20 ways to improve health literacy in Europe


IROHLA researchers have assessed the quality and feasibility of a large number of practices to improve health literacy among the ageing population.

Classification of interventions

Classification of interventions

From the promising interventions that were previously identified last summer in the health, social and private sectors, a group of researchers have now identified the best 20 available methods and intervention mechanisms. These interventions address the health literacy needs of the ageing population in Europe in different ways.

These 20 “shining examples” of interventions, which are presented at the bottom of this article, cover a broad range of areas. However, most of them focus on provision of information, skills training and behavioural change for person with low health literacy.

“The interventions give a good picture of what is going on in public health and healthcare to support vulnerable groups, ageing people and chronic patients. They offer a good insight into successes in health literacy, self-management and related programmes,” says Janine Vervoordeldonk at the Dutch Institute for Healthcare Improvement (CBO), who led the work on selection of the interventions.

Comprehensive approach to health literacy interventions

The IROHLA project performs research into a comprehensive approach, focusing both on the individual and his or her context as well as health professionals and the health system. 

“These interventions can indeed strengthen health literacy by either increasing the ability of people to make better decisions, or by providing easier solutions and simpler information. In our model, interventions target the individual and their partners, families, peers, communities and societies, as well as health professionals or providers of health literacy interventions and the health system they work in. Using such a comprehensive approach will help us tackle the problems associated with limited health literacy abilities in individuals,” says Jaap Koot, University Medical Centre Groningen and coordinator of IROHLA.

Classification of interventions in clusters

The most promising practices and working mechanisms of some interventions have been grouped into the following clusters: communication, empowerment, community, capacity of professionals and reducing barriers. The clustering helps to understand the underlying theory of change and to identify how the interventions contribute to improved health literacy. All clusters are equally important when designing comprehensive approaches in health literacy programmes for the ageing populations.

  • Communication – interventions that target the interaction between health professionals and patients and explicitly or inexplicitly try to achieve behavioural change of both parties. This cluster includes interventions addressing patient-centredness and shared decision-making and enhancing self-management, as well as follow-up activities with repeated messages with low social and physical barriers. The essence of these interventions that the involve the provider and the client at the same time.
  • Empowerment – interventions that focus on persons with low health literacy and aim at increasing their self-efficacy and self-confidence. These interventions promote problem analysis and problem solving skills, active networking, social activation as well as learning skills. In these interventions it is important to make explicit how provision of information or skills development can result in behavioural change
  • Community – interventions that mobilise the community (including persons with low health literacy) and make use of the problem solving capacities of peers, families or community members. This group of interventions includes community-based courses or trainings as well as networking and peer support, such as organisations and advocacy groups for older people, peer groups, buddy programmes, volunteers and home visitors.
  • Capacity of professionals – interventions that enhance health professionals’ communications skills as well as empathy and understanding of how people with low health literacy experience their limitations. Again the behavioural change element is very important for sustainable results. Mutual support between professional and interdisciplinary collaboration help to maintain performance.
  • Reducing barriers – interventions that facilitate the utilisation of health services, such as simplification of procedures and communication, accessible websites or interventions with a purely logistical or organisational character such as improved transportation and voucher schemes. Easy access to healthcare and prevention programmes is an important issue for ageing people with low health literacy to ensure that they maintain good health.

Top 20 health literacy interventions

  1. Automated Telephone Self-Management Support System. The importance of a tailored and personalised approach and an intervention easy accessible through low social and physical barriers was emphasized by Schillinger (2008)  in an article referring to the IDEALL project (Improving Diabetes Efforts across Language and Literacy (USA). This tele-health, online self-management diabetes intervention had multiple complimentary components, which facilitated provider patient communication with patient self-management and health education in a supportive format (e.g. regular calls with tele-health nurse).  Another strong point of this intervention is the fact that it is quite easily transferable to other contexts.
  2. DeWalt (2012)  showed in ‘Multisite Randomized Trial of a single-session versus multi-session literacy-sensitive self-care intervention for patients with heart failure (USA) that follow-up calls are very important especially in case of vulnerable groups with low health literacy skills. Other strong point for this intervention is the cultural adapted information.
  3. In Laforest (2007) ‘I am taking Charge of my arthritis’ the most prominent aspects for the health literacy research are the components of patient-centeredness and shared- decision making of the intervention. It shows that a tailor-made approach together with home visits by a diversity of professionals is very important aspects with respect to the reach of frail seniors with arthritis.
  4. Lorig et al. (2013) and Griffiths et al. (2005) showed with ‘the Chronic disease Self-management Program (CDSMP)’ an intervention with the focus on the community (and not on the health system).  It shows that an additional course on self-management (here coping skills) next to the regular treatment is very useful. The transferability of this intervention is high and the fact that they already worked with many different target groups shows that it is culturally adapted. The focus is at people with severe mental illness and the programme shows that there is a range of items (medicines, physical activity etc.) that are discussed during the course.
  5. Robare (2011) highlights in ‘10 keys to healthy ageing’ the importance with respect to self management of one to one counselling at home (personalised approach, coping skills) and trained health counsellors in the community. Also in this intervention we see efforts of changing the paradigm of medical care to more emphasis on prevention and an active lifestyle, which is a very important aspect in self-care and self-management.
  6. In Pruthi et al. (2010) ‘Promoting a Breast Cancer Screening Clinic for underserved women; a community collaboration’ a plan of action for a screening program (breast cancer) is highlighted. Here taking away all kind of barriers  (social/physical/cultural) is the most important driving force together with building trust. Examples are: transportation vouchers provided, language interpreters and use of pictorial charts. Furthermore important aspect is that the activities are embedded in existing structures and that educational materials are adapted to the various target groups.
  7. In ‘EXSOTE: Remote monitoring and Health Coaching in South Karelia (Finland)’ (Renewing Health project, June 2014) , the most important success factor in the reach of vulnerable older adults with a chronic disease is the combination of e-health and mobile techniques together with the attention of personal health coaches. This Finnish example is part of the European project ‘Renewing health’ and shows that remote monitoring of diseases should be accompanied by human support in order to be effective.
  8. The ‘Talking touch screen,’ developed in the Netherlands, is an interesting example because of its user’s centred design approach: patients with low health literacy skills in physiotherapy practices were actively involved in the development of the talking touch screen; which resulted in the use of simple language, visual elements, pictures and an easy to use touch screen. With the Talking Touch Screen patients (Dutch and Turkish) with low health literacy skills are supported to fill in a patient’s specific list of complaints (PSK)) on their own. See also other example of Talking Touch Screen: E.A. Hahn et all. (2004) . In this example from the USA a multimedia program was developed to provide a quality of life assessment platform that would be acceptable to patients with varying literacy skills and computer experience. One item at a time is presented on the computer touchscreen, accompanied by a recorded reading of the question. Various colours, fonts and graphic images are used to enhance visibility, and a small picture icon appears near each text element allowing patients to replay the sound as many times as they wish. Evaluation questions are presented to assess patient burden and preferences.
  9. The ‘Age action alliance’ in the UK is a supporting network/platform where many activities in the field of health ageing are being carried out. The Age Action Alliance is a network, which brings together organizations and older people, in partnership. Drawn from civil society and the public and private sectors, it takes a positive approach to ageing and seeks practical ways to improve services and support to older people. The network is aiming at a comprehensive approach regarding ageing population, where social inclusion (including digital inclusion) and participation of older adults are an important factor.
  10. The voice of older people is the most prominent success factor in the ‘KOVE: Kilburn Older Voices Exchange’ project  in UK. The intervention is focusing on giving older people an important voice in the community and in this way empowering them to influence the existing system. The intervention offers them the opportunity to be engaged in problem solving in the community and adjusting the environment (context).
  11. The intervention ‘Erlebnis Internet’ is a interesting German example of how barriers to the access of the use of internet (digital literacy) by older adults with low SES or from other cultural backgrounds are been tackled by means of social support of peers, volunteers, tailor-made education materials etc. In the IROHLA research more interventions on the subject of digital literacy have been found. We can mention here also the intervention ‘Electronic health information for life long learning via collaborative learning (EHILLL-CL), which is an interesting example of collaborative learning in an informal setting. This theory-driven intervention, developed and tested in public libraries, aims to improve older adults' e-health literacy. Participants were highly positive about the intervention and reported positive changes in health-related behaviour and decision-making.
  12. In the case of the online platform ‘50plusnet’ in the Netherlands strong points are the low threshold character of the intervention, the positive attitude and personal approach of peers and volunteers. 50plusnet is a social network focusing on social inclusion and the prevention of mental health. Participants of the social network can get in contact with fellows quite easily and it is possible to start up all kinds of activities together like physical activities, cooking classes, cultural activities etc.
  13. Cooper et all. (2011)  stress in  ‘Physician communication skills training and patient coaching by community health workers’ (USA), how important it is to focus in an intervention on the communication skills of both professionals as patients. Here physician and patient interventions were designed in tandem to support the therapeutic partnership from both perspectives.  Furthermore the intervention shows us the importance of the adaptation of the traditional role of Community Health Workers (CHW’s) to the role of coach—an approach that the investigators used because of the evidence for cultural relevance and effectiveness of CHWs in health education and promotion among patients from minority and underserved groups.
  14. The intervention ‘Activ ins Alter; investition in die Zukunft alterer Menschen’  (Austria) is focusing really at the vulnerable group of older people. It is a good example of a personalised approach and activation of elderly. The strong element is that it starts with a needs assessment; people are asked what their needs are with respect to a broad range of things (social & health infrastructures) and about the possible ways to the needed support. The intervention is promising in its outreaching character, through the use of home visits by health counsellors. Networks with stakeholders are built and awareness of the problem is raised. It is a very well described and analysed intervention. Also the evaluation on implementation, transferability, and sustainability is reported. A thorough analysis is available in the report Health pro Elderly.
  15. The intervention ‘Lebenswerte Lebenswelten’ focuses specifically at older women with low socio-economic status. This community-based intervention uses existing structures and networks in the community in order to empower older people with respect to caring for their own health. Home visits by volunteers, intergenerational learning, health café’s and communication and networking amongst different organization are key elements in this intervention.
  16. ‘Emerging technology for at risk chronically ill veterans’ (USA) creates a ‘Health buddy’ for veterans (mobile device). This e-health intervention is aimed at supporting patients in health problems in the home setting. The ‘buddy’ stands for having support (a friend) nearby as well as raising the feeling of security. Results are positive both at the level of users (decrease in hospital/nursing home/emergency room admissions) as for professionals. The intervention belongs to the cluster ‘E-health interventions’ with emphasis on ‘tailor-made’ and ‘interactive’.
  17. The ‘Pairs program’ (USA) is an educational programme where students are getting experience with the ‘Daily living problems’ of Alzheimer patients. The project is a replica of the Buddy program, which has positive evaluations on the level of attitude (empathy) of professionals. The intervention fits to two clusters of interventions:  ‘educational interventions’ and ‘Peer/social support-interventions’.
  18. ‘Filmauve’ (France) aims at informing and empowering caregivers. Relatives/care givers learn strategies how to cope with the problems of patients with dementia. It explores and educates the social context (spouse/children) of patients. Insight, knowledge and strategies are implemented in all day life of relatives of Alzheimer patients in four sessions (‘Lab’s’). The intervention is targeted at the empowerment of caregivers.
  19. ‘Ask me 3’ (USA). This intervention – an educational website - is based on the principle that every patient should ask their health care providers three questions: (1) What is my main problem? (2) What do I need to do?; (3) Why is it important for me to do this?. The ‘communication between patient/client and professional’ is a relevant theme for IROHLA as it increases the Health Literacy by increasing awareness/sensitivity in both patients and professionals. This intervention has low cost for implementation, but the website should be culturally adapted to the European context. This intervention has a match with the ‘Teach-back method’ (also focussing on 2-way-communication).
  20. I want to learn (I will lernen) (Germany). This intervention is an e-learning module, specific for people with low literacy and numeracy skills. It shows that the use of interactive websites with games/exercises (blended learning) is very relevant.  I want to learn is comparable with the Dutch intervention Oefenen.nl.
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