Association between health literacy and mortality: a systematic review and meta-analysis

BACKGROUND: To identify the relationship between health literacy (HL) and mortality based on a systematic review and meta-analysis. METHODS: Literature published from database inception until July 2020 was searched using the PubMed and Web of Science databases, using relevant keywords and clear inclusion and exclusion criteria. The search was limited to English language articles. Two reviewers independently selected studies and extracted data. Pooled correlation coefficients and their 95% confidence intervals (CI) between HL and mortality were estimated using Stata 15.0 software. Potential sources of heterogeneity were explored using subgroup analysis, sensitivity analysis, and meta-regression. Quality of the original studies that were included in the meta-analysis was evaluated using the Newcastle–Ottawa Scale. A funnel plot and Egger’s test were used to determine whether significant publication bias was present. RESULTS: Overall, 19 articles were included, reporting on a total of 41,149 subjects. Eleven were prospective cohort studies, and all articles were considered “good” quality. The most used screening instruments were the short Test of Functional Health Literacy (S-TOFHLA) in Adults and the Brief Health Literacy Screen (BHLS). Among 39,423 subjects (two articles did not report the number of patients with low HL), approximately 9202 (23%) had inadequate or marginal HL. The correlation coefficient between HL and mortality was 1.25 (95%CI = 0.25–0.44). CONCLUSION: Lower HL was associated with an increased risk of death. This finding should be considered carefully and confirmed by further research.