Review

Health

 

literacy

 

and

 

cancer

 

screening:

 

A

 

systematic

 

review

Benjamin

 

R.

 

Oldach

a

,

 

Mira

 

L.

 

Katz

a

,

b

,

*

a

Comprehensive

 

Cancer

 

Center,

 

The

 

Ohio

 

State

 

University,

 

Columbus,

 

USA

b

Division

 

of

 

Health

 

Behavior

 

and

 

Health

 

Promotion,

 

College

 

of

 

Public

 

Health,

 

The

 

Ohio

 

State

 

University,

 

Columbus,

 

USA

Contents

1.

 

Introduction

 

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149

2.

 

Methods

 

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151

2.1.

 

Identification

 

of

 

relevant

 

studies

 

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151

2.2.

 

Data

 

extraction

 

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151

3.

 

Results

 

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152

3.1.

 

Colorectal

 

cancer

 

screening

 

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152

3.2.

 

Breast

 

cancer

 

screening

 

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154

3.3.

 

Cervical

 

cancer

 

screening

 

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154

3.4.

 

Prostate

 

cancer

 

screening

 

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154

4.

 

Discussion

 

and

 

conclusion.

 

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154

4.1.

 

Discussion

 

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154

4.2.

 

Conclusions

 

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155

4.3.

 

Practice

 

implications.

 

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155

References

 

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156

1.

 

Introduction

Cancer

 

mortality

 

rates

 

have

 

decreased

 

during

 

the

 

past

 

decades,

however,

 

cancer

 

remains

 

a

 

significant

 

cause

 

of

 

mortality

 

in

 

the

United

 

States

 

(U.S.)

 

[1]

.

 

Factors

 

contributing

 

to

 

the

 

decrease

 

in

cancer

 

mortality

 

rates

 

include

 

increases

 

in

 

cancer

 

screening

 

rates,

appropriate

 

abnormal

 

screening

 

test

 

follow-up,

 

and

 

treatment

Patient

 

Education

 

and

 

Counseling

 

94

 

(2014)

 

149–157

A

 

R

 

T

 

I

 

C

 

L

 

E

 

I

 

N

 

F

 

O

Article

 

history:

Received

 

14

 

March

 

2013

Received

 

in

 

revised

 

form

 

12

 

August

 

2013

Accepted

 

5

 

October

 

2013

Keywords:
Health

 

literacy

Cancer

 

screening

Cancer

A

 

B

 

S

 

T

 

R

 

A

 

C

 

T

Objective:

 

To

 

evaluate

 

published

 

evidence

 

about

 

health

 

literacy

 

and

 

cancer

 

screening.

Methods:

 

Seven

 

databases

 

were

 

searched

 

for

 

English

 

language

 

articles

 

measuring

 

health

 

literacy

 

and

cancer

 

screening

 

published

 

in

 

1990–2011.

 

Articles

 

meeting

 

inclusion

 

criteria

 

were

 

independently

reviewed

 

by

 

two

 

investigators

 

using

 

a

 

standardized

 

data

 

abstraction

 

form.

 

Abstracts

 

(n

 

=

 

932)

 

were

reviewed

 

and

 

full

 

text

 

retrieved

 

for

 

83

 

articles.

 

Ten

 

articles

 

with

 

14

 

comparisons

 

of

 

health

 

literacy

 

and

cancer

 

screening

 

according

 

to

 

recommended

 

medical

 

guidelines

 

were

 

included

 

in

 

the

 

analysis.

Results:

 

Most

 

articles

 

measured

 

health

 

literacy

 

using

 

the

 

S-TOFHLA

 

instrument

 

and

 

documented

 

cancer

screening

 

by

 

self-report.

 

There

 

is

 

a

 

trend

 

for

 

an

 

association

 

of

 

inadequate

 

health

 

literacy

 

and

 

lower

 

cancer

screening

 

rates,

 

however,

 

the

 

evidence

 

is

 

mixed

 

and

 

limited

 

by

 

study

 

design

 

and

 

measurement

 

issues.

Conclusion:

 

A

 

patient’s

 

health

 

literacy

 

may

 

be

 

a

 

contributing

 

factor

 

to

 

being

 

within

 

recommended

 

cancer

screening

 

guidelines.

Practice

 

implications:

 

Future

 

research

 

should:

 

be

 

conducted

 

using

 

validated

 

health

 

literacy

 

instruments;

describe

 

the

 

population

 

included

 

in

 

the

 

study;

 

document

 

cancer

 

screening

 

test

 

completion

 

according

 

to

recommended

 

guidelines;

 

verify

 

the

 

completion

 

of

 

cancer

 

screening

 

tests

 

by

 

medical

 

record

 

review;

 

adjust

for

 

confounding

 

factors;

 

and

 

report

 

effect

 

size

 

of

 

the

 

association

 

of

 

health

 

literacy

 

and

 

cancer

 

screening.

ß

 

2013

 

Elsevier

 

Ireland

 

Ltd.

 

All

 

rights

 

reserved.

* Corresponding

 

author

 

at:

 

The

 

Ohio

 

State

 

University,

 

Suite

 

525,

 

1590

 

North

 

High

Street,

 

Columbus,

 

OH

 

43201,

 

USA.

 

Tel.:

 

+1

 

614

 

293

 

6603;

 

fax:

 

+1

 

614

 

293

 

5611.

E-mail

 

address:

 

mira.katz@osumc.edu

 

(M.L.

 

Katz).

Contents

 

lists

 

available

 

at

 

ScienceDirect

Patient

 

Education

 

and

 

Counseling

j o

 

u r

 

n

 

a l

 

h

 

o

 

m e p

 

a g

 

e :

 

w

 

w w

 

. e l s e v i e r

 

. c o

 

m

 

/ l o c

 

a t e / p

 

a t e d

 

u

 

c o

 

u

0738-3991/$

 

–

 

see

 

front

 

matter

 

ß

 

2013

 

Elsevier

 

Ireland

 

Ltd.

 

All

 

rights

 

reserved.

http://dx.doi.org/10.1016/j.pec.2013.10.001

advances.

 

Certain

 

populations,

 

mainly

 

minority

 

and

 

low

 

socioeco-

nomic

 

status

 

(SES)

 

groups,

 

have

 

not

 

benefited

 

equally

 

from

 

cancer

screening

 

and

 

continue

 

to

 

have

 

elevated

 

cancer

 

mortality

 

rates

 

[2]

.

Inadequate

 

health

 

literacy

 

may

 

be

 

a

 

reason

 

for

 

the

 

lack

 

of

awareness

 

and/or

 

knowledge

 

about

 

the

 

importance

 

of

 

completing

cancer

 

screening

 

tests

 

within

 

U.S.

 

Preventive

 

Services

 

Task

 

Force

(USPSTF)

 

recommended

 

intervals,

 

and

 

may

 

be

 

a

 

contributing

 

factor

to

 

cancer

 

screening

 

disparities

 

[3]

.

Health

 

literacy

 

is

 

defined

 

as

 

the

 

degree

 

to

 

which

 

individuals

have

 

the

 

capacity

 

to

 

obtain,

 

communicate,

 

process,

 

and

 

understand

basic

 

health

 

information

 

and

 

services

 

needed

 

to

 

make

 

appropriate

health

 

decisions

 

[4]

.

 

Due

 

to

 

the

 

multiple

 

skill

 

domains

 

required

 

to

obtain

 

health

 

information

 

and

 

receive

 

appropriate

 

health

 

services,

health

 

literacy

 

is

 

conceptualized

 

as

 

the

 

intersection

 

of

 

education,

culture,

 

experience,

 

setting,

 

and

 

other

 

factors

 

[4]

.

 

A

 

framework

 

for

health

 

literacy

 

may

 

consist

 

of

 

multiple

 

components

 

including

cultural

 

and

 

conceptual

 

knowledge,

 

print

 

literacy

 

(ability

 

to

 

read,

write,

 

and

 

understand

 

text),

 

numeracy

 

(capability

 

to

 

complete

numerical

 

tasks),

 

oral

 

literacy

 

(listening,

 

speaking,

 

communica-

tion),

 

and

 

media

 

literacy

 

(ability

 

to

 

access

 

and

 

evaluate

 

media

information

 

including

 

ehealth)

 

within

 

a

 

health

 

context

 

[4,5]

.

 

Each

component

 

of

 

health

 

literacy

 

or

 

combination

 

of

 

components

 

may

influence

 

an

 

individual’s

 

ability

 

to

 

make

 

a

 

decision

 

about

completing

 

a

 

cancer

 

screening

 

test.

Understanding

 

the

 

potential

 

benefits,

 

harms,

 

alternatives,

 

and

uncertainties

 

associated

 

with

 

undergoing

 

a

 

recommended

 

cancer

screening

 

test

 

is

 

important

 

when

 

making

 

a

 

cancer

 

screening

decision.

 

To

 

better

 

understand

 

the

 

role

 

that

 

health

 

literacy

 

may

play

 

in

 

health

 

decisions,

 

including

 

cancer

 

screening,

 

instruments

 

to

measure

 

health

 

literacy

 

have

 

been

 

developed

 

in

 

the

 

past

 

few

decades.

 

Health

 

literacy

 

measurement

 

is

 

challenging,

 

however,

because

 

it

 

encompasses

 

knowledge,

 

multiple

 

skills,

 

previous

personal

 

experiences,

 

setting,

 

and

 

context

 

[4]

.

Instruments

 

with

 

accumulated

 

evidence

 

of

 

validity

 

and

reliability

 

measuring

 

different

 

relevant

 

components

 

of

 

health

literacy

 

needed

 

to

 

navigate

 

the

 

health

 

care

 

system

 

exist

 

and

 

have

been

 

used

 

in

 

research

 

focused

 

on

 

a

 

variety

 

of

 

health

 

issues

 

[4,6]

.

The

 

National

 

Center

 

for

 

Education

 

Statistics’

 

National

 

Assessment

of

 

Adult

 

Literacy

 

(NAAL)

 

assesses

 

prose,

 

document,

 

and

 

quantita-

tive

 

literacy

 

in

 

the

 

health

 

context

 

[7]

.

 

The

 

Rapid

 

Estimate

 

of

 

Adult

Literacy

 

in

 

Medicine

 

(REALM)

 

tests

 

word

 

recognition

 

and

pronunciation

 

[8,9]

.

 

The

 

Test

 

Of

 

Functional

 

Health

 

Literacy

 

in

Adults

 

(TOFHLA)

 

is

 

a

 

reading

 

comprehension

 

test

 

which

 

includes

numeracy

 

[10,11]

.

 

Additional

 

instruments

 

include

 

the

 

Newest

Vital

 

Sign

 

which

 

measures

 

reading

 

and

 

quantitative

 

skills

 

[12]

,

 

and

a

 

three

 

item

 

and

 

single

 

item

 

screener

 

of

 

health

 

literacy

 

[13–15]

.

More

 

recently,

 

the

 

health

 

literacy

 

skills

 

instrument

 

has

 

been

developed

 

and

 

measures

 

skills

 

associated

 

with

 

reading

 

and

understanding

 

text,

 

locating

 

and

 

interpreting

 

information

 

in

documents,

 

numeracy,

 

oral

 

literacy,

 

and

 

the

 

ability

 

to

 

seek

information

 

via

 

the

 

Internet

 

(navigation)

 

[16]

.

 

Some

 

health

 

literacy

instruments

 

are

 

available

 

in

 

shorter

 

versions

 

to

 

decrease

 

partici-

pant

 

burden

 

[9,10,17]

,

 

and

 

some

 

instruments

 

have

 

been

 

validated

in

 

other

 

languages

 

[11,12]

.

A

 

systematic

 

review

 

of

 

health

 

literacy

 

found

 

that

 

inadequate

health

 

literacy

 

is

 

associated

 

with

 

less

 

health

 

knowledge,

 

poor

health

 

status,

 

and

 

improper

 

use

 

of

 

health

 

services

 

[18]

.

 

Although

previous

 

research

 

suggests

 

that

 

inadequate

 

health

 

literacy

 

may

contribute

 

to

 

lower

 

cancer

 

screening

 

rates,

 

to

 

the

 

best

 

of

 

our

knowledge

 

there

 

has

 

not

 

been

 

a

 

comprehensive

 

review

 

of

 

this

topic.

 

If

 

inadequate

 

health

 

literacy

 

contributes

 

to

 

lower

 

cancer

screening

 

rates,

 

the

 

development

 

of

 

materials

 

and

 

interventions

Initial database search  

(non-duplicated articles) 

(n=932) 

Full-text articles 

retrieved 

(n=83) 

Articles excluded based on abstract review (n=849) 
   Health literacy and cancer screening not measured (n=315) 
   Lacks original data (n=182) 
   Cancer survivors (n=166) 
   Cancer screening not measured (n=126) 
   Health literacy not measured (n=49) 
   Dissertations (n=9) 
   Abstract only

 

(n=2

 

)

Studies reporting health 

literacy and cancer 

screening 

(n=29

 

)

Full-text articles excluded (n=54) 
   Cancer screening not measured (n=17) 
   Health literacy and cancer screening not measured (n=16) 
   Health literacy not measured (n=12) 
   Lacks original data (n=9) 

Articles excluded based on methodology (n=19) 

Health literacy and cancer screening association not reported (n=9) 
Screening measured outside recommended guidelines (n=4) 
Lacked a validated health literacy instrument (n=2) 
Used a combine cancer screening measure (n=2) 
Study conducted outside the U.S. (n=2)  

 Articles included  

in review 

(n=10) 

Fig.

 

1.

 

Study

 

flow

 

diagram.

B.R.

 

Oldach,

 

M.L.

 

Katz

 

/

 

Patient

 

Education

 

and

 

Counseling

 

94

 

(2014)

 

149–157

150

aimed

 

at

 

low

 

literacy

 

populations

 

is

 

vital

 

to

 

improving

 

cancer

screening

 

rates,

 

and

 

ultimately

 

reducing

 

cancer

 

disparities.

 

This

systematic

 

review

 

synthesizes

 

the

 

evidence

 

about

 

health

 

literacy

and

 

cancer

 

screening

 

and

 

suggests

 

direction

 

for

 

future

 

research.

2.

 

Methods

2.1.

 

Identification

 

of

 

relevant

 

studies

In

 

January

 

2012,

 

a

 

comprehensive

 

search

 

of

 

PUBMED,

 

CINAHL,

PSYCINFO,

 

Social

 

Science

 

Citation

 

Index,

 

Comabstracts,

 

ERIC,

 

and

LISTA

 

was

 

conducted

 

to

 

identify

 

English

 

language

 

articles

 

that

included

 

health

 

literacy

 

and

 

cancer

 

screening.

 

Since

 

health

 

literacy

instruments

 

with

 

strong

 

psychometric

 

properties

 

were

 

not

available

 

until

 

the

 

1990s;

 

the

 

search

 

was

 

from

 

January

 

1990

through

 

December

 

2011.

 

Articles

 

were

 

individually

 

identified

 

by

searching

 

the

 

terms

 

health

 

literacy

 

and

 

literacy

 

with

 

the

 

following

key

 

search

 

terms:

 

cancer,

 

cancer

 

screening,

 

colon

 

cancer

 

screening,

colorectal

 

cancer

 

screening,

 

fecal

 

occult

 

blood

 

test

 

(FOBT),

 

flexible

sigmoidoscopy,

 

colonoscopy,

 

breast

 

cancer

 

screening,

 

mammog-

raphy,

 

cervical

 

cancer

 

screening,

 

Pap,

 

prostate

 

cancer

 

screening,

and

 

prostate

 

specific

 

antigen

 

(PSA).

Resulting

 

abstracts

 

were

 

reviewed

 

for

 

a

 

measure

 

of

 

health

literacy

 

and

 

cancer

 

screening.

 

Articles

 

focused

 

on

 

cancer

 

survivors

were

 

excluded

 

to

 

ensure

 

the

 

review

 

focused

 

on

 

the

 

early

 

detection

of

 

cancer

 

and

 

not

 

the

 

detection

 

of

 

cancer

 

recurrence

 

or

 

a

 

second

cancer.

 

Articles

 

identified

 

as

 

literature

 

reviews,

 

editorials,

 

summa-

ries,

 

abstracts,

 

dissertations,

 

or

 

critiques

 

were

 

excluded

 

resulting

in

 

the

 

inclusion

 

of

 

only

 

peer-reviewed

 

empirical

 

research.

 

The

 

full

text

 

of

 

articles

 

lacking

 

an

 

abstract

 

with

 

sufficient

 

information

 

to

determine

 

study

 

inclusion

 

were

 

reviewed

 

using

 

the

 

previously

stated

 

criteria.

After

 

removal

 

of

 

duplicates,

 

the

 

abstracts

 

of

 

932

 

articles

 

were

reviewed

 

(

Fig.

 

1

).

 

Articles

 

(n

 

=

 

849)

 

were

 

excluded

 

because

 

they:

lacked

 

measures

 

of

 

both

 

health

 

literacy

 

and

 

cancer

 

screening

behavior

 

(n

 

=

 

315);

 

did

 

not

 

include

 

original

 

data

 

(n

 

=

 

182);

 

focused

on

 

cancer

 

survivors

 

(n

 

=

 

166);

 

failed

 

to

 

report

 

cancer

 

screening

behavior

 

(n

 

=

 

126);

 

lacked

 

a

 

measure

 

of

 

health

 

literacy

 

(n

 

=

 

49);

were

 

dissertations

 

(n

 

=

 

9);

 

or

 

were

 

meeting

 

abstracts

 

(n

 

=

 

2).

 

The

remaining

 

83

 

articles

 

were

 

reviewed

 

for

 

study

 

inclusion.

 

An

additional

 

54

 

articles

 

were

 

excluded

 

because

 

they:

 

lacked

information

 

about

 

cancer

 

screening

 

behavior

 

(n

 

=

 

17);

 

failed

 

to

measure

 

both

 

health

 

literacy

 

and

 

cancer

 

screening

 

behavior

(n

 

=

 

16);

 

failed

 

to

 

measure

 

health

 

literacy

 

(n

 

=

 

12);

 

or

 

did

 

not

include

 

original

 

data

 

(n

 

=

 

9).

2.2.

 

Data

 

extraction

The

 

articles

 

(n

 

=

 

29)

 

meeting

 

inclusion

 

criteria

 

were

 

indepen-

dently

 

reviewed

 

by

 

two

 

investigators

 

using

 

a

 

standardized

 

data

abstraction

 

form

 

to

 

document

 

the:

 

(1)

 

first

 

author;

 

(2)

 

journal;

 

(3)

publication

 

date;

 

(4)

 

sample

 

size

 

and

 

characteristics

 

(including

geographic

 

location);

 

(5)

 

study

 

design;

 

(6)

 

health

 

literacy

instrument

 

and

 

proportion

 

of

 

participants

 

with

 

inadequate

 

health

literacy;

 

(7)

 

cancer

 

type;

 

(8)

 

cancer

 

screening

 

test;

 

(9)

 

determina-

tion

 

of

 

screening

 

status

 

and

 

screening

 

proportion

 

(participants

screened

 

during

 

time

 

interval

 

defined

 

within

 

the

 

study);

 

(10)

 

study

setting;

 

and

 

(11)

 

the

 

association

 

between

 

health

 

literacy

 

and

Table

 

1

Health

 

literacy

 

and

 

colorectal

 

cancer

 

screening.

Author

 

(year)

 

Shelton

 

[38]

 

(2011)

 

White

 

[39]

 

(2008)

a

Liu

 

[40]

 

(2011)

 

Miller

 

[41]

 

(2007)

Sample

 

size

 

&

 

gender

 

400

 

M&F

 

18,100

 

M&F

 

42

 

M&F

 

50

 

M&F

Study

 

design

 

CSS

 

CSS

 

QES

 

CSS

Health

 

literacy/numeracy

 

Instrument

 

SAHLSA

 

NAAL

 

S-TOFHLA

 

REALM

Inadequate

 

health

literacy

 

definition

NP

 

0–225

 

0–22

 

0–60

Inadequate

 

health

literacy

 

(%)

NP

 

36

 

NP

b

48

Cancer

 

screening

 

Test

 

FOBT,

 

COL

c,e

CRC

 

screening

 

(undefined)

c

FOBT,

 

FS,

 

COL

c,d,e

FOBT,

 

FS,

 

COL

c,d,e

Measure

 

SR

 

SR

 

SR

 

SR

Study

 

population

completion

 

rate

 

(%)

59

 

40

 

55

 

56

Population

 

characteristics

 

Clinic

 

based

 

sample

 

Yes

 

No

 

No

 

Yes

Female

 

(%)

 

72

 

52

 

60

 

72

Age

 

range

 

50–65+

 

16–65+

 

50+

 

50+

White

 

(%)

 

NP

 

71

 

43

 

42

Black

 

(%)

 

NP

 

11

 

57

 

58

Latino

 

(%)

 

100

 

12

 

NP

 

NP

Uninsured

 

(%)

 

7

 

18

 

NP

 

20

Household

 

income

 

(%)

 

67

 

<

$10,000

 

17

 

<

poverty

 

level

 

NP

 

87

 

<

$25,000

Association

 

Effect

 

size

 

OR:

 

0.99

 

(0.95–1.05)

 

MML

 

probit

 

coefficient:

 

50–64

 

years

old:

 

0.04

 

(0.3SE)

65+

 

years

 

old:

 

0.10

 

(0.03

 

SE)

NP

 

RR:

 

0.99

 

(0.64–1.55)

Adjusted

 

Yes

 

Yes

 

No

 

Yes

Significance

 

No

 

significant

association

50–64

 

years

 

old:

 

no

 

significant

 

association

65+

 

years

 

old:

 

inadequate

 

health

 

literacy

significantly

 

associated

 

with

 

LESS

 

screening

No

 

significant

association

No

 

significant

association

F:

 

female;

 

M:

 

male;

 

CSS:

 

Cross

 

Sectional

 

Survey;

 

QES:

 

Quasi-Experimental

 

Pre-Post

 

Survey;

 

SAHLSA:

 

Short

 

Assessment

 

of

 

Health

 

Literacy

 

for

 

Spanish

 

Adults

 

(Scale

 

0–50);

NAAL:

 

National

 

Assessment

 

of

 

Adult

 

Literacy

 

(Scale:

 

0–500);

 

S-TOFHLA:

 

Short

 

Test

 

of

 

Functional

 

Health

 

Literacy

 

in

 

Adults

 

(Scale:

 

0–36);

 

REALM:

 

Rapid

 

Estimate

 

of

 

Adult

Literacy

 

in

 

Medicine

 

(Scale:

 

0–66);

 

NP:

 

not

 

provided;

 

FOBT:

 

fecal

 

occult

 

blood

 

test;

 

FS:

 

flexible

 

sigmoidoscopy;

 

COL:

 

colonoscopy;

 

and

 

CRC:

 

colorectal

 

cancer;

 

SR:

 

self-report.

a

Population

 

characteristics

 

provided

 

for

 

the

 

total

 

sample.

b

Mean

 

score

 

=

 

33.62.

c

Previous

 

year.

d

Previous

 

5

 

years.

e

Previous

 

10

 

years.

B.R.

 

Oldach,

 

M.L.

 

Katz

 

/

 

Patient

 

Education

 

and

 

Counseling

 

94

 

(2014)

 

149–157

 

151

cancer

 

screening

 

(effect

 

size

 

estimate

 

and

 

direction).

 

The

investigators

 

resolved

 

any

 

discrepancies

 

through

 

discussion

 

and

differences

 

were

 

resolved

 

through

 

consensus.

To

 

be

 

able

 

to

 

compare

 

results

 

across

 

studies,

 

the

 

quality

 

of

methodology

 

was

 

assessed

 

for

 

each

 

study.

 

Additional

 

articles

(n

 

=

 

19)

 

were

 

excluded

 

because

 

they:

 

failed

 

to

 

report

 

on

 

the

association

 

between

 

health

 

literacy

 

and

 

cancer

 

screening

 

behavior

(n

 

=

 

9)

 

[19–27]

;

 

documented

 

cancer

 

screening

 

less

 

often

 

than

USPSTF

 

recommended

 

guidelines

 

at

 

the

 

time

 

of

 

the

 

study

 

(e.g.

having

 

ever

 

been

 

screened)

 

(n

 

=

 

4)

 

[28–31]

;

 

did

 

not

 

assess

 

health

literacy

 

with

 

a

 

validated

 

instrument

 

(n

 

=

 

2)

 

[32,33]

;

 

presented

combined

 

cancer

 

screening

 

behaviors

 

for

 

multiple

 

anatomic

 

sites

into

 

one

 

overall

 

cancer

 

screening

 

rate

 

(n

 

=

 

2)

 

[34,35]

;

 

or

 

were

conducted

 

outside

 

of

 

the

 

U.S.

 

(n

 

=

 

2)

 

[36,37]

.

3.

 

Results

The

 

resulting

 

10

 

articles,

 

including

 

14

 

comparisons

 

of

 

health

literacy

 

and

 

cancer

 

screening,

 

were

 

published

 

between

 

2004

 

and

electronically

 

by

 

the

 

beginning

 

of

 

2012.

 

The

 

articles

 

include

 

4

studies

 

of

 

colorectal

 

cancer

 

screening

 

(

Table

 

1

)

 

[38–41]

,

 

5

 

studies

of

 

breast

 

cancer

 

screening

 

(

Table

 

2

)

 

[39,42–45]

,

 

3

 

studies

 

of

cervical

 

cancer

 

screening

 

(

Table

 

3

)

 

[39,42,46]

,

 

and

 

2

 

studies

 

of

prostate

 

cancer

 

screening

 

(

Table

 

4

)

 

[39,47]

.

3.1.

 

Colorectal

 

cancer

 

screening

Participants

 

were

 

recruited

 

from

 

medical

 

clinics

 

and

 

commu-

nity-based

 

samples

 

in

 

urban

 

and

 

rural

 

settings

 

for

 

the

 

four

studies

 

about

 

health

 

literacy

 

and

 

colorectal

 

cancer

 

(CRC)

screening

 

(

Table

 

1

).

 

Two

 

studies

 

were

 

conducted

 

in

 

Spanish

 

or

English

 

[38,39]

,

 

with

 

one

 

study

 

conducting

 

the

 

literacy

 

assess-

ment

 

only

 

in

 

English

 

[39]

.

 

Most

 

studies

 

did

 

not

 

mention

 

if

individuals

 

were

 

excluded

 

based

 

on

 

increased

 

risk

 

for

 

CRC

 

or

included

 

individuals

 

at

 

increased-risk

 

or

 

high-risk

 

for

 

CRC

 

[39–

41]

.

 

All

 

studies

 

included

 

both

 

males

 

and

 

females

 

in

 

their

 

study

population

 

and

 

used

 

cross

 

sectional

 

data

 

to

 

investigate

 

the

relationship

 

between

 

health

 

literacy

 

and

 

CRC

 

screening.

 

The

single

 

study

 

using

 

a

 

quasi-experimental

 

design

 

analyzed

 

pre-test

data

 

only

 

to

 

investigate

 

the

 

possible

 

relationship

 

between

 

health

literacy

 

and

 

screening

 

[40]

.

 

All

 

studies

 

used

 

self-report

 

of

 

CRC

screening,

 

and

 

screening

 

ranged

 

from

 

40%

 

to

 

59%

 

[38–41]

.

 

Two

studies

 

did

 

not

 

provide

 

the

 

study

 

sample’s

 

inadequate

 

health

literacy

 

proportion

 

[38,40]

 

and

 

it

 

was

 

reported

 

as

 

36%

 

and

 

48%

 

in

the

 

other

 

two

 

studies

 

[39,41]

.

One

 

large

 

study

 

found

 

a

 

significant

 

positive

 

relationship

between

 

health

 

literacy

 

and

 

CRC

 

screening

 

among

 

adults

 

65

 

years

of

 

age

 

and

 

older

 

and

 

no

 

significant

 

association

 

among

 

adults

 

50–64

years

 

old

 

[39]

.

 

The

 

remaining

 

three

 

studies

 

found

 

no

 

significant

association

 

between

 

health

 

literacy

 

and

 

CRC

 

screening

 

[38,40,41]

.

Table

 

2

Health

 

literacy

 

and

 

breast

 

cancer

 

screening.

Author

 

(year)

 

White

 

[39]

 

(2008)

a

Garbers

 

[42]

(2009)

a

Bennett

 

[43]

 

(2009)

a

Guerra

 

[44]

 

(2005)

 

Pagan

 

[45]

 

(2012)

Sample

 

size

 

18,100

 

(52%

 

female)

 

697

 

2668

 

(55%

 

female)

 

97

 

722

Study

 

design

 

CSS

 

CSS

 

CSS

 

CSS

 

CSS

Health

 

literacy/

numeracy

Instrument

 

NAAL

 

TOFHLA-S

 

NAAL

 

S-TOFHLA
(English

 

or

 

Spanish)

S-TOFHLA
(English

 

or

 

Spanish)

Inadequate

 

health

literacy

 

definition

0–225

 

0–59

 

0–225

 

0–22

 

0–22

Inadequate

 

health

literacy

 

(%)

36

 

24

 

58

 

52

 

50

Cancer

 

screening

 

Test

 

Mammo

b

Mammo

c

Mammo

b

Mammo

b

Mammo

b,d

Measure

 

SR

 

EDR

 

SR

 

SR

 

SR

Study

 

population

completion

 

rate

 

(%)

61

 

57

 

66

 

69

 

62

 

(last

 

2

 

years)

44

 

(last

 

1

 

years)

Population

characteristics

Clinic

 

based

 

sample

 

No

 

Yes

 

No

 

Yes

 

No

Age

 

range

 

16–65+

 

40+

 

65+

 

41–85

 

40–70+

White

 

(%)

 

71

 

NP

 

85

 

NP

 

NP

Black

 

(%)

 

11

 

NP

 

7

 

NP

 

NP

Latino

 

(%)

 

12

 

100

 

5

 

100

 

100

Uninsured

 

(%)

 

18

 

99

 

NP

 

26

 

27

Household

 

income

 

(%)

 

17

 

<

poverty

 

level

 

100

 

<

250%

poverty

 

level

18

 

<

poverty

 

level

 

63

 

<

$10,000

 

58

 

$10,000

Association

 

Effect

 

size

 

MML

 

probit

 

coefficient:

40–64

 

years

old:

 

0.05

 

(0.03

 

SE)

65+

 

years

old:

 

0.20

 

(0.04SE)

X

2

:

 

0.58

 

MML

 

probit

 

coefficient:

0.17(0.04)

OR:

 

1.01

(0.95–1.08)

OR:

 

past

 

year:

2.30

 

(1.54–3.43)

Past

 

2

 

years:

 

1.70

(1.14–2.53)

Adjusted

 

Yes

 

No

 

Yes

 

Yes

 

Yes

Significance

 

40–64

 

years

 

old:

no

 

significant

association
65+

 

years

 

old:

inadequate

 

health

literacy

 

significantly

associated
with

 

LESS

 

screening

No

 

significant

association

Inadequate

 

health

 

literacy

significantly

 

associated

with

 

LESS

 

screening

No

 

significant

association

Inadequate

 

health

literacy

 

significantly

associated

 

with

 

LESS

screening

CSS:

 

Cross

 

Sectional

 

Survey;

 

NAAL:

 

National

 

Assessment

 

of

 

Adult

 

Literacy

 

(Scale:

 

0–500);

 

TOFHLA-S:

 

Test

 

of

 

Functional

 

Health

 

Literacy

 

in

 

Adults-Spanish

 

(Scale:

 

0–100);

 

S-

TOFHLA:

 

Short

 

Test

 

of

 

Functional

 

Health

 

Literacy

 

in

 

Adults

 

(Scale:

 

0–36);

 

Mammo:

 

mammogram;

 

SR:

 

self

 

report;

 

EDR:

 

Electronic

 

Database

 

Review;

 

NP:

 

not

 

provided.

a

Population

 

characteristics

 

provided

 

for

 

the

 

total

 

sample.

b

Previous

 

year.

c

Previous

 

8

 

months.

d

Previous

 

2

 

years.

B.R.

 

Oldach,

 

M.L.

 

Katz

 

/

 

Patient

 

Education

 

and

 

Counseling

 

94

 

(2014)

 

149–157

152

Table

 

3

Health

 

literacy

 

and

 

cervical

 

cancer

 

screening.

Author

 

(year)

 

White

 

[39]

 

(2008)

a

Garbers

 

[42]

 

(2009)

a

Garbers

 

[46]

 

(2004)

Sample

 

size

 

18,100

 

(52%

 

female)

 

310

 

205

Study

 

design

 

CSS

 

CSS

 

CSS

Health

 

literacy/numeracy

 

Instrument

 

NAAL

 

TOFHLA-S

 

TOFHLA-S

Inadequate

 

health

literacy

 

definition

0–225

 

Inadequate:

 

0–59

Marginal:

 

60–74

0–59

Inadequate

 

health

literacy

 

(%)

36

 

Inadequate:

 

24

Marginal:

 

14

Inadequate:

 

30

Score

 

0:

 

12

Cancer

 

screening

 

Test

 

PAP

c

PAP

b

PAP

d

Measure

 

SR

 

EDR

 

SR

 

(10%

 

sampled

 

MRR)

Study

 

population

completion

 

rate

 

(%)

69

 

75

 

92

Population

 

characteristics

 

Clinic

 

based

 

sample

 

No

 

Yes

 

Yes

Age

 

range

 

16–65+

 

40+

 

40–78

White

 

(%)

 

71

 

NP

 

NP

Black

 

(%)

 

11

 

NP

 

NP

Latino

 

(%)

 

12

 

100

 

100

Uninsured

 

(%)

 

18

 

99

 

58

Household

 

income

 

(%)

 

17

 

<

poverty

 

level

 

100

 

<

250%

 

poverty

 

level

 

NP

Association

 

Effect

 

size

 

MML

 

probit

 

coefficient:

18–39

 

years

 

old:

 

0.05

 

(0.02

 

SE)

40–64

 

years

 

old:

 

0.06

 

(0.03

 

SE)

OR:

 

inadequate

 

and

 

marginal:

2.27

 

(1.13–4.60)

OR:

 

inadequate:

 

0.53

 

(0.21–1.35)

Score

 

0:

 

0.24

 

(0.07–0.85)

Adjusted

 

Yes

 

Yes

 

Yes

Significance

 

18–39

 

years

 

old:

 

inadequate

 

health

literacy

 

significantly

 

associated

with

 

LESS

 

screening

40–64

 

years

 

old:

 

No

 

significant

association

Inadequate

 

health

 

literacy

significantly

 

associated

with

 

MORE

 

screening

Inadequate:

 

no

 

significant

association
Score

 

=

 

0:

 

inadequate

 

health

literacy

 

significantly

 

associated

with

 

LESS

 

screening

CSS:

 

Cross

 

Sectional

 

Survey;

 

NAAL:

 

National

 

Assessment

 

of

 

Adult

 

Literacy

 

(Scale:

 

0–500);

 

TOFHLA-S:

 

Test

 

of

 

Functional

 

Health

 

Literacy

 

in

 

Adults-Spanish

 

(Scale:0–100);

 

Pap:

Papanicolaou

 

test;

 

SR:

 

self

 

report;

 

EDR:

 

Electronic

 

Database

 

Review;

 

MRR:

 

Medical

 

Record

 

Review;

 

NP:

 

not

 

provided.

a

Population

 

characteristics

 

provided

 

for

 

the

 

total

 

sample.

b

Previous

 

60

 

days.

c

Previous

 

year.

d

Previous

 

3

 

years.

Table

 

4

Health

 

literacy

 

and

 

prostate

 

cancer

 

screening.

Author

 

(year)

 

White

 

[39]

 

(2008)

a

Ross

 

[47]

 

(2010)

Sample

 

size

 

18,100

 

(48%

 

male)

 

49

Study

 

design

 

CSS

 

QES

Health

 

literacy/numeracy

 

Instrument

 

NAAL

 

TOFHLA

Inadequate

 

health

 

literacy

 

definition

 

0–225

 

0–59

Inadequate

 

health

 

literacy

 

(%)

 

36

 

22

Cancer

 

screening

 

Test

 

Prostate

 

cancer

 

screening

(unspecified

 

test)

b

PSA

b

Measure

 

SR

 

SR

Study

 

population

 

completion

 

rate

 

(%)

 

31

 

55

Population

 

characteristics

 

Clinic

 

based

 

sample

 

No

 

No

Age

 

range

 

16–65+

 

35–91

White

 

(%)

 

71

 

0

Black

 

(%)

 

11

 

100

Latino

 

(%)

 

12

 

NP

Uninsured

 

(%)

 

18

 

NP

Household

 

income

 

(%)

 

17

 

<

poverty

 

level

 

33

 

<

$25,000

Association

 

Effect

 

size

 

MML

 

probit

 

coefficient:

40–64

 

years

 

old:

 

0.09

 

(0.03

 

SE)

65+

 

years

 

old:

 

0.08

 

(0.04

 

SE)

NP

Adjusted

 

Yes

 

No

Significance

 

40–64

 

years

 

old:

 

inadequate

 

health

literacy

 

significantly

 

associated

with

 

LESS

 

screening

65+

 

years

 

old:

 

inadequate

 

health

 

literacy

significantly

 

associated

 

with

 

LESS

 

screening

No

 

significant

association

CSS:

 

Cross

 

Sectional

 

Survey;

 

QES:

 

Quasi-Experimental

 

Pre-Post

 

Survey;

 

NAAL:

 

National

 

Assessment

 

of

 

Adult

 

Literacy

 

(Scale:

 

0–500);

 

TOFHLA:

 

Test

 

of

 

Functional

 

Health

Literacy

 

in

 

Adults

 

(Scale:

 

0–100);

 

PSA:

 

prostate

 

specific

 

antigen;

 

SR:

 

self-report;

 

NP:

 

not

 

provided.

a

Population

 

characteristics

 

provided

 

for

 

the

 

total

 

sample.

b

Previous

 

year.

B.R.

 

Oldach,

 

M.L.

 

Katz

 

/

 

Patient

 

Education

 

and

 

Counseling

 

94

 

(2014)

 

149–157

 

153