Comprehensive approach more effective

What makes interventions focusing on health literacy succesful?

Research on promising interventions, as well as working components within these interventions, shows that a comprehensive approach for improving health literacy of older adults is more effective if interventions address knowledge, skills, and attitudes of all relevant stakeholders within their context and also reduce barriers for access and participation in self-management and care. In this approach intervention strategies are combined that improve health literacy skills of people and at the same time strategies that mitigate the negetice effects of low health literacy by decreasing the demands within the health system. For example, interventions that simultaneously strengthen the capacities of patients and professionals are more succesful than an approach targeted at professionals or patients.

Why a comprehensive approach?

Earlier research results underline the importance of tailoring health literacy interventions to the needs and values of different target groups, e.g. the older adults or professionals and tailoring of interventions to community-specific social, cultural and economic circumstances to improve the effectiveness of interventions. Most successful interventions use multiple strategies of information transfer, have a patient-empowering approach and pay attention to contextual factors that could be social, physical of cultural barriers for the improvement of health literacy.

So next to addressing knowledge skills and attitudes, it is also important to take into account context factors such as the importance for older adults to have autonomy, a supportive social network, trust in the health professional and health system, less complexity regarding access to services or information and access to affordable prevention activities. Together all these components contribute to effective health literacy interventions. Older adults’ needs are also shaped in the interaction with health professionals and the health system. Therefore it is important to consider both domains when developing health literacy interventions.

Definition and examples of core components

Several core components (shortly described here), their effects or theoretical support found in IROHLA research on health literacy interventions are:

Inform and educate 

Information and education is part of nearly every intervention. Combinations of knowledge transfer methods increase effectiveness, and repeating messages and information contributes to increased understanding. Find more information here

In nearly all identified interventions the component ‘inform and educate is present, either for individuals and their social context, or for professionals, or both. This is not surprising as more comprehensive or complex interventions often start with information and education. Several types and different combinations of knowledge transfer are applied (e.g. group sessions and additional internet information). In general the knowledge transfer takes place in multiple sessions or recurrent contacts. Repetition increases the learning effect, certainly for target groups not used to theoretical work or learning.

Often immediate effects of increased knowledge are visible and measured (pre- and post-test). For maintaining knowledge levels, follow-up after training or information sessions is needed, as knowledge often wears off after 6 – 12 months. A combination of knowledge transfer strategies and follow-up activities could be an answer to this. Sometimes education by peers has similar effects or even better effects compared to professional education.

Teach skills

Skills training is an important component of health literacy interventions.Individuals and their families often concentrate on self-management skills and professionals mostly concentrate on communication skills. A variety of methods for skills training exist, sometimes combining digital technology with face-to-face elements. Effects are often measured through patients’ data. Find more information here

Training skills is often combined with knowledge transfer. Sometimes the line between the two components is difficult to draw, especially when in original articles there is no detailed description of the curriculum of the training programmes presented. Some interventions make use of combinations of types of training, e.g. group and internet learning, and blended learning. Strategies to improve patients’ skills in self-management are frequently used. Computer literacy or financial literacy training are other examples of relevant skills training either in groups or on individual basis. Nowadays smartphone applications (apps) or interactive websites and gaming aim to improve skills of individuals in managing health and chronic diseases. Skills training for professionals is mostly concentrating on communication skills and ways to enhance technical competencies of professionals. Sometimes patients (or actors) are involved in the training of professionals, e.g. they provide feedback to enhance training effects. The effects of skills training are often measured indirectly, e.g. how patients measure their blood pressure or use their medication or other elements of behaviour. Only few publications describe the theoretical basis for skills training, e.g. models of chronic care management. Most interventions are practice-oriented.

Supporting behavior change and maintenance

Supporting behavioural change and maintenance is the objective of most health literacy interventions, even if only information or skills training is involved. It involves strategies to encourage and motivate older adults or professionals to adopt, change and maintain behaviors, such as patients’participation in screening or self-management or professionals’ actions to decrease or mitigate health literacy problems. Behavioural change interventions in general take longer and apply multiple methods. Behavioural change theories are mentioned in effective interventions, more often for individuals than for professionals. Effects range from self-reported efficacy to biometrical proof of adherence.Find more information here

Behavioural change is often mentioned in the publications as the objective of training programmes or interventions, even if they only concentrate on knowledge transfer and skills training. Rarely the authors of publications identify the mechanisms in the education or training that lead to behavioural change. Often the assumption is that when people understand why activities should happen, they indeed will behave in a way to facilitate the desired outcomes. Often a mixture of different types of behavioural change activities is used in interventions to add effect, especially group work with individual follow-up through individual communication (e.g. telephone calls). There is also a broad range of digital communication systems available to influence the behaviour of professionals. The effects measured range from biometrical data proving adherence to medical plans to self-declared sense of self-efficacy or well-being.

Strengthen the support from the local community

Contextual support creates continuity of support to implement health literacy interventions. It mobilises social networks and peer support, community volunteers and other types of informal care and support, and builds on theories of networking and social capital. There is a clear role for computer-based interventions in this type of activities, e.g. in virtual networks. Find more information here

Many of the activities classified as contextual support in this analysis are not identified as such by the authors of publications, as they focus on topics within that contextual support (e.g. information sharing or skills training). There is a wide range of activities availablethat can be applied, including support by direct family members, volunteers, or peer groups. Electronic devices can play a useful part in addition to other interventions. With regard to contextual support for professions, a smaller number of interventions were identified, but they are valuable for the implementation of health literacy interventions.

The contextual support activities focus more on continuity of interventions and apply theories of social capital, networking or health promotion. Reported results include better adherence to medical plans and improved self-management of chronic diseases. Also virtual communities are effective as far as evaluated.

Involvement older people in design of health services

Involvement in the health system (co-creation or co-ownership) is not often mentioned as a component of interventions, but in several cases implicitly implemented to enhance commitment of chronic patients or health professionals. Find more information here

Adapting existing interventions to fit older people with low health literacy is not frequently mentioned in the literature, although it may be more frequently executed than reported, like programmes for migrants, blind people, etc. For example information material for low literacy patients is not presented as adapted from regular material. Adapting existing health programmes for minority groups or for migrants was mentioned several times. Involving peers or volunteers to take over from professionals may also be considered as a type of adaptation. ICT-based modular learning can be considered as a way to customise health interventions. As personalised healthcare is more and more important and options using electronic devices become more and more relevant in customising healthcare. Very few interventions for professionals, such as special treatment guidelines, etc., were identified.

Theories mentioned were related to cross-cultural communication, to trust building or to social capital.

Reduce barriers to acces to healthcare

Removing barriers to access to care is rarely mentioned as an explicit activity. Interventions in the social sector can often be considered to be helpful for strengthening health literacy interventions. Find more information here

In the identified interventions of the IROHLA research there are componentsthat aim to remove barriers to access to care, or literally remove physical barriers in homes or hospitals. Access to internet and access to means of communication can help implementation of self-management programmes. For older people with low health literacy this is an important component. The interventions are more based on practice than on a theoretical concept.

Key messages refering to a comprehensive approach:

  1. Component information and training
    1. Most successful interventions use multiple methods of information transfer, have a patient empowering approach and pay attention to contextual factors that could be social, physical or cultural barriers (e.g. in the EXSOTE project) for the improvement of health literacy. It is clear that emphasis on self-management (patient centredness, self-efficacy) in addition to standard treatment is contributing to better outcomes of interventions (as described in interventions by Schillinger (2008), DeWalt (2012) and Laforest (2007). Improving communication skills of health professionals also plays an important role in achieving patient-centred healthcare.
    2. A very important aspect in the support of older people with low health literacy skills seems to be the repetition of the health-related messages and any means of follow-up, e.g. follow-up calls during a certain period of time, see DeWalt (2012) and Robare (2011) . Also the mix of group work and individual follow-up is effective in behavioural change (DeWalt (2012), Pruthi (2010), Exsote project and Erlebnis internet).
  2. Contextual support
    1. Peer groups, buddies, volunteers and home visitors are instrumental in communication and skills (social network). The set of 20 interventions shows some good examples of interventions with this approach, e.g. in ‘Erlebnis Internet’, ‘50plus net’and the ‘Pairs Programme’). Buddy programmes and interventions for informal caregivers like ‘Filmauve’) can help to create more knowledge and empathy on low health literacy in both professionals (students), and citizen groups.
  3. Information and training
    1. Interventions with e-health components such as gaming, e-learning and e-coaching are predominantly present in the set of 20 interventions, (e.g. )‘Exsote’, ‘Ask me 3’, ‘I want to learn’). The interaction aspects of e-health interventions (and the fact that they are ‘anonymous’) are important for their effects on increasing health literacy. Especially the combination of personal contact and e-health components seems to be effective (EXSOTE project).
    2. Platform-oriented interventions, such as ‘Age Action Alliance’ and ‘50plus net’ show that they have a stimulating effect on the participation of older adults in society and in this way support the fight against social exclusion and mental health problems. The ‘KOVE’ intervention is a good example of a platform-based approach where activation is combined with co-creation, engaging the target group in problem solving and adjusting contextual factors.
    3. The importance of tailor-made interventions, which is a characteristic of a patient-centred approach, is clearly described in Laforest and in interventions such as ‘Erlebnis Internet’ and ‘Emerging technology for Chronically ill Veterans’. One aspect of this tailor-made approach is adapting educational materials and methods to the needs of people with low heatlh literacy (Pruthi (2010), Talking touch screen and Erlebnis internet).

A significant number of the 20 interventions on our list place explicit emphasis on removing barriers (social, physical, or cultural) as part of the approach to increase health literacy (Schillinger (2008), DeWalt (2012), Pruthi (2010), Talking Touch Screen) indicating the importance of contextual factors.

On the list there are several strong examples of community-based interventions that use existing (local) social and health structures to improve the health literacy of older people.These interventions put an emphasis on needs assessment, capacity building, activation, co-creation, accessibility of social and health services and group sessions by peers (Lorig (2013), Pruthi (2010), Activ ins Alter, Lebenswerte Lebenswelte).

References:

D. Schillinger et al.Seeing in 3-D: Examining the Reach of Diabetes Self-Management Support: Strategies in a Public Health Care System. Health Education & BehaviorBehaviorBehaviourBehavior; Vol. 35 (5): 664-682 :October 2008.

D.A. DeWalt et al. Multisite Randomized Trial of a Single-Session Versus Multisession Literacy-Sensitive; Self-Care Intervention for Patients With Heart Failure. Circulation;125:2854-2862: 2012.

S. Laforest et al. “I’m Taking Charge of My Arthritis”: Designing a Targeted Self-Management, Program for Frail Seniors. Physical & Occupational Therapy in Geriatrics,; Vol. 26(4): 2007.

J.F. Robare.The ”10 Keys” to Healthy Aging: 24-Month Follow-Up Results From an Innovative Community-Based Prevention Program. Health Education & Behaviour:2011.

S. Pruthi et al. Promoting a breast cancer screening clinic for underserved women; a community collaboration. Ethnicity & Disease; Volume 20:Autumn 2010.

Renewing Health. EKSOTE. Remote monitoring and Health Coaching in South Karelia; Renewing Health project, June 2014. Available from: http://www.renewinghealth.eu/south-karelia-social-and-health-care-district.

A.L. Jefferson et al. Medical student education program in Alzheimer’s disease: The PAIRS Program. BMC Medical Education: 2012.

K. Lorig et al. Effectiveness of the Chronic Disease Self-Management Program for Persons with a Serious Mental Illness: A Translation Study. Community Ment Health J DOI 10.1007/s10597-013-9615-5; Springer Science+Business Media New York: 2013.

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Institute for Healthcare Improvement (IHI). Ask me 3. IHI:2014. Available from: Find website here and Download PDF here

Deutscher Volkshochschul-Verband e.V. (DVV). Ich-will-lernen.de-das DVV Lernportal. Available from: Find website here. (Accessed November 2014)

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