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研究生: 王桂芸
論文名稱: 氣喘病人健康素養與健康結果之因果模式驗證
Validation of the Causal Model Linking Health Literacy to Health Outcomes of Asthma Patients
指導教授: 賴香如
學位類別: 博士
Doctor
系所名稱: 健康促進與衛生教育學系
Department of Health Promotion and Health Education
論文出版年: 2010
畢業學年度: 98
語文別: 中文
論文頁數: 177
中文關鍵詞: 氣喘病人健康素養健康結果因果模式
英文關鍵詞: asthma patients, health literacy, health outcomes, causal model
論文種類: 學術論文
相關次數: 點閱:738下載:45
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  • 背景及研究目的
    全球氣喘協會 (Global Initiative for Asthma) 於2004年預估,到2025年世界人口中罹患氣喘人數將增加45-59%,故氣喘將成為全球一項重要健康議題。目前國內尚未見氣喘病人健康素養之資料,而相關研究顯示氣喘病人的健康素養與健康結果有關,但並未證實兩者的因果關係,故本研究之目的是驗證健康素養與健康結果的因果模式。
    研究方法
    本研究為一橫斷式調查研究(Cross-sectional survey research),以至北部三所醫學中心及一所區域教學醫院胸腔內科門診就診之20歲以上氣喘病人為對象,共收案300人。以問卷收集社會人口學、疾病特性、健康素養、醫療決策、氣喘知識、態度和自我效能、接受健康照護經驗,以及健康結果 (MDI使用技能、醫療資源利用及自我管理行為) 等資料,再採SPSS 15.0 版之結構方程式驗證健康素養對健康結果之直接效應及中介效應因果模式,並以P< .05為統計上的顯著水準。

    結果
    健康素養之平均值為80.43(滿分120),其中不足者佔13.67%、邊緣者13.33%、而足夠者佔73%。健康素養與健康結果的直接效應模式不成立,但加入社會人口學及疾病特性變項後,健康素養對健康結果之MDI使用技能具直接效果。另,不論是否加入社會人口學及疾病特性變項,健康素養會經由中介變項對健康結果產生間接效果。
    結論
    本研究顯示,研究對象的健康素養與健康結果間有因果關係,包括直接效應及間接效應模式,但解釋力不高,顯示可能尚有具影響力之變項未置入模式中,值得未來繼續探究。然本研究為驗證兩者因果模式之第一項研究,故可作為相關研究設計和介入措施成效評價之參考。

    Background and Research Purposes
    The Global Initiative for Asthma (GINA) estimated that by 2025 the number of people with asthma will have grown by 45-59% and asthma will become as an important health issue globally. Although the relationship between health literacy and health outcome has been identified in the literature, the health literacy of asthma sufferers in Taiwan and the causal models linking health literacy and health outcomes have yet been adequately explored. This study was to examine the causal model linking health literacy and health outcome.
    Research Methodology
    This study was a cross-sectional survey. Using purposive sampling, we identified and invited potential participants from the thoracic medicine outpatient clinics of three medical centers and one district teaching hospital located in northern Taiwan. Qualified participants were aged 20 or over with a diagnosis of asthma. A total of 300 agreed to participate and were enrolled as subjects. A self-administered questionnaire was used to collect socio-demographics, disease characteristics, knowledge, attitudes and self-efficacy of asthma, medical decision-making, healthcare experience, and health outcome including MDI usage proficiency, medical utilization and self-management behavior. Data was analyzed using SPSS 15.0 software and a structured equation model (SEM) was used to validate the direct and mediating effects of health literacy on health outcomes. Statistical significance was defined as P< .05.
    Results
    The mean value for health literacy was 80.43 (total score = 120) with 13.67%, 13.33% and 73% categorized as “inadequate”, “borderline” or “adequate”, respectively. The direct effect of health literacy on health outcome was not supported. However, after considering socio-demographics and disease characteristics, the direct effect of health literacy on MDI usage proficiency was supported. Regardless of socio-demographic and disease characteristics, health literacy was found to have an indirect effect via mediated variables on the health outcomes of MDI usage proficiency, medical utilization and self-management behavior.
    Conclusions
    There was a causal relationship between between health literacy and health outcomes, both direct and indirect, but the variance explained was not high. The findings suggest that some variables with potentially explanative effects on health outcomes might not include and need to explore. Furthermore, this study was the first validation study to consider this issue. It is hoped that our findings and suggestions may be incorporated into the design of research and the evaluation of intervention effectiveness in the future.

    中文摘要 I 英文摘要 III 誌謝 V 目次 VI 表次 XI 圖次 XV 第一章 緒論 1 第一節 研究動機及重要性 1 第二節 研究目的 5 第三節 待答問題 6 第四節 研究假設 7 第五節 名詞界定 7 第六節 研究限制 10 第二章 文獻探討 11 第一節 氣喘之相關概念 11 第二節 健康素養之相關概念 14 第三節 健康素養相關因素研究 18 第三章 研究方法 34 第一節 研究設計與架構 34 第二節 研究場所及對象 36 第三節 研究工具 37 第四節 實施步驟 45 第五節 資料處理與統計分析 46 第六節 倫理考量 53 第四章 結果 54 第一節 各類變項之分佈情形 54 第二節 社會人口學變項及疾病特性與健康素養之相關分析 57 第三節 健康素養與醫療決策程度、氣喘知識、氣喘態度、氣喘自我效能或接受健康照護之經驗之相關分析 63 第四節 醫療決策、氣喘知識、態度和自我效能、接受健康照護之經驗與健康結果之相關分析 64 第五節 健康素養與健康結果之關係 69 第六節 健康素養與健康結果假定之直接效應模式驗證分析 70 第七節 健康素養與健康結果之中介效應模式驗證分析 78 第五章 討論 107 第一節 健康素養之現況 107 第二節 社會人口學變項與健康素養 107 第三節 疾病特性與健康素養 108 第四節 健康素養與醫療決策、氣喘知識、氣喘態度、氣喘自我效能、接受健康照護之經驗 109 第五節 醫療決策、氣喘知識、氣喘態度、氣喘自我效能或接受健康照護之經驗與健康結果 110 第六節 健康素養與健康結果 111 第七節 健康素養與健康結果的直接效應模式 112 第八節 健康素養與健康結果的中介效應模式 113 第六章 結論與建議 118 第一節 結論 118 第二節 建議 120 參考資料 124 附錄一、初步因素分析結果 137 附錄二、因素分析後保留之題項 139 附錄三、最後因素分析之結果 140 附錄四、健康素養對健康結果假定之直接效應模式 142 附錄五、 加入人口學變項及疾病特性後健康素養對健康結果假定之直接效應模式 143 附錄六、第一次模式修正圖 144 附錄七、第二次模式修正圖 145 附錄八、第三次模式修正圖(最終模式) 146 附錄九、健康素養與健康結果假定之中介效應模式 147 附錄十、第一次模式修正圖 148 附錄十一、第二次模式修正圖 149 附錄十二、第三次模式修正圖 150 附錄十三、第四次模式修正圖 151 附錄十四、第五次模式修正圖 152 附錄十五、第六次模式修正圖 153 附錄十六、第七次模式修正圖 154 附錄十七、第八次模式修正圖 155 附錄十八、第九次模式修正圖 156 附錄十九、第十次模式修正圖 157 附錄二十、第十一次模式修正圖 158 附錄二十一、第十二次模式修正圖 159 附錄二十二、第十三次模式修正圖(最終模式) 160 附錄二十三、人口學變項、疾病特性、健康素養透過中介變項與健康結果關係假定之中介效應模式 161 附錄二十四、第一次模式修正圖 162 附錄二十五、第二次模式修正圖 163 附錄二十六、第三次模式修正圖 164 附錄二十七、第四次模式修正圖 165 附錄二十八、第五次模式修正圖 166 附錄二十九、第六次模式修正圖 167 附錄三十、第七次模式修正圖 168 附錄三十一、第八次模式修正圖 169 附錄三十二、第九次模式修正圖 170 附錄三十三、第十次模式修正圖 171 附錄三十四、第十一次模式修正圖 172 附錄三十五、第十二次模式修正圖 173 附錄三十六、第十三次模式修正圖 174 附錄三十七、第十四次模式修正圖 175 附錄三十八、第十五次模式修正圖(最終模式) 176 附錄三十九、問卷內容效度專家名單 177 表1 社會人口學變項之分佈 55 表2 疾病特性之分佈 56 表3 知識、態度、自我效能、接受健康照護之經驗及健康結果得分之分佈 58 表4 人口學變項及疾病特性與健康素養之單迴歸分析 59 表 5 社會人口學變項、疾病特性的容忍度及變異數膨脹因素 60 表 6 社會人口學變項、疾病特性的條件指標 61 表 7 人口學變項及疾病特性與健康素養之多元迴歸分析 62 表8 健康素養與醫療決策、氣喘知識、氣喘態度、氣喘自我效能、接受健康照護之經驗之單迴歸分析 64 表9 醫療決策、氣喘知識、氣喘態度、氣喘自我效能、接受健康照護之經驗與MDI使用技能之單迴歸分析 65 表10 醫療決策、氣喘知識、氣喘態度、氣喘自我效能、接受健康照護之經驗與醫療資源利用之單迴歸分析 65 表11 醫療決策、氣喘知識、氣喘態度、氣喘自我效能、接受健康照護之經驗與自我管理行為之單迴歸分析 66 表12 醫療決策、氣喘知識、態度和自我效能、健康照護經驗之容忍度及變異數膨脹因素 67 表13 醫療決策、氣喘知識、態度和自我效能、健康照護經驗之條件指標 67 表14 醫療決策、氣喘知識、氣喘態度、氣喘自我效能、接受健康照護之經驗與MDI使用技能之多元迴歸分析 68 表15 醫療決策、氣喘知識、氣喘態度、氣喘自我效能、接受健康照護之經驗與醫療資源利用之多元迴歸分析 68 表16 醫療決策、氣喘知識、氣喘態度、氣喘自我效能、接受健康照護之經驗與自我管理行為之多元迴歸分析 69 表17 健康素養與健康結果之單迴歸分析 70 表18 健康素養、自我管理行為、醫療資源利用、及MDI使用技能之常態性檢定 71 表19 年齡、教育程度、氣喘患病年數、共病數、健康素養、MDI 使用技能、及自我管理行為之常態性檢定 73 表20 模式修正適配度指標之比較 74 表21 模式修正過程各變項間之非標準化迴歸係數顯著性機率值 75 表22 各變項間之非標準化迴歸係數值 75 表23 各變項間之標準化迴歸係數 76 表24 各變項間之決定係數 76 表25 標準化殘差的共變數矩陣 77 表26 各變項間之直接效果值 77 表27 各變項間之間接效果值 78 表28 各變項間之整體效果值 78 表29 各變項之常態性檢定 79 表30 模式修正適配度指標之比較 83 表31 模式修正過程各變項間之非標準化迴歸係數顯著性機率值 84 表32 各變項間之非標準化迴歸係數值 85 表33 各變項間之標準化迴歸係數 86 表34 變項間之決定係數 87 表35 標準化殘差的共變數矩陣 88 表36 各變項間之直接效果值 89 表37 各變項間之間接效果值 90 表38 各變項間之整體效果值 91 表39 各變項之常態性檢定 92 表40 模式修正適配度指標之比較 97 表41 模式修正過程各變項間之非標準化迴歸係數顯著性 98 表42 各變項間之非標準化迴歸係數值 99 表43 各變項間之標準化迴歸係數 100 表44 各變項間之決定係數 101 表45 標準化殘差的共變數矩陣 102 表46 各變項間之直接效果值 103 表47 各變項間之間接效果值 104 表48 各變項間之整體效果值 105 圖 1 假定之直接效應模式 35 圖 2 假定之中介效應模式 36

    內政部統計處(2007)。內政統計年報。2008年8月取自
    http://www.moi.gov.tw/stat/year.aspx。
    行政院衛生署(2004)。全民健康保險醫療統計年報。2006年8月25日
    取自http://www.doh.gov.tw/statistic/data/全民健康保險統計年報/新版93醫療統計年報/2/93206.xls。
    行政院衛生署(2008)。衛生統計系列(一)死因統計。2009年1月13日取自
    http://www.doh.gov.tw/CHT2006/DM/DM2_2.aspx?now_fod_list_no=10642&class_no=440&level_no=3 97年度死因統計記者會發布資料-死因統計結果分析 。
    宋佩宜(2008)。中文版成人功能性健康知能量表之發展及驗證。國防醫學院護理學研究所碩士論文,未出版,台北。
    吳明隆(2006)。SPSS 統計應用學習實務:問卷分析與應用統計。台北市:知城數位科技股份有限公司。
    吳清平(2000)。氣喘的分類 。 國防醫學,31(4):265-271。
    周文賢(2002)。多變量統計分析:SAS/STAT 使用方法。台北市:智勝文化事業有限公司。
    翁德昌、周炳克、孫斌、陳家勉、馮煥光、陳宏一(2005)。氣喘藥物治療的趨勢。台灣醫界,48(7),19-22。
    陳黛娜、李從業(1997)。台北市國小氣喘學童的疾病知識與適應行為之探討 。 護理研究,5(2),160-169。
    彭萬誠(2000)。氣喘之診斷及臨床表徵。國防醫學,31 (4),272-277。
    黃詩勳(2007)。氣喘病患自我管理行為預測因子之探討。國防醫學院護理學研究所碩士論文,未出版,台北。
    郭壽雄(2004)。氣喘、棄喘200問答篇。台北:台大醫院胸腔內科。
    楊志偉、曾定強、侯文萱、蘇娳敏(2007)。健康知能在公共衛生及醫療照護領域的應用。高雄縣醫師會誌,24,45-50。
    蔡記甄 (2005) 。氣喘病患自我照顧行為及生活品質探討。長庚大學護理研究所碩士論文,未出版,桃園。
    鍾燕宜(2007)。國民健康知能的發展與衡量。醫藥產業管理與教育論叢,1(1),51-70。
    蘇哲能、張淑鳳、陳榮基、潘豐泉、陳清軒、劉偉文(2007)。台灣健康知能量表之初探性研究。台灣醫學,12(5), 525-536。

    Adams, R. J., Smith, B., J., & Ruffin, R. E.(2000). Factors associated with
    hospital admissions and repeat emergency department visits for adults with
    asthma. Thorax, 55, 566-573.
    American Medical Association Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs (1999). Health Literacy: report of the council on scientific affairs. Journal of the American Medical Association, 281, 552-557.
    Baker, D. W., Gazmararian, J. A., Williams, M. V., Scott, T., Parker, R. M., Green, D., Ren, J., & Peel, J. (2002). Functional health literacy and the risk of hospital admission among Medicare managed care enrollees. American Journal of Public Health, 92(8), 1278-83.
    Baker, D. W., Gazmararian, J. A., Williams, M. V. et al. (2004). Health literarcy and use of outpatient physician services by Medicare managed care enrollees. Journal of General Internal Medicine, 19(3), 215-220.
    Baker, D. W., Parker, R. M., Williams, M.V., Clark, M. S. (2006) Health literacy and the risk of hospital admission. The Journal of General Internal Medicine, 13(12), 791-8.
    Baker, D.W., Parker, R.M., Williams M. V., Clark, W. S., & Nurss, J. (1997). The relationship of patient reading ability to self-reported health and use of health services. American Journal of Public Health, 87(6), 1027-1030.
    Baker, D.W., Parker, R.M., Williams, M.V., Pitkin, K., Parikh, N. S., Coates, W., Imara, M. (1996). The health care experience of patients with low literarcy. Archives Family Medicine, 5 (6), 329-334.
    Baker, D.W., Williams, M.V., Parker, R.M., Gazmararian, J.A., & Nurss, J. (1999). Development of a brief test to measure functional health literacy. Patient Education and Counseling, 38, 33-42.
    Baker, D. W., Wolf, M. S., Feinglass, J. Thompson, J. A., Gazmaraian, J. A., Huang, J. (2007). Health literacy and mortality among elderly persons. Archives of Internal Medicine, 167(14), 1503-1509.
    Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84, 191-215.
    Bennett, I, M,. Chen, J., Soroui, J. S., White, S. (2009). The contribution of health literacy to disparities in self-rated health status and preventive health behaviors in older adults. Annals of Family Medicine, 7, 204-211.
    Bollen, K. A. (1989). Structural equations with latent variables. New York: Wiley.
    Browne, M. W., & Cudeck, R. (1993). Alternative ways of assessing model fit. In K. A. Bollen & J. S. Long (eds.), Testing structural equation models (pp. 136-162). Newbury Park, CA: Sage.
    Burney, P.G.J., Luczynska, C., Chinn, S., et al. (1994). The European
    community respiratory health survey. European Respiratory Journal,
    7, 954-960.
    Burney, P.G.J., Chinn, S., Jarvis, D, et al. (1996). Variations in the prevalence
    of respiratory symptoms, self-reported asthma attacks, and use of
    asthma medication in the European Community Respiratory Health
    Survey (ECRHS). European Respiratory Journal, 9, 687-695.
    Carmines., E. G., & McIver, J. P. (1981). Analyzing models with unobservable variables. In G. W. Bohrnstedt and E. E. Borgatta (eds.), Social measurement current issues (pp. 65-115). Beverly Hills, CA: Sage.
    Davis, T., Crouch, M., Willis, G., Miller, S., Abdehou, D. (1990). The gap between patient reading comprehension and the readability of patient education materials. Journal Family Practice, 31, 533-538.
    Davis, T.C., Michielutte, R., Askov, E.N., Williams, M.V., & Weiss, B.D.(1998). Practical assessment of adult literacy in health care. Health Education & Behavior. 25(5), 613-612.
    Davis, T. C., Long, S. W., Jackson, R. H., Mayeaux, E. J., George, R. B., Murphy, P. W. and Crouch, M. A. (1993) Rapid estimate of adult literacy in medicine: a shortened screening instrument. Family Medicine, 25, 391–395.
    Davis, A. R., Ware, J. E. (1991). GHAA’s consumer satisfaction survey and user’s manual. Washington, DC: Group Health Association of American.
    DeWalt, D. A., Berkman, N. D., Sheridan, S., Lohr, K. N., & Pignone, M. P.(2004). Literarcy and health outcomes:A systematic review of the literature. Journal of General Internal Medicine, 19, 1228-1239.
    DeWalt, D. A., Boone, R. S., & Pignone, M. P. (2007). Literarcy and its relationship with self-efficacy, trust, and participation in medical decision-making. American Journal of Health Behavior, 31(Suppl 1 Sep/Oct), 27-35.
    Emtner, M., Hedin, A., Andersson, M., & Janson, C. (2009). Impact of patient characteristics, education, and knowledge on emergency room visits in patients with asthma and COPD: A descriptive and correlative study. BMC Pulmonary Medicine, 9(43), 1-8.
    Flower, F. J. (1984). Survey research methods, Applied Social Research Methods Series, Vol. 1. Beverly Hills: Sage Publication.
    Gazmararian, J. A., Baker, D. W., Parker, R. M., & Blazer, D. (2000). A multivariate analysis of factors associated with depression: evaluating the role of health literacy as a potential contributor. American Medical Association, 160(21), 3307-3314.
    Gazmararian, J. A., Kripalani, S., Miller, M. J., Echt, K. V., Ren, J., Rask, K. (2006). Factors Associated with Medication Refill Adherence in Cardiovascular-related Diseases: A Focus on Health Literacy. The Journal of General Internal Medicine, 21(12), 1215-1221.
    Gazmararian, J.A., Williams, M.V., Peel, J., & Baker, D.W. (2003). Health literacy and knowledge of chronic disease. Patient Education and Counseling, 29(5), 267-275.
    Gibson, P. G., Ram, F. S., & Powell, H. (2003). Asthma education. Respiratory Medicine, 97, 1036-1044.
    Gibson, P. G., Talbot, P. I., & Toneguzzi, R. C.(1995). Self-management, autonomy, and quality of life in asthma. Chest, 107, 1003-1008.
    Global Initiative for Asthma [GINA] (2004, February). Global Burden of Asthma Report. Retrieved July 15, 2006, from http://www.ginasthma.com/ReportItem.asp.
    Gregory, R. J. (2007). Psychological Testing: History, principles, and application (5th ed.). Boston, MA: Allyn and Bacon.

    Hoelter, J. W. (1983). The analysis of covariance structures: Goodness-of-fit indices. Sociological Methods and Research, 11, 325-344.
    Howard, D. H., Gazmararian, J., & Parker, R. M. (2005). The impact of low health literacy on the medical costs of Medicare managed care enrollees. American Journal of Medicine, 118(4), 371-377.
    Hu, L. T., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in covariance. Structural Equation Modeling, 6(1), 1-55.
    Jan, I. S., Chou, W. H., Wang, J. D., & Kuo, S. H. (2004). Prevalence of and major risk factors for adult bronchial asthma in Taipei city. Journal of the Formosan Medical Association, 103 (4), 259-263.
    Kalichman, S. C., Benotsch, E., Suarez, E. T., Catz, S., Miller, J., & Rompa, D.,(2000). Health literarcy and health-related hnowledge among persons living with HIV/AIDS. American Journal of Preventive Medicine, 18, 325-331.
    Kalichman, S. C. & Rompa, D. (2000). Functional health literarcy is associated with health status and health-related knowledge in people living with HIV-AIDS. Journal of Acquired Immune Deficiency Syndrome, 25(4), 337-344.
    Kim, S., Love, F., Quistberg, D. A., & Shea, J. A. (2004). Association of health literarcy with self-management behavior in patients with diabetes. Diabetes Care, 27(12), 2980-2982.
    Kline, R. B. (1998). Principles and practice of structural equation modeling. New York: Guilford Press.
    Knight, S., J.(1999). Methodologies for assessing quality of life in low literarcy populations. Presentation at the second annual cancer care symposium, Chicago, November 12.
    Kuo, L. C., Shau, W. Y., Yang, P. C., & Kuo, S. H. (2003). Trends in asthma mortality in Taiwan, 1981-2000. Journal of the Formosan Medical Association, 102(8), 534-538.
    Lincoln, A., Paasche-Orlow, M. K., Cheng, D. M. et al. (2006). Impact of health literarcy on depressive symptoms and mental health-related quality of life among adults with addiction. Journal of General Internal Medicine, 21(8), 818-822.
    Lindau, S.T., Tomori, C., Lyons, T., Langseth, L., Bennett, C.L., & Garcia, P. (2002). The association of health literacy with cervical cancer prevention knowledge and health behaviors in a multiethnic cohort of women. American Journal of Obstetrics and Gynecology, 186, 938-943.
    Mancuso, C. A., & Rincon, M. (2006 a). Impact of health literacy on longitudinal asthma outcomes. Journal of General Internal Medicine, 21(8), 813-817.
    Mancuso, C. A., & Rincon, M. (2006 b ). Asthma patients’ assessments of health care and medical decision making: The role of health literarcy. Journal of Asthma, 43(1), 41-44.
    Mayeaux, E. J., Davis, T. C., and Jackson, R. H .Literacy and self-reported
    educational levels in relation to Mini-mental State Examination scores.
    FamMed 1995;27(10):658-62.
    Mintz, M. (2004). Asthma update:Part I.diagnosis,monitoring,and prevention of disease progression. American Family Physician, 70(5), 893-898.
    National Work Group on Literacy and Health.(1998) Communicating with patients who have limited literacy skills: report of the National Work Group on Literacy and Health. Journal of Family Practice,46,168-76.
    National Centre for Education Statistics. (2004). National Adult Literacy survey. US Department of Education, [Online] available at: http://nces.ed.gov/naal.
    Nurss, J., Parker, R., & Baker, D. (2001). TOFHLA: Test of Functional Health Literacy in Adults. Peppercorn Books and Press, Inc., Snow Camp, NC.
    Nutbeam, D. (2000). Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century. Health Promotion International, 15(3), 259-267.
    Paasche-Orlow, M. K., Parker, R. M., Gazmararian, J. A., Nielsen-Bohlman, L. T., Rudd, R. R. (2005). The Prevalence of Limited Health Literacy. The Journal of General Internal Medicine, 20(2), 175-184.
    Paasche-Orlow, M. K., Riekert, K. A., Bilderback, A., Chanmugam, A., Hill, P., Rand, C. S., et al. (2005). Tailored education may reduce health literacy disparities in asthma self-management. American Journal of Respiratory & Critical Care Medicine, 172(8), 980-986.
    Paasche-Orlow, M. K., & Wolf, M. S. (2007). The causal pathways linking health literarcy to health outcomes. American Journal of Health Behavior, 31(Suppl 1), S19-S26.
    Parikh, N.S., Parker, R.M., Nurss, J.R., Baker, D.W., & Williams, M.V. (1996). Shame and health literacy: the unspoken connection. Patient and Counseling, 27, 33-39.
    Parker, R. M., Baker, D. W., Williams, M. V., Nurss, J. R. (1995). The test of functional health literacy in adults (TOFHLA): a new instrument for measuring patients’ literacy skills. Journal of General Internal Medicine, 10, 537-541.
    Parker, R. M., Williams, M. V., Weiss, B., Baker, D. W., Davis, T. C., Doak, L. G. et al. (1999). Health literacy: report on the Council on Scientific Affairs. Journal of the American Medical Association, 281(6), 552-557.
    Pignone, M., DeWalt, D. A., Sheridan, S., Berkman, N., & Lohr, K. N. ( 2005). Intervention to improve health outcome for patients with low literarcy: A systematic review. Journal of General Internal Medicine, 20, 185-192.
    Pignone, M. P., DeWalt, D. A. (2006). Literacy and health outcomes: is adherence the missing link? Journal of General Internal Medicine.21(8), 896-7.
    Rothman, R. L., DeWalt, D. A., Malone, R., Bryant, B., Shintani, A., Crigler, B., Weinberger, M., & Pignone, M. (2004). Influence of patient literarcy on the effectiveness of a primary care-based diabetes disease management program. Journal of the American Medical Association, 292(14), 1711-1716.
    Sarker, U., Fisher, L., & Schillinger, D. (2006). Is self-efficacy associated with diabetes self-management across race/ethnicity and health literarcy? Diabetes Care, 29(4), 823-829.
    Sarang, K., Frances, L., Quistberg, D.A., & Shea, J.A. (2004). Association of health literacy with self-management behavior in patients with diabetes. Diabetes Care, 27(12), 2980-2982.
    Scherer, Y. K.,& Bruce, S.(2001). Knowledge, attitudes, and self-efficacy
    and compliance with medical regimen, number of emergency
    department visits, and hospitalizations in adults with asthma. Heart &
    lung ,30, 250-257.
    Schillinger, D., Barton, L. R., Karter, A. J., Wang, F., & Adler, N. (2006). Does
    literarcy mediate the relationship between education and health outcomes?
    A study of a low-income population with diabetes. Public Health Reports,
    121, 245-254.
    Schillinger, D., Grumbach, K., Piette, J., Wang, F., Osmond, D., Daher, C., Palacios, J., Suillivan, G. D., Bindman, A. B. (2002). Association of health literacy with diabetes outcomes, The Journal of the American Medical Association, 288(4), 475-8.
    Schloman, Barbara, F. (2004). Health literacy: a key ingredient for managing personal health. Online Journal of Issues in Nursing, 9(2), 1091-3734.
    Scott, T. L., Gazmararian, J. A., Williams, M. V., Baker, D. W.(2002). Health literarcy and preventive health care use among medicare enrollees in a managed care organization. Medical Care, 40(5), 395-404.
    Selden, C.R., Zorn, M., Ratzan, S.C., & Parker, R.M. (2000). Health literacy (Current Bibliographies in Medicine 2000-1). Retrieved December 30, 2003, from www.nlm.nih.gov/pubs/cbm/hliteracy.html
    Speros, C. (2005). Health literacy: concept analysis. Journal of Asvanced Nursing, 50(6), 633-640.
    Sudore, R. L., Mehta, K. M., Simonsick, E. M., Harris, T. B., Newman, A. B., Satterfield, S., et al. (2006). Limited literarcy in loder people and disparities in health and healthcare access. The American Geriatrics Society, 54(5), 770-776.
    Tenhave, T.R., Horn, B.V., Kumanyika, S., Askow, Eunice., Matthews, Y., Lucile, L., & Campbell, A. (1997). Literacy assessment in a cardiovascular nutrition education seeting. Patient Education and Counseling, 7(7), 139-150.
    U.S. Department of Health and Human Services (2000). Health people 2010, 2nd ed. With Understanding and improving Health and Objectives for Improving Health, 2 vols. US Government Printing Office,Washington, DC.
    Wason, R., McKenna, H., Cowman, S., & Keady, J. (2008). Nursing Research: Designs and Methods. Edinburgh: Churchill Livingstone.
    Williams, M. V., Baker, D. W., Honig, E. G., Lee, T. M., & Nowlan, A. (1998). Inadequate literacy is a barrier to asthma knowledge and self-care. Chest, 114(4), 1008-15.
    Williams, M.V., Baker, D.W., Parker, R.M., & Nurss, J.R. (1998). Relationship of functional health literacy to patients’ knowledge of their chronic disease: a study of patients with hypertension and diabetes. Journal of the American Medical Association, 158(3), 166-172.
    Williams, M.V., Parker, R. M., Baker, D. W., Parikh, N. S., Pitkin, K., Coates, W. C., & Nurss, J. R. (1995). Inadequate functional health literacy among patients at two public hospitals. Journal of the American Medical Association, 274, 1677-1682.
    Wolf, M.S., Gazmararian, J.A., & Baker, D.W. (2005). Health literacy and functional health status among older adults. American Medical Association, 165, 1946-1952.
    World Health Organization (WHO). (1998). Division of Health Promotion, Education and Communications Health Education and Health Promotion Unit. Health Promotion Glossary. World Health Organization, Geneva.

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