Easton et al. BMC Public Health 2010, 10:459 http://www.biomedcentral.com/1471-2458/10/459 Although both used the REALM, in the US study, parti- cipants fell into a broad range of health literacy levels and those scoring below 9th grade were compared with those at 9th grade or above [29]. The UK study con- verted the scores to UK reading ages; all participants had a reading age of 12 and above and comparisons were made between those with a reading age of 12-14 and 15+ [22]. This may explain some of the variance in the evidence; however, the studies also differed in the age by which first sexual intercourse was reported and the time period over which previous sexual partners were reported. Sexual health behaviours may also have been subject to different cultural influences in the two study settings. Multivariate analysis was not carried out in the UK study but the authors of the US study consid- ered years of education, knowing someone with cervical cancer and having previous colposcopy as potential con- founding factors. Multivariate analysis from two further US studies found no association between health literacy and health risk behaviour. In a study of 600 pregnant women, no correlation was found between reading level and smok- ing prevalence [30]. In this group, race was significantly associated with smoking practice, African American women being significantly less likely to smoke and being significantly more likely to have lower health literacy. In a study of 423 female prison inmates, many of whom had dropped out of school, HIV risk behaviour was associated with educational attainment but not with health literacy [31]. One of the studies [31] compared 3 and the other [30], 4 health literacy levels across the REALM score. In a further US study, lower health promoting beha- viour in those with low literacy did not reach statistical significance. A cross-sectional study of 61 new mothers found that those with lower health literacy were less likely to initiate and sustain breastfeeding for the first two months of their infant’s life. Breast feeding for at least two months was associated, but not significantly, with higher (12th grade+) health literacy [32]. This study had an insufficient number of participants and only two literacy categories, 7th-8th grade and 12th grade+ and this may have contributed to the lack of statistical significance. This small group of 5 studies did not produce convin- cing evidence of a clear association between functional or health literacy and preventive health or health risk behaviours. Relationship between functional or health literacy and access to and use of health services One small qualitative study of 8 adults who participated in a community college literacy program and had been hospitalised met our inclusion criteria [33]. We assessed Page 5 of 10 this study to establish what issues were identified in relation to the research questions and to ascertain whether any of these had been investigated in the quan- titative studies. Participants had experienced impaired decision-making and given uninformed consent to inter- ventions [33]. They reported having been unsure of what was expected of them as patients because they had been unable to read instructions, for example, on menus and notices [33]. They experienced fear; worry; power- lessness; stigma; vulnerability; diminished self-efficacy in accessing health services, and they balanced the risks of exposure of their literacy difficulties (stigma, decreased self-esteem) with the risks of non-disclosure (lack of knowledge gathering). Some, however, felt that the hos- pital was a special place where vulnerability could be shared and staff would keep information confidential. The frequency and distribution of these issues were not explored in the quantitative studies. A further 6 quantitative studies focused on access to and use of health services. Two studies found no evi- dence [21,25] and one found some evidence [26] of associations between health literacy and uptake of ser- vices. One study found an association between low health literacy and poorer access to treatment [27] in some cases. Evidence of association between health lit- eracy and relationships with healthcare staff was mixed and unclear [34,35]. A study of 543 parents found, as a secondary outcome measure, no correlation between total REALM score and accessing of preventive services for their children [25]. This could also have been considered as health promoting behaviour. A study of 202 African American women’s use of prenatal care found no difference between high and low health literacy groups in the pro- portions of women beginning prenatal care. This study was underpowered, however, and had sought to exclude women who had no prenatal care notes [21]. Evidence from three studies suggested that low health literacy - as measured by the TOFHLA - may be asso- ciated with less appropriate use of health services or access to optimum treatment. A cross-sectional study of 1892 people attending an emergency walk-in depart- ment found that those with inadequate health literacy were more likely to have been hospitalised in the pre- vious year than those with adequate health literacy [26] although their more frequent use of health services in general was non-significant after adjustment [26]. A study of 339 people with HIV-AIDS found those with lower health literacy were less likely to have been pre- scribed antiretroviral medication [27]. A further study reported an association between health literacy and rela- tionships with healthcare staff, which may have implica- tions for ensuring access to optimum treatment. Among 294 people living with HIV/AIDS, those with lower