***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 Background Insecticide-treated bed nets ( ITN ) provide real hope for the reduction of the malaria burden across Africa . Underst and ing factors that determine access to ITN is crucial to debates surrounding the optimal delivery systems . The influence of homestead wealth on use of nets purchased from the retail sector is well documented , however , the competing influence of mother 's education and physical access to net providers is less well understood . Methods Between December 2004 and January 2005 , a r and om sample of 72 rural communities was selected across four Kenyan districts .  Demographic , assets , education and net use data were collected at homestead , mother and child ( aged < 5 years ) levels . An assets-based wealth index was developed using principal components analysis , travel time to net sources was modelled using geographic information systems , and factors influencing the use of retail sector nets explored using a multivariable logistic regression model . Results Homestead heads and guardians of 3,755 children < 5 years of age were interviewed . Approximately 15 % ( 562 ) of children slept under a net the night before the interview ; 58 % ( 327 ) of the nets used were purchased from the retail sector . Homestead wealth ( adjusted OR = 10.17 , 95 % CI = 5.45–18.98 ) , travel time to nearest market centres ( adjusted OR = 0.51 , 95 % CI = 0.37–0.72 ) and mother 's education ( adjusted OR = 2.92 , 95 % CI = 1.93–4.41 ) were significantly associated with use of retail sector nets by children aged less than 5 years . Conclusion Approaches to promoting access to nets through the retail sector disadvantage poor and remote communities where mothers are less well educated When using community-based participatory methods to develop health promotion programs for specific communities , it is important to determine if participation differs based on sociodemographics and the extent to which program participants are demographically representative of the target community , especially when non-r and om recruitment methods are used . We evaluated rates of participating in a  health promotion program  among African American residents in an urban community and determined if program participants were representative of community residents in terms of sociodemographic factors  . While participation in the program was modest , participation did not differ based on psychological factors or body mass index . However , individuals who were unemployed were significantly more likely to participate in the program compared with those who were employed . Our sample included a greater proportion of individuals who only had a high school education compared with community residents but was similar to community residents in terms of gender , marital status and employment Background We examined independent influences of context ual variables on  cardiovascular risk factors in Shilin county , Yunnan province , South-west China . Methods Three villages were selected from each of the ten townships based on probability proportional to size . In each selected village , 200 individuals aged ≥ 45 years were chosen based on simple r and om sampling method . From 6006 individuals , information on demographic characteristics , smoking and drinking status was obtained by interview . Blood pressure , height , weight , and waist and hip girth were measured .  Fasting blood sugar  was measured in a 10-percent sub sample . Context ual data were from official reports . Multi-level regression modelling with adjustment for individual and context ual variables was used . Results Context ual variables associated with CVD risk factors included : remoteness of village with higher blood pressure and fasting blood sugar , high proportion of Yi minority with drinking , high literacy rate with a lower rate of smoking and a lower mean waist-hip ratio , and high average income with lower systolic blood pressure and body mass index ( BMI ) but higher FBS . Conclusion While context ual SES is associated with a few CVD risk factors , villages with high level of income are worse off in fasting blood sugar . Strategies of economic development should be review ed to avoid adverse effects on health BACKGROUND Developmental impairments in children have been attributed to persistent middle-ear effusion in their early years of life . Previously , we reported that among children younger than 3 years of age with persistent middle-ear effusion , prompt as compared with delayed insertion of tympanostomy tubes did not result in improved cognitive , language , speech , or psychosocial development at 3 , 4 , or 6 years of age . However , other important components of development could not be assessed until the children were older . METHODS We enrolled 6350 infants soon after birth and evaluated them regularly for middle-ear effusion . Before 3 years of age , 429 children with persistent effusion were r and omly assigned to undergo the insertion of tympanostomy tubes either promptly or up to 9 months later if effusion persisted . We assessed literacy , attention , social skills , and academic achievement in 391 of these children at 9 to 11 years of age . RESULTS Mean ( + /-SD ) scores on 48 developmental measures in the group of children who were assigned to undergo early insertion of tympanostomy tubes did not differ significantly from the scores in the group that was assigned to undergo delayed insertion . These measures included the Passage Comprehension subtest of the Woodcock Reading Mastery Tests ( mean score , 98+/-12 in the early-treatment group and 99+/-12 in the delayed-treatment group ) ; the Spelling , Writing Sample s , and Calculation subtests of the Woodcock-Johnson III Tests of Achievement ( 96+/-13 and 97+/-16 ; 104+/-14 and 105+/-15 ; and 99+/-13 and 99+/-13 , respectively ) ; and inattention ratings on visual and auditory continuous performance tests . CONCLUSIONS In otherwise healthy young children who have persistent middle-ear effusion , as defined in our study , prompt insertion of tympanostomy tubes does not improve developmental outcomes up to 9 to 11 years of age . ( Clinical Trials.gov number , NCT00365092 [ Clinical Trials.gov ] . ) Current st and ard neuropsychology practice is to examine normative sample performance for systematic influences of demographic variables and then to correct for these influences . The most commonly examined demographic variables are age , gender , and years of education , and current normative data bases frequently take these into consideration . However , there is a literature to suggest that self-reported years of educational attainment may not be an accurate reflection of some patients ' level of performance and may actually overpredict grade estimates based on reading level . Many of these studies have focused on older sample s of individuals who were free of neurological or psychiatric symptoms . In this study , a younger sample ( average age = 44.5 ) of African American ( N = 62 ) and Caucasian ( N = 133 ) patients referred to an outpatient psychiatry unit was examined . Results suggest that the prior findings of a significant discrepancy between self-reported years of education and Wide Range Achievement Test-3rd Edition Reading Recognition performance hold for a younger sample with a broad range of clinical diagnoses . How these findings might influence clinical practice are discussed 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 The authors examined whether tailored self-management support ( SMS ) strategies reach patients in a safety net system and explored variation by language , literacy , and insurance . English- , Spanish- , and Cantonese-speaking diabetes patients were r and omized to weekly automated telephone disease  management ( ATDM ) or monthly group medical visits . The SMS programs employ distinct communication methods but share common objectives , including behavioral “ action plans . ” Reach was measured using three complementary dimensions : ( a ) participation among clinics , clinicians , and patients ; ( b ) patient representativeness ; and ( c ) patient engagement with SMS . Participation rates were high across all levels and preferentially attracted Spanish- language speakers , uninsured , and Medicaid recipients . Although both programs engaged a significant proportion in action planning , ATDM yielded higher engagement , especially among those with limited English proficiency and limited literacy . These results provide important insights for health communication and translational research with respect to realizing the public health benefits of SMS and can inform system-level planning to reduce health disparities BACKGROUND Hearing loss is a prevalent and significant disability that impairs functional development and educational 
    Output:
    
Differences in health literacy level were consistently associated with increased hospitalizations , greater emergency care use , lower use of mammography , lower receipt of influenza vaccine , poorer ability to demonstrate taking medications appropriately , poorer ability to interpret labels and health messages , and , among seniors , poorer overall health status and higher mortality .
Health literacy level potentially mediates disparities between blacks and whites .