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Abstract: TH-PO980

Health Literacy and Inequity in Access to Transplantation: Results from the ATTOM Study

Session Information

Category: Transplantation

  • 1702 Transplantation: Clinical and Translational


  • Taylor, Dominic, University of Southampton, Southampton, United Kingdom

Group or Team Name

  • On behalf of ATTOM investigators

Access to kidney transplantation is reduced among people with low socioeconomic status, a component of which is low educational level. Transplant preparation requires patients to understand complex concepts, demanding adequate health literacy (HL). In the Access to Transplant and Transplant Outcome Measures (ATTOM) study, low HL was associated with low educational level and was more common in incident dialysis patients compared to wait-listed or transplanted patients. We hypothesised that HL mediates the association between low educational level and reduced access to transplantation.


ATTOM recruited UK incident dialysis patients, 2011-13. Data collected included the exposure (no educational qualifications vs any), outcomes (time to transplant wait listing/time to live donor transplant censored at 2 years), the mediator (HL, defined by 'Single Item Literacy Screener' on a five-point scale, 5 indicating lowest HL), and covariates (age, ethnicity, comorbidity by Charlson index).
Structural Equation Modelling was used to calculate effect sizes for the exposure on the mediator, the mediator on the outcome and the exposure on the outcome, adjusted for the covariates. From these, the total effect of education on access to transplant and the indirect effect mediated by HL were calculated.
Weibull AFT models were used and effect size expressed as time-to-event ratio (TR). p<0.05 was deemed significant.


2463 of 2621 recruited patients responded to the SILS, and were included.
A 1-point increase in HL score was independently associated with 15% increased time to wait listing (TR 1.15;95% CI 1.07-1.25) and 25% increased time to live donor transplant (TR 1.25;95% CI 1.06-1.47).
In the mediation model, the total effect of low educational level was to increase time to wait listing by 22% (TR 1.22;95% CI 1.02-1.48) and time to live donor transplant by 47% (TR 1.47;95% CI 1.04-2.08). The indirect effect mediated by HL accounted for 35% of the increase in time to wait listing and 30% of the increase in time to live donor transplant.


In this large UK cohort study, HL mediated a substantial proportion of the effect of low educational level on reduced access to deceased-donor transplant wait listing and live donor transplantation. Interventions to improve patients’ understanding of the transplantation process have potential to reduce socioeconomic inequity in access to transplantation.


  • Other NIH Support