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Welcome!
Improving the Health
of Adults with
Limited Literacy:
What’s the evidence?
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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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This webinar has been made possible with support from the
Canadian Institutes of Health Research
Welcome!
Improving the Health
of Adults with
Limited Literacy:
What’s the evidence?

The Health Evidence Team
Kara DeCorby Heather Husson Jennifer Yost
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Maureen Dobbins
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Lori Greco Robyn Traynor Lyndsey McRae
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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  Videos
 Verbal presentation  Audiotapes
 Material in simplified language  Checking for understanding
 Pictorial information  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*
*Only the primary outcomes from each study are
 Clinical Outcomes addressed in this evidence table. Review authors reported
on primary and secondary outcomes but only included
 Health Knowledge data for primary outcomes.
 Health Behaviours
 Self-Reported Health Status / Quality of Life
 Health-Related Self-Efficacy / Confidence
 Utilization of Health Care
 Health Provider Behaviour / Skills
 Satisfaction Levels

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.

Questions?

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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