***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: RATIONALE Although inadequate health literacy has been associated with lower asthma medication knowledge and worse metered-dose inhaler ( MDI ) technique , the relationship between health literacy and the capacity to learn asthma self-management skills is unknown . OBJECTIVES In this prospect i ve cohort study of adults hospitalized for severe asthma exacerbations at two inner-city hospitals , we examined the relationship between inadequate health literacy and difficulties learning and retaining instructions about discharge medications and appropriate MDI technique . METHODS At hospital discharge , participants received one-on-one , 30-min , guideline -based , written and oral instruction about their asthma discharge regimen as well as appropriate MDI technique . MEASUREMENTS AND MAIN RESULTS Seventy-three patients were enrolled . Inadequate health literacy was identified in 16 ( 22 % ) participants . Before instruction , inadequate health literacy was associated with lower asthma medication knowledge ( 5.2/10 vs. 7.2/10 , p < 0.001 ) and worse MDI technique ( 3.2/6 vs. 3.9/6 , p = 0.03 ) . However , inadequate health literacy was not associated with difficulty learning ( p = 0.33 ) or retaining ( p = 0.35 ) instructions about the discharge regimen . Similarly , inadequate health literacy was not associated with difficulty learning ( p = 0.26 ) or retaining ( p = 0.97 ) appropriate MDI technique . Results were similar in multivariable models adjusted for demographic characteristics and asthma severity indicators . CONCLUSIONS These findings suggest that inadequate health literacy is a surmountable barrier to learning and remembering key asthma self-management skills Objective To evaluate the effect of a video decision support tool on the preferences for future medical care in older people if they develop advanced dementia , and the stability of those preferences after six weeks . Design R and omised controlled trial conducted between 1 September 2007 and 30 May 2008 . Setting Four primary care clinics ( two geriatric and two adult medicine ) affiliated with three academic medical centres in Boston . Participants Convenience sample of 200 older people ( ≥65 years ) living in the community with previously scheduled appointments at one of the clinics . Mean age was 75 and 58 % were women . Intervention Verbal narrative alone ( n=106 ) or with a video decision support tool ( n=94 ) . Main outcome measures Preferred goal of care : life prolonging care ( cardiopulmonary resuscitation , mechanical ventilation ) , limited care ( admission to hospital , antibiotics , but not cardiopulmonary resuscitation ) , or comfort care ( treatment only to relieve symptoms ) . Preferences after six weeks . The principal category for analysis was the difference in proportions of participants in each group who preferred comfort care . Results Among participants receiving the verbal narrative alone , 68 ( 64 % ) chose comfort care , 20 ( 19 % ) chose limited care , 15 ( 14 % ) chose life prolonging care , and three ( 3 % ) were uncertain . In the video group , 81 ( 86 % ) chose comfort care , eight ( 9 % ) chose limited care , four ( 4 % ) chose life prolonging care , and one ( 1 % ) was uncertain ( χ2=13.0 , df=3 , P=0.003 ) . Among all participants the factors associated with a greater likelihood of opting for comfort care were being a college graduate or higher , good or better health status , greater health literacy , white race , and r and omisation to the video arm . In multivariable analysis , participants in the video group were more likely to prefer comfort care than those in the verbal group ( adjusted odds ratio 3.9 , 95 % confidence interval 1.8 to 8.6 ) . Participants were re-interviewed after six weeks . Among the 94/106 ( 89 % ) participants re-interviewed in the verbal group , 27 ( 29 % ) changed their preferences ( κ=0.35 ) . Among the 84/94 ( 89 % ) participants re-interviewed in the video group , five ( 6 % ) changed their preferences ( κ=0.79 ) ( P<0.001 for difference ) . Conclusion Older people who view a video depiction of a patient with advanced dementia after hearing a verbal description of the condition are more likely to opt for comfort as their goal of care compared with those who solely listen to a verbal description . They also have more stable preferences over time . Trial registration Clinical trials.gov NCT00704886 OBJECTIVE To evaluate a clinic-based multimedia intervention for diabetes education targeting individuals with low health literacy levels in a diverse population . RESEARCH DESIGN AND METHODS Five public clinics in Chicago , Illinois , participated in the study with computer kiosks installed in waiting room areas . Two hundred forty-four subjects with diabetes were r and omized to receive either supplemental computer multimedia use ( intervention ) or st and ard of care only ( control ) . The intervention includes audio/video sequences to communicate information , provide psychological support , and promote diabetes self-management skills without extensive text or complex navigation .  HbA(1c ) ( A1C ) , BMI , blood pressure , diabetes knowledge , self-efficacy , self-reported medical care , and perceived susceptibility of complications were evaluated at baseline and 1 year . Computer usage patterns and implementation barriers were also examined . RESULTS Complete 1-year data were available for 183 subjects ( 75 % ) . Overall , there were no significant differences in change in A1C , weight , blood pressure , knowledge , self-efficacy , or self-reported medical care between intervention and control groups . However , there was an increase in perceived susceptibility to diabetes complications in the intervention group . This effect was greatest among subjects with lower health literacy . Within the intervention group , time spent on the computer was greater for subjects with higher health literacy . CONCLUSIONS Access to multimedia lessons result ed in an increase in perceived susceptibility to diabetes complications , particularly in subjects with lower health literacy . Despite measures to improve informational access for individuals with lower health literacy , there was relatively less use of the computer among these participants Background Self-management programs for patients with heart failure can reduce hospitalizations and mortality . However , no programs have analyzed their usefulness for patients with low literacy . We compared the efficacy of a heart failure self-management program design ed for patients with low literacy versus usual care .  Methods We performed a 12-month r and omized controlled trial . From November 2001 to April 2003 , we enrolled participants aged 30–80 , who had heart failure and took furosemide .  Intervention patients received education on self-care emphasizing daily weight measurement , diuretic dose self-adjustment , and symptom recognition and response . Picture-based educational material s , a digital scale , and scheduled telephone follow-up were provided to reinforce adherence . Control patients received a generic heart failure brochure and usual care . Primary outcomes were combined hospitalization or death , and heart failure-related quality of life . Results 123 patients ( 64 control , 59 intervention ) participated ; 41 % had inadequate literacy . Patients in the intervention group had a lower rate of hospitalization or death ( crude incidence rate ratio ( IRR ) = 0.69 ; CI 0.4 , 1.2 ; adjusted IRR = 0.53 ; CI 0.32 , 0.89 ) . This difference was larger for patients with low literacy ( IRR = 0.39 ; CI 0.16 , 0.91 ) than for higher literacy ( IRR = 0.56 ; CI 0.3 , 1.04 ) , but the interaction was not statistically significant . At 12 months , more patients in the intervention group reported monitoring weights daily ( 79 % vs. 29 % , p < 0.0001 ) . After adjusting for baseline demographic and treatment differences , we found no difference in heart failure-related quality of life at 12 months ( difference = -2 ; CI -5 , + 9 ) . Conclusion A primary care-based heart failure self-management program design ed for patients with low literacy reduces the risk of hospitalizations or death PURPOSE This study examined the role of literacy in patients with poorly controlled diabetes who were participating in a diabetes management program that included low-literacy-oriented interventions . METHODS A before-after analysis was performed of a pharmacist-led diabetes management program for 159 patients with type 2 diabetes and poor glycemic control ( hemoglobin A1c [ A1C ] > or = 8.0 % ) .  Clinic-based pharmacists offered one-to-one education and medication management for these patients using techniques that did not require high literacy . Literacy was measured by the Rapid Estimate of Adult Literacy in Medicine ( REALM ) test and dichotomized at the 6th- grade level . The A1C values were collected prior to enrollment , at enrollment , and approximately 6 months after enrollment . RESULTS Of the 111 patients with follow-up data , 55 % had literacy levels at the 6th- grade level or below . Lower literacy was more common among African Americans , older patients , and patients who required medication assistance . There was no significant relationship between literacy status and A1C prior to enrollment or at enrollment . Over the 6-month study period , patients with low and high literacy had similar improvements in A1C . CONCLUSIONS This diabetes care program , which used individualized teaching with low-literacy techniques , significantly improved A1C values independent of literacy status PURPOSE Low health literacy is a significant problem in the United States . At the same time written screening tools such as the American Urological Association symptom score are used more frequently at hospitals and clinics . We previously reported that many patients do not fully underst and this tool and often provide inaccurate information . To combat this problem we developed a novel multimedia version of the American Urological Association symptom score . MATERIAL S AND METHODS In this r and omized , controlled trial we divided 232 patients into a control arm that self-administered the traditional written version of the symptom score and an experimental arm that self-administered the new multimedia version .  Patients in each arm were later administered the tool a second time by an interviewer for comparison . Using multivariate analysis we measured disagreement between the self-administered and interviewer administered scores , and compared the 2 arms . RESULTS Patients assigned the written and the multimedia version showed an average error of 3.48 and 1.97 , respectively ( p < 0.001 ) , for a 43 % decrease . Improvement was noted regardless of patient literacy . Errors by patients with low and high literacy decreased from 4.55 to 2.24 and 3.10 to 1.86 ( p = 0.03 and < 0.001 , respectively ) . CONCLUSIONS As a model , the American Urological Association symptom score multimedia version represents an exciting opportunity to improve many other written screening tools since it increased underst and ing and decreased scoring errors across all literacy levels , possibly allowing physicians to treat patients more effectively BACKGROUND To improve medication adherence in cardiac patients , in partnership with a safety-net provider , this research team developed and evaluated a low-literacy medication education tool . METHODS Using principles of community-based participatory research , the team developed a prototype of a low-literacy hospital discharge medication education tool , customizable for each patient , featuring instruction-specific icons and pictures of pills . In 2007 , a r and omized controlled clinical trial was performed , testing the tool 's effect on posthospitalization self-reported medication adherence and knowledge , 2 weeks postdischarge in English- and Spanish-speaking safety-net in patients . To vali date the self-report measure , 4 weeks postdischarge , investigators collected self-reports of the number of pills remaining for each medication in a sub sample of participants . Nurses rated tool acceptability . RESULTS Among the 166/210 eligible participants ( 79 % ) completing the Week-2 interview , self-reported medication adherence was 70 % ( 95 % CI=62 % , 79 % ) in intervention participants and 78 % ( 95 % CI=72 % , 84 % ) in controls ( p=0.13 ) . Among the 85 participants ( 31 % ) completing the Week-4 interview , self-reported pill counts indicated high adherence ( greater than 90 % ) and did not differ between study arms . Self-reported adherence was correlated with self-reported pill count in intervention participants ( R=0.5 , p=0.004 ) but not in controls ( R=0.07 , p=0.65 ) . There were no differences by study arm in medication knowledge . The nurses rated the tool as highly acceptable . CONCLUSIONS Although the evaluation did not demonstrate the tool to have any effect on self-reported medication adherence , patients who received the schedule self-reported their medication adherence more accurately , perhaps indicating improved underst and ing of their medication regimen and awareness of non-adherence The impact of an adherence enhancement program for low income HIV-infected Spanish-speaking Latinos on health literacy , patient-provider relationships , and adherence to HAART was examined . Evaluations were conducted at baseline , 6 weeks , and 6 months for participants ( n = 85 ) r and omly assigned to either the intervention group or a comparison group ; 69 ( 81 % ) remained in the study for the entire 6-month duration . The intervention group scored significantly better than the comparison group on 3 of 5 measures of HIV health literacy at 6 weeks and on 2 of 5 measures , at 6 months . While there was a weak trend for the intervention group to report an increase in self-efficacy of medication adherence management , baseline to 6 weeks , no other changes were significant . Perceptions of the quality of relationship and communications with their HIV-treating phys 
    Output:
    
In a few studies , we also found consistent , direct , fair or good- quality evidence that  intensive self-management interventions reduced emergency department visits and hospitalizations ; and  intensive self- and disease-management interventions reduced disease severity .
Multiple interventions show promise for mitigating the effects of low health literacy and could be considered for use in clinical practice