Lee et al. BMC Public Health 2010, 10:614 http://www.biomedcentral.com/1471-2458/10/614 a high rate of literacy. This finding lends support to the claim that low health literacy may be prevalent around the world. However, the prevalence itself is not necessa- rily indicative of the need for interventions. As our results suggest, the health effects of low health literacy may vary as a result of the socio-demographic composi- tion of the population and the structure of the health care delivery and financing systems. To the extent this is true, interventions that focus solely on enhancing health literacy may have a limited impact on health and health care utilization in certain countries. Further research that examines the impact of low health literacy on health outcomes across countries would help to ver- ify our contention and inform health policy in other countries. Acknowledgements We would like to thank the health literacy research team for their support and assistance. The authors also recognize the contribution of Li-Chuan Chang who assisted data management and analysis. This study was supported by National Health Research Institutes (Grant Number: HP-097-PP-04) Author details 1Department of Health Management and Policy, School of Public Health, University of Michigan, 1420 Washington Heights, Ann Arbor, MI 48109-2029, USA. 2School of Nursing, National Yang-Ming University, No.155, Sec.2, Linong Street, Taipei, 112, Taiwan. 3Institute of Health and Welfare Policy, National Yang-Ming University, No.155, Sec.2, Linong Street, Taipei, 112, Taiwan. 4Health Policy Research and Development, Institute of Population Health Sciences, National Health Research Institutes, 35, Keyan Road, Zhunan Town, Miaoli County, 350, Taiwan. Authors’ contributions SYDL conceived of the study, participated in the design of the study, interpretation of the data, and led the manuscript preparation. TIT conceived of the study, participated in the design of the study, carried out the survey and analysis, interpretation of the data, and involve in drafting the manuscript. YWT participated in the design of the study, carried out the survey, and participated in manuscript preparation. KNK participated in the survey design and coordination. All authors read and approved the final manuscript. Competing interests The authors declare that they have no competing interests. Received: 14 May 2010 Accepted: 16 October 2010 Published: 16 October 2010 References 1. Seldon CR, Zorn M, Ratzan SC, Parker RM: National Library of Medicine Current Bibliographies in Medicine: Health Literacy. Volume NLM Pub. No. CBM 2000-1 National Institutes of Health 2000. 2. Nutbeam D, Kickbusch I: Advancing health literacy: A global challenge for the 21st century. Health Promotion International 2000, 15(3):183-184. 3. CSDH: Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Final Report of the Commission on Social Determinants of Health. Geneva: World Health Organization 2008. 4. Cho YI, Lee S-YD, Arozullah AM, Crittenden KS: Effects of health literacy on health status and health service utilization amongst the elderly. Social Science & Medicine 2008, 66(8):1809-1816. 5. Davis TC, Wolf MS, Bass PF, Middlebrooks M, Kennen E, Baker DW, Bennett CL, Durazo-Arvizu R, Bocchini A, Savory S: Low literacy impairs comprehension of prescription drug warning labels. Journal of General Internal Medicine 2006, 21(8):847-851. Page 7 of 8 6. Gazmararian JA, Williams MV, Peel J, Baker DW: Health literacy and knowledge of chronic disease. Patient Education and Counseling 2003, 51(3):267-275. 7. Parker RM, Ratzan SC, Lurie N: Health literacy: A policy challenge for advancing high-quality health care. Health Affairs 2003, 22(4):147. 8. Baker DW, Gazmararian JA, Williams MV, Scott T, Parker RM, Green D, Ren J, Peel J: Health literacy and use of outpatient physician services by Medicare managed care enrollees. J Gen Intern Med 2004, 19(3):215-220. 9. Lindau ST, Tomori C, Lyons T, L L, Bennett CL, Garcia P: The association of health literacy with cervical cancer prevention knowledge and health behavior in a multiethnic cohort of women. American Journal of Obstetrics and Gynecology 2002, 186:938-943. 10. Lindau ST, Basu A, Leitsch SA: Health literacy as a predictor of follow-up after an abnormal Pap smear: A prospective study. Journal of General Internal Medicine 2006, 21:829-834. 11. Scott TL, Gazmararian JA, Williams MV, Baker DW: Health literacy and preventive health care use among Medicare enrollees in a managed care organization. Med Care 2002, 40(5):395-404. 12. Rogers ES, Wallace LS, Weiss BD: Misperceptions of medical understanding in low-literacy patients: Implications for cancer prevention. Cancer Control 2006, 13(3):225-229. 13. von Wagner C, Knight K, Steptoe A, Wardle J: Functional health literacy and health-promoting behaviour in a national sample of British adults. J Epidemiol Community Health 2007, 61(12):1086-1090. 14. Baker DW, Gazmararian JA, Williams MV, Scott T, Parker RM, Green D, Ren J, Peel J: Functional health literacy and the risk of hospital admission among Medicare managed care enrollees. Am J Public Health 2002, 92(8):1278-1283. 15. Howard DH, Sentell T, Gazmararian JA: Impact of health literacy on socioeconomic and racial differences in health in an elderly population. Journal of General Internal Medicine 2006, 21(8):857-861. 16. Sudore RL, Yaffe K, Satterfield S, Harris TB, Mehta KM, Simonsick EM, Newman AB, Rosano C, Rooks R, Rubin SM, et al: Limited literacy and mortality in the elderly: the health, aging, and body composition study. J Gen Intern Med 2006, 21(8):806-812. 17. Department of Statistics: Statistical Yearbook of Interior.Edited by: Ministry of the Interior. Taipei: Ministry of the Interior, Taiwan; , 2009 2007:. 18. Davis K, Tuang AT: Learning from Taiwan: Experience with universal health insurance. Annals of Internal Medicine 2008, 148(4):313-314. 19. Tsai TI, Lee S-YD, Tsai YW, Kuo KN: Methodology and validation of health literacy scale development in Taiwan. Journal of Health Communication . 20. Liu CY, Hung YT, Chuang YL, Chen YJ, Weng WS, Liu JS, Liang KY: Incorporating development stratification of Taiwan townships into sampling design of large scale health interview survey. Journal of Health Management 2006, 4(1):1-22. 21. Parikh NS, Parker RM, Nurss JR, Baker DW, Williams MV: Shame and health literacy: the unspoken connection. Patient Education and Counseling 1996, 27(1):33-39. 22. Wolf MS, Williams MV, Parker RM, Parikh NS, Nowlan AW, Baker DW: Patients’ shame and attitudes toward discussing the results of literacy screening. Journal of Health Communication 2007, 12(8):721-732. 23. Kutner M, Greenberg E, Yin J, Paulsen C, White S: The health literacy of America’s adults: Results from the 2003 national assessment of adult literacy. US Department of Education. Washington, DC 2006. 24. Tokuda Y, N D, Butler JP, Paasche-Orlow MK: Health literacy and physical and psychological wellbeing in Japanese adults. Patient Education and Counseling 2009, 75(3):411-417. 25. Gazmararian JA, Baker DW, Williams MV, Parker RM, Scott TL, Green DC, Fehrenbach SN, Ren J, Koplan JP: Health literacy among Medicare enrollees in a managed care organization. Journal of the American Medical Association 1999, 281(6):545-551. 26. Jovic-Veanes A, Bejgovic-Mikanovic V, Marinkovic J: Functional health literacy among primary health-care patients: data from the Belgrade pilot study. Journal of Public Health 2009, 31:490-495. 27. Nielsen-Bohlman L, Panzer AM, Kindig DA: Health Literacy: A prescription to end confusion Washington, D.C.: Institute of Medicine of The National Academies 2004. 28. Weiss BD: Health literacy: an important issue for communicating health information to patients. Zhonghua Yi Xue Za Zhi (Taipei) 2001, 64(11):603-608.