Health literacy interventions for reducing the use of primary and emergency services for minor health problems: a systematic review
Authors: O’Cathain Alicia , Foster Alexis , Carroll Christopher , Preston Louise , Ogden Margaret , Clowes Mark , Protheroe Joanne 
Published: December 2022

Background
Health literacy is the ability to find information, understand information, know how to act on information and know which services to use. Having higher levels of health literacy may help patients to look after minor problems themselves (self-care). It may also help to reduce patients’ perceived need for contacting health services for minor health problems, to reduce the perceived urgency of problems or to improve patients’ ability to identify and choose from the range of available services. Interventions to improve health literacy for minor health problems have been evaluated, but their effectiveness at reducing use of primary care and emergency services has not been synthesised.

Objectives
The key objectives were as follows: (1) to construct a typology of interventions that aim to reduce primary or emergency care use, (2) to synthesise evidence of the effectiveness of different types of health literacy interventions and (3) to consider how stakeholders in the UK could operationalise the evidence.

Interventions
The interventions being reviewed were initiatives that help members of the population to self-care or make decisions about whether or not and where to seek health care for minor health problems.

Design
This study was a systematic review with stakeholder involvement.

Data sources and review methods
A meeting was held with 14 stakeholders (including patients, carers and the public) to guide the systematic review. This was followed by a multicomponent review of quantitative and qualitative research. Database literature searches were undertaken in Ovid MEDLINE, The Cochrane Library (via Wiley Interscience), EMBASE (via OVID), the Cumulative Index to Nursing and Allied Health Literature (via EBSCO), PsycINFO (via OVID), Web of Science and Sociological Abstracts. The search was limited to English-language publications from 1990–2020. To assess study quality, the Cochrane Risk of Bias tool was used for randomised controlled trials and the Newcastle–Ottawa Scale was used for non-randomised studies. A narrative synthesis was undertaken. The review was followed by a meeting with 16 stakeholders to interpret the results.

Results
A total of 67 articles (64 studies) were included: 37 from the USA, 16 from the UK, 12 from the rest of Europe and two from the rest of the world. There were seven intervention types: navigation tools directing people to the range of services available (n = 7); written education about managing minor health problems in booklet or website format (n = 17); person-delivered education (n = 5); written education with person-delivered education (n = 17); multicomponent of written education, person-delivered education and mass media campaign (n = 5); self-triage (n = 9); and other (n = 7). Our team assessed the readability and user-friendliness of interventions, and found that these varied widely. When assessed, most studies measuring satisfaction with the intervention, enablement and perceived changes to behaviour showed positive results. Of 30 articles reporting impact on emergency department attendances, 19 (63%) showed a reduction, and 16/27 (59%) articles measuring impact on general practice consultations showed a reduction. Variation in the evidence base was not explained by any research, context or intervention characteristics. Only eight articles measured safety: these identified no problems.

Limitations
There was inconsistency in how the outcomes were measured, so a meta-analysis was not possible.

Conclusions
Health literacy interventions have potential to affect emergency and primary care use, but the evidence base is inconsistent.

Future research
It is important to continue to evaluate these types of initiatives.

Study registration
This study is registered as PROSPERO CRD42020214206.

Funding
This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 38. See the NIHR Journals Library website for further project information.