Health literacy interventions

Health literacy is the degree to which people have the capacity to obtain, process, and understand basic health information and services required to make appropriate health decisions (Ratzan 2000). Low levels of health literacy are associated with limited health-related knowledge, poor health outcomes, and behaviors such as limited use of preventive care (AHRQ-Berkman 2011, AHRQ-Berkman 2004), as well as higher health care costs and expenditures (Eichler 2009). Elderly individuals, those with low levels of income and education, and racial and ethnic minority groups are at higher risk of having low health literacy (NCES-Kutner 2006, Eichler 2009). Approaches to addressing limited health literacy include improving patient-provider communication, simplifying health information in educational materials, eHealth interventions (i.e., PCs and tablets with videos & interactive self-help tools), and efforts to improve underlying health literacy skills, such as the ability to read. These approaches can be delivered by various health care providers, clinic staff, and public health professionals (AHRQ-Berkman 2011, , Pignone 2005).

Expected Beneficial Outcomes (Rated)

  • Improved health-related knowledge

  • Improved adherence to treatment

Other Potential Beneficial Outcomes

  • Improved patient-provider communication

  • Improved mental health

  • Increased patient satisfaction

Evidence of Effectiveness

There is some evidence that interventions designed to address limited health literacy increase health-related knowledge (Perazzo 2017Brainard 2016Brijnath 2016DeWalt 2009Pignone 2005) and comprehension (Sheridan 2011), and improve adherence to treatment (Perazzo 2017Miller 2016). Additional evidence is needed to confirm effects and determine which interventions are most effective.

Health literacy interventions that use written and print-based materials designed to be easy to read and understand have been shown to increase health-related knowledge among children and adults more than traditional materials (DeWalt 2009, Pignone 2005). Primary care-based group education programs designed to be sensitive to health literacy limitations also appear to increase knowledge among adults (Brega 2013). Health literacy programs for older adults offered in community settings can build capacity to access and apply relevant health information (). Similarly, broader health intervention programs tailored for older adults and designed to be sensitive to health literacy limitations can increase participants’ knowledge and capacity to find relevant health information (Brainard 2016). More intense interventions appear to increase the likelihood of improvement (Dennis 2012).

Health literacy interventions that combine multiple approaches (e.g., written and visual materials that are easy to read and understand, video tutorials, health literacy training for physicians, and in-person patient assessments) appear to increase patients’ comprehension and appropriate use of health care (Sheridan 2011). Interventions that use multi-media approaches, focus on interpersonal interactions (), or face-to-face communication appear to promote improved communication between patients and providers (Miller 2016). Health literacy interventions that use technology or the internet (i.e., eHealth interventions) can increase knowledge of HIV (Perazzo 2017), colorectal cancer (), and mental health conditions such as post-traumatic stress disorder (PTSD) (Brijnath 2016). Web-based interventions can reduce symptoms of depression and anxiety (Brijnath 2016).

Health literacy interventions can improve adherence to medical treatment, particularly for patients following non-medication regimens or with cardiovascular disease (Miller 2016). Benefits appear greater for minorities and individuals with low incomes than for non-Hispanic whites and those with higher incomes (Miller 2016, Mantwill 2015). Interventions that include in-person counseling with interactive or technology-assisted education can also increase treatment adherence for those taking HIV medications (Perazzo 2017).

Health literacy interventions that include skills-building in communication and self-management techniques can increase patient satisfaction and improve chronic disease management for older adults (Brainard 2016). Health literacy-sensitive diabetes self-management interventions may reduce HbA1C levels, particularly for patients with low health literacy levels ().

Tailoring interventions to minorities, those with low levels of education, or limited experience with computers can promote patient engagement (). Classes that teach participants how to access health information on the internet may increase self-efficacy in health information seeking and health information comprehension, improving the ability to find, evaluate, and use online health information ().

Experts suggest that health care providers may have difficulty accurately identifying patients’ health literacy limitations (, ) and recommend that medical educators train medical students and residents to assess health literacy for all patients ().

Impact on Disparities

Likely to decrease disparities

Implementation Examples

The US Department of Health and Human Services, the National Academies of Medicine, the American Medical Association, and the National Institutes of Health promote health literacy as a research priority (CDC-NCHS 2012). Federal initiatives including the Affordable Care Act (ACA), the National Action Plan to Improve Health Literacy, the Plain Writing Act (), and Healthy People 2020 also emphasize health literacy (CDC-Healthy People 2020 HL). 

There are a number of statewide programs that aim to improve health literacy; at least 20 states maintain health literacy coalitions or working groups, including Arizona, Kentucky, Ohio, and Texas (CDC-Health literacy). Specific examples include the North Carolina Program on Health Literacy (NCPHL), the Colorado Health Literacy Coalition (Colorado-HL), and Engage for Health, a Pennsylvania-based program that uses the Agency for Healthcare Research and Quality’s (AHRQ’s) “Questions are the Answer” patient engagement tools and resources (AHRQ-Tools).

Research organizations such as the University of Michigan Taubman Health Sciences Library, Duke University Medical Center, and the Harvard T.H. Chan School of Public Health provide information and training materials for patients, providers, and educators on strategies to improve health literacy (UM-HL resources, Duke-HL, Harvard-Health literacy). Students may also receive specific training in health literacy; the University of Missouri, for example, offers an online Health Literacy Certificate Program at the undergraduate level (MU-Health literacy).

Implementation Resources

CDC-Health literacy - Centers for Disease Control and Prevention (CDC). Health literacy: Accurate, accessible and actionable health information for all.

AHRQ-Health literacy toolkit - Brega AG, Barnard J, Mabachi NM, et al. AHRQ Health literacy universal precautions toolkit, 2nd edition. Rockville: Agency for Healthcare Research and Quality (AHRQ); 2015.

HRSA-Health literacy - Health Resources and Services Administration (HRSA). Health literacy.

NNLM-Health literacy - National Network of Libraries of Medicine (NN/LM). Health literacy.

CDC-Cross-cultural tools - Centers for Disease Control and Prevention (CDC). Tools for Cross-Cultural Communication and Language Access Can Help Organizations Address Health Literacy and Improve Communication Effectiveness.

AHRQ-Teach-Back - Agency for Healthcare Research and Quality (AHRQ). Teach-Back intervention: Patient and family engagement in primary care.

Georgetown-Patient education - Georgetown University, School of Nursing and Health Studies. Nursing @ Georgetown. Back to school: Patient education.

Harvard-Health literacy - Harvard T.H. Chan School of Public Health, Department of Social and Behavioral Sciences. Health literacy studies.

AHRQ-Shoemaker 2014 - Shoemaker S, Wolf M, Brach C. The patient education materials assessment tool (PEMAT) and user’s guide: An instrument to assess the understandability and actionability of print and audiovisual patient education materials. Rockville: Agency for Healthcare Research and Quality (AHRQ); 2014.

PLAIN - The Plain Language Action and Information Network (PLAIN). Plain language in healthcare. An official website of the US government.

Citations - Evidence

* Journal subscription may be required for access.

DeWalt 2009 - DeWalt DA, Hink A. Health literacy and child health outcomes: A systematic review of the literature. Pediatrics. 2009;124(Suppl 3):S265-74.

Pignone 2005 - Pignone M, DeWalt DA, Sheridan S, Berkman N, Lohr KN. Interventions to improve health outcomes for patients with low literacy: A systematic review. Journal of General Internal Medicine. 2005;20(2):185-92.

Sheridan 2011 - Sheridan SL, Halpern DJ, Viera AJ, et al. Interventions for individuals with low health literacy: A systematic review. Journal of Health Communication. 2011;16(Suppl 3):30-54.

Wilson 2012a* - Wilson EA, Makoul G, Bojarski EA, et al. Comparative analysis of print and multimedia health materials: A review of the literature. Patient Education and Counseling. 2012;89(1):7-14.

Manafo 2012* - Manafo E, Wong S. Health literacy programs for older adults: A systematic literature review. Health Education Research. 2012;27(6):947–60.

Cochrane-Car 2011* - Car J, Lang B, Colledge A, Ung C, Majeed A. Interventions for enhancing consumers’ online health literacy. Cochrane Database of Systematic Reviews. 2011;(6):CD007092.

Dennis 2012 - Dennis S, Williams A, Taggart J, et al. Which providers can bridge the health literacy gap in lifestyle risk factor modification education: A systematic review and narrative synthesis. BMC Family Practice. 2012;13(1):44.

Perazzo 2017 - Perazzo J, Reyes D, Webel A. A systematic review of health literacy interventions for people living with HIV. AIDS and Behavior. 2017;21(3):812-821.

Kim 2016b* - Kim SH, Lee A. Health-literacy-sensitive diabetes self-management interventions: A systematic review and meta-analysis. Worldviews on Evidence-Based Nursing. 2016;13(4):324-333.

Brainard 2016 - Brainard J, Loke Y, Salter C, et al. Healthy ageing in Europe: Prioritizing interventions to improve health literacy. BMC Research Notes. 2016;9(1):270.

Jacobs 2014a* - Jacobs RJ, Lou JQ, Ownby RL, Caballero J. A systematic review of eHealth interventions to improve health literacy. Health Informatics Journal. 2016;22(2):81-98.

Miller 2016 - Miller TA. Health literacy and adherence to medical treatment in chronic and acute illness: A meta-analysis. Patient Education and Counseling. 2016;99(7):1079-1086.

Brijnath 2016 - Brijnath B, Protheroe J, Mahtani KR, Antoniades J. Do web-based mental health literacy interventions improve the mental health literacy of adult consumers? Results from a systematic review. Journal of Medical Internet Research. 2016;18(6):e165.

Brega 2013 - Brega AG, Pratte KA, Jiang L, et al. Impact of targeted health promotion on cardiovascular knowledge among American Indians and Alaska Natives. Health Education Research. 2013;28:437-449.

Mantwill 2015 - Mantwill S, Monestel-Umana S, Schulz PJ. The relationship between health literacy and health disparities: A systematic review. PLoS ONE. 2015;10(12):e0145455.

Kelly 2007* - Kelly PA, Haidet P. Physician overestimation of patient literacy: A potential source of health care disparities. Patient Education and Counseling. 2007;66(1):119-122.

Rogers 2006* - Rogers ES, Wallace LS, Weiss BD. Misperceptions of medical understanding in low-literacy patients: Implications for cancer prevention. Cancer Control. 2006;13(3):225-229.

Citations - Implementation Examples

* Journal subscription may be required for access.

CDC-NCHS 2012 - Centers for Disease Control and Prevention (CDC). Healthy People 2010 final review. National Center for Health Statistics (NCHS). 2012.

CDC-Health literacy - Centers for Disease Control and Prevention (CDC). Health literacy: Accurate, accessible and actionable health information for all.

NCPHL - NC Program on Health Literacy (NCPHL). North Carolina program on health literacy.

Koh 2012* - Koh HK, Berwick DM, Clancy CM, et al. New federal policy initiatives to boost health literacy can help the nation move beyond the cycle of costly “crisis care.” Health Affairs. 2012;31(2):434-43.

AHRQ-Tools - Agency for Healthcare Research and Quality (AHRQ). AHRQ tools help consumers across Pennsylvania take an active role in their health care.

UM-HL resources - University of Michigan (UM), Taubman Health Sciences Library (THSL). Improving health literacy (HL): Training resources.

Duke-HL - Duke University Medical Center Library and Archives. Health literacy (HL): initiatives, research, and tools for patients, clinicians, multi-lingual patients, and educators.

CDC-Healthy People 2020 HL - Centers for Disease Control and Prevention (CDC). Healthy People 2020. Health communication and health information technology objectives: Improve the health literacy (HL) of the population.

Colorado-HL - Colorado Health Literacy Coalition. Assist the Colorado community with health navigation, promote wellness, and achieve quality outcomes.

MU-Health literacy - University of Missouri (MU). Mizzou Online. Health literacy: Online courses and undergraduate dean's certificate.

Harvard-Health literacy - Harvard T.H. Chan School of Public Health, Department of Social and Behavioral Sciences. Health literacy studies.

Date Last Updated

May 23, 2019