Study characteristics of descriptive quantitative studies and results on study quality and associations and findings within the HL–mediators–health outcomes pathway, organized by the Paasche-Orlow-derived mechanisms
| Study characteristics . | Study results . | ||||||
|---|---|---|---|---|---|---|---|
| Study . | CKD-pop (N) country . | Design . | Measure (% LHL) . | Q . | Mechanism(s) . | Association of health literacy with mediator within this mechanism(s) or other result related to mechanism . | Association of health literacy or mediator with health outcome? . |
| Studies with results on multiple mechanisms (n = 18) | |||||||
| Devraj et al. [33] | 1–4 (181) USA | Cross-sectional | NVSa (63) | + | Self-care management Utilization of care | Yes: CKD awareness with self-management behaviours No: LHL with CKD awareness or duration of participation in clinic | Yes: Worse kidney function associated with higher CKD awareness No: LHL with severity of CKD |
| Taylor et al. [34] | 5 (6842) UK | Cross-sectional | SILSa (14.6) | + | Self-care management Utilization of care | Yes: LHL with current smoking Other: LHL is more prevalent in non-waitlisted incident dialysis (20%) patients than in waitlisted dialysis patients (15%) Transplant recipients have the lowest prevalence of LHL (12%) | Yes: LHL with more comorbidities, long-term disabilities, depression and psychosis |
| Ricardo et al. [8] | 1–3 (2340) USA | Cross-sectional | sTOFHLAa (16) | + | Self-care management Utilization of care | Yes: LHL with current smoking, perceived health and more frequent visits to the nephrologist No: LHL with medication use | Yes: LHL with lower eGFR, higher urine protein, more cardiovascular disease and more diabetes |
| Chen et al. [35] | 1–5 (410) Taiwan | Cross-sectional | Mandarin HL scalea (n.a.) | ± | Self-care management Social context | Yes: LHL with worse self-management behaviours and decreased function of social support. Social support associated with self-management behaviours and treatment adherence | No results reported on health outcomes |
| Serper et al. [36] | 5 (T) (98) USA | Mixed-method | NVSa (37) | ± | Self-care management Social context | Yes: LHL with choosing to spend money on expenses other than medication. These decisions were associated with lower medication adherence and explained by the social context | Yes: Choosing to spend money on expenses other than medications with higher rates of hospital admission |
| Demian et al. [37] | 5 (T) (96) Canada | Cross-sectional | HL-Qa,b,c (n.a.) | ± | Self-care management Utilization of care P–P interaction | Other: Multifaceted HL screener indicates: actively managing health is the greatest HL challenge for transplant recipients, while navigating the health system, engaging with providers and understanding information are minor HL challenges | Yes: Appraising/understanding information associated with worse kidney health |
| Jain et al. [38] | 5 (D) (32) USA | Cross-sectional | REALMa (19) | ± | Self-care management Utilization of care | No: LHL with treatment regimens, time on peritoneal dialysis or hospitalization | No: LHL with peritonitis, exit-site infections or dialysis adequacy |
| Kazley et al. [39] | 5 (92) USA | Cross-sectional | REALMa NVSa (n.a.) | ± | Utilization of care Social context | Yes: LHL with lower likelihood of being waitlisted for transplantation and lower social support | Yes: LHL with worse transplant outcomes |
| Lai et al. [40] | 5 (D) (63) Singapore | Cross-sectional | (n.a.) | ± | Self-care management Utilization of care | Yes: LHL with worse blood glucose testing and foot care. Limited communicative and critical with worse diabetes self-management. Limited communicative HL with less exercise Limited critical HL associated with worse general diet No: LHL with duration of diabetes treatment | No: LHL with blood glucose levels |
| Gordon et al. [41] | 5 (T) (124) USA | Cross-sectional | sTOFHLAa (9) REALMa | ± | Self-care management Utilization of care | Yes: LHL with shorter time after transplant. In open questions: patients express the need to improve understanding of transplantation and medication use | Yes: LHL with higher serum creatinine levels |
| Wright Nunes et al. [42] | 1–4 (399) USA | Cross-sectional | REALMa (n.a.) | ± | Self-care management P–P interaction | Yes: LHL with lower perceived kidney disease specific knowledge No: LHL with satisfaction with the provider | Yes: Lower knowledge with lower eGFR awareness of CKD |
| Zhong et al. [43] | 1–5 (61) USA | Cross-sectional | REALMa (40.7) | − | Self-care management Utilization of care P–P interaction | Yes: LHL with medication and lifestyle behaviours, lower healthcare transition readiness from paediatric care to adult care services (a.o. ability to visit doctors and make appointments), less seeking of information and asking questions in a group of 18–29 years adolescents. Communication with providers positively influences knowledge. Greater nutrition knowledge predicted healthcare transition readiness | No results reported on health outcomes |
| Photharos et al. [44] | 2–4 (275) Thailand | Cross-sectional | HLS-14a,b,c | − | Self-care management Social context | Yes: LHL influences self-efficacy in and performance of lifestyle activities. Self-efficacy is not a mediator of association between LHL and self-management No: LHL has no direct or indirect effect on social support or family functioning | No results reported on health outcomes |
| Dodson et al. [45] | 5 (D) (913) Australia | Cross-sectional | HL-Q a,b,c (n.a.) | − | Self-care management Utilization of care P–P interaction Social context | Other: Multifaceted HL screener indicates: compared to a control group of other chronic patients, actively managing health is a greater HL challenge for dialysis patients, while they are better in navigating the health system, engaging with providers, understanding and applying information and enabling social support | Yes: LHL with worse serum albumin, depressive and anxiety symptoms and disease and mental burden |
| Patzer et al. [46] | 5 (T) (99) USA | Mixed-method | REALMa (24.7) | − | Self-care management Utilization of care | Yes: LHL with lower medication knowledge and self-reported treatment adherence No: LHL with demonstrated proper use of medications and hospitalization | No: LHL with graft rejection |
| Tuot et al. [47] | 1–5 (264) USA | Cross-sectional | Brief HLSa (46.6) | − | Self-care management P–P interaction | Yes: Providers’ word choice important to create awareness about CKD No: LHL with CKD awareness | No results reported on health outcomes |
| Lambert et al. [48] | 4–5 (153) Australia | Cross-sectional | HeLMSa,b,c (n.a.) | − | Self-care management Utilization of care P–P interaction | Other: Multifaceted HL screener indicates: incorporation of lifestyle is the greatest HL challenge. Filling in forms and accessing healthcare is a frequent HL problem. Communication with providers is a greater HL challenge for peritoneal dialysis patients compared with other CKD patients | No results reported on health outcomes |
| Dageforde et al. [49] | 5 (104) USA | Cross-sectional | Brief HLSa (23.1) | − | Utilization of care P–P interaction | Yes: LHL with not knowing the next step in the transplantation process. Attending consultations improves transplant knowledge and gives more concerns about finding a donor No: LHL with first-time centre visits | No results reported on health outcomes |
| Studies with results on self-care management (n = 9) | |||||||
| Schrauben et al. [50] | 1–3 (5499) USA | Cohort study | sTOFHLAa (13) | + | Self-care management | Yes: LHL with less healthy behaviour patterns (smoking, obesity, lack of physical activity etc.) in ≥65 subgroup | Yes: Less healthy patterns associated with increased risk of dead, CKD progression and cardiovascular risks |
| Wong et al. [51] | 1–4 (137) USA | Cross-sectional | HL-Qa,b,c (26) | + | Self-care management | Yes: LHL with decreased fast food intake No: LHL with medication adherence and physical activity | No results reported on health outcomes |
| Devraj et al. [7] | 1–4 (150) USA | Cross-sectional | NVSa (63) | + | Self-care management | Yes: LHL with decreased self-management knowledge and decreased controlling for blood pressure No: LHL with other self-management knowledge, such as taking medication, sugar and salt intake, having lab checks | Yes: LHL with lower eGFR |
| Eneanya et al. [52] | 4–5 (149) USA | Cross-sectional | REALMa (34) | − | Self-care management | Yes: LHL with reduced knowledge of cardiopulmonary resuscitation. LHL mediates racial disparities for CPR knowledge | No results reported on health outcomes |
| Jones et al. [53] | 4–5 (D) (41) Canada | Cross-sectional | sTOFHLAa (5) | − | Self-care management | Yes: LHL with lower transplant and medication knowledge, lower adherence confidence, higher beliefs in medication importance and concerns regarding side effects | No results reported on health outcomes |
| Umeukeje et al. [54] | 5 (D) (100) USA | Cross-sectional | sTOFHLAa (50) | − | Self-care management | No: LHL with self-motivation of dialysis patients to adhere to phosphate treatment | Yes: Lower self-motivation and medication adherence with lower serum phosphorus levels |
| Adeseun et al. [55] | 5 (D) (72) USA | Cross-sectional | sTOFHLAa (21) | − | Self-care management | No: LHL with history of tobacco use | Yes: LHL with higher blood pressure No: LHL with other lifestyle markers, such as BMI |
| Green et al. [56] | 5 (D) (288) USA | Cohort study | REALMa (16) | − | Self-care management | No: LHL with quality of life | Yes: LHL with burden of comorbidities No: LHL with symptom burden, depression, dialysis adequacy and lab values (i.e. albumin, haemoglobin) |
| Foster et al. [57] | 5 (D) (62) USA | Cross-sectional | sTOFHLAa (30.3) | − | Self-care management | No: LHL with disaster preparedness (such as having extra medications) | No results reported on health outcomes |
| Studies with results on mechanisms related to utilization of care (n = 10) | |||||||
| Taylor et al. [58] | 5 (D) (2274) UK | Cohort study | SILSa (24) | + | Utilization of care | Yes: LHL with reduced access to deceased-donor transplant listing and receiving a transplant from a living donor. This is likely related to patients’ preparation No: LHL with pre-emptive waitlisting or dialysis modality | No: LHL with catheter use or mortality |
| Warsame et al. [59] | 4–5 (D) (1578) USA | Cohort study | Brief HLSa (8.9) | + | Utilization of care | Yes: LHL with lower likelihood of being waitlisted for kidney transplant | Yes: LHL with lower likelihood of undergoing living donor transplant and greater risk of waitlist mortality |
| Green et al. [60] | 5 (D) (260) USA | Cohort study | REALMa (16) | + | Utilization of care | Yes: LHL with missed dialysis treatments, more emergency department visits, and more hospitalization No: LHL with abbreviating dialysis treatments | Yes: LHL with higher prevalence of comorbidities and fistula use No: LHL with mortality, lab values or receiving transplant |
| Dageforde et al. [61] | 5 (T) (360) USA | Cross-sectional | SLSa (10) | ± | Utilization of care | Other: LHL more prevalent in patients with a deceased donor (14%) than in patients with a living donor (9%). Living donors have even lower prevalence of LHL (6%) | No results reported on health outcomes |
| Levine et al. [62] | 2–5 (142) USA | Cohort study | NVSa (12) | − | Utilization of care | No: LHL with emergency department visits, hospitalization or length of hospital stay | No results reported on health outcomes |
| Vilme et al. [63] | 4–5 (D) (155) USA | Cross-sectional | REALMa REALM-sfa (n.a) | − | Utilization of care | No: LHL with patient interest in receiving a kidney from a living donor or with facilitators or barriers to pursue a living donor kidney transplantation, in a cohort of African-Americans | No results reported on health outcomes |
| Wong et al. [64] | 4–5 (121) Canada | Cross-sectional | SLSa (n.a.) | − | Utilization of care | Yes: LHL with requiring help to fill in measurements with tablets, and finding this task difficult or tiring | No results reported on health outcomes |
| Flythe et al. [65] | 4–5 (154) USA | Cross-sectional | REALMa (43.3) | − | Utilization of care | Yes: LHL shows a trend towards higher likelihood of 30-day hospital readmission (non-significant in adjusted models) | No results reported on health outcomes |
| Tohme et al. [66] | 5 (D) (286) USA | Mixed-method | REALMa (16) | − | Utilization of care | Yes: LHL with missing dialysis No: LHL with patients’ abbreviation of dialysis treatment | Missing dialysis with mortality. Abbreviation with hospitalization |
| Grubbs et al. [67] | 5 (D) (62) USA | Cross-sectional | sTOFHLAa (32.3) | − | Utilization of care | Yes: LHL with lower referral change for transplant evaluation No: LHL with treatment preference, uncertainties about treatment decision or being waitlisted | No results reported on health outcomes |
| Studies with results on mechanisms related to P–P interaction (n = 1) | |||||||
| Bahadori et al. [68] | 5 (D) (130) Iran | Cross-sectional | HELIAa,b,c (53.8) | − | P–P interaction | Yes: Various subdomains of LHL (understanding and using information, decision-making) with perceived general health | Yes: LHL with physical and psychological symptoms |
| Study characteristics . | Study results . | ||||||
|---|---|---|---|---|---|---|---|
| Study . | CKD-pop (N) country . | Design . | Measure (% LHL) . | Q . | Mechanism(s) . | Association of health literacy with mediator within this mechanism(s) or other result related to mechanism . | Association of health literacy or mediator with health outcome? . |
| Studies with results on multiple mechanisms (n = 18) | |||||||
| Devraj et al. [33] | 1–4 (181) USA | Cross-sectional | NVSa (63) | + | Self-care management Utilization of care | Yes: CKD awareness with self-management behaviours No: LHL with CKD awareness or duration of participation in clinic | Yes: Worse kidney function associated with higher CKD awareness No: LHL with severity of CKD |
| Taylor et al. [34] | 5 (6842) UK | Cross-sectional | SILSa (14.6) | + | Self-care management Utilization of care | Yes: LHL with current smoking Other: LHL is more prevalent in non-waitlisted incident dialysis (20%) patients than in waitlisted dialysis patients (15%) Transplant recipients have the lowest prevalence of LHL (12%) | Yes: LHL with more comorbidities, long-term disabilities, depression and psychosis |
| Ricardo et al. [8] | 1–3 (2340) USA | Cross-sectional | sTOFHLAa (16) | + | Self-care management Utilization of care | Yes: LHL with current smoking, perceived health and more frequent visits to the nephrologist No: LHL with medication use | Yes: LHL with lower eGFR, higher urine protein, more cardiovascular disease and more diabetes |
| Chen et al. [35] | 1–5 (410) Taiwan | Cross-sectional | Mandarin HL scalea (n.a.) | ± | Self-care management Social context | Yes: LHL with worse self-management behaviours and decreased function of social support. Social support associated with self-management behaviours and treatment adherence | No results reported on health outcomes |
| Serper et al. [36] | 5 (T) (98) USA | Mixed-method | NVSa (37) | ± | Self-care management Social context | Yes: LHL with choosing to spend money on expenses other than medication. These decisions were associated with lower medication adherence and explained by the social context | Yes: Choosing to spend money on expenses other than medications with higher rates of hospital admission |
| Demian et al. [37] | 5 (T) (96) Canada | Cross-sectional | HL-Qa,b,c (n.a.) | ± | Self-care management Utilization of care P–P interaction | Other: Multifaceted HL screener indicates: actively managing health is the greatest HL challenge for transplant recipients, while navigating the health system, engaging with providers and understanding information are minor HL challenges | Yes: Appraising/understanding information associated with worse kidney health |
| Jain et al. [38] | 5 (D) (32) USA | Cross-sectional | REALMa (19) | ± | Self-care management Utilization of care | No: LHL with treatment regimens, time on peritoneal dialysis or hospitalization | No: LHL with peritonitis, exit-site infections or dialysis adequacy |
| Kazley et al. [39] | 5 (92) USA | Cross-sectional | REALMa NVSa (n.a.) | ± | Utilization of care Social context | Yes: LHL with lower likelihood of being waitlisted for transplantation and lower social support | Yes: LHL with worse transplant outcomes |
| Lai et al. [40] | 5 (D) (63) Singapore | Cross-sectional | (n.a.) | ± | Self-care management Utilization of care | Yes: LHL with worse blood glucose testing and foot care. Limited communicative and critical with worse diabetes self-management. Limited communicative HL with less exercise Limited critical HL associated with worse general diet No: LHL with duration of diabetes treatment | No: LHL with blood glucose levels |
| Gordon et al. [41] | 5 (T) (124) USA | Cross-sectional | sTOFHLAa (9) REALMa | ± | Self-care management Utilization of care | Yes: LHL with shorter time after transplant. In open questions: patients express the need to improve understanding of transplantation and medication use | Yes: LHL with higher serum creatinine levels |
| Wright Nunes et al. [42] | 1–4 (399) USA | Cross-sectional | REALMa (n.a.) | ± | Self-care management P–P interaction | Yes: LHL with lower perceived kidney disease specific knowledge No: LHL with satisfaction with the provider | Yes: Lower knowledge with lower eGFR awareness of CKD |
| Zhong et al. [43] | 1–5 (61) USA | Cross-sectional | REALMa (40.7) | − | Self-care management Utilization of care P–P interaction | Yes: LHL with medication and lifestyle behaviours, lower healthcare transition readiness from paediatric care to adult care services (a.o. ability to visit doctors and make appointments), less seeking of information and asking questions in a group of 18–29 years adolescents. Communication with providers positively influences knowledge. Greater nutrition knowledge predicted healthcare transition readiness | No results reported on health outcomes |
| Photharos et al. [44] | 2–4 (275) Thailand | Cross-sectional | HLS-14a,b,c | − | Self-care management Social context | Yes: LHL influences self-efficacy in and performance of lifestyle activities. Self-efficacy is not a mediator of association between LHL and self-management No: LHL has no direct or indirect effect on social support or family functioning | No results reported on health outcomes |
| Dodson et al. [45] | 5 (D) (913) Australia | Cross-sectional | HL-Q a,b,c (n.a.) | − | Self-care management Utilization of care P–P interaction Social context | Other: Multifaceted HL screener indicates: compared to a control group of other chronic patients, actively managing health is a greater HL challenge for dialysis patients, while they are better in navigating the health system, engaging with providers, understanding and applying information and enabling social support | Yes: LHL with worse serum albumin, depressive and anxiety symptoms and disease and mental burden |
| Patzer et al. [46] | 5 (T) (99) USA | Mixed-method | REALMa (24.7) | − | Self-care management Utilization of care | Yes: LHL with lower medication knowledge and self-reported treatment adherence No: LHL with demonstrated proper use of medications and hospitalization | No: LHL with graft rejection |
| Tuot et al. [47] | 1–5 (264) USA | Cross-sectional | Brief HLSa (46.6) | − | Self-care management P–P interaction | Yes: Providers’ word choice important to create awareness about CKD No: LHL with CKD awareness | No results reported on health outcomes |
| Lambert et al. [48] | 4–5 (153) Australia | Cross-sectional | HeLMSa,b,c (n.a.) | − | Self-care management Utilization of care P–P interaction | Other: Multifaceted HL screener indicates: incorporation of lifestyle is the greatest HL challenge. Filling in forms and accessing healthcare is a frequent HL problem. Communication with providers is a greater HL challenge for peritoneal dialysis patients compared with other CKD patients | No results reported on health outcomes |
| Dageforde et al. [49] | 5 (104) USA | Cross-sectional | Brief HLSa (23.1) | − | Utilization of care P–P interaction | Yes: LHL with not knowing the next step in the transplantation process. Attending consultations improves transplant knowledge and gives more concerns about finding a donor No: LHL with first-time centre visits | No results reported on health outcomes |
| Studies with results on self-care management (n = 9) | |||||||
| Schrauben et al. [50] | 1–3 (5499) USA | Cohort study | sTOFHLAa (13) | + | Self-care management | Yes: LHL with less healthy behaviour patterns (smoking, obesity, lack of physical activity etc.) in ≥65 subgroup | Yes: Less healthy patterns associated with increased risk of dead, CKD progression and cardiovascular risks |
| Wong et al. [51] | 1–4 (137) USA | Cross-sectional | HL-Qa,b,c (26) | + | Self-care management | Yes: LHL with decreased fast food intake No: LHL with medication adherence and physical activity | No results reported on health outcomes |
| Devraj et al. [7] | 1–4 (150) USA | Cross-sectional | NVSa (63) | + | Self-care management | Yes: LHL with decreased self-management knowledge and decreased controlling for blood pressure No: LHL with other self-management knowledge, such as taking medication, sugar and salt intake, having lab checks | Yes: LHL with lower eGFR |
| Eneanya et al. [52] | 4–5 (149) USA | Cross-sectional | REALMa (34) | − | Self-care management | Yes: LHL with reduced knowledge of cardiopulmonary resuscitation. LHL mediates racial disparities for CPR knowledge | No results reported on health outcomes |
| Jones et al. [53] | 4–5 (D) (41) Canada | Cross-sectional | sTOFHLAa (5) | − | Self-care management | Yes: LHL with lower transplant and medication knowledge, lower adherence confidence, higher beliefs in medication importance and concerns regarding side effects | No results reported on health outcomes |
| Umeukeje et al. [54] | 5 (D) (100) USA | Cross-sectional | sTOFHLAa (50) | − | Self-care management | No: LHL with self-motivation of dialysis patients to adhere to phosphate treatment | Yes: Lower self-motivation and medication adherence with lower serum phosphorus levels |
| Adeseun et al. [55] | 5 (D) (72) USA | Cross-sectional | sTOFHLAa (21) | − | Self-care management | No: LHL with history of tobacco use | Yes: LHL with higher blood pressure No: LHL with other lifestyle markers, such as BMI |
| Green et al. [56] | 5 (D) (288) USA | Cohort study | REALMa (16) | − | Self-care management | No: LHL with quality of life | Yes: LHL with burden of comorbidities No: LHL with symptom burden, depression, dialysis adequacy and lab values (i.e. albumin, haemoglobin) |
| Foster et al. [57] | 5 (D) (62) USA | Cross-sectional | sTOFHLAa (30.3) | − | Self-care management | No: LHL with disaster preparedness (such as having extra medications) | No results reported on health outcomes |
| Studies with results on mechanisms related to utilization of care (n = 10) | |||||||
| Taylor et al. [58] | 5 (D) (2274) UK | Cohort study | SILSa (24) | + | Utilization of care | Yes: LHL with reduced access to deceased-donor transplant listing and receiving a transplant from a living donor. This is likely related to patients’ preparation No: LHL with pre-emptive waitlisting or dialysis modality | No: LHL with catheter use or mortality |
| Warsame et al. [59] | 4–5 (D) (1578) USA | Cohort study | Brief HLSa (8.9) | + | Utilization of care | Yes: LHL with lower likelihood of being waitlisted for kidney transplant | Yes: LHL with lower likelihood of undergoing living donor transplant and greater risk of waitlist mortality |
| Green et al. [60] | 5 (D) (260) USA | Cohort study | REALMa (16) | + | Utilization of care | Yes: LHL with missed dialysis treatments, more emergency department visits, and more hospitalization No: LHL with abbreviating dialysis treatments | Yes: LHL with higher prevalence of comorbidities and fistula use No: LHL with mortality, lab values or receiving transplant |
| Dageforde et al. [61] | 5 (T) (360) USA | Cross-sectional | SLSa (10) | ± | Utilization of care | Other: LHL more prevalent in patients with a deceased donor (14%) than in patients with a living donor (9%). Living donors have even lower prevalence of LHL (6%) | No results reported on health outcomes |
| Levine et al. [62] | 2–5 (142) USA | Cohort study | NVSa (12) | − | Utilization of care | No: LHL with emergency department visits, hospitalization or length of hospital stay | No results reported on health outcomes |
| Vilme et al. [63] | 4–5 (D) (155) USA | Cross-sectional | REALMa REALM-sfa (n.a) | − | Utilization of care | No: LHL with patient interest in receiving a kidney from a living donor or with facilitators or barriers to pursue a living donor kidney transplantation, in a cohort of African-Americans | No results reported on health outcomes |
| Wong et al. [64] | 4–5 (121) Canada | Cross-sectional | SLSa (n.a.) | − | Utilization of care | Yes: LHL with requiring help to fill in measurements with tablets, and finding this task difficult or tiring | No results reported on health outcomes |
| Flythe et al. [65] | 4–5 (154) USA | Cross-sectional | REALMa (43.3) | − | Utilization of care | Yes: LHL shows a trend towards higher likelihood of 30-day hospital readmission (non-significant in adjusted models) | No results reported on health outcomes |
| Tohme et al. [66] | 5 (D) (286) USA | Mixed-method | REALMa (16) | − | Utilization of care | Yes: LHL with missing dialysis No: LHL with patients’ abbreviation of dialysis treatment | Missing dialysis with mortality. Abbreviation with hospitalization |
| Grubbs et al. [67] | 5 (D) (62) USA | Cross-sectional | sTOFHLAa (32.3) | − | Utilization of care | Yes: LHL with lower referral change for transplant evaluation No: LHL with treatment preference, uncertainties about treatment decision or being waitlisted | No results reported on health outcomes |
| Studies with results on mechanisms related to P–P interaction (n = 1) | |||||||
| Bahadori et al. [68] | 5 (D) (130) Iran | Cross-sectional | HELIAa,b,c (53.8) | − | P–P interaction | Yes: Various subdomains of LHL (understanding and using information, decision-making) with perceived general health | Yes: LHL with physical and psychological symptoms |
CKD-pop: population of interest by CKD stages (1, 2, 3, 4 or 5), when applicable specified for transplant (T) or dialysis (D); NVS: Newest Vital Sign; SILS, Single Item Literacy Screener; sTOFHLA: short Test of Functional Health Literacy in Adults; eGFR, estimated glomerular filtration rate; Mandarin HL Scale, Mandarin HL Scale; HL-Q, Health Literacy Questionnaire; REALM-SF, Rapid Estimate of Adult Literacy in Medicine—Short Form; FCCHL, Functional Communicative Critical Health Literacy; HLS, Health Literacy Scale; HeLMS, Health Literacy Management Scale; SLS, Short Literacy Survey; HELIA, Health Literacy for Iranian Adults; BMI, body mass index; n.a., not available; N, number of participants in the study; Q, study quality; +, high-quality study; ±, moderate-quality study; −, low-quality study, based on quality assessment.
Functional HL measure.
Communicative HL measure.
Critical HL measure.
Study characteristics of descriptive quantitative studies and results on study quality and associations and findings within the HL–mediators–health outcomes pathway, organized by the Paasche-Orlow-derived mechanisms
| Study characteristics . | Study results . | ||||||
|---|---|---|---|---|---|---|---|
| Study . | CKD-pop (N) country . | Design . | Measure (% LHL) . | Q . | Mechanism(s) . | Association of health literacy with mediator within this mechanism(s) or other result related to mechanism . | Association of health literacy or mediator with health outcome? . |
| Studies with results on multiple mechanisms (n = 18) | |||||||
| Devraj et al. [33] | 1–4 (181) USA | Cross-sectional | NVSa (63) | + | Self-care management Utilization of care | Yes: CKD awareness with self-management behaviours No: LHL with CKD awareness or duration of participation in clinic | Yes: Worse kidney function associated with higher CKD awareness No: LHL with severity of CKD |
| Taylor et al. [34] | 5 (6842) UK | Cross-sectional | SILSa (14.6) | + | Self-care management Utilization of care | Yes: LHL with current smoking Other: LHL is more prevalent in non-waitlisted incident dialysis (20%) patients than in waitlisted dialysis patients (15%) Transplant recipients have the lowest prevalence of LHL (12%) | Yes: LHL with more comorbidities, long-term disabilities, depression and psychosis |
| Ricardo et al. [8] | 1–3 (2340) USA | Cross-sectional | sTOFHLAa (16) | + | Self-care management Utilization of care | Yes: LHL with current smoking, perceived health and more frequent visits to the nephrologist No: LHL with medication use | Yes: LHL with lower eGFR, higher urine protein, more cardiovascular disease and more diabetes |
| Chen et al. [35] | 1–5 (410) Taiwan | Cross-sectional | Mandarin HL scalea (n.a.) | ± | Self-care management Social context | Yes: LHL with worse self-management behaviours and decreased function of social support. Social support associated with self-management behaviours and treatment adherence | No results reported on health outcomes |
| Serper et al. [36] | 5 (T) (98) USA | Mixed-method | NVSa (37) | ± | Self-care management Social context | Yes: LHL with choosing to spend money on expenses other than medication. These decisions were associated with lower medication adherence and explained by the social context | Yes: Choosing to spend money on expenses other than medications with higher rates of hospital admission |
| Demian et al. [37] | 5 (T) (96) Canada | Cross-sectional | HL-Qa,b,c (n.a.) | ± | Self-care management Utilization of care P–P interaction | Other: Multifaceted HL screener indicates: actively managing health is the greatest HL challenge for transplant recipients, while navigating the health system, engaging with providers and understanding information are minor HL challenges | Yes: Appraising/understanding information associated with worse kidney health |
| Jain et al. [38] | 5 (D) (32) USA | Cross-sectional | REALMa (19) | ± | Self-care management Utilization of care | No: LHL with treatment regimens, time on peritoneal dialysis or hospitalization | No: LHL with peritonitis, exit-site infections or dialysis adequacy |
| Kazley et al. [39] | 5 (92) USA | Cross-sectional | REALMa NVSa (n.a.) | ± | Utilization of care Social context | Yes: LHL with lower likelihood of being waitlisted for transplantation and lower social support | Yes: LHL with worse transplant outcomes |
| Lai et al. [40] | 5 (D) (63) Singapore | Cross-sectional | (n.a.) | ± | Self-care management Utilization of care | Yes: LHL with worse blood glucose testing and foot care. Limited communicative and critical with worse diabetes self-management. Limited communicative HL with less exercise Limited critical HL associated with worse general diet No: LHL with duration of diabetes treatment | No: LHL with blood glucose levels |
| Gordon et al. [41] | 5 (T) (124) USA | Cross-sectional | sTOFHLAa (9) REALMa | ± | Self-care management Utilization of care | Yes: LHL with shorter time after transplant. In open questions: patients express the need to improve understanding of transplantation and medication use | Yes: LHL with higher serum creatinine levels |
| Wright Nunes et al. [42] | 1–4 (399) USA | Cross-sectional | REALMa (n.a.) | ± | Self-care management P–P interaction | Yes: LHL with lower perceived kidney disease specific knowledge No: LHL with satisfaction with the provider | Yes: Lower knowledge with lower eGFR awareness of CKD |
| Zhong et al. [43] | 1–5 (61) USA | Cross-sectional | REALMa (40.7) | − | Self-care management Utilization of care P–P interaction | Yes: LHL with medication and lifestyle behaviours, lower healthcare transition readiness from paediatric care to adult care services (a.o. ability to visit doctors and make appointments), less seeking of information and asking questions in a group of 18–29 years adolescents. Communication with providers positively influences knowledge. Greater nutrition knowledge predicted healthcare transition readiness | No results reported on health outcomes |
| Photharos et al. [44] | 2–4 (275) Thailand | Cross-sectional | HLS-14a,b,c | − | Self-care management Social context | Yes: LHL influences self-efficacy in and performance of lifestyle activities. Self-efficacy is not a mediator of association between LHL and self-management No: LHL has no direct or indirect effect on social support or family functioning | No results reported on health outcomes |
| Dodson et al. [45] | 5 (D) (913) Australia | Cross-sectional | HL-Q a,b,c (n.a.) | − | Self-care management Utilization of care P–P interaction Social context | Other: Multifaceted HL screener indicates: compared to a control group of other chronic patients, actively managing health is a greater HL challenge for dialysis patients, while they are better in navigating the health system, engaging with providers, understanding and applying information and enabling social support | Yes: LHL with worse serum albumin, depressive and anxiety symptoms and disease and mental burden |
| Patzer et al. [46] | 5 (T) (99) USA | Mixed-method | REALMa (24.7) | − | Self-care management Utilization of care | Yes: LHL with lower medication knowledge and self-reported treatment adherence No: LHL with demonstrated proper use of medications and hospitalization | No: LHL with graft rejection |
| Tuot et al. [47] | 1–5 (264) USA | Cross-sectional | Brief HLSa (46.6) | − | Self-care management P–P interaction | Yes: Providers’ word choice important to create awareness about CKD No: LHL with CKD awareness | No results reported on health outcomes |
| Lambert et al. [48] | 4–5 (153) Australia | Cross-sectional | HeLMSa,b,c (n.a.) | − | Self-care management Utilization of care P–P interaction | Other: Multifaceted HL screener indicates: incorporation of lifestyle is the greatest HL challenge. Filling in forms and accessing healthcare is a frequent HL problem. Communication with providers is a greater HL challenge for peritoneal dialysis patients compared with other CKD patients | No results reported on health outcomes |
| Dageforde et al. [49] | 5 (104) USA | Cross-sectional | Brief HLSa (23.1) | − | Utilization of care P–P interaction | Yes: LHL with not knowing the next step in the transplantation process. Attending consultations improves transplant knowledge and gives more concerns about finding a donor No: LHL with first-time centre visits | No results reported on health outcomes |
| Studies with results on self-care management (n = 9) | |||||||
| Schrauben et al. [50] | 1–3 (5499) USA | Cohort study | sTOFHLAa (13) | + | Self-care management | Yes: LHL with less healthy behaviour patterns (smoking, obesity, lack of physical activity etc.) in ≥65 subgroup | Yes: Less healthy patterns associated with increased risk of dead, CKD progression and cardiovascular risks |
| Wong et al. [51] | 1–4 (137) USA | Cross-sectional | HL-Qa,b,c (26) | + | Self-care management | Yes: LHL with decreased fast food intake No: LHL with medication adherence and physical activity | No results reported on health outcomes |
| Devraj et al. [7] | 1–4 (150) USA | Cross-sectional | NVSa (63) | + | Self-care management | Yes: LHL with decreased self-management knowledge and decreased controlling for blood pressure No: LHL with other self-management knowledge, such as taking medication, sugar and salt intake, having lab checks | Yes: LHL with lower eGFR |
| Eneanya et al. [52] | 4–5 (149) USA | Cross-sectional | REALMa (34) | − | Self-care management | Yes: LHL with reduced knowledge of cardiopulmonary resuscitation. LHL mediates racial disparities for CPR knowledge | No results reported on health outcomes |
| Jones et al. [53] | 4–5 (D) (41) Canada | Cross-sectional | sTOFHLAa (5) | − | Self-care management | Yes: LHL with lower transplant and medication knowledge, lower adherence confidence, higher beliefs in medication importance and concerns regarding side effects | No results reported on health outcomes |
| Umeukeje et al. [54] | 5 (D) (100) USA | Cross-sectional | sTOFHLAa (50) | − | Self-care management | No: LHL with self-motivation of dialysis patients to adhere to phosphate treatment | Yes: Lower self-motivation and medication adherence with lower serum phosphorus levels |
| Adeseun et al. [55] | 5 (D) (72) USA | Cross-sectional | sTOFHLAa (21) | − | Self-care management | No: LHL with history of tobacco use | Yes: LHL with higher blood pressure No: LHL with other lifestyle markers, such as BMI |
| Green et al. [56] | 5 (D) (288) USA | Cohort study | REALMa (16) | − | Self-care management | No: LHL with quality of life | Yes: LHL with burden of comorbidities No: LHL with symptom burden, depression, dialysis adequacy and lab values (i.e. albumin, haemoglobin) |
| Foster et al. [57] | 5 (D) (62) USA | Cross-sectional | sTOFHLAa (30.3) | − | Self-care management | No: LHL with disaster preparedness (such as having extra medications) | No results reported on health outcomes |
| Studies with results on mechanisms related to utilization of care (n = 10) | |||||||
| Taylor et al. [58] | 5 (D) (2274) UK | Cohort study | SILSa (24) | + | Utilization of care | Yes: LHL with reduced access to deceased-donor transplant listing and receiving a transplant from a living donor. This is likely related to patients’ preparation No: LHL with pre-emptive waitlisting or dialysis modality | No: LHL with catheter use or mortality |
| Warsame et al. [59] | 4–5 (D) (1578) USA | Cohort study | Brief HLSa (8.9) | + | Utilization of care | Yes: LHL with lower likelihood of being waitlisted for kidney transplant | Yes: LHL with lower likelihood of undergoing living donor transplant and greater risk of waitlist mortality |
| Green et al. [60] | 5 (D) (260) USA | Cohort study | REALMa (16) | + | Utilization of care | Yes: LHL with missed dialysis treatments, more emergency department visits, and more hospitalization No: LHL with abbreviating dialysis treatments | Yes: LHL with higher prevalence of comorbidities and fistula use No: LHL with mortality, lab values or receiving transplant |
| Dageforde et al. [61] | 5 (T) (360) USA | Cross-sectional | SLSa (10) | ± | Utilization of care | Other: LHL more prevalent in patients with a deceased donor (14%) than in patients with a living donor (9%). Living donors have even lower prevalence of LHL (6%) | No results reported on health outcomes |
| Levine et al. [62] | 2–5 (142) USA | Cohort study | NVSa (12) | − | Utilization of care | No: LHL with emergency department visits, hospitalization or length of hospital stay | No results reported on health outcomes |
| Vilme et al. [63] | 4–5 (D) (155) USA | Cross-sectional | REALMa REALM-sfa (n.a) | − | Utilization of care | No: LHL with patient interest in receiving a kidney from a living donor or with facilitators or barriers to pursue a living donor kidney transplantation, in a cohort of African-Americans | No results reported on health outcomes |
| Wong et al. [64] | 4–5 (121) Canada | Cross-sectional | SLSa (n.a.) | − | Utilization of care | Yes: LHL with requiring help to fill in measurements with tablets, and finding this task difficult or tiring | No results reported on health outcomes |
| Flythe et al. [65] | 4–5 (154) USA | Cross-sectional | REALMa (43.3) | − | Utilization of care | Yes: LHL shows a trend towards higher likelihood of 30-day hospital readmission (non-significant in adjusted models) | No results reported on health outcomes |
| Tohme et al. [66] | 5 (D) (286) USA | Mixed-method | REALMa (16) | − | Utilization of care | Yes: LHL with missing dialysis No: LHL with patients’ abbreviation of dialysis treatment | Missing dialysis with mortality. Abbreviation with hospitalization |
| Grubbs et al. [67] | 5 (D) (62) USA | Cross-sectional | sTOFHLAa (32.3) | − | Utilization of care | Yes: LHL with lower referral change for transplant evaluation No: LHL with treatment preference, uncertainties about treatment decision or being waitlisted | No results reported on health outcomes |
| Studies with results on mechanisms related to P–P interaction (n = 1) | |||||||
| Bahadori et al. [68] | 5 (D) (130) Iran | Cross-sectional | HELIAa,b,c (53.8) | − | P–P interaction | Yes: Various subdomains of LHL (understanding and using information, decision-making) with perceived general health | Yes: LHL with physical and psychological symptoms |
| Study characteristics . | Study results . | ||||||
|---|---|---|---|---|---|---|---|
| Study . | CKD-pop (N) country . | Design . | Measure (% LHL) . | Q . | Mechanism(s) . | Association of health literacy with mediator within this mechanism(s) or other result related to mechanism . | Association of health literacy or mediator with health outcome? . |
| Studies with results on multiple mechanisms (n = 18) | |||||||
| Devraj et al. [33] | 1–4 (181) USA | Cross-sectional | NVSa (63) | + | Self-care management Utilization of care | Yes: CKD awareness with self-management behaviours No: LHL with CKD awareness or duration of participation in clinic | Yes: Worse kidney function associated with higher CKD awareness No: LHL with severity of CKD |
| Taylor et al. [34] | 5 (6842) UK | Cross-sectional | SILSa (14.6) | + | Self-care management Utilization of care | Yes: LHL with current smoking Other: LHL is more prevalent in non-waitlisted incident dialysis (20%) patients than in waitlisted dialysis patients (15%) Transplant recipients have the lowest prevalence of LHL (12%) | Yes: LHL with more comorbidities, long-term disabilities, depression and psychosis |
| Ricardo et al. [8] | 1–3 (2340) USA | Cross-sectional | sTOFHLAa (16) | + | Self-care management Utilization of care | Yes: LHL with current smoking, perceived health and more frequent visits to the nephrologist No: LHL with medication use | Yes: LHL with lower eGFR, higher urine protein, more cardiovascular disease and more diabetes |
| Chen et al. [35] | 1–5 (410) Taiwan | Cross-sectional | Mandarin HL scalea (n.a.) | ± | Self-care management Social context | Yes: LHL with worse self-management behaviours and decreased function of social support. Social support associated with self-management behaviours and treatment adherence | No results reported on health outcomes |
| Serper et al. [36] | 5 (T) (98) USA | Mixed-method | NVSa (37) | ± | Self-care management Social context | Yes: LHL with choosing to spend money on expenses other than medication. These decisions were associated with lower medication adherence and explained by the social context | Yes: Choosing to spend money on expenses other than medications with higher rates of hospital admission |
| Demian et al. [37] | 5 (T) (96) Canada | Cross-sectional | HL-Qa,b,c (n.a.) | ± | Self-care management Utilization of care P–P interaction | Other: Multifaceted HL screener indicates: actively managing health is the greatest HL challenge for transplant recipients, while navigating the health system, engaging with providers and understanding information are minor HL challenges | Yes: Appraising/understanding information associated with worse kidney health |
| Jain et al. [38] | 5 (D) (32) USA | Cross-sectional | REALMa (19) | ± | Self-care management Utilization of care | No: LHL with treatment regimens, time on peritoneal dialysis or hospitalization | No: LHL with peritonitis, exit-site infections or dialysis adequacy |
| Kazley et al. [39] | 5 (92) USA | Cross-sectional | REALMa NVSa (n.a.) | ± | Utilization of care Social context | Yes: LHL with lower likelihood of being waitlisted for transplantation and lower social support | Yes: LHL with worse transplant outcomes |
| Lai et al. [40] | 5 (D) (63) Singapore | Cross-sectional | (n.a.) | ± | Self-care management Utilization of care | Yes: LHL with worse blood glucose testing and foot care. Limited communicative and critical with worse diabetes self-management. Limited communicative HL with less exercise Limited critical HL associated with worse general diet No: LHL with duration of diabetes treatment | No: LHL with blood glucose levels |
| Gordon et al. [41] | 5 (T) (124) USA | Cross-sectional | sTOFHLAa (9) REALMa | ± | Self-care management Utilization of care | Yes: LHL with shorter time after transplant. In open questions: patients express the need to improve understanding of transplantation and medication use | Yes: LHL with higher serum creatinine levels |
| Wright Nunes et al. [42] | 1–4 (399) USA | Cross-sectional | REALMa (n.a.) | ± | Self-care management P–P interaction | Yes: LHL with lower perceived kidney disease specific knowledge No: LHL with satisfaction with the provider | Yes: Lower knowledge with lower eGFR awareness of CKD |
| Zhong et al. [43] | 1–5 (61) USA | Cross-sectional | REALMa (40.7) | − | Self-care management Utilization of care P–P interaction | Yes: LHL with medication and lifestyle behaviours, lower healthcare transition readiness from paediatric care to adult care services (a.o. ability to visit doctors and make appointments), less seeking of information and asking questions in a group of 18–29 years adolescents. Communication with providers positively influences knowledge. Greater nutrition knowledge predicted healthcare transition readiness | No results reported on health outcomes |
| Photharos et al. [44] | 2–4 (275) Thailand | Cross-sectional | HLS-14a,b,c | − | Self-care management Social context | Yes: LHL influences self-efficacy in and performance of lifestyle activities. Self-efficacy is not a mediator of association between LHL and self-management No: LHL has no direct or indirect effect on social support or family functioning | No results reported on health outcomes |
| Dodson et al. [45] | 5 (D) (913) Australia | Cross-sectional | HL-Q a,b,c (n.a.) | − | Self-care management Utilization of care P–P interaction Social context | Other: Multifaceted HL screener indicates: compared to a control group of other chronic patients, actively managing health is a greater HL challenge for dialysis patients, while they are better in navigating the health system, engaging with providers, understanding and applying information and enabling social support | Yes: LHL with worse serum albumin, depressive and anxiety symptoms and disease and mental burden |
| Patzer et al. [46] | 5 (T) (99) USA | Mixed-method | REALMa (24.7) | − | Self-care management Utilization of care | Yes: LHL with lower medication knowledge and self-reported treatment adherence No: LHL with demonstrated proper use of medications and hospitalization | No: LHL with graft rejection |
| Tuot et al. [47] | 1–5 (264) USA | Cross-sectional | Brief HLSa (46.6) | − | Self-care management P–P interaction | Yes: Providers’ word choice important to create awareness about CKD No: LHL with CKD awareness | No results reported on health outcomes |
| Lambert et al. [48] | 4–5 (153) Australia | Cross-sectional | HeLMSa,b,c (n.a.) | − | Self-care management Utilization of care P–P interaction | Other: Multifaceted HL screener indicates: incorporation of lifestyle is the greatest HL challenge. Filling in forms and accessing healthcare is a frequent HL problem. Communication with providers is a greater HL challenge for peritoneal dialysis patients compared with other CKD patients | No results reported on health outcomes |
| Dageforde et al. [49] | 5 (104) USA | Cross-sectional | Brief HLSa (23.1) | − | Utilization of care P–P interaction | Yes: LHL with not knowing the next step in the transplantation process. Attending consultations improves transplant knowledge and gives more concerns about finding a donor No: LHL with first-time centre visits | No results reported on health outcomes |
| Studies with results on self-care management (n = 9) | |||||||
| Schrauben et al. [50] | 1–3 (5499) USA | Cohort study | sTOFHLAa (13) | + | Self-care management | Yes: LHL with less healthy behaviour patterns (smoking, obesity, lack of physical activity etc.) in ≥65 subgroup | Yes: Less healthy patterns associated with increased risk of dead, CKD progression and cardiovascular risks |
| Wong et al. [51] | 1–4 (137) USA | Cross-sectional | HL-Qa,b,c (26) | + | Self-care management | Yes: LHL with decreased fast food intake No: LHL with medication adherence and physical activity | No results reported on health outcomes |
| Devraj et al. [7] | 1–4 (150) USA | Cross-sectional | NVSa (63) | + | Self-care management | Yes: LHL with decreased self-management knowledge and decreased controlling for blood pressure No: LHL with other self-management knowledge, such as taking medication, sugar and salt intake, having lab checks | Yes: LHL with lower eGFR |
| Eneanya et al. [52] | 4–5 (149) USA | Cross-sectional | REALMa (34) | − | Self-care management | Yes: LHL with reduced knowledge of cardiopulmonary resuscitation. LHL mediates racial disparities for CPR knowledge | No results reported on health outcomes |
| Jones et al. [53] | 4–5 (D) (41) Canada | Cross-sectional | sTOFHLAa (5) | − | Self-care management | Yes: LHL with lower transplant and medication knowledge, lower adherence confidence, higher beliefs in medication importance and concerns regarding side effects | No results reported on health outcomes |
| Umeukeje et al. [54] | 5 (D) (100) USA | Cross-sectional | sTOFHLAa (50) | − | Self-care management | No: LHL with self-motivation of dialysis patients to adhere to phosphate treatment | Yes: Lower self-motivation and medication adherence with lower serum phosphorus levels |
| Adeseun et al. [55] | 5 (D) (72) USA | Cross-sectional | sTOFHLAa (21) | − | Self-care management | No: LHL with history of tobacco use | Yes: LHL with higher blood pressure No: LHL with other lifestyle markers, such as BMI |
| Green et al. [56] | 5 (D) (288) USA | Cohort study | REALMa (16) | − | Self-care management | No: LHL with quality of life | Yes: LHL with burden of comorbidities No: LHL with symptom burden, depression, dialysis adequacy and lab values (i.e. albumin, haemoglobin) |
| Foster et al. [57] | 5 (D) (62) USA | Cross-sectional | sTOFHLAa (30.3) | − | Self-care management | No: LHL with disaster preparedness (such as having extra medications) | No results reported on health outcomes |
| Studies with results on mechanisms related to utilization of care (n = 10) | |||||||
| Taylor et al. [58] | 5 (D) (2274) UK | Cohort study | SILSa (24) | + | Utilization of care | Yes: LHL with reduced access to deceased-donor transplant listing and receiving a transplant from a living donor. This is likely related to patients’ preparation No: LHL with pre-emptive waitlisting or dialysis modality | No: LHL with catheter use or mortality |
| Warsame et al. [59] | 4–5 (D) (1578) USA | Cohort study | Brief HLSa (8.9) | + | Utilization of care | Yes: LHL with lower likelihood of being waitlisted for kidney transplant | Yes: LHL with lower likelihood of undergoing living donor transplant and greater risk of waitlist mortality |
| Green et al. [60] | 5 (D) (260) USA | Cohort study | REALMa (16) | + | Utilization of care | Yes: LHL with missed dialysis treatments, more emergency department visits, and more hospitalization No: LHL with abbreviating dialysis treatments | Yes: LHL with higher prevalence of comorbidities and fistula use No: LHL with mortality, lab values or receiving transplant |
| Dageforde et al. [61] | 5 (T) (360) USA | Cross-sectional | SLSa (10) | ± | Utilization of care | Other: LHL more prevalent in patients with a deceased donor (14%) than in patients with a living donor (9%). Living donors have even lower prevalence of LHL (6%) | No results reported on health outcomes |
| Levine et al. [62] | 2–5 (142) USA | Cohort study | NVSa (12) | − | Utilization of care | No: LHL with emergency department visits, hospitalization or length of hospital stay | No results reported on health outcomes |
| Vilme et al. [63] | 4–5 (D) (155) USA | Cross-sectional | REALMa REALM-sfa (n.a) | − | Utilization of care | No: LHL with patient interest in receiving a kidney from a living donor or with facilitators or barriers to pursue a living donor kidney transplantation, in a cohort of African-Americans | No results reported on health outcomes |
| Wong et al. [64] | 4–5 (121) Canada | Cross-sectional | SLSa (n.a.) | − | Utilization of care | Yes: LHL with requiring help to fill in measurements with tablets, and finding this task difficult or tiring | No results reported on health outcomes |
| Flythe et al. [65] | 4–5 (154) USA | Cross-sectional | REALMa (43.3) | − | Utilization of care | Yes: LHL shows a trend towards higher likelihood of 30-day hospital readmission (non-significant in adjusted models) | No results reported on health outcomes |
| Tohme et al. [66] | 5 (D) (286) USA | Mixed-method | REALMa (16) | − | Utilization of care | Yes: LHL with missing dialysis No: LHL with patients’ abbreviation of dialysis treatment | Missing dialysis with mortality. Abbreviation with hospitalization |
| Grubbs et al. [67] | 5 (D) (62) USA | Cross-sectional | sTOFHLAa (32.3) | − | Utilization of care | Yes: LHL with lower referral change for transplant evaluation No: LHL with treatment preference, uncertainties about treatment decision or being waitlisted | No results reported on health outcomes |
| Studies with results on mechanisms related to P–P interaction (n = 1) | |||||||
| Bahadori et al. [68] | 5 (D) (130) Iran | Cross-sectional | HELIAa,b,c (53.8) | − | P–P interaction | Yes: Various subdomains of LHL (understanding and using information, decision-making) with perceived general health | Yes: LHL with physical and psychological symptoms |
CKD-pop: population of interest by CKD stages (1, 2, 3, 4 or 5), when applicable specified for transplant (T) or dialysis (D); NVS: Newest Vital Sign; SILS, Single Item Literacy Screener; sTOFHLA: short Test of Functional Health Literacy in Adults; eGFR, estimated glomerular filtration rate; Mandarin HL Scale, Mandarin HL Scale; HL-Q, Health Literacy Questionnaire; REALM-SF, Rapid Estimate of Adult Literacy in Medicine—Short Form; FCCHL, Functional Communicative Critical Health Literacy; HLS, Health Literacy Scale; HeLMS, Health Literacy Management Scale; SLS, Short Literacy Survey; HELIA, Health Literacy for Iranian Adults; BMI, body mass index; n.a., not available; N, number of participants in the study; Q, study quality; +, high-quality study; ±, moderate-quality study; −, low-quality study, based on quality assessment.
Functional HL measure.
Communicative HL measure.
Critical HL measure.
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