BACKGROUND: Emerging evidence suggests the relationship between health literacy and health outcomes could be explained by cognitive abilities. OBJECTIVE:To investigate to what degree cognitive skills explain associations between health literacy, performance on common health tasks, and functional health status. DESIGN: Two face-to-face, structured interviews spaced a week apart with three health literacy assessments and a comprehensive cognitive battery measuring 'fluid' abilities necessary to learn and apply new information, and 'crystallized' abilities such as background knowledge. SETTING: An academic general internal medicine practice and three federally qualified health centers in Chicago, Illinois. PATIENTS: Eight hundred and eighty-two Englishspeaking adults ages 55 to 74. MEASUREMENTS: Health literacy was measured using the Rapid Estimate of Adult Literacy in Medicine (REALM), Test of Functional Health Literacy in Adults (TOFHLA), and Newest Vital Sign (NVS). Performance on common health tasks were globally assessed and categorized as 1) comprehending print information, 2) recalling spoken information, 3) recalling multimedia information, 4) dosing and organizing medication, and 5) healthcare problem-solving. RESULTS: Health literacy measures were strongly correlated with fluid and crystallized cognitive abilities (range: r=0.57 to 0.77, all p<0.001). Lower health literacy and weaker fluid and crystallized abilities were associated with poorer performance on healthcare tasks. In multivariable analyses, the association between health literacy and task performance was substantially reduced once fluid and crystallized cognitive abilities were entered into models (without cognitive abilities: β=−28.9, 95 % Confidence Interval (CI) -31.4

The relationship between literacy and health outcomes are well documented in adult medicine, yet specific causal pathways are not entirely clear. Despite an incomplete understanding of the problem, numerous interventions have already been implemented with variable success. Many of the earlier strategies assumed the problem to originate from reading difficulties only. Given the timely need for more effective interventions, it is of increasing importance to reconsider the meaning of health literacy in order to advance our conceptual understanding of the problem and how best to respond. One potentially effective approach might involve recognizing the known associations between a larger set of cognitive and psychosocial abilities with functional literacy skills. We review the current health literacy definition and literature and draw upon relevant research from the fields of education, cognitive science, and psychology. In this framework, a research agenda is proposed that considers an individual's health learning capacity, referring to the broad constellation of cognitive and psychosocial skills patients or family members must draw upon to effectively promote, protect, and manage their own or a child's health. This new, related concept will ideally lead to more effective ways of thinking about health literacy interventions, including the design of health education materials, instructional strategies, and the delivery of healthcare services to support patients and families across the lifespan.

Background Limited literacy has repeatedly been linked to problems comprehending health information, although the majority of studies to date have focused on reading various print health materials. We sought to investigate patients’ ability to recall spoken medical instructions in the context of a hypothetical clinical encounter, and whether limited health literacy would adversely affect performance on the task. Methods A total of 755 patients age 55–74 were recruited from one academic internal medicine clinic and three federally qualified health centers. Participants’ health literacy skills and recall of spoken medical instructions for two standard, hypothetical video scenarios (wound care, GERD diagnosis)were assessed. Results The majority (71.6%) of participants had adequate health literacy skills, and these individuals performed significantly better in correctly recalling spoken information than those with marginal and low literacy in both scenarios: [wound care - mean (SD): low 2.5 (1.3) vs. marginal 3.5 (1.3) vs adequate 4.6 (1.1); p<0.001), GERD: low 4.2(1.7) vs. marginal 5.2(1.7) vs. adequate 6.5 (1.7);p<0.001]. Regardless of literacy level, overall recall of information was poor. Few recognized pain (28.5%) or fever (28.2%) as signs of infection. Only 40.5% of participants correctly recalled when to take their GERD pills. Conclusions Many older adults may have difficulty remembering verbal instructions conveyed during clinical encounters. We found those with lower health literacy to have poorer ability to recall information. Greater provider awareness of the impact of low health literacy on the recall of spoken instructions may guide providers to communicate more effectively and employ strategies to confirm patient understanding.

Background There is considerable variability in the manner in which prescriptions are written by physicians and transcribed by pharmacists, resulting in patient misunderstanding of label instructions. A ‘universal medication schedule’ (UMS) was recently proposed for standardizing prescribing practices to four daily time intervals thereby helping patients simplify and safely use their medicine. We investigated whether patients consolidate their medications, or if there is evidence of unnecessary regimen complexity that would support standardization. Methods Structured interviews were conducted with 464 adults ages 55–74 who were receiving care at either an academic general medicine practice or one of three federally qualified health centers in Chicago, Illinois. Subjects were given a hypothetical, seven-drug medication regimen and asked to demonstrate how and when they would take all of the medicine in a 24-hour period. The regimen could be consolidated into four dosing episodes per day. The primary outcome was the number of times per day individuals would take medicine. Root causes for patients complicating the regimen (> four times a day) were examined. Results Participants on average identified six times in 24 hours to take the seven drugs (SD=1.8; range 3 to 14). One third (29.3%) found seven or more times per day to take their medicine, while only 14.9% organized the regimen into four or fewer times a day. In multivariable analysis, low literacy was an independent predictor of more times per day for dosing out the regimen (β=0.67; 95% Confidence Interval 0.12 to 1.22, p=0.018). Instructions for two of the drugs were identical, yet 31% of patients did not dose these medicines at the same time. Another set of drugs had similar instructions with the primary exception of one having the added instruction to take “with food and water”. Half (49.5%) of participants dosed these medicines at different times. When medicines had variable expressions of the same dose frequency (“every 12 hours” vs. “twice daily”), 79.0% did not consolidate the medicines. Conclusion Many patients, especially those with limited literacy, do not consolidate prescription regimens in the most efficient manner, which could impede adherence. Standardized instructions proposed with the UMS and other task-centered strategies could potentially help patients routinely organize and take medication regimens.

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