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Health in the 'hidden population' of people with low literacy. A systematic review of the literature

Easton, Phyllis; Entwistle, Vikki A; Williams, Brian


Phyllis Easton

Vikki A Entwistle

Brian Williams


Background: Much of the evidence of an association between low functional or health literacy and poor health comes from studies that include people who have various cognitive difficulties or who do not speak the dominant language of their society. Low functional or health literacy among these people is likely to be evident in spoken conversation. However, many other people can talk readily about health and other issues but have problems using written information. Consequently, their difficulties may be far less evident to healthcare professionals, creating a 'hidden population' whose functional or health literacy problems have different implications because they are less likely to be recognised and addressed. We aimed to review published research to investigate relationships between low functional or health literacy and health in working age adults who can converse in the dominant language but have difficulty with written language. Methods: We searched reviews and electronic databases for studies that examined health-related outcomes among the population of interest. We systematically extracted data relating to relationships between low functional or health literacy and both health status and various possible mediators or moderators of the implications of literacy for health. We developed a narrative review. Results: Twenty-four studies met our inclusion criteria. Lower functional or health literacy in this population was found to be associated with worse health status. This may be mediated by difficulties accessing healthcare, and poorer self-management of health problems. It is currently unclear whether, how or to what extent these difficulties are mediated by poorer knowledge stemming from low functional or health literacy. The variation in functional or health literacy measures and comparisons make it difficult to compare study findings and to establish the implications of different literacy issues for health outcomes. Conclusions: There is evidence in the literature that low functional or health literacy is associated with poor health in the 'hidden population' of adults whose literacy difficulties may not be evident to health care providers. Further research is needed to help understand the particular disadvantages faced by this population and to establish appropriate responses.


Easton, P., Entwistle, V. A., & Williams, B. (2010). Health in the 'hidden population' of people with low literacy. A systematic review of the literature. BMC Public Health, 10, Article 459.

Journal Article Type Article
Acceptance Date Aug 5, 2010
Online Publication Date Aug 5, 2010
Publication Date Aug 5, 2010
Deposit Date Sep 13, 2016
Publicly Available Date Sep 13, 2016
Journal BMC Public Health
Electronic ISSN 1471-2458
Publisher BMC
Peer Reviewed Peer Reviewed
Volume 10
Article Number 459
Keywords Public Health, Environmental and Occupational Health
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Health in the 'hidden population' of people with low literacy. A systematic review of the literature (303 Kb)

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Published in BMC Public Health which is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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