A review of the literature identified three interventional studies on health literacy in the heart failure population. One single-center study performed by Murray et al37
randomized 314 low-income patients with heart failure to receive usual care versus a 9-month multifaceted intervention designed for patients with low literacy. The intervention included support from an individual pharmacist, in-person verbal instructions, written materials developed for patients with low literacy, and therapeutic monitoring and communication with patients’ providers.38
Adherence was measured through the use of electronic monitoring prescription container lids, patient self-report, and medication refill history. Methods used to determine subjects’ health literacy were not disclosed. The intervention group had greater medication adherence than the usual care group; however, after the 3-month intervention stopped, medication adherence decreased. In addition, the intervention group had significantly fewer emergency room visits, hospitalizations, lower direct costs, and greater patient satisfaction than the patients in the usual care group.
DeWalt et al13
developed a 12-month intervention that provided practical self-management instructions to manage fluid volume status in patients with heart failure. The intervention was targeted toward patients with low literacy and consisted of the use of educational materials that were written at a third-grade level. Patients also received follow-up phone calls from a clinician to monitor their progress and answer any questions. Of 127 patients, 41% with low-literacy skills were randomized to receive the intervention or usual care. The intervention group did not show a significant decrease in hospitalizations or mortality, although the study was powered to detect a difference only in the primary outcome, quality of life. The intervention group did show a significant improvement compared with the usual care group in heart failure knowledge (12%, P
< .001), self-efficacy score (2 points, P
= .0026) and self-care behavior (79% versus 29%, P
< .001). There was no significant difference in quality of life, as measured on the Minnesota Living with Heart Failure Questionnaire between the groups.
A study by Smith et al39
used a disease management approach to improve self-care in patients with heart failure. The intervention included a comprehensive, standardized program, including education, telephone follow-up, and tools for self care including a weighing scale, blood pressure cuff, and pulse oximetry. This study focused on improving all aspects of self-care, including medication management, dietary adherence, symptom management, and self-monitoring skills. The intervention group had lower all-cause mortality and hospitalizations when compared with the usual care group, but on performing a secondary analysis comparing patients with low and high educational attainment, no difference in morbidity and mortality outcomes was found. However, sodium intake differed significantly by education (P
= .04), with the largest drop (−838 mg/day) observed in the least-educated group. This suggests that patients with lower education benefited from the intervention by increasing self-care skills.
Studies of health literacy, including those focusing on heart failure, are often multifaceted interventions involving care and follow-up from providers trained in disease management and self-care education. Many require additional resource allocation, including equipment, medications, and transportation. This makes it difficult to compare studies and confounds interpretation of results and subsequent application. In addition, literacy or health literacy is measured differently in different studies, making comparisons difficult.
Interventions tailored to meet the needs of a low literacy population affect outcomes, including: symptom monitoring and management, perceived knowledge, quality of life, mortality, and hospitalizations. However, intervention trials related to heart failure and health literacy are small and limited. Many questions remain as to which specific educational strategies best serve particular patient groups with low health literacy and heart failure.