Interventions to improve care for patients with limited health literacy

Journal of Clinical Outcomes Management

Volumn 16, Issue 1, 2009, Pages 20-29

  Sudore, L Rebecca ^a,b   Schillinger, Dean ^a  

^a UNIVERSITY OF CALIFORNIA   (United States)

^b NONE   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

EVIDENCE BASED MEDICINE; HEALTH; HEALTH CARE; HEALTH CARE MANAGEMENT; HEALTH CARE POLICY; HEALTH DISPARITY; HUMAN; KNOWLEDGE; MEDICAL INFORMATION; OUTCOME ASSESSMENT; PATIENT CARE; READING; REVIEW;

EID: 61449250748     PISSN: 10796533     EISSN: None     Source Type: Journal    
DOI: None     Document Type: Review

References (140)

1. Kutner M, Greenbery E, Baer J. A first look at the literacy of America's adults in the 21st century. National Center for Education Statistics. Washington (DC): US Dept. of Education; 2005.
2. Paasche-Orlow MK, Parker RM, Gazmararian JA, et al. The prevalence of limited health literacy. J Gen Intern Med 2005;20:175-84.
3. Nielsen-Bohlman L, Panzer AM, Kindig DA, editors; Institute of Medicine. Health literacy: a prescription to end confusion. Washington (DC): National Academies Press; 2004.
4. Baker DW. The meaning and the measure of health literacy J Gen Intern Med 2006;21:878-83.
5. Dewalt DA, Berkman ND, Sheridan S, et al. Literacy and health outcomes: a systematic review of the literature. J Gen Intern Med 2004;19:1228-39.
6. Sudore RL, Mehta KM, Simonsick EM, et al. Limited literacy in older people and disparities in health and healthcare access. J Am Geriatr Soc 2006;54:770-6.
7. Kalichman SC, Rompa D. Functional health literacy is associated with health status and health-related knowledge in people living with HIV-AIDS. J Acquir Immune Defic Syndr 2000;25: 337-44.
8. Weiss BD, Hart G, McGee DL, D'Estelle S. Health status of illiterate adults: relation between literacy and health status among persons with low literacy skills. J Am Board Fam Pract 1992;5: 257-64.
9. Wolf MS, Gazmararian JA, Baker DW. Health literacy and functional health status among older adults. Arch Intern Med 2005; 165:1946-52.
10. Williams MV, Parker RM, Baker DW, et al. Inadequate functional health literacy among patients at two public hospitals. JAMA 1995;274:1677-82.
11. Sudore RL, Yaffe K, Satterfield S, et al. Limited literacy and mortality in the elderly: the health, aging, and body composition study J Gen Intern Med 2006;21:806-12.
12. Baker DW, Wolf MS, Feinglass J, et al. Health literacy and mortality among elderly persons. Arch Intern Med 2007;167: 1503-9.
13. Baker DW, Gazmararian JA, Williams MV, et al. Health literacy and use of outpatient physician services by Medicare managed care enrollees. J Gen Intern Med 2004;19:215-20.
14. Scott TL, Gazmararian JA, Williams MV, Baker DW. Health literacy and preventive health care use among Medicare enrollees in a managed care organization. Med Care 2002;40: 395-404.
15. Wolf MS, Davis TC, Arozullah A, et al. Relation between literacy and HIV treatment knowledge among patients on HAART regimens. AIDS Care 2005;17:863-73.
16. Fang MC, Machtinger EL, Wang F, Schillinger D. Health literacy and anticoagulation-related outcomes among patients taking warfarin. J Gen Intern Med 2006;21:841-6.
17. Davis TC, Fredrickson DD, Potter L, et al. Patient understanding and use of oral contraceptive pills in a southern public health family planning clinic. South Med J 2006;99:713-8.
18. Kripalani S, Henderson LE, Chiu EY, et al. Predictors of medication self-management skill in a low-literacy population. J Gen Intern Med 2006;21:852-6.
19. Rothman RL, Housam R, Weiss H, et al. Patient understanding of food labels: the role of literacy and numeracy. Am J Prev Med 2006;31:391-8.
20. Cavanaugh K, Huizinga MM, Wallston KA, et al. Association of numeracy and diabetes control. Ann Intern Med 2008;148: 737-46.
21. Paasche-Orlow MK, Riekert KA, Bilderback A, et al. Tailored education may reduce health literacy disparities in asthma self-management. Am J Respir Crit Care Med 2005;172:980-6.
22. Williams MV, Baker DW, Honig EG, et al. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest 1998;114: 1008-15.
23. Baker DW, Parker RM, Williams MV, et al. The health care experience of patients with low literacy. Arch Fam Med 1996;5: 329-34.
24. Schillinger D, Bindman A, Wang F, et al. Functional health literacy and the quality of physician-patient communication among diabetes patients. Patient Educ Couns 2004;52:315-23.
25. Mancuso CA, Rincon M. Asthma patients' assessments of health care and medical decision making: the role of health literacy. J Asthma 2006;43:41-4.
26. DeWalt DA, Boone RS, Pignone MP. Literacy and its relationship with self-efficacy, trust, and participation in medical decision making. Am J Health Behav 2007;31 Suppl 1:S27-35.
27. Friedland R. Understanding health literacy: new estimates of the costs on inadequate health literacy. Washington (DC): National Academy on Aging Society; 1998.
28. World Health Organization. Health promotion: report by the Secretariat. Geneva: World Health Organization; 2000.
29. U.S. Dept. of Health and Human Services. Healthy people 2010: understanding and improving health. Washington (DC): U.S. Government Printing Office; 2000.
30. The Joint Commision on the Accreditation of Healthcare Organizations Available at www.jointcommission.org. Accessed 12 Dec 2008.
31. Pignone M, DeWalt DA, Sheridan S, et al. Interventions to improve health outcomes for patients with low literacy. A systematic review. J Gen Intern Med 2005;20:185-92.
32. Paasche-Orlow MK, Wolf MS. Evidence does not support clinical screening of literacy. J Gen Intern Med 2008;23:100-2.
33. Castro CM, Wilson C, Wang F, Schillinger D. Babel babble: physicians' use of unclarified medical jargon with patients. Am J Health Behav 2007;31 Suppl 1:S85-95.
34. Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med 2003;163:83-90.
35. King TE, Wheeler MB. Medical management of vulnerable and underserved patients: principles, practice, and populations. New York: McGraw Hill Medical Pub. Division; 2007.
36. Roter DL, Stashefsky-Margalit R, Rudd R. Current perspectives on patient education in the US. Patient Educ Couns 2001; 44:79-86.
37. Doak CC Doak LG, Root JH. Teaching patients with low literacy skills. Philadelphia: J.B. Lippincott; 1996.
38. Doak CC, Doak LG, Friedell GH, Meade CD. Improving comprehension for cancer patients with low literacy skills: strategies for clinicians. CA Cancer J Clin 1998;48:151-62.
39. Rudd RE, Comings JP. Learner developed materials: an empowering product. Health Educ Q 1994;21:313-27.
40. Wallerstein N, Bernstein E. Empowerment education: Freire's ideas adapted to health education. Health Educ Q 1988;15: 379-94.
41. Roter D. The medical visit context of treatment decision- making and the therapeutic relationship. Health Expect 2000; 3:17-25.
42. DeWalt DA. Low health literacy: epidemiology and interventions. N C Med J 2007;68:327-30.
43. Kripalani S, Weiss BD. Teaching about health literacy and clear communication. J Gen Intern Med 2006;21:888-90.
44. Schwartzberg JC, VanGeest JB, Wang CC, editors. Understanding health literacy: implications for medicine and public health. Chicago: American Medical Association; 2005.
45. Schwartzberg JC, Cowett A, VanGeest J, Wolf MS. Communication techniques for patients with low health literacy: a survey of physicians, nurses, and pharmacists. Am J Health Behav 2007;31 Suppl 1:S96-104.
46. Hironaka LK, Paasche-Orlow MK. The implications of health literacy on patient-provider communication. Arch Dis Child 2008;93:428-32.
47. Rothman RL, DeWalt DA, Malone R, et al. Influence of patient literacy on the effectiveness of a primary care-based diabetes disease management program. JAMA 2004;292:1711-6.
48. Williams N, Ogden J. The impact of matching the patient's vocabulary: a randomized control trial. Fam Pract 2004;21:630-5.
49. Sudore RL, Landefeld CS, Williams BA, et al. Use of a modified informed consent process among vulnerable patients: a descriptive study. J Gen Intern Med 2006;21:867-73.
50. Johnson A, Sandford J, Tyndall J. Written and verbal information versus verbal information only for patients being discharged from acute hospital settings to home. Cochrane Database Syst Rev 2003;(4):CD003716.
51. Schillinger D, Machtinger EL, Wang F, et al. Language, literacy, and communication regarding medication in an anticoagulation clinic: a comparison of verbal vs. visual assessment. J Health Commun 2006;11:651-64.
52. Machtinger EL, Wang F, Chen LL, et al. A visual medication schedule to improve anticoagulation control: a randomized, controlled trial. Jt Comm J Qual Patient Saf 2007;33:625-35.
53. Houts PS, Witmer JT, Egeth HE, et al. Using pictographs to enhance recall of spoken medical instructions II. Patient Educ Couns 2001;43:231-42.
54. Houts PS, Doak CC, Doak LG, Loscalzo MJ. The role of pictures in improving health communication: a review of research on attention, comprehension, recall, and adherence [published erratum appears in Patient Educ Couns 2006;64:393-4]. Patient Educ Couns 2006;61:173-90.
55. Yin HS, Dreyer BP, van Schaick L, et al. Randomized controlled trial of a pictogram-based intervention to reduce liquid medication dosing errors and improve adherence caregivers of young children. Arch Pediatr Adolesc Med 2008;162:814-22.
56. Wofford JL, Smith ED, Miller DP. The multimedia computer for office-based patient education: a systematic review. Patient Educ Couns 2005;59:148-57.
57. O'Connor AM, Stacey D, Entwistle V, et al. Decision aids for people facing health treatment or screening decisions. Co- chrane Database Syst Rev 2003;(2):CD001431.
58. Pignone M, Harris R, Kinsinger L. Videotape-based decision aid for colon cancer screening. A randomized, controlled trial. Ann Intern Med 2000;133:761-9.
59. Murphy PW, Chesson AL, Walker L, et al. Comparing the effectiveness of video and written material for improving knowledge among sleep disorders clinic patients with limited literacy skills. South Med J 2000;93:297-304.
60. Meade CD, McKinney WP, Barnas GP. Educating patients with limited literacy skills: the effectiveness of printed and videotaped materials about colon cancer. Am J Public Health 1994; 84:119-21.
61. Campbell FA, Goldman BD, Boccia ML, Skinner M. The effect of format modifications and reading comprehension on recall of informed consent information by low-income parents: a comparison of print, video, and computer-based presentations. Patient Educ Couns 2004;53:205-16.
62. Volandes AE, Lehmann LS, Cook EF, et al. Using video images of dementia in advance care planning. Arch Intern Med 2007;167:828-33.
63. Youmans SL, Schillinger D. Functional health literacy and medication use: the pharmacist's role. Ann Pharmacother 2003;37:1726-9.
64. Fagerlin A, Ubel PA, Smith DM, Zikmund-Fisher BJ. Making numbers matter: present and future research in risk communication. Am J Health Behav 2007;31 Suppl 1:S47-56.
65. Schwartz LM, Woloshin S, Black WC, Welch HG. The role of numeracy in understanding the benefit of screening mam- mography. Ann Intern Med 1997;127:966-72.
66. Estrada CA, Martin-Hryniewicz M, Peek BT, et al. Literacy and numeracy skills and anticoagulation control. Am J Med Sci 2004;328:88-93.
67. Zikmund-Fisher BJ, Smith DM, Ubel PA, Fagerlin A. Validation of the subjective numeracy scale: effects of low numeracy on comprehension of risk communications and utility elicitations. Med Decis Making 2007;27:663-71.
68. Burkell J. What are the chances? Evaluating risk and benefit information in consumer health materials. J Med Libr Assoc 2004;92:200-8.
69. Feldman-Stewart D, Kocovski N, McConnell BA, et al. Perception of quantitative information for treatment decisions. Med Decis Making 2000;20:228-38.
70. Mazur DJ, Merz JF. How the manner of presentation of data influences older patients in determining their treatment preferences. J Am Geriatr Soc 1993;41:223-8.
71. Schapira MM, Fletcher KE, Gilligan MA, et al. A framework for health numeracy: how patients use quantitative skills in health care. J Health Commun 2008;13:501-17.
72. Schapira MM, Nattinger AB, McHorney CA. Frequency or probability? A qualitative study of risk communication formats used in health care. Med Decis Making 2001;21:459-67.
73. Woloshin S, Schwartz LM, Welch HG. Risk charts: putting cancer in context. J Natl Cancer Inst 2002;94:799-804.
74. Malenka DJ, Baron JA, Johansen S, et al. The framing effect of relative and absolute risk. J Gen Intern Med 1993;8:543-8.
75. Hoffrage U, Gigerenzer G. Using natural frequencies to improve diagnostic inferences. Acad Med 1998;73:538-40.
76. Peters E, Vastfjall D, Slovic P, et al. Numeracy and decision making. Psychol Sci 2006;17:407-13.
77. McNeil BJ, Pauker SG, Sox HC Jr, Tversky A. On the elicitation of preferences for alternative therapies. N Engl J Med 1982; 306:1259-62.
78. Stone VE, Jordan J, Tolson J, et al. Perspectives on adherence and simplicity for HIV-infected patients on antiretroviral therapy: self-report of the relative importance of multiple attributes of highly active antiretroviral therapy (HAART) regimens in predicting adherence. J Acquir Immune Defic Syndr 2004;36: 808-16.
79. Schroeder K, Fahey T, Ebrahim S. Interventions for improving adherence to treatment in patients with high blood pressure in ambulatory settings. Cochrane Database Syst Rev 2004;(2): CD004804.
80. Roberts KJ. Barriers to and facilitators of HIV-positive patients' adherence to antiretroviral treatment regimens. AIDS Patient Care STDS 2000;14:155-68.
81. Kripalani S, Henderson LE, Jacobson TA, Vaccarino V. Medication use among inner-city patients after hospital discharge: patient-reported barriers and solutions. Mayo Clin Proc 2008; 83:529-35.
82. Kripalani S, Robertson R, Love-Ghaffari MH, et al. Development of an illustrated medication schedule as a low-literacy patient education tool. Patient Educ Couns 2007;66:368-77.
83. Zermansky AG, Petty DR, Raynor DK, et al. Randomised controlled trial of clinical medication review by a pharmacist of elderly patients receiving repeat prescriptions in general practice. BMJ 2001;323:1340-3.
84. Gattis WA, Hasselblad V, Whellan DJ, O'Connor CM. Reduction in heart failure events by the addition of a clinical pharmacist to the heart failure management team: results of the Pharmacist in Heart Failure Assessment Recommendation and Monitoring (PHARM) Study. Arch Intern Med 1999;159: 1939-45.
85. U.S. Department of Health and Human Services. Quick guide to health literacy and older adults. Available at www.health.gov/communication/literacy/ olderadults/literacy.htm. Accessed 11 Nov 2008.
86. Whiteside MM, Wallhagen MI, Pettengill E. Sensory impairment in older adults: part 2: vision loss. Am J Nurs 2006;106: 52-61.
87. Wallhagen MI, Pettengill E. Hearing impairment: significant but underassessed in primary care settings. J Gerontol Nurs 2008;34:36-42.
88. Wallhagen MI, Pettengill E, Whiteside M. Sensory impairment in older adults: part 1: hearing loss. Am J Nurs 2006;106):40-8.
89. Plassman BL, Langa KM, Fisher GG, et al. Prevalence of dementia in the United States: the aging, demographics, and memory study. Neuroepidemiology 2007;29:125-32.
90. Plassman BL, Langa KM, Fisher GG, et al. Prevalence of cognitive impairment without dementia in the United States. Ann Intern Med 2008;148:427-34.
91. Weintraub D, Maliski SL, Fink A, et al. Suitability of prostate cancer education materials: applying a standardized assessment tool to currently available materials. Patient Educ Couns 2004;55:275-80.
92. Stenner AJ, Burdick H, Sanford EE, Burdick DS. How accurate are lexile text measures? J Appl Meas 2006;7:307-22.
93. Davis TC, Bocchini JA Jr, Fredrickson D, et al. Parent comprehension of polio vaccine information pamphlets. Pediatrics 1996;97(6 Pt 1):804-10.
94. Jacobson TA, Thomas DM, Morton FJ, et al. Use of a low-literacy patient education tool to enhance pneumococcal vaccination rates. A randomized controlled trial. JAMA 1999;282: 646-50.
95. Tait AR, Voepel-Lewis T, Malviya S, Philipson SJ. Improving the readability and processability of a pediatric informed consent document: effects on parents' understanding. Arch Pediatr Adolesc Med 2005;159:347-52.
96. Hayes KS. Randomized trial of geragogy-based medication instruction in the emergency department. Nurs Res 1998;47: 211-8.
97. Seligman HK, Wallace AS, DeWalt DA, et al. Facilitating behavior change with low-literacy patient education materials. Am J Health Behav 2007;31 Suppl 1:S69-78.
98. Sudore RL, Landefeld CS, Barnes DE, et al. An advance directive redesigned to meet the literacy level of most adults: a randomized trial. Patient Educ Couns 2007;69:165-95.
99. Harvard School of Public Health. Health literacy studies. Available at www.hsph.harvard.edu/healthliteracy/materials. html. Accessed 12 Dec 2008.
100. Society of General Internal Medicine Health Literacy Special Interest Group. Avaiable at www.sgim.org/AM06/handouts/IF19.pdf. Accessed 11 Nov 2008.
101. The Coalition for Health Communication. Available at www. healthcommunication.net/Online-Resources.html. Accessed 11 Nov 2008.
102. U.S. Dept. of Health and Human Services, Office of Disease Prevention and Health Promotion. Health communication activities. Available at www.health.gov/communication/ literacy. Accessed 11 Nov 2008.
103. AMA Foundation. Health literacy. American Medical Association. Available at www.ama-assn.org/ama/pub/category/8115.html. Accessed 11 Nov 2008.
104. American College of Physicians. Health literacy resources. Available at http://foundation.acponline.org/hl/hlresources. htm. Accessed 11 Nov 2008.
105. Davis TC, Berkel HJ, Arnold CL, et al. Intervention to increase mammography utilization in a public hospital. J Gen Intern Med 1998;13:230-3.
106. Davis TC, Fredrickson DD, Arnold C, et al. A polio immunization pamphlet with increased appeal and simplified language does not improve comprehension to an acceptable level. Patient Educ Couns 1998;33:25-37.
107. Wolf MS, Bailey SC. Improving prescription drug labeling. N C Med J 2007;68:340-2.
108. Sarkar U, Handley MA, Gupta R, et al. Use of an interactive, telephone-based self-management support program to identify adverse events among ambulatory diabetes patients. J Gen Intern Med 2008;23:459-65.
109. Davis TC, Wolf MS, Bass PF 3rd, et al. Literacy and misunderstanding prescription drug labels. Ann Intern Med 2006;145: 887-94.
110. Wolf MS, Davis TC, Shrank W, et al. To err is human: patient misinterpretations of prescription drug label instructions. Patient Educ Couns 2007;67:293-300.
111. Webb J, Davis TC, Bernadella P, et al. Patient-centered approach for improving prescription drug warning labels. Patient Educ Couns 2008;72:443-9.
112. Wolf MS, Davis TC, Shrank WH, et al. A critical review of FDA-approved medication guides. Patient Educ Couns 2006;62: 316-22.
113. Wolf MS. Prescription medication labeling in the United States: can we confuse patients less? Presented at the American College of Physicians Foundation National Health Communication Conference; 2006 Nov 29; Washington, DC.
114. Shrank W, Avorn J, Rolon C, Shekelle P. Effect of content and format of prescription drug labels on readability, understanding, and medication use: a systematic review. Ann Pharmaco- ther 2007;41:783-801.
115. Dewalt DA, Pignone M, Malone R, et al. Development and pilot testing of a disease management program for low literacy patients with heart failure. Patient Educ Couns 2004;55:78-86.
116. Dewalt DA, Malone RM, Bryant ME, et al. A heart failure self-management program for patients of all literacy levels: a randomized, controlled trial. BMC Health Serv Res 2006;6:30.
117. Schillinger D, Hammer H, Wang F, et al. Seeing in 3-D: examining the reach of diabetes self-management support strategies in a public health care system. Health Educ Behav 2008;35: 664-82.
118. Rudd RE, Anderson JE. The health literacy environment of hospitals and health centers. Partners for action: making your healthcare facility literacy-friendly. The National Center for the Study of Adult Learning and Literacy. Available at www.ncsall.net/?id=1163. Accessed 11 Nov 2008.
119. Agency for Healthcare Research and Quality. Questions are the answer. Get more involved with your health care. Available at www.ahrq.gov/ questionsaretheanswer. Accessed 11 Nov 2008.
120. Partnership for Clear Health Communication. Ask me 3. Available at www.askme3.org. Accessed 11 Nov 2008.
121. U.S. Dept. of Health and Human Services Health Resources and Services Administration. Unified health communication 101: addressing health literacy, cultural competency, and limited English proficiency. Available at www.hrsa.gov/healthliteracy/training.htm. Accessed 11 Nov 2008.
122. Manning KD, Kripalani S. The use of standardized patients to teach low-literacy communication skills. Am J Health Behav 2007;31 Suppl 1:S105-10.
123. Harper W, Cook S, Makoul G. Teaching medical students about health literacy: 2 Chicago initiatives. Am J Health Behav 2007; 31 Suppl 1:S111-4.
124. Weiss BD, Francis L, Senf JH, et al. Literacy education as treatment for depression in patients with limited literacy and depression: a randomized controlled trial. J Gen Intern Med 2006; 21:823-8.
125. Poresky RH, Daniels AM. Two-year comparison of income, education, and depression among parents participating in regular Head Start or supplementary Family Service Center Services. Psychol Rep 2001;88(3 Pt 1):787-96.
126. Auger S, Verbiest S. Lay health educators' roles in improving patient education. N C Med J 2007;68:333-5.
127. Feldman PJ, Dunkel-Schetter C, Sandman CA, Wadhwa PD. Maternal social support predicts birth weight and fetal growth in human pregnancy. Psychosom Med 2000;62:715-25.
128. Gilmer TP, Walker C, Johnson ED, et al. Improving treatment of depression among Latinos with diabetes using project Dulce and IMPACT. Diabetes Care 2008;31:1324-6.
129. Sarkisian CA, Prohaska TR, Davis C, Weiner B. Pilot test of an attribution retraining intervention to raise walking levels in sedentary older adults. J Am Geriatr Soc 2007;55:1842-6.
130. Kim S, Koniak-Griffin D, Flaskerud JH, Guarnero PA. The impact of lay health advisors on cardiovascular health promotion: using a community-based participatory approach. J Cardiovasc Nurs 2004;19:192-9.
131. Levine DM, Becker DM, Bone LR. Narrowing the gap in health status of minority populations: a community-academic medical center partnership. Am J Prev Med 1992;8:319-23.
132. Whitley EM, Everhart RM, Wright RA. Measuring return on investment of outreach by community health workers. J Health Care Poor Underserved 2006;17(1 Suppl):6-15.
133. Sudore RL, Landefeld CS, Pantilat SZ, et al. Reach and impact of a mass media event among vulnerable patients: the Terri Schiavo Story. J Gen Intern Med 2008;23:1854-7.
134. Cram P, Fendrick AM, Inadomi J, et al. The impact of a celebrity promotional campaign on the use of colon cancer screening: the Katie Couric effect. Arch Intern Med 2003;163:1601-5.
135. Kim SP, Knight SJ, Tomori C, et al. Health literacy and shared decision making for prostate cancer patients with low socioeconomic status. Cancer Invest 2001;19:684-91.
136. Aagaard EM, Nadler P, Adler J, et al. An interactive computer kiosk module for the treatment of recurrent uncomplicated cystitis in women. J Gen Intern Med 2006;21:1156-9.
137. Munoz RF, Lenert LL, Delucchi K, et al. Toward evidence- based internet interventions: a Spanish/English web site for international smoking cessation trials. Nicotine Tob Res 2006;8: 77-87.
138. Cox D, Ritterband L, Magee J, et al. Blood glucose awareness training delivered over the internet. Diabetes Care 2008;31: 1527-8.
139. Greenhalgh T, Wood GW, Bratan T, et al. Patients' attitudes to the summary care record and HealthSpace: qualitative study. BMJ 2008;336:1290-5.
140. Sudore RL, Landefeld CS, Perez-Stable EJ, Schillinger D. Unraveling the relationship between literacy, language & doctor-patient communication [abstract]. Annual meeting of the Society of General Internal Medicine. J Gen Intern Med 2008;54 (2 Suppl):431.