***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 determine whether or not limited caregiver health literacy is associated with adherence to a daily multi-vitamin with iron regimen in infants . METHODS 110 caregiver/infant dyads were enrolled in a prospect i ve study to assess the relationship between caregiver health literacy and adherence to a daily multi-vitamin with iron regimen for infants . Households were contacted biweekly over a 3-month period . Adherence was based upon caregiver report . High adherence , our primary outcome , was defined as the administration of the  multi-vitamin with iron  on 5 - 7 days over the past week . RESULTS As measured by the Short Test of Functional Health Literacy in Adults ( S-TOFHLA ) , 18 % of caregivers had limited health literacy skills . Caregivers with limited health literacy skills were more likely to have higher adherence than caregivers with adequate health literacy , after adjusting for a number of possible confounding variables ( AOR=2.13 ; 95 % 1.20 - 3.78 ) . CONCLUSION Caregivers with limited health literacy were twice as likely to report high adherence to a daily multi-vitamin with iron regimen in infants as caregivers with adequate health literacy in adjusted analysis . PRACTICE IMPLICATION S Health literacy may exert a differential influence on adherence depending upon the complexity of the desired health behavior We determined the factors associated with exacerbation of heart failure , using a cohort ( n = 192 ) nested within a r and omized trial at a university‐affiliated ambulatory practice . Factors associated with emergency or hospital care included left ventricular ejection fraction , hematocrit and serum sodium levels , refill adherence , and the ability to read a prescription label . Refill adherence of < 40 % was associated with a threefold higher incidence of hospitalization for heart failure than a refill adherence of ≥80 % ( P = 0.002 ) . In multivariable analysis , prescription label reading skills were associated with a lower incidence of heart failure – specific emergency care ( incidence rate ratio , 0.76 ; 95 % confidence interval ( CI ) , 0.19–0.69 ) , and participants with adequate health literacy had a lower risk of hospitalization for heart failure ( incidence rate ratio , 0.34 ; 95 % CI , 0.15–0.76 ) . We conclude that inadequate treatment adherence and health literacy skills are key factors in the exacerbation of heart failure . These findings emphasize the need for careful instruction of patients about their medications OBJECTIVE To assess the impact of numeracy and health literacy on client 's ability to learn information orally communicated during a BRCA 1/2 genetic counseling session . METHODS Fifty-nine  videotaped simulated genetic counseling sessions were shown to 246 analogue clients ( AC ) recruited to imagine themselves as the client in the genetic counseling session . AC numeracy , genetic literacy , state and trait anxiety , and decisional conflict were assessed . The primary outcome was AC learning about BRCA 1/2 . RESULTS Health literacy and numeracy were moderately correlated , and each independently predicted learning . Higher numeracy was associated with higher knowledge scores only among ACs with adequate literacy . Decisional conflict was not related to literacy , numeracy , or knowledge acquisition . It was , however , inversely related to state anxiety so that the higher post-session state anxiety , the lower the AC 's decisional conflict . CONCLUSION Numeracy and health literacy are associated with learning of orally communicated information during genetic counseling . It appears that numeracy can facilitate learning for literate subjects ; it does not , however , make any difference in learning ability of clients with significant literacy deficits . PRACTICE IMPLICATION S Numeracy plays an important role in client 's ability to learn information communicated during medical sessions , especially among clients who are otherwise regarded as literate CONTEXT Although the ability to work with numbers is important to the practice of medicine , little is known about physician numeracy ( basic skill with numbers ) . OBJECTIVE To test medical students ' numeracy and how it relates to the ability to interpret risk-reduction information . DESIGN R and omized , cross-sectional survey . SAMPLE 62 first-year medical students at the University of North Carolina at Chapel Hill medical school who attended a risk-communication seminar and had usable survey data ( 46 % of the 134 students who received the survey ) . INTERVENTION Students were given information about the baseline risk for developing a hypothetical disease and were r and omly assigned to one of four risk-reduction presentations-relative risk reduction , absolute risk reduction , number needed to treat ( NNT ) , or a combination of these three formats-about how two drugs would reduce this risk . OUTCOME MEASURES Number of correct answers to three numeracy questions ( stating that 500 heads would be expected in 1000 coin flips ; converting " 1 % of 1000 " to 10 ; and converting " 1 in 1,000 " to 0.1 % ) . Correct data interpretation was judged with two tasks : a comparative task ( i.e. , state which drug provides greater benefit ) and a quantitative task ( i.e. , calculate how much one of the drugs reduces disease risk ) . RESULTS 77 % of students answered all three numeracy questions correctly ; 18 % answered two correctly ; and 5 % answered one or none correctly . While 90 % correctly stated which drug worked better , only 61 % accurately interpreted the quantitative data . The ability to interpret data varied with numeracy : 71 % of students who answered all three numeracy questions correctly also accurately interpreted the quantitative data , compared with 36 % who answered two questions correctly and 0 % who answered one or no questions correctly ( P < 0.01 ) . Correct quantitative interpretation was lower with the NNT format than with the other three formats ( 25 % vs. 75 % ; P = 0.01 ) . CONCLUSIONS Almost one quarter of first-year medical students in our study had trouble performing basic numerical tasks . Those who had trouble also seemed to have difficulty interpreting medical data . This difficulty seemed to be exacerbated by presenting data in the NNT format Background Low health literacy and low cognitive abilities both predict mortality , but no study has jointly examined these relationships . Methods We conducted a prospect i ve cohort study of 3,260 community-dwelling adults age 65 and older . Participants were interviewed in 1997 and administered the Short Test of Functional Health Literacy in Adults and the Mini Mental Status Examination . Mortality was determined using the National Death Index through 2003 . Measurements and Main Results In multivariate models with only literacy ( not cognition ) , the adjusted hazard ratio was 1.50 ( 95 % confidence of interval [ CI ] 1.24–1.81 ) for inadequate versus adequate literacy . In multivariate models without literacy , delayed recall of 3 items and the ability to serial subtract numbers were associated with higher mortality ( e.g. , adjusted hazard ratios [ AHR ] 1.74 [ 95 % CI 1.30–2.34 ] for recall of zero versus 3 items , and 1.32 [ 95 % CI 1.09–1.60 ] for 0–2 vs 5 correct subtractions ) . In multivariate analysis with both literacy and cognition , the AHRs for the cognition items were similar , but the AHR for inadequate literacy decreased to 1.27 ( 95 % CI 1.03 – 1.57 ) . Conclusions Both health literacy and cognitive abilities independently predict mortality . Interventions to improve patient knowledge and self-management skills should consider both the reading level and cognitive dem and s of the material OBJECTIVE To determine the effectiveness of a pictorial ' mind map ' together with the Arthritis Research Campaign ( ARC ) booklet for imparting knowledge to participants with rheumatoid arthritis ( RA ) . Also , we wished to relate this to their reading ability . METHODS We studied 363 participants with RA . Reading ability was assessed using the REALM , and knowledge was assessed using the Knowledge Scale Question naire ( KSQ ) . Information on educational attainment , disease state and levels of anxiety and depression was also collected . Participants were r and omly assigned to receive either the ARC booklet alone or the booklet and the mind map together . RESULTS A significant minority ( 15 % ) of participants were functionally illiterate .  There was a statistically significant increase in knowledge across both groups from baseline to re assessment after they were given the literature , but there was no difference in attainment between the groups . The more literate participants gained more knowledge regardless of the information they were given . They were also significantly less anxious and less depressed . CONCLUSIONS The ARC booklet with or without the mind map was associated with a significant increase in knowledge .  Poor readers had poor educational attainment and poor knowledge acquisition . The information on the mind map was not more accessible to them . Different educational strategies will be necessary to educate these patients Background Limited literacy is common among patients with chronic conditions and is associated with poor health outcomes . We sought to determine the association between literacy and blood pressure in primary care patients with hypertension and to determine if this relationship was consistent across distinct systems of healthcare delivery . Methods We conducted a cross-sectional study of 1224 patients with hypertension utilizing baseline data from two separate , but similar r and omized controlled trials . Patients were enrolled from primary care clinics in the Veterans Affairs healthcare system ( VAHS ) and a university healthcare system ( UHS ) in Durham , North Carolina . We compared the association between literacy and the primary outcome systolic blood pressure ( SBP ) and secondary outcomes of diastolic blood pressure ( DBP ) and blood pressure ( BP ) control across the two different healthcare systems . Results Patients who read below a 9th grade level comprised 38.4 % of patients in the VAHS and 27.5 % of the patients in the UHS . There was a significant interaction between literacy and healthcare system for SBP . In adjusted analyses , SBP for patients with limited literacy was 1.2 mmHg lower than patients with adequate literacy in the VAHS ( 95 % CI , -4.8 to 2.3 ) , but 6.1 mmHg higher than patients with adequate literacy in the UHS ( 95 % CI , 2.1 to 10.1 ) ; ( p = 0.003 for test of interaction ) . This literacy by healthcare system interaction was not statistically significant for DBP or BP control . Conclusion The relationship between patient literacy and systolic blood pressure varied significantly across different models of healthcare delivery . The attributes of the healthcare delivery system may influence the relationship between literacy and health outcomes Background Inconsistent findings reported in the literature contribute to the lack of complete underst and ing of the association of literacy with health outcomes . We evaluated the association between literacy , physiologic control and diabetes complications among adults with diabetes . Methods A cross-sectional study of 1,002 English speaking adults with diabetes , r and omly selected from the Vermont Diabetes Information System , a cluster-r and omized trial of a diabetes decision support system in a region-wide sample of primary care practice s was conducted between July 2003 and March 2005 . Literacy was assessed by the Short-Test of Functional Health Literacy in Adults . Outcome measures included glycated hemoglobin , low density lipoprotein , blood pressure and self-reported complications . Results After adjusting for sociodemographic characteristics , duration of diabetes , diabetes education , depression , alcohol use , and medication use we did not find a significant association between literacy and glycemic control ( beta coefficent,+ 0.001 ; 95 % confidence interval [ CI ] , -0.01 to + 0.01 ; P = .88 ) , systolic blood pressure ( beta coefficent , + 0.08 ; 95 % CI , -0.10 to + 0.26 ; P = .39 ) , diastolic blood pressure ( beta coefficent , -0.03 ; 95 % CI , -0.12 to + 0.07 , P = .59 ) , or low density lipoprotein ( 
    Output:
    
Poor health literacy partially explains racial disparities in some outcomes .
Review ers could not reach firm conclusions about the relationship between numeracy and health outcomes because of few studies or inconsistent results among studies .
No evidence concerning oral health literacy ( speaking and listening skills ) and outcomes was found .
Low health literacy is associated with poorer health outcomes and poorer use of health care services .