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Policymaker Summary – Mar. 7, 2011

Considering Low Health Literacy in the Development or Support of Patient & Consumer Information

Formats

Table of Contents

Key Policy Issue

While limited, evidence suggests that health care organizations can create information and education materials that mitigate the effects of low health literacy.

Improving Health Outcomes for Low Literacy Audiences

Low health literacy is a significant problem in the United States. In 2003, approximately 80 million adults in the U.S. (36 percent) had limited health literacy. Rates in certain population subgroups were higher, including the elderly, minorities, individuals who have not completed high school, adults who spoke a language other than English before starting school, and people living in poverty.

The negative effect of low or limited health literacy on the use of health services and on overall health outcomes is significant, especially for seniors.

In 2010, the United States Department of Health and Human Services created a National Action Plan to Improve Health Literacy. Among its goals, the plan calls for further research into interventions that mitigate the effects of low health literacy. The plan also encourages the use of evidence-based interventions among clinicians, health communicators, and health educators that can improve the health of this important audience.

While limited, research suggests that some strategies can improve patient or health consumer comprehension and choicemaking. Evidence also suggests that interventions employing multiple strategies can improve the utilization of some healthcare services, and can improve health outcomes for consumer and patient audiences with limited health literacy.

About the Research

An independent research team conducted an update of a 2004 systematic review of the evidence concerning health literacy outcomes and interventions.The review was conducted through support from the Agency for Healthcare Research and Quality (AHRQ). The update reviewed 132 individual studies. The conclusions of that update are the basis of this guide. An online version of this guide provides direct links to the full report as well as the original studies. It is available at www.effectivehealthcare.ahrq.gov/literacyhcguide.cfm.

Understanding the Need

The Effect of Low Health Literacy on Use of Services and Health Outcomes

Strength of Evidence Ratings

evidence high There are consistent results from good-quality studies. Further research is very unlikely to change the conclusions.
evidence medium Findings are supported, but further research could change the conclusions.
evidence low There are very few studies, or existing studies are flawed.

Evidence About Interventions for Low Literacy Audiences

Improving Comprehension and Choicemaking

While the overall rating of the evidence was low, the following single intervention strategies suggested promise for improving comprehension and/or quality of choice for low-health-literacy populations in one or more studies. Direct links to the original studies and interventions are available online.

Individual Strategy Example
Presenting essential information only. Presenting information on hospital death rates without other distracting information, such as information on consumer satisfaction.
Presenting essential information first. Presenting information on hospital death rates before information about consumer satisfaction.
Alternative numerical presentation.
Adding icon arrays to numerical presentations of treatment benefit. Use of pictographs to display benefit or risk ratios, and grouping icons by their representation rather than scatteredth roughout pictograph.
Using a reduced reading level. Writing materials at a 7th or 8th grade level or lower, using simple language and a larger font size.
Using video. Using video as an adjunct to verbal narative to increase the understanding of care options.
Using illustrated narratives. Using personal or third-person stories with corresponding illustrations.

Improving Use of Services and Health Outcomes

A moderate level of evidence exists to support a variety of communication/education interventions employing multiple strategies as being associated with improved health outcome or health services utilization. Direct links to the original studies and interventions are available online.

The Intervention Example Outcome (All Moderate Level of Confidence)
Intensive self-management and
adherence interventions.

Patients with heart failure received education on self-care emphasizing daily weight
measurement, diuretic dose self-adjustment, and symptom recognition and response.

Pharmacists provided a 9-month multilevel intervention to low-income patients on
multiple medications for heart failure.

Reduced emergency room visits,
hospitalizations, and mortality.
Educational interventions and/
or cues for screening..
Health care providers were trained in how to communicate to low literacy patients
and were given feedback on their rates of recommending specific screening tests.
Patients received a video, brochure, and simplified instructions for the at-home
test (if recommended).
Increased screening rates.
Intensive disease management
programs.
Individual meetings with a diabetes educator were followed by telephone or in-person
contact every 2 - 4 weeks.
Reduced disease severity, improved
measures of disease.
The evidence is insufficient to draw conclusions about the impact of multiple strategy interventions on knowledge, self-efficac, yadherence, health-related skills, quality of life, or cost. Results across studies were mixed. With these multi-faceted interventions it is not possible to identify the effectiveness of any single component on the overall outcome.

General Observations From Research

  1. Several common features of successful interventions may be important in designing interventions that mitigate the effects of low health literacy, such as improving self-management, and reducing rates of hospitalizations and mortality. These include:
    • Basing the program or intervention on theory.
    • Designing programs of high intensity.
    • Emphasizing skill-building within the program or intervention.
    • Using health professionals to deliver the information.
    • Pilot testing before implementation of the program or intervention.
  2. Effective interventions that mitigate the effects of low health literacy may work by focusing on three intermediate outcomes:

Implications for Policymakers

  • Consideration of the health literacy level for the intended audience receiving materials and/or interventions is warranted.
  • Requiring health organizations that produce or support patient/consumer materials to employ evidence-based strategies that mitigate the efects of low health literacy is warranted.
  • There may be benefit to piloting intensive, clinician-delivered selfmanagement or disease management interventions to determine if these might yield improved health status among low-literacy patients and consumers.

Conclusion

Awareness of the prevalence and impact of low health literacy is critical for organizations producing health information and education materials and interventions for patients and consumers. The use of evidence-based approaches is warranted to improve the health outcomes for individuals with low or limited health literacy.

Source

Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Viera A, Crotty K, Holland A, Brasure M, Lohr KN, Harden E, Tant E, Wallace I, Viswanathan M. Health Literacy Interventions and Outcomes: An Updated Systematic Review. Evidence Report/Technology Assesment No. 199. (Prepared by RTI International–University of North Carolina Evidence-based Practice Center under contract No. 290-2007-10056-I. AHRQ Publication Number 11-E006. Rockville, MD. Agency for Healthcare Research and Quality. March 2011. 

This summary was prepared by the John M. Eisenberg Center for Clinical Decisions and Communications Science at Baylor College of Medicine, Houston, TX. It was written by Thomas Workman, Ph.D. and Michael Fordis, M.D. 

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