Health literacy has been defined as the ability to obtain, process, and understand the basic health information that is needed to make appropriate healthcare decisions. Studies have shown that many adults in the United States have limited health literacy. This can lead to underuse of preventative services, worse self-management skills, and poor outcomes among patients with chronic diseases. “The role of health literacy in COPD and its effect on health status and outcomes have received relatively little attention in clinical studies,” says Theodore A. Omachi, MD, MBA. “Understanding the role of health literacy in COPD outcomes is critical to informing communication strategies in clinical settings and developing appropriate self-management support approaches.”

Poor Health Literacy and COPD Outcomes

In the Journal of General Internal Medicine, Dr. Omachi and colleagues had a study published that explored the links between poor health literacy and COPD-related health and outcomes in 277 patients with the disease. The analysis measured health literacy with a validated three-item questionnaire that can be incorporated readily into routine clinical practice:

“How often do you have someone like a family member, friend, hospital or clinic worker, or caregiver help you read hospital materials?”

“How often do you have problems learning about your medical condition because of difficulty understanding written information?”

“How confident are you filling out medical forms by yourself?”

Scores on the questionnaire were then tabulated to measure health literacy on a point scale ranging from 3 to 15.

“It’s becoming increasingly clear that improving self-management is key to preventing poor outcomes in chronic diseases.”

According to the study, lower health literacy scores were associated with worse outcomes, including hospitalization and ED visits (Figure 1). Patients who scored in the lowest third for health literacy also had worse disease severity, greater COPD-related learned helplessness, and worse respiratory-specific quality of life than those scoring in the top third.

As expected, better health literacy scores correlated with greater educational attainment and higher income. Nonetheless, these findings remained even after controlling for poor health literacy’s relationship not only with sociodemographic factors, but also with education and income (Figure 2).



Overall, 14% of patients reported visiting an emergency room, and 8% were admitted to a hospital due to COPD in the year leading up to the survey. “When compared with patients with higher health literacy, those with lower health literacy scores were almost five times more likely to go to the ED for their COPD,” notes Dr. Omachi. “They were almost seven times as likely to have been hospitalized for their COPD.”

Important Implications: COPD Patients at Risk

Results from the study by Dr. Omachi and colleagues underscore that COPD patients with poor health literacy may be at particular risk for poor health-related outcomes. “It’s becoming increasingly clear that improving self-management is key to preventing poor outcomes in chronic diseases,” Dr. Omachi says. “Improvements in self-management skills are one way to potentially decrease healthcare utilization in patients with limited health literacy. For COPD, patients need to be better educated about how to use inhaled medications and recognize when acute medical attention is needed. It’s a daunting task, especially for clinicians managing patients who have trouble understanding medical information or obtaining such information of their own initiative.”

In previous studies, several tools have been identified to help reinforce advice and information given during patient consultations. These include using written or pictorial information materials, telephone consultations and reviews, and posters, audiotapes, videos, and DVDs. “For my patients with limited health literacy,” notes Dr. Omachi, “I have found that one of the most effective and proven communication strategies is the ‘teach-back’ method. Using this strategy, patients reiterate to me their understanding of my recommendations.”

Investing Resources Into COPD Self-Management

Developing system-based strategies to improve communication and understanding in COPD patients with limited health literacy may potentially improve outcomes. “Similar approaches have achieved some success in diabetes and heart failure,” adds Dr. Omachi. “However, more research is needed to elucidate causal pathways and potential interventions for COPD.”

Demonstrating a relationship between poorer health literacy and worse outcomes specifically in COPD is an important step for disease-specific interventions, according to Dr. Omachi. “It’s hoped that our study can serve as a basis for such interventions and increase awareness of health literacy issues among physicians caring for these patients. This is an issue that cannot be ignored if we truly want to decrease the burden of disease. It’s critical that we don’t miss opportunities to use effective interventions and that we invest more in resources for COPD self-management training directed at those with more limited health literacy.”