Interventions to Improve Health among Reproductive-Age Women of Low Health Literacy: A Systematic Review

International Journal of Environmental Research and Public Health Review Interventions to Improve Health among Reproductive-Age Women of Low Health Literacy: A Systematic Review Rafael Vila-Candel 1,2 , Francisco Miguel Martínez-Arnau 3,* , Juan María de la Cámara-de las Heras 4, Enrique Castro-Sánchez 5and Pilar Pérez-Ros 2 1Department of Obstetrics and Gynaecology, Hospital Universitario de la Ribera, 46600 Valencia, Spain; [email protected] 2Department of Nursing and Podiatry, Faculty of Nursing and Podiatry, Universitat de València, 46010 Valencia, Spain; [email protected] 3Department of Physiotherapy, Universitat de València, 46010 Valencia, Spain 4Library Department, Hospital Universitario de la Ribera, FISABIO. Crta. Corbera km 1, 46600 Valencia, Spain; [email protected] 5School of Health Sciences, University of London, London EC1V, UK; [email protected] *Correspondence: [email protected] Received: 3 September 2020; Accepted: 8 October 2020; Published: 12 October 2020   Abstract: Background: Limited or low health literacy (HL) has been associated with poor health outcomes, including inadequate self-caring and preventive behaviors. A few studies have systematically summarized the effect of interventions to improve reproductive health and care in women with insufficient HL. The main objective of the study was to investigate health care promotion interventions and examine their effectiveness on women with inadequate HL through a systematic review of randomized controlled trials (RCT). Methods: RCTs and quasi-experimental studies that assessed HL interventions to improve reproductive health of women with low HL were included. The study protocol was registered with PROSPERO (CRD42020137059). Results: Of the 292 records initially identified, a total of 6 articles were included for review. Five different HL screening tools wereused. Fourdifferent interventionswere included: educationalintervention, communicationskills, a multimedia interactive tool, and text adaptation to enhance reading comprehension. Not enough research practice has been conducted on the influence of interventions on HL, and thus, it is difficult to implement evidence-based interventions. Conclusions: Interventions aiming to benefit and improve HL should consider the complex web of intersectional determinants that end up shaping the opportunities of women to make optimal decisions regarding their health and care, and which may require attention to much more than clinical or service delivery factors. Keywords: health literacy; numeracy; reading ability; reading skill; pregnant women; intervention 1. Background Health literacy (HL) relates to a person’s knowledge and skills in decision-making in a medical and social context necessary for meeting the complex health demands of modern society [ 1 ]. Essential HL skills include reading, writing, numeracy, and searching for information [ 2 ], using multimedia technologies and solving problems, all of which are essentially personal and social skills for navigating the health system [ 3 ]. HL it is considered one of the most important factors and determinants of individual health and health service use [4]. A strong heterogeneity in defining and measuring HL between women and men has been reported [ 5 ]. There have been different studies validating the correlation between poor or low HL in Int. J. Environ. Res. Public Health 2020,17, 7405; doi:10.3390/ijerph17207405 www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2020,17, 7405 2 of 17 women and poor health outcomes [ 6 , 7 ]. A woman’s level of HL has the potential of impacting the health outcome of her entire family [8,9]. Currently, various standardized and validated tools have been proposed for assessing HL, but, to date, none of them are considered the “gold standard” [ 10 , 11 ]. There is currently controversy regarding the routine use of HL screening for clinical purposes, although most disagreement is focused on its use on patients or on specific individuals rather than the overall population [ 12 ]. Some authors recommend considering the entire population as having a low HL level [ 9 ], claiming that routine screening of HL lacks benefits and could have undesired effects. On the other hand, different professional organizations promote HL screening to reach the largest possible population and provide understandable and accessible information, regardless of the level of HL [13]. Inadequate HL serves as a potential mediator of health disparities, and has been related to level of education (less than high school), low socioeconomic status, Hispanic ethnicity, Black race, and older age [ 14 ]. Limited or low HL has been associated with poor health outcomes, including inadequate self-caring and preventive behaviors [15]. Different interventions have been already designed to improve the outcomes and experience of patients with low HL in relation to health problems or pathologies surrounding maternal health: gestational weight gain [ 16 ], diabetes mellitus [ 17 ], breastfeeding promotion [ 18 ]; Zika virus [ 19 ], medication errors [ 20 ], breast cancer [ 21 ], and down syndrome screening [ 22 ]. These interventions have focused on increasing health-related knowledge in these processes, increasing patients’ comprehension, improving adherence to treatment, or improving patient–provider communication. Furthermore, these interventions include a variety of approaches and components, from face-to-face communication to personalized teaching classes with in-person counselling, and interactive or technology-assisted or education multi-media with interpersonal interactions. Overall, there has been relatively little systematic research comparing the effectiveness of interventions, specifically with regards to any relationships between HL and health outcomes [ 23 , 24 ]. More evidence is needed to identify the optimal way to design interventions to decrease health disparities in women with low HL. Among these areas of research, further validation of the benefits of clearer health communication on health outcomes, assessment of mediators other than communication in the pathway between literacy and poor health outcomes, and further assessment of the homogeneity of persons with low HL are required to develop appropriate interventions for them [ 25 ]. Thus, the objectives of this study were to investigate the breadth, depth and quality of the literature relating to the following questions: 1. What screening tools have been used to measure the level of health literacy of women or pregnant women? 2. What interventions and characteristics were carried out in this group? 3. What is the effect of interventions carried out on women with limited or inadequate health literacy, including pregnant women, in order to improve health care? 2. Methods The PICO format (population/intervention/comparation/outcomes) was used to prepare the research question, as shown in Table 1[ 26 ]. To address these questions, a systematic review of published research was conducted between October to November 2019 following guidelines outlined in the Cochrane Handbook for Systematic Reviews of Interventions. The details of the protocol for this systematic review were registered on PROSPERO ID: CRD42020137059. Int. J. Environ. Res. Public Health 2020,17, 7405 3 of 17 Table 1. PICO strategy: category, definition, and search terms in databases. Category Definition Search Terms for Embase Pregnancy Search Terms for Medline Pregnancy Search Terms for CINAHL Population Women or pregnant women exp PREGNANCY/or exp WOMEN/.ti,kw. exp Pregnancy/or Women prepregnancy OR pre pregnancy OR pregnant preconception* OR pre conception* OR periconception* OR women Intervention Interventions that authors report are designed specifically to mitigate the effects of low health literacy. Uses single or multiple literacy-directed strategies. (“poor health literacy” or “health literacy” or “literacy, health”).mp. or exp “health literacy”/use oemezd or exp “Health Literacy”/use medall health literacy OR literacy OR numeracy OR reading ability OR reading skills OR poor health literacy OR litercy, health health literacy OR poor health literacy OR literacy, health Comparisons Not applicable Outcomes Health care, obstetric care, reproductive care exp OBSTETRIC PROCEDURE/or exp BREAST FEEDING/or exp BREAST FEEDING EDUCATION/or exp BIRTH/or exp CHILDBIRTH/or CHILDBIRTH EDUCATION/or LABOR PAIN/or (ante natal or antenatal* or pre natal* or prenatal* or puerper* or postnatal* or postpartum or post partum or post natal* or peripartum or peri partum or prepregnancy or pre pregnancy or preconception* or pre conception* or periconception* or peri conception* or or (pregnancy or pregnancies or pregnant)((preterm or premature) and (labor or labour)) or eclamp* or preeclamp* or pre eclamp* or amniocentes* or chorion* vill* or breastfe* or breast fe* or lactation* or cesarean or caesarean or cesarian or caesarian or cesarien or caesarien or newborn* or new born* or tocoly* or fetal or foetal or fetus or foetus or miscarriage*) or care or health care.ti,ab,kw. exp Pregnancy Complications/or exp Obstetrics/or exp Breast Feeding/or exp Prenatal Education/or exp Labor Pain/or (breast-feeding education or parturition or ante natal antenatal* or pre natal* or prenatal* or puerper* or postnatal* or postpartum or post partum or post natal* or peripartum or peri partum or prepregnancy or pre pregnancy or preconception* or pre conception* or periconception* or peri conception* or ((preterm or premature) and (labor or labour)) or eclamp* or preeclamp* or pre eclamp* or amniocentes* or chorion* vill* or breastfe* or breast fe* or lactation* or cesarean or caesarean or cesarian or caesarian or cesarien or caesarien or newborn* or new born* or tocoly* or fetal or foetal or fetus or foetus or miscarriage* or pregnancy or pregnancies or pregnant) or care or health care.ti,ab,kf. (antenatal* OR prenatal* OR puerper* OR postnatal* OR postpartum* OR post partum OR post natal* OR peripartum OR peri partum) OR care OR health care OR PICO: population/intervention/comparation/outcomes; CINAHL: Cumulative Index to Nursing and Allied Health Literature. Int. J. Environ. Res. Public Health 2020,17, 7405 4 of 17 2.1. Search Strategy Studies were identified from MEDLINE (from OVID SP), the Cumulative Index to Nursing and Allied Health Literature (CINAHL from EBSCO), Embase (from OVID SP), and the Cochrane Database of Systematic Reviews (from OVID SP). Each database was searched using the search terms shows in Table 1as a single search term or in combination using Medical Subjects Heading (MeSH) terms with the Boolean operators AND/OR [27]. The search for unpublished studies included an electronic search of trial records: current controlled trials (http://www.controlled-trials.com), the National Institute of Clinical Health Databases (https://clinicaltrials.gov), the Universal Index of Doctoral Dissertations in Progress, Mednar, review of the grey literature and Google search. 2.2. Inclusion and Exclusion Criteria The inclusion criteria were as follows: (a) peer reviewed; (b) studies on interventions reported as specifically designed to mitigate the effects of low HL in women or pregnant women; (c) articles that measured HL using a previously validated HL assessment; (d) outcome measures provided evidence on the relationship between HL and reproductive health outcomes or related knowledge or behaviors; (e) studies published in English or Spanish languages; (f) studies from January 1995 to November 2019; (g) randomized clinical trials and quasi-experimental studies conducted with comparison groups with level of HL. 2.3. Data Extraction and Quality Assessment The authors created a data extraction form tailored to this investigation using the guidelines outlined in the Cochrane Handbook for Systematic Reviews of Interventions [ 28 ]. Two independent authors reviewed the papers. The data extraction procedure was conducted in two phases: (1) by title and abstract, and (2) by full text. Following the assessment of title and abstract, the primary reviewer (RVC) and secondary reviewer (FMMA) performed the full-text evaluation. A third reviewer (PPR) acted to resolve any disagreements. The first and second authors thoroughly reviewed each study and extracted the main data: study design, sample characteristics, sample size, location of the study, the HL screening tool, health intervention characteristics, HL measures, outcome measures, and reported results. Any coding discrepancies between the two authors were resolved through subsequent review. Abstracted data were then compiled, reviewed, and summarized in table format by one study author (RVC). After determining article inclusion, one reviewer entered data about each study onto the evidence tables, with the second author checking and validating the information for accuracy. 2.4. Assessment of Risk of Bias within Selected Studies Two reviewers independently rated the quality of studies using the Cochrane protocol that assesses bias (RoB2). The RoB2 tool comprises seven domains: random sequence generation; allocation concealment; blinding of participants and personnel; blinding of outcome assessment; incomplete outcome data; selective reporting; and other sources of bias. Each evaluation was classified by two independent authors to a high risk of bias, a low risk of bias, or an unclear bias. 2.5. Data Synthesis and Analysis As the number of studies with similar outcomes was modest, and the interventions heterogeneous, a narrative synthesis was agreed upon. However, to central tendency and dispersion values contributed by the authors at the preand post-moment, a percentage of change in the main variables was calculated to facilitate comparison between the groups. Int. J. Environ. Res. Public Health 2020,17, 7405 5 of 17 3. Results 3.1. Characteristics of Clinical Trials The search retrieved 292 articles. After the study selection process, six articles were included in the analysis. The full study selection process is presented in Figure 1as per recommended preferred reporting items for systematic reviews and meta-analyses (PRISMA) criteria [29]. Int. J. Environ. Res. Public Health 2020, 16, x 5 of 18 3. Results 3.1. Characteristics of Clinical Trials The search retrieved 292 articles. After the study selection process, six articles were included in the analysis. The full study selection process is presented in Figure 1 as per recommended preferred reporting items for systematic reviews and meta-analyses (PRISMA) criteria [29]. Figure 1. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow diagram. Details of the study characteristics are presented in Table 2. The included studies were published between 2011 and 2019. Six studies from three countries met the criteria: The United States of America (n = 3), Iran (n = 2) and Australia (n = 1). Five studies applied an RCT design, while only one used quasi-experimental design. The sample sizes ranged from 80 to 1126 patients. The themes in which HL were evaluated, including self-care in pregnant women, teach-back in telehealth services for women, gestational diabetes in pregnant women, preterm prevention in pregnant women, prenatal genetic information in pregnant women, and informed consent in tubal sterilization. 3.2. Results of Health Literacy Screening Tools Table 2 presents the five HL screening tools used. Two studies (33.3%) used the Single Item Literacy Screener (SILS) test. The remaining tools were the Maternal Health Literacy and Pregnancy Outcome Questionnaire (MHLAPQ), the Iranian Health Literacy Questionnaire (IHLQ), the Short version of the Test of Functional Health Literacy in Adults (S-TOFHLA), and the Rapid Estimate of Adult Literacy in Medicine (REALM). Figure 1. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow diagram. Details of the study characteristics are presented in Table 2. The included studies were published between 2011 and 2019. Six studies from three countries met the criteria: The United States of America (n=3), Iran (n=2) and Australia (n=1). Five studies applied an RCT design, while only one used quasi-experimental design. The sample sizes ranged from 80 to 1126 patients. The themes in which HL were evaluated, including self-care in pregnant women, teach-back in telehealth services for women, gestational diabetes in pregnant women, preterm prevention in pregnant women, prenatal genetic information in pregnant women, and informed consent in tubal sterilization. Int. J. Environ. Res. Public Health 2020,17, 7405 6 of 17 Table 2. Characteristics of the studies included in the review. Author Design Study Period nTheme Age Country HL Tool Solhi et al., 2019 [30] RCT Jan to June 2016 80 Self-care in pregnant women >18 years Iran MHLAPQ Morony et al., 2018 [31] QES July to Oct 2018 637 callers and 18 nurses Teach-back in telehealth service 31.3 ±6.5 Australia SILS Gharauchourlo et al., 2018 [32]RCT 6 weeks (1.5-h session once a week) 84 Pregnant women with gestational diabetes IG: 31.5 ±4.4 CG: 30.8 ±3.8 p=0.734 Iran IHLQ Webb et al., 2014 [33] RCT Sep 2004 to Aug 2008 1126 Preterm prevention project 25.6 ±6.6 USA S-TOFHLA Yee et al., 2014 [34] RCT Aug 2010 to March 2011 150 Prenatal genetic information 26.6 ±5.3 USA REALM Zite et al., 2011 [35] RCT May to July 2010 203 Informed consent in tubal sterilization 21–45 years USA SILS HL: Health Literacy; RCT: randomized clinical trial; MHLAPQ: Maternal Health Literacy and Pregnancy Outcome Questionnaire; QES: quasi-experimental study; SILS: Single Item Literacy Screener Test; IG: intervention group; CG: control group; IHLQ: Iranian Health Literacy Questionnaire; S-TOFHLA: Short version of the Test of Functional Health Literacy in Adults; REALM: Rapid Estimate of Adult Literacy in Medicine. 3.2. Results of Health Literacy Screening Tools Table 2presents the five HL screening tools used. Two studies (33.3%) used the Single Item Literacy Screener (SILS) test. The remaining tools were the Maternal Health Literacy and Pregnancy Outcome Questionnaire (MHLAPQ), the Iranian Health Literacy Questionnaire (IHLQ), the Short version of the Test of Functional Health Literacy in Adults (S-TOFHLA), and the Rapid Estimate of Adult Literacy in Medicine (REALM). 3.3. Results of Interventions to Support Women with Low Health Literacy Table 3presents the results of interventions for six studies. Four different components were included: educational sessions, communication skills by telephone, a multimedia interactive tool, and text adaptation to enhance reading comprehension. Three studies used educational intervention (50.0%), and the others used communication skills by telephone (16.7%), a multimedia interactive tool (16.7%), and text adaptation (16.7%). Int. J. Environ. Res. Public Health 2020,17, 7405 7 of 17 Table 3. Description of articles that explored health literacy. Author Intervention Health Interventions Outcome 1 Intervention Group Average and SD Control Group Average and SD Other Reported Findings Outcome 2 Intervention Group Average and SD Control Group Average and SD Solhi et al., 2019 [30] Control group (n=40) received the routine educational program. The intervention group (n=40) received the routine educational program and additionally followed the educational intervention sessions. Educational intervention sessions of 45 min each in the form of lectures, group discussion, question and answer session, counselling, practical exercises, and educational materials (e.g., booklets and films about pregnancy). Determine the effect of health literacy education on self-care in pregnant women. Before intervention 30.9 ±5.3 1 month after intervention 40.0 ±3.5 2 months after intervention 40.6 ±3.1 Before intervention 30.4 ±4.9 1 month after intervention 30.9 ±4.6 2 months after intervention 31.6 ±4.6 Before intervention p=0.62 1 month after intervention p<0.001 2 months after intervention p<0.001 Self-care questionnaire Before intervention 62.9 ±6.3 1 month after intervention 76.8 ±4.3 2 months after intervention 78.0 ±3.9 Before intervention 62.6 ±6.5 1 month after intervention 65.0 ±6.2 2 months after intervention 66.0 ±6.7 Morony et al., 2018 [31] Training in theory and skills for using teach-back was a 2-h “communication skills” workshop. For the duration of the study, nurses were encouraged to reflect after each call on how effectively they communicated and how well the caller understood. Caller outcomes were assessed in a single telephone survey conducted by population research laboratory PRL approximately one week following initial contact. Handling of telephone calls by means of the teach-back method. Evaluate the impact of teach-back on communication quality in a national telephone-based telehealth service for callers varying in health literacy. 45.5% (n= 116) in highest category 40.2% (n= 150) in highest category Odd ratio OR=0.77 (95% CI 0.44–1.37); p=0.37 Satisfaction of callers and nurses 72.3% (n= 188) in highest category 70.7% (n= 266) in highest category Int. J. Environ. Res. Public Health 2020,17, 7405 8 of 17 Table 3. Cont. Author Intervention Health Interventions Outcome 1 Intervention Group Average and SD Control Group Average and SD Other Reported Findings Outcome 2 Intervention Group Average and SD Control Group Average and SD Gharauchourlo et al., 2018 [32] Six weeks (1.5 h sessions once a week) IG (n=50): received counselling on routine pregnancy care and a health literacy approach to counselling for modifying lifestyle. CG (n=50): received counselling on routine pregnancy care as well as a training package containing all the subjects discussed in the intervention group. Educational intervention with counselling on routine pregnancy care and a health literacy approach to counselling for modifying lifestyle. Investigate the effect of a health literacy approach to counselling on the lifestyle of women with gestational diabetes. HL: Before intervention 9.95 ±2.52 After intervention 14.4 ±1.3 3 weeks after intervention 13.2 ±1.8 HL: Before intervention 10.4 ±2.1 After intervention 11.7 ±1.9 3 weeks after intervention 11.3 ±1.9 p<0.001; F = 278.7 Lifestyle Questionnaire (LSQ) Before intervention 144.7 ±21.5 After intervention 175.6 ±12.8 3 weeks after intervention 184.0 ±12.2 Before intervention 143.5 ±19.9 After intervention 151.3 ±18.3 3 weeks after intervention 153.4 ±16.6 Webb et al., 2014 [33] Women randomized into the treatment group (n= 565) were regularly assessed for the presence of the pre-specified risk factors and invited to avail themselves of the state-of-the-art treatment and services offered as part of the Philadelphia Collaborative Preterm Prevention project PCPPP protocol. Women who were randomized into the control group (n=561) were administered identical assessments as the intervention group, were informed of the results, and were referred to appropriate medical or social service providers in the community. Educational intervention with specific management of risk factors in intervention group. The efficacy of individual level risk-reduction efforts designed to prevent preterm/repeat preterm (describe low literacy as their main outcome). Prevalence of low HL 22.5% (n=106) Not specified Women on Medicaid or without insurance were more likely than women with private insurance to have low HL (26.2% vs. 14.1%) Acceptance rate and participation rate Acceptance rate (68.9%; n =73) and participation rate (40.2%, n =43) Not specified Int. J. Environ. Res. Public Health 2020,17, 7405 9 of 17 Table 3. Cont. Author Intervention Health Interventions Outcome 1 Intervention Group Average and SD Control Group Average and SD Other Reported Findings Outcome 2 Intervention Group Average and SD Control Group Average and SD Yee et al., 2014 [34] CG (n=75): receiving standard of care counselling. IG (n=75): receiving standard of care counselling and an interactive patient education tool for prenatal screening and diagnosis tests. Interactive education tool. Determine whether an interactive computer program could improve patient knowledge regarding genetic screening and diagnostic concepts. % of questions correctly answered: pre 69.4 ±14.2 post 23 days: 60.6 ±16.0 % of questions correctly answered: pre 46.0 ±15.2 post 23 days: 49.7 ±18.9 pre-test p<0.001 post-test p=0.001 Zite et al., 2011 [35] Each participant was provided with a copy of either the standard (n=99) or the low-literacy Medicaid-Title XIX SCF (n =102) and an allocated sterilization consent form after that. Text adaptation to HL level. To estimate whether the Medicaid-Title XIX Sterilization Consent Form (SCF) format standard compared with low literacy is associated with women’s understanding of tubal sterilization. 77.5% of correct answers 49.0% of correct answers p<0.01 women randomized to the low-literacy Medicaid-Title XIX SCF group better understood the length of time required between signing the form and undergoing sterilization Preference of subjects 94% (n=189) preferred low-literacy Medicaid-Title XIX SCF 6% (n =12) preferred Medicaid-Title XIX SCF Int. J. Environ. Res. Public Health 2020,17, 7405 16 of 17 17. Finbråten, H.S.; Pettersen, K.S.; Wilde-Larsson, B.; Nordström, G.; Trollvik, A.; Guttersrud, Ø. Validating the European Health Literacy Survey Questionnaire in People with Type 2 Diabetes: Latent Trait Analyses Applying Multidimensional Rasch Modelling and Confirmatory Factor Analysis. J. Adv. Nurs. 2017 . [CrossRef] 18. Mackert, M.; Guadagno, M.; Lazard, A.; Champlin, S.; Pounders, K.; Walker, L. 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