Health literacy, health literacy interventions and decision-making: a systematic literature review

1.1 Research model

Healthcare is moving towards an ever-increasing deployment of technology-based services and new technologies (e.g. e-health or m-health) are increasingly being incorporated into healthcare service portfolios (Pita Barros et al., 2019). The emergence of e-health services increases the availability of medical online information and digital health-related tools for patients (Faggini et al., 2019). This requires individuals – especially those in greater need of healthcare services – to motivate themselves to improve their ability to navigate digital health platforms and make use of digital health services (Alami et al., 2017). To intensify and strengthen people's ability to use digital health services (tools and platforms), one suggested strategy is to focus on providing those with a potentially increased need for healthcare services with educational programmes that aim to enhance their health literacy (Nahm et al., 2018). In addition to improving health literacy, educational programmes contribute to the enhancement of other skills, competencies, and attitudes, including digital literacy skills (Xie, 2012), self-efficacy (Broering et al., 2006) and attitudes towards adopting technology and using digital health services (Xie, 2012). Based on the literature, the provision of health literacy training programmes can also promote self-efficacy among elderly persons by refining their awareness and knowledge of their health (Kim et al., 2014), and empowering them with the skills needed to adopt and use digital technologies (Xie, 2012), coupled with positive changes in their attitude regarding technology-based healthcare services (e.g. less stress, more interest) (Xie, 2011b). Change in attitude towards using digital health services can also contribute to an increased adoption of such services since elderly people have sometimes been observed to hold a negative attitude towards technology (Hoffman-Goetz et al., 2006). Thus, it can be expected that health literacy intervention programmes may lead to an improvement in skills and a tendency towards more positive attitudes that could prompt and assist elderly people to use digital health services to make informed medical decisions (Mancuso, 2008). Based on the current literature, we developed the following framework (see Figure 1), which we used to analyse the corpus of literature retrieved for the systematic review.

3.1 Intervention strategies

The analysis revealed that the retained studies were found to have applied two major intervention strategies to improve the health literacy skills of the elderly participants, labelled as “collaborative” and “individualistic” strategies. These two strategies were applied using two different approaches, either tailored or untailored. Studies applied different content mediation styles ranging from individual uptake/consumption (watching a video and listening to audio) to the teach-back learning method.

3.2 Study design

In this section, the reviewed studies were assessed based on their study design, and two general approaches were identified: First, all the study participants were engaged in a training programme, making it possible to compare pre-and post-intervention outcomes (one-group study design). Second, the study sample was divided into different groups (two groups or more). Some groups received educational material (intervention groups), and some did not receive such material (control groups). Studies which compared the results between intervention and control groups adopted an approach known as a multiple-case study design. Twenty-one studies used a one-group study design (e.g. Goeman et al., 2016; Chiu et al., 2016), and the improvement in this category was measured using pre-and post-tests. Thirteen studies adopted a multiple-case approach (e.g. Masi et al., 2003; Kim et al., 2014), and the improvement was measured by comparing the results of the intervention group with the control group.

3.3 Content mediation styles

Content mediation style refers to the way in which educational materials can be communicated to the trainees. A wide variety of different strategies have been used in the reviewed studies. Most of the styles adopted include handouts (reading materials) to back up the learning process. (1) Individual uptake/consumption: Participants are exposed to educational materials, in the form of videos or audio. Individuals in the intervention group have the opportunity to learn either by watching prepared videos or by listening to the audio, both of which are effective ways to capture lecture content and present direct instruction. This method was used in seven of the reviewed studies (e.g. Xie, 2011a). (2) Lecturing: One of the commonest ways to communicate educational content is lecturing, since it is both economical and practical. This method is especially practical when there are many participants, and when resources are limited. This method was used in ten of the reviewed studies (e.g. Masi et al., 2003). (3) Hands-on (on-the-job training): In this method, elderly participants are provided with the opportunity to participate in workshops, and to learn by practising. This method may be very useful for samples involving very elderly participants, who might very easily forget the content of the learning material. This method was used in 13 of the reviewed studies (e.g. Willis et al., 2018). (4) Comprehensive: Comprehensive support is used especially in preventive care, which is a complex process. The core objective of this method is to promote active, authentic, flexible, and scenario-based learning. This method is used in three of the reviewed studies (e.g. Serbim et al., 2019). (5) Teach-back: This is the least popular method and was used in only one of the reviewed studies (Goeman et al., 2016). Here, health information providers, such as nurses, assume full responsibility for the training process.

3.4 Study setting

In order to implement health literacy interventions among elderly people, scholars have selected different channels (modalities) such as face to face and online (remotely via ICTs) at different venues (e.g. public libraries or senior centres). Among the 34 reviewed studies, 22 relied on face-to-face learning to communicate educational content. Moreover, our analysis revealed that among the 34 reviewed studies, 18 were conducted in the form of informal learning settings (e.g. public libraries or senior centres) (e.g. Susic, 2009). In addition, three studies were conducted in clinical settings (e.g. Edwards et al., 2012) and one study was carried out in a university setting (e.g. Czaja et al., 2013). Twelve of the reviewed studies were administered remotely via ICT systems, including online tutoring delivered via video or telephone conferencing (e.g. Redfern et al., 2020). Based on the results, recent studies have shown that ICTs are being utilised more frequently. This indicates that technology is being increasingly used in educational settings in recent years to communicate educational content to elderly people. Taking this forward, online channels could potentially be integrated into all intervention strategies. In addition, online channels, which are more cost-effective could be adapted for larger populations (Watkins and Xie, 2014).

3.5 Barriers to improving health literacy skills among elderly people

In this section, we review the reviewed studies based on barriers identified as obstacles towards improving the health literacy of elderly people. Some authors, such as Watkins and Xie (2014), argue that before implementing any intervention or learning programme aimed at improving the health literacy of elderly people, any potential barriers and obstacles should be identified and tackled. According to the existing literature, the obstacles could be related to the individual characteristics (e.g. personal characteristics or living circumstances). Based on the review findings, we have identified two barriers: personal obstacles and infrastructural obstacles.

4.1 Literacy skills

Unsurprisingly, the predominant research theme in the reviewed studies was literacy skills, which can be further categorised into three types of literacies: (1) health literacy, (2) e-health literacy, and (3) digital literacy. All reviewed studies (34 articles) dealt directly or indirectly with how to empower elderly people with the ability to navigate digital health platforms in order to access digital health platforms, to find trusted health information on the Internet, to evaluate obtained information, and to understand health information sufficiently to know what to do and how to use online health-related information (e.g. Aspinall et al., 2012; Parker et al., 2018).

4.2 Management competency perspective

According to the reviewed studies, management competency refers to the ability of elderly people to make appropriate health decisions or resolve health problems to manage their own health condition by having access to sufficient online health information (Banbury et al., 2019; Bertera et al., 2007; Broering et al., 2006; Manafò and Wong, 2013; Xie, 2011a) or using digital health tools (Parker et al., 2018).

Some studies refer to general conditions. For example, Xie (2011b, c) studied e-health literacy interventions, in which participants were empowered with their ability to locate information from medical websites to determine the recommended treatment for an illness or better manage their health condition. Some authors, such as Masi et al. (2003), Susic (2009) Willis et al. (2018) and Xie and Bugg (2009) demonstrated the usefulness of health literacy intervention programmes regarding the ability of elderly people to “surf the web” and develop the skills they need to promote their health and well-being by making informed health decisions. In addition, a telephone coaching session was found to help enhance participants' knowledge regarding the use of resources and tools (e.g. my snapp) to develop and maintain their motivation towards a healthier lifestyle, to promote self-monitoring of diet, physical activities, and weight, and to resolve health problems (Parker et al., 2018).

Some studies have explored patients' ability to have more control over a specific medical condition. For example, intervention programmes help elderly people to resolve their health-related problems (Goeman et al., 2016; Kim et al., 2014) or manage their own health status and take care of themselves independently (e.g. by taking responsibility for checking their own blood pressure with use of a blood pressure monitoring tool) (Bosworth et al., 2009; Sarfati et al., 2018). Another health literacy intervention study conducted by Gross et al. (2007), who focussed on a specific health issue (e.g. stroke) of the participants. However, as there was no data reported on the participants' pre- and post-intervention stroke knowledge, its effectiveness remains uncertain. In addition, changes in health literacy capacities within an individually targeted intervention programme devised by Long and Gambling (2012) were evident in the shift from specific to more general knowledge, lesser reliance on external support, greater self-responsibility, and enhanced confidence, resulting in more control in their self-care decision-making (e.g. monitoring glycaemic variability, diet, exercise, and medication adherence).

Some of the reviewed studies focus on shared decision-making, referring to the practical reconciliation of respect for persons (autonomy) and the monopoly and power of physicians. For example, Serbim et al. (2019) add to the weight of evidence in support of the notion that delivering an intervention leads to increased use of existing services and resources and provides meaningful improvements in health behaviours (e.g. diet or physical activities). This, in turn, better equips elderly people to make a range of more autonomous decisions relating to their health, or at least engage in the process of making health decisions. Moreover, in other studies (Aspinall et al., 2012; Edwards et al., 2012; Nahm et al., 2015, 2018) participants in an intervention group developed more autonomy in their decision-making – from developing their health knowledge to becoming more active communicators and decision makers in their healthcare. In addition, Hoffman-Goetz et al. (2006) and Xie (2012) focussed on shared decision-making and argue that health literacy training sessions for elderly people have led to an improved understanding of Internet search strategies, increased ability to search independently for cancer resources (increasing knowledge), and active participation in the healthcare process. Moreover, a study conducted by Perestelo-Perez et al. (2020) found that a series of massive open online health literacy courses facilitated shared decision-making processes among elderly people by progressing their health literacy skills and enabling them to use digital health platforms.

In contrast to several favourable findings, however, Redfern et al. (2020) found no evidence of a positive impact of intervention programmes and no indication of improved health behaviour (e.g. improved medication adherence) among the intervention group participants, suggesting that the study participants' health management competency did not improve as expected.

In summary, this theme focusses on how intervention programmes could empower elderly people to take control over their personal medical situations, resolve their health problems in the post-intervention stage, and take advantage of digital medical tools. In addition, this theme concentrates on enhancing the ability of the participants in the intervention programmes to engage in their medical decision-making process (shared decision-making with their healthcare professionals) by utilising health information technologies.

4.3 Attitude and confidence

The final research theme identified in the material consists of two different sub-themes: attitude towards using digital health services, and self-efficacy.

5.1 Intervention process

The reviewed studies report various changes in the skills, attitudes, beliefs, and confidence of elderly people as a result of interventions. In other words, the implementation of health literacy intervention programmes on different participants results in four principal outcomes, as described below.

1. Those who have participated in a health literacy training programme have been trained to use digital platforms to find, evaluate, understand, and use trusted and accurate online health information (Xie, 2011a, 2012). Obtaining these skills has been found to be crucial for elderly people to be able to manage their health conditions and make medical decisions through the use of digital health information platforms (Banbury et al., 2019; Czaja et al., 2013).

2. Knowledge regarding the use of computers, the web, or other digital devices and services has been found to increase among elderly people when pre-and post-intervention programme outcomes were compared (Xie, 2011a, c). Owing to a noticeable advancement in technology, the healthcare sectors have increasingly transformed their services towards being digitalised across the globe. Therefore, it is vital that elderly people have the basic knowledge to work with digital tools.

3. A noticeable change in the attitudes of elderly people post-intervention was reported in the reviewed studies. In the post-intervention phase, studies reported a higher level of interest and less anxiety when working with digital tools and using digital health platforms (e.g. Xie, 2012). Also, personal attitude appears to be a pertinent factor affecting the use of digital health services.

4. The health literacy interventions were useful in enhancing elderly people's competency for utilising technology and retrieving online health-related information. The higher levels of confidence and self-efficacy among elderly people after interventions seem to act as a driving force that motivates them to use digital health services (Nahm et al., 2018). However, the studies by Chiu et al. (2016) and Fink and Beck (2015) did not report any improvement in self-efficacy. Therefore, the impact of self-efficacy (improved confidence) was not conclusive in all the reviewed studies.

The intervention process is expected to have both individual and societal outcomes. The personal outcomes mostly concentrate on the effect of the intervention process on individuals, while the societal outcomes demonstrate the effects of the intervention process on societies. Based on an analysis of the examined studies and discussions presented above, this research presents a holistic research model consisting of three layers: the intervention process, individual layer, and societal layer (Figure 3). This integrative framework, which takes into account personal and environmental factors, highlights which abilities might change as a result of an intervention programme and which benefits might be gained.

5.2 Individual level

The review results show that health literacy interventions have direct and indirect effects on elderly people's health behaviours. After participating in the health literacy training sessions and learning how to use digital health services (platforms and tools), elderly people can participate more actively in their medical decision-making, since they will be able to obtain sufficient, and appropriate, medical information via digital health platforms. Furthermore, it is expected that health-literate elderly people could better resolve their health problems when they are more able to use digital health services. Owing to a higher likelihood of cognitive and physical impairments, elderly people face various health issues, which increase their need to access health services. Therefore, health literacy intervention programmes are of practical benefit to them. Despite the impact of health literacy interventions on elderly people, at the individual level there are several obstacles, which are mainly related to personal attitudes, thoughts, and characteristics (e.g. computer anxiety; lack of experience at working with digital devices). These obstacles could withhold or prolong the process of implementing health literacy interventions and enhancing elderly people's learning; therefore, addressing any obstacles arising in the pre-intervention phase is vital (Watkins and Xie, 2014).

5.3 Societal level

The third and final layer of the research model is the societal level, denoting the expected society-level outcomes and consequences of implementing health literacy intervention programmes among elderly people. The overall results of the review reveal that the two positive consequences of intervention programmes – transparent at the societal level – are having better health status and better overall well-being (Parker et al., 2018). As demonstrated in the literature, the higher the ability to manage one's personal health life, the better one's health status and well-being (Long and Gambling, 2012). At a deeper level, the intervention process in the core layer could positively influence medical decision-making or problem-solving ability among elderly people, which subsequently results in a higher quality of life in society as a whole.

In addition, improved health literacy and decision-making among elderly people may result in reduced use of emergency rooms and lower medical costs. Furthermore, such positive health outcomes for elderly people will contribute to the overall economic growth of the country, with reduced dependency rates and positive effects on the economy (Huang et al., 2019). This layer also encompasses the existing barriers present in societies which adopt a passive stance to adopting and using digital health services for elderly people (e.g. limited access to digital tools or digital sources, lack of impetus to support intervention programmes). All these obstacles may jeopardise the healthy life of elderly people and make it difficult for them to access digital health services (Chu et al., 2009). Authorities are responsible for creating these obstacles and so must find ways to tackle them since these problems are not within the control of the individuals.

6.1 Practical implications

This study also suggests several practical implications.

1. There is an increasing need to implement additional health literacy intervention programmes, for two reasons: (1) to satisfy elderly people's appetite for accessing health services on account of their cognitive and physiological impairments, and (2) to make digital medical platforms, widely available globally, applicable for elderly people, thereby providing them with rich medical information (re)sources. In this way, the consequences of the lack of information (e.g. increased use of emergency rooms, increased health expenditure) are mitigated. As a result, we suggest that government and healthcare organisations should design free and public health literacy training sessions for elderly people and promote the usefulness of the existing platforms.

2. Healthcare providers should also be aware of the importance of digital technologies and strive to motivate elderly people to utilise digital information services. One solution is to consider the capability of elderly people when designing, implementing, and developing information services. The best services must make it more convenient for its users to access information. In other words, the medical platforms must be sufficiently user-friendly for elderly people.

3. Healthcare professionals and other stakeholders must be aware of the importance of intervention programmes in terms of empowering elderly people to improve their health literacy as well as in their effects on the adoption and use of digital information (re)sources. However, implementing successful training sessions for elderly people is challenging for several personal and infrastructural reasons. It is vital to tackle the obstacles before initiating any training programmes.

6.2 Limitations and suggestions for the future research agenda

This systematic literature review has several limitations. First, only studies with full text written in English were included in the sample. Second, this review paper only considers empirical studies. Third, we only included studies published between 2000 and 2020. The tentative research model (Figure 3) is offered as a basis for future empirical research and validation. Similarly, as we did not focus on identifying any correlation between theories and intervention strategies, further research on the relation between theoretical frameworks and health literacy interventions – especially among elderly people – could bring clarity to theories concerning the development of successful interventions. Moreover, demographic variables (e.g. education, gender, age, and income) were not analysed in this systematic literature review. Therefore, in future investigations, scholars should consider the impact demographic variables on the success of health literacy interventions and health decision-making among elderly people. Moreover, this study did not quantitatively validate the relationships in the suggested model. Thus, in future investigations, we suggest scholars aim to affirm these relationships.