Community-Based Health Literacy Interventions Proceedings of a Workshop (2018) / Chapter Skim
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Appendix C: A Review and Report of Community-Based Health Literacy Interventions - by Cynthia Baur, Lourdes M. Martinez, Nedelina Tchangalova, and Don Rubin
Appendix C: A Review and Report of Community-Based Health Literacy Interventions - by Cynthia Baur, Lourdes M. Martinez, Nedelina Tchangalova, and Don Rubin
Pages 99-226
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Commissioned by the Roundtable on Health Literacy Health and Medicine Division National Academies of Sciences, Engineering, and Medicine 99
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Horowitz Center for Health Literacy School of Public Health University of Maryland, College Park, MD 20742 Phone: (301) 405-0388 Email: cbaur@umd.edu Lourdes M
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Alice M Horowitz, University of Maryland, College Park, for guidance on review design and comments on manuscript drafts; three coders who reviewed articles and prepared spreadsheets; and Heather Platter, M.S., University of Maryland, College Park, for help with coding and manuscript review and preparation.
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Conclusions: A wide range of community-based health literacy interventions provide qualitative and quantitative evidence of positive outcomes; knowledge change was the most common outcome. Interventions can be strengthened in a number of ways to continue to build the body of knowledge about when and how to best address health literacy in community interventions.
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The roundtable asked for a review that summarized previous work on community-based health literacy interventions; described new interventions; used a published evaluation framework to evaluate interventions; and reported intervention effect sizes, when available. To identify relevant publications, the roundtable also asked the review team to use broad definitions of "community" and "interventions" that could include policy and system levels as well as individual and group-level activities.
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If the sole "community" component was that researchers used an organization, such as a community hospital or community health center, to recruit individuals for an individual-based study, the review team excluded the paper. Studies with community health workers (CHWs)
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skills or processes that people can deploy in response to changing topics and circumstances, and the latter seeks to impart a non-transferable body of information about particular health conditions or practices; however, health education contributes to health literacy. METHODS The definition of "community-based health literacy intervention," along with the search terms used in 14 databases (see Tables C-1, C-2, and C-3)
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journals; (community OR communities) publication date AND AB (education OR 2010–2017; English awareness OR communication OR promotion OR knowledge OR skills OR understanding OR comprehension)
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8 PsycINFO Academic journals, SU "health literacy" AND 441 books, dissertations; (community OR communities) publication date AND AB education OR 2010–2017; English awareness OR communication OR promotion OR knowledge OR skills OR understanding OR comprehension)
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publication date AND AB (education OR 2010–2017; English awareness OR communication OR promotion OR knowledge OR skills OR understanding OR comprehension) NOT ("information literacy" OR "media literacy" OR "computer literacy" OR "digital literacy")
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AND 86 publication date (community OR communities) from 5/1/10 to AND AB(education OR 2017; English awareness OR communication OR promotion OR knowledge OR skills OR understanding OR comprehension)
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The following definitions guided the search strategy: • Community-based health literacy intervention: Any purposeful, organized activity to help a group of people find, understand, use, or communicate about health information, services, or issues for themselves or their communities. • Health literacy: Both how people find, process, understand, and communicate about health information and services to protect and promote their health, and how organizations and systems sup port or hinder people in these activities (modified definition from Healthy People, U.S.
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. The aim for the scoping review was to identify community-based health literacy interventions that have been developed, implemented, and evaluated after the Institute of Medicine health literacy report (IOM 2004)
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Only one author had published results, but the study was not included in the final results. The first two authors also identified twenty review articles; the librarian reviewed the reference lists and added studies that met the inclusion criteria.
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when the intervention did the intervention place happened and any location details, such as city, happen? state, or country names; if none provided, record "none." NOTES: All coding is about the intervention and its results, not an evaluation of the intervention (e.g., for the "description" coding label, describe the intervention, not the evaluation of the intervention; record the intervention reach, not the evaluation reach)
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What are the Benefits/risks Record any author statements about how the intervention's intended target population benefited from benefits or risks? the intervention or was put at risk or harmed by the intervention; if no author statements, record "none." Does the Health equity Record any author statements about how intervention the intervention affected health disparities or promote health health equity; if no author statements, record equity?
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author statements, record "none." continued
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2013) , and the Guide to Community Preventive Services study design categories (HHS 2001)
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. Of the included papers, 55 reported that the intervention communities were selected because of health literacy concerns; 63 reported that health literacy principles or techniques were used for content or program development; 54 used health literacy measures; and 53 included health literacy outcome information (Note: one paper could include one to four of the health literacy elements)
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118 COMMUNITY-BASED HEALTH LITERACY INTERVENTIONS Records identified through Additional records identified Identification database searching through other sources (n = 4,939)
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. Another achieved very large magnitude increases in breast cancer and cervical cancer screening among Korean Americans by conducting a single educational session led by community health workers (Han et al.
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120 COMMUNITY-BASED HEALTH LITERACY INTERVENTIONS TABLE C-8 Included Studies Author Community Setting Topic Intervention Anderson Intervention Football/netball Mental health Community MHL and Pierce focused on coach training program focused on 2012 coaches and in rural Victoria, sports team coaches leaders of Australia and other club sports teams leaders to assist as a means them in providing of reaching Mental Health particularly First Aid (MHFA) young males by improving their in rural understanding communities of mental health who might conditions, otherwise not increasing their be reached by confidence to assist a mental health those with mental literacy (MHL)
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APPENDIX C 121 Health Literacy Component Study Design Outcomes Magnitude Measures Before–after At pretraining, 51% felt Not reported Content study "not at all confident" or "a Outcomes little bit confident" to help someone experiencing mental illness. Following training, 90% felt "moderately confident" or "quite a bit confident" that they could help (p < 0.0010)
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participants Intervention were 21 to included in-person 59 years old, training and a majority manual covering female, and introduction to married, mental health and half the disorders, mental participants health first aid, (46.9%) had practice-based not completed skills, and mental high school health promotion.
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APPENDIX C 123 Health Literacy Component Study Design Outcomes Magnitude Measures Before–after Percentage of participants Not reported Content study able to correctly identify Outcomes depression and psychosis increased from 22.7% preintervention to 43.9% 3 months following intervention (p ≤ 0.05)
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hospitals, Each of nine community sites identified health centers, or different needs municipalities and approaches to improving HL in their community. Interventions included reforming health care navigation systems, training for web-based health information searching, and direct instruction in HL.
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effect sizes varied from zero for subscales 4, 5, and 9 to small for subscales 2 and 8, to moderate for subscales 2, 5, 6, and 7. continued
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, and CVD among older, lower SES African Americans. Three-year study.
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. Community Before–after At the end of the series, Not reported Content study participants lost 35 cumulative pounds.
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Curriculum focused on oral health during pregnancy, baby teeth, steps for a healthy smile, classroom tooth brushing program, and oral health preventive services. Burghardt et Urban, Community Medicine Interactive al.
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Results showed similar improvements in dental use regardless of parents' HL levels. Community Before–after Game participants were Not reported Content study significantly more likely than the control group to indicate they would seek pharmacist medication advice in the future (p = 0.03)
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Assessment Tool. Chan 2012a Older adults Community Chronic Chronic disease with one or centers disease self-management more chronic program is delivered diseases in in six 2.5-hour Hong Kong group sessions by a professional or lay person.
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No change in BC cultural beliefs, HL, and screening intentions. Community Non- After adjusting for Illiteracy/low education Content randomized demographic variables, level interacted with the trial the intervention group had treatment on fatigue level significant improvements such that low-literacy in all self-management individuals who received behaviors and SE outcomes, the intervention obtained and 5 of 10 health status a disproportionately measures (all p < 0.05)
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132 COMMUNITY-BASED HEALTH LITERACY INTERVENTIONS TABLE C-8 Continued Author Community Setting Topic Intervention Chan 2012a Older adults Community Diabetes Diabetes mellitus with non- centers self-management insulin– program had eight dependent weekly 2-hour diabetes in sessions that Hong Kong delivered disease related information, teaching and practicing routine self-management tasks and generic self-management skills, enhancing psychosocial support, promoting exercise, and modifying unrealistic beliefs and negative attitudes toward disease. Chang et al.
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Content Non- Program in primary and Not reported Measures randomized middle schools significantly Outcomes trial enhanced students' knowledge, SE, and skills in correct medication use and pain medication literacy (p < 0.001)
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. Creech 2014 Older adults Retirement Medication Brief low-HL dwelling in an community management tailored single independent intervention, living facility established within monthly health education seminar series, on medication management issues.
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Community Before–after The intervention more than Not reported Measures study doubled knowledge scores Content in 100% of participants. Outcomes However, SE scores were not significantly changed.
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Lessons on on urban asthma, obesity/ communities overweight, of high need: accidental injury, at risk for and drug/alcohol chronic disease use. and qualified REALM-Teen for no-cost assessment tool lunches)
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APPENDIX C 137 Health Literacy Component Study Design Outcomes Magnitude Community Before–after Program increased Not reported Content study knowledge and retention of Measures information across years. Outcomes Instructor reports show positive behavior change and an increase in curiosity about health and the body.
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Four group interventions, intervention was five sessions, 1.5 hours each. Flecha, Children Preprimary and HL skills Health programs García, and and parents primary schools with different Rudd 2011 in low-SES, in Spain topics for school immigrant, children at six and cultural schools and parents minority areas in the surrounding connected to community.
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. General knowledge and beliefs about nutrition, about physical activity, and about sleep hygiene at posttest and at delayed posttest exceeded pretest (p < 0.05)
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The adults program also provided direct contact/service opportunities with people recovering from mental illness and required design of school based mental health promotion materials. Self developed measures.
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APPENDIX C 141 Health Literacy Component Study Design Outcomes Magnitude Community Case study Multiple strategies from Not applicable Measures cognitive psychology and Outcomes adult learning theories help adults learn HL skills and carry health behavior change into everyday life. Content Other: At posttest student and adult/ Not reported Measures posttest volunteer participants had Outcomes only with a higher level of MHL and comparison lower level of stigma toward group individuals with mental illness, compared with those who did not participate in the program.
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The project encompasses nine diverse health care services, but this study focuses on a home nursing service. This intervention included materials and training for home nursing service nurses and client materials for diabetes education and support.
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As health and understanding predicted, zero effect health information was found on subscale sufficiently to guide action -- 5 (appraisal of health did increase from pre- to information)
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144 COMMUNITY-BASED HEALTH LITERACY INTERVENTIONS TABLE C-8 Continued Author Community Setting Topic Intervention Goodman, Community Libraries in Scientific Community Dias, and leaders, Suffolk County, and research Alliance for Stafford including New York literacy Research 2010 community Empowering health Social Change workers, (CARES) training leaders of was an academic faith- and and community community- partnership based consisting of a organizations, 15-week public and health curriculum community to train community members members about improving evidence-based minority health public health, increase community members' scientific literacy, and develop the infrastructure for community based participatory research to analyze and address health disparities in the community.
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Ten of the thirteen Fellows submitted pilot grant proposals for feedback. continued
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Church Mammogram, This study was 2017 Korean Pap smear designed to test a American community health women worker intervention attending 1 to increase of 23 ethnic mammogram and churches in Pap screening Washington, among Korean DC, Maryland, American women. and Baltimore CHWs delivered metro areas HL skills training in 1.5- to 2-hour meeting.
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Community Randomized Greater likelihood of Effect sizes were large. Content trial intervention group to After adjusting for Measures receive mammograms and covariates, the odds of Outcomes Pap screening at 6-month participants receiving follow-up.
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behaviors HL survey used. Hart, Berry, People living Neighborhood Mental health The purpose of this and Tonna in rural Rural Adversity 2011 communities Mental Health in New Services program South Wales was to disseminate significantly information and impacted by organize community drought social events to raise MHL and analyze the effects of drought on mental health.
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At 6 months following the intervention, the effect size was small for total attitudes and for intentions to work with mentally ill persons, and small to moderate for three MHL items. Content Other: Health Teachers and students rated Not reported Measures curriculum the curriculum favorably, Outcomes using but little documented discussion improvement in knowledge; and activities mismatches in curriculum during school and what students wanted to learn.
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educational United States Midwestern city program based with English in the United on adult learning as a second States principles and language topics identified through a community needs assessment (self management; provider communication about medicines, tests, and forms)
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Community Before–after Average total HL score Not reported Measures study following intervention Content exceeded the pretest average Outcomes (p < 0.001)
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Specifically, this study evaluated a fotonovela delivered in a multifaceted approach to health education used by promotoras. Used Short Test of Functional Health Literacy in Adults (S-TOFHLA)
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Community Randomized Participants in intervention Not reported Content trial group had better medication Measures adherence; lower blood Outcomes pressure; better HL scores at the 12- and 18-month follow-ups; more blood pressure knowledge; and less depression. continued
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Lam 2014 Chinese Diabetes centers Diabetes A nurse and middle-aged in two hospitals and physical certified exercise and older in Hong Kong activity trainer led a 6-week adults with group program diabetes using books and audiotapes to encourage participants to increase their physical activity. Six-week program with one 60-minute lesson a week at diabetes center.
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APPENDIX C 155 Health Literacy Component Study Design Outcomes Magnitude Community Randomized Participants in HL-oriented Not reported Measures trial program on physical activity Content behavior doubled their Outcomes physical activity and attained acceptable levels. Content Randomized Participants in HL-oriented Not reported Measures trial program on physical Outcomes activity behavior doubled their physical activity from the sedentary to the internationally acceptable level.
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Levin-Zamir Ethiopian Community Health care Refuah Shlema et al. 2011 immigrants clinic access program: Promote living in Israel the health of the Ethiopian community via improved communication between primary care workers (physicians, nurses, pharmacists, and administrative staff)
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Community Policy Analysis of goals, Not applicable analysis activities, stakeholders, and factors affecting policy implementations showed intentions to use health squares for health promotion and HL, but did not share understanding of the concept. continued
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2015 rural villages center and depression compared in India knowledge and attitudes toward depression in villages where educational programs have targeted mental illness and stigma versus control villages. Series of interventions.
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APPENDIX C 159 Health Literacy Component Study Design Outcomes Magnitude Community Program Participant satisfaction with Not reported Content evaluation via the health fair was positive. survey Community Before–after Adherence to Refills and Not reported Measures study Medications Scale (p < 0.05)
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Socially Adult education HL Australian 2016 disadvantaged colleges in adaptation of adults with Australia U.K. Skilled for low literacy Health Program with content about managing health conditions and disease prevention/ health promotion embedded in literacy instruction.
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Community Cross- Quantitative results Not reported Measures sectional showed improvements in Content study participants' functional HL Outcomes skills and confidence; very little change in mean total functional, critical, and communicative HL scores from baseline. Qualitative analysis identified positive student and teacher engagement with course content and self-reported improvements in health knowledge, attitudes, and communication with health care professionals.
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NVS used. Oves 2013 Homeless Residential Maternal and A 6-hour maternal mothers living rehabilitation child health HL training to in a residential facility increase the health rehabilitation care knowledge of facility in mothers who have Atlanta, been homeless.
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Community Before–after Pre- to posttest shows Not reported Measures study training positively impacted Content reported maternal and child Outcomes health knowledge; 2- to 4-month follow-up survey to 11% of the total sample showed women retained a considerable amount of knowledge. Content Other Community profiling Not reported projects regarded by pupils and teachers as meaningful learning experiences, with a positive impact on their sociopolitical development.
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164 COMMUNITY-BASED HEALTH LITERACY INTERVENTIONS TABLE C-8 Continued Author Community Setting Topic Intervention Paul et al. Rural residents Households in Water Community 2015 who use wells Tuftonboro, contamination presentations for water New Hampshire on water supply contamination and protective actions; community informational campaign; well water testing service for residents to make testing accessible and reduce inconvenience.
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The intervention did not reduce mental illness stigma at 4- and 8-week follow-up. The intervention did improve MHL at 4- and 8-week follow-up.
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Internet and online health information resources
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Community Before–after Workshops showed modest Not reported Measures improvement in posttest Outcomes scores and postcards showed that people found the workshops interesting and helpful. continued
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Ramaswamy, English- Jail Cervical cancer The Sexual Health Simmons, speaking Empowerment and Kelly women over (SHE) Project was a 2015 age 18 in a five-session, 2-hour county jail in cervical cancer Kansas City, education program Kansas implemented in a jail over 5 days.
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Community Other Increased confidence in Not reported Content navigating providers and Measures health systems (p = 0.02)
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Ramos et al. Hispanic males Not listed HL and Impact of culturally 2013 in rural areas disparities tailored health of Shelbyville, classes on the Kentucky health knowledge of Hispanic residents of a rural town.
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APPENDIX C 171 Health Literacy Component Study Design Outcomes Magnitude Community Cross- In the interviews, participants Not reported Measures sectional reported implementing the Outcomes study exposure-reducing actions. Community Before–after Improved performance scores Not reported Measures study in 100% of participants in Content Phase II.
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172 COMMUNITY-BASED HEALTH LITERACY INTERVENTIONS TABLE C-8 Continued Author Community Setting Topic Intervention Rodriguez Adult Schools Dementia This dissertation 2015 community evaluated a college and dementia-themed night school fotonovela class attendees (graphic novel) to (consisting of measure increase English- and/ and maintenance or Spanish- of knowledge speaking adults of dementia and (n = 212; 91% improvement of Latino)
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Community Before–after The mean CVD knowledge Not reported Content study score for all participants increased from 39% to 66% postintervention. Completion of the program was associated with a 68% increase in overall mean CVD scores.
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2015 American cervical to determine the women cancers cost-effectiveness of overdue for an intervention. The mammograms intervention was and Pap tests aimed at increasing breast and cervical cancer screenings of Korean American women.
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Community Before–after Prevalence of current Not reported Measures study depression decreased from Content 14.6% to 11.3% at 18 Outcomes months (p = 0.005)
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Son et al. Incarcerated Cuyahoga Reproductive An interactive 3-day 2017 youth County Juvenile health curriculum was Detention Center implemented in a juvenile detention center with the goal of increasing reproductive health knowledge and teachers' comfort level when teaching the topic.
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; scale is 21 to 84. Community Cohort Increased knowledge Not reported Measures regarding sexually Content transmitted infections and Outcomes self-reported confidence in condom use (p = 0.002)
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, large hotel using different Martinez town chain (Site 2) , community settings community and community for improving church HL among adult (Site 3)
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Community Randomized Intervention participants Not reported Measures trial had a significant average Content change score on TOFHLA Outcomes after intervention (p < 0.01)
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Taylor et al. Aboriginal Three Aboriginal Dementia This study piloted 2012 Australian communities in a dementia community Australia education program members (16-minute DVD)
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Content Qualitative Participants found the Not applicable analysis of program practical, regardless participants' of their professional responses to orientation and experience. training Participation in the course, for people with mixed experience of meeting those with mental health issues, appears to contribute to an increased confidence and inclination to act when meeting a person suspected of having mental health problems.
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182 COMMUNITY-BASED HEALTH LITERACY INTERVENTIONS TABLE C-8 Continued Author Community Setting Topic Intervention Tuerk et al. Residents of Community Posttraumatic Trainings were 2013 Mito, Japan, auditorium stress, mental held to address area hit by a health posttraumatic stress devastating after an earthquake earthquake in Japan.
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Community Randomized Increased depression Not reported Content trial knowledge in both groups p < 0.05, retained at 1 month, but decreased. Knowledge increase significantly larger for fotonovela at post (p < 0.05)
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184 COMMUNITY-BASED HEALTH LITERACY INTERVENTIONS TABLE C-8 Continued Author Community Setting Topic Intervention Vanderbilt et Participants Resource centers eHealth This computeral. 2016 were required in participants' Literacy, based intervention to be over the communities preterm birth sought to increase age of 18, pass HL HL regarding the computer preterm birth.
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to educate adults in an underserved community about preterm birth and HL have the potential to decrease health disparities. Community Other Evaluation results highlight Not reported Measures the need to continue to Content build both survivor and Outcomes professional resources to address the unique impact of cancer on AYA cancer survivors.
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This study did not attempt to change health behavior, and states that it is policy driven. Primary outcome: change in number of general practitioner (GP)
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While for moderate effect sizes treatment groups were for pretest to posttest equivalent at pretest, at changes in two MHL posttest and delayed posttest items. the MHFA group exceeded the control, except for two MHL items.
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BC = breast cancer; CAMI = Community Attitudes toward the Mentally Ill Scale; CHW = community health worker; CVD = cardiovascular diseases; E–E = entertainment–education; EHS = Early Head Start; ESL = English as a second language; GP = general practitioner; HBP = high blood pressure; HL = health literacy; HLQ = Health Literacy Questionnaire; IDA = iron-deficiency anemia; MAKS = Mental Health Knowledge Scale; MHFA = mental health first aid; MHL = mental health literacy; NGO = nongovernmental organization; NIH = National Institutes of Health; NVS = Newest Vital Sign; REALM = Rapid Assessment of Adult Literacy in Medicine; RIBS = Reported and Intended Behavior Scale; SE = self-efficacy; SES = socioeconomic status; SNAP = Supplemental Nutrition Assistance Program; S-TOFHLA = Short Test of Functional Health Literacy in Adults; YMCA = Young Men's Christian Association.
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Community Before–after Public HL scores increased Not reported Measures study 1.5 points, from 61.8 to Content 63.3, after SMS intervention Outcomes for 1 year (p < 0.01) ; increase greater for males than females (p < 0.01)
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. The researchers described their program as a health literacy intervention because they aimed to create a trained, volunteer public health workforce to help meet the needs of low-literacy communities and build health knowledge.
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The health content consisted of data, explanations, and recommended health behaviors encouraging action. Using a pre/post 22-item questionnaire with dimensions of health knowledge, behavior, and skill, researchers found that the intervention group had slightly higher health literacy scores after 1 year than the control group.
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. The goal was to bridge cultural divides and increase residents' "science" and "research" literacy so that they could participate in a community health collaborative.
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Pre- and posttests showed significant improvements in computer and Web knowledge, along with decreased anxiety, increased efficacy, and increased participation in health care. Culturally Sensitive Interventions to Build Knowledge and Skills Five interventions aimed to increase not only health knowledge, but also behaviors and skills, such as communicating with others about health, seeking information, asking questions, and analyzing information, for d istinct cultural groups; more interventions targeting cultural groups are discussed in the adult learners, chronic disease, mental health (other)
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Adult Learners and Health Literacy Interventions A subset of health literacy knowledge and skill improvement interventions focused on adult learners. Several projects examined the effects of integrating health literacy content in adult education programs (Brown, Collie-Akers, and Fernandez-Ortega 2015; Chervin et al.
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. The project goal was not only to improve adult learners' health literacy skills and increase their self-efficacy, but also to show how to teach health literacy as part of adult education.
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. Early Childhood Education and Health Literacy Interventions The review includes three articles that involved Head Start programs, parents, or children (Burgette 2016; Fleary 2012; Stockwell et al.
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Researchers reported that parents' knowledge increased, and parents' attitudes about appropriate care changed. Schools as Health Literacy Intervention Sites This section reports on four studies that used schools as the setting for health literacy interventions; three additional school-based and one university-based study are reported in the mental health section (Fung et al.
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The evaluation found that even though students could recall information, there was little improvement in student knowledge, confidence, help- eeking behavior, or ability or desire to access health services. s Other Settings or Topics for Health Literacy Interventions Son and colleagues (2016)
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Chronic Disease Risks and Management Eight interventions focused on low health literacy adult groups with respect to chronic disease risk reduction and disease self-management. The interventions integrated health literacy techniques, such as simplified content and easy, action-oriented recommendations, to improve health literacy and sometimes change behavioral or physiological outcomes related to diabetes and cardiovascular risks or disease.
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in Hong Kong, again because of their low health literacy and its relation to chronic disease management; the purpose was to increase their physical activity and improve their diabetes outcomes. Lam describes the intervention as culture, language, disease, and age appropriate, as well as theory based and "health literacy-oriented," meaning the intervention was "a patient self-care empowerment program to nurture patients' ability to obtain, understand, comprehend, and analyze the health information and services that they needed [sic]
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. Mental Health Literacy Interventions Seventeen articles reported interventions to increase knowledge about mental health, increase confidence in identifying a person with a mental health problem, and reduce social stigma about mental illness.
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Anderson and Pierce (2012) trained coaches and leaders of sports teams in rural settings in Australia to improve their understanding of mental health conditions, increase their confidence in assisting those with mental illness, and decrease stigma.
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Armstrong and colleagues (2011) trained community health workers within rural communities in India to reduce stigma, but there was only evidence of a minor reduction.
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Participants who received the fotonovela were more likely to report they shared the fotonovela with more than one other person compared to the group receiving the text pamphlet. Two papers described the effect of community health workers delivering mental health literacy programs in rural villages in India (Mindlis et al.
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The intervention group demonstrated an improved attitude toward people with mental illness, confidence in assisting someone with mental illness in accessing help, belief that medication and psychotherapy can help, and belief that people with mental illness can fully recover. Mosuro, Malcolm, and Guishard-Pine (2014)
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Two studies used games to deliver an intervention. The first recruited adults ages 18 to 64 from an urban, multiethnic community setting to assess how interactive, educational board games influenced participants' knowledge about medicines and communication skills with their pharmacist (Burghardt et al.
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Findings demonstrated that health literacy mean scores increased, but were not statistically significant. Cancer and Health Literacy Eight papers reported health literacy interventions about cancer focused primarily on increasing knowledge and self-efficacy.
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Community health workers received training and later trained participants in CHW homes, food courts, and ethnic cafes and grocery stores (Han et al.
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and found that people's limited understanding of health promotion and empowerment concepts was a weakness, but a strength was a wide choice of health information materials and individualized counseling with staff. The authors suggest that the actors in the policy/community process
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Although the interventions did not match the inclusion criteria, the team believes the papers can foster discussion about how health literacy insights can contribute to the broad domain of community-based interventions. Some excluded papers may also suggest potential research partnerships and intervention designs that can benefit from health literacy insights.
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In a second example, researchers in Venezuela described an advocacy and social mobilization intervention over a 4-year period to increase health literacy about breast cancer in Venezuela (Eid and Nahon-Serfaty 2015)
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DISCUSSION This review's results show the existence of a wide variety of c ommunity-based health literacy interventions. These interventions have positively affected several types of outcomes for many different groups of people.
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. Health Literacy Components of Interventions A second theme pertains to the way "health literacy" was used in interventions.
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The interventions were typically trying to increase knowledge and sometimes self-efficacy, empowerment, or other factors related to health attitudes and behaviors; and to change one or more health behaviors. The papers, however, did not address explicitly the four health literacy components.
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Health Literacy and Knowledge Outcomes The review team expected to find many knowledge-building interventions, and the third discussion theme pertains to how to think about knowledge improvement as a community intervention outcome. Although increasing health knowledge is popular, it can also be a disparaged outcome when researchers, practitioners, and policy makers expect every intervention to result in a behavior or health status change.
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A continued focus on knowledge building as part of health literacy interventions may be necessary because communities often come to interventions isolated from the larger universe of science-based health information and lacking foundational knowledge that affects health literacy. Challenges Applying an Evaluation Framework The last discussion theme addresses the fit between evaluation frameworks for generally-used public health interventions and the ommunity-based c health literacy interventions in this review.
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CONCLUSION The Horowitz Center review team identified a wide variety of c ommunity-based health literacy interventions, encompassing different communities, topics, settings, and outcomes. Researchers applied the health literacy concept to choose communities of interest; design or apply measures; design or adapt materials and programs; and identify outcomes.
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2011. "Health Literacy Interventions and Outcomes: An Updated Systematic Review." Evidence Report/Technology Assessment 199(March)
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2012. "Health Literacy in Adult Educa tion: A Natural Partnership for Health Equity." Health Promotion Practice 13(6)
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2017. "Breast and Cervical Cancer Screening Literacy Among Korean American Women: A Community Health Worker-Led Intervention." American Journal of Public Health 107(1)
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2010. "Mental Health First Aid Training for the Chinese Community in Melbourne, Australia: Effects on Knowledge About and Attitudes Toward People with Mental Illness." International Journal of Mental Health Systems 4:18.
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2015. "Eco nomic Evaluation of a Community Health Worker-Led Health Literacy Intervention to Promote Cancer Screening Among Korean American Women." Journal of Health Care for the Poor and Underserved 26(2)
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2015. "A Multisite Community-Based Health Literacy Intervention for Spanish Speakers." Journal of Community Health 40(3)
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1998. "Relationship of Functional Health Literacy to Patients' Knowledge of Their Chronic Disease: A Study of Patients with Hypertension and Diabetes." Archives of Internal Medicine 158(2)
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Key Terms
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