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Improving the Health of Adults with
Limited Literacy:
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What’s the evidence? Clement, S., Ibrahim, S., Crichton, N., Wolf, M.,
Rowlands, G. (2009). Complex interventions to improve the health of people with limited literacy: A systematic review. Patient Education & Counseling, 75(3): 340-351.
http://health-evidence.ca/articles/show/19393
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Limited Literacy:
What’s the evidence?
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Review Clement, S., Ibrahim, S., Crichton, N., Wolf, M.,
Rowlands, G. (2009). Complex interventions to improve the health of people with limited literacy: A systematic review. Patient Education & Counseling, 75(3): 340-351.
Questions?
Summary Statement: Clement(2009) P Adults with limited literacy or numeracy I Complex, multi-faceted interventions C Any active or inactive control O Health-related outcomes: clinical outcomes; health
knowledge; health behaviours; self-reported health status/quality of life; health-related self-efficacy/confidence; utilization of health care; health professional behaviour/skills
Quality Rating: 10 (strong)
Complex Interventions
Multi-faceted intervention (more than one element) & intended to improve outcomes for people with limited literacy.
Main categories:
Health professional-directed Literacy education Health education/management
Most common elements included: Care management Verbal presentation Material in simplified language Pictorial information
Videos Audiotapes Checking for understanding Spacing information
Definition of Health Literacy Canadian Expert Panel on Health Literacy, 2008
“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.”
Overall Considerations
Complex interventions are effective in improving some health-related outcomes – health-related self efficacy/confidence; utilization of health care; and health provider behaviour/skills – for people with limited literacy
The evidence is mixed on clinical outcomes, health knowledge and health behaviours.
There is no impact on self-reported health status/quality of life.
General Implications Public health should promote/support/implement: Complex, multi-faceted interventions to address
patients with limited literacy in the areas of health-related self efficacy, utilization of health care, and communication with health providers.
Public health should consider that…
High quality review, based on low-moderate quality RCTs
Many outcomes are based on the results of 1 study; majority of included studies may not have had an adequate sample size to observe statistical significance
Interventions studied varied widely – health issue addressed; duration, intensity, and delivery; extent to which literacy factored into the intervention – as did the types of measures and control groups used.
Due to this variation, it is not possible to identify if specific intervention components were more effective than others.
What’s the evidence? Outcomes reported in the review*
Clinical Outcomes Health Knowledge Health Behaviours Self-Reported Health Status / Quality of Life Health-Related Self-Efficacy / Confidence Utilization of Health Care Health Provider Behaviour / Skills Satisfaction Levels
*Only the primary outcomes from each study are addressed in this evidence table. Review authors reported on primary and secondary outcomes but only included
data for primary outcomes.
What’s the evidence? Clinical Outcomes Literacy education: Reduced median depression scores in adults with depressive
symptoms (6) vs. usual care (10) in a community setting (p=0.04).
What’s the evidence? Clinical Outcomes (continued)
Health education: Educational session with clinical pharmacist reduced
death/hospital admission for adults with heart failure (IRR 0.53, 95% CI 0.32-0.89).
Educational session with pharmacist reduced systolic (mm Hg, -7 vs. 2, 95% CI -16 to -3, p=0.008) and diastolic blood pressure (mm Hg, -4 vs. 1, 95% CI -9 to -1, p=0.002) in adults with poorly controlled type II diabetes. No impact on total blood cholesterol or haemoglobin levels.
No impact on blood pressure and cholesterol for African-American adults with high blood pressure or cholesterol.
What’s the evidence? Health Knowledge Health education: Verbal counseling, provided with dispensed medication,
increased understanding of dosage regimen (% correctly reporting, 88%) vs. usual care (70%) in a hospital pharmacy (p=0.03).
Group education improved understanding of HIV-related terms (mean score (SD), 6.16 (7.97)) vs. usual care (1.91 (3.60)), (t=-3.16, p<0.0001) but had no impact on overall HIV knowledge in Latino Spanish-speaking adults with HIV.
What’s the evidence? Health Knowledge (continued)
Health education (continued): No impact on mothers’ knowledge of newborn hearing
screening in a maternity unit setting but, in a subgroup analysis, there was a significant increase for mothers with lower levels of education (5.00 vs. 3.38, p<0.05)
No impact on: veterans’ hypertension knowledge; medication knowledge in adults aged 65+ with a chronic illness.
What’s the evidence? Health Behaviours
Health education: Personalized dietary feedback, booklets and structured
telephone calls reduced self-reported fat intake (mean score (SD), 1.87 (0.35)) vs. usual care (1.95 (0.34)) (p=0.0027) but had no impact on self-reported fiber intake for adults in a rural area.
A nutrition-focused heart disease prevention program reduced sodium intake (mean mg (SD), 2545.97 (1164.12)) vs. attention control (3118.13 (2386.19)), (p<0.05) in Hispanic adults, but had no impact on total fat, saturated fat, or cholesterol intake.
What’s the evidence? Health Behaviours (continued)
Health education (continued): Low-fat nutrition group education improved self-reported
healthy low fat eating in low-income families (mean difference, -0.03, 95% CI -0.01 to -0.005).
Low-fat nutrition group education reduced caloric intake (change in % calories from total fat, -2.8 (2.4)) vs. an alternative program (-0.5 (2.0)), (p=0.01).
What’s the evidence? Health Behaviours (continued)
Health education (continued): Intensive diabetes management program improved self-report
of Aspirin use by adults with poorly controlled type II diabetes (% correctly reporting, 91%) vs. usual care + 1 hr educational session (58%), (p<0.0001).
No impact on medication adherence for veterans with hypertension or Latino Spanish-speaking adults with HIV.
What’s the evidence? Self-Reported Health Status
Health education: Education session with a clinical pharmacist had no impact on
heart failure-related quality of life reporting in adults with heart failure.
What’s the evidence? Health-Related Self-Efficacy Health education: Tailored health education telephone intervention (with verbal
medication explanation) increased self confidence in hypertension management for veterans (mean score change, 0.33) vs. usual care (-0.10), (p=0.007)
What’s the evidence? Utilization of Health Care Health professional-directed: Health professional-directed intervention, in which
professionals receive training on screen and patient communication, increased percentage of patients screened for colorectal cancer (42.3%) vs. usual care (32.4%) (p=0.003).
There was no impact in a subgroup analysis of higher literacy groups in the same study.
What’s the evidence? Health Provider Behaviour Health professional-directed: Health professional-directed intervention, in which physicians
were notified of patients’ literacy status, increased use of literacy-relevant management strategies when treating adults with type II diabetes (% reporting use of >3 strategies, 20%) vs. usual care (7%) (OR 4.7, 95% CI 1.4-16.0, p=0.01).
Health education: Group health education improved Latino Spanish-speaking
adults with HIV’s perceived quality of communication with health providers (mean score change (SD), 5.28 (5.37)) vs. usual care (1.11 (5.97)) (p<0.001).
What’s the evidence? Satisfaction Levels Patients: Intervention group (adults with poorly
controlled type II diabetes in an intensive educational session) were more satisfied than those receiving usual care (Diabetes Treatment Satisfaction Questionnaire, difference in mean change, 3, 95% CI 1-6).
Providers: Intervention group (physicians notified of diabetes patients’ literacy status) were less satisfied (82%) than those receiving usual care (96%) (adjusted OR 0.2, 95% CI 0.1-0.5)
General Implications Public health should include and/or support complex, multi-faceted interventions, for adults with limited literacy, to improve:
Health-related self efficacy
Utilization of health care
Communication with health providers
**Public health decision makers should be aware that limited evidence (i.e. 1 study) is available for most of the outcomes described in this review.
General Implications
For adults with limited literacy:
The evidence does not recommend complex interventions for improving self-reported health status or quality of life.
The evidence cannot definitively recommend/reject complex interventions to address dietary outcomes, overall health knowledge and behaviours. However, the interventions appear to be effective in improving specific knowledge and behaviours, such as understanding key terms, medication dosage regimes and correct medication self-reporting.
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References
Rootman, I. & Gordon-El-Bihbety, D. (2008) A vision for a health literate Canada: Report of the Canadian Expert Panel on Health Literacy. Ottawa, ON: Canadian Public Health Association. Retrieved from http://www.cpha.ca/uploads/portals/h-l/report_e.pdf
Begoray, D., Gillis, D., Rowlands, G. (Eds.) (2012) Health Literacy in Context: International Perspectives. Nova Science Publishers, Inc., New York
Public Health Association of British Columbia. (2012). An inter-sectoral approach for improving health literacy for Canadians: A discussion paper. Victoria, BC: Author. Retrieved from http://www.phabc.org/userfiles/file/IntersectoralApproachforHealthLiteracy-FINAL.pdf
National Collaborating Centre for Determinants of Health. (2007). Scan of family literacy and health: Final report. Antigonish: NS: Author. Retrieved from http://nccdh.ca/resources/entry/scan-of-family-literacy-and-health