A rapid evidence review of interventions for improving health literacy : insights into health communication..
Date: 2012-07-18
Institutions: European Centre for Disease Prevention and Control
Subjects: disease prevention, dissemination of information, public health, scientific press, sexually transmitted disease

ECDC TECHNICAL REPORT 
A rapid evidence review of interventions 
for improving health literacy  

Insights into health communication 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
This rapid evidence review was commissioned by the European Centre for Disease Prevention and Control (ECDC) 
as one of the outputs of the Framework Partnership Agreement Grant /2009/007 ‘Establishing a programme for 
dissemination of evidence-based health communication activities and innovations on communicable diseases for 
country support in the EU and EEA/EFTA, 2009–12’, with a consortium of universities comprised of the Health 
Promotion Research Centre at the National University of Ireland Galway, as the lead coordinating centre, and the 
Institute for Social Marketing, University of Stirling, Scotland, and the University of Navarra Clinic, Pamplona, 
Spain. 

This review was produced by Maureen D’Eath, Margaret M. Barry, Jane Sixsmith, Health Promotion Research 
Centre, National University of Ireland Galway. 

The project was overseen by Ülla-Karin Nurm, Piotr Wysocki, Andrea Würz and Susana Barragan, Public Health 
Capacity and Communication Unit, ECDC. 

Suggested citation: D’Eath M, Barry MM, Sixsmith J. Rapid Evidence Review of Interventions for Improving Health 
Literacy. Stockholm: ECDC; 2012. 

Stockholm, May 2012 

ISBN 978-92-9193-332-7 

doi 10.2900/20189 

© Copyright is held jointly by the members of the Translating Health Communications Project Consortium, 2012 

Reproduction is authorised, provided the source is acknowledged.

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TECHNICAL REPORT 

Rapid evidence review of interventions for improving health literacy 

Contents  

Summary ..................................................................................................................................................... 1 
Background ............................................................................................................................................. 1 
Aims ....................................................................................................................................................... 1 
Findings .................................................................................................................................................. 1 
Conclusions ............................................................................................................................................. 1 

Introduction ................................................................................................................................................. 2 
Typology of interventions ......................................................................................................................... 3 
Measurement .......................................................................................................................................... 3 

Methodology ................................................................................................................................................ 5 
Aims of the review ................................................................................................................................... 5 
Scope of the review ................................................................................................................................. 5 
Databases .......................................................................................................................................... 5 
Search strategy .................................................................................................................................. 5 

Findings ....................................................................................................................................................... 6 
Contexts ................................................................................................................................................ 10 
The studies ....................................................................................................................................... 10 
Quality assessment ............................................................................................................................ 11 
Study design ..................................................................................................................................... 11 
Country ............................................................................................................................................ 12 
Study participants .............................................................................................................................. 12 
Measures of literacy levels .................................................................................................................. 12 
Provider-focussed interventions .......................................................................................................... 13 
Disadvantaged/minority groups .......................................................................................................... 13 
Interventions .......................................................................................................................................... 13 
Health concerns ................................................................................................................................ 14 
Outcomes .............................................................................................................................................. 14 
Reviewers’ conclusion on studies......................................................................................................... 16 
Cochrane review 2011 ....................................................................................................................... 16 

Conclusions ................................................................................................................................................. 18 
Identification of gaps in the evidence and recommendations for further research ......................................... 18 

References .................................................................................................................................................. 19 

Appendix .................................................................................................................................................... 22 
Three studies focussing on a communicable disease .................................................................................. 22 

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TECHNICAL REPORT 

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TECHNICAL REPORT 

Rapid evidence review of interventions for improving health literacy 

Summary 

Background 

The promotion of health literacy is critical to active and informed participation in health and healthcare [1] and is 
identified as a key action to reduce health inequalities within the European Union [2]. Health literacy may be 
defined as a multi-level concept encompassing basic/functional literacy, communication/iterative literacy and 
critical literacy [3]. This paper reports on a rapid review of the evidence on the effectiveness of interventions to 
improve health literacy with a specific focus on communicable diseases and interventions for disadvantaged 
populations within the European region.  

Aims 

This review of reviews seeks to: identify and synthesise review-level evidence on effective strategies for improving 
health literacy, highlight gaps in the evidence and provide recommendations. 

Findings 

Five evidence reviews, published between the years 2000 and 2010, were identified. The vast majority of the 
intervention studies concerned written health information and/or use of other formats such as audiovisual material. 
The studies reviewed were predominantly located in North America and encompassed a very broad range of health 
concerns. No studies fell within the categories of low-literacy initiatives or targeted mass media campaigns. The 
only studies included in the reviews that referred to communicable diseases concerned HIV, and all three of these 
had medication adherence as an outcome of the intervention. The review exposed a paucity of research 
concerning disadvantaged or hard-to-reach groups.  

Most interventions identified in the reviews focus on the functional level of health literacy and work at the 
traditional health education level. There is little evidence of interventions targeted at the interactive or critical 
levels of health literacy. Not all reviews identified whether the study results were stratified across literacy levels, 
but from those that did, it is clear that few of the studies provided this analysis. Without such information it is 
impossible to measure impacts on people with varying levels of health literacy and to effectively target 
interventions to reduce disparities and inequalities. Two of the five reviews reported on the quality assessment of 
the included studies. In one, only half the studies achieved the ‘good’ benchmark, while four of five did so in the 
other review. The lack of information from the other reviews leaves the issue of quality of evidence subject to 
uncertainty. 

Conclusions  

There are considerable gaps in the evidence reviewed concerning which interventions are most effective in 
improving health literacy, particularly with regard to communicable diseases and studies conducted in Europe. 
Further research is needed on the impact of health literacy interventions in the public health field, paying particular 
attention to evaluating communication about communicable diseases, and determining the most effective 
strategies for meeting the needs of population groups with low literacy levels, and those who are vulnerable, 
disadvantaged and hard to reach. 

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Introduction 

Health literacy has been defined as the degree to which individuals have the capacity to obtain, process and 
understand the basic health information and services needed to make appropriate health decisions [4]. Health 
literacy is clearly linked to general literacy skills [5] but general literacy skills do not necessarily equip an individual 
for the complexity of literacy demands in the context of healthcare [6]. Health literacy also incorporates health 
numeracy which impacts a wide range of competencies from counting pills and counting calories to decision 
making with regard to risk and benefit [7]. The earliest definitions of health literacy focussed on the ability to read 
and understand information and instructions given in a medical context – a functional, clinical definition. However, 
definitions have evolved to reflect a broader and more empowering conceptualisation of health literacy. Nutbeam 
outlines a three-level definition expressing health literacy as not simply a measure of reading and writing skills but 
also as a strategy for empowerment [3]. Thus, Nutbeam proposes that health literacy comprises: 

• 

• 

• 

Basic/functional literacy — sufficient basic skills in reading and writing to be able to function effectively 
in everyday situations;  
Communicative/interactive literacy — more advanced cognitive and literacy skills which, together with 
social skills, can be used to actively participate in everyday activities, to extract information and derive 
meaning from different forms of communication, and to apply new information to changing circumstances; 
Critical literacy — more advanced cognitive skills which, together with social skills, can be applied to critically 
analyse information and use this information to exert greater control over life events and situations [3]. 

Health literacy, therefore, can impact on disadvantage and health inequalities by empowering active and informed 
participation in healthcare [1]. 

Health literacy is dynamic, requiring an individual to discard outdated information and learn new information on an 
ongoing basis, and demands continuous involvement between the individual, healthcare providers and other 
community resources [5, 8]. An individual’s health literacy may also change over their life course as their skills set 
becomes subject to different information processing demands. To reflect this, a recent Canadian Expert Panel 
adopted the following definition of health literacy:  

The ability to access, understand, evaluate and communicate information as a way to promote, maintain and improve 
health in a variety of settings across the life-course [9]. 

Thus, health literacy demands not just the ability to read but the skills of listening, analysing and decision making 
and the ability to apply these skills in the health context [10]. The broader, more evolved definition of health 
literacy also locates the issue of health literacy not just with an individual but also with healthcare professionals, 
politicians and other policy makers, and with society. The US Department of Health and Human Services label the 
ability of healthcare professionals and organisations to enhance positive health outcomes by recognising ‘the 
cultural beliefs, values, attitudes, traditions, language preferences, and health practices of diverse populations’ as 
cultural competence [11]. Such cultural competence includes communication which is linguistically and culturally 
appropriate.  

Rudd illustrates the limitations of enhancing an individual’s functional health literacy without addressing the 
broader public health issues with regard to asthma prevention and management [12]. A functional approach to low 
health literacy may help an individual to manage their medication regime optimally, yet it leaves unaddressed the 
wider social and environmental triggers of the asthma. Thus, she argues: 

Becoming aware of new findings, gathering information, participating in tenants’ associations and involvement in 
community action groups require skills related to research, discussion, analysis, decision-making and action. Thus, as 
we explore this area and define needed skills, we must be sure to move beyond the realm of medical care and include 
action taken at home, at work, in the community and in the policy arena [12]. 

Inadequate health literacy limits the ability to access and use health information and act on public health alerts, 
and is associated with worse health outcomes [13]. Bankson argues that ‘the inability to read and process health 
information is a matter of grave importance, not only to the patient, but to the state of public health’ [14]. The 
importance of health literacy for health outcomes was equally emphasised by the European Commission in 2007 
when it identified the promotion of health literacy as a key action to reduce health inequalities within the EU [15]. 
In response to the importance of health literacy, a number of countries have incorporated health literacy objectives 
into strategic national policies [16]. Expert respondents within a Scottish scoping study recommended that the 
concepts which underpin health literacy should be built into existing health improvement initiatives and 
programmes, because to pursue a separate policy would be counterproductive due to the complexity and 
diffuseness of the issues underpinning health literacy [16].  

Much of the research on health literacy to date, has sought to measure levels of health literacy and, to a lesser 
extent, correlate levels of health literacy with health status. Identified consequences of low health literacy are 
manifold and include: lower health status; more frequent hospital visits and longer hospital stays; greater 
utilisation of emergency departments; poorer medication adherence and more frequent medication errors; less use 

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of preventative service and engagement in health-promoting behaviours; and a decreased ability to make 
appropriate health decisions, to communicate with health professionals and to share decision making [1; 5]. 
Although low health literacy impacts across the age, education and socioeconomic spectrums, minority and 
disadvantaged groups are particularly vulnerable. Low health literacy also extorts a high economic cost from 
individuals, healthcare systems and society as a whole.   

Typology of interventions 

The US Institute of Medicine identified three broad factors that contribute to health literacy and suggested that 
each of these factors could be utilised as potential settings for health literacy [4]. The factors were: health 
systems, culture and society, and the education system. Coulter & Ellins [1] used the ‘health system’ and ‘culture 
and society’ categories to classify health literacy interventions into four types, and give examples in each category: 

• 

• 

• 

• 

Written health information interventions include those designed to make written information more 
accessible to consumers by the use of plain language, targeted information, increased accessibility and 
increased readability. Coulter & Ellins give the example of a toolkit for producing patient information 
designed to offer practical advice, checklists and templates for providing written information for patients. 
This collaboration between the UK Department of Health, the Patient Information Forum, the Royal National 
Institute for the Blind and the Plain English Campaign is available from: 
www.nhsidentity.nhs.uk/patientinformationtoolkit.  
Alternative format interventions include those which use technologies such as computers, videos 
and/or audio tapes to support and enhance consumers’ knowledge, as well as decision-making and 
problem-solving skills. Coulter & Ellins give the example of the Comprehensive Health Enhancement 
Support System (CHESS) a computer-based system developed in the University of Wisconsin-Madison’s 
Center for Health Enhancement Systems Studies. It provides reliable, tailored, personalised health 
information and social support, as well as decision-making and problem-solving tools, in language that can 
be understood by most people. CHESS has been installed in community centres, health centres, workplaces 
and college dormitories, and individuals who are taking part in the project and who do not have a computer 
are lent one for a period of up to one year (http://chess.wisc.edu/chess/projects/about_chess.aspx).  
Low-literacy initiatives which may target specific populations or which may cover geographical areas. 
Coulter & Ellins give the example of the California Health Literacy Initiative, which describes itself as a 
‘groundbreaking, national model for health literacy’ and the most complex state-wide health literacy 
initiative ever undertaken. It provides web-based health literacy resources to anyone wanting a clear 
understanding of health information (http://literacyworks.org). 
Targeted mass media campaigns are often designed around specific health behaviours such as sexual 
health promotion, alcohol intake or utilisation of health screening. In the UK, Developing Patient 
Partnerships was a collaboration between the Department of Health and the British Medical Association to 
design and conduct health education campaigns. Unfortunately it was forced to close down in 2008 when 
the Department of Health withdrew funding.  

Health literacy can be framed in terms of the discipline from which it emerges and is often framed in a health-
focussed approach such as the above. However, health literacy can also be approached from other perspectives, 
such as that of adult education or business. In 2006, the Canadian Public Health Association (CPHA) recognised 
that health literacy had become a component of the adult education curriculum in some US states and beyond, and 
noted the trend away from direct health content and towards the development of literacy skills required for health-
related action [17]. Health literacy is also the focus of some corporate initiatives. The Centre for Corporate 
Responsibility (CSR), a European business network of more than 70 multinational corporations and 27 national 
partner organisations, established an initiative in October 2010 which embarked on a collaboration to explore ways 
of actively contributing to improving health literacy in Europe. Improved health literacy, CSR states, will help the 
private sector develop various programmes in this field in order to empower not ‘only their employees, but society 
as a whole’ [18]. 

Measurement 

A number of countries – including Canada, the United States of America, the United Kingdom and Ireland – have 
conducted population-level surveys of health literacy. The first international survey has recently taken place in 
eight European countries as part of the European Health Literacy Survey (HLS-EU) (2010). The HLS-EU project 
includes in its objectives the development of a conceptual-based measurement instrument for health literacy and 
the development of national and regional structures that would translate the survey findings into political action 
(www.health-literacy.eu). However, most of the existing research in health literacy has taken place in clinical 
settings in North America, and at this level the most frequently used health literacy measurement tools are the 
Rapid Assessment of Literacy in Medicine (REALM) [19] and the Test of Functional Health Literacy in Adults 
(TOFHLA) [20]. Such measures are subject to criticism, including that they do not actually measure health literacy, 
only give an approximation of reading skills [9] and that they are incapable of assessing other important aspects of 

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TECHNICAL REPORT 

health literacy, such as understanding, motivation and the ability of individuals to access or use information 
concerning health and healthcare [21]. The CPHA argues that reviews of interventions that focus on trials using a 
literacy measure eliminate from consideration the large body of work carried out with respect to chronic disease 
prevention and management. Waterton describes the work on measuring wider aspects of health literacy as being 
in its infancy [16]. 

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Rapid evidence review of interventions for improving health literacy 

Methodology 

Aims of the review 

This report comprises a review of reviews which aims to: 

• 
• 

identify and synthesise review-level evidence on strategies for improving health literacy; and  
highlight gaps in the evidence, and provide recommendations for research. 

Scope of the review  

This review initially sought to identify evidence reviews on health literacy interventions in Europe focusing on 
communicable diseases, including assessments and evaluations of programmes and interventions. A database 
search identified the absence of relevant literature, necessitating a widening of the search to reviews of health 
literacy interventions and activities internationally. 

Databases 

• 

• 

• 

• 
• 

• 

SCOPUS – the world’s largest abstract and citation database of peer-reviewed literature and quality web 
sources 
Web of Knowledge – a citation indexing and search service covering the sciences, social sciences, arts 
and humanities 
EBSCO – the following databases, selected from the EBSCO database: Academic Search Complete, 
CINAHL, Health Source, Medline, Psychology and Behavioural Sciences Collection, SocIndex and ERIC  
DARE – the Database of Abstracts of Reviews of Effects 
HealthComm Key – a database containing comprehensive summaries from published peer-reviewed 
studies related to health communication 
The Cochrane Library. 

Search strategy  

• 

• 
• 
• 
• 

• 

Search terms included: (‘health literacy’ OR ‘health literacy activities’ OR ‘health communication’) AND 
(‘communicable disease’ OR ‘public health’ OR ‘health communication’ OR influenza OR ‘sexually transmitted 
diseases’ OR HIV OR evidence OR campaign OR initiative OR pandemic OR infectious OR intervention) 
Languages consulted: English 
Geographical spread: initially Europe, latterly worldwide 
Time frame: 2000 –2011 
Types of literature: peer-reviewed literature from the databases above; the archives of the Journal of 
Health Communication were searched, as were the websites of ECDC and WHO. In addition, the reference 
lists and the citations of the retrieved documents were searched. The Agency for Healthcare Research and 
Quality (AHRQ) has commissioned an update of their 2004 systematic review of the impact of health 
literacy on health outcomes and of interventions implemented to improve health outcomes, to be published 
in 2011. A search was carried out of their preliminary list of citations for the review.  
Relevance: following the second, refined search, the relevance criteria was that it reviewed health literacy 
activities or interventions. 

In response to the absence of literature pertaining to health literacy and communicable diseases, an additional 
search was undertaken using search terms specific to a particular infectious disease to test whether this strategy 
would identify literature which had not been identified in the earlier searches. Pubmed and Psyclit were searched 
using the terms ‘health literacy’ and ‘immunisation/immunization’, and ‘health literacy and ‘vaccination’. Six results 
were saved for review; none was relevant to this review.  

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Findings 

Five relevant reviews, the summary details of which may be found in Table 1, were identified by the search: 

• 
• 
• 
• 
• 

Clement S, Ibrahim S, Crichton N, Wolf M, Rowlands G (2009) [22]. 
DeWalt DA, Hink A (2009) [23]. 
Pignone M, DeWalt DA, Sheridan S, Berkman N, Lohr KN (2005) [24]. 
Santo A, Laizner AM, Shohet L (2005) [25]. 
Schaefer CT (2008) [26]. 

Table 1: Summary of reviews identified 

Authors 

Santo A, Laizner AM, 
Shohet L (2005). [25] 

Clement S, Ibrahim S, 
Crichton N, Wolf M, 
Rowlands G (2009). 
[22] 

Study aims 

‘Evaluate the efficacy of 
audiotapes as a health 
information exchange 
intervention, specifically 
looking for use with the 
‘hard-to-reach’ 
population’. 

‘To evaluate the published 
literature of the effects of 
complex interventions 
intended to improve the 
health-related outcomes of 
individuals with limited 
literacy or numeracy’. 

Pignone M, 
DeWalt DA, 
Sheridan S, 
Berkman N, 
Lohr KN 
(2005). [24] 
Systematic 
review of 
interventions 
designed to 
improve health 
outcomes for 
persons with low 
literacy. 

Studies included 

28 (only 24 listed in 
review without 
explanation, all 28 
referred to in the 
discussion) 

15 

20 

16 (but 17 listed 
in review) 

Study design 

Randomised control trial 
(RCT) on efficacy of 
audiotapes (n=17). 
Non-randomised trial 
(n=1). 
Tandem assignment 
(n=1). 
Surveys (n=9). 

Complex interventions: 
randomised and quasi-
randomised. 
Randomised control trials 
(n=11). 
Quasi randomised control 
trials (n=4). 

Randomised 
controlled trials 
(n=9). 
Non-randomised 
control trials 
(n=8). 
Uncontrolled 
single-group 
trials (n=3) 

Randomised 
control trials 
(n=11). 
Non-randomised 
trial (n=1). 
Exploratory pilot 
intervention 
(n=1). 
Quasi 
experimental 
(n=1). 
Prospective 
observational 
(n=1). 
Quasi-
experimental 
(n=1). 
Correlational 
descriptive (n=1). 

Dates of included 
studies 
Number 
participants in 
study 

1976–2003 

1997–2006 

1992–2002 

19972006 

1996–2008 

34–632; 
Plus CAN_DIAL with 
68 700 calls 

40–2046 

28–1 744 

26–445 

Not specified 

6 

Schaefer CT 
(2008). [26] 

DeWalt DA, 
Hink A (2009). 
[23] 

To examine the 
effectiveness of 
experimental 
design 
intervention 
strategies related 
to health literacy. 

‘To review the 
relationship 
between parent 
and child literacy 
and child health 
outcomes and 
interventions 
designed to 
improve child 
health outcomes 
for children or 
parents with low 
literacy skills’. 

Five reviews of 
interventions in 
a review that 
sourced 24 
studies of 
related question 

Randomised 
control trial 
(n=2). 
Non-randomised 
control trial 
(n=2). 
Uncontrolled trial 
(n=1). 

 
 
 
 
 
 
 
 
 
 
 
TECHNICAL REPORT 

Rapid evidence review of interventions for improving health literacy 

Authors 

Santo A, Laizner AM, 
Shohet L (2005). [25] 

Age of 
participants 

Age not part of the 
criteria. 

Clement S, Ibrahim S, 
Crichton N, Wolf M, 
Rowlands G (2009). 
[22] 

Included reviews whose 
participants were adults or 
adults consulting on behalf 
of dependents. 

Pignone M, 
DeWalt DA, 
Sheridan S, 
Berkman N, 
Lohr KN 
(2005). [24] 
Not part of 
criteria. 

Schaefer CT 
(2008). [26] 

DeWalt DA, 
Hink A (2009). 
[23] 

Included reviews 
whose subjects 
were ’12 years 
and older’. 

Included 
interventions 
that focussed on 
paediatric health 
outcomes. Four 
of five included 
studies were 
with parents, 
one was with 
children. 

Language 
exclusion criteria 

Does not specify 

Geography as 
review criteria 

Not specified. 

No language restriction 
(one study Nepal but 
seems to be in English) 
Did not exclude developing 
countries. 

English only 

English only 

English 

Excluded 
developing world 
countries. 

Not specified. 

Studies had to 
be conducted in 
a developed 
country defined 
as the US, 
Canada, Western 
Europe, Japan, 
Australia or New 
Zealand. 

All five from 
North America 

Not specified 

13/15 from North America  18 from USA, one 

No 

Not specified 

from UK, one 
from Nepal 
Yes 

Not specified 

Yes 

Yes 

Geographic 
spread of studies 
in review 
Required a 
literacy measure 
to have been used 
Type of study 
required for 
review 

Specified 
outcomes of 
interest for 
inclusion in 
review 
Duration of 
interventions and 
follow-up 

RCTs ‘given priority’ also 
included descriptive 
articles and articles with 
a quasi-experimental 
design. 

Not specified 

Not specified (in some 
studies, patients took 
recording home with 
them therefore it would 
appear that the 
intervention was as long 
as they made it). 

Not specified 

Not specified 

Studies which 
included 
numeracy 
Review 
assessment of 
quality of studies 
included 

Review confined to 
complex interventions. 

Used a controlled 
or uncontrolled 
experimental 
design. 

Used a control 
and experimental 
group. 

Yes, specified seven 
(including self-efficacy) 

Yes, eight 
identified health 
outcomes 

Did not specify 

Used a 
controlled or 
uncontrolled 
experimental 
design. 

Yes, seven 
identified 

In most studies (9/15) 
outcomes were measured 
in the intervention session 
or immediately afterwards. 
One study did not specify 
its follow-up period. The 
other five studies reported 
follow-up periods ranging 
from one week to 10.5 
months with a median 5.5 
months. 
Three 

In most studies, 
interventions and 
outcome 
measurement 
took place in a 
single session.  

Educational 
sessions which 
range from a 
single session to 
enhance self-care 
to a year-long, 
intensive program 
with one-to-one 
session.  

One study 
required children 
to attend a two-
hour class 
weekly for six 
months and a 
five-day camp. 

Not specified 

Not specified 

Not specified 

Nine quality criteria set:  
five studies (of 15) met six 
or more  
five studies met three or 
fewer 

Good: n=10 
Fair: n=9 
Poor: n=1 

Not specified 

Good: n=4 
Fair: n=1 

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Pignone M, 
DeWalt DA, 
Sheridan S, 
Berkman N, 
Lohr KN 
(2005). [24] 
Easy-to-read 
printed materials 
(n=4) 
Video/ 
audiotapes (n=4) 
Computer-based 
programmes 
(n=3) 
Individual or 
group 
instructions 
(n=9) 

Polio vaccine; 
cancer trial 
consent form; 
prostate cancer; 
colorectal cancer; 
cervical cancer 
screening; sleep 
apnea; labelling- 
emergency 
contraception; 
self-care cancer; 
breast self-exam; 
nutrition; 
medication 
adherence; 
mammography 
uptake; Head 
Start programme 

Knowledge and 
comprehension 
(n=8); health 
behaviours 
(n=4); 
biochemical or 
biometric 
markers (n=2); 
preventative care 
(n=1); measures 
of disease 
incidence, 
prevalence or 
severity (n=2); 
health outcome 
(n=1) 

Schaefer CT 
(2008). [26] 

DeWalt DA, 
Hink A (2009). 
[23] 

Directed at 
parents (n=4) 
Directed at 
children (n=1) 

Polio 
vaccination; 
asthma; 
medication 
adherence 

Personal contact 
intervention 
(n=7)  
Multi-prong 
approach (n=2)  
Written material 
intervention 
(n=4) 
Computer 
intervention 
(n=3) 

Diabetes (n=3); 
HIV (n=3); 
breast cancer 
(n=1);  
congestive heart 
failure (n=1); 
prostate cancer 
(n=1); 
orthopaedic 
surgery (n=1); 
cancer screening 
(n=2); 
elderly (n=2); 
low income (n=2) 

Self-care (n=2); 
medication 
adherence and 
self-confidence re 
same; providers 
use of literacy 
strategies and 
perceptions of 
their effectiveness 
and impact on 
biomedical marker 
and screening; 
health 
knowledge; 
comprehension; 
behaviour 
change; 
discussion re 
vaccine; 
screening uptake 

Recall of consent 
information; 
comprehension 
of vaccine 
information 
(n=2); 
caregivers 
medication 
errors, 
preparation and 
instrument use; 
asthma-related 
health service 
utilisation and 
improved self-
efficacy re 
emergency 
department visits 

Qualitative 
synthesis 

Qualitative 
synthesis 

Qualitative 
synthesis 

Authors 

Santo A, Laizner AM, 
Shohet L (2005). [25] 

Clement S, Ibrahim S, 
Crichton N, Wolf M, 
Rowlands G (2009). 
[22] 

Focus of included 
studies 

Audiotapes to record 
consultations and 
health-related 
information in specific 
health situations. 

Those directed at health 
professionals (n=2) 
Literacy education (n=1) 
Health 
education/management 
interventions (n=12) 

Health issues 

Outcomes 
measured 

Chemotherapy; cancer 
consultation recall; 
anxiety before 
sigmoidoscopy; 
anxiety – COPD; asthma 
self care; breast care 
exam; lower extremity 
reconstruction; stroke 
prevention; cardiac 
discharge information; 
cancer education; ocular 
malignancy; 
consultations advanced 
cancer; empowerment – 
prostate cancer; breast 
cancer; ‘bad news’ 
consultations; various 
cancer information/ 
communication/recall; 
outpatients 
consultations 
Knowledge/recall 
(n=12); behavioural 
change (1); 
anxiety (n=7); self-care 
(n=3);satisfaction 
(n=17) 

Hypertension; heart 
failure; colorectal cancer 
screening; nutrition 
education for cancer; 
cardiovascular disease 
prevention; medication 
adherence (chronic 
condition); understanding 
of medication; diabetes 
disease management; HIV 
medication adherence and 
knowledge; depression; 
hearing screening in 
newborns 

Clinical outcomes (n=8); 
health knowledge (n=9); 
health behaviours (n=9); 
self-reported health 
status/QoL (n=2); health-
related self-
efficacy/confidence (n=7); 
utilisation of health care 
(n=4); health provider 
behaviour/skills (n=2) 

Synthesised 
results of studies 

Qualitative synthesis 

Reviewers concluded that 
the diversity of measures 
and the range of time 
periods to follow-up 
rendered statistical 
aggregation of the 
findings, inappropriate. 
Therefore, narrative 
analysis was applied. 

8 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Rapid evidence review of interventions for improving health literacy 

Authors 

Santo A, Laizner AM, 
Shohet L (2005). [25] 

Hard-to-reach/ 
disadvantaged 
groups included 

Initially review to focus 
on hard-to-reach groups 
but found no studies – 
studies systematically 
excluded hard to reach 
groups. 

Clement S, Ibrahim S, 
Crichton N, Wolf M, 
Rowlands G (2009). 
[22] 

Not specifically discussed. 
Four studies limited to 
those with low levels of 
literacy/numeracy.  
Latino Spanish-speaking 
adults with HIV (n= 1). 
Hispanic adults enrolled in 
English as a second 
language classes (n=1). 
African-American adults 
(n=1). 

Stratification 
across literacy 
levels 

Does not specify (only 
two of the studies 
included participants 
with ‘low literacy’). 

Four studies reported a 
sub-group analysis by 
literacy level. 

Settings 

Not specified 

Key findings 

Apart from enhanced 
patient satisfaction, the 
benefits of audio taped 
messages: ‘remain 
unclear’. 

Outpatients (n=5). 
Community (n=3). 
Telephone and/or mail 
intervention with 
recruitment on outpatients 
(n=3).  
Maternity unit (n=1). 
Hospital pharmacy (n=1). 
Recruited in outpatients 
for intervention in 
community (n=1). 
Recruited in community for 
intervention in out-patients 
(n=1). 
Primary outcomes: 
statistically significant in 
13/15 trials though 8 of 
these 13 had mixed results 
across primary outcomes. 
Two trials showed no 
significant positive finding 
in primary outcomes:  
One failed to show a 
significant improvement in 
health knowledge. 
One failed to show 
significant changes in 
cholesterol and blood 
pressure changes.  

Pignone M, 
DeWalt DA, 
Sheridan S, 
Berkman N, 
Lohr KN 
(2005). [24] 
One included 
study targeted 
older people and 
one targeted 
African 
Americans. 
However, 
reviewers 
commented that 
they found: ‘no 
studies 
examining 
whether 
interventions for 
patients 
with low literacy 
affected health 
disparities based 
on race, 
ethnicity, 
culture, or age’. 
Five of the 
controlled trials 
stratified.  

Schaefer CT 
(2008). [26] 

DeWalt DA, 
Hink A (2009). 
[23] 

Review 
specifically 
excluded studies 
that ‘included 
subjects with 
physical or mental 
impairments’. 

The review 
stated that many 
of the 24 studies 
reported 
attempting to 
adjust for age, 
socio-economic 
status, 
race/ethnicity; 
however no 
other reference 
was made. 

Not specified 

Only identifies 
that two of the 
five did. 
(Results 
demonstrate 
improvements 
across all levels 
of literacy but 
not a reduction 
in disparities). 

Not specified 

Not specified 

Not specified 

Diversity of range 
of outcomes 
limits conclusions 
about 
effectiveness 
though 
effectiveness 
‘appeared mixed’. 
Limitations in 
research quality 
also hamper the 
drawing of 
conclusions. The 
five articles which 
concerned the 
interaction 
between literacy 
level and the 
effect of the 
intervention 
reported mixed 
results. 

Improvements 
reported in 
health 
knowledge and 
health 
behaviours. No 
study reported a 
reduction ‘in the 
disparity 
between parents 
with low and 
higher literacy’ 
(p.272). 

9 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rapid evidence review of interventions for improving health literacy 

TECHNICAL REPORT 

Authors 

Santo A, Laizner AM, 
Shohet L (2005). [25] 

Review 
recommendations 

With respect to health 
literacy, a large 
percentage of the 
population may be 
disadvantaged and 
health care practices 
must be inclusive of 
them. However, 
particular attention must 
be paid to populations 
with communication 
barriers and focussed 
research should 
investigate the value of 
recording health 
information and medical 
consultations. 

Clement S, Ibrahim S, 
Crichton N, Wolf M, 
Rowlands G (2009). 
[22] 

Health related 
improvements were 
reported across all four 
intervention types, 
however, all interventions 
were complex 
interventions and it is not 
known which components 
of each initiative were 
effective. This, combined 
with the fact that some of 
the interventions were 
resource intensive, 
demands that future 
initiatives are carefully 
designed and based on 
sound theoretical and 
empirical underpinnings. 
The wider empowerment 
and community 
participation aspect of 
some of the interventions 
represent a welcome, 
broader approach to 
health literacy. 

Schaefer CT 
(2008). [26] 

DeWalt DA, 
Hink A (2009). 
[23] 

Too little is yet 
known to 
establish ‘best 
practice’ in health 
literacy strategies 
and further 
research is 
needed to 
determine the 
effectiveness of 
interventions and 
to maximise their 
impact. 

Too little is 
known about the 
relationship 
between health 
knowledge and 
behaviours to 
target 
interventions 
towards those 
most associated 
with positive 
health 
outcomes.  
Interventions 
should seek to 
reduce the 
outcome 
disparity 
between those 
with high and 
low health 
literacy as well 
as improve the 
outcomes for all. 

Pignone M, 
DeWalt DA, 
Sheridan S, 
Berkman N, 
Lohr KN 
(2005). [24] 
Research is 
needed to 
establish whether 
the link between 
low literacy and 
poor health 
outcomes is 
direct or indirect 
so as to most 
efficiently direct 
interventions. 
Results of 
interventions 
should be 
stratified by 
literacy level. 
Future studies 
should focus on 
intermediate or 
longer term 
outcomes rather 
than short-term 
knowledge 
outcomes or 
health 
behaviours. 
There is no 
research which 
has considered 
how interventions 
may impact on 
health disparities 
or care costs 
based on race, 
ethnicity, culture 
or age.  
Multi-component 
interventions 
should be 
analysed to 
establish efficacy 
and 
effectiveness. 

By its nature, the investigation in a review of reviews is confined to the review reports and its quality is constrained 
by the quality of the reviews. A number of inconsistencies were noted in some of the reviews: one stated that it 
included 16 studies but listed 17 and another stated that it included 28 studies but tabled only 24 without 
explanation. In the report of another study, it was stated that the outcome was patient discussion of the 
pneumococcal vaccine with a physician, however, the intervention was listed as a nutritional sheet versus an 
information sheet on pneumococcal vaccine which would be an intuitively unlikely comparator. However, the 
confines of a review of reviews preclude drilling into these inconsistencies. 

The findings will be presented under the heading of contexts, interventions, and outcomes, each with a number of 
subheadings. A closer examination of the only three studies that focussed on a communicable disease (HIV) is also 
presented in the Appendix. 

Contexts 

The studies 

Four of the five reviews [22, 23, 24, 25] were described as systematic reviews; the fifth review was described as 
an integrated review. The studies included in the reviews were dated between 1976 and 2008 – a span of 32 
years. The articles included in the five studies totalled to 84 (however, 81 studies were charted in the reviews), 13 
were included in two or more reviews, and two of these were included in three of the five reviews.  

Three of the five reviews used the English language as an inclusion criteria for the selection of studies included in 
their review and one did not specify. One review did not use a language criterion and includes a study from Nepal, 

10 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
TECHNICAL REPORT 

Rapid evidence review of interventions for improving health literacy 

though this was published in English. Two of the reviews excluded studies conducted in the developing world and 
although one explicitly included such countries, only one study from the developing world is apparent. 

Quality assessment 

Two of the five reviews [25, 26] did not report what, if any, quality criteria were used to assess the studies 
included in the review. Three of the five reviews reported the quality criteria. The criterion used by two of the 
reviews was the same. These criteria and that of the third of the reporting reviews can be seen in Table 2 below. 

Table 2: Review quality criteria  

Pignone, et al. (2005) [24] 

DeWalt, et al. (2009) [23] 

Clement, et al. (2009) [22] 

Adequacy of study population 

Adequacy of study population 

Method of randomisation performed 

Comparability of subjects 

Comparability of subjects 

Treatment allocation concealed 

Validity of the literacy measurement  Validity of the literacy 

measurement 

Groups similar at baseline regarding 
important prognostic indicators 

Reliability of the literacy 
measurement 

Reliability of the literacy 
measurement 

Eligibility criteria specified 

Maintenance of comparable groups  Maintenance of comparable 

groups 

Appropriateness of the outcome 
measure 

Appropriateness of the outcome 
measure 

Outcome assessor blinded for all 
primary outcomes 

Point estimates and measure of 
variability given for all primary 
outcomes 

Appropriateness of statistical 
analysis 

Appropriateness of statistical 
analysis 

Intention-to-treat analysis 

Control of confounders 

Control of confounders 

A priori sample size calculation included 

Participant flow diagram included 

• 

• 

• 

Clement, et al. (2009): Of the 15 studies in the review, three studies met five or more criteria and five 
met three or less. The least likely criteria to be met were blinding of outcome assessors and concealment of 
treatment allocation [22]. 
Pignone, et al. (2005): Of the 19 studies included in the review, 10 were rated ‘good’, nine were rated 
‘fair’ and one was rated ‘poor’ [24]. 
DeWalt & Hinks (2009): Of the five studies in the review which were of relevance to this review, four 
were rated to be of ‘good’ quality and one was rated to be of ‘fair’ quality [23]. 

Study design 

Three of the reviews only included studies that used a control and experimental group, another ‘gave priority’ to 
Randomised Control Trials (RCTs) but also included descriptive articles and articles with a quasi-experimental 
design. One review focussed only on complex interventions.  

The designs of the studies included in the reviews were identified as:  

• 
• 
• 
• 
• 
• 

randomised control trials n=50;  
non-randomised control trials n=12;  
survey n=9;  
quasi-randomised control trials n=4;  
uncontrolled single group trials n=3 and n=1 tandem assignment trial;  
as well as exploratory pilot intervention, prospective observational trial, quasi-experimental trial, 
correlational descriptive study and uncontrolled study. 

Three reviews required that specific outcomes should have been measured in the studies in order to be included in 
the review (see Table 3), two of these are almost identical and the other has a high level of overlap.  

The intensity of the interventions covered by the reviews ranged widely. In many studies, such as those comparing 
adapted or low literacy-level written materials, or imparting information, there was only one contact point and no 
follow-up. Other interventions included numerous contact points and varying contact points within the intervention 
– the range of contact within one mental health intervention was between 0 and 72 hours. Some interventions 

11 

 
 
 
 
 
 
 
 
 
 
 
 
Rapid evidence review of interventions for improving health literacy 

TECHNICAL REPORT 

took place in a one-to-one format and some in a group session, and whereas many comprised a single session, 
others comprised intensive input over periods of time (12 months). 

Table 3: Review study outcome criteria  

Pignone, et al. (2005) [24] 

DeWalt, et al. (2009) [23] 

Clement, et al. (2009) [22] 

Health knowledge, assessed by 
objective scale 

Health knowledge, objectively 
assessed 

Health knowledge 

Health behaviours 

Health behaviours 

Health behaviours 

Biochemical or biometric outcomes  Biochemical or biometric 

outcomes 

Measures of disease incidence, 
prevalence, morbidity and mortality 

Measures of disease incidence, 
prevalence, morbidity and 
mortality 

Physical or psychological clinical 
outcomes 

Self-efficacy/confidence relating to 
health/health behaviour 

Self-reported general health status  Self-reported general health 

status 

Self-reported health status/quality of 
life 

Health service utilisation 

Health services utilisation 

Health service utilisation 

Cost of care 

Cost of care 

Health professional behaviour 

Interventions to reduce disparities 
in health outcomes on the basis of 
race, ethnicity, culture or age 

Country 

A UK study relating to hearing screening for newborns in the UK and a study from Nepal relating to an intervention 
at a hospital pharmacy for patients with low literacy were included in the reviews. However, almost all the included 
studies emanate from North America, with most from the USA. 

Study participants 

Four of the five studies reported sample sizes for the included studies and these ranged from 26 to 2 046. One 
other study included 68 700 calls received to CAN-DIAL, a phone line for health education and cancer control, and 
included the use of audiotapes [27]. The review of paediatric interventions did not give participant numbers.  

Two studies included in the reviews focussed on healthcare providers rather than, or as well as, users of the health 
services.  

One review focussed only on children and the parents of children, whereas the other four specifically excluded 
studies whose participants were aged less than 18 years of age.  

Measures of literacy levels  

Three of the reviews required eligible studies to have used a literacy measure within the intervention. In another 
there was no such requirement, although most (11/16) of the interventions did use such a measure. The fifth 
review focussed on interventions that used audiotapes, and such interventions had outcome variables that included 
increased knowledge or recall, behaviour change and/or reductions in anxiety, rather than changes in literacy as 
measured by literacy measures. The literacy measures used in the interventions in the reviews were:  

• 

• 

• 

• 

the Rapid Estimate of Adult Literacy in Medicine (REALM) – a word recognition screening test of 
common medical words or lay terms for parts of the body or illnesses – cited in 25 of the reports of the 
interventions (overlaps not counted);  
the Test of Functional Health Literacy in Adults (TOFHLA) and the truncated version of this test (s-
TOFHLA) – cited in 10 articles; 
the Wide Range Achievement Test (WRAT), which has a version applicable to 5–11 year olds – cited in 
six; and 
the Adult Basic Learning Examination (ABLE ) – cited in three studies.  

Seven other measures were cited in studies included in the reviews. Although many studies used the same 
measure, the comparability of these studies is reduced due to the lack of a consistent threshold to define low 
health literacy. 

12 

 
 
 
 
 
 
 
 
 
 
 
 
TECHNICAL REPORT 

Rapid evidence review of interventions for improving health literacy 

Provider-focussed interventions 

Two of the reviews included studies focussing on healthcare providers [26, 22]. Schaefer reports that: 

• 

• 

in a RCT wherein the intervention group providers were informed of their patients’ health literacy levels, 
they were more likely to use low health-literacy management strategies and less likely to feel that they 
were effective during the consultation [28]; 
a RCT identified a significantly increased rate of adherence to colorectal cancer screening among patients 
whose healthcare providers attended workshops and training on colorectal cancer screening including 
enhancing communication with patients with low health literacy [29]. 

Disadvantaged/minority groups 

People with low levels of literacy may be considered a disadvantaged group per se, however, there is little 
evidence of the specific inclusion of disadvantaged or hard-to-reach groups in any of the reviews. Schaefer 
excluded studies that included people with mental or physical disabilities [26]. Santo, et al. designed their review 
to focus on the use of audiotapes with ‘hard to reach’ groups but broadened their review after failing to find any 
relevant studies [25]. Indeed, Santo, et al. reported that such ‘hard to reach’ groups were often excluded from the 
interventions. DeWalt & Hink identified that some of the 24 studies in the review attempted to adjust for age, 
socioeconomic status and/or race/ethnicity, but it is not clear whether this was the case in the five studies that 
were relevant to this review [23]. Pignone, et al. stated that they found no studies which examined whether 
interventions delivered to individuals with low literacy impacted health disparities based on race/ethnicity, culture 
or age [24]. 

Within the studies included in the reviews, some specifically indicate that the target group involved in the 
interventions had defining characteristics such as ‘African-American’ or ‘Latino-speaking’ or ‘Hispanic adults’. 
However, there is no indication that these target groups have been chosen because they were perceived to be 
disadvantaged.  

Interventions 

The types of interventions included in the reviews were diverse and are presented in Table 4 according to the 
focus ascribed to them in each review. 

Table 4: Types of interventions included in the reviews 

Focus of 
included 
studies 

Santo A, 
Laizner AM, 
Shohet L 
(2005) [25] 

Audiotapes to 
record 
consultations and 
health-related 
information in 
specific health 
situations 

Clement S, Ibrahim S, 
Crichton N, Wolf M, 
Rowlands G (2009) [22] 

Pignone M, DeWalt 
DA, Sheridan S, 
Berkman N, Lohr KN 
(2005) [24] 

Schaefer CT 
(2008) [26] 

DeWalt DA, 
Hink A (2009) 
[23] 

Those directed at health 
professionals (n=2) 

Easy-to-read printed 
materials (n=4) 

Literacy education (n=1) 

Health education/management 
interventions (n=12) 

Video/audiotapes 
(n=4) 

Computer-based 
programmes (n=3) 

Individual or group 
instructions (n=9 
studies) 

Personal contact 
intervention 
(n=7) 

Multi-prong 
approach (n=2) 

Written material 
intervention 
(n=4) 

Computer 
interventions 
(n=3) 

Easy-to-read 
brochures for 
parents/care-
givers (n=2) 

Modified print, 
video and 
computer 
information for 
parental consent 
purposes (n=1) 

Picture-based 
instructions and 
teach-back 
counselling for 
parents of 
children taking 
medication 
(n=1) 

Classes and 
summer camp 
for asthmatic 
children (n=1) 

13 

 
 
 
 
 
 
 
 
 
 
 
 
 
Rapid evidence review of interventions for improving health literacy 

TECHNICAL REPORT 

The intensity of the interventions ranged considerably from a one session intervention to an intensive education 
programme over one year, and from group interventions to one-to-one interventions. 

Two studies were directed at health professionals, four studies at parents, and one study was directed at children. 
The interventions included in the reviews spanned a range of strategies. One review focussed exclusively on the 
use of audiotapes and another included interventions that used video/audiotapes, others included individual and 
group instructions, health education/management interventions and easy-to-read printed materials. 

If the studies included in the reviews are considered within the framework suggested by Coulter and Ellins, it is 
clear that some types of interventions are absent and others are notable for their diversity [1]. None of the studies 
fall within the categories of ‘low literacy initiatives’ as exemplified by Coulter and Ellins or within the ‘targeted mass 
media campaign’ category. Many studies can be placed within the ‘written health information category’ including: 

• 

• 

one designed to assess the differential comprehensibility of a consent form taken from a 16th grade reading 
level to a seventh grade reading level [30]; and  
one focussing on the labelling on an over-the-counter emergency contraception package [31]. 

Likewise, many studies fall within the Alternative Format Responses category, with one review focussing 
exclusively on these. Studies within this category include: 

• 

• 

a study which focussed on the impact of information given in an oncology outpatient clinic through 
handouts and audiotapes, versus handouts alone and usual care [32]; and 
the knowledge impacts of a CD-ROM for patients newly diagnosed with prostate cancer [33]. 

Health concerns  

The reviews encompassed a very broad range of health concerns, presented below in Table 5. 

Table 5: Health topics addressed in the reviews 

Health areas  

Santo A,Laizner AM, 
Shohet L (2005) [25] 

chemotherapy; 
cancer consultations: 
recall, breaking bad 
news & communication, 
information; 
anxiety due to 
sigmoidoscopy;  
anxiety due to chronic 
obstructive pulmonary 
disease (COPD);  
asthma self care; 
breast care exam; 
lower-extremity 
reconstruction; 
stroke prevention; 
cardiac-discharge 
information; 
prostate cancer; 
outpatient consultations 

Clement S, Ibrahim 
S, Crichton N, Wolf 
M, Rowlands G 
(2009) [22] 
Hypertension; 
heart failure; 
colorectal cancer 
screening; 
nutrition education for 
cancer; 
cardiovascular disease 
prevention; 
medication adherence 
(chronic condition); 
understanding of 
medication; 
diabetes disease 
management; 
HIV medication 
adherence and 
knowledge; 
depression; 
hearing screening in 
newborns 

Pignone M, DeWalt 
DA, Sheridan S, 
Berkman N, Lohr KN 
(2005) [24] 
polio vaccine; 
cancer-trial consent 
form; 
prostate cancer; 
colorectal cancer; 
cervical cancer 
screening; 
sleep apnea; 
labelling-emergency 
contraception; 
self-care cancer; 
breast self-exam; 
nutrition; 
medication adherence; 
mammography uptake; 
family support 
programme 

Schaefer CT 
(2008) [26] 

DeWalt DA, 
Hink A (2009) 
[23] 

polio 
vaccination; 
asthma; 
medication 
adherence 

Diabetes; 
HIV; 
breast cancer; 
congestive heart 
failure; 
prostate cancer; 
orthopaedic surgery; 
cancer screening; 
elderly; 
low income 

Cancer was the focus of many of the interventions but with a multiplicity of approaches including screening, 
preparation for screening and consultations about cancer. Chronic diseases such as asthma and diabetes also 
featured frequently as did medication adherence for such conditions. No reviews included interventions for 
communicable or infectious diseases. In fact, the reviews only included three studies focussing on communicable 
disease – all three studies are concerned with HIV and all are included in the same review. Details of these three 
interventions are presented in the Appendix. 

Outcomes  

The outcomes of the interventions are categorised according to those outcomes that were measured in four of the 
five reviews, and an overview of the findings are presented below: 

Health knowledge/recall or comprehension assessed by objective scale: the review of 
interventions of audiotapes reported that of the 12 studies included in the review, 10 found some significant 
results. Across the other reviews, the results were mixed. Clement, et al. state that health knowledge and 
health-related self-efficacy were the outcomes that were most likely to show improvement. Four of the nine 

• 

14 

 
 
 
 
 
 
 
 
 
 
 
 
TECHNICAL REPORT 

Rapid evidence review of interventions for improving health literacy 

studies in that review reported that the intervention group had significantly better outcomes than the 
control group, with another four reporting no significant outcomes and one reporting mixed outcomes [22]. 
The four studies showing significant results for this outcome included: 
− 
− 

a one-contact hospital pharmacy-delivered intervention in Nepal [34]; 
a six-month (11 contacts) heart failure self-management education intervention delivered by a 
clinical pharmacist and a health educator [35]; 
a 12-month (17 contacts) intervention addressing the  barriers experienced by adults with poorly 
controlled diabetes, which was delivered by a pharmacist and a diabetes care coordinator [36,37]; 
and 
an 18-week (12 contacts) low fat nutrition education intervention delivered to adults attending an 
adult education class and delivered by nutrition professionals [38]. 

− 

− 

• 

• 

• 

• 

• 
• 

Health behaviours/self care: 19 studies in the reviews considered this outcome and most reported 
mixed outcomes. The studies that reported positive findings included: 
− 

following a low-literacy pamphlet intervention, women performed more accurate breast 
examinations on silicone breast models [39]; 
a six-month (11 contacts) heart failure self-management education intervention delivered by a 
clinical pharmacist and a health educator [35]; 
an intervention utilising picture-based instructions and counselling which reported that participants 
were significantly more likely to use a standardised dosing instrument, and were significantly less 
likely to report incorrect medication preparation or to make dosing errors [40]; 
informational audiotapes significantly improved self-care behaviours of patients having 
radiotherapy [41]; 
the recovery outcomes after coronary artery bypass surgery were significantly enhanced in an 
intervention group who received their discharge information by audiotape [42]; 
an instructional audiotape significantly improving women’s breast examination proficiency [43]; 
men, newly diagnosed with prostate cancer, who received both written and audio-taped 
instructions took a significantly more active role in their treatment [44]; 
participants with low literacy reduced the contribution of fats to their overall calorie intake following 
six specially designed nutrition classes [38]. 

− 

− 

− 

− 

− 
− 

− 

Biochemical or biometric outcomes: one review included two studies which demonstrated small or no 
improvement in blood pressure, cholesterol or lipids levels after nutrition interventions. Eight studies were 
included in another review – four studies reported no significant outcomes, two studies reported mixed 
outcomes and two reported significant outcomes: 
− 

A six-month (11 contacts) heart failure self-management education intervention delivered by a 
clinical pharmacist and a health educator [35]. 
A 12-month education programme for adults with depressive symptoms comprising one contact 
plus varying contact between 0 and 72 extra hours [45]. 
Nutrition education for African-American women with limited literacy comprising eight contacts over 
12 months with follow-up at 4, 8 and 12 months [46]. 
A one-on-one intensive diabetes management education intervention reported significant 
improvements in diabetic biochemical markers in patients with lower health literacy [36].  

− 

− 

− 

Measures of disease incidence, prevalence, morbidity and mortality: one study compared a 
comprehensive family support service with the standard Head Start 1 provision and reported improved 
parental reading skills and reduced prevalence of parental depression [47]. 
Self-reported general health status/quality of life: two studies reported this outcome and neither 
reported significant results [35, 48]. 
Cost of care: the reviews contained no studies that reported cost of care as an outcome. 
Health services utilisation: four studies reported a significant outcome under this heading: 
− 

Mammogram uptake was significantly higher in an intervention group that received a video-based 
coaching tool in addition to verbal recommendation or verbal recommendation plus brochure. 
However, this significance was only found at six months but not at 24 months [49]. 
Male veterans who received simplified brochures, simplified instructions and a video, plus an 18-
month follow-up, had significantly higher rates of colorectal screening [29]. 
Weekly two-hour literacy and education classes over six month, plus a five-day camp for children 
with asthma, significantly reduced their asthma-related visits to Emergency Departments [50]. 
Older people with chronic health conditions who were given information at fifth grade reading level 
were significantly more likely to discuss pneumococcal vaccination [51]. 

− 

− 

− 

1 In the US, Head Start is a federally funded, comprehensive support programme to boost the school readiness of low-income 
children. It provides medical, dental, and mental healthcare alongside family support and pre-school education (US Department 
of Health and Human Services, Administration for Children and Families, January 2010). 

15 

 
 
 
 
 
 
 
 
 
 
                                                                    
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TECHNICAL REPORT 

• 

• 

• 

• 

Interventions to reduce disparities in health outcomes on the basis of race, ethnicity, culture 
or age: the reviews contained no studies that reported on these outcomes. 
Self-efficacy/confidence relating to health/health behaviour: one review included one study 
reporting such outcomes and one review included seven studies of which three reported significant 
outcomes: 
− 

Weekly two-hour literacy and education classes over six months plus a five-day camp improved the 
self-efficacy of children with asthma [50].  
A six-month (11 contacts) heart failure self-management education intervention delivered by a 
clinical pharmacist and a health educator [35]. 
An 18-week (12 contacts) low-fat nutrition education intervention delivered to adults attending an 
adult education class and delivered by nutrition professionals [38]. 
A 24-month (12 contacts) telephone intervention directed towards veterans with hypertension [52]. 

− 

− 

− 
Health professional behaviour/skills: two studies reported this outcome: 
− 

Patients of professionals who attended a workshop, and four group sessions on colorectal 
screening and communication with people with low literacy, were significantly more likely to 
present for colorectal screening [29]. 
In a study in which physicians were alerted to a diabetic patient’s low literacy status, the physicians 
reported significantly less satisfaction with the consultation than the control group physicians [28]. 

− 

Satisfaction or helpfulness of the intervention: of the 24 studies in the review of audiotape 
interventions, 17 tested satisfaction as an outcome and four reported the significance level [53, 41, 54, 55].  

Most commonly, the evidence reviewed reported effects on knowledge and comprehension as an outcome with 
fewer including health behaviours or health service utilisation or health/clinical outcomes.  

Reviewers’ conclusion on studies 

The review which focussed on audiotapes concluded that ‘with the exception of positive patient satisfaction, the 
benefits of audio taped messages remain unclear’ [25]. The review reported consistently high levels of patient 
satisfaction but inconclusive evidence as to whether audio-taped messages improved either health knowledge or 
health behaviour.  

Pignone, et al.’s review concluded that the effectiveness of the interventions ‘appeared mixed’ but noted that the 
variable research quality and the heterogeneity in outcome measures limit the scope for drawing firm conclusions 
regarding the effectiveness of the intervention strategies [24]. The reviewers assessed 10 of the included 
interventions as of good quality, nine as of fair quality and one as of poor quality. 

The review that focussed on interventions to improve health outcomes for children identified improved health 
knowledge and behaviours across all levels of literacy, but did not identify a reduction in the disparity between 
participants with high levels of literacy and those with low levels [23]. The review assessed four of the five 
interventions as of good quality and one as of fair quality. 

Clement, et al.’s review of complex interventions concluded that ‘a wide variety of complex interventions for adults 
with limited literacy are able to improve some health-related outcomes’ and identified that knowledge and self-
efficacy were the outcomes most likely to show significant improvement [22]. 

Schaefer concluded that there is a need for further research to assess the effectiveness of health literacy strategies 
and determine best practice [26]. 

Cochrane review 2011 

In June 2011, after the literature search for this review was concluded, the Cochrane Collaboration published a 
systematic review of ‘Interventions for enhancing consumers’ online health literacy [56]. Although it is not possible 
to incorporate this research into this current review, it will be referred to here in order to maximise completeness. 
The objective of the Cochrane review was to assess the effects of interventions designed to enhance online literacy 
in terms of the skills required to search, evaluate and use online health information. Following a search strategy 
that returned 41,225 citations, only two studies met the criteria for inclusion in the review: 

• 
• 

Cortner D (2006) [57]. 
Kalichman SC, Cherry C, Cain D, Pope H, Kalichman M, Eaton L, et al. (2006) [58]. 

Both interventions were located in North America and both sought to enhance online health literacy through adult 
education classes. Key characteristics of the studies are listed in Table 6 below: 

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TECHNICAL REPORT 

Rapid evidence review of interventions for improving health literacy 

Table 6: Characteristics of Cochrane review on interventions for online health literacy 

Design 
Participants  

Literacy measure  
Intervention 

Kalichman SC, et al. (2006) [57] 
Randomised control trial 
HIV-positive adults 
Intervention: n=217 
Control: n= 231 
TOFHLA 
Skills-based educational intervention 
8 X two-hour session 

Outcome measured  Self-efficacy for information seeking 
Health information evaluation skills  
Use of the internet 
Information seeking coping 
Social support 
Affective depression 

Car, et al (2011) [56]. 

The Cochrane review [56] concluded that there was:  

Cortner D (2006) [58] 
Two-group controlled before and after study 
Adults with basic internet knowledge aged 60+. 
Intervention: n=11 
Control: n=11 
None 
Adult education internet classes 
4 X 90-minute classes 
Individual readiness to adopt the internet as a 
tool for preventive health information as 
measured by a self-report questionnaire 

Low quality evidence that these interventions improve aspects of online health literacy, specifically regarding the 
outcomes of ‘self efficacy for health information seeking’, ‘health information evaluation skills’, ‘number of times the 
patient discussed online information with a health care provider’ and ‘readiness to adopt the internet as a tool for 
preventive health information’.  

The lack of studies in the area, and the variable methodological quality of the two included in the review, 
precluded any conclusions about the effects of such interventions for online health literacy. The authors 
recommended that high-quality studies, particularly a randomised control trial, should be designed to investigate 
the effects of such interventions. 

17 

 
 
 
 
 
 
 
 
 
 
 
 
 
Rapid evidence review of interventions for improving health literacy 

TECHNICAL REPORT 

Conclusions 

The diversity of interventions included in the reviews, the categorisation of outcomes, and the information 
provided within, intrinsically limits the potential to draw firm conclusions; however, some points can be made. 

There is a paucity of studies that reported on interventions relating to communicable disease. The only studies 
included in the reviews that referred to communicable diseases concerned HIV and all three had medication 
adherence as an outcome of the intervention. Medication adherence has been documented as a serious issue in 
communicable diseases such as HIV and TB and these studies may, therefore, have particular relevance. However, 
this focus is limited and only one of the three studies reported significant benefits deriving from the intervention. 

Although all reviews include interventions that indicate positive and/or significant improvements, the outcome 
measured was often that of knowledge rather than health outcomes. Clement, et al. [22] and Pignone, et al. [24], 
argue that although health knowledge and health behaviour are important, it is also the case that improvements to 
these do not always translate into improvements in health, health services utilisation or in disease prevalence. 
Pignone, et al. [24] also conclude that: 

No research to date has examined how interventions affect the general health status of persons with low literacy or 
whether interventions can affect health care costs or health disparities based on race, ethnicity, culture, or age. 

It is also the case that most of the interventions identified in the reviews focus on the functional level of health 
literacy and work at the traditional health education level. There is little evidence of interventions targeted at the 
interactive or critical levels of health literacy with skill development and opportunities based, for example, in 
schools or communities. 

Not all reviews identified whether the study results were stratified across literacy levels but, from those that did, it is 
clear that few of the studies provided this analysis. Without such information it is impossible to measure impacts on 
people with varying levels of health literacy and to effectively target interventions to reduce disparities and inequalities. 

Given that such a large majority of the trials were located in North America, and more specifically in the USA, the 
reviews may only be generalised in a limited way to other contexts and heath systems.  

Three of the five reviews reported on quality assessment of the studies included. In one of these, only half the 
studies achieved the ‘good’ benchmark while in another only one third of the studies met six or more of the nine 
criteria and the same number met three or less. In the third review, four of the five studies received a rating of 
‘good’. These results, and the lack of information from the other reviews, leave the issue of quality subject to 
uncertainty and render conclusions invidious.  

The review exposed a paucity of research involving disadvantaged or hard-to-reach groups and there is some 
evidence that some such groups may have been specifically excluded from interventions. 

Identification of gaps in the evidence and recommendations 
for further research 

Clearly, there are considerable gaps in the research evidence concerning which interventions are most effective in 
improving health literacy, particularly with regard to communicable diseases and studies conducted in Europe. 
There is a need for European research to study the issues of health literacy in a European context, and to explore 
how possible it is to generalise existing North American research to a European context. Even within the North 
American context, there is an almost complete absence of published research on interventions concerning 
communicable diseases, and the significance of health literacy in this realm demands that this should become a 
priority research issue. The development of measures of health literacy at a level other than that of functional 
literacy is fundamental to any progression of health literacy beyond the limits of the conceptualisation of health 
literacy as reflected in this review.  

In addition, future research is needed on the following research areas: 

the impact of health literacy interventions in the public health field, paying particular attention to evaluating 
communication about communicable diseases 
evaluating the most effective strategies for meeting the needs of population groups with low literacy levels 
the most effective way of delivering health information and education to vulnerable, disadvantaged and 
hard-to-reach groups 
reliable measures of the impact of health literacy on health status, health behaviours and knowledge, health 
motivation and self-efficacy, and health service utilisation 
studies evaluating the relative effectiveness of different approaches to improving health literacy, including 
mass media campaigns combined with other strategies 
the cost-effectiveness of health-literacy strategies. 

• 

• 
• 

• 

• 

• 

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Appendix 
Three studies focussing on a communicable disease 

The earliest intent of this evidence review was to focus on interventions for communicable disease but the absence of 
such studies in the literature necessitated a widening of the focus of the review. In acknowledgement of this earlier 
intent, data from the three studies within the reviews that concerned a communicable disease are presented below. 

Table 5: Three studies focussing on a communicable disease  

Van Servellen, et al. (2003) [48] 

Kalichman, Cherry & Cain 
(2005) [59] 

Pilot study.  
Medication adherence counselling 
intervention for HIV positive men 
and women with lower health 
literacy.  
Two sessions plus a booster 
session:  
session 1: understanding HIV and 
HIV medications; 
session 2: Medications and Your 
Health;  
session 3: Stick to it: maintenance 
of adherence behaviours.  
Delivered in a motivational 
interviewing style by nurses. 

Yes 
The Information, Motivation and 
Behavioural skills model (IMB)  

Participants significantly increased 
their level of AIDS related 
knowledge at one month, two 
months and three months post 
intervention. 
Significantly more participants 
indicated understanding their viral 
load and their CD4 counts at all 
three post-intervention 
measurements. 
Motivational indicators showed 
significant increase (all three 
measurement points) in intention 
not to miss any medication doses 
and in intention to keep medication 
to hand. 
Behavioural indicator of self-efficacy 
for understanding HIV, taking 
medications on time and without 
missing any doses increased at all 
three follow-ups. 
Medication adherence outcomes 
demonstrated a significant 
reduction in missed doses at the 
two-month and three-month follow-
up; a significant reduction in off-
schedule medication taking at the 
two-month follow-up. 

The result of this pilot study was 
encouraging and ‘brief counselling 
intervention warrants further 
research’. (p14) 

Intervention 

Pilot study.  
Culturally sensitive HIV group education 
programme for Latino, Spanish-speaking 
HIV positive adults.  
Programme targeted: functional health 
literacy, social network support, mastery 
of adherence management and 
communication with health providers.  
Delivered, in Spanish, by treatment 
advocates and a nurse practitioner.  
Comprised a five-week, one-day-a-week, 
instructional support modular program 
with follow-up at six weeks and six 
months 

Theoretical 
base reported 

No 

Results 

At six-week follow-up the intervention 
group had significantly greater 
knowledge about HIV treatment. 
The intervention group had greater 
levels of recognition of and 
understanding of HIV terms. 
There were no significant differences 
between the intervention and control 
group in their understanding of 
prescription medication instructions, on 
medication adherence or in medication 
behaviours. 
The control group reported significantly 
greater quality of patient-provider 
communication at base line and at six-
week follow-up. 

Authors’ 
conclusions 

The lack of change in medication 
adherence and mastery might be 
expected in the short term and would be 
more meaningful if analysed over time.  
‘The significance of the program seems 
to be in its ability to enable and 
empower participants to more fully 
participate in their care’. (p592) 

22 

Holzemer, Bakken, Portillo, 
Grimes, Welch, Wantland & 
Mullan (2006) [60] 
RCT of a tailored nurse-delivered 
HIV medication adherence 
intervention programme.  
Interventions related to: 
medication knowledge, 
adherence and managing side 
effects. 
Repeated measures over a six-
month period. 

Yes 
The Ickovics and Meisler 
framework for adherence in 
clinical research and clinical care 

No significant differences 
between the control and 
interventions groups were 
reported over time on any of the 
five medication adherence 
measures.  
Minimal correlation with clinical 
markers was reported and little 
correlation between the five 
adherence measures. 

The measures of medication 
adherence may not have 
performed as they were expected 
to and may not be adequate to 
measure medication adherence.  
Otherwise it is unclear why the 
intervention did not succeed in 
improving adherence.