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PLoS One. 2012;7(7):e40210. doi: 10.1371/journal.pone.0040210. Epub 2012 Jul 6.

Impact of health literacy in patients with chronic musculoskeletal disease--systematic review.

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  • 1Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom.



To estimate the prevalence of low health literacy, and evaluate the impact of low health literacy on outcomes in patients with chronic musculoskeletal conditions.


We searched Embase, Pubmed, PsycInfo, and CINAHL in January 2011 for relevant studies, restricted to English-language articles.


Studies were included if they measured health literacy and/or reported on the link between outcomes and health literacy levels in patients with osteoporosis, osteoarthritis, or rheumatoid arthritis. We assessed risk of bias from participant selection, methods of measuring health literacy and functional outcomes, missing data, and potential for confounding.


We reviewed 1863 citations and judged 8 studies to be relevant. Most were cross-sectional in nature, and five were based in the United States. Diversity in measurements, participant characteristics, and settings meant that results had to be synthesized narratively. Prevalence of low health literacy varied from 7% to 42%. Of the five studies that reported on musculoskeletal outcomes, only one showed an association (unadjusted) between low health literacy and greater pain and limitations in physical functioning. However, other studies, including those with multivariate analyses, found no significant relationship between health literacy and measures of pain or disease specific questionnaires. One clinical trial found short-term improvements in the mental health of patients with musculoskeletal conditions after an intervention to improve health literacy.


Most of the studies were cross-sectional in nature, which precludes interpretation of a causal relationship. The sample sizes may not have been sufficiently large to enable detection of significant associations.


The current evidence does not show a consistent association between low health literacy and poorer functional outcomes in patients with chronic musculoskeletal conditions. In the absence of a definite link, efforts to develop interventions to improve health literacy would not necessarily improve health service or patient-related outcomes.

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