Table 2 a. Studies Evaluating Clinical Outcomes that Reported One or More HL Outcomes. b. Studies Evaluating Behavioral Outcomes that Reported One or More HL Outcomes. c. Studies Evaluating Social/Psychological Outcomes that Reported One or More HL Outcomes
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Study | Design (Sample size) | Population/Disease type/Setting | Age/Sex | Tools applied to measure clinical outcomes of interest | Intervention | Main outcome measured | Key findings related to health literacy outcomes |
Apter AJ, Wang X, Bogen DK, Rand CS, McElligott S, Polsky D, et al. Problem solving to improve adherence and asthma outcomes in urban adults with moderate or severe asthma: A randomized controlled trial. J Allergy Clin Immunol. 2011; 128:516–23.e1. 10.1016/j.jaci.2011.05.010 | RCTπ (333) | Moderate or severe Asthma. Inpatients at large inner-city hospital and specialty respiratory clinic in US | 49 ± 14 years 72% female | S-TOFHLA1 ACT2, Health-related Quality of Life (HRQL)3, FEV1, and disease knowledge | Problem-solving (PS) approach vs standard asthma education (AE) Checked Reading ability and word Understanding | Treatment adherence and Healthcare services utilization | Mean treatment adherence (61% ± 27%) declined significantly (p = 0.0004) over time by 14% and 10% in the intervention and control groups, respectively. Asthma control improved overall by 15% (p = 0.002). Problem-solving (intervention) was not better than asthma education (control) in improving disease knowledge and asthma outcomes, and reducing hospitalizations and ED visits (all p > .05) |
Azkan Ture D, Bhattacharya S, Demirci H and Yildiz T. Health Literacy and Health Outcomes in Chronic Obstructive Pulmonary Disease Patients: An Explorative Study. Front. Public Health. 2022; 10:846768. https://doi.org/10.3389/fpubh.2022.846768 | Pragmatic intervention study (336) | Moderate to Severe COPD in Turkey | 62.5 ± 10.04 years 85% Male | HLS-EU4, CRQ5, MMRC6 | Health coaching study Included: knowledge, understanding, and Use aspect of HL | Disease severity | The results shown the proportion of patients with inadequate HL was higher in the severe COPD group (73.20%). In patients with inadequate HL, the risk of developing severe COPD was 1.80 times higher |
Eikelenboom N, van Lieshout J, Jacobs A, et al. Effectiveness of personalised support for self-management in primary care: a cluster randomised controlled trial. Br J Gen Pract. 2016;66(646): e354–e361. https://doi.org/10.3399/bjgp16X684985 | Cluster RCT (644) | Adult patients with at least one chronic condition (asthma, COPD, diabetes mellitus, or cardiovascular Diseases in Netherland | 65.8 ± 10.5 years 53% Male | S-TOFHLA | Personalized self-management support training sessions Checked Reading ability and word Understanding | Patients’ activation and health-related behaviours | Personalized self-management intervention (training sessions) has not effect on Patient Activation (score did not differ significantly between the control and intervention groups at 6 months and follow-up assessments, but, the effect of the intervention was significant on the patients performed self-monitoring (intervention group scored higher than the control group (p = 0.01). The HL scores correlated significantly with outcomes of interest (p < 0.001), but the differences were not significant between the study groups |
Thom DH, Willard-Grace R, Tsao S, Hessler D, Huang B, DeVore D, et al. Randomized Controlled Trial of Health Coaching for Vulnerable Patients with Chronic Obstructive Pulmonary Disease. Annals ATS. 208; 15 (10): 1159–1168 | RCT (192) | Moderate to severe COPD. Patients in seven urban public health primary care clinics in US | 61.3 ± 7.6 years 65.5% male | CRQ, Chronic Illness Care, and Patient Health Outcomes, HRQL, Healthcare utilization | Health coaching training vs usual care Included Communication, Understanding, and Use aspect of HL | ED Visits, Hospitalization rates, and HRQL | There were no significant differences between the intervention (health coaching) and control (usual care) groups in either primary or secondary outcomes (p > .05). The findings from this study may inform expectations of benefits and limitations of health coaching for patients with COPD |
Apter AJ, Bryant-Stephens T, Morales Andrea J, Wan F, Hardy S, Reed-Wells S, et al. Using IT to improve access, communication, and asthma in African American and Hispanic/Latino Adults: Rationale, design, and methods of a randomized controlled trial. Contemporary Clinical Trials. 2015; 44: 119–128 | RCT (301) | Moderate to severe Asthma. Patients in 1 University Medical Complex in the US | 49 ± 12 87% female | S-TOFHLA, eHEALS5, ANQ6. ACT, Asthma Control, HRQL, assessed literacy and language barriers, Healthcare utilization | Patient portal training (PT) vs patient portal training plus home visits (PT + HV) Checked Reading ability and word Understanding | Asthma Control, Health-related Quality of Life, patient– provider communication, and health outcomes | Both the PT and PT + HV groups improved, with fewer asthma symptoms, better QOL, less need for oral steroids, fewer asthma-related hospitalizations and ED visits per year. In all measures of effect, the group receiving home visits showed more improvement, but in hospitalization, the improvement was not statistically significant (P > 0.05). This trial improved communication with healthcare providers in a population of high asthma morbidity and low-income through the use of electronic patient portals and home visits |
Wang LH, Zhao Y, Chen LY, Zhang L, Zhang YM. The effect of a nurse-led self-management program on outcomes of patients with chronic obstructive pulmonary disease. Clin. Respir. J. 2019; https://doi.org/10.1111/crj.13112 | RCT (154) | Moderate to severe COPD. Patients in a teaching hospital in China | 68.7 ± 6.2 76.6% male | SGRQ7, 6MWD8, and CTCPSQ9, Disease satisfaction, exercise capacity, hospital readmission (open-ended questionnaire) | Nurse-led self-management program in addition to routine care vs usual care Included Communication, Understanding, and Use aspects of HL | Hospital readmission, emergency department visits, Exercise tolerance, HRQL, satisfaction | The Intervention group showed significantly fewer COPD-related hospital admissions (p = 0.03) and emergency department visits (p = 0.001) compared to the control group. Intervention group participants had greater satisfaction with health care and higher quality of life (both p = 0.001), compared to the control group. The intervention group also had significantly greater improvement in exercise capacity and health status (p < 0.05) compared with control participants The Nurse-led self-management program was effective in improving COPD patient knowledge and disease management skills to manage symptoms and exacerbation |
Monninkhof E, van der Valk P, van der Palen J, van Herwaarden C, Zielhuis G. Effects of a comprehensive self-management programme in patients with chronic obstructive pulmonary disease. Eur Respir J. 2003; 22(5): 815–20 | RCT (248) | Moderately severe COPD. Outpatient pulmonary clinics in the Netherlands | 65 ± 7 years 68.15% male | SGRQ and HRQL, Exercise capacity, Self-confidence, and health outcomes | Comprehensive self-management intervention vs. standard of care Included Understanding, and Use aspects of HL | Exacerbation rates, HRQL, physical activity | No statistically significant differences were observed between the Intervention and control groups over 1 year (p > 0.05). No significant differences in symptom scores and 6-min walking distance were found within and between groups (p > 0.05). The intervention group reported more exacerbations than the control group. This study did not show positive effects of a self-management program among moderately severe chronic obstructive pulmonary disease patients |
Goeman D, Jenkins C, Crane M, Paul E, Douglass J. Educational intervention for older people with asthma: A randomised controlled trial,. Patient Education and Counseling. 2013; 93 (3): 586–595, ISSN 0738–3991, https://doi.org/10.1016/j.pec.2013.08.014 | RCT (123) | Asthma. Outpatients from emergency departments, GP clinics and pharmacies in Australia | 67.4 ± 6.4 72.4% female | ACT, HROL, Patient Health Questionnaire, and MAQ10 | Person-centered self-management education intervention vs. written (brochure) information-only education Included Understanding, and Use aspects of HL | Asthma Control and Exacerbation rates | Intervention group participants experienced significant improvements in asthma control and quality of life, (both p < 0.01). Adherence to asthma preventer medication improved in both study groups with no statistically significant difference (p = 0.17. The exacerbation rates in both study groups decreased during the study period and the difference between groups was not statistically significant (p = 0.52). Asthma outcomes in older individuals may be improved by delivering tailored education that identifies specific patient concerns and unmet needs |
Ko FW,Cheung NK, Rainer TH, Lum C, Wong I, Hu DS. Comprehensive care programme for patients with chronic obstructive pulmonary disease: a randomised controlled. Thorax 2017;72:122–128. https://doi.org/10.1136/thoraxjnl-2016-208396.trial. | RCT (180) | COPD Patients discharged from hospital after having acute exacerbation. Department of pulmonary medicine of a teaching hospital in Netherlands | 74.7 ± 8.2 95.6% male | MMRC, 6MWD, SGRQ, HRQL, exercise capability. Health outcomes | Comprehensive educational program vs. usual care Included Communication, Understanding, and Use aspects of HL | Hospital Readmission and length of hospital stay | The incident rate of readmission in the intervention group was significantly lower than the control group (p = 0.047) compared with control group participants. The intervention patients had shorter length of hospital stay for acute exacerbation than the control group (p ≤ 0.001). There were no improvements in 6-min walk test, MMRC score and SGRQ score at the 12-month follow-up, compared to baseline, in either group A comprehensive, individualized care plan could decrease the hospital readmission rate and length of hospital stay compared with usual care. However, the intervention had minimal effects on self-efficacy and health-promoting behaviour |
Mayo PH, Richman J, Harris HW. Results of a program to reduce admissions for adult asthma. Ann Intern Med. 1990 Jun 1;112(11):864–71. https://doi.org/10.7326/0003-4819-112-11-864. PMID: 2344111 | RCT (104) | Moderate to severe Asthma with multiple hospitalizations for asthma attacks Patients in a general hospital in the US | 42.7 ± 13.3 72.12% female | Self-reported checklist of self-treatment (using ICS with spacer and taking prednisone based on pattern of asthma symptoms and exacerbation, and applying peak fellow meter daily), inhaler techniques, and disease knowledge | Intensive personalized self-management education intervention plus special clinic treatment vs. routine clinic care Included Communication, Understanding, Evaluation, and Use aspects of HL | Hospital readmissions and hospital days used | The intervention resulted in a threefold reduction in readmission rate and a twofold reduction in hospital days use rate (p < 0.003 and p < 0.004, respectively) in the intervention group compared to the control group The educational intervention reduced hospital use among a group of adults with asthma, but it did not influence patient’s decision to use provided training to initiate self-treatment for asthma exacerbation |
Fan VS, Gaziano JM, Lew R, Bourbeau J, Adams SG, Leatherman S, Thwin SS, Huang GD, Robbins R, Sriram PS, et al. A comprehensive care management program to prevent chronic obstructive pulmonary disease hospitalizations: a randomized, controlled trial. Ann Intern Med 2012;156:673–683 | RCT (426) | Severe COPD. 20 Veterans Affairs hospital-based outpatient clinics across the US | 65.9 ± 8.4 96% male | SGRQ, PHQ11, CCQ12, COPD exacerbations and hospitalizations, HRQL, patient satisfaction, disease knowledge, and self-efficacy | Comprehensive care management educational intervention vs. usual care Included Understanding, Communication, and Use aspects of HL | COPD hospitalization, exacerbation, Mortality | COPD-related hospitalization decreased in both study groups with no statistically significant difference between the groups (p = 0.62). No significant difference was found between two groups for treating exacerbation (p = 0.118). Significantly more deaths due to COPD was reported in the intervention group compared to the usual care group (p = 0.003). Significant improvement was observed in self-confidence in managing COPD within the intervention group (p = 0.044) The intervention had no effect in reduced COPD-related hospitalizations, exacerbation, or COPD knowledge. The intervention did not improve COPD knowledge, nor did it yield a structural behavioral change to motivate intervention patients to use their action plan for worsening respiratory symptoms. Behaviour change requires both a sufficient understanding of the problem and the self-confidence to address it effectively |
Galbreath AD, Smith B, Wood PR, et al. Assessing the value of disease management: impact of 2 disease management strategies in an underserved asthma population. Ann Allergy Asthma Immunol. 2008;101:599–607 | RCT (902) | Moderate to severe Asthma. Patients from one general hospital in the US (429 adults; 473 children) | Adult: 42.7 ± 12.3 77.6% female Pediatric: 9.47 ± 3.3 59.5% male | HLQL, ATC, ATAQ13, and MAQ | Telephonic Asthma management (TAM) consulting, Augmented approach plus in-home visits by a respiratory therapist-AAM), vs. usual care Included Communication, Understanding, and Use aspects of HL | Exacerbations, health care utilization, HRQL | No significant differences found between study groups in time to exacerbation event or health care utilization (p > 0.05) for either pediatric or adult patients. TAM group in adult group had greater improvement in HRQL (p = .04) and a decrease in asthma symptoms (p = .001). Compared to usual care, the interventions did not result in significant improvement in disease knowledge, nor did it yield a gain in skills to improve clinical outcomes in either adults or children |
Khdour MR, Kidney JC, Smyth BM, McElnay JC. Clinical pharmacy-led disease and medicine management programme for patients with COPD. British Journal of Clinical Pharmacology. 2009; 68, 588–598. https://doi.org/10.1111/J.1365-2125.2009.03493.x | RCT (173) | Moderate to severe COPD. Outpatients from COPD clinic at a general Hospital in Northern Ireland | 67 ± 7.9 55% female | SGRQ, COPD Knowledge, MAQ | Pharmacy-led disease and medicine management intervention vs. usual care Knowledge, understanding, communication Included Communication, Understand, and Use aspects of HL | Medication Adherence, HRQL and Health resource utilization | There were significant differences between the intervention and usual care groups regarding decreased in ED visits (p = 0.02), reduced hospitalizations (p = 0.01), increased adherence to medication (p = 0.019), and greater knowledge scores (p = 0.001). On the SGRQ scores, significant differences were reported in the intervention group on the symptom (p = 0.04) and impact subscales p = 0.03) but not on the physical activity subscale. The clinical pharmacy-led disease management program may improve adherence, reduce the need for hospital care in patients with COPD and improve aspects of their HRQL |
Wilson SR, Strub P, Buist AS, Knowles SB, Lavori PW, Lapidus J, Vollmer WM. Shared treatment decision making improves adherence and outcomes in poorly controlled asthma. Am J Respir Crit Care Med. 2010;181(6):566–77. https://doi.org/10.1164/rccm.200906-0907OC | RCT (612) | Poorly or very poorly controlled Asthma Patients from five lung specialty clinical Sites in the US | 46.9 ± 6 12 55.9% female | ATAQ, ATC, HRQL, MAQ and health care utilization | Shared Decision-making (SDM) vs. Clinician decision-making (CDM. Disease Knowledge, Included Communication, Understanding, and Use aspects of HL | Medication Adherence, asthma control and HRQL | Medication adherence was significantly higher in the SDM group (p < 0.0001) compared with usual care (CMA). The SDM group also had significantly better asthma control (p = 0.0225) than the CDM group. Asthma QOL improved significantly in both study groups over time, but did not differ significantly from each other. Asthma-related visits were significantly lower after the intervention in both study groups but did not differ significantly from each other. The SDM approach is efficacious in improving both medication adherence and clinical outcomes among poorly controlled asthma patients |
Chavannesa N, Grijsen M, van den Akker M. et al. Integrated disease management improves one-year quality of life in primary care COPD patients: a controlled clinical trial. Prim Care Respir J. 2009; 18 (3): 171–176 | RCT (162) | Mild to moderate COPD Patients form community primary care setting in Netherlands | 63 ± 5 81 | SGRQ,CCQ, HLQL, MMRC,MAQ. Healthcare utilization and self-efficacy | Integrated disease management (IDM) vs. standard care Included Understanding and Use aspects of HL | Dyspnea, self-efficacy and HRQL | Dyspnea rates decreased (p = 0.001) and QOL improved significantly in the intervention group (p = 0.002) compared to the usual care group. The IDM intervention improved quality of life in primary care COPD patients, compared to usual care. The improvement in SGRQ was both clinically relevant and statistically significant, in the intervention group |
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Source | Design (Sample size) | Population/Disease type/Setting | Age/Sex | Tools applied to measure behavioral outcomes of interest | Intervention | Main outcome measured | Key findings & conclusions |
Efraimsson EO, Hillervik C, Ehrenberg A. Effects of COPD selfcare management education at a nurse-led primary health care clinic. Scand J Caring Sci. 2008; 22(2): 178–185. DOI:10.1111/j. 1471–6712.2007.00510.x | RCT (52) | Moderate, severe or very severe COPD. Patients from Swedish primary care setting | 68 ± 9.7 50% female | SGRQ, COPD Knowledge, smoking habits | Structured educational intervention vs. standard care Included Communication, Understanding, and Use aspects of HL | Self-care, Smoking Cessation, Disease knowledge and HRQL | A statistically significant increase was noted in the intervention group on SGRQ scores (p = 0.00035), dyspnea (p = 0.0267), quality of life ((p = 0.00030)), the number of patients who stopped smoking (p = 0.0185), and patients’ knowledge about COPD (p < 0.001) when compared to usual care group. The evidence from this study suggests integrating a structured program with self-care education to usual care can motivate patients’ lifestyle changes |
Pur Ozyigit L, Ozcelik B, Ciloglu SO, Erkan F. The effectiveness of a pictorial asthma action plan for improving asthma control and the quality of life in illiterate women. J Asthma. 2014; 51:423–8. 10.3109/02770903.2013.863331 | RCT (40) | Illiterate women with moderate-severe persistent asthma Three clinics in a under-developed province in Turkey | 34.8 ± 6.88 100% female | ACT, HRQL SGRQ, and healthcare utilization | Educational intervention and access to pictorial asthma action plan vs. asthma education alone Included Understanding, and Use aspects of HL | Asthma control and quality of life | ACT and HLQOL scores of both groups improved significantly at the follow-up stage (p < 0.001), but did not differ significantly from each other (p < 0.07). The SGRQ scores at follow up were significantly higher than the control group (p = 0.033). The ED visits were reduced significantly in intervention group (p = 0.001). Use of pictorial asthma action plan in addition to patient education provides a significant improvement in asthma control, HRQL, and managing of asthma treatment in illiterate asthma women. These findings suggests that education and management plans for asthma patients from various socio-cultural levels should be tailored based on literacy and understanding level |
Wan ES, Kantorowski A, Homsy D, Teylan M, Kadri R, Richardson CR, et al. Promoting physical activity in COPD: Insights from a randomized trial of a web-based intervention and pedometer use. Respiratory Medicine. 2017; 130: 102–110. https://doi.org/10.1016/j.rmed.2017.07.057 | RCT (114) | Veteran COPD patients in 1 general pulmonary clinics in the US | 68.6 ± 8.3 98.5% male | SGRQ, HRQL, MMRC, COPD Knowledge, and motivation and confidence to exercise and perform daily walking | Pedometer and website educational intervention vs. Pedometer alone Included Understanding, and Use aspects of HL | Physical Activity, daily walking, self-efficacy, disease knowledge | Daily step counts, 6-min walking, and physical activity increased over 3 months in the intervention group compared to control group (all p = 0.02). Self-efficacy and disease knowledge improved in both groups, but no significant differences were noted between groups. A website portal added to the pedometer use improved daily step counts, and sustained walking in COPD patients |
Mendes de Oliveira, J.C., Studart Leitão Filho, F.S., Malosa Sampaio, L.M. et al. Outpatient vs. home-based pulmonary rehabilitation in COPD: a randomized controlled trial. Multidiscip Respir Med. 2010; 5(6): 401–408. https://doi.org/10.1186/2049-6958-5-6-401 | RCT (117) | Clinically stable COPD patients. Inpatients and outpatients treated at the Institute of the Lung PR center in Brazil | 69.2 ± 8.7 76.5% male | BODE Index15, MMRC and 6MWT scales | Supervised hospital-based vs. unsupervised home-based pulmonary rehabilitation Included Communication, Understanding, and Use aspects of HL | Rehabilitation Program Attendance and Adherence | There was a significant difference in the distance covered on the six-minute walk test and MMRC in both study groups after participating in the PR program (p < 0.05), but the groups did not differ significantly from each other (p = 0.44). There was a significant reduction in the BODE index in both study groups at the end of the study (p < 0.001). However, no significant difference was found between the outpatient and at-home groups (p = 0.90), Findings of this study demonstrates that a self-monitored home pulmonary rehabilitation program can achieve similar results to a supervised outpatient pulmonary rehabilitation program and is a valid alternative in the therapeutic approach to patients with COPD |
Alsomali HJ, Vines DL, Stein BD, et al. Evaluating the effectiveness of written dry powder inhaler instructions and health literacy in subjects diagnosed With COPD. Respir Care. 2017;62(2): 172–178. https://doi.org/10.4187/respcare.04686 | Educational RCT (24) | Stable COPD. Outpatients in pulmonary function laboratory of an urban teaching medical center in the US | 65.6 ± 10.0 63% female | S-TOFHLA, Inhaler technique, ability to use peak flow meter, disease knowledge | Educational intervention vs. Usual care (control) Included Understanding, and Use aspects of HL | Inhaler technique and ability to perform peak respiratory fellow | The education improved patients’ inhaler technique (p < .002), but not the ability to perform proper peak flew meter use ((p = 0.96)). Health literacy was not associated with the ability to learn inhaler technique (p = 0.85). Use of inhaler device handouts alone without any verbal instructions or demonstration improved inhaler technique. Reading ability, as tested by the Health literacy tool, was not associated with patients’ capability to learn inhaler technique using written educational handout (p > . 0.05) |
Janson SL, McGrath KW, Covington JK, Cheng S, Boushey HA. Individualized asthma self-management improves medication adherence and markers of asthma control. Journal of Allergy and Clinical Immunology. 2009; 123 (4): 840–846. https://doi.org/10.1016/j.jaci.2009.01.053 | RCT (95) | Moderate-to-severe asthma. Outpatients from private and public community clinics in the US | 38.3 ± 9.3 53% female | HLQOL, ACT, Peak flow, MAQ, and ICS adherence (assessed by the electronic device validated for monitoring metered dose inhaler use) | Computer-generated individualized self-management education intervention vs. self-monitoring alone process Included Understanding, and Use aspects of HL | ICS adherence, HRQL, proper use of Peak inspiratory flow | Mean ICS adherence improved in both study groups over time, but stayed consistently higher over time in the intervention group but the differences were not statistically significant (p = 0.79). The incidence of rescue medication use decreased significantly over time in both study group (p < .001), with no significant differences between groups. The mean change in symptom scores also decreased significantly for both groups over time, and the change rates were not significantly different between the two groups (p = 0.19). The peak flow scores improved significantly for both intervention and control groups during the intervention period, with no significant differences in the change rates between groups (p = 0.62). Perceived control of asthma and QOL improved significantly in the intervention group (p = 0.006, and p = 0.07), respectively. Intervention subjects reported significantly more changes in self-management behavior in the study group than in the control group (p < 0.0005). Individualized self-management education coupled with self-monitoring of asthma symptoms, and peak flow confers additional benefits in adults with asthma beyond self-monitoring alone |
Poureslami I, Nimmon L, Doyle-Waters M, Rootman I, Schulzer M, Kuramoto L, et al. Effectiveness of educational interventions on asthma self-management in Punjabi and Chinese asthma patients: a randomized controlled trial. J Asthma. 2012;49:542–51. 10.3109/02770903.2012.682125 | RCT (92) | Moderate to severe asthma. One specialty lung clinic in Canada | 62.9 ± 15.3 50.6% female | Functional knowledge. Open-ended HL questionnaire, inhaler techniques (use a standardized nine-step observational checklist), MAQ, Medication adherence, Disease Knowledge | Culturally and linguistically sensitive educational intervention vs. routine patient education Included Communication, Understanding, and Use aspects of HL | Asthma control, asthma knowledge, inhaler technique, HRQL | Proper use of inhalers improved significantly in both study groups (p < 0. 001), with female participants showed significantly greater improvements compared to male patients (p = 0.04). Participants’ knowledge of asthma symptoms improved significantly over time in all participants (p < 0.01), with more improvements were observed among patients with high school diploma or more education (p = 0.03) and patients younger than 60 years (p < 0.01). Patients’ understanding of physicians’ instructions improved significantly over time among all participants (p < 0.01), with female participants showed significantly greater improvements compared to male patients (p < 0.05). Language and cultural barriers were identified as major issues to access and communicate with care providers. Access to culturally and linguistically appropriate educational material (written in community language and audio-visual instructions in story-format) improved disease-related knowledge, helped better understand and act on asthma symptoms, and promoted self-management practices among asthma patients from ethno-cultural communities |
Wang KY, Chu NF, Lin SH, Chiang EC, Perng WC, Lai HR. Examining the causal model linking health literacy to health outcomes of asthma patients. Journal of Clinical Nursing. 2014; 23 (13–14): 2031–2042 | Observational study (326) | Asthma. Pulmonary medicine outpatient departments at three medical centers and a regional teaching hospital in Taiwan | 51 ± 18.3 50.7% female | TOFHLA16, asthma knowledge, inhaler techniques; healthcare use and PHQ | Assessed how low health literacy may influence health outcomes in adult asthma patients Checked Reading ability, Literacy, Understanding | Health literacy skills and Engagement in Self-Management | Overall, 72.3% of participants had adequate functional health literacy, based on TOFHLA scoring scale. Health literacy correlated positively with inhaler technique performance (p = 0.009), but correlated negatively with self-management behavior (p = 0.779). Health literacy correlated positively with asthma knowledge (p < 0.001), asthma attitudes (p = 0.001) and medical decision-making (p = 0.007) but correlated negatively with medical care experience (p = 0.639). Health literacy intervention can improve health out-comes of asthma patients. Increasing health literacy may lead to improved self-efficacy and control of asthma symptoms and help to reduce emergency department visits and hospitalizations |
Press VG, Arora VM, Trela KC, et al. Effectiveness of Interventions to Teach Metered-Dose and Diskus Inhaler Techniques. A Randomized Trial. Ann Am Thorac Soc. 2016;13(6): 816–824 | RCT (120) | Asthma and COPD. Inpatients at a teaching hospital in the US (82 Asthma and 38 COPD) | 48.5 73% female | TOFHLA, Inhaler technique, MAQ, and Disease Knowledge | Comprehensive Teach-to-goal (TTG) Educational intervention vs. brief verbal Instruction (BVI) intervention Included Communication, Understanding, and Use aspects of HL | Inhaler Technique and exacerbation | Immediately after the interventions, the inhaler techniques significantly improved among the TTG group (p = , 0.001), but was not sustained at 30 days follow-up (p = 0.11). Acute care events were less common among teach-to-goal participants than brief intervention participants were at 30 days (p = 0.02), but not at 90 days (p = 0.6). Inpatient treatment-to-goal education may be an important first step toward improving self-management and health outcomes for hospitalized patients with asthma or COPD, especially among patients with lower levels of health literacy |
Beatty CR, Flynn LA, Costello TJ. The Impact of Health Literacy Level on Inhaler Technique in Patients With Chronic Obstructive Pulmonary Disease. J Pharm Pract. 2017 Feb;30(1):25–30. https://doi.org/10.1177/0897190015585759. Epub 2016 Jul 10. PMID: 26033793 | RCT (46) | Moderate to severe COPD. Patients in a community hospital in the US | 67 ± 10.5 82.6% male | REALM-SF17, and Inhaler technique | Plain language handouts vs. standard hospital education materials Included Understanding, and Use aspects of HL | Inhaler Technique and medication adherence | Correct use of inhaler improved significantly among participants in both study groups, at the end of intervention, with significantly more improvements observed in intervention group compared to control group (p = 0.03). There was no significant difference in health literacy scores between the study groups at the end of the study (p > 0.05) There is a need for multiple educational modalities written in simple language for COPD patients, especially those with low health literacy to help them involve in disease management of their health condition |
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Source | Design (Sample size) | Population/Disease type/Setting | Age/Sex | Tools applied to measure social and psychological outcomes of interest | Intervention | Main Outcome measured | Key findings & Conclusions |
Apter AJ, Wan J, Reisine S, Bender B, Rand C, Bogen DK, et al. The association of health literacy with adherence and outcomes in moderate-severe asthma, Journal of Allergy and Clinical Immunology. 2013;132(2): 321–327, | RCT (284) | Moderate or severe asthma. Outpatients primary care and asthma from specialty practices of a inner-city hospital in the US | 48 ± 14 71% female | S-TOFHLA, ANQ, HRQL, and ACT | Individualized problem-solving (PS) strategy vs. standard asthma education (AE) Included Communication, Understanding, and Use aspects of HL | Adherence to ICS, HRQL and exacerbation rate | Higher HL was significantly associated with better Asthma quality of life (p = .006), asthma control (p = .005), and medication adherence (NS) in both study groups at the end of the study period (6-month). There were no significant interaction between time and HL or between group assignment (PS, AE) and HL. In adults with moderate or severe asthma, higher health literacy scores were associated with better subsequent quality of life and asthma control. The relationship between HL and health is complex, and this study illustrated such complexity and pointed out that this is more than a cross-sectional association |
Steurer-Stey C, Dalla Lana K, Braun J, Ter Riet G, Puhan MA. Effects of the “Living well with COPD” intervention in primary care: A comparative study. Eur. Respir. J. 2018, 51, 1701375 | RCT (467) | Moderate to severe COPD. Patients from several primary care settings in Switzerland | 67.7 ± 10.1 54.18% male | CRQ and PACIC18.HLQL, CCQ, CTCPSQ | Self-management intervention (LWWCOPD) vs. usual care Checked Knowledge and Behavior change | Exacerbation, health related quality of life, and medication adherence | The intervention group showed significant, clinically relevant improvement in all CRQ subscale scores (p < 0.05) and had considerably fewer moderate to severe exacerbations rates compared to the control group (NS). Significant increases were observed in intervention group patients’ confidence in performing the correct inhalation technique (p < 0.001) and confidence in the timely and correct use of the action plan (p < 0.05). No significant differences between the two groups were found related to smoking cessation and self-efficacy scores (NS). The structured self-management intervention program effectively improved disease coping skills and quality of life, and reduced the risk of exacerbations in patients with COPD |
Thomas RM, Locke ER, Woo DM, Nguyen EHK, Press VG, Layouni TA, Trittschuh EH, Reiber GE, Fan VS. Inhaler Training Delivered by Internet-Based Home Video-conferencing Improves Technique and Quality of Life. Respir Care. 2017; 62(11):1412–1422. https://doi.org/10.4187/respcare.05445 | RCT (48) | COPD. Parents in Veterans Affairs Health Care System in the US | 67.5 ± 6.6 93% male | Hl (used 1-item question on self-reported confidence filling out medical forms), CRQ, HLQL, COPE20, and MAQ | Internet-based home videoconference educational intervention using teach-to-goal (TTG) approach vs. standard care Included Communication, Understanding, and Use aspects of HL | Self-Esteem, inhaler technique, and COPD quality of life, | COPD self-confidence (coping skills), inhaler adherence, and COPD quality of life improved significantly following the intervention (p < .0.003, (p < 0.045, and p < 0.001), respectively. Inhaler training using teach-to-goal methodology delivered by home videoconference is a promising means to provide training to patients with COPD that can improve technique, quality of life, self-efficacy, and adherence |
Martin MA, Catrambone CD, Kee BA, Evans AT, Sharp LK, Lyttle C, et al. Improving asthma self-efficacy: Developing and testing a pilot community-based asthma intervention for African American adults, Journal of Allergy and Clinical Immunology, 2009; 123 (1): 153–159.e3, https://doi.org/10.1016/j.jaci.2008.10.057 | RCT (107) | Poorly controlled persistent asthma. Patients from 2 primary care clinics in the US | 37 ± 8 69.05% female | CES-D scales19, HRQL, COPE, ASES21, and PHQ | Face-to-face educational intervention vs. educational handouts Included Communication, Understanding, and Use aspects of HL | Self-efficacy, disease management | The intervention group had higher asthma self-efficacy (p < 0.001), use of asthma action plan (p = 0.06), higher HRQL (p = 0.002), and improved coping (p = 0.01) compared with the control group patients. Trends in behavioral and clinical outcomes favored the intervention group but were not statistically significant. A community-based asthma intervention improved asthma self-efficacy, self-perceived coping skills, and asthma quality of life for low-income adult patients |
Poureslami I, Kwan S, Lam S, FitzGerald JM. Assessing the effect of culturally-specific educational interventions on attaining self-management skills for COPD in Mandarin and Cantonese speaking patients. Int J Chron Obstruct Pulmon Dis. 2016; 3 (11):1811–1822 | RCT(91) | Moderate to severe COPD. Outpatients from ethno-cultural communities in one pulmonary medicine clinic Canada | 60.23 ± 18.4 78.1% male | HL (too developed for HL and clinical outcomes assessment), Inhaler techniques, CRQ, SGRQ, and Disease Knowledge | Culturally, linguistically, and literally appropriate educational self-management Interventions vs. pictorial self-management Pamphlet Included Communication, Understanding, and Use aspects of HL | Empowerment, self-efficacy, and COPD management | Compared to the control subjects, patients in the Intervention group, had significantly more improvements in managing a COPD exacerbation (p < 0.01), better inhaler techniques (p < 0.001), ability to achieve goals in managing COPD (p < 0.01), and better understanding of pulmonary rehabilitation procedures (p < 0.05). Culturally appropriate educational interventions designed specifically to meet the needs of COPD patients are associated with better understanding of self-management and its practices |
Paasche-Orlow MK, Riekert KA, Bilderback A, et al. Tailored education may reduce health literacy disparities in asthma self-management. Am J Respir Crit Care Med. 2005; 15: 172(8): 980–986 | RCT (73) | Asthma. Inpatients in two inner-city hospitals in the US | 40.9 ± 10.9 66% female | S-TOFHLA, ASES,MAQ, ATAQ, Inhaler techniques | Educational intervention vs. standard care Checked Literacy, and Understanding | Improved knowledge, medication adherence | After education, HL was positively associated with disease knowledge (p = 0.05) in all intervention patients. In addition, inhaler technique was significantly improved with the intervention patients with low HL (p = 0.02). Inadequate health literacy was not associated with poor adherence to corticosteroid therapy and Asthma Symptom Control (p = 0.86 and p = 0.84, respectively). Inadequate asthma self-management and HL skills are common. In this study, inadequate HL was associated with worse asthma medication knowledge and inhaler techniques, but it was not associated with medication adherence and asthma control |