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Center for Health Literacy Promotion Blog

Research Review - Health Literacy for Prevention: Improvement Requires Intense Intervention

SNAPW: Improve these behaviors to prevent chronic disease
Smoking, Nutrition, Alcohol, Physical activity, Weight
To find out which providers can improve health literacy for prevention,  Australian researchers completed a systematic review of quantitative studies (What works?) and narrative synthesis of qualitative work (Why? How?). The review covers research published 1985 to 2009, much of which was done by US researchers. The authors focused on “members of the primary care team” —providers working in general and family practice, community health, home nursing, private or public allied health, health education, or information— and evaluated  their effectiveness in promoting positive change in health literacy and SNAPW behaviors. 

The researchers ran into some issues that I’ve come up against in an ongoing scoping review  to discover what is known about the impact of mothers’ health literacy on maternal-child health. Health literacy and related concepts are poorly indexed, so it is necessary to search on lots of terms. The Aussies wrestled 4691 papers down to 94. We started with 2600+ and are still wrestling. There are many varied outcome measures. There are 50+ instruments to measure functional heath literacy (reading & math) and none to measure interactive or critical health literacy.  Nonetheless, this research report is on my must-read list.
Take Home Messages
1.    Health literacy can be improved; 71% of reviewed studies demonstrated improvement in health literacy.  (A round of applause for the researchers who published what did not work.)    Some interventions improved health literacy (measured as knowledge, skill, attitude, self-efficacy, states of change, motivation, or patient activation) without affecting behaviors. This result supports other findings that knowledge and skill do not necessary translate to health promoting action; people make informed choices to not act on what they know.   On the other hand, some interventions resulted in improved behavior (smoking) without affecting health literacy; that supports previous findings that specific knowledge may not be a prerequisite for behavior change. One RCT* found that brief counseling by a physician led to increased patient action, but only those who were referred to group programs demonstrated improvement in diet and weight.  I suspect that improvement in one health literacy indicator is insufficient to support behavior change, which likely requires some combination of knowledge and skills and motivations and self-efficacy and social support.

2.    Non-physician providers are effective health literacy promoters. Nine of 10 interventions provided by nurses, dietitians, health educators (92%) or multidisciplinary teams (91%) improved health literacy. Compare that to three of nine (33%) interventions provided by physicians.

3.    Intensity of the intervention seems to be the difference. One study found the average length of visit with a primary care physician was 8 minutes shorter than the time it takes to deliver smoking cessation counseling. Indeed, time was the barrier to improving health literacy most frequently mentioned mentioned by providers, followed by attitudes and beliefs. Most physician-delivered interventions were brief, one-time encounters. In comparison, interventions delivered by non-medical service providers ranged from 6 hours to 2 years. Limited time in clinical settings may preclude the trusting relationship required to support behavior change.     
Conclusion: Moderate to high intensity interventions are needed to address SNAPW behaviors.  Production demands in primary care settings (see 30 patients a day) limit physicians to brief interventions that can increase knowledge and motivate patient action but rarely result in improved behaviors.

Call to Action
Clinicians:  to improve health literacy for prevention of chronic disease, collaborate with-, refer to- and promote participation in intensive programs led by other health professionals and paraprofessionals.

Health educators, home visitors, community health workers, dietitians, public health nurses, social workers, case managers, parent educators, program directors: collaborate with clinicians to integrate health literacy promotion into your usual activities, organize referral relationships, bridge home and healthcare.
*RCT: Randomized Controlled Trial
Dennis S, Williams, A, Taggart J, et al. (2012). Which providers can bridge the health literacy gap in lifestyle risk factor modification education: a systematic review and narrative synthesis. BMC Family Practice. 13:44. 91 citations.  Open Access. Free at

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