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Interventions to improve health outcomes for patients with low literacy

A systematic review

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Abstract

OBJECTIVE: To perform a systematic review of interventions designed to improve health outcomes for persons with low literacy skills.

DATA SOURCES: We searched MEDLINE, Cumulative Index to Nursing and Allied Health (CINAHL), Educational Resources Information Center (ERIC), Public Affairs Information Service (PAIS), Industrial and Labor Relations Review (ILLR), PsycInfo, and Ageline from 1980 to 2003.

STUDY SELECTION: We included controlled and uncontrolled trials that measured literacy and examined the effect of interventions for people with low literacy on health outcomes, including health knowledge, health behaviors, use of health care resources, intermediate markers of disease status, and measures of morbidity or mortality. Two abstractors reviewed each study for inclusion. Disagreements were resolved by consensus among the research team.

DATA EXTRACTION: One reviewer abstracted data from each article into an evidence table; the second reviewer checked each entry. Disagreements about information in evidence tables were resolved by team consensus. Both data extractors independently completed an 11-item quality scale for each article; scores were averaged to give a final measure of article quality.

DATA SYNTHESIS: We identified 20 articles examining interventions designed to improve health among people with low literacy. The most common outcome studied was health knowledge; fewer studies examined health behaviors, intermediate markers, or measures of disease prevalence or severity. The effectiveness of interventions appeared mixed. Limitations in research quality and heterogeneity in outcome measures make drawing firm conclusions about effective strategies difficult. Only 5 articles examined the interaction between literacy level and the effect of the intervention; they also found mixed results.

CONCLUSIONS: Several interventions have been developed to improve health for people with low literacy. Limitations in study design, interventions tested, and outcomes assessed make drawing conclusions about effectiveness difficult. Further research is required to understand better the types of interventions that are most effective and efficient for overcoming literacy-related barriers to good health.

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References

  1. Kirsch I, Jungeblut A, Jenkins L, Kolstat A. Adult literacy in America: a first look at the findings of the national adult literacy survey. 2002;1–201.

  2. Berkman ND, Dewalt DA, Pignone MP, et al. (RTI International-University of North Carolina Evidence-based Practice Center): Literacy and health outcomes: evidence report/technology assessment number. Available at: http://www.ahrq.gov/clinic/litinv.htm. Accessed February 13, 2004.

  3. DeWalt DA, Berkman ND, Sheridan SL, Lohr KN, Pignone M. Literacy and health outcomes: a systematic review of the literature. J Gen Intern Med. 2004;19:1228–39.

    Article  PubMed  Google Scholar 

  4. Nielsen-Bohlman L, Panzer AM, Kindig DA. Health literacy: a prescription to end confusion. Available at: http://www.nap.edu/books/0309091179/html/. Accessed February 11, 2004.

  5. Selden CR, Zorn M, Ratzan S, Parker RM. Health literacy [bibliography online]. Current Bibliographies in Medicine; no. 2000-1. Vol. 2003. National Library of Medicine. Available at: http://www.nlm.nih.gov/pubs/cbm/hliteracy.html. Accessed March 2, 2004.

  6. Rudd RE, Colton T, Schacht R (National Center for the Study of Adult Learning and Literacy). An overview of the medical and public health literature addressing literacy issues: an annotated bibliography. Available at: http://www.hsph.harvard.edu/healthliteracy/litreview.pdf. Accessed March 3, 2004.

  7. West SL, King V, Carey TS (Agency for Healthcare Research and Quality). Systems to rate the strength of scientific evidence. Available at: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat1.chapter.70996. Accessed February 15, 2004.

  8. Lillington L, Royce J, Novak D, Ruvalcaba M, Chlebowski R. Evaluation of a smoking cessation program for pregnant minority women. Cancer Pract. 1995;3:157–63.

    PubMed  CAS  Google Scholar 

  9. Mulrow C, Bailey S, Sonksen PH, Slavin B. Evaluation of an audiovisual diabetes education program: negative results of a randomized trial of patients with non-insulin-dependent diabetes mellitus. J Gen Intern Med. 1987;2:215–9.

    Article  PubMed  CAS  Google Scholar 

  10. Fitzgibbon ML, Stolley MR, Avellone ME, Sugerman S, Chavez N. Involving parents in cancer risk reduction: a program for Hispanic American families. Health Psychol. 1996;15:413–22.

    Article  PubMed  CAS  Google Scholar 

  11. Aill-Harvey D, Rippey R, Abeles M, et al. Outcome of an osteoarthritis education program for low-literacy patients taught by indigenous instructors. Patient Educ Couns. 1989;13:133–42.

    Article  Google Scholar 

  12. Fouad MN, Kiefe CI, Bartolucci AA, Burst NM, Ulene V, Harvey MR. A hypertension control program tailored to unskilled and minority workers. Ethn Dis. 1997;7:191–9.

    PubMed  CAS  Google Scholar 

  13. Jacobson TA, Thomas DM, Morton FJ, Offutt G, Shevlin J, Ray S. Use of a low-literacy patient education tool to enhance pneumococcal vaccination rates. A randomized controlled trial. JAMA. 1999;282:646–50.

    Article  PubMed  CAS  Google Scholar 

  14. Gans K, Lovell H, Fortunet R. Low-literacy audio intervention for lowering fat intake. J Nutr Educ. 1998;30:410B.

  15. Powell EC, Tanz RR, Uyeda A, Gaffney MB, Sheehan KM. Injury prevention education using pictorial information. Pediatrics. 2000;105:e16.

    Google Scholar 

  16. Hugo J, Skibbe A. Facing visual illiteracy in South African health education: a pilot study. J Audiov Media Med. 1991;14:47–50.

    PubMed  CAS  Google Scholar 

  17. Davis TC, Bocchini JA Jr, Fredrickson D, et al. Parent comprehension of polio vaccine information pamphlets. Pediatrics. 1996;97:804–10.

    PubMed  CAS  Google Scholar 

  18. Davis TC, Fredrickson DD, Arnold C, Murphy PW, Herbst M, Bocchini JA. A polio immunization pamphlet with increased appeal and simplified language does not improve comprehension to an acceptable level. Patient Educ Couns. 1998;33:25–37.

    Article  PubMed  CAS  Google Scholar 

  19. Davis TC, Holcombe RF, Berkel HJ, Pramanik S, Divers SG. Informed consent for clinical trials: a comparative study of standard versus simplified forms. J Natl Cancer Inst. 1998;90:668–74.

    Article  PubMed  CAS  Google Scholar 

  20. Eaton ML, Holloway RL. Patient comprehension of written drug information. Am J Hosp Pharm. 1980;37:240–3.

    PubMed  CAS  Google Scholar 

  21. Kim SP, Knight SJ, Tomori C, et al. Health literacy and shared decision making for prostate cancer patients with low socioeconomic status. Cancer Invest. 2001;19:684–91.

    Article  PubMed  CAS  Google Scholar 

  22. Meade CD, McKinney WP, Barnas GP. Educating patients with limited literacy skills: the effectiveness of printed and videotaped materials about colon cancer. Am J Public Health. 1994;84:119–21.

    Article  PubMed  CAS  Google Scholar 

  23. Michielutte R, Bahnson J, Dignan MB, Schroeder EM. The use of illustrations and narrative text style to improve readability of a health education brochure. J Cancer Educ. 1992;7:251–60.

    Article  PubMed  CAS  Google Scholar 

  24. Hayes KS. Randomized trial of geragogy-based medication instruction in the emergency department. Nurs Res. 1998;47:211–8.

    Article  PubMed  CAS  Google Scholar 

  25. Murphy PW, Davis TC, Mayeaux EJ, Sentell T, Arnold C, Rebouche C. Teaching nutrition education in adult learning centers: linking literacy, health care, and the community. J Community Health Nurs. 1996;13:149–58.

    Article  PubMed  CAS  Google Scholar 

  26. Murphy PW, Chesson AL, Walker L, Arnold CL, Chesson LM. Comparing the effectiveness of video and written material for improving knowledge among sleep disorders clinic patients with limited literacy skills. South Med J. 2000;93:297–304.

    PubMed  CAS  Google Scholar 

  27. Wydra EW. The effectiveness of a self-care management interactive multimedia module. Oncol Nurs Forum. 2001;28:1399–407.

    PubMed  CAS  Google Scholar 

  28. Howard-Pitney B, Winkleby MA, Albright CL, Bruce B, Fortmann SP. The Stanford Nutrition Action Program: a dietary fat intervention for low-literacy adults. Am J Public Health. 1997;87:1971–6.

    PubMed  CAS  Google Scholar 

  29. Hussey LC. Minimizing effects of low literacy on medication knowledge and compliance among the elderly. Clin Nurs Res. 1994;3:132–45.

    Article  PubMed  CAS  Google Scholar 

  30. Hartman TJ, McCarthy PR, Park RJ, Schuster E, Kushi LH. Results of a community-based low-literacy nutrition education program. J Community Health. 1997;22:325–41.

    Article  PubMed  CAS  Google Scholar 

  31. Kumanyika SK, Adams-Campbell L, Van Horn B, et al. Outcomes of a cardiovascular nutrition counseling program in African-Americans with elevated blood pressure or cholesterol level. J Am Diet Assoc. 1999;99:1380–91.

    Article  PubMed  CAS  Google Scholar 

  32. Davis TC, Berkel HJ, Arnold CL, Nandy I, Jackson RH, Murphy PW. Intervention to increase mammography utilization in a public hospital. J Gen Intern Med. 1998;13:230–3.

    Article  PubMed  CAS  Google Scholar 

  33. Pepe MV, Chodzko-Zajko WJ. Impact of older adults’ reading ability on the comprehension and recall of cholesterol information. J Health Educ. 1997;28:21–7.

    Google Scholar 

  34. Raymond EG, Dalebout SM, Camp SI. Comprehension of a prototype over-the-counter label for an emergency contraceptive pill product. Obstet Gynecol. 2002;100:342–9.

    Article  PubMed  Google Scholar 

  35. Coleman EA, Coon S, Mohrmann C, et al. Developing and testing lay literature about breast cancer screening for African American women. Clin J Oncol Nurs. 2003;7:66–71.

    PubMed  Google Scholar 

  36. Poresky RH, Daniels AM. Two-year comparison of income, education, and depression among parents participating in regular Head Start or supplementary Family Service Center Services. Psychol Rep. 2001;88:787–96.

    Article  PubMed  CAS  Google Scholar 

  37. Parker RM, Baker DW, Williams MV, Nurss JR. The test of functional health literacy in adults: a new instrument for measuring patients’ literacy skills. J Gen Intern Med. 1995;10:537–41.

    Article  PubMed  CAS  Google Scholar 

  38. Wilkinson GS. Wide-range Achievement Test: Administration Manual. Wilmington, DE: Wide Range, Inc.; 1993.

    Google Scholar 

  39. Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163:83–90.

    Article  PubMed  Google Scholar 

  40. Rothman R, Malone R, Bryant B, Horlen C, Pignone M. Pharmacistled, primary care-based disease management improves hemoglobin Alc in high-risk patients with diabetes. Am J Med Qual. 2003;18:51–8.

    Article  PubMed  Google Scholar 

  41. Schillinger D. Improving the quality of chronic disease management for populations with low functional health literacy: a call to action. Dis Manag. 2003;4:103–9.

    Article  Google Scholar 

  42. DeWalt DA, Pignone MP, Malone R. Development and pilot testing of a disease management program for low literacy patients with heart failure. Patient Educ Couns. 2004;55:78–86.

    Article  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Division of General Internal Medicine and Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA

    Michael Pignone MD, MPH, Darren A. DeWalt MD & Stacey Sheridan MD, MPH

  2. Robert Wood Johnson Clinical Scholars Program, University of North Carolina, Chapel Hill, NC, USA

    Darren A. DeWalt MD

  3. RTI International, Research Triangle Park, NC, USA

    Nancy Berkman PhD & Kathleen N. Lohr PhD

Authors
  1. Michael Pignone MD, MPH
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  2. Darren A. DeWalt MD
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  3. Stacey Sheridan MD, MPH
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  4. Nancy Berkman PhD
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  5. Kathleen N. Lohr PhD
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Corresponding author

Correspondence to Michael Pignone MD, MPH.

Additional information

Drs. Pignone and DeWalt have received research funding from Pfizer, Inc. for literacy-related research.

Supported by a contract to the Agency for Healthcare Research and Quality (290-02-0016), Rockville, MD.

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Pignone, M., DeWalt, D.A., Sheridan, S. et al. Interventions to improve health outcomes for patients with low literacy. J GEN INTERN MED 20, 185–192 (2005). https://doi.org/10.1111/j.1525-1497.2005.40208.x

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  • DOI: https://doi.org/10.1111/j.1525-1497.2005.40208.x

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