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Unformatted text preview: Evidence Report/Technology Assessment Number 199 Health Literacy Interventions and Outcomes: An Updated Systematic Review Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 540 Gaither Road Rockville, MD 20850 Contract No. 290-2007-10056-I Prepared by: RTI International–University of North Carolina Evidence-based Practice Center Research Triangle Park, North Carolina Investigators: Nancy D. Berkman, Ph.D., M.L.I.R. Stacey L. Sheridan, M.D., M.P.H. Katrina E. Donahue, M.D., M.P.H. David J. Halpern, M.D., M.P.H. Anthony Viera, M.D., M.P.H. Karen Crotty, Ph.D., M.P.H. Audrey Holland, M.P.H. Michelle Brasure, Ph.D. Kathleen N. Lohr, Ph.D. Elizabeth Harden, M.P.H. Elizabeth Tant, B.A. Ina Wallace, Ph.D. Meera Viswanathan, Ph.D. AHRQ Publication No. 11-E006 March 2011 This document is in the public domain and may be used and reprinted without special permission. Citation of the source is appreciated. None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report. Suggested citation: 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 Evidencebased Practice Center under contract No. 290-2007-10056-I. AHRQ Publication Number 11E006. Rockville, MD. Agency for Healthcare Research and Quality. March 2011. This report is based on research conducted by the RTI International–University of North Carolina at Chapel Hill, North Carolina (RTI-UNC) Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2007-10056-I). The findings and conclusions in this document are those of the author(s), who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this article should be construed as an official position of the Agency for Healthcare Research and Quality or of the U.S. Department of Health and Human Services. The information in this report is intended to help health care decision-makers, patients and clinicians, health system leaders, and policymakers make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients. This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied. ii Preface The Agency for Healthcare Research and Quality (AHRQ), through its Evidence-based Practice Centers (EPCs), sponsors the development of evidence reports and technology assessments to assist public- and private-sector organizations in their efforts to improve the quality of health care in the United States. The reports and assessments provide organizations with comprehensive, science-based information on common, costly medical conditions and new health care technologies. The EPCs systematically review the relevant scientific literature on topics assigned to them by AHRQ and conduct additional analyses when appropriate prior to developing their reports and assessments. To bring the broadest range of experts into the development of evidence reports and health technology assessments, AHRQ encourages the EPCs to form partnerships and enter into collaborations with other medical and research organizations. The EPCs work with these partner organizations to ensure that the evidence reports and technology assessments they produce will become building blocks for health care quality improvement projects throughout the Nation. The reports undergo peer review prior to their release. AHRQ expects that the EPC evidence reports and technology assessments will inform individual health plans, providers, and purchasers as well as the health care system as a whole by providing important information to help improve health care quality. We welcome comments on this evidence report. They may be sent by mail to the Task Order Officer named below at: Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850, or by e-mail to [email protected] Carolyn M. Clancy, M.D. Director Agency for Healthcare Research and Quality Jean Slutsky, P.A., M.S.P.H. Director, Centre for Outcomes and Evidence Agency for Healthcare Research and Quality Marian James, Ph.D., M.A. EPC Program Task Order Officer Agency for Healthcare Research and Quality Stephanie Chang, M.D., M.P.H. Director, EPC Program Agency for Healthcare Research and Quality iii Acknowledgments This study was supported by Contract 290-2007-10056-I from the Agency for Healthcare Research and Quality (AHRQ), Task No. 5. We acknowledge the continuing support of Stephanie Chang, M.D., M.P.H., Director of the AHRQ Evidence-based Practice Center (EPC) Program, and Marian D. James, Ph.D., M.A., the AHRQ Task Order Officer for this project. We extend our appreciation to our Technical Expert Panel (TEP). All provided thoughtful advice and input during our research process. The TEP was both a substantive resource and a “sounding board” throughout the study. It was also the body from which expertise was formally sought at several junctions. The investigators would like to particularly thank Cindy Brach for her assistance in querying intervention study researchers. TEP members are listed below: Michael Paasche-Orlow, M.D., M.A., M.P.H. Internal Medicine, Boston University School of Medicine Boston, MA Cindy Brach, M.P.P. Agency for Healthcare Research and Quality Rockville, MD Darren DeWalt, M.D. Internal Medicine, University of North Carolina Chapel Hill, NC Sue Stableford, M.P.H., M.S.B. Health Literacy Institute, University of New England Portland, ME Marilyn Shapira, M.D., M.P.H. Medical College of Wisconsin Milwaukee, WI David Baker, M.D. Internal Medicine, Northwestern University Chicago, IL Rima Rudd, Sc.D. Harvard School of Public Health Boston, MA Joanne Schwartzberg, M.D. American Medical Association Chicago, IL The investigators deeply appreciate the considerable support, commitment, and contributions of the EPC team staff at RTI International and the University of North Carolina at Chapel Hill. We express our gratitude to Megan Van Noord, M.S.I.S., Christiane Voisin, M.S.L.S., and Lynn Whitener, M.S.L.S., Dr.P.H. our EPC Librarians; Loraine Monroe, our EPC publications specialist; Jennifer Drolet, M.A., our editor; and Linda Lux, M.P.A., the RTI-UNC Administrator. We would also like to thank Shrikant Bangdiwala, Ph.D. for his helpful consultation on questions related to statistical methodology included in the literature. Finally, we would like to thank Michael Pignone and Darren Dewalt, who were our collaborators on the original review we performed in 2004; our discussions and work with them provided a critical foundation for the current review. iv Health Literacy Interventions and Outcomes: An Updated Systematic Review Structured Abstract Objectives. To update a 2004 systematic review of health care service use and health outcomes related to differences in health literacy level and interventions designed to improve these outcomes for individuals with low health literacy. Disparities in health outcomes and effectiveness of interventions among different sociodemographic groups were also examined. Data sources. We searched MEDLINE,® the Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, PsychINFO, and the Educational Resources Information Center. For health literacy, we searched using a variety of terms, limited to English and studies published from 2003 to May 25, 2010. For numeracy, we searched from 1966 to May 25, 2010. Review methods. We used standard Evidence-based Practice Center methods of dual review of abstracts, full-text articles, abstractions, quality ratings, and strength of evidence grading. We resolved disagreements by consensus. We evaluated whether newer literature was available for answering key questions, so we broadened our definition of health literacy to include numeracy and oral (spoken) health literacy. We excluded intervention studies that did not measure health literacy directly and updated our approach to evaluate individual study risk of bias and to grade strength of evidence. Results. We included good- and fair-quality studies: 81 studies addressing health outcomes (reported in 95 articles including 86 measuring health literacy and 16 measuring numeracy, of which 7 measure both) and 42 studies (reported in 45 articles) addressing interventions. Differences in health literacy level were consistently associated with increased hospitalizations, greater emergency care use, lower use of mammography, lower receipt of influenza vaccine, poorer ability to demonstrate taking medications appropriately, poorer ability to interpret labels and health messages, and, among seniors, poorer overall health status and higher mortality. Health literacy level potentially mediates disparities between blacks and whites. The strength of evidence of numeracy studies was insufficient to low, limiting conclusions about the influence of numeracy on health care service use or health outcomes. Two studies suggested numeracy may mediate the effect of disparities on health outcomes. We found no evidence concerning oral health literacy and outcomes. Among intervention studies (27 randomized controlled trials [RCTs], 2 cluster RCTs, and 13 quasi-experimental designs), the strength of evidence for specific design features was low or insufficient. However, several specific features seemed to improve comprehension in one or a few studies. The strength of evidence was moderate for the effect of mixed interventions on health care service use; the effect of intensive self-management inventions on behavior; and the effect of disease-management interventions on disease prevalence/severity. The effects of other mixed interventions on other health outcomes, including knowledge, self-efficacy, adherence, and quality of life, and costs were mixed; thus, the strength of evidence was insufficient. Conclusions. The field of health literacy has advanced since the 2004 report. Future research priorities include justifying appropriate cutoffs for health literacy levels prior to conducting studies; developing tools that measure additional related skills, particularly oral (spoken) health v literacy; and examining mediators and moderators of the effect of health literacy. Priorities in advancing the design features of interventions include testing novel approaches to increase motivation, techniques for delivering information orally or numerically, “work around” interventions such as patient advocates; determining the effective components of already-tested interventions; determining the cost-effectiveness of programs; and determining the effect of policy and practice interventions. vi Contents Executive Summary .................................................................................................................ES-1 Introduction ....................................................................................................................................1 Health Literacy.....................................................................................................................1 Definition .................................................................................................................1 Burden of Low Literacy and Low Health Literacy ..............................................................1 Measuring Health Literacy ..................................................................................................3 Relationship Between Health Literacy and Outcomes ........................................................8 Effects of Interventions To Reduce Burden of Low Health Literacy ..................................9 Need for Update of the Earlier Review................................................................................9 Production of This Report ..................................................................................................10 Organization...........................................................................................................10 Technical Expert Panel ......................................................................................................10 Use of This Updated Systematic Review...........................................................................11 Methods .........................................................................................................................................12 Key Questions and Analytic Framework ...........................................................................15 Literature Search and Retrieval Process ............................................................................17 Database Search Terms ..........................................................................................17 Study Selection Process .....................................................................................................17 Inclusion and Exclusion Criteria............................................................................17 Process for Considering Abstracts and Full Articles for Inclusion....................................20 Literature Synthesis ...........................................................................................................21 Development of Evidence Tables and Data Abstraction Process ......................................21 Quality Rating of Individual Studies .................................................................................21 Data Synthesis ....................................................................................................................22 Grading the Strength of Available Evidence .....................................................................22 Applicability of the Evidence ............................................................................................23 Peer Review Process ..........................................................................................................23 Results: Relationship of Health Literacy to Outcomes and Disparities..................................24 Results of Literature Search ...............................................................................................26 Key Question 1. Relationship of Health Literacy to Various Outcomes and Disparities ..........................................................................................................................26 KQ 1a. Use of Health Care Services ......................................................................27 Summary of Outcomes on Use of Health Care Services ...................................................30 KQ 1b. Health Outcomes .......................................................................................30 Summary of Outcomes and Strength of Evidence on Health Outcomes ...........................39 KQ 1c. Costs of Health Care..................................................................................39 KQ 1d. Disparities in Health Outcomes or Health Care Service Use ....................40 Key Question 1. Relationship of Numeracy to Various Outcomes and Disparities ..........41 KQ 1a. Use of Health Care Services ......................................................................41 KQ 1b. Health Outcomes .......................................................................................42 KQ 1c. Costs ..........................................................................................................45 KQ 1d. Potential Mediator of Disparities ..............................................................45 The Effect of Interventions To Mitigate the Effects of Low Health Literacy ......................143 Introduction ......................................................................................................................143 Search Results ..................................................................................................................143 vii Study Quality ...................................................................................................................144 Characteristics of Included Studies ..................................................................................144 Effects of Health Literacy Interventions Using Single Strategies, by Intervention Type .................................................................................................................................144 Intervention: Alternative Document Design ........................................................144 Intervention: Alternative Numerical Presentation ...............................................145 Intervention: Additive and Alternative Pictorial Representation.........................146 Intervention: Alternative Media ...........................................................................148 Intervention: Alternative Readability and Document Design ..............................150 Intervention: Physician Notification of Patient Literacy Status ..........................151 Summary of Interventions Using Single Intervention Design Strategies ............151 Effects of Mixed Strategy Interventions, by Analytic Framework ..................................152 KQ 2a. Effect of Mixed Interventions on Use of Health Care Services ..............152 KQ 2b. Effect of Mixed Interventions on Health Outcomes ...............................153 KQ 2c. Effect of Mixed Interventions on Health Care Costs ..............................157 KQ 2d. Effect of Mixed Interventions on Disparities ..........................................158 Summary of Interventions Using Mixed Intervention Strategies ....................................158 Cross-Cutting Observations About Interventions Designed To Mitigate Low Health Literacy ............................................................................................................................158 Discussion....................................................................................................................................216 Overview ..........................................................................................................................216 Principal Findings ............................................................................................................216 KQ 1. Health Literacy and Outcomes ..................................................................216 KQ 2. Interventions To Improve Health Literacy................................................218 What This Update Adds to the Literature Included in the 2004 Review .........................220 Limitations .......................................................................................................................221 Limitations of the Literature ............................................................................................221 Limitations of Our Review ..............................................................................................222 Opportunities for Future Research ...................................................................
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