Shahid et al.

BMC Health Services Research (2022) 22:1148

https://doi.org/10.1186/s12913-022-08527-9

RESEARCH Open Access

Impact of low health literacy on patients’

health outcomes: a multicenter cohort study
Rabia Shahid1*, Muhammad Shoker2, Luan Manh Chu3, Ryan Frehlick2, Heather Ward1 and Punam Pahwa4

Abstract
Background: This study aims to assess the health literacy of medical patients admitted to hospitals and examine its
correlation with patients’ emergency department visits, hospital readmissions, and durations of hospital stay.
Methods: This prospective cohort study recruited patients admitted to the general internal medicine units at the
two urban tertiary care hospitals. Health literacy was measured using the full-length Test of Functional Health Literacy
in Adults. Logistic regression analyses were performed to examine the correlation between health literacy and the
desired outcomes. The primary outcome of interest of this study was to determine the correlation between health
literacy and emergency department revisit within 90 days of discharge. The secondary outcomes of interest were to
assess the correlation between health literacy and length of stay and hospital readmission within 90 days of discharge.
Results: We found that 50% had adequate health literacy, 32% had inadequate, and 18% of patients had marginal
health literacy. Patients with inadequate health literacy were more likely to revisit the emergency department as
compared to patients with adequate health literacy (odds ratio: 3.0; 95% Confidence Interval: 1.3–6.9, p = 0.01). In
patients with inadequate health literacy, the mean predicted probability of emergency department revisits was
0.22 ± 0.11 if their education level was some high school or less and 0.57 ± 0.18 if they had completed college. No
significant correlation was noted between health literacy and duration of hospital stay or readmission.
Conclusions: Only half of the patients admitted to the general internal medicine unit had adequate health literacy.
Patients with low health literacy, but high education, had a higher probability of emergency department revisits.
Keywords: Health literacy, Hospital readmission, Emergency department revisit, Patient outcomes, Length of stay

Background maintain good health and wellbeing for themselves

Health literacy is the ability of an individual to effectively and those around them” [3]. It is essential that patients
use their reading, writing, verbal, and numerical skills and their families are able to “... obtain, process, and
to contribute to their personal healthcare positively [1, understand [the] basic health information and services
2]. An individual’s health literacy skills are crucial for needed to make appropriate health decisions to manage
health-related decisions. Health literacy is described their health.” More than 43 million people in the United
as “personal knowledge and competencies which States have inadequate health literacy, and nearly half
enable people to access, understand, appraise, and use of the adult Canadians have literacy skills below a high
information and services in ways which promote and school level, affecting their ability to function [4–8].
The relationship between eudcation and health literacy
is not well understood. Education has been suggested to
*Correspondence: rabiakshahid@gmail.com be a key factor for adequate health literacy and thereby
1
Department of Medicine, University of Saskatchewan, 103 Hospital Drive, good health [9, 10]. Evidence shows that people with
Saskatoon SK7N OW8, Canada lower education have lower health literacy skills as
Full list of author information is available at the end of the article compared to people with higher education. Nevertheless,

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Shahid et al. BMC Health Services Research (2022) 22:1148 Page 2 of 9

health literacy and general literacy are not identical evaluated or recorded in patients’ medical records and
concepts. Inadequate health literacy is not uncommon administrative data. However, health literacy can be an
among patients with a high level of education [10]. important indicator in evaluating patients’ risks of poor
General literacy does not provide all the skills required outcomes after hospital discharge and improving patient-
to manage and communicate critical health information physician communication [30].
and concerns [11, 12]. Evidence supports an incongruity Most of the studies that have assessed outcomes of
between the average reading ability of patients and their patients with inadequate health literacy were performed
ability to interpret and comprehend health information, either in the emergency department or in outpatient
as when managing health and complex diseases, patients settings. Therefore, current knowledge of the outcomes
require more than the ability to read and manipulate of inadequate health literacy in hospitalized patients
numbers [13]. with multiple comorbid conditions is limited. This study
Inadequate health literacy is recognized as a stronger aims to assess the health literacy of patients admitted to a
predictor of poor health than age, income, employment hospital general medical unit and examine its correlation
status, education level, or race [14]. It has been found with emergency room visits, readmissions, and duration
that people with inadequate health literacy often of hospital stay.
have difficulty understanding prescription labels,
participating in medical decisions, following medical
recommendations, and attending their follow-up Methods
appointments [15, 16]. Individuals with inadequate or Setting and study participants
marginal health literacy often struggle with poor self- This study was approved by the University of
care behaviors, receive fewer preventive measures, and Saskatchewan Research Ethics Board (Bio#308). This
have increased all-cause mortality [17–23]. Williams prospective cohort study was conducted in the two urban
et al. showed that a quarter of the patients visiting the tertiary care hospitals in Saskatoon, Canada. Based on
emergency department had inadequate health literacy, the assumption that approximately 50% patients will have
and one-third did not understand how many pills inadequate or marginal health literacy and about 10%
should be taken in their prescription [15]. Inadequate pateints will loss to follow up we estimated a smple size
health literacy affects the use of health services and of 150 patients with an alpha error of 0.05 with a 2-sided
impacts patient satisfaction and the physician–patient p value. This sample size was felt to have adequate power
relationship [24]. Furthermore, inadequate health for subgroups analysis. Adult patients admitted to the
literacy is one of the key barriers in the delivery of hospitals’ general internal medicine units were enrolled
effective healthcare and quality outcomes [25]. Low in the study after written informed consent was obtained.
health literacy is considered a key source of economic Research assistants recruited patients over the period
inefficiency in the U.S. healthcare system [25, 26]. of June–September 2019. Patients who could read,
It is estimated that inadequate health literacy adds write, speak English, and were 18 years and older were
additional 106 to $238 billion cost to the health care eligible for enrollment in this study. Patients with known
system representing 7–17% of all personal healthcare diagnoses of dementia were excluded. Participating
expenditures [26]. patients had their visual acuity checked using a pocket
People with inadequate health literacy may utilize Snellen chart to ensure their ability to complete the
more resources through more frequent use of inpatient assessment.
and emergency department visits and have higher care
costs with poorer health outcomes. A systematic review Data collection instrument
examined health literacy in emergency departments and Health literacy was measured using the full-length Test
found that a substantial portion of emergency patients of Functional Health Literacy in Adults (TOFHLA). The
does not have adequate health literacy [27]. Howard TOFHLA was developed and validated as a measure of
et al. found an increase in emergency department use functional health literacy used by healthcare providers
and higher costs for patients with inadequate health and researchers [31]. This tool measures health literacy
literacy (as compared to those with adequate literacy) on the assumption that more than general literacy
after controlling for age, sex, race or ethnicity, income, is necessary to understand and negotiate healthcare
education, health behaviors, and chronic conditions [28]. systems adequately. We used the full-length TOFHLA
Despite the negative implications of low health literacy, as it provides richer information about the levels of
physicians are typically unaware of their patients’ functioning. It is also recommended to use the full-length
health literacy levels and its subsequent effects on their TOFHLA when health literacy is used as a dependent
patients’ outcomes [29]. Health literacy is not routinely or independent variable in research [31]. A license was
Shahid et al. BMC Health Services Research (2022) 22:1148 Page 3 of 9

obtained to reproduce the TOFHLA for use in research some college, and complete college); and Charleston
from Peppercorn Book and Press Inc. Comorbidity Index (CCI).
The TOFHLA assesses an individual’s numeracy and
reading comprehension. In this context, numeracy is Statistical analysis
defined as a patient’s ability to understand and act on Data were analyzed using SPSS (Version 26.0, IBM,
numerical directions given by healthcare providers Armonk, NY, USA) and Stata 13 (Stata Corp, College
or pharmacists, and reading compression is defined Station, TX, USA). Descriptive data were presented for
as a patient’s ability to read passages using actual patient demographics, health literacy levels’ hospital
materials from healthcare settings. The test takes readmissions, emergency department revisits, and
10–20 minutes to complete. The TOFHLA assigns length of stay, including medians with interquartile
scores into three groups of health literacy: adequate, range values, frequencies, and proportions where
marginal, and inadequate. An adequate score ranges applicable. Multivariate logistic regression was
from 75 to 100 and indicates that patients should be performed to examine whether health literacy affects
able to read, understand, and interpret most health a patient’s emergency department revisits and hospital
care texts; a marginal score ranges from 60 to 74 and readmissions, controlling for other possible confounders.
indicates that patients will have difficulty reading and Multiple linear regression modeling was conducted after
interpreting health texts; an inadequate score ranges log-transforming to examine the length of stay variable.
from 0 to 59 and indicates that patients will have Bivariate analyses were conducted first, retaining
difficulty reading, understanding, and interpreting variables significant at the 0.2 alpha level when
most health materials. modeled alone and with an alpha less than 0.05 in the
The primary outcome of interest of this study was final multivariate models. In the multivariate levels,
to determine the correlation between health literacy interactions among independent variables and covariates
and emergency department revisit within 90 days of were examined. If interaction effects were present,
discharge. The secondary outcomes of interest were the mean predicted probabilities with their standard
to assess the correlation between health literacy and deviation were calculated. A two-sided p < 0.05 was
length of stay and hospital readmission within 90 days considered to be significant.
of discharge. Hospital readmission was defined as
any admission, for any cause, to either of the two Patient and public involvement
study hospitals within 90 days after discharge from an Patients were not involved.
index hospitalization. If a patient had a subsequent
admission after their emergency department revisit,
that emergency department revisit was not included Results
in the analysis. We included measures of whether A total 174 (63%) of 278 eligible patients were consented
a patient had readmission (yes or no) and the total to be interviewed (Fig. 1). Patient’s characteristics are
number of readmissions experienced within 90 days described in Table 1. In multivariate analysis 7 (4%)
post-discharge. We categorized readmissions into patients were excluded due to missing data on length
no readmission and ≥ 1 readmission. Similarly, we of stay, ER revisits and hospital readmissions. Overall,
categorized emergency department revisit within 46% were men and 54% were women (ratio men/
90 days after discharge into no revisit and ≥ 1 revisit. women = 1:1.2). Out of the study population, only 50%
Length of stay was kept as a continuous variable in of patients had adequate health literacy, 32 and 18% of
days. All eligible patients close to their discharge from patients had inadequate and marginal health literacy,
a medical unit were provided with the full-length respectively. Of the men, 30.4% had inadequate health
TOFHLA. Patients were prospectively followed, and literacy, 19.0% had marginal health literacy, and 50.6%
the length of their hospital stay was recorded. Data had adequate health literacy; however, of the women,
for hospital readmissions and emergency department 33.0% had inadequate health literacy, 17.0% had marginal
revisits was obtained from the Discharge Abstract health literacy, and 50% had adequate health literacy.
Database (DAD) and National Ambulatory Care Older patients had a significantly higher rate of
Reporting System (NACRS). inadequate health literacy compared to younger patients.
The following covariates were examined: age In patients over 65 years of age, 45.6% had inadequate
groups (< 65 and ≥ 65 years old); sex (male or female); health literacy, 22.8% had marginal health literacy, and
employment status (disabled or injured, retired, and 31.7% had adequate health literacy; however, in patients
other); household income, marital status; education under 65 years of age, 20% had inadequate health literacy,
(some high school or less, completed high school,
Shahid et al. BMC Health Services Research (2022) 22:1148 Page 4 of 9

Fig. 1 Flow chart showing eligible patients

14.4% had marginal health literacy, and 65.6% had the emergency department as compared to patients
adequate health literacy (p < 0.05). with adequate health literacy; the odds ratio (OR) for
Only 24% of patients had full-time employment. inadequate health literacy was 3.0 (95% Confidence
Overall, 26.8% of patients who were full-time employed Interval [CI]: 1.3–6.89, p = 0.01), whereas the OR for
had inadequate or low health literacy as compared with emergency department revisit for marginal health
51.4% of patients who were disabled (< 0.5). Likewise, literacy was 2.28 (95% CI: 0.82–6.32, p = 0.11) (Table 4).
64.9% of patients with no income or annual income The final model for multivariate analysis was adjusted
below $20,000 had inadequate or low health literacy for education, age, sex, CCI, and marital status. In
compared with 25% of patients with an annual income of multivariate analysis, the test for interaction between
$75,000 or greater (< 0.05). Of all patients, 37% received health literacy and education status was positive.
some high school or less education, 19% completed high Therefore, mean predicted probabilities and standard
school, 13% received some college education, and 31% deviations were calculated on the interaction between
completed college. In patients who received some high health literacy and education status.
school or less education, 56.3% had inadequate health In patients with inadequate health literacy, the mean
literacy, 18.8% had marginal health literacy, and 18.4% predicted probability (±SD) of emergency department
had adequate health literacy (p < 0.05). In patients who revisit was 0.22 ± 0.11 if they had received some
completed a college education, 13.0% had inadequate high school or less education and 0.57 ± 0.18 if they
health literacy, 14.8% had marginal health literacy, and had completed a college (Table 5). In other words, in
72.2% had adequate health literacy (p < 0.05). patients with inadequate health literacy, two of ten
Overall, 23% of the patients revisited the emergency with no college education and six of ten with a college
department, and 30% required readmission to the education, revisited the emergency department within
hospital at least once within 90 days after their discharge 90 days of their discharge. In patients with marginal
(Table 2). Characteristics of patients who revisited the health literacy, the mean predicted probability (±SD) of
emergency department are described in Table 3. revisiting the emergency department was 0.25 ± 0.08 if
In univariate analysis, patients who had inadequate they had completed some high school or less education
and marginal health literacy were more likely to revisit and 0.15 ± 0.08 if they had completed a college. In
patients with adequate health literacy, the mean
Shahid et al. BMC Health Services Research (2022) 22:1148 Page 5 of 9

Table 1 Baseline characteristics of study participants admitted in two urban tertiary care hospitals’ medical units
Patients Characteristics n (%) Health Literacy P value
174
Inadequate Marginal Adequate

56 (32.0) 31 (18.0) 87 (50.0)

% % %

Age Group (in years) < 0.05

Under 65 92 (53) 20.0 14.4 65.6
65 and over 82 (47) 45.6 22.8 31.7
Sexa > 0.05
Male 79 (46) 30.4 19.0 50.6
Female 94 (54) 33.0 17.0 50.0
Employment Status < 0.05
Disabled 35 (20) 34.3 17.1 48.6
Retired 84 (48) 42.9 20.2 36.9
Full time 41 (24) 9.8 17.1 73.2
Other 14 (8) 28.6 7.1 64.3
Household Income < 0.05
No income- $20,000 37 (21) 46.0 18.9 35.1
$20,000-$40,000 36 (21) 30.6 27.8 41.7
$40,000- $74,999 25 (14) 24.0 16.0 60.0
$75,000+ 36 (21) 16.7 8.3 75.0
Not stated 40 (23) 40.0 17.5 42.5
Marital Status =0.05
Single/Never married 40 (23) 27.5 22.5 50.0
Divorced/Separated or Widowed 58 (33) 39.7 24.1 36.2
Married 76 (44) 29.0 10.5 60.5
Educationb < 0.05
Some high school or less 64 (37) 56.3 18.7 25.0
Complete high school 33 (19) 30.3 15.2 54.6
Some college 22 (13) 9.1 27.3 63.6
Complete college 54 (31) 13.0 14.8 72.2
Charlson Comorbidity Index (CCI) (mean, SD) 3.10 (2.7) 4.7 (2.7) 3.3 (2.2) 2.0 (2.2) > 0.05
Charlson Comorbidity Index (CCI) (median, IQR) 3.00 (4.0) 4.0 (3.0) 3.0 (3.0) 2.0 (3.0) > 0.05
a
information was missing in 1 patient;b information was missing in 1 paitent

Table 2 Outcomes of interest according to health literacy of the study participants

Outcomes of Interest N (%) Inadequate % Marginal % Adequate % P value
167

ER Revisit < 0.05

No revisit 129 (77) 27.9 16.3 55.8
1 or more than re-visit 38 (23) 47.4 21.1 31.6
Hospital Readmission > 0.05
No readmission 117 (70) 29.1 15.4 55.6
1 or more readmission 50 (30) 40.0 22.0 38.0
Length of Stay in Days (mean, SD) 17.45 (23.01) 19.63 (21.32) 20.24 (27.95) 15.03 (22.20) > 0.05
Length of Stay in Days (median, IQR) 9.00 (15.00) 12.50 (17.50) 13.00 (18.00) 7.5 (12.00) > 0.05
ER Emergency Room, SD Standard Deviation, IQR Interquartile Range
Shahid et al. BMC Health Services Research (2022) 22:1148 Page 6 of 9

Table 3 Characteristics of patients who revisited the emergency had adequate health literacy; however, this was not
department statistically significant (p = 0.115).
Baseline Characteristics Emergency P value The median duration of hospital stay was 9 days.
Department Revisit Patients with inadequate health literacy had a median
N (%) None (%) More
duration of hospital stay of 12.5 days, while patients
than once with marginal and adequate health literacy had median
(%) durations of 13 days and 7.5 days (p > 0.05), respectively.
Health Literacy Score 0.02
Regarding the length of stay, in univariate regression
Inadequate 54 (32.3) 66.7 33.3
analysis, the average duration was higher for patients
Marginal 29 (17.3) 72.4 27.6
with marginal and inadequate health literacy; however,
Adequate 84 (50.3) 85.7 14.3
this was not statistically significant.
Age Group (in years) 0.54
Under 65 87 (52.5) 77.7 22.4
Discussion
Our findings indicate a low rate of adequate health
65 and over 80 (47.5) 76.6 23.4
literacy in hospitalized patients in medical units. Only
Sex 0.89
about 50% of hospitalized patients had adequate health
Male 77 (46.4) 76.6 23.4
literacy, suggesting that almost half of the hospitalized
Female 90 (53.6) 77.5 22.5
patients in medical units have difficulty reading,
Education 0.21
understanding, and interpreting healthcare information.
Some high school or less 61 (36.8) 77.1 23.0
Patients with inadequate health literacy were more
Complete high school 33 (19.9) 66.7 33.3
likely to revisit the emergency department as compared
Some college 22 (13.3) 72.7 27.3
to patients with adequate health literacy. Patients with
Complete college 50 (30.1) 86.0 14.0
low health literacy, but high education, had a higher
probability of emergency department revisits. No
significant correlation was noted between health literacy
predicted probability (±SD) of revisiting the emergency and duration of hospital stay or readmission.
department was 0.24 ± 0.12 if they had received some To the best of our knowledge, there is a scarcity of
high school and or less education and 0.10 ± 0.04 if research on health literacy, and its impact on patients’
they had completed college. emergency department revisits and hospital readmissions
In the univariate analysis of all patients who had at after their discharge from the medical units in hospitals.
least one hospital readmission, 40% had marginal health The reported prevalence of inadequate health literacy in
literacy, 22% had inadequate health literacy, and 38% hospital settings ranges from 29 to 76.7% in the literature

Table 4 Univariate logistic regression results for health literacy levels, emergency department revisits, and hospital readmissions’
association
Emergency Department Revisit P value Hospital Readmission P value
­ORunadj (95% CI)b ORunadj (95% CI)b

Total health literacy Inadequate 3.00 (1.30–6.90) 0.01 2.01 (0.95–4.27) 0.069
scorea
Marginal 2.28 (0.82–6.32) 0.11 2.01 (0.84–5.18) 0.111
a
Reference: Adequate, b ORunadj. Unadjusted Odds Ratio, CI Confidence Interval

Table 5 Mean predicted probabilities for emergency department revisit stratified by education levels and health literacy s­ coresa
Health Literacy Some High School or Less Complete High School Some College Complete College
Mean (SD) Mean (SD) Mean (SD) Mean (SD)

Inadequate 0.22 (0.11) 0.50 (0.19) 0.50 (0.10) 0.57 (0.18)

(0–59 points)
Marginal (60–74 points) 0.25 (0.08) 0.4 (0.19) 0.33 (0.21) 0.15 (0.08)
Adequate (75+ points) 0.24 (0.12) 0.22 (0.11) 0.23 (0.11) 0.05 (0.04)
SD Standard Deviation, aAdjusted For Age, Sex, Education, Marital Status, And Comorbidity (Cci)
Shahid et al. BMC Health Services Research (2022) 22:1148 Page 7 of 9

[32–34]. This wide range can be due to the use of different and delays in seeking medical attention could result in
health literacy tools in diverse patient populations. There detrimental effects on their health outcomes.
was no difference in health literacy scores between men This study has many implications and contributions
and women in this study which is consistent with the to society and the medical field at large. Our findings
literature [35]. Our findings indicate that a higher number underscore the importance of health literacy
of patients older than 65 years of age had inadequate or interventions. Health education can reduce a patient’s
marginal health literacy as compared to younger patients, probability of revisiting the emergency department. It is
which is also found in previous research [34, 36]. The vital to develop and evaluate interventions that run from
lower level of health literacy in the older population during a patient’s stay in hospital to their discharge that
could be due to the decline in comprehension, memory, aim to improve health knowledge. Similarly, it would be
and word recognition abilities that occur in older age. necessary to explore factors outside the hospital setting
Although patients with a known diagnosis of dementia that decreases emergency department revisits for patients
were excluded [37], some may have had undetected mild with low health literacy. These factors could include access
cognitive deficits, which influenced this study’s results. In to primary care physicians, support in the community,
addition, social determinants of health, including low or and knowledge of underlying medical illnesses [39].
no income or disability, were correlated with a lower level Unlike earlier reports [40–43], this study did not find
of health literacy. a significant association between low health literacy and
We found that patients with low health literacy scores duration of stay or hospital readmission. Patients with
had a higher probability of emergency department inadequate or marginal health literacy had an average
revisits when controlling for other factors, including length of stay almost twice that of patients with adequate
age, sex, marital status, comorbidity, and education health literacy; however, this was not statistically
level. Notably, we observed that patients with low health significant in univariate analysis.
literacy and low education levels had a significantly lower The key strengths of our study are that patients were
probability of revisiting the emergency department followed prospectively, and a validated tool was used
compared to patients with low health literacy and high to assess health literacy. Furthermore, we were able to
education levels. It has been previously shown that low adjust for essential variables in multivariate modeling.
education was associated with a higher probability of However, our study has some limitations; significant
emergency department visits after surgery [38]. The data limitations are that non-English speaking patients were
data in patients who were admitted to general internal not included, and the sample size was relatively small.
medicine is sparse. A retrospective secondary analysis We were not able to capture if patients had readmission
of clinical trial dataset in medical patients examined or revisits to the ER for the same or differrent medical
the relationship between health literacy and hospital conditions due to multiple medical conditons. In
reutilization within 30 days of discharge [32]. The study addition, instead of short TOFHLA we used full-lenght
showed that 49% patients had inadequate or marginal TOFHLA which takes about 20 minutes to complete. A
health literacy and that inadequate health literacy was an comprehensive measurement of health litrecacy in the
independent factor for 30-day hospital reutilization after acute care setting may be challenging for some patients
discharge. as refelcted by 37% refusal rate to particpate in our
Given our findings, it is plausible that not only education study. Lastly, our patient population was sampled from
but education and health literacy combined have an two tertiary care hospitals, and although both hospitals
essential role in the probability of patients revisiting the received referrals from remote communities, most of
emergency department and thus their health outcomes. the patients were likely from urban areas; therefore,
To our knowledge, this study is the first to report that rural and remote populations were underrepresented in
patients with low health literacy but high education have a this sample, making the results not generalizable to the
higher probability of revisiting the emergency department greater population.
than patients with low health literacy and low education.
Further data is needed to identify the critical factors in
this result. It is plausible that patients with low education Conclusions
and low health literacy are not fully aware of the harmful Our results indicate that only half of the patients
effects of underlying illness and are, therefore, less likely admitted to general internal medicine units have
to seek early medical attention. Patients with low health adequate health literacy. Patients with inadequate or
literacy may not fully understand and follow the medical marginal health literacy scores are more likely to revisit
instructions provided to them at their hospital discharge, the emergency room within 90 days following their
and the consequent inability to attend follow-up visits discharge from the hospital. It is prudent to address the
Shahid et al. BMC Health Services Research (2022) 22:1148 Page 8 of 9

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This study was approved by the University of Saskatchewan Biomedical
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