Improving health literacy: a step on the road to better choices about health

People’s ability to read, understand and use information on health and healthcare (health literacy) is a really important factor in the decisions they make in relation to their health, from lifestyle choices to the management of illness. Whilst we don’t know what levels of health literacy are in England, we do know that England has low levels of general literacy and numeracy and so levels of health literacy are also likely to be be low.

apple with nutritional information label

Better health literacy is linked with healthier choices

Studies have shown that people with low health literacy have poorer health and higher rates of hospitalisation and mortality than people with adequate health literacy. They have poorer knowledge of diseases, lower uptake of screening, don’t follow medication regimes so well and engage less in health promoting behaviours. Higher levels of health literacy have been asociated with making healthy choices such as eating five portions of fruit and vegetables a day and not smoking.

A research team from Australia has published a systematic review evaluating interventions used in primary care to improve health literacy for promoting change in smoking, nutrition, alcohol, physical activity and weight (SNAPW).They conducted an extensive search for studies conducted with adults and found 52 suitable for inclusion (43 randomised trials, 6 before and after studies, 2 quasi experimental and a non-randomised controlled trial).

They grouped interventions into six categories:

  • individual motivational interviewing and counselling
  • group education
  • multiple interventions
  • written materials
  • telephone counselling
  • computer interventions

Interventions were also classified by intensity (high ≥ 8 hours/points of contact, moderate 4-7, low ≤ 3) and settings (primary health care, community, and other).

Interventions were judged to be effective if a statistically significant positive change was reported for health literacy or a SNAPW outcome. The interventions varied widely; results could not be combined in a meta-analysis and are presented as counts of studies.

Here’s what they found:

Most of the included studies (36) were of moderate quality, with only 11 assessed as high quality

Intervention type

  • Telephone counselling was the only intervention not effective for SNAPW behaviours
  • Individual counselling and written materials were more effective in smoking cessation than group education
  • All intervention types were similarly effective for physical activity
  • Written materials and multiple interventions were most effective in improving nutrition

Intervention intensity/delivery

  • More studies of low intensity interventions (43%) reported significant positive outcomes for SNAPW risk factors than studies of high intensity evaluations (33%)
  • Low and high intensity interventions were equally effective for health literacy (39% each)
  • More interventions delivered by non-medical health care providers (such as dieticians and nurses) were effective than those delivered by doctors, but these also varied in intensity, with doctors more often delivering low intensity interventions and other health professionals moderate or high-intensity interventions

Intervention settings

  • More interventions in primary health care were effective in supporting smoking cessation than those in community settings
  • More interventions in community settings were effective in improving physical activity and nutrition than in primary health care
  • Settings showed similar results for weight and health literacy

Some limitations highlighted by the research team

  • The focus of the studies was often on behavioural risk factors rather than health literacy, and studies used different measures of health literacy. They note that since the review the Health Literacy Skills Instrument has been developed and validated as a way of measuring a person’s ability to obtain and use health information and that this may be promising for future research in this topic
  • Sample size, which affects the significance of a result, was not taken into consideration
  • No studies with significant negative results were found, which may be due to publication bias
  • The search was restricted to studies from the 34 countries within the Organisation for Economic Co-operation and Development and the results may not apply to countries outside this group

The authors concluded:

“Group and individual interventions of varying intensity in primary health care and community settings are useful in supporting sustained change in health literacy for change in behavioural risk factors.”

This may be promising but, as so often, it looks like there’s a need for more and better research and greater clarity about what works. For those in the UK who are interested in health literacy, there is a special interest group of health and education academics and practitioners, service providers and service users, whose website can be found here.


Taggart J, Williams A, Dennis S, Newall A, Shortus T, Zwar N, Denney-Wilson E, Harris MF. A systematic review of interventions in primary care to improve health literacy for chronic disease behavioral risk factors. BMC Family Practice 2012, 13:49.

Dennis S, Williams A, Taggart J, Newall A, Denney-Wilson E, Zwar N, Shortus T, Harris MF. Which providers can bridge the health literacy gap in lifestyle risk factor modification education: a systematic review and narrative synthesis. BMC Family Practice 2012, 13:44.

Health Literacy Group UK