interactive Journal of Medical Research

A general medical journal, focussing on innovation in health and medical research


Interact J Med Res articles are indexed in PubMed ( and the full text is immediately deposited in PubMed Central ( The Interact J Med Res adheres to the same quality standards as JMIR and all articles published here are also cross-listed in the Table of Contents of JMIR, the worlds' leading medical journal in health sciences / health services research and health informatics (

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Journal Description

i-JMR is a new general medical journal, harnessing the power of the Internet and mobile platforms (iPad) for knowledge dissemination and translation.

i-JMR is a general medical journal with a focus on innovation in health, health care, and medicine - through new medical techniques and innovative ideas and/or research, including - but not limited to - technology, clinical informatics, or groundbreaking research.

Published by JMIR Publications, publisher of JMIR, the leading eHealth/mHealth journal (Impact Factor 2011: 4.4), i-JMR has a broader scope and features a rapid and thorough peer-review process, professional copyediting, professional production of PDF, XHTML, and XML proofs (ready for deposit in PubMed Central), and an ipad App (in prep.).


Recent Articles:

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    Perceived Reasons, Incentives, and Barriers to Physical Activity in Swedish Elderly Men


    Background: Knowledge about factors influencing physical activity behavior is needed in order to tailor physical activity interventions to the individual. Objective: The aim of this study was to explore and describe the perceived reasons, barriers, and incentives to increased physical activity, as well as preferable activities, among elderly men in Sweden. Methods: In total, 150 men aged 50-86 years responded to a Web-based questionnaire. Men who reported that they exercised sometimes or often received questions about reasons for physical activity (n=104), while men who reported that they never or seldom exercised received questions about barriers (n=46). Results: The most frequent perceived reason for being physically active was health (82%), followed by enjoyment (45%), and a desire to lose/maintain weight (27%). Lack of interest/motivation was identified as the primary perceived barrier (17%). Incentives for increasing the level of activity included becoming more motivated and having a training partner. Walking was the most preferred activity. Conclusions: Enjoyment and maintaining a good health were important reasons for engaging in physical activity among Swedish elderly men.
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    Validity and Usability of Low-Cost Accelerometers for Internet-Based Self-Monitoring of Physical Activity in Patients With Chronic Obstructive Pulmonary Disease


    Background: The importance of regular physical activity for patients with chronic obstructive pulmonary disease (COPD) is well-established. However, many patients do not meet the recommended daily amount. Accelerometers might provide patients with the information needed to increase physical activity in daily life. Objective: Our objective was to assess the validity and usability of low-cost Internet-connected accelerometers. Furthermore we explored patients’ preferences with regards to the presentation of and feedback on monitored physical activity. Methods: To assess concurrent validity we conducted a field validation study with patients who wore two low-cost accelerometers, Fitbit and Physical Activity Monitor (PAM), at the same time along with a sophisticated multisensor accelerometer (SenseWear Armband) for 48 hours. Data on energy expenditure assessed from registrations from the two low-cost accelerometers were compared to the well validated SenseWear Armband which served as a reference criterion. Usability was examined in a cross-over study with patients who, in succession, wore the Fitbit and the PAM for 7 consecutive days and filled out a 16 item questionnaire with regards to the use of the corresponding device Results: The agreement between energy expenditure (METs) from the SenseWear Armband with METs estimated by the Fitbit and PAM was good (r=.77) and moderate (r=.41), respectively. The regression model that was developed for the Fitbit explained 92% whereas the PAM-model could explain 89% of total variance in METs measured by the SenseWear. With regards to the usability, both the Fitbit and PAM were well rated on all items. There were no significant differences between the two devices. Conclusions: The low-cost Fitbit and PAM are valid and usable devices to measure physical activity in patients with COPD. These devices may be useful in long-term interventions aiming at increasing physical activity levels in these patients.
  • By jannoon028, published on 07 August 2011 Stock Photo - image ID: 10052994;

    The Relation Between Caregivers' Multiliterate Reading Habits and Their Children's Oral Health Status


    Background: Caregivers’ oral health literacy (OHL) assessment results have been found to be related to their children’s oral health status. A further aspect of this relationship may be the role of caregivers’ reading habits. Objective: Our goal was to describe the relationship between caregivers’ multimodal (digital and print) and multilingual (English and Chinese) reading habits, their OHL, and their child’s oral health status in Hong Kong. Methods: A random sample of 301 child-caregiver dyads was recruited from kindergartens in Hong Kong. Data included sociodemographic information and caregivers’ self-reported digital print and reading habits across two languages (Chinese and English). Caregivers’ OHL levels were assessed by two locally developed and validated oral health literacy assessment tasks: Hong Kong Rapid Estimate of Adult Literacy in Dentistry-30 (HKREALD-30) and the Hong Kong Oral Health Literacy Assessment Task for Pediatric Dentistry (HKOHLAT-P). Children’s oral health status was assessed using two measures: dental caries experience (number of decayed, missing, and filled teeth) and oral hygiene status (Visible Plaque Index). Results: Bivariate variations revealed significant differences in mean OHL scores between caregivers with different reading habits (P<.01). Correlations revealed significant associations between caregivers’ practices of reading multimodal (print/digital) and multilingual (English/Chinese) texts, their literacy levels, and their children’s oral health status (P<.01). Adjusting for sociodemographics and all other reading habits in the regression analysis, the caregivers' habit of reading digital and print texts was significantly retained in the final model. Regression analysis revealed significant associations between caregivers’ reading habits (digital Chinese) and their OHL word recognition scores: OR 5.00, 95% CI 1.10-3.65, P=.027. Significant associations were also evident for their OHL comprehension scores (digital Chinese: OR 2.30, 95% CI 1.30-4.20, P=.004; print Chinese: OR 2.50, 95% CI 1.40-4.30, P=.001). However, no significant associations were found between caregivers' reading habits and child’s oral health status (P>.05). Conclusions: Caregivers’ habits of reading print and digital Chinese texts are significantly associated with their OHL scores. Their reading habits, however, do not affect their children’s oral health status.
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    Web Search Behavior and Information Needs of People With Multiple Sclerosis: Focus Group Study and Analysis of Online Postings


    Background: Multiple sclerosis (MS) patients and their family members increasingly seek health information on the Internet. There has been little exploration of how MS patients integrate health information with their needs, preferences, and values for decision making. The INtegrating and Deriving Evidence, Experiences, and Preferences (IN-DEEP) project is a collaboration between Italian and Australian researchers and MS patients, aimed to make high-quality evidence accessible and meaningful to MS patients and families, developing a Web-based resource of evidence-based information starting from their information needs. Objective: The objective of this study was to analyze MS patients and their family members’ experience about the Web-based health information, to evaluate how they asses this information, and how they integrate health information with personal values. Methods: We organized 6 focus groups, 3 with MS patients and 3 with family members, in the Northern, Central, and Southern parts of Italy (April-June 2011). They included 40 MS patients aged between 18 and 60, diagnosed as having MS at least 3 months earlier, and 20 family members aged 18 and over, being relatives of a person with at least a 3-months MS diagnosis. The focus groups were audio-recorded and transcribed verbatim (Atlas software, V 6.0). Data were analyzed from a conceptual point of view through a coding system. An online forum was hosted by the Italian MS society on its Web platform to widen the collection of information. Nine questions were posted covering searching behavior, use of Web-based information, truthfulness of Web information. At the end, posts were downloaded and transcribed. Results: Information needs covered a comprehensive communication of diagnosis, prognosis, and adverse events of treatments, MS causes or risk factors, new drugs, practical, and lifestyle-related information. The Internet is considered useful by MS patients, however, at the beginning or in a later stage of the disease a refusal to actively search for information could occur. Participants used to search on the Web before or after their neurologist’s visit or when a new therapy was proposed. Social networks are widely used to read others’ stories and retrieve information about daily management. A critical issue was the difficulty of recognizing reliable information on the Web. Many sources were used but the neurologist was mostly the final source of treatment decisions. Conclusions: MS patients used the Internet as a tool to integrate information about the illness. Information needs covered a wide spectrum, the searched topics changed with progression of the disease. Criteria for evaluating Internet accuracy and credibility of information were often lacking or generic. This may limit the empowerment of patients in health care choices.
  • (cc) Pitter et al. CC-BY-SA-2.0, please cite as (

    The Impact of Different Surgical Modalities for Hysterectomy on Satisfaction and Patient Reported Outcomes


    Background: There is an ongoing debate regarding the cost-benefit of different surgical modalities for hysterectomy. Studies have relied primarily on evaluation of clinical outcomes and medical expenses. Thus, a paucity of information on patient-reported outcomes including satisfaction, recovery, and recommendations exists. Objective: The objective of this study was to identify differences in patient satisfaction and recommendations by approach to a hysterectomy. Methods: We recruited a large, geographically diverse group of women who were members of an online hysterectomy support community. US women who had undergone a benign hysterectomy formed this retrospective study cohort. Self-reported characteristics and experiences were compared by surgical modality using chi-square tests. Outcomes over time were assessed with the Jonkheere-Terpstra trend test. Logistic regression identified independent predictors of patient satisfaction and recommendations. Results: There were 6262 women who met the study criteria; 41.74% (2614/6262) underwent an abdominal hysterectomy, 10.64% (666/6262) were vaginal, 27.42% (1717/6262) laparoscopic, 18.94% (1186/6262) robotic, and 1.26% (79/6262) single-incision laparoscopic. Most women were at least college educated (56.37%, 3530/6262), and identified as white, non-Hispanic (83.17%, 5208/6262). Abdominal hysterectomy rates decreased from 68.2% (152/223) to 24.4% (75/307), and minimally invasive surgeries increased from 31.8% (71/223) to 75.6% (232/307) between 2001 or prior years and 2013 (P<.001 all trends). Trends in overall patient satisfaction and recommendations showed significant improvement over time (P<.001).There were differences across the surgical modalities in all patient-reported experiences (ie, satisfaction, time to walking, driving and working, and whether patients would recommend or use the same technique again; P<.001). Significantly better outcomes were evident among women who had vaginal, laparoscopic, and robotic procedures than among those who had an abdominal procedure. However, robotic surgery was the only approach that was an independent predictor of better patient experience; these patients were more satisfied overall (odds ratio [OR] 1.31, 95% CI 1.13-1.51) and on six other satisfaction measures, and more likely to recommend (OR 1.64, 95% CI 1.39-1.94) and choose the same modality again (OR 2.07, 95% CI 1.67-2.57). Abdominal hysterectomy patients were more dissatisfied with outcomes after surgery and less likely to recommend (OR 0.36, 95% CI 0.31-0.40) or choose the same technique again (OR 0.29, 95% CI 0.25-0.33). Quicker return to normal activities and surgery after 2007 also were independently associated with better overall satisfaction, willingness to recommend, and to choose the same surgery again. Conclusions: Consistent with other US data, laparoscopic and robotic hysterectomy rates increased over time, with a concomitant decline in abdominal hysterectomy. While inherent shortcomings of this retrospective Web-based study exist, findings show that patient experience was better for each of the major minimally invasive approaches than for abdominal hysterectomy. However, robotic-assisted hysterectomy was the only modality that independently predicted greater satisfaction and willingness to recommend and have the same procedure again.
  • This image depicts the IDF humanitarian mission

    Military Medicine Publications: What has Happened in the Past Two Decades?


    Background: Military medical personnel, like all other physician specialists, face the challenge of keeping updated with developments in their field of expertise, in view of the great amount of new medical information published in the literature. The availability of the Internet has triggered tremendous changes in publication characteristics, and in some fields, the number of publications has increased substantially. The emergence of electronic open access journals and the improvement in Web search engines has triggered a significant change in the publication processes and in accessibility of information. Objective: The objective of this study was to characterize the temporal trends in the number and types of publications in military medicine in the medical literature. Methods: We searched all PubMed-registered publications from January 1, 1990 to December 31, 2010 using the keywords “military” or “army”. We used the publication tag in PubMed to identify and examine major publication types. The trends were tested using the Mann-Kendall test for trend. Results: Our search yielded 44,443 publications in military medicine during the evaluation period. Overall, the number of publications showed two distinct phases over time: (1) a moderate increase from 1990 to 2001 with a mean annual increase of 2.78% (r2=.79, P<.002), and (2) a steeper mean annual increase of 11.20% (r2=.96, P<.002) from 2002 to 2010. Most of the examined publication types showed a similar pattern. The proportion of high-quality-of-evidence publication types (randomized controlled trials, systematic reviews, and meta-analyses) increased from 2.91% to 8.43% of the overall military medicine publications with a mean annual incremental increase of 14.20%. These publication types demonstrated a similar dual phase pattern of increase (10.01%, r2=.80, P<.002 for 1990-2001 and 20.66%, r2=.88, P<.002 for 2002-2010). Conclusions: We conclude that over the past twenty years, scholarly work in the field of military medicine has shown a significant increase in volume, particularly among high quality publication types. However, practice guidelines remain rare, and meta-analyses are still limited in number.
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    A European Network of Email and Telephone Help Lines Providing Information and Support on Rare Diseases: Results From a 1-Month Activity Survey


    Background: Information on rare diseases are often complex to understand, or difficult to access and additional support is often necessary. Rare diseases helplines work together across Europe to respond to calls and emails from the public at large, including patients, health care professionals, families, and students. Measuring the activity of helplines can help decision makers to allocate adequate funds when deciding to create or expand an equivalent service. Objective: Data presented are referred to a monthly user profile analysis, which is one of the activities that each helpline has to carry out to be part of the network. This survey aimed to explore the information requests and characteristics of users of rare diseases helplines in different European countries. Another aim was to analyze these data with respect to users’ characteristics, helpline characteristics, topics of the inquiries, and technologies used to provide information. With this survey, we measure data that are key for planning information services on rare diseases in the context of the development of national plans for rare diseases. Methods: A survey was conducted based on all calls, emails, visits, or letters received from November 1 to 30, 2012 to monitor the activity represented by 12 helplines. Data were collected by a common standardized form, using ORPHA Codes for rare diseases, when applicable. No personal data identifying the inquirer were collected. It was a descriptive approach documenting on the number and purpose of inquiries, the number of respondents, the mode of contact, the category of the inquirer in relation to the patient, the inquirer’s gender, age and region of residence, the patient’s age when applicable, the type and duration of response, and the satisfaction as scored by the respondents. Results: A total of 1676 calls, emails, or letters were received from November 1 to 30, 2012. Inquiries were mostly about specific diseases. An average of 23 minutes was spent for each inquiry. The inquirer was a patient in 571/1676 inquiries (ie, 34.07% of all cases; 95% CI 31.8-36.3). Other inquirers included relatives (520/1676, 31.03%; 95% CI 28.9-33.3), health care professionals (354/1676, 21.12%; 95% CI 19.2-23.1), and miscellaneous inquirers (230/1676, 13.72%; 95% CI 12.1-15.4). Telephone remained the main mode of contact (988/1676, 58.95%; 95% CI 56.6-61.3), followed by emails (609/1676, 36.34%; 95% CI 34.0-38.6). The three main reasons of inquiries were to acquire about information on the disease (682/2242, 30.42%; 95% CI 27.8-32.1), a specialized center/expert (404/2242, 18.02%; 95% CI 15.9-19.6), and social care (240/2242, 10.70%; 95% CI 9.1-12.0). Conclusions: The helplines service responds to the demands of the public, however more inquiry-categories could be responded to. This leaves the possibility to expand the scope of the helplines, for example by providing assistance to patients when they are reporting suspected adverse drug reactions as provided by Directive 2010/84/EU or by providing information on patients’ rights to cross-border care, as provided by Directive 2010/24/EU.
  • (cc) by Chiragpatel90, CC-BY-SA 3.0 (

    A Qualitative Analysis of User Experiences With a Self-Tracker for Activity, Sleep, and Diet

    Authors List:


    Background: The recent increase in chronic diseases and an aging population warrant the necessity of health self-management. As small electronic devices that track one’s activity, sleep, and diet, called self-trackers, are being widely distributed, it is prudent to investigate the user experience and the effectiveness of these devices, and use the information toward engineering better devices that would result in increased efficiency and usability. Objective: The aim of this study was to abstract the constructs that constitute the user experiences of the self-tracker for activity, sleep, and diet. Additionally, we aimed to develop and verify the Health Information Technology Acceptance Model-II (HITAM-II) through a qualitative data analysis approach. Methods: The study group consisted of 18 female college students who participated in an in-depth interview after completing a 3-month study of utilizing a self-tracker designed to monitor activity, sleep, and diet. The steps followed in the analysis were: (1) extraction of constructs from theoretical frameworks, (2) extraction of constructs from interview data using a qualitative methodology, and (3) abstraction of constructs and modeling of the HITAM-II. Results: The constructs that constitute the HITAM-II are information technology factors, personal factors, social factors, attitude, behavioral intention, and behavior. These constructs are further divided into subconstructs to additionally support the HITAM-II. Conclusions: The HITAM-II was found to successfully describe the health consumer’s attitude, behavioral intention, and behavior from another perspective. The result serves as the basis for a unique understanding of the user experiences of HIT.
  • Physicians use knowledge resources frequently. 
(c) 2014 Mayo Foundation.

    Speed and Accuracy of a Point of Care Web-Based Knowledge Resource for Clinicians: A Controlled Crossover Trial


    Background: Effective knowledge translation at the point of care requires that clinicians quickly find correct answers to clinical questions, and that they have appropriate confidence in their answers. Web-based knowledge resources can facilitate this process. Objective: The objective of our study was to evaluate a novel Web-based knowledge resource in comparison with other available Web-based resources, using outcomes of accuracy, time, and confidence. Methods: We conducted a controlled, crossover trial involving 59 practicing clinicians. Each participant answered questions related to two clinical scenarios. For one scenario, participants used a locally developed Web-based resource, and for the second scenario, they used other self-selected Web-based resources. The local knowledge resource (“AskMayoExpert”) was designed to provide very concise evidence-based answers to commonly asked clinical questions. Outcomes included time to a correct response with at least 80% confidence (primary outcome), accuracy, time, and confidence. Results: Answers were more often accurate when using the local resource than when using other Web-based resources, with odds ratio 6.2 (95% CI 2.6-14.5; P<.001) when averaged across scenarios. Time to find an answer was faster, and confidence in that answer was consistently higher, for the local resource (P<.001). Overconfidence was also less frequent with the local resource. In a time-to-event analysis, the chance of responding correctly with at least 80% confidence was 2.5 times greater when using the local resource than with other resources (95% CI 1.6-3.8; P<.001). Conclusions: Clinicians using a Web-based knowledge resource designed to provide quick, concise answers at the point of care found answers with greater accuracy and confidence than when using other self-selected Web-based resources. Further study to improve the design and implementation of knowledge resources may improve point of care learning.
  • Telemedicine-Based Approach for Obstructive Sleep Apnea Management: Building Evidence


    Background: Telemedicine seems to offer reliable solutions to health care challenges, but significant contradictory results were recently found. Therefore, it is crucial to carefully select outcomes and target patients who may take advantage of this technology. Continuous positive airway pressure (CPAP) therapy compliance is essential to treat patients with obstructive sleep apnea (OSA). We believe that OSA patients could benefit greatly from a telemedicine approach for CPAP therapy management. Objective: The objective of our study was to evaluate the application of a telemedicine-based approach in the CPAP therapy management, focusing on patients’ CPAP follow-up and training. Methods: We performed two studies. First, (study 1) we enrolled 50 consecutive OSA patients who came to our sleep center for the CPAP follow-up visit. Patients performed a teleconsultation with a physician, and once finalized, they were asked to answer anonymously to a questionnaire regarding their opinion about the teleconsultation. In a second randomized controlled trial (RCT) (study 2), we included 40 OSA patients scheduled for CPAP training. There were 20 that received the usual face-to-face training and 20 that received the training via videoconference. After the session, they were blindly evaluated on what they learned about OSA and mask placement. Results: More than 95% (49/50) of the interviewed patients were satisfied with the teleconsultation, and 66% (33/50) of them answered that the teleconsultation could replace 50%-100% of their CPAP follow-up visits. Regarding the RCT, patients who received the CPAP training via videoconference demonstrated the same knowledge about OSA and CPAP therapy as the face-to-face group (mean 93.6% of correct answers vs mean 92.1%; P=.935). Performance on practical skills (mask and headgear placement, leaks avoidance) was also similar between the two groups. Conclusions: OSA patients gave a positive feedback about the use of teleconsultation for CPAP follow-up, and the CPAP training based on a telemedicine approach proved to be as effective as face-to-face training. These results support the use of this telemedicine-based approach as a valuable strategy for patients’ CPAP training and clinical follow-up.
  • Screenshot captured from the PRO-based overview accessed from the EHR of the Central Denmark Region. The color codes in the upper row indicate the result of the automated PRO algorithm (red: definite need of contact; yellow: possible need of contact; green: no need of contact). Labels were translated from Danish.

    Use of Patient-Reported Outcome (PRO) Measures at Group and Patient Levels: Experiences From the Generic Integrated PRO System, WestChronic


    Background: Patient-reported outcome (PRO) measures may be used at a group level for research and quality improvement and at the individual patient level to support clinical decision making and ensure efficient use of resources. The challenges involved in implementing PRO measures are mostly the same regardless of aims and diagnostic groups and include logistic feasibility, high response rates, robustness, and ability to adapt to the needs of patient groups and settings. If generic PRO systems can adapt to specific needs, advanced technology can be shared between medical specialties and for different aims. Objective: We describe methodological, organizational, and practical experiences with a generic PRO system, WestChronic, which is in use among a range of diagnostic groups and for a range of purposes. Methods: The WestChronic system supports PRO data collection, with integration of Web and paper PRO questionnaires (mixed-mode) and automated procedures that enable adherence to implementation-specific schedules for the collection of PRO. For analysis, we divided functionalities into four elements: basic PRO data collection and logistics, PRO-based clinical decision support, PRO-based automated decision algorithms, and other forms of communication. While the first element is ubiquitous, the others are optional and only applicable at a patient level. Methodological and organizational experiences were described according to each element. Results: WestChronic has, to date, been implemented in 22 PRO projects within 18 diagnostic groups, including cardiology, neurology, rheumatology, nephrology, orthopedic surgery, gynecology, oncology, and psychiatry. The aims of the individual projects included epidemiological research, quality improvement, hospital evaluation, clinical decision support, efficient use of outpatient clinic resources, and screening for side effects and comorbidity. In total 30,174 patients have been included, and 59,232 PRO assessments have been collected using 92 different PRO questionnaires. Response rates of up to 93% were achieved for first-round questionnaires and up to 99% during follow-up. For 6 diagnostic groups, PRO data were displayed graphically to the clinician to facilitate flagging of important symptoms and decision support, and in 5 diagnostic groups PRO data were used for automatic algorithm-based decisions. Conclusions: WestChronic has allowed the implementation of all proposed protocol for data collection and processing. The system has achieved high response rates, and longitudinal attrition is limited. The relevance of the questions, the mixed-mode principle, and automated procedures has contributed to the high response rates. Furthermore, development and implementation of a number of approaches and methods for clinical use of PRO has been possible without challenging the generic property. Generic multipurpose PRO systems may enable sharing of automated and efficient logistics, optimal response rates, and other advanced options for PRO data collection and processing, while still allowing adaptation to specific aims and patient groups.
  • (cc) Marrie et al. CC-BY-SA-2.0, please cite as (

    Health Literacy Association With Health Behaviors and Health Care Utilization in Multiple Sclerosis: A Cross-Sectional Study


    Background: Low health literacy is generally associated with poor health outcomes; however, health literacy has received little attention in multiple sclerosis (MS). Objective: The aim of this study was to investigate the health literacy of persons with MS using the North American Research Committee on Multiple Sclerosis (NARCOMS) Registry. Methods: In 2012, we conducted a cross-sectional study of health literacy among NARCOMS participants. Respondents completed the Medical Term Recognition Test (METER) which assesses the ability to distinguish medical and nonmedical words, and the Newest Vital Sign (NVS) instrument which evaluates reading, interpretation, and numeracy skills. Respondents reported their sociodemographic characteristics, health behaviors, comorbidities, visits to the emergency room (ER), and hospitalizations in the last 6 months. We used logistic regression to evaluate the characteristics associated with functional literacy, and the association between functional literacy and health care utilization. Results: Of 13,020 eligible participants, 8934 (68.6%) completed the questionnaire and were US residents. Most of them performed well on the instruments with 81.04% (7066/8719) having functional literacy on the METER and 74.62% (6666/8933) having adequate literacy on the NVS. Low literacy on the METER or the NVS was associated with smoking, being overweight or obese (all P<.001). After adjustment, low literacy on the METER was associated with ER visits (OR 1.28, 95% CI 1.10-1.48) and hospitalizations (OR 1.19, 95% CI 0.98-1.44). Findings were similar for the NVS. Conclusions: In the NARCOMS cohort, functional health literacy is high. However, lower levels of health literacy are associated with adverse health behaviors and greater health care utilization.

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