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Revista CEFAC

Print version ISSN 1516-1846On-line version ISSN 1982-0216

Rev. CEFAC vol.18 no.1 São Paulo Jan./Feb. 2016 


Conceptual aspects and factors associated with Functional Health Literacy: a literary review

Poliana Cristina Rocha1 

Stela Maris Aguiar Lemos2 

1Prefeitura Municipal de Belo Horizonte, Belo Horizonte, MG, Brasil.

2Departamento de Fonoaudiologia da Universidade Federal de Minas Gerais - UFMG, Belo Horizonte, MG, Brasil.


The purpose of this study is to review scientific productions concerning the evaluation of functional health literacy, which is associated with quality of life, and methodologically analyze the observational studies about this theme. An integrative review has been produced using scientific articles related to the following themes: functional health literacy and quality of life through searches in the PubMed, Lilacs and "Biblioteca Virtual de Saúde" databases. After applying the inclusion criteria, 538 articles were obtained, then, after applying the exclusion criteria, 11 articles were selected. Nine out of the eleven articles are international and the remaining 2 are national. The review consisted of compiling and constructing a historical timeline of the publications with methodological analysis of observational studies and the elaboration of word clouds. Most of the articles have quantitative analysis, adults and elders as target groups and measurements of the levels of functional health literacy. This study verified the positive associations between functional health literacy, low education, advanced age, the male gender and low income. Most scenarios were healthcare environments. Functional health literacy presented an association with social-demographic variables, such as sex, age and education. Most studies presented in this study had the goal of relating literacy to pathologies and were done in clinical environments such as hospitals and health clinics. All eight observational articles included in the review fit the methodological criteria for the elaboration of this type of study.

Keywords: Health Literacy; Health Education; Information Literacy; Quality of Life


O objetivo deste estudo é revisar as produções científicas acerca da avaliação do letramento funcional em saúde em associação com a qualidade de vida; e analisar metodologicamente os estudos observacionais sobre a temática. Trata-se de revisão integrativa de literatura produzida com base em artigos relacionados aos seguintes eixos temáticos: letramento funcional em saúde e qualidade de vida, com busca realizada nas bases de dados PubMed, Lilacs, Biblioteca Virtual em Saúde. Após a aplicação dos critérios de inclusão obteve-se 538 artigos e após a aplicação dos critérios de exclusão foram selecionados 11 artigos sendo nove estudos internacionais e dois nacionais. A revisão constou de compilação e construção de linha histórica das publicações, análise metodológica dos estudos observacionais e elaboração de nuvem de textos. A maior parte dos artigos tem análise quantitativa; público alvo adultos e idosos e medem o nível de letramento funcional em saúde. Os estudos verificaram relação positiva do letramento funcional em saúde com a baixa escolaridade, idade mais avançada, sexo masculino e baixa renda. Os principais cenários foram ambientes assistenciais. O letramento funcional em saúde apresentou associação com variáveis sócio-demográficas como sexo, idade e escolaridade. A maior parte dos estudos encontrados na busca teve como objetivo relacionar o letramento a patologias e foi realizado em ambientes clínicos (ambulatórios e hospitais). Dos oito artigos observacionais incluídos na presente revisão atenderam totalmente aos critérios metodológicos para elaboração desse tipo de estudo.

Descritores: Alfabetização em Saúde; Educação em Saúde; Competência em Informação, Qualidade de Vida


Functional health literacy is a topic of interest for researchers and health professionals. In addition to the term "functional health literacy", the literature also uses "health literacy" and "health alphabetization". Although these terms are often used as synonyms, there are important distinctions that should be considered.

The terms "alphabetization" or "literacy" refer to the results of the process of acquiring the ability to read and write; whereas, "functional literacy" refers to the knowledge and abilities acquired as a result of the ability to read and write which provide an individual the conditions needed to participate in specific activities of a particular field1. When this concept is applied to the health area, functional health literacy represents the cognitive ability to understand, interpret and apply written or spoken health information1. For the American Medical Association health literacy is a set of skills including the ability to read basic literature and perform numerical tasks required to function in the healthcare environment. The Institute of Medicine in the United States defines functional health literacy as the capacity to obtain, process and understand basic health and health services information necessary to adequately make health decisions. In practice, individuals with adequate functional health literacy tend to have better health conditions1.

The World Health Organization defines functional health literacy as the cognitive and social abilities which determine the motivation and capacity of a person to access, comprehend and utilize information as a means of promoting and maintaining health, which does not mean only knowing how to read leaflets and schedule consultations2.

Yet, health literacy is defined as "the degree to which people are able to find, understand and share health information in order to maintain and promote health throughout life within different contexts"3. Sociodemographic factors seem to affect functional health literacy, with education strongly influencing its level4.

It should be noted that there are not extensive studies in Brazil showing the level of functional health literacy of the population1. Generally studies on functional health literacy utilize generic reading tests or evaluations based on math and reading skills, but the definition of functional health literacy goes beyond these skills including fields such oral communication, among others. Furthermore, functional health literacy is dynamic and is found at the intersect between patient abilities and the demands of the specific situation5.

In this context, an interrelation between functional health literacy and quality of life is possible in the perspective of self-care6.

The term "quality of life" is by nature subjective, multidimensional and defined as the perception that people have of their position in life considering the cultural context and value systems in which they are inserted, along with their objectives, expectations, standards and worries7. As such, the perceptions of individuals of their own health, as well as other aspects of their lives, should be considered8.

The use of quality of life assessment tools in healthcare is recommended, which would align Brazilian studies with the international agenda for theoretical and methodological advancement of the field, since the methodologies utilized to obtain this measurement are still controversial in the country9.

Thus, there are theoretical and methodological questions that have yet to be adequately addressed, justifying the investigation, systematization and discussion of the national and international literature.

Therefore, the objectives of this study were to review the scientific literature on evaluations of functional health literacy in association with quality of life and to methodically analyze observational studies in the area.


This study consisted of an integrative literature review of articles related to the following themes: functional health literacy and quality of life. The search was conducted in the PubMed, Lilacs and Biblioteca Virtual em Saúde (BVS) databases.

The inclusion criteria were: articles in Portuguese, English or Spanish; published within the last 10 years; available in its entirety free of charge; and, with an objective of defining or measuring functional health literacy or evaluating the relationship between functional health literacy and quality of life. The exclusion criteria were: articles addressing the relationship between functional health literacy and pathologies or treatments; case reports; and, expert opinions.

The selection of articles occurred in two stages with the first consisting of selection of the descriptors followed by the database search. To elaborate the search and selection strategy, the following free terms were used, along with their Portuguese and Spanish translations: literacy, health literacy, alphabetization, health alphabetization and quality of life.

The initial search returned 538 articles, of which 93 were from LILACS, 76 from BVS and 369 from PubMed. Of these, 405 articles met the inclusion criteria. After reading titles and abstracts, 360 articles were excluded. Thus, 45 articles were selected for a complete read: 01 from LILACS, 04 from BVS and 40 from PubMed. After reading the articles in entirety, 33 articles with objectives not in alignment with the study objectives were excluded. Finally, 11 articles were selected for inclusion in the study (Figure 1).

Figure 1: Flowchart demonstrating the search and selection of articles stages of this review. 

Data analysis was undergone in three stages. The first stage consisted of compiling and describing articles focusing on the themes: location, design, methodology and primary results of each included study. In this stage, a historical timeline was constructed with chronological distribution of the studies according to their main themes. The second stage included analyzing observational studies and constructing categories according to guidelines established by the STROBE (STrengthening the Reporting of OBservational studies in Epidemiology) initiative10. This methodology consists of 22 items related to information which should be included in the title, abstract, introduction, methodology, results and discussions of the study articles. The STROBE Initiative was developed by researchers in the field of epidemiology, statistics, scientific methodology and editors of scientific journals with the objective to guide the description of observational studies. These guidelines were used for data analysis in the present study.

The third stage of data analysis was the creation of word clouds based on the conclusions of studies included in the review using Wordle Copyright (c)2008. It should be noted that word clouds are a form of visualizing linguistic data to show the frequency with which certain words appear in the text. Word size is proportional to the number of times that word appears in the text making the word cloud is a visually hierarchized11.

Literature Review

In the present literature review, eleven studies were selected (Figure 2), of which nine international studies and two national studies were distributed as follows: one study article on "literacy", nine on "health literacy" and one on "health literacy and quality of life".

Figure 2: Synthesis of study data included in the literature review. 

The analysis of the article in the "literacy" category1) clarifies the terms related to the study and their differences showing that there still exists the use of both "functional health literacy" and "alphabetization/literacy in health" in several ways. This finding reflects the reality of health literacy as a new theme in the academic and scientific settings.

Of the nine articles in the "health literacy" category, four are from the United States and one each from Canada, Turkey, the United Kingdom, Argentina and Brazil. Eight studies had a cross-sectional design. Eight studies12)-(19) also addressed the level of functional health literacy and its relation with sociodemographic data with quantitative analysis. One study20 utilized qualitative analysis methods related to the movement of adolescents within the health system and their perceptions of their abilities in functional health literacy. Six studies12)-(16),(19) targeted adults and the elderly, two18),(20) targeted adolescents and one study17) evaluated all three of these audiences.

Two articles13),(16) utilized the Test of Functional Health Literacy (TOFHLA), two12),(19) used the Rapid Estimate of Adult Literacy in Medicine (REALM) test and two17),(19) applied the Newest Vital Sign (NVS) test, being that these were the most utilized in the analyzed studies. The TOFHLA and the REALM are tests used for measuring functional health literacy and its relation to care, evolution and the impact of health interventions. The TOFHLA aims to measure reading comprehension (in three health related areas: instructions for preparing for an upper gastrointestinal tract evaluation, patient rights and responsibilities and informed consent agreement form) and numerical skills. A person's functional health literacy is classified as inadequate (incapable of reading and interpreting health texts) and adequate (capable of reading and interpreting the majority of health texts)21.

Another questionnaire proposed to evaluate health literacy is the REALM, a test that evaluates only the recognition of words related to the human body. It associates the number of points with reading skills for each schoolyear. The Newest Vital Sign (NVS) intends to measure functional health literacy through the use of an ice cream label accompanied by six questions each worth a point. Test scores are classified as follows: 0-1 high chance of limited literacy, 2-3 limited literacy, and 4-6 adequate literacy21.

The utilization of different instruments partially limited comparisons between studies. However, it was possible to compile data and analyze the categorizations deriving from the main tests of these studies (Figure 3).

Figure 3: Synthesis of the characteristics of the instruments used in the literature for measuring functional health literacy. 

The greatest production of studies related to the theme originated from the United States12),(15),(17),(20. There is limited research in the area from Latin America with only one study from Brazil16) and one from Argentina14.

Quantitative analysis found associations between limited health literacy and low educational attainment, older age, low income and the male sex12)-(18. A study which found better health literacy among males when compared to females should be highlighted19. However, discrepancies between studies in relation to literacy according to gender could be related to social and cultural differences between the study sites.

This study found that research in health literacy predominately utilized adult and elderly participants.

Few studies include adolescents and discuss their abilities and behaviors in relation to their self-care. This finding suggests the need to study this theme in relation to childhood and adolescence, especially considering the importance of these developmental stages in the establishment of and adherence to self-care practices and the health system in adulthood.

Most of the studies are of a quantitative nature and evaluate reading and comprehension of the supplied information, but they do not consider evaluating self-care capabilities which are included in the broad concept of functional health literacy. It is important to consider that the realities of the health systems differ among the countries; therefore, it is often difficult to compare studies realized in different localities.

In the literature, the majority of the studies referred to specific situations, such as associations between functional health literacy and health knowledge of primagravidae22, manifestations of depression23,treatment of chronic diseases such as asthma or diabetes4),(24)-(26, mental health27, child's health28),(29, nephrological diseases30) and utilization of health services31.

Literature that evaluates the level of functional health literacy without relating it to a pathology or health service is still scarce in general and research of this theme is in its infancy in Brazil. This finding shows that despite the importance of this theme for the evaluation and formulation of public policy, Brazil still needs to advance in scientific production in this area.

The analysis of scientific production on functional health literacy shows that these studies occur predominantly in the healthcare setting with few studies based in other scenarios such as schools. Thus highlighting the need for studies on functional health literacy in an array of settings where the effects of potential enhancers such as autonomy and self-care in health can be evaluated.

The search for studies relating functional health literacy and quality of life resulted in only one article32) that evaluated the influence of health literacy on quality of life of people with prostate cancer. Despite focusing on a particular pathology (prostate cancer), this article was included in the review because completely reading the article showed that the study associated level of functional health literacy with quality of life through a generic measurement instrument that did not focus on the disease. This study detected an association between these two variables indicating that elevated functional health literacy could lead to better quality of life. The results showed a statistically significant association between low functional health literacy and low educational attainment, older age and the presence of comorbidities. These findings are supported by other studies12),(13),(15),(17),(18) in this review under the descriptor "health literacy".

Analysis of the themes "quality of life" and "health literacy" revealed that studies related these themes with a focus on chronic conditions such as asthma33),(34) and heart disease35 and with specific areas such as oral health22),(36.

A paucity of literature which evaluates the relationship between functional health literacy and quality of life in the general population without the presence of specific pathologies was observed. Similarly no articles were found relating studies of these associations in the adolescent population.

These findings demonstrate the need to advance research in this area, especially on associations between functional health literacy and quality of life for the advancement of health promotion and not only for rehabilitation after diseases have already developed.

Of the descriptive observational studies in Figure 1, in relation to the title and abstract, 11.1% completely met, 77.7% partially met and 11.1% did not meet the criteria established by the STROBE initiative. Of the introductions, 66.7% completely and 33.3% partially met these criteria, and, when considering the methodologies, 77.8% completely and 22.2% partially met them. Of the results, 88.9% totally met the established criteria compared to 11.1% that only partially met them. Of the discussions, 66.7% completely and 33.3% partially met the established criteria. Only one of the observational articles included in this review met in its entirety the established criteria, thus partial compliance of the analysis protocol of the STROBE initiative dominated (Figure 4).

Legend: CM = completely meets the criteria described in the STROBE initiative; PM= Partially meets the criteria described in the STROBE initiative; DM = does not meet the criteria described in the STROBE initiative.

Figure 4: Analysis of observational studies according to the STROBE initiative. 

The analyzed items consisted of information which observational studies need in order to allow for critical reading10.

A deficiency in complete and detailed information in observational studies included in this review may compromise the interpretation of results, reproducibility and planning for further studies.

The historical timeline of the articles in the "health literacy" strategy (Figure 5) shows a shift in focus of the articles evaluating functional health literacy from only a measuring functional health literacy to also including its relation with health behaviors and disease prevention.

Another observation revolved around the setting of the studies mostly occurring in the clinical setting. The inclusion of other settings, such as the school, appears in 2012 (the end of the timeline) along with the inclusion of studies on functional health literacy in adolescence.

This analysis shows that although efforts to include non-clinical environments and adolescent populations have begun, these efforts are still in their infancy and need to advance due to this population's distance from the health system and their potential to adopt healthy habits.

Figure 5: Historical timeline of national and international scientific production evaluating functional health literacy without relating it to pathologies. 

According to the word cloud (Figure 6) the words with the greatest frequency in the conclusions of the studies are related to the abilities, level and care related to functional health literacy. This reflects the existence of more studies measuring and defining functional health literacy and few studies addressing its improvement.

Figure 6: Word cloud 


The literature review suggested association between level of functional health literacy and sociodemographic aspects such as income, gender and educational attainment level. The most of the studies aimed to relate functional health literacy with pathologies and were conducted in clinical settings (outpatient and hospital).

It should be noted that only one of the eight observational studies included in this review completely met the criteria described in the STROBE initiative (Strengthening the Reporting of OBservational studies in Epidemiology) for the elaboration of observational studies.

Research on functional health literacy in Brazil is limited, especially those which attempt to related this with quality of life. Since this field is still in its infancy in Brazil, this should be a health research focus.


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Received: June 30, 2015; Accepted: September 30, 2015

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