ns (H
L Mea
sure
)M
ain R
esul
tsSu
n et
al.
(201
3)
Dev
elop
and
val
idat
e a
HL
mod
el to
ex
plai
n th
e de
term
inan
ts o
f HL
and
the
asso
ciat
ions
bet
wee
n H
L an
d he
alth
beh
avio
rs
3,22
2 ci
ty-d
wel
ling
Chin
ese
adul
t re
side
nts
Coun
try:
Chi
na
Age:
16-
81 y
; mea
n ag
e: 3
3.8
y; <
HS
grad
u-at
e: 3
8.4%
; inc
ome
<3,0
00 Y
uan
(~$4
38):
83.2
%
Ethn
icity
: 100
% A
sian
HL
leve
ls: n
ot s
tate
d
Prin
t lite
racy
, num
erac
y (S
kill-
base
d H
L to
ol)a
Educ
atio
n ha
s po
sitiv
e an
d di
rect
effe
ct o
n pr
ior
know
ledg
e of
infe
ctio
us re
spira
tory
dis
ease
s (b
eta
= 0.
324,
p <
.01)
and
HL
(bet
a =
0.34
6)
HL
dire
ctly
rela
ted
to h
ealth
beh
avio
r (be
ta =
0.
101)
. Age
dire
ctly
ass
ocia
ted
with
hea
lth st
atus
(b
eta
= 0.
107)
Zou,
Che
n, F
ang,
Zh
ang,
& F
an (2
017)
Ex
plor
e fa
ctor
s as
soci
ated
with
sel
f-ca
re b
ehav
iors
and
exa
min
e m
edia
t-in
g ro
le o
f sel
f-ca
re c
onfid
ence
321
adul
ts w
ith c
hron
ic h
eart
failu
re
recr
uite
d fr
om c
ardi
ovas
cula
r uni
ts in
Sh
ando
ng, C
hina
Coun
try:
Chi
na
Mea
n ag
e: 6
4 y;
fem
ale:
49%
; <H
S gr
adu-
ate:
65.
1%; u
nem
ploy
ed: 5
9.2%
; inc
ome
<1,0
00 Y
uan
(~$1
55):
27.4
%
Ethn
icity
: 100
% A
sian
HL
leve
ls: n
ot s
tate
d
Func
tiona
l Lite
racy
(Chi
-ne
se v
ersi
on o
f Hea
lth
Lite
racy
Sca
le fo
r pat
ient
s w
ith C
hron
ic D
isea
se)
Func
tiona
l cap
acity
(bet
a =
0.15
5, p
< .0
1) a
nd
know
ledg
e (b
eta
= 0.
321,
p <
.01)
dire
ctly
ass
oci-
ated
with
self-
care
man
agem
ent.
HL
(bet
a =
0.04
3,
p <
.01)
and
soci
al su
ppor
t (be
ta =
0.1
46, p
< .0
1)
are
dire
ctly
ass
ocia
ted
with
self-
care
mai
nten
ance
. Se
lf-ca
re c
onfid
ence
is d
irect
ly a
ssoc
iate
d w
ith
both
self-
care
mai
nten
ance
(bet
a =
0.12
3, p
< .0
5)
and
man
agem
ent (
beta
= .3
09, p
< .0
1). A
ge
(bet
a =
0.19
4, p
< .0
1) a
nd h
ealth
failu
re d
urat
ion
(b
eta
= 0.
105,
p <
.05)
are
sign
ifica
ntly
ass
ocia
ted
with
self-
care
mai
nten
ance
. Sel
f-car
e co
nfide
nce
med
iate
s rel
atio
nshi
ps b
etw
een
know
ledg
e
(bet
a =
0.02
25, p
< .0
1), H
L (B
= 0
.162
, p <
.01)
, so
cial
supp
ort (
beta
= 0
.174
, p <
.01)
, and
self-
care
be
havi
ors
Not
e. D
esig
n of
all
the
stud
ies w
as cr
oss-
sect
iona
l exc
ept f
or th
e st
udy
by In
tara
kam
hang
& In
tara
kam
hang
(201
7), w
hich
use
d m
ixed
met
hods
. ED
= e
mer
genc
y de
part
men
t; H
bA1c
= h
emog
lobi
n A
1C; H
L =
heal
th li
tera
cy; H
LS-E
U-Q
: Eur
opea
n H
ealth
Li
tera
cy S
urve
y Q
uest
ionn
aire
; HRQ
OL
= he
alth
-rel
ated
qua
lity
of li
fe; H
S =
high
scho
ol; R
EALM
= R
apid
Est
imat
e of
Adu
lt Li
tera
cy in
Med
icin
e; S
ES =
soci
oeco
nom
ic st
atus
; S-T
OFH
LA =
Sho
rt T
est o
f Fun
ctio
nal H
ealth
Lite
racy
in A
dults
; TO
FHLA
= T
est o
f Fu
nctio
nal H
ealth
Lite
racy
in A
dults
. a H
ealth
lite
racy
inst
rum
ent d
esig
ned
for p
urpo
ses o
f the
stud
y.
e33HLRP: Health Literacy Research and Practice • Vol. 4, No. 1, 2020
the European Health Literacy Survey Questionnaire, and the Chinese Version of Health Literacy Scale for Patients with Chronic Disease (E. H. Lee et al., 2016; Y. J. Lee et al., 2016; Zou et al., 2017), which were mostly used in international studies (Taiwan, South Korea, Thailand, and China) to assess functional HL in the context of breast cancer, chronic kidney disease, diabetes, and heart failure management. Similarly, two studies (Guo et al., 2014; Hickman et al., 2016) conduct-ed in the U.S. across ethnically diverse samples (predomi-nantly Black, non-Hispanic middle-aged women) assessed functional literacy using Chew’s 3-item scale and 1-item scale (Chew et al., 2008).
Antecedents and Outcomes of HLTable 3 details the antecedents, mediators, moderators, and
outcomes of HL as outlined in the studies. All but four studies identified demographics and psychosocial factors as the most common antecedent to HL (Hickman et al., 2016; Osborn et al., 2010; Photharos et al., 2018; Zou et al., 2017). The authors reported the following sociodemographic and medical charac-teristics: age, education, income, health insurance status, race/ethnicity (Brega et al., 2012; Chen, 2014; Cho et al., 2008; Como, 2018; Guo et al., 2014; Hou et al., 2018; Osborn, Paasche-Orlow, et al., 2011; Schillinger et al., 2006), general literacy and language (English proficiency) (Schillinger et al., 2006), marital status (Como, 2018; Y. J. Lee et al., 2016), Internet use (Crook et al., 2016; Jin et al., 2019), disease duration (Y. J. Lee et al., 2016), and cognition (Soones et al., 2017). Older age (Hou et al., 2018; Osborn, Paasche-Orlow, et al., 2011), low education (Os-born, Paasche-Orlow, et al., 2011), and Black race (Osborn, Cavanaugh, et al., 2011; Osborn, Paasche-Orlow, et al., 2011) were linked to low HL, whereas increased years of education (Schillinger et al., 2006; Sun et al., 2013) and Internet use (Crook et al., 2016; Jin et al., 2019) were linked to high HL; however, a study conducted in China with a sample of older adults with low-income (N = 295, mean age of 58 years) reported no asso-ciation between age and HL (Y. J. Lee et al., 2016). Psychosocial antecedents included perceived health knowledge and perceived knowledge (Crook et al., 2016; Y. J. Lee et al., 2016; Sun et al., 2013). A statistically significant association was reported among perceived empowerment, prior knowledge, and HL (Y. J. Lee et al., 2016; Sun et al., 2013). One study among a sample of pre-dominantly middle-aged (mean age, 38 years) women (69%) reported a nonstatistically significant association between per-ceived heart health knowledge and HL (Crook et al., 2016). The lack of association can be attributed to potential selection bias.
Studies addressed the following health behaviors and health outcomes: chronic disease self-management (n = 9) (Brega et al., 2012; Chen, 2014; Hickman et al., 2016; Y. J. Lee et al.,
2016; Osborn et al., 2010; Osborn, Paasche-Orlow, et al., 2011; Photharos et al., 2018; Schillinger et al., 2006; Zou et al., 2017), colorectal cancer screening (n = 1) (Jin et al., 2019), medication adherence (n = 2) (Osborn, Cavanaugh, et al., 2011; Soones et al., 2017), overall health status (n = 4) (Como, 2018; Hou et al., 2018; E. H. Lee et al., 2016; Sun et al., 2013), oral care (n = 1) (Guo et al., 2014), health information sharing (n = 1) (Crook et al., 2016), physical activity and eating behaviors (n = 1) (Intarakamhang & Intarakamhang, 2017), shared decision-making in relation to breast cancer care (n = 1) (Hou et al., 2018), and emergency department visits (n = 1) (Cho et al., 2008). These studies reported that HL leads to better self-care and medication adherence, improved health status, improved self-reported oral health, less frequent emergency depart-ment visits, shorter hospitalizations, and improved physical activity and healthy eating behaviors (Brega et al., 2012; Cho et al., 2008; Guo et al., 2014; Hou et al., 2018; Intarakamhang & Intarakamhang, 2017; Soones et al., 2017; Sun et al., 2013; Zou et al., 2017). However, HL did not affect information-sharing behaviors (Crook et al., 2016), patients’ participation in shared decision-making (Hou et al., 2018), and colorectal cancer screening (Jin et al., 2019). Six studies did not find a sig-nificant association between HL and reported health behaviors (physical activity, medication adherence, glycemic control) or health outcomes (self-rated health of patients with diabetes and chronic heart failure) (Como, 2018; Y. J. Lee et al., 2016; Osborn, Cavanaugh, et al., 2011; Osborn et al., 2010; Osborn, Paasche-Orlow, et al., 2011; Schillinger et al., 2006).
Pathways Linking HL and Health Behaviors/OutcomesAll but three studies assessed a number of variables as
possible mediators between HL and health behaviors/out-comes (Hou et al., 2018; Intarakamhang & Intarakamhang, 2017; Schillinger et al., 2006). Eight studies examined the mediating effect of self-efficacy on the relationship between HL and diabetes management, heart failure management, and general self-care (Como, 2018; Chen, 2014; E. H. Lee et al., 2016; Y. J. Lee et al., 2016; Osborn et al., 2010; Osborn, Paasche-Orlow et al., 2011; Photharos et al., 2018; Zou et al., 2017). Of the five studies that measured disease-specific (diabetes, heart failure, chronic kidney disease) self-efficacy (E. H. Lee et al., 2016; Y. J. Lee et al., 2016; Osborn et al., 2010; Photharos et al., 2018; Zou et al., 2017), four stud-ies found self-efficacy as a statistically significant mediator (E. H. Lee et al., 2016; Y. J. Lee et al., 2016; Osborn et al., 2010; Zou et al., 2017). However, only two studies (E. H. Lee et al., 2016; Y. J. Lee et al., 2016) controlled for possible demographic confounders (age, gender, education, marital status).
e34 HLRP: Health Literacy Research and Practice • Vol. 4, No. 1, 2020
TAB
LE 3
Theo
reti
cal F
ram
ewor
ks o
f Hea
lth
Lite
racy
Refe
renc
eHo
w Fr
amew
ork
Was
Info
rmed
Prop
osed
An
tece
dent
s to H
LPr
opos
ed M
ediat
ors a
nd M
oder
ator
sHy
poth
esis
Teste
dHe
alth
Beh
avio
rs/Ou
tcom
esFit
Indi
ces f
or Fi
nal
Mod
els
Breg
a et
al.
(201
2)
Not
sta
ted
Age,
gen
der,
in
com
e, e
duca
tion
Med
iato
rs: d
iabe
tes
know
ledg
e;
beha
vior
(hea
lthy
and
unhe
alth
y fo
od c
onsu
mpt
ion,
phy
sica
l act
ivity
, se
lf-m
onito
ring
bloo
d gl
ucos
e)
Mod
erat
ors:
non
e
Dia
bete
s-re
late
d kn
owle
dge
and
beha
vior
(hea
lthy
diet
, phy
sica
l ac
tivity
, sel
f-mon
itorin
g of
blo
od
suga
r) m
edia
te re
latio
nshi
p be
-tw
een
HL
and
glyc
emic
con
trol
Gly
cem
ic c
ontr
olX2
= 97
6.78
, df =
255
(p
not
repo
rted
) CF
I: 0
.85
RM
SEA
: 0.0
3 Ac
cept
able
fit
Chen
et a
l. (2
014)
O
rem
’s th
eory
of
sel
f-ca
re;
Band
ura’s
soc
ial
cogn
itive
theo
ry
Year
s of
form
al
educ
atio
nM
edia
tors
: kno
wle
dge;
sel
f-effi
cacy
Mod
erat
ors:
non
e
Form
al e
duca
tion
is a
ssoc
iate
d w
ith H
L an
d ha
s a
dire
ct e
ffect
on
hear
t fai
lure
kno
wle
dge.
Dire
ct
rela
tions
hip
amon
g H
L, h
ealth
fa
ilure
kno
wle
dge,
and
sel
f-effi
cacy
. H
eart
failu
re k
now
ledg
e m
edia
tes
rela
tions
hip
betw
een
HL
and
self-
effi
cacy
. Hea
rt fa
ilure
kno
wle
dge
and
self-
effica
cy m
edia
te th
e re
la-
tions
hip
betw
een
HL
and
self-
care
Hea
rt fa
ilure
sel
f-ca
re (m
aint
enan
ce
and
man
agem
ent)
X2 =
3.05
, df =
4
(p =
.55)
CF
I: 1
RMSE
A: 0
GFI
: 0.9
8
NFI
: 0.9
5
Goo
d m
odel
fit
Cho,
Lee
, A
rozu
llah,
&
Critt
ende
n (2
008)
Not
sta
ted
Gen
der,
race
and
ed
ucat
ion
Med
iato
rs: d
isea
se k
now
ledg
e;
heal
th b
ehav
ior;
prev
entiv
e ca
re;
med
icat
ion
com
plia
nce
Mod
erat
ors:
non
e
Med
iatin
g fa
ctor
s (d
isea
se k
now
l-ed
ge, h
ealth
beh
avio
r, pr
even
tive
care
, and
com
plia
nce
with
med
ica-
tion)
link
HL
and
outc
omes
(hea
lth
stat
us, h
ealth
car
e, E
D v
isit
and
hosp
italiz
atio
n)
Hea
lth s
tatu
s, ho
spi-
taliz
atio
n, E
D v
isit
X2 = 1
5.26
, df =
13
(p
= .2
9)
RMSE
A: 0
AGFI
: 0.9
1
NFI
: 0.9
9 Ad
equa
te fi
t
Com
o (2
018)
Paas
che-
Orlo
w
and
Wol
f cau
sal
path
way
s lin
king
lim
ited
heal
th
liter
acy
to h
ealth
ou
tcom
es
Band
ura’s
sel
f-effi
cacy
theo
ry
Patie
nt d
emog
raph
-ic
s (a
ge, e
duca
tion,
et
hnic
ity)
Soci
al fa
ctor
s (e
m-
ploy
men
t, in
com
e,
lang
uage
, soc
ial
supp
ort,
mar
ital
stat
us)
Illne
ss s
ever
ity
indi
cato
rs (n
umbe
r of
med
icat
ions
/day
s, fr
eque
ncy/
day)
Med
iato
rs: m
edic
atio
n ad
here
nce;
se
lf-effi
cacy
Mod
erat
ors:
non
e
HL,
med
icat
ion
adhe
renc
e, a
nd s
elf-
effica
cy a
re a
ssoc
iate
d w
ith p
hysi
cal
heal
th s
tatu
s. M
edic
atio
n ad
her-
ence
med
iate
s th
e re
latio
nshi
p be
twee
n H
L an
d ph
ysic
al h
ealth
st
atus
. HL,
sel
f-effi
cacy
, and
med
ica-
tion
adhe
renc
e ar
e as
soci
ated
with
m
enta
l hea
lth s
tatu
s. M
edic
atio
n ad
here
nce
med
iate
s th
e re
latio
n-sh
ip b
etw
een
HL
and
men
tal h
ealth
st
atus
Hea
lth o
utco
mes
(p
hysi
cal h
ealth
st
atus
, men
tal
heal
th s
tatu
s)
Not
repo
rted
e35HLRP: Health Literacy Research and Practice • Vol. 4, No. 1, 2020
TAB
LE 3
(con
tinue
d)
Theo
reti
cal F
ram
ewor
ks o
f Hea
lth
Lite
racy
Refe
renc
eHo
w Fr
amew
ork
Was
Info
rmed
Prop
osed
An
tece
dent
s to H
LPr
opos
ed M
ediat
ors a
nd M
oder
ator
sHy
poth
esis
Teste
dHe
alth
Beh
avio
rs/Ou
tcom
esFit
Indi
ces f
or Fi
nal
Mod
els
Croo
k,
Step
hens
, Pa
stor
ek,
Mac
kert
, &
Don
ovan
(2
016)
Theo
ry o
f diff
u-si
on o
f in
nova
tions
Perc
eive
d he
alth
kn
owle
dge,
Inte
rnet
us
e
Med
iato
rs: i
nfor
mat
ion
over
load
; at
titud
e to
war
d in
form
atio
n
Mod
erat
ors:
non
e
Freq
uent
Inte
rnet
use
is d
irect
ly
rela
ted
to h
igh
HL;
hig
her p
erce
ived
he
alth
kno
wle
dge
is d
irect
ly re
late
d to
freq
uent
Inte
rnet
use
, hig
h H
L,
posi
tive
attit
ude
tow
ard
info
rma-
tion,
and
low
er p
erce
ptio
n of
in
form
atio
n ov
erlo
ad
Hig
her H
L as
soci
ated
with
low
er
leve
ls o
f inf
orm
atio
n ov
erlo
ad a
nd
posi
tive
attit
udes
tow
ard
in
form
atio
n
Perc
eive
d le
vel o
f inf
orm
atio
n ov
er-
load
neg
ativ
ely
pred
icts
att
itude
to
war
d in
form
atio
n
Inte
ntio
n to
sha
re in
form
atio
n po
sitiv
ely
pred
icts
beh
avio
ral i
nten
-tio
ns; a
ttitu
de to
war
d in
form
atio
n po
sitiv
ely
pred
icts
beh
avio
ral
inte
ntio
ns a
nd in
form
atio
n-sh
arin
g in
tent
ions
Att
itude
tow
ard
info
rmat
ion
med
i-at
es re
latio
nshi
p be
twee
n H
L an
d be
havi
oral
inte
ntio
ns, a
s w
ell a
s re
latio
nshi
p be
twee
n pe
rcei
ved
over
load
and
info
rmat
ion-
shar
ing
inte
ntio
ns
Beha
vior
al in
ten-
tion,
info
rmat
ion
shar
ing
X2 =
13.0
0, d
f = 1
2
(p =
.37)
RMSE
A: 0
.02
CFI:
1
TLI:
0.99
SRM
R: 0
.06
Goo
d m
odel
fit
Guo
et a
l. (2
014)
Not
sta
ted
Age,
gen
der,
race
, ed
ucat
ion,
inco
me,
ha
ving
a re
gula
r de
ntis
t
Med
iato
rs: p
atie
nt-d
entis
t co
mm
unic
atio
n; d
enta
l car
e pa
t-te
rns
Mod
erat
ors:
non
e
Hyp
othe
sis:
hig
h H
L as
soci
ated
with
be
tter
pat
ient
-den
tist c
omm
unic
a-tio
n, a
nd b
ette
r com
mun
icat
ion
is
in tu
rn a
ssoc
iate
d w
ith in
crea
sed
likel
ihoo
d to
see
k re
gula
r den
tal
care
, res
ultin
g in
bet
ter s
elf-r
ated
or
al h
ealth
Self-
rate
d or
al
heal
thX2 =
0.4
3 (p
= .5
1)
RMSE
A: 0
.01
CFI:
0.99
Goo
d m
odel
fit
e36 HLRP: Health Literacy Research and Practice • Vol. 4, No. 1, 2020
TAB
LE 3
(con
tinue
d)
Theo
reti
cal F
ram
ewor
ks o
f Hea
lth
Lite
racy
Refe
renc
eHo
w Fr
amew
ork
Was
Info
rmed
Prop
osed
An
tece
dent
s to H
LPr
opos
ed M
ediat
ors a
nd M
oder
ator
sHy
poth
esis
Teste
dHe
alth
Beh
avio
rs/Ou
tcom
esFit
Indi
ces f
or Fi
nal
Mod
els
Hic
kman
, Cl
och-
esy,
& A
laam
ri (2
016)
Inte
grat
ed m
odel
of
clie
nt h
ealth
be
havi
or
Non
eM
edia
tors
: qua
lity
of p
rovi
der i
nter
-ac
tion;
per
ceiv
ed c
omm
unic
atio
n sk
ills;
beh
avio
r act
ivat
ion
Mod
erat
ors:
non
e
The
asso
ciat
ion
betw
een
HL
and
bloo
d pr
essu
re c
ontr
ol is
med
iate
d by
qua
lity
of p
rovi
der i
nter
actio
n,
perc
eive
d co
mm
unic
atio
n sk
ills,
and
beha
vior
al a
ctiv
atio
n
Bloo
d pr
essu
re
cont
rol
X2 =
1.1,
(p =
.76)
CFI:
1
RMSE
A: 0
SRM
R: 0
.03
TLI:
1.1
Exce
llent
fit
Hou
et a
l. (2
018)
Inte
grat
ed m
odel
of
HL
Age,
edu
catio
n, c
an-
cer s
tage
, tim
e si
nce
diag
nosi
s, m
arita
l st
atus
, res
iden
tial
area
, occ
upat
ion
Med
iato
rs: n
one
Mod
erat
ors:
non
e
Inte
rcor
rela
ted
dete
rmin
ants
of
HL
(age
, edu
catio
n, c
ance
r sta
ge,
time
sinc
e di
agno
sis,
mar
ital s
tatu
s, re
side
ntia
l are
a, o
ccup
atio
n) p
redi
ct
patie
nts’
HL
and
influ
ence
the
con-
sequ
ence
s of
HL
(par
ticip
atio
n in
de
cisi
on-m
akin
g, s
elf-r
ated
hea
lth
stat
us).
Ther
e is
dire
ct re
latio
nshi
p be
twee
n de
term
inan
ts a
nd c
on-
sque
nces
of H
L
Part
icip
atio
n in
sh
ared
dec
isio
n-m
akin
g
Self-
rate
d he
alth
st
atus
X2 =
55.1
2, d
f = 3
2
(p =
.007
)
RMSE
A: 0
.04
CFI:
0.99
SRM
R: 0
.03
AIC
: –8.
88
Goo
d m
odel
fit
Inta
raka
m-
hang
& In
ta-
raka
mha
ng
(201
7)
Nut
beam
mod
elH
ealth
kno
wle
dge
Med
iato
rs: n
one
Mod
erat
ors:
non
e
Dire
ct re
latio
nshi
p be
twee
n ba
sic
heal
th s
kill
(hea
lth k
now
ledg
e an
d un
ders
tand
ing)
and
eat
ing
beha
vior
s. A
ssoc
iatio
n be
twee
n ba
sic
heal
th s
kill
(hea
lth k
now
ledg
e an
d ea
ting
beha
vior
s) is
med
iate
d by
inte
ract
ive
skill
s (c
omm
unic
atin
g fo
r add
ed s
kills
) and
crit
ical
ski
lls
(mak
ing
appr
opria
te h
ealth
-rel
ated
de
cisi
on)
Obe
sity
pre
vent
ive
beha
vior
s (e
atin
g be
havi
ors,
exer
cise
be
havi
ors,
and
emo-
tiona
l cop
ing)
X2 = 6
0.1,
df =
12
(p
= .0
0)
RMSE
A: 0
.05
CFI:
0.99
AGFI
: 0.9
9
PNFI
: 0.7
2
Goo
d m
odel
fit
Jin,
Lee
, & D
ia
(201
9)H
L sk
ills f
ram
e-w
ork,
cog
nitiv
e m
edia
tion
mod
el
Onl
ine
info
rmat
ion-
se
ekin
g be
havi
ors
(usi
ng e
mai
ls to
co
mm
unic
ate
with
pr
ovid
ers;
vis
it so
cial
ne
twor
king
site
to
read
and
sha
re
med
ical
topi
cs)
Med
iato
rs: d
ecis
iona
l bal
ance
; in
form
atio
n ov
erlo
ad
Mod
erat
ors:
non
e
Onl
ine
heal
th in
form
atio
n-se
ekin
g be
havi
or is
pos
itive
ly a
ssoc
iate
d w
ith H
L
Onl
ine
heal
th in
form
atio
n-se
ekin
g be
havi
or is
ass
ocia
ted
with
info
rma-
tion
over
load
Info
rmat
ion
over
load
is in
vers
ely
asso
ciat
ed w
ith H
L
Colo
rect
al c
ance
r sc
reen
ing
Not
repo
rted
e37HLRP: Health Literacy Research and Practice • Vol. 4, No. 1, 2020
TAB
LE 3
(con
tinue
d)
Theo
reti
cal F
ram
ewor
ks o
f Hea
lth
Lite
racy
Refe
renc
eHo
w Fr
amew
ork
Was
Info
rmed
Prop
osed
An
tece
dent
s to H
LPr
opos
ed M
ediat
ors a
nd M
oder
ator
sHy
poth
esis
Teste
dHe
alth
Beh
avio
rs/Ou
tcom
esFit
Indi
ces f
or Fi
nal
Mod
els
HL
is p
ositi
vely
ass
ocia
ted
with
co
lore
ctal
can
cer s
cree
ning
HL
is p
ositi
vely
ass
ocia
ted
with
de
cisi
onal
bal
ance
Dec
isio
nal b
alan
ce is
pos
itive
ly
asso
ciat
ed w
ith c
olor
ecta
l can
cer
scre
enin
g
E.H
. Lee
, Le
e, &
Moo
n (2
016)
Not
sta
ted
Age,
gen
der,
educ
atio
n, m
arita
l st
atus
, tre
atm
ent
regi
men
(die
t/ex
-er
cise
, ins
ulin
, ora
l hy
pogl
ycem
ic o
nly,
or
al h
ypog
lyce
mic
&
insu
lin),
HbA
1c,
dura
tion
of d
isea
se
Med
iato
rs: s
elf-
effica
cy; s
elf-
care
ac
tiviti
es
Mod
erat
ors:
non
e
Stud
y ai
m: t
est r
elat
ions
hip
amon
g H
L, s
elf-
effica
cy, s
elf-
care
act
iviti
es,
and
HRQ
OL
HRQ
OL
(em
otio
nal
suffe
ring,
soc
ial
func
tioni
ng, a
dher
-en
ce to
trea
tmen
t, di
abet
es-s
peci
fic
sym
ptom
s)
X2 = 2
65.7
9, d
f = 7
1
RMSE
A: 0
.07
CFI:
0.92
GFI
: 0.9
2
SRM
R: 0
.07
NFI
: 0.9
2
Goo
d m
odel
fit
Y.J.
Lee
et a
l. (2
016)
Paas
che-
Orlo
w
and
Wol
f mod
elEd
ucat
ion,
age
, em
pow
erm
ent
perc
eptio
ns
Med
iato
rs: s
elf-
effica
cy; s
elf-
care
be
havi
ors
(med
icat
ion,
exe
rcis
e,
diet
, blo
od s
ugar
mon
itorin
g, a
dver
-si
ty p
reve
ntio
n)
Mod
erat
ors:
non
e
Self-
care
beh
avio
rs m
edia
te re
la-
tions
hip
betw
een
HL
and
glyc
emic
co
ntro
l (i.e
., H
bA1c
)
Dire
ct re
latio
nshi
ps: (
1) H
L an
d se
lf-effi
cacy
, (2)
HL
and
glyc
emic
co
ntro
l; (3
) em
pow
erm
ent a
nd H
L,
self-
care
beh
avio
rs, s
elf-
effica
cy,
and
glyc
emic
con
trol
Gly
cem
ic c
ontr
ol
(HbA
Ic)
X2 / df
= 1
.79
RMSE
A: 0
.052
CFI:
0.94
GFI
: 0.9
5
AGFI
: 0.9
6
AIC
: 145
.25
Acce
ptab
le m
odel
fit
Osb
orn,
Ca
vana
ugh,
et
al. (
2011
)
Not
sta
ted
Race
Med
iato
rs: n
one
Mod
erat
ors:
non
e
Blac
k ra
ce a
ssoc
iate
d w
ith p
oor
med
icat
ion
adhe
renc
e; n
umer
acy
asso
ciat
ed w
ith m
edic
atio
n ad
her-
ence
and
exp
lain
s as
soci
atio
n be
twee
n ra
ce a
nd a
dher
ence
Med
icat
ion
ad
here
nce
X2 = 0
.08
(p =
0.7
8)
RMSE
A: 0
.00
CFI:
1.00
Exce
llent
mod
el fi
t
e38 HLRP: Health Literacy Research and Practice • Vol. 4, No. 1, 2020
TAB
LE 3
(con
tinue
d)
Theo
reti
cal F
ram
ewor
ks o
f Hea
lth
Lite
racy
Refe
renc
eHo
w Fr
amew
ork
Was
Info
rmed
Prop
osed
An
tece
dent
s to H
LPr
opos
ed M
ediat
ors a
nd M
oder
ator
sHy
poth
esis
Teste
dHe
alth
Beh
avio
rs/Ou
tcom
esFit
Indi
ces f
or Fi
nal
Mod
els
Osb
orn,
Ca
vana
ugh,
W
alls
ton,
&
Roth
man
(2
010)
Not
sta
ted
Non
eM
edia
tors
: dia
bete
s se
lf-effi
cacy
Mod
erat
ors:
non
e
HL
is d
irect
ly re
late
d to
gly
cem
ic
afte
r con
trol
ling
for d
emog
raph
-ic
s (a
ge, g
ende
r, ra
ce, e
duca
tion,
in
com
e, in
sulin
use
, dia
bete
s ty
pe,
and
year
s si
nce
diag
nosi
s).
Self-
effica
cy m
edia
tes
HL
and
glyc
e-m
ic c
ontr
ol
Gly
cem
ic c
ontr
olX2 =
6.1
7, (p
= 0
.41)
CFI:
1
RMSE
A: 0
.01
Exce
llent
mod
el fi
t
Osb
orn,
Pa
asch
e-O
rlow
, Bai
ley,
&
Wol
f (20
11)
Paas
che-
Orlo
w
and
Wol
f mod
elRa
ce, e
duca
tion,
age
Med
iato
rs: k
now
ledg
e; s
elf-
effica
cy;
self-
care
Mod
erat
ors:
non
e
Patie
nt d
emog
raph
ics
(rac
e/et
hnic
-ity
, edu
catio
n, a
ge) p
redi
ct H
L
HL
pred
icts
det
erm
inan
ts o
f sel
f-ca
re a
t the
pat
ient
leve
l (kn
owle
dge
and
self-
effica
cy)
Patie
nt-le
vel d
eter
min
ants
of
self-
care
pre
dict
sel
f-ca
re b
ehav
ior
(phy
sica
l act
ivity
)
Self-
care
beh
avio
r pre
dict
s he
alth
st
atus
(sub
ject
ive
heal
th)
Hea
lth s
tatu
s
(sub
ject
ive
heal
th)
X2 = 6
.75,
(p =
.40)
RMSE
A: 0
.01
CFI:
1
Exce
llent
mod
el fi
t
Phot
haro
s, W
acha
rasi
n, &
D
uong
paen
g (2
018)
Indi
vidu
al a
nd
fam
ily s
elf-
man
agem
ent
theo
ry
Non
eM
edia
tors
: chr
onic
kid
ney
dise
ase
self-
effica
cy
Mod
erat
ors:
non
e
Fam
ily fu
nctio
ning
, illn
ess
per-
cept
ion,
and
HL
dire
ctly
affe
ct
self-
man
agem
ent b
ehav
iors
and
in
dire
ctly
affe
ct s
elf-m
anag
emen
t be
havi
ors
thro
ugh
chro
nic
kidn
ey
dise
ase
self-
effica
cy
Fam
ily fu
nctio
ning
influ
ence
s se
lf-m
anag
emen
t beh
avio
rs th
roug
h so
cial
sup
port
Self-
man
agem
ent
beha
vior
s (a
dher
-en
ce to
chr
onic
ki
dney
dis
ease
re
com
men
datio
n,
self-
inte
grat
ion,
pr
oble
m s
olvi
ng,
seek
ing
soci
al s
up-
port
)
X2 / df
= 1
.63
RMSE
A: 0
.48
GFI
: 0.9
3
AGFI
: 0.9
Acce
ptab
le m
odel
fit
Schi
lling
er,
Bart
on, K
arte
r, W
ang,
& A
dler
(2
006)
Not
sta
ted
Educ
atio
nal
leve
l, ag
e, p
rimar
y la
ngua
ge, h
ealth
in
sura
nce
stat
us
Med
iato
rs: n
one
Mod
erat
ors:
non
e
HL
med
iate
s th
e re
latio
nshi
p be
-tw
een
educ
atio
n le
vel a
nd g
lyce
mic
co
ntro
l
Gly
cem
ic c
ontr
olX2 =
12.
22, d
f = 3
1
(p =
0.1
0)
RMSE
A <
0.0
001
CFI:
1
AGFI
: 0.9
9
Goo
d m
odel
fit
e39HLRP: Health Literacy Research and Practice • Vol. 4, No. 1, 2020
TAB
LE 3
(con
tinue
d)
Theo
reti
cal F
ram
ewor
ks o
f Hea
lth
Lite
racy
Refe
renc
eHo
w Fr
amew
ork
Was
Info
rmed
Prop
osed
An
tece
dent
s to H
LPr
opos
ed M
ediat
ors a
nd M
oder
ator
sHy
poth
esis
Teste
dHe
alth
Beh
avio
rs/Ou
tcom
esFit
Indi
ces f
or Fi
nal
Mod
els
Soon
es e
t al.
(201
7)
Not
sta
ted
Cogn
ition
Med
iato
rs: i
llnes
s be
liefs
; med
ica-
tion
conc
erns
; med
icat
ion
nece
ssity
Mod
erat
ors:
non
e
Ast
hma
illne
ss a
nd m
edic
atio
n be
liefs
med
iate
the
rela
tions
hip
betw
een
HL
and
med
icat
ion
adhe
r-en
ce
Med
icat
ion
ad
here
nce
RMSE
A: 0
.05
CFI:
0.93
Adeq
uate
fit
Sun
et a
l. (2
013)
Ba
ker,
Paas
che-
Orlo
wAg
e, e
duca
tion,
in
com
e, p
rior k
now
l-ed
ge o
f inf
ectio
us
resp
irato
ry d
isea
ses
Med
iato
rs: h
ealth
beh
avio
r
Mod
erat
ors:
non
e
Prio
r kno
wle
dge
influ
ence
s de
vel-
opm
ent o
f HL
skill
s
HL
has
dire
ct e
ffect
on
heal
th
beha
vior
s
HL
med
iate
s re
latio
nshi
p be
twee
n pr
ior k
now
ledg
e an
d he
alth
be
havi
or
Hea
lth b
ehav
ior i
nflue
nces
hea
lth
stat
us
Hea
lth s
tatu
sX2 : 1
0.22
, df =
6
(p =
.115
9)
RMSE
A: 0
.05
CFI:
0.1
AGFI
: 0.1
Goo
d m
odel
fit
Zou,
Che
n,
Fang
, Zha
ng,
& F
an (2
017)
Capa
bilit
y op
por-
tuni
ty m
otiv
atio
n an
d be
havi
or
mod
el
Non
eM
edia
tors
: sel
f-ca
re c
onfid
ence
Mod
erat
ors:
Non
e
Capa
bilit
y (fu
nctio
nal c
apac
ity,
know
ledg
e, H
L) a
nd o
ppor
tuni
ty
(soc
ial s
uppo
rt, s
ocio
econ
omic
st
atus
) are
ass
ocia
ted
with
beh
avio
r (s
elf-
care
mai
nten
ance
, sel
f-ca
re
man
agem
ent)
thro
ugh
mot
ivat
ion
(sel
f-ca
re c
onfid
ence
)
Hea
rt fa
ilure
sel
f-ca
re m
aint
enan
ce
Hea
rt fa
ilure
sel
f-ca
re m
anag
emen
t
X2 = 1
4.04
, df =
11
(p =
.23)
RMSE
A: 0
.029
CFI:
0.99
Goo
d m
odel
fit
Not
e. A
GFI
: Adj
uste
d G
oodn
ess o
f Fit;
AIC
: Aka
ike
Info
rmat
ion
Crit
erio
n; C
FI =
Com
para
tive
Fit I
ndex
; DF
= de
gree
s of f
reed
om; E
D =
em
erge
ncy
depa
rtm
ent;
GFI
= G
oodn
ess o
f Fit
Inde
x; H
bA1c
= h
emog
lobi
n A
1c; H
L =
heal
th li
tera
cy; H
RQO
L =
heal
th-
real
ted
qual
ity o
f life
; NFI
= N
orm
ed F
it In
dex;
RM
SEA
= ro
ot m
ean
squa
re e
rror
of a
ppro
xim
atio
n; X
2 = ch
i-squ
are.
e40 HLRP: Health Literacy Research and Practice • Vol. 4, No. 1, 2020
Four studies that examined how HL is related to health behavior through disease knowledge found the following: only one study showed a statistically significant mediat-ing effect of knowledge in the context of diabetes manage-ment (Brega et al., 2012), and three studies found a direct association between HL and knowledge (Chen, 2015; Cho et al., 2008; Osborn, Paasche-Orlow et al., 2011). All four stud-ies that examined the mediating effect of disease knowledge did not describe how knowledge instruments were scored, however. In addition, all four studies had a large propor-tion (65%-70%) of study participants with a high school education or less (Chen, 2015; Cho et al., 2008; Osborn, Paasche-Orlow et al., 2011; Zou et al., 2017).
Of the eight studies that examined self-care activities (medication adherence, physical activity, self-monitoring of blood glucose, foot care, healthy diet) as factors linking the pathway between HL and health outcomes (glycemic control, emergency department visits, blood pressure control, and physical and mental health status) (Brega et al., 2012; Cho et al., 2008; Como, 2018; Hickman et al., 2016; E. H. Lee et al., 2016; Y. J. Lee et al., 2016; Osborn, Paasche-Orlow, et al., 2011; Sun et al., 2013), two reported a significant, mediating effect (Brega et al., 2012; E. H. Lee et al., 2016). Both stud-ies controlled for known demographic covariates such as age, gender, education, marital status, treatment regimen (insulin or oral hypoglycemic use), hemoglobin A1c level, as well as duration of disease in the mediation analysis (Brega et al., 2012; E. H. Lee et al., 2016).
Other proposed mediators included patient-provider interaction (Guo et al., 2014; Hickman et al., 2016), de-cisional balance (Como, 2018), medication compliance (Cho et al., 2008; Soones et al., 2017), preventive care use (Cho et al., 2008; Guo et al., 2014), information overload (Como, 2018) and attitude and beliefs toward information (Crook et al., 2016). Only one study across a sample of predominately White (66%), urban-dwelling adults (mean age, 53 years) found that patient-dentist communication and the frequent use of dental care services mediates the relationship between HL (navigation) and self-rated oral health (p = .01) (Guo et al., 2014). The remaining stud-ies found no statistically significant mediation pathways linking HL to health behaviors and outcomes (Cho et al., 2008; Crook et al., 2016; Hickman et al., 2016; Soones et al., 2017). Only 3 of the 20 studies included in this review assessed the interaction of HL and study outcomes (gly-cemic control, medication adherence), but the authors did not describe this relationship as moderating (Osborn, Paasche-Orlow et al., 2011; Schillinger et al., 2006; Soones et al., 2017).
Validation of Theory-Based Conceptual FrameworksFourteen studies (Chen, 2014; Crook et al., 2016; Guo et
al., 2014; Hickman et al., 2016; Hou et al., 2018; Intaraka-mhang & Intarakamhang, 2017; E. H. Lee et al., 2016; Y. J. Lee et al., 2016; Osborn, Cavanaugh, et al., 2011; Osborn, Cavanaugh et al., 2010; Osborn, Paasche-Orlow et al., 2011; Schillinger et al., 2006; Sun et al., 2013; Zou et al., 2017) re-ported good to excellent goodness of fit in which all indi-ces were statistically significant; two studies did not report fit indices (Como, 2018; Jin et al., 2019). Of the 20 studies included in this review, all but one hypothesized the relation-ships among proposed study variables (E. H. Lee et al., 2016). Twelve studies used theory to inform the selection and op-erationalization of study variables (Chen, 2014; Como, 2018; Crook et al., 2016; Hickman et al., 2016; Hou et al., 2018; Intarakamhang & Intarakamhang, 2017; Jin et al., 2019; Y. J. Lee et al., 2016; Osborn, Paasche-Orlow, et al., 2011; Photharos et al., 2018; Sun et al., 2013; Zou et al., 2017). Three stud-ies validated the theory by Paasche-Orlow and Wolf (2007) across a sample of low-income, middle-aged (>50 years) adults with chronic disease (Como, 2018; Y. J. Lee et al., 2016; Osborn, Paasche-Orlow, et al., 2011). Of the three studies, one study (Y. J. Lee et al., 2016), which used participants’ self-reports of glycemic control, showed an acceptable framework fit, and an excellent framework fit was reported for the study (Osborn, Paasche-Orlow, et al., 2011) that used patients’ medical records. One study validated the Nutbeam HL model (Nutbeam, 2008) in the context of obesity prevention using a national sample of school-age children (N = 2,000; age range, 9-14 years); fit indices indicated a good fit (Intarakamhang & Intarakamhang, 2017). One study conducted in China with a sample of city-dwelling adults (N = 3,222) validated an adapted framework of various HL theoretical models (Baker [2006], Paasche-Orlow and Wolf [2007], and McCormack [2009] models) and reported a good fit of the proposed framework (Sun et al., 2013). The authors of the study did not clearly describe how study variables were operationalized, however (Sun et al., 2013). Two studies conducted in the U.S. (Como, 2018; Jin et al., 2019) also adapted multiple theoreti-cal models (i.e. Paasche-Orlow and Wolf model [2007], Ban-dura’s self-efficacy theory [Bandura, 1977], health literacy skills framework [Squires, Peinado, Berkman, Boudewyns, & McCormack, 2012] and cognitive mediation model [Eve-land & Dunwoody, 2001]) but failed to report fit indices. Additionally, five studies (Chen, 2014; Crook et al., 2016; Hickman et al., 2016; Photharos et al., 2018; Zou et al., 2017) that reported good to excellent fit indices were informed by theories that do not specifically address HL but are common-ly used in nursing and public health research to study health
e41HLRP: Health Literacy Research and Practice • Vol. 4, No. 1, 2020
behaviors and overall health outcomes: Orem’s theory of self-care and Bandura’s social cognitive theory, theory of diffusion of innovations, model of client health behavior, individual and family self-management theory, and capability opportu-nity motivation and behavior model. (Bandura, 1977; Cox, 1982; Michie, Stralen, van Stralen, & West, 2011; Orem, 2003; Rogers, 2002; Ryan & Sawin, 2009.)
DISCUSSION To our knowledge, this is the first systematic review to
critically appraise studies that have empirically tested the po-tential pathways linking HL to health behaviors and health outcomes. We found evidence to support that theoretically selected mediators (i.e., self-efficacy, disease knowledge, self-care activities, and patient-provider communication) medi-ate the identified relationship between HL and chronic dis-ease management, with self-efficacy as the commonly tested mediator (E. H. Lee et al., 2016; Y. J. Lee et al., 2016). Our findings show that unless people possess adequate HL, they may perceive low confidence in their abilities to manage their chronic diseases. In addition, improving people’s HL is an essential first step to increasing their knowledge about their disease, improving their ability to adequately perform self-care activities, and effectively communicate and collaborate with health care providers in their chronic disease man-agement (Charlot et al., 2017; Chisholm-Burns, Spivey, & Pickett, 2018). We also found evidence to support that inter-vention outcomes (glycemic control, medication adherence) differ by the HL levels of study participants, suggesting HL as a moderator (Schillinger et al., 2006; Soones et al., 2017). This finding highlights an important implication for future research, particularly in relation to intervention research as it relates to the role of HL beyond mediation.
We identified several factors that may have contributed to the mixed findings we reported: study design, selection bias, small sample sizes, measurement errors, and non–theory-guided operationalization of study variables. Although all studies in this review aimed to examine the pathways link-ing HL to health behaviors and outcomes, these studies ex-clusively used cross-sectional and a mixed-methods designs, which preclude causality and temporality. Secondly, only 7 of 20 studies conducted sample size calculations and power analyses a priori (Chen, 2015; Como, 2018; Hou et al., 2018; Intarakamhang & Intarakamhang, 2017; E. H. Lee et al., 2016; Y. J. Lee et al., 2016; Photharos et al., 2018). The lack of statistical power in most of the studies could account for the mixed findings reported. Thirdly, although all U.S.-based studies used well-validated HL measures, the remaining studies either lacked psychometric testing results or had only
been tested in a single population; therefore, the validity and reliability of those measures could not be established (Intara-kamhang & Intarakamhang, 2017; E. H. Lee et al., 2016; Y. J. Lee et al., 2016; Sun et al., 2013; Zou et al., 2017). Also impor-tant is that the studies were predominantly across a conve-nience sample of female, urban-dwelling adults with less than a high school education who were recruited from health care facilities. Therefore, findings cannot be generalized to other populations that do not use the health care system due to lan-guage barriers or a lack of health insurance. Finally, theory provides a systematic foundation and a logical pathway for il-lustrating the relationship among various study concepts and variables. However, only a limited number of studies (n = 12) included in the review explained how theory informed the selection and operationalization of study variables, delimit-ing the generalizability of findings.
Findings from this review call for the need to use theo-retically grounded, methodologically rigorous research with statistically powered sample sizes to adequately examine the interplay between HL and health behaviors or outcomes in diverse study populations. For example, the studies included in this review exclusively used a cross-sectional design to test the indirect pathways linking HL to health behaviors. Hence, there is still a need for establishing temporality and causal-ity using more rigorous study designs such as longitudinal cohort design. Several studies have used longitudinal data to examine the role of HL on health behaviors and outcomes; however, they did not meet the inclusion criteria for this re-view because the authors did not specify a HL conceptual framework to be tested (Kobayashi, Wardle, & Wagner, 2015; Washington, Curtis, Waite, Wolf, & Paasche-Orlow, 2018). In addition, although a recent systematic review showed that HL has gained importance on the European health agenda, none of the studies identified from our extensive search of various database were conducted in Europe (Sørensen et al., 2015). Further, among U.S.-based studies, all were conducted on fe-male, English-speaking adults (Brega et al., 2012; Chen, 2014; Cho et al., 2008; Como, 2018; Crook et al., 2016; Guo et al., 2014; Hickman et al., 2016; Jin et al., 2019; Osborn, Cavana-ugh, et al., 2011; Osborn et al., 2010; Osborn, Paasche-Orlow, et al., 2011; Schillinger et al., 2006; Soones et al., 2017). Al-though people who belong to ethnic/racial minority groups and those with low English proficiency, particularly immi-grants, are known to be disproportionately burdened by low HL, they were excluded from the U.S.-based studies (Alper, 2018; Wang et al., 2013). In particular, African immigrants, an exponentially increasing immigrant group in the U.S. with worse health outcomes in comparison to other immigrant groups, were excluded in all the U.S.-based studies (Anderson,
e42 HLRP: Health Literacy Research and Practice • Vol. 4, No. 1, 2020
2015). Although there is a possibility that African immigrants were categorized as Black Americans in some of these studies, it has been established that people of African descent (Black, African immigrant, and Afro-Caribbean) in the U.S. have dif-ferent cultural and linguistic characteristics that affect their health outcomes differently. Therefore, there is a need to dis-aggregate these subgroups in health research (Commodore-Mensah et al., 2017; Forney-Gorman & Kozhimannil, 2016).
STUDY STREGNTHSThe Cochrane Collaboration and the U.S. Institute of
Medicine have endorsed that review teams must have content and methodological expertise (Bigendako & Syriani, 2018; Gøtzsche & Ioannidis, 2012; Institute of Medicine, 2011). A major strength of this study is that our contributors have un-dergone training in systematic review methodology and have published prior reviews (Cajita, Cajita, & Han, 2016; Han, Floyd, et al., 2018; Han, Kim, et al., 2018). Additionally, most of the authors are clinicians with expertise in health promo-tion among populations with poor health literacy. These skill-sets helped us capture a heterogeneity of opinions and allowed for high interrater reliability when reviewing articles for inclu-sion in the review. These strengths add to the degree of con-fidence when reporting our study findings, which also speaks to the thoroughness of this systematic review.
STUDY LIMITATIONSThis systematic review is limited in that despite our exten-
sive database searches, there may be other relevant and un-published studies that may not have been identified. There-fore, the theories we identified as guiding the development of HL conceptual frameworks may not be exhaustive. The majority of studies included in this review assessed HL using REALM and TOFHLA, which assess reading ability and com-prehension, respectively, but do not comprehensively address the multidimensionality of HL (i.e., ability to understand written text, speak and listen effectively, and use quantitative data to make appropriate health decisions) (Sørensen et al., 2012). Most studies used a cross-sectional design that pre-cludes causality and temporality. In addition, we only includ-ed studies published in English. This may have also resulted in the small number of studies included in this review as well as the number of studies that included non–English-speaking populations.
CONCLUSIONOur review adds to the existing body of knowledge on the
impact of HL on health behavior by providing a comprehen-sive understanding of how theory informs the development of
HL conceptual frameworks, and the systematic selection and evaluation of variables that inform HL-focused studies. We found evidence to support that HL is related to health be-haviors, particularly chronic disease management, through mediators such as self-efficacy and disease knowledge.
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TABLE A
Database Search Strategy
PubMed
((“HL”[Mesh] OR “HL”)) AND (“Models, Theoretical”[Mesh] OR “conceptual framework” OR “conceptual frameworks” OR “con-ceptual model” OR “conceptual models”)
CINAHL
((MH “Conceptual Framework”) OR (“conceptual framework” ) OR (conceptual N3 (framework* OR model*)) OR (MH “Models, Theo-retical+”) OR (“theoretical models”) AND ( (MH “HL”) OR (“HL” ) OR (health N3 (literacy OR literate OR illiteracy OR illiterate))
Embase
“HL”/exp OR (health NEAR/3 (literacy OR literate OR illiterate OR illiteracy)):ab,ti AND “conceptual framework”/exp OR (con-ceptual NEAR/3 (framework* OR model*)):ab,ti OR “theoretical model”/exp