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Reading Intervention Strategies for Struggling Readers

Amy Endo

Reading is the way some find joy and spend the day unwinding—curling up with a favorite novel, poring over current news, or reading the latest trend in various topics. But for some, reading is a chore, another dreadful assignment to complete, and an anxiety-ridden task particularly when it involves reading in front of others.

Reading instruction plays a central role throughout K-12 education, and much time and resources are allocated with the goal of ensuring our students are reaching grade-level expectations year after year. Yet, statistics show that many of our students are reading below grade level, and some studies find that interrupted schooling from the pandemic exacerbated the issue.

What Is Reading Intervention?

Reading intervention entails intensive or targeted instruction on reading to accelerate those who are reading below grade level. In the multi-tiered system of supports (MTSS) framework , intervention can be provided at various stages: a) providing students with additional supports in the Tier 1 core space; b) delivering push-in or pull-out targeted interventions in Tier 2; or c) allocating a designated time for a smaller group of students for intensive intervention who are multiple years behind in Tier 3.

What Are Evidence-Based Reading Intervention Strategies?

In order to accelerate students’ reading to grade-level proficiency, here is a list of reading intervention strategies on specific areas of focus:

Cracking the Code: Word Study

Sometimes, students’ difficulty with text comprehension stems from underlying issues with their foundational literacy skills . All students need a systematic scope and sequence that introduces each phonics skill progressing from simplest to more complex using controlled text.

  • Phonemic Awareness : Provide opportunities for students to segment, blend, and manipulate phonemes that are presented orally before moving to print.
  • Decoding : Instruct students on letter-sound correspondences and word patterns. Have students apply that knowledge when decoding as they segment and blend letter sounds to form words.
  • High-frequency words : Deliver discrete lessons on high-frequency words from regular phonics lessons so that students know there are some words that they should commit to memory when reading sentences.
  • Syllabication : Teach the six syllable types and have students break down longer multisyllabic words into syllables and readable chunks.
  • Spelling : Explicitly teach students spelling patterns and complement their reading activity with spelling tasks.

Focusing on Fluency :

On top of reading words accurately, learning to read words with automaticity and connected text with fluency are crucial for comprehension. Try a few of these activities and strategies to help your students develop their fluency skills.

  • Modeled fluent oral reading (teacher-led and audio) - Students listen to the text read aloud by the teacher or through audiobooks and eBooks that emphasize expressive reading and intentional pausing.
  • Assisted reading - Students listen to a modeled reading (either teacher-led or at a computer station) and are actively reading aloud the same text at the same time. Echo and choral reading are examples of assisted reading.
  • Guided oral reading - Students read a text aloud with feedback and explicit guidance from the teacher. Providing error correction for the students is paramount to reinforce appropriate word reading strategies and phrasing that will aid in text comprehension.
  • Partner reading - The students read a section of text and a partner will read the next section of text in an alternating fashion. Alternating reading texts aloud allows for sufficient cognitive breaks needed for students to persevere through longer texts, stay engaged, and build reading stamina.
  • Prosody development - Explicit instruction on prosody development is needed so students can focus beyond word reading recognition and rate of reading. Prosody elements include intonation, volume and stress, smoothness, phrasing, and expression

study literacy intervention

Unpacking the Words: Vocabulary

Reading is meaningless unless students understand the meaning behind the words they decode. Teachers can incorporate vocabulary instruction through a variety of ways, whether in their daily conversations with students, explicit vocabulary lessons, or selecting a variety of genres of texts. Here are some best practices for vocabulary instruction:

  • Teaching language for discussing books: Teachers can model and explain the vocabulary used to discuss narrative and informational texts, including organizing and then discussing the actions in a story shared during oral reading time.
  • Teaching academic vocabulary: Teach academic vocabulary where students may not understand the different technical meanings for words used in informational texts or content-area books.
  • Deepening students’ knowledge of words used: Select different genres and topics that include content-specific vocabulary to expand students’ understanding of concepts. Also, teachers can help students connect new words to words or word parts students already know.
  • Building morphological awareness: Teach students the word parts that carry meaning—inflectional endings, base words, prefixes, and suffixes—and how they can be combined to form words or broken down to understand their meaning.

Building Comprehension : Content Knowledge and Comprehension Strategies

Vocabulary is critical, but it is not enough for text comprehension. Students also need to possess knowledge on the content or topic of the text in order to grasp its full meaning. The more readers know about a topic, the easier it will be to comprehend a text written about that topic. Wide reading expands readers’ background knowledge and adds to their vocabulary. Implement these strategies into your everyday instruction to help improve your students’ comprehension.

  • Activate prior knowledge: Before students read, have them think about what they know about the topic. As they read the text, have them connect their own understanding or experiences to the text.
  • Multiple genres: Use narratives, narrative nonfiction, and informational texts.
  • Multiple texts on the same topic: Rather than moving quickly from topic to topic, engage students with multiple texts on the same topic. Expose students to the same vocabulary in different contexts and teach difficult concepts repeatedly for deeper understanding.
  • Text Structure: Introduce different text structures and key words associated with texts such as compare and contrast, cause and effect, problem and solution, etc.
  • Retell and Summarize: Have students retell what the story was about, and gradually encourage students to summarize the key points of the text.
  • Language engagement: Engage students tin discussions about what they are learning and make connections to their own life.

Implementing Reading Intervention Strategies

How you implement these strategies for reading intervention students depends on their needs and the time allocated in your school’s schedule. However, effective instruction entails the following:

Use Data to Determine Eligibility and Inform Instruction

First, teachers need to determine who is eligible for intervention. Intervention eligibility differs from district to district. Teachers can use various assessment results that either show students’ performance compared to the national norm or how many years they are reading below grade level. This data will determine those that need additional supports in Tier 1, Tier 2 targeted intervention, or Tier 3 intensive intervention.

Once students have been identified as needing intervention, teachers can use data from various assessments to further identify students’ strengths and gaps, monitor how the students are progressing with the targeted instruction, and adjust instruction as needed. Teachers can administer formative assessments during the course of instruction to provide feedback and adjust ongoing teaching, diagnostic assessments to provide in-depth data on students' learning accomplishments and areas that are not well developed, and benchmark assessments at specified times of the year to evaluate students' progress against a determined set of longer-term goals.

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Deliver Explicit Systematic, and Cumulative Instruction

Whether it’s foundational literacy skills, fluency, vocabulary, or comprehension instruction, explicitly explaining all concepts in both the whole- or small-group setting is integral for understanding.

  • Explicit instruction and practice on foundational reading skills such as recognizing and manipulating word parts presented orally (phonemic awareness), understanding letter-sound relationships (phonics), blending letter-sound patterns to produce words (decoding), or understanding common spelling patterns (encoding).
  • Targeted, whole-class reading instruction in a teacher-led lesson as a precursor to the longer period of independent or small-group work; during the mini-lesson, the teacher (1) ties new content or skills to what has been learned previously; (2) states the teaching point that will be presented; (3) models or explains the teaching point, usually with some textual support; (4) asks students to practice the teaching point with partners; and (5) restates the focus of the mini-lesson.
  • Small-group instruction , during which teachers meet with small groups and other students work independently, work with partners, work in centers, or practice their developing skills. Both print and digital practice activities are available to reinforce what students have been learning.

Provide Scaffolded Independent Reading Practice

Teachers can provide a variety of interactive and independent reading activities using different strategies to enhance engagement.

  • Self-agency : Have students select books in their field of interest that are within the range of their reading level. Students are more motivated to read when they have a choice in their book selection.
  • Digital classroom libraries provide scaffolded supports such as online dictionaries, highlighting tools, or accessibility features that keep students engaged while having access to instructional support.
  • Comprehension quizzes allow for accountability of the books that students have read independently.
  • Book clubs : Independent reading can be done as a collaborative project. Have students read the same books on their own and then come together to work on reading assignments and projects in small groups.

Implementing effective reading intervention strategies into our classrooms allows for students to experience moments of success and even joy through their reading, no matter how short or long the text may be. The cumulative process of experiencing these small wins will help make our students “page turners” not only in the books that they read but also equips them to start new chapters in their personal achievements.

You can find additional articles on oral fluency by Dr. Amy Endo on the blog, including What is Oral Fluency? and Optimizing Literacy Instruction with Oral Reading Fluency Assessments .

Learn more about our science of reading curriculum , an evidence-based approach to help students in their reading journeys.

Watch our webinar Secondary Newcomers: Equitable Pathways for Diverse EL Profiles to learn how to best address newcomers entering U.S. schools post-primary education.

Get our free Reading Intervention eBook today.

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Structured Literacy Interventions

Teaching students with reading difficulties, grades k-6, edited by louise spear-swerling.

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  • All titles by Louise Spear-Swerling
  • contributors Stephanie Al Otaiba , PhD, Simmons School of Education and Human Development, Southern Methodist University, Dallas, TX Jill H. Allor , EdD, Simmons School of Education and Human Development, Southern Methodist University, Dallas, TX Erin Munce Anderson , MEd, College of Education, University of Washington, Seattle, WA Christy R. Austin , PhD, University of Utah, Salt Lake City, UT Michael D. Coyne , PhD, Neag School of Education, University of Connecticut, Storrs, CT Charles Winthrop Haynes , EdD, School of Health and Rehabilitation Sciences, MGH Institute of Health Professions, Boston, MA Roxanne F. Hudson , PhD, College of Education, University of Washington, Seattle, WA Devin M. Kearns , PhD, Neag School of Education, University of Connecticut, Storrs, CT Shannon L. Kelley , MAT, Neag School of Education, University of Connecticut, Storrs, CT Susan Lambrecht Smith , PhD, School of Health and Rehabilitation Sciences, MGH Institute of Health Professions, Boston, MA Susan M. Loftus-Rattan , PhD, School of Education, Duquesne University, Pittsburgh, PA Cheryl P. Lyon , MAT, Neag School of Education, University of Connecticut, Storrs, CT Melissa McGraw , MEd, College of Education, University of Washington, Seattle, WA Donna D. Merritt , PhD, independent consultant, Mansfield Center, CT Louisa C. Moats , EdD, Moats Associates Consulting, Inc., Sun Valley, ID Rebecca Ray , MA, University of Washington, Seattle, WA Louise Spear-Swerling , PhD, Southern Connecticut State University, New Haven, CT Elizabeth A. Stevens , PhD, Georgia State University, Atlanta, GA Jennifer Stewart , PhD, Simmons School of Education and Human Development, Southern Methodist University, Dallas, TX Alison Wilhelm , MEd, College of Education, University of Washington, Seattle, WA Richard P. Zipoli , PhD, Southern Connecticut State University, New Haven, CT -->
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  • Research article
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Establishing the efficacy of interventions to improve health literacy and health behaviours: a systematic review

  • Ronie Walters   ORCID: orcid.org/0000-0002-9330-9909 1 ,
  • Stephen J. Leslie 1 , 2 ,
  • Rob Polson 1 ,
  • Tara Cusack 3 &
  • Trish Gorely 1  

BMC Public Health volume  20 , Article number:  1040 ( 2020 ) Cite this article

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The primary aim of this review was to establish whether health literacy interventions, in adults, are effective for improving health literacy. Two secondary aims assessed the impact of health literacy interventions on health behaviours and whether health literacy interventions have been conducted in cardiovascular patients.

A systematic review (Prospero registration: CRD42018110772) with no start date running through until April 2020. Eligible studies were conducted in adults and included a pre/post measure of health literacy. Medline, Embase, Eric, PsychINFO, CINAHL, Psychology and Behavioural Science, HMIC, Web of Science, Scopus, Social Care Online, NHS Scotland Journals, Social Policy and Practice, and Global Health were searched. Two thousand one hundred twenty-seven papers were assessed, and 57 full text papers screened to give 22 unique datasets from 23 papers. Risk of bias was assessed regarding randomisation, allocation sequence concealment, blinding, incomplete outcome data, selective outcome reporting and other biases. Intervention reporting quality was assessed using the TIDieR checklist.

Twenty-two studies were included reporting on 10,997 participants in nine countries. The majority of studies (14/22) were published in 2018 or later. Eight studies (n = 1268 participants) also reported on behavioural outcomes. Health literacy interventions resulted in improvements in at least some aspect of health literacy in 15/22 studies (n = 10,180 participants) and improved behavioural outcomes in 7/8 studies (n = 1209 participants). Only two studies were conducted with cardiovascular patients. All studies were at risk of bias with 18 judged as high risk. In addition, there was poor reporting of intervention content with little explication of the theoretical basis for the interventions.


Health literacy interventions can improve health literacy and can also lead to changes in health behaviours. Health literacy interventions offer a way to improve outcomes for populations most at risk of health inequalities. Health literacy is a developing field with very few interventions using clear theoretical frameworks. Closer links between health literacy and behaviour change theories and frameworks could result in higher quality and more effective interventions.

Prospero registration

Prospero registration: CRD42018110772

Peer Review reports

Health literacy as a concept first emerged in the 1970’s [ 1 ] and the definition further refined in 2000 by Nutbeam [ 2 ] who added interactive health literacy and critical health literacy to the existing focus on functional health literacy. These three aspects have endured throughout the subsequent developments of health literacy and are conceptualised as representing different levels of skills and understanding that move progressively towards greater autonomy and empowerment. They start from a base of functional health literacy (basic ability to read and understand health information [ 2 , 3 ]) through interactive health literacy (more advanced cognitive and social skills that demonstrate greater engagement with a wider variety of health information, improved self-efficacy, and decision making [ 2 , 3 , 4 , 5 , 6 ]) and finally critical health literacy (higher order cognitive and critical decision making skills, alongside social, political and organisational level actions to improve wider determinants of health [ 2 , 3 , 4 , 5 , 6 , 7 ]).

In 2012 the European Health Literacy Consortium [ 6 ] conducted a major review of the literature and developed a new definition of health literacy - “Health literacy is linked to literacy and entails people’s knowledge, motivation and competences to access, understand, appraise, and apply health information in order to make judgments and take decisions in everyday life concerning healthcare, disease prevention and health promotion to maintain or improve quality of life during the life course.” (Pg.3). Applying this definition suggests that health literacy pervades patient’s encounters with healthcare services at every level. For a while the focus was on health literacy as a skill or asset that the patient was required to improve [ 8 ]. More recently there has been a recognition of the responsibility that healthcare services have to ensure they are providing information in a way that patients can understand [ 9 ].

Health literacy and cardiovascular disease

The European health survey found that almost half of adults in eight countries had inadequate or problematic health literacy [ 10 ]. Weak health literacy competencies can result in increased rates of hospital readmission, low health related quality of life (HRQOL), higher anxiety levels and lower social support [ 11 ], less healthy choices, and poorer self-reported health status [ 12 ]. Health literacy is also a key predictor of self-assessed health second only to age [ 13 ].

Other studies have shown that patients with chronic conditions have lower levels of health literacy, and amongst this sector, cardiovascular patients have the highest number of problems understanding health information [ 14 , 15 ]. Given this limitation, it is possible that interventions to improve health literacy may be important to support and facilitate subsequent behaviour change.

Cardiovascular diseases are the leading cause of mortality worldwide, responsible for 31% of deaths in 2015 [ 16 ]. Cardiovascular diseases are predominantly the result of lifestyle behavioural factors such as poor diet, inadequate physical activity, smoking or harmful alcohol consumption. Other physiological factors include high blood pressure, high cholesterol, high blood sugar or glucose. Both the physiological and the behavioural factors are linked with socio-economic and societal drivers such as ageing, income, location, education and housing [ 17 ].

Following a cardiac diagnosis there is a need for patients to learn to self-manage their condition, and for many a change in lifestyle could reduce the risk of further cardiovascular events. This can be supported through a course of cardiac rehabilitation offered through the national health service (NHS), though uptake is low [ 18 ]. Whilst there are many reasons why this may be the case [ 19 , 20 , 21 , 22 ], some of it may be due to inadequate levels of health literacy.

There has been a significant increase in the amount of research conducted into health literacy in recent years, including a much higher proportion with a European focus, however, much of this has been focused on identifying definitions, prevalence and associations [ 23 ]. Less research has been conducted into possible interventions for health literacy – in any health condition, and particularly within cardiac populations [ 24 ].

Limitations with previous reviews

From a pool of 96 reviews in the field of health literacy none focused specifically on health literacy interventions in cardiac patients. Four reviews focused on health literacy in cardiac populations [ 25 , 26 , 27 , 28 ] and covered aspects such as prevalence, adherence to medication and measurement tools. Whilst some of these did include interventions, none required pre-post measures as an inclusion criterion. To be certain that a specified intervention has made a change to the outcome of interest (in this case health literacy) measuring before and after the intervention is an essential requirement. Including a control condition, increases the likelihood that outcomes are a result of the intervention content, rather than the contact the intervention brought. Both of these requirements are missing in all reviews identified by the search team.

Many chronic or long-term health conditions such as cardiovascular disease, benefit from behavioural changes to support lifestyle modification. Improving health literacy skills is believed to result in patients being better able to manage lifestyles, seek information and have the confidence to apply it. As a consequence, improved health literacy may result in improved behavioural outcomes such as smoking cessation, increased physical activity, improved diet quality, successful weight management and reduced alcohol consumption.

The primary aim of this review is to establish whether controlled health literacy interventions, in adults, are effective for improving health literacy. Two secondary aims, using the studies identified for the primary aim, are to explore whether 1) health literacy interventions lead to a change in health behaviours and 2) which of the eligible studies were conducted with cardiovascular patients and examine the outcomes in this population.

The protocol was registered with PROSPERO (registration number: CRD42018110772).

Eligibility criteria

Eligible papers included any full text articles published in peer reviewed journals with adults (aged 18 or over) as the subject of the intervention (as opposed to parents/caregivers). Searches were restricted to English language only due to the capacity of the review team to translate or work with other language texts. Eligible interventions included any intervention evaluated in a controlled trial that included a pre-post measure of health literacy. Eligible control conditions include any usual care or alternative approach to the intervention. Primary outcomes were self-reported or objectively measured health literacy measured at baseline and post-intervention (either directly after intervention completion or at follow up, regardless of the duration). Secondary outcomes of interest for this study are changes in behavioural outcomes such as health screening, smoking, nutrition, alcohol or physical activity behaviours. In common with Nutbeam et al. (2018) we excluded mental health literacy interventions as the field is conceptually distinct from health literacy.

Papers were excluded if they were not available in English to allow the review team to effectively review them, if they did not report full peer reviewed results of an intervention (for example abstracts, unpublished studies, protocols), or if they did not report both pre and post measures of health literacy. It is worth noting that many of the excluded papers were either observational/correlational studies, or they only used health literacy to segment the intervention population, or the intervention was designed to improve health literacy but they did not measure health literacy as an outcome of interest. None of these studies were eligible for this review.

Information sources

Searches were conducted on electronic databases with no start date restriction through to 10th April 2020. The following databases were searched: Medline, Embase, Eric, PsychINFO, CINAHL, Psychology and Behavioural Science, HMIC, Web of Science, Scopus, Social Care Online, NHS Scotland Journals, Social Policy and Practice, Global Health. Full search strategies for each database can be found in additional file  1 . In addition, the references of the papers included in the systematic review were searched, along with several published systematic reviews in related areas to make sure no relevant articles were missed.

Search strategy

Initial scoping searches to develop the search strategy included cardiology specific terms. The search strategy was then broadened and the results backchecked to ensure the strategy was still retrieving the cardiology related materials. Searches included a combination of terms from MESH headings and keywords in the title and abstract. The search included multiple terms for health literacy (e.g. health literacy, functional health literacy), intervention (e.g. intervention, pre-post, trial) and health literacy measurements (e.g. health literacy screen, health literacy measurement, REALM, TOFHLA). All terms within each category were combined with “OR” and then the three categories were combined with “AND”. The search strategy was created by RW, TG and RP (an experienced information specialist) and run by RW. Detailed search strategies can be found in supplementary Table 1 (additional file 1 ).

Study selection

Search results were imported into Endnote X9 reference management software and duplicates were removed. The remaining papers were exported to RAYYAN [ 29 ] (a systematic review web application) and titles and abstracts screened through application of the inclusion/exclusion criteria by RW, with a random 10% screened independently (TG) with 100% concordance. Full texts of potentially relevant studies were screened independently by two reviewers (RW, TG). All included texts had the references hand searched to check for additional eligible papers.

Data extraction

All data from included studies were extracted into Word independently by two reviewers (RW, TG). Details extracted included study details, (design, population), health literacy details (definition, measure of health literacy used, aspects of health literacy measured), intervention details (intervention content, contact time, aspect of health literacy targeted in the intervention) and outcomes (health literacy and secondary behavioural outcomes).

Data analysis

All papers were assessed using the template for intervention description and replication (TIDieR) independently by RW and TG with 84% initial concordance, rising to 100% following discussion. Quality appraisal was conducted independently using risk of bias in non-randomised studies of interventions (ROBINS-1) for non-randomised controlled trials and the appropriate version of risk of bias 2 (RoB 2.0) for individual randomised, cluster randomised and cross-over trials. Earlier versions were adjusted in domain 5 to provide consistency with the questions in the latest version for randomised controlled trial (RCT) studies. Initial inter-rater agreement was 91% for overall risk of bias and 83% for sub-domains. After discussion all differences were resolved with 100% agreement.

Results are presented using a narrative synthesis as the variation in definitions and measurements rendered a meta-analysis unsuitable.

Study characteristics

This systematic review identified 3387 papers. After the removal of duplicates 2127 unique publications were screened and 2076 excluded based on title or abstract because they did not meet the inclusion criteria (see additional file 1 for detailed breakdown). Fifty-seven papers were retrieved for full text assessment, of which 35 failed to meet the inclusion criteria. Twenty-three papers [ 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 ] exploring 22 data sets (summarised in Table 1 ) were included in the final review (see Fig. 1 ). The two papers by Mas et al. [ 45 , 46 ] were confirmed by the authors to relate to the same data set. Information from both papers was extracted to complete the review, however for clarity the reference for the latest paper will be used [ 45 ].

figure 1

PRISMA Flow Diagram

Of the 22 included studies, the earliest study was from 2014 [ 30 ], the latest from 2020 [ 35 , 36 , 37 ] with the majority (fourteen) being published since 2018 [ 32 , 33 , 34 , 35 , 36 , 37 , 44 , 45 , 47 , 48 , 49 , 50 , 51 , 52 ]. Eighteen studies were randomised and included 1 cross over design [ 50 ], 5 cluster randomised [ 39 , 41 , 44 , 47 , 51 ] and 12 individually randomised trials [ 30 , 31 , 32 , 34 , 36 , 37 , 38 , 40 , 43 , 45 , 49 , 52 ]. The remaining four were quasi-experimental pre-post controlled trials [ 33 , 35 , 42 , 48 ]. Studies took place in nine countries –USA [ 30 , 31 , 37 , 39 , 40 , 42 , 43 , 45 ], Australia [ 35 , 51 , 52 ], Iran [ 32 , 34 , 47 ], China [ 41 , 44 ], Japan [ 36 , 49 ], Taiwan [ 48 ], Niger [ 38 ], Germany [ 50 ] and Demark [ 33 ].

Two studies focused on the domain of disease prevention (cancer screening [ 39 ] and malaria health literacy [ 38 ]), eight focused on healthcare (diabetes [ 30 , 37 ], gestational diabetes [ 32 ], breast cancer [ 36 ], cardiac conditions [ 33 , 34 ], one or more chronic conditions [ 35 ] and people taking two or more medications daily [ 31 ]). The remaining 12 studies focused on health promotion with eight focusing on general health promotion [ 41 , 42 , 44 , 45 , 48 , 50 , 51 , 52 ], two focusing on nutrition [ 40 , 43 ], one on nutrition and physical activity [ 49 ] and one on smoking prevention [ 47 ]. Studies are summarised in Table 1 .

TIDieR assessment

Reporting was adequate for 58% of the intervention conditions and 57% of the control conditions. Six studies planned to tailor the intervention but only two reported adequately. Only one study modified the delivery of the intervention.

Across the 22 studies only seven reported on planned fidelity checks (reporting was adequate for four of the studies and unclear for the other three). Of these seven only two reported on actual fidelity, with only one being sufficiently clear to be considered adequate. Studies were generally good at providing a descriptive name or phrase (95%), rationale (100%), and details of how (86% for intervention, 69% for control) and frequency and intensity (73% for intervention, 64% for control). Planned fidelity (18%) and actual fidelity (5%) were the most poorly described. It should also be noted that whilst materials were described in 95% of intervention conditions and 69% of control conditions the percentage that were adequately reported was much lower (41% of intervention, 38% of control). See supplementary Tables 2 & 3 (additional files  2 & 3 ) for TIDieR reporting and percentage summary tables.

Risk of Bias

No studies were rated at a low risk of bias overall, with 18 being at a high or serious risk of bias and just four being rated at some concerns (see supplementary Table 4 (additional file  4 )). Studies were generally poorly rated in the randomisation process with only three being at low risk of bias. The majority of studies showed low risk of bias for the deviations from intended intervention (20 studies). Thirteen studies had low risk of bias for measurement of the outcome and 12 studies for missing outcome data domains. No study analysed data in accordance with a pre-published statistical analysis plan (SAP) causing all studies to be rated with some concerns for the risk of selection bias.

Participant characteristics

The studies included 10,997 participants. Six studies focused exclusively on women [ 32 , 36 , 39 , 40 , 43 , 48 ], the remaining 16 included both genders. One study did not provide a gender split [ 41 ] but the remaining 15 studies had an average of 55.6% female participants (range 2.98–81.7%).

Eight studies focused on specific ethnic groups or migrants from either Asia (Korea [ 37 , 39 ], China [ 38 ], Vietnam or Indonesia [ 48 ]), or Mexico [ 30 , 40 , 42 , 45 ]. All participants were adults and most studies covered the whole age spectrum however one study only included people aged 18–35 [ 32 ], two specified working age adults [ 38 , 39 ], and six focused on the later years in life with minimum age of 40 [ 40 ], 50 [ 35 ], 55 [ 31 , 52 ], 60 [ 44 ] and 65 [ 49 ] respectively.

Health literacy definitions and measures

There was considerable variation in how health literacy was defined and measured (see Table  2 ). Six studies [ 36 , 40 , 42 , 43 , 45 , 47 ] did not provide a definition, two [ 31 , 34 ] gave a definition but no clear reference to identify it, and the remaining 14 studies referenced 10 different definitions (three studies [ 30 , 35 , 48 ] gave multiple definitions) with Ratzan and Parker [ 54 ] used in five studies [ 30 , 35 , 37 , 39 , 51 ] and Sorensen [ 6 ] cited in four studies [ 33 , 48 , 49 , 50 ].

A variety of health literacy measures were used across the 22 studies. Four studies used condition specific measures [ 30 , 37 , 38 , 39 ], four used culture specific measures [ 32 , 44 , 47 , 50 ], and three created measures for use in the studies [ 30 , 41 , 48 ]. The rest used validated general instruments such as newest vital sign -NVS [ 37 , 40 , 43 ], test of functional health literacy in adults / short test of functional health literacy in adults -TOFHLA/STOFHLA [ 31 , 34 , 37 , 42 , 45 ], Health Literacy Questionnaire – HLQ [ 33 , 35 , 51 , 52 ], HLS-EU-Q16 [ 49 ], and HLS14 [ 49 ]. Two studies used multiple measures [ 37 , 49 ].

Studies did not always clearly describe measures used to assess health literacy. Nine studies used clearly objective measures [ 31 , 34 , 37 , 39 , 40 , 41 , 42 , 43 , 45 ], 12 used clearly subjective measures [ 30 , 32 , 33 , 35 , 36 , 44 , 47 , 48 , 49 , 50 , 51 , 52 ]. In addition one [ 38 ] was more difficult to determine and appears to be a mixed measure. The author has not responded to requests for clarification. With regards to the different aspects of health literacy (functional, interactive, critical) as shown in Table 3 , all but one [ 48 ] measured functional health literacy, nine measured interactive health literacy [ 32 , 33 , 35 , 36 , 48 , 49 , 50 , 51 , 52 ] with a further two [ 38 , 47 ] providing insufficient information to determine, and just six [ 32 , 35 , 36 , 48 , 49 , 52 ] measured critical health literacy, with an additional three being unclear for this aspect [ 38 , 47 , 50 ].

Intervention characteristics

All interventions targeted functional aspects of health literacy (see Table 3 ), in addition sixteen [ 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 43 , 45 , 48 , 49 , 50 , 51 , 52 ] also targeted interactive aspects (with a further one [ 42 ] providing insufficient information to determine) and four of these [ 35 , 48 , 50 , 52 ] also targeted critical health literacy (with a further three [ 38 , 49 , 51 ] being unclear). Intervention designs (as shown in Table 1 ) included small group sessions [ 32 , 34 , 35 , 37 , 39 , 40 , 42 , 43 , 44 , 45 , 48 , 49 , 50 , 51 ], text or social media messages [ 38 , 41 , 47 ], animation [ 30 ], multi-media learning [ 52 ], app [ 36 ] and one to one education [ 31 , 33 ]. The most common approach was for small group educational classes (14 studies).

Of the text/social media interventions the frequency of messages ranged from 3x/week for 4 months [ 38 ] through to once a week for a year [ 41 ]. One study used social media for health education counselling for a total of 6 sessions [ 47 ], but there was insufficient detail to identify length, duration or content of the sessions.

The 14 small group studies ranged from 40 min [ 44 ] to full day sessions [ 50 ], with a frequency ranging between twice a week [ 51 ], weekly [ 32 , 35 , 37 , 40 , 42 , 45 , 49 ] fortnightly [ 43 , 48 ] and monthly [ 44 ]. The intervention duration period ranged from 2 weeks [ 40 ] to 12 months [ 37 ] of active content. One study did not specify frequency or total intervention duration, just individual session lengths [ 34 ]. Across all studies follow-up ranged from the same day [ 30 ] to 12 months [ 37 , 41 , 50 ]. The time lag between intervention end and follow up ranged from none [ 30 , 36 , 37 , 38 , 41 , 42 , 43 , 45 , 49 ] to 6 months [ 39 , 48 , 50 ].

Intervention effects on main outcomes

Table 4 summarises the effect of intervention on both health literacy and behavioural outcomes.

  • Health literacy

Twelve of the studies showed a significant increase in health literacy in the intervention group compared to the control group [ 30 , 31 , 32 , 34 , 37 , 38 , 39 , 40 , 41 , 44 , 45 , 47 ]. Six showed no significant difference [ 35 , 36 , 42 , 43 , 48 , 52 ], three showed an increase in health literacy for some but not all domains or subscales [ 33 , 49 , 51 ] and one was inconclusive due to mixed results in a crossover design [ 50 ]. Four out of the six with no change employed subjective measures [ 35 , 36 , 48 , 52 ].

Behavioural outcomes

Many of the studies included additional outcomes such as knowledge [ 39 , 40 , 47 ], self-efficacy [ 34 , 37 , 52 ] morbidity [ 38 ], perceptions [ 39 , 47 ], physical and cognitive function [ 49 ], health education impact [ 35 ], patient activation [ 33 ] and behavioural outcomes [ 32 , 34 , 39 , 40 , 43 , 45 , 47 , 49 ]. Behaviour was measured in smoking prevention behaviours [ 47 ], nutrition related behaviours [ 40 , 43 , 49 ], physical activity behaviours [ 49 ], cancer screening behaviours [ 39 ], and some measures which encompassed a variety of domains (lifestyle [ 32 ], self-care [ 34 ] and cardiovascular health [ 45 ]).

Smoking prevention behaviours, physical activity and cancer screening were measured in a single study each, and all showed significant changes in favour of the intervention group [ 39 , 47 , 49 ]. Nutrition and diet related behaviours were measured in three studies. Two [ 40 , 49 ] showed significant results in favour of the intervention group (fat related diet habits, food frequency and dietary variety). The third study [ 43 ] measured nutrition literacy and fruit and vegetable intake and found no significant effect of intervention.

Lifestyle factors were measured in one study [ 32 ]. This measure considered 10 dimensions of health and found a statistically significant effect of the intervention for overall lifestyle, and for 8 out of 10 sub-dimensions. Cardiovascular health was measured in one study [ 45 ] by measuring nutrition and physical activity behaviours and found a significant change in intervention group compared to control. Finally one study [ 34 ] found a significant change in intervention compared to control for self-care behaviours in heart failure patients.

Cardiac patients

Two studies focused on cardiac patients [ 33 , 34 ] and a further two of the studies used a cardiovascular health curriculum within healthy adults to reduce the risk of cardiovascular disease [ 40 , 45 ]. Tavakoly Sany [ 34 ] focused on heart failure patients and ran three educational group workshops using techniques such as teach back and role playing. The study measured health literacy, self-efficacy and self-care behaviours and found a significant effect of intervention in all three aspects – both immediately post intervention and at the three month follow up. Knudsen [ 33 ] compared tele-rehabilitation with usual care cardiac rehabilitation for both health literacy and patient activation. They found that neither method of rehabilitation improved patient activation and only one of the HLQ subscales (ability to engage with healthcare providers) showed a significant effect in the intervention group.

Two studies focused on reducing cardiovascular risk in health adults. Both studies were conducted in America and targeted Spanish speaking immigrants. Mas [ 45 ] used a combined health literacy and standard English as a second language (ESL) curriculum which used “Salud para su Corazon” (health for your heart) as the main resource. The study measured both health literacy and cardiovascular health behaviours and found a significant effect of intervention in both (although they were not correlated). Otilingam [ 40 ] used specifically designed content in two 2-h workshops designed to improve heart health and brain health in Latina’s. The paper measured health literacy and dietary fat reduction behaviours and found significant effects of intervention in both.

This systematic review included 22 studies from nine countries involving almost 11,000 participants. In 68% of studies a significant improvement in health literacy was seen. Additionally, eight studies measured behavioural outcomes and in seven of the studies a significant effect in favour of the intervention group was found. Only two studies have been carried out with cardiovascular patients.

Quality appraisal found that no studies were at low risk of bias. This was largely influenced by the lack of pre-published SAP protocols and issues with effective randomisation, allocation concealment and blinding which can be more challenging in this type of interventional study, though not impossible [ 73 ]. Analysis of intervention reporting showed that studies were generally poor at reporting sufficient detail of the intervention content to allow replication (and in some cases, effective categorisation of intervention focus).

Notwithstanding this, this systematic review has highlighted the growth in the health literacy field. This review set no lower limit date yet the oldest study including a pre-post measure of health literacy in a controlled trial was 2014. The number of studies has steadily increased (with over half being published since 2018) suggesting a growth in work to establish the evidence base for health literacy interventions. Whilst the most commonly used approach was small group educational interventions it is worth noting that other methods that are less time/resource intensive show promise. A short animation [ 30 ], a single 10 min training session [ 31 ], remote videoconferencing/tele-rehabilitation [ 33 , 35 ] and three studies that used social media or SMS messages [ 38 , 41 , 47 ] were all effective at increasing health literacy.

The search for this systematic review captured studies that were not available when the review of community-based interventions was conducted by Nutbeam et al. in 2018 [ 74 ]. As Nutbeam [ 74 ] indicated, there is a move towards the inclusion of wider aspects of health literacy, with 16 of the interventions in the current review now clearly including interactive aspects but only four interventions clearly including aspects of critical health literacy. It is promising to see more interactive content, but there is an evident lag in including aspects of critical health literacy. This could reflect difficulties in operationalising critical health literacy in measures. For example, a recent study into health literacy interventions in Europe [ 75 ] found seven studies (not eligible for this systematic review) with critical health literacy content, but in common with this review, only three of the interventions included any form of critical health literacy measure, and even then it was measured via skills lists, interview or decision-making skills rather than specific health literacy instruments.

This mismatch between measures and intervention content can have significant effects. Half of the studies in this review did not have measures capable of measuring all aspects of health literacy targeted in the intervention [ 34 , 37 , 38 , 39 , 40 , 42 , 43 , 45 , 48 , 50 , 51 ]. Notably four out of the seven studies that did not find an increase in health literacy as a result of the intervention fell within this group [ 42 , 43 , 48 , 50 ]. In addition, only 12 of the studies [ 35 , 37 , 38 , 40 , 41 , 43 , 45 , 47 , 48 , 49 , 51 , 52 ] included an indication of their intervention’s theoretical underpinnings. Whilst there is debate as to whether theory contributes to the efficacy of interventions [ 76 , 77 ], in a field which is striving to develop an evidence base, theory allows for the systematic development, comparison and refinement of interventions and is something that should be encouraged [ 78 ].

As a determinant of health, health literacy may offer a way to improve outcomes for populations most at risk of health inequalities. Whilst several studies focus on migrants, other at-risk populations have not been similarly targeted for intervention. This is particularly noticeable with regards to gender. Recent studies have suggested men have lower health literacy than women [ 79 , 80 , 81 ], and are more likely to have multiple lifestyle risks [ 68 , 82 , 83 ] yet from our pool of 22 studies six focused exclusively on women and no study focused solely on men.

Only two studies (both within the past year) have been conducted with cardiac patients. One of these compared two different modes of cardiac rehabilitation, and the other conducted three education sessions with heart failure patients. It is surprising that more interventions have not been conducted with cardiac patients as yet, given that evidence shows they are at higher risk for health literacy issues [ 14 , 15 ] and that they can benefit from behavioural interventions. The evidence in this review suggests that health literacy interventions are effective at influencing behaviour, though as no study conducted mediation analysis, we are unable to confirm the direction of this influence.

This review has highlighted rapid growth in intervention studies with just five studies published up until 2016 and then a rapid increase with three in 2017, six in 2018, five in 2019 and three in the first quarter of 2020. We can also see evidence of improved methodological designs in later studies – perhaps as a result of comments by Brainard et al. [ 84 ] regarding methodological challenges in health literacy research. A key observation was that there is not enough focus on patient-centred outcomes, and interventions could be more useful if they involved patients in the design - rather than assuming that simply telling people what they need to do is sufficient to bring about change. Three studies [ 34 , 35 , 37 ] in 2019 and 2020 involved participants in intervention content and design. In addition, the only four studies [ 34 , 36 , 37 , 52 ] with lower risk of bias (some concerns) were from 2019 to 2020.

The ultimate aim of health literacy interventions is to bring about behaviour change in order to make an individual/agent/organisation behave in a health literate way. In recent years we can see the behaviour change field has developed a considerable number of frameworks, theories, components and techniques. Whilst this review started out asking if health literacy interventions influenced behaviour change, it has become apparent that heath literacy interventions can both influence behaviour change but could also learn from behaviour change theory. Interventions designed along behaviour change principles have the potential to be more robust, effective and applicable – at all levels.


This review is the first (to the best of our knowledge) to focus on controlled trial health literacy interventions with pre and post measures, in adults across all health conditions and domains. It adds to the body of knowledge by demonstrating that controlled trial health literacy interventions are increasing rapidly and can be an effective method of both improving health literacy and changing health behaviours. Nevertheless, there are limitations. It is known that there are close links between the concept of health literacy and other concepts such as activation, empowerment and education. By restricting the search terms to studies which identify themselves as health literacy interventions and include a pre-post health literacy measure it is possible we have missed other studies which may have demonstrated effects on health literacy. In addition, we have restricted the search to full peer reviewed and published English language quantitative papers only, and there may well be qualitative studies, or studies in other languages that can contribute to the review question. In addition, it should be noted that all included studies were at risk of bias with 18 judged at high risk. This may impact on ability to draw reliable conclusions from the included studies.

Given health literacy has been around as a concept with dedicated measures for over 30 years it is essential that health literacy begins to operate as a clearly defined concept, with its own terms, measures and dedicated interventions. By restricting the search terms to health literacy specific studies, we begin to demarcate the field and strengthen the evidence base for health literacy interventions.

Even allowing for the strict inclusion criteria applied, 22 studies were found with health literacy interventions. Fifteen of these studies demonstrated that interventions targeting health literacy can improve health literacy. In addition, seven out of eight studies with a behavioural outcome found that the health literacy intervention had a significant effect on behaviour. The health literacy field is growing rapidly, with all studies published since 2014 and over half since 2018. In order to continue to develop the evidence base, health literacy interventions should begin to consider the wider aspects of health literacy and make better use of behaviour change theory to more effectively change the health literacy behaviour of participants – which in turn may help behaviour change interventions be more effective.

Availability of data and materials

The data that support the findings of this study are available from the corresponding author upon reasonable request.


English as a second language

Health literacy questionnaire

Health related quality of life

National health service

Newest vital sign

Preferred reporting items for systematic reviews and meta-analyses

Randomised controlled trial

Risk of Bias 2

Risk of bias in non-randomised studies of interventions

Statistical analysis plan

Short test of functional health literacy in adults

Template for intervention description and replication

Test of functional health literacy in adults

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Additional file 1: supplementary table 1..

PRISMA-S, search results, screening decisions and search strategies.

Additional file 2: Supplementary Table 2.

Coding for the 12 TIDieR items for individual studies, divided into intervention and control conditions.

Additional file 3: Supplementary Table 3.

Percentage of studies scoring at each reporting grade for the 12 TIDieR items for individual studies, divided into intervention and control conditions.

Additional file 4: Supplementary Table 4.

Risk of bias.

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Walters, R., Leslie, S.J., Polson, R. et al. Establishing the efficacy of interventions to improve health literacy and health behaviours: a systematic review. BMC Public Health 20 , 1040 (2020). https://doi.org/10.1186/s12889-020-08991-0

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

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The purpose of this paper is to assess the relationship between elderly people's health literacy skills and those people's decision to make use of digital health service platforms. Despite the substantial influence of digitisation on the delivery of healthcare services, understanding how health intervention strategies might help empower elderly people's health literacy skills is critical.


This paper analyses the existing trends in research on the convergence of health literacy, health intervention programmes and digital health service platforms by reviewing 34 studies published between 2000 and 2020.

The findings of the review indicate three primary themes (health literacy skills, health management competency and attitude/confidence), which provide a summary of the current literature, and in all three the results show that health intervention programmes help to enhance health literacy skills of elderly people. Based on the review results and by organising the fragmented status quo of health intervention research, the authors develop a comprehensive research model and identify future research directions for research in this domain.

Practical implications

The findings will be useful to health professionals in two ways: (1) the findings provide practical information about the growing need to implement health literacy intervention programmes to satisfy elderly people's appetite for accessing health services due to cognitive and physiological impairments, and (2) the finding help them to understand that with digital health platforms, elderly people have quicker access to health services, improving the quality of care provided to them.


This paper presents a comprehensive research model for analysing the impact of health literacy skills on older people's ability and intention to access digital health information sources, considering various health intervention approaches.

  • Health literacy
  • Elderly people
  • Health decision-making
  • Health interventions
  • Digitalisation
  • E-Health services

Ghorbanian Zolbin, M. , Huvila, I. and Nikou, S. (2022), "Health literacy, health literacy interventions and decision-making: a systematic literature review", Journal of Documentation , Vol. 78 No. 7, pp. 405-428. https://doi.org/10.1108/JD-01-2022-0004

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Copyright © 2022, Maedeh Ghorbanian Zolbin, Isto Huvila and Shahrokh Nikou

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1. Introduction

Over the last few years, the average human lifespan has increased, and the number of individuals aged 65 and over has risen significantly ( Bhattarai and Phillips, 2017 ). As people age, they become more susceptible to difficult conditions (e.g. arthritis, heart disease, cancer and diabetes) ( Martin et al. , 2010 ), which may contribute to impaired quality of life and an increased likelihood of fatality ( Mueller et al. , 2020 ). One way to tackle this issue and help elderly people to enjoy a healthier life is to empower them with the essential skills and abilities to use available digital health services (e.g. e-health or m-health) ( Jackson et al. , 2020 ). Digital health services provided through digital health platforms enable individuals to access a large amount of health-related information and allow them to manage their chronic diseases more easily ( Sarfati et al. , 2018 ). For example, by using online health information and digital health platforms, elderly diabetic patients could considerably improve their understanding of their health condition(s) (e.g. diet, exercise, medication adherence) and gain better control over such conditions ( Long and Gambling, 2012 ). Therefore, it is important to understand how elderly people's quality of life can be improved by using digital health services and online health platforms. And it is also important to understand the skills needed to empower elderly people to use digital health services and absorb the available health information on digital platforms and apply the knowledge gained to manage their own health, address their potential health problems, and make more appropriate and informed health decisions ( Goeman et al. , 2016 ).

The empirical evidence in the literature demonstrates that to access and use digital health services, literacy skills – particularly health literacy or e-health literacy – are vital ( Gross et al. , 2007 ; Xie et al. , 2020 ; Zimmerman, 2021 ). Both terms “health literacy” and “e-health literacy” in the contemporary literature and in practice refer to the ability of individuals to deal with health information ( Del Giudice et al. , 2018 ), these two terms will be used interchangeably in this paper. The literature indicates that health literacy skills are often less well developed among elderly people (65+) ( Yang et al. , 2019 ); therefore, they utilise fewer technology–based-health services and online health platforms ( Xie et al. , 2020 ). In this regard, several researchers emphasise that one way of overcoming such problems is to improve health literacy among elderly people; for instance, through intervention programmes ( Banbury et al. , 2019 ; Kim et al. , 2014 ). The research results have shown that improvement of health literacy skills from pre-to post-intervention phases among elderly people ( Xie, 2012 ), empowers them to locate and identify trustworthy health resources ( Xie and Bugg, 2009 ), maintain or enhance their self-management skills ( Vogt et al. , 2017 ), reduce risky behaviours ( Liu et al. , 2015 ), resolve health-related problems, and make informed health decisions, which in turn lead to a better quality of life and improved health status ( Park et al. , 2018 ).

How does health literacy contribute to the ability of elderly people to use digital health services and thus their ability to make informed health decisions?

How do health intervention strategies and different content mediation styles contribute to an improvement in literacy skills among elderly people, and which have been the most popular ones?

What obstacles and challenges are faced in efforts to enhance the health literacy skills of elderly people?

This paper makes two important contributions. First, by providing a timely assessment of the literature, we identify the present state of knowledge and highlight options for combining various streams of research at the confluence of health literacy, health literacy intervention, and digital health services usage in the context of elderly people. In addition, based on the review results, three themes and trends relating to health literacy skills, health management competency, and attitude and confidence are identified and analysed. By providing such insights, we highlight the importance of empowering elderly people to become health literate as a prerequisite to use digital health services. Considering that elderly people are more likely to be at higher risk of various health-related issues and more susceptible to disease, the findings show the necessity to pay greater attention to empowering elderly people to acquire or improve their health literacy skills. Second, the review results indicate that we should, in parallel, focus more on to different styles of health intervention, as intervention programmes are essential in enabling elderly people to cope more effectively with their health conditions and technology-based healthcare systems. This study begins by developing a proposed research model. Next, the research methodology is discussed. Then we summarise the descriptive, and narrative results, followed by the discussions on the findings from the reviewed and analysed studies. Finally, we discuss the possible practical implications and conclude the research by proposing a framework, outlining the theoretical and methodological contributions, limitations, and suggestions for a future research agenda.

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.

First, we conducted a systematic literature review in accordance with the PRISMA guidelines (Preferred Reporting Items for Systematic reviews and Meta-Analyses. Following the procedure described by Steinmetz et al. (2021) , the search process involved four main steps: identification, screening, eligibility, and inclusion. We began the review process by performing searches of the main sources and repositories of the electronic databases Scopus, MEDLINE, Web of Science, EBSCO, and PubMed, as they are the most comprehensive databases in terms of scientific articles. The search was restricted to articles published in English. Inclusion criteria were as follows: (1) the study had to describe and include a health literacy intervention(s) and use of digital health services; (2) the study participants should include elderly people (65+); and (3) the study had to be published between 2000 and 2020. With regards to the overall objectives of the paper and research question stated earlier, the following search terms were used to screen the most relevant studies:

(“health literac*” OR “health information literac*” OR “ehealth literac*” OR “e-health literac*” OR “digital health literac*”) AND (?lder* OR “senior citizen*” OR “senior population” OR “old people” OR elderly OR “aged adult”) AND (“health service*” OR “digital health service*” OR “ehealth service” OR “e-health service*” OR “health information service*” OR “ehealth information service*” OR “e-health information service*”).

In addition, articles were excluded if (1) the study population did not comprise elderly people (65+); (2) the study population was comprised entirely of individuals with diagnosed cognitive or mental health impairments; and (3) the study was focussed solely on improving mental health literacy. The initial database searches yielded 1892 articles (from journals, conference proceedings, books, and book chapters): 909 articles were retrieved from PubMed, 339 from Scopus, 295 from EBSCO, 227 from Medline, and 122 from Web of Science. In addition, five articles were identified through other sources, so the total number of articles retrieved was 1897. After eliminating duplicates ( n  = 566), 1,331 articles remained.

In the second step (i.e. screening), we examined the articles by screening the titles and abstracts of the 1,331 articles. We began the initial screening phase by checking the title, abstract, and keywords of each study. In this step, 1,118 papers were excluded. In the third step (i.e. eligibility), we checked the full text of all the remaining 213 articles; each of these articles was read in full. In the fourth step (i.e. inclusion), after applying strict inclusion/exclusion criteria, articles that met the primary selection criteria were then critically appraised based on their relevance to the research questions. We finally retained 34 articles (see Appendix ) for inclusion in the systematic literature review: 29 studies were retrieved from database searches and five studies were retrieved from other sources by crosschecking of the citations. A PRISMA flow diagram describing the search selection process is shown in Figure 2 , and depicts the four main stages of identification, screening, eligibility, and inclusion. It is important to mention that the first author began the initial search, screening, and data extraction. In addition to the lead author, another senior researcher double-checked the entire work. In the following section, the results of the literature review are described.

The reviewed studies were categorised based on intervention strategy, study setting, content mediation styles, study design, and the potential barriers (obstacles) to improving literacy skills among elderly people.

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.

3.1.1 Collaborative versus individualistic strategy

Within a collaborative strategy , participants work collaboratively with other members to help each other learn, they work together to solve a problem, complete a task, or create a product ( Xie, 2011a ). This strategy requires the active engagement of the participants in the learning process by jointly performing meaningful activities and reflecting collaboratively on what they are learning ( Xie, 2011b ) and by being involved in discussions or interacting with each other ( Banbury et al. , 2019 ). This learning strategy had been used in 14 of the reviewed studies (e.g. Strong et al. , 2012 ; Xie, 2012 ). With an individualistic (i.e. independently working) strategy, participants are working on their own with little or no interaction with others ( Xie, 2011c ). This strategy had been used in 17 of the reviewed studies (e.g. Parker et al. , 2018 ; Redfern et al. , 2020 ). In addition, three studies applied both approaches simultaneously ( Goeman et al. , 2016 ; Xie, 2011a , c ).

3.1.2 Tailored versus untailored intervention

A tailored intervention is based on individuals' personal characteristics (e.g. personality, needs, preferences, and experience) ( Tse et al. , 2008 ). Tailored messages attract more attention and are more likely to be read, elaborated upon, recalled, and understood deeply. Therefore, this method is more suitable when it is necessary to improve the knowledge of the sample group in a critical field or to convey an important message ( Watkins and Xie, 2014 ). Seven of the reviewed studies used this intervention method (e.g. Campbell and Nolfi, 2005 ; Broering et al. , 2006 ). In comparison, an untailored intervention does not address an individual's characteristics. This approach presumes that a method can be employed for any individual or group without the need to consider their personal differences. Based on the review results, 27 of the reviewed studies used the untailored intervention method (e.g. Masi et al. , 2003 ; Broering et al. , 2006 ).

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.

3.5.1 Personal obstacles

Information interaction obstacles : poor acceptance and compliance, reliance on health professionals for information, emotional issues (shock, fear), avoidance of information ( Edwards et al. , 2012 ), lack of trust regarding online information (re)sources ( Perestelo-Perez et al. , 2020 ), and lack of ability to evaluate medical webpages and find reliable information on the Internet ( Tse et al. , 2008 ; Xie et al. , 2020 ).

Cognitive and physical obstacles : vision or hearing problems and limited dexterity ( Bertera et al. , 2007 ).

Technology self-efficacy obstacles: lack of experience in using digital platforms ( Broering et al. , 2006 ; Strong et al. , 2012 ); or even lack of experience in basic computer/Internet operations (e.g. opening a web browser or scrolling horizontally) ( Xie, 2011b ); a negative attitude towards technology-based health services ( Hoffman-Goetz et al. , 2006 ); reluctance to use digital health platforms ( Banbury et al. , 2019 ; Czaja et al. , 2013 ); computer anxiety; lack of self-esteem, lack of self-efficacy; lack of personal motivation; lack of computer interest; and lack of efficacy ( Campbell and Nolfi, 2005 ; Goeman et al. , 2016 ; Manafò and Wong, 2013 ).

Learning-related obstacles: lack of sufficient prior education ( Chiu et al. , 2016 ), reluctance to learn ( Goeman et al. , 2016 ); decreased learning capabilities, leading to prolonged learning time, especially when using digital health services ( Chu et al. , 2009 ; Xie, 2011a ).

3.5.2 Infrastructural obstacles

Accessibility-related obstacles: limited access to computers or digital resources ( Gross et al. , 2007 ; Susic, 2009 ), and unaffordability of the digital tools (expenses) ( Hoffman-Goetz et al. , 2006 ).

Education-related obstacles : lack of sufficient trained staff and supports to design and implement intervention programmes for elderly people ( Nahm et al. , 2018 ; Xie and Bugg, 2009 ), use of inappropriate learning programmes, or use of overly complex intervention methods ( Parker et al. , 2018 ).

Technology-related obstacles : overly complex technical medical terminology significantly discourages elderly people from searching for online medical information ( Aspinall et al. , 2012 ). In addition, complexity of the medical websites ( Manafò and Wong, 2013 ) and other technical problems make difficulties for elderly people (e.g. difficulty in navigation) ( Broering et al. , 2006 ).

4. Research themes

To understand the thematic distribution of the literature, we clustered the reviewed studies into the following three categories (themes): (1) literacy skills, (2) management competency perspective, and (3) attitudes and level of confidence. In the following, we discuss and elaborate on these themes.

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 ).

4.1.1 Health literacy

William et al. (1995) defined health literacy as the ability of people to find health information, interpret it, and apply it to health-related decisions. The first concept used by most of the authors was health literacy (e.g. Czaja et al. , 2013 ). The theme covers studies on e-health literacy interventions and their outcomes. For example, Serbim et al. (2019) demonstrated the practical feasibility of delivering a comprehensive education programme aimed at improving health literacy skills among elderly people. In this study, health literacy encompasses the ability to access, understand, and evaluate health information. In this study, all participants had basic computer skills and the ability to use the Internet, but they were not able to search for relevant health information effectively before the training sessions. However, the study results validated the long-term usefulness of the training programme. In a study of health literacy intervention programmes conducted by Long and Gambling (2012) , the authors aimed to equip individuals with a greater knowledge and understanding of diabetes by navigating healthcare systems to find information and self-manage certain elements. In addition, Parker et al. (2018) implemented an intervention programme focussing on better preventive care for overweight and obese patients with low health literacy among elderly people in Australia. Three different time points (baseline, six months, and 12 months) were compared to observe changes. The results of the study showed changes in some factors as primary outcomes, such as in health literacy, lifestyle behaviours, weight, waist circumference, and blood pressure between baseline and other time points. Both Kim et al. (2104) and Gross et al. (2007) indicated that the improvement in health literacy skills among elderly people observed in the post-intervention step was helpful in enhancing the healthy behaviours among elderly people.

In two of the studies – conducted by Aspinall et al. (2012) and Strong et al. (2012) – the intervention process improved the health information literacy skills of the elderly people in addition to other literacy skills (e.g. health literacy and digital literacy). Health information literacy can be comprehended as a similar concept to health literacy, in terms of refereeing information behaviours, including needs, along with seeking and using medical information.

4.1.2 E-health literacy

Norman and Skinner (2006) define the concept of e-health literacy as the ability of an individual to seek, find, understand, and appraise health information from digital (re)sources and apply the knowledge gained to address a health issue. E-health literacy is gaining attention worldwide owing to its high Internet penetration rate and massive Internet usage around the world. The theme covers studies on e-health literacy interventions and their outcomes. For example, Xie (2011a , c) employed both collaborative and individualistic interventions, which were theory driven and found improvement in e-health literacy from pre-to post-intervention among elderly people, leading to positive changes in their own healthcare. Xie (2011b) showed the usefulness of a theory-driven collaborative e-health literacy intervention among elderly people which could increase the ability of elderly people to cope successfully with digital health platforms. Furthermore, Nahm et al. (2018) applied self-efficacy theory to a theory-based patient portal e-learning programme that aimed to improve e-health literacy and found that the e-health literacy skills of participants in the intervention group had increased in the post-intervention phase. Moreover, Chiu et al. (2016) showed an increment in the level of e-health literacy for elderly people in Taiwan after their participation in eight weeks of training sessions.

4.1.3 Digital literacy

Regarding empowering elderly people to enhance their digital literacy skills, Strong et al. (2012) argued that to encourage the use of digital health services by elderly people, their digital literacy skills must be increased simultaneously with their health literacy skills. Digital literacy refers to “[t]he ability to use ICTs and the internet” ( Martin and Grudziecki, 2006 ). Xie (2011b , c and 2012) and Masi et al. (2003) found that with e-health literacy intervention program, the level of computer/web knowledge and ability to use information technologies increased significantly from pre-to post-intervention among elderly people. Some other scholars have demonstrated significant improvement in elderly persons in their use of computers (digital literacy skills) to access digital platforms via e-health literacy interventions ( Strong et al. , 2012 ), or in their use of Internet or medical webpages to answer health-related questions (e.g. Fink and Beck, 2015 ; Manafò and Wong, 2013 ; Perestelo-Perez et al. , 2020 ; Tse et al. , 2008 ). In addition, several other studies (e.g. Bosworth et al. , 2009 ; Kim et al. , 2014 ; Parker et al. , 2018 ) have reported the positive outcome of such interventions and have demonstrated that e-health literacy intervention programmes are effective at enhancing the knowledge that elderly people need to work with digital health tools effectively. Chiu et al. (2016) found that the implementation of a health literacy training course enabled elderly people to be able to use certain health applications, including the Internet preregistration system for clinic visits, and medication reminders.

In summary, this theme focusses on how health literacy intervention programmes can increase the level of computer/web knowledge among elderly people and empower them to use authoritative medical online (digital) platforms to find, evaluate, and utilise accurate and medical information. It has been found that such empowerment enables elderly people to better manage their health conditions and enhance their ability to practise preventive self-care. In addition, this theme indicates that the implementation of health literacy intervention programmes for elderly people could have a long-reaching effect.

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.

4.3.1 Attitude towards using digital health services

In total, twelve of the reviewed and analysed studies focussed on attitude towards use. To measure attitude towards using digital health services two different aspects were considered: (1) anxiety about using digital tools and services, and (2) interest in using digital tools and services. According to the statistical information provided in the reviewed studies during the intervention programme, there was an upward trend in all the identified sub-themes with the exception of the computer or web anxiety. Scholars have identified that health literacy training programmes may lead to lower levels of anxiety in elderly people when they are using computers to search for online health information ( Chiu et al. , 2016 ; Chu et al. , 2009 ; Xie, 2011b ; Xie and Bugg, 2009 ). Specifically, when elderly people underwent a health literacy training programme, their levels of stress and anxiety – in relation to using computers and webpages – were decreased. Furthermore, Xie (2012) demonstrated a negative association between computer anxiety linked to computer use and technology adoption after implementation of an e-health literacy intervention programme. The second sub-theme concerns the level of interest of elderly people in using digital tools and services, which refers to the interest in accessing health information via the Internet or computer/web usage. Some studies have shown that after implementation of a health literacy intervention programme, there was an increase in elderly people's level of interest and intention to adopt technology and use a computer and the Internet (digital platforms) to identify online health information ( Campbell and Nolfi, 2005 ; Tse et al. , 2008 ; Xie, 2011b , 2012 ).

4.3.2 Self-efficacy

E-health literacy efficacy refers to “skills and comfort with using the internet for health information and decision-making; for instance, [I know how to find helpful health resources on the internet]” ( Xie, 2011b , c ). Studies by Broering et al. (2006) , Kim et al. (2014) , Hoffman-Goetz et al. (2006) and Manafò and Wong (2013) showed an improvement in the efficacy and self-efficacy of elderly people when evaluating medical webpages. In another study, conducted by Nahm et al. (2018) , intervention group participants showed higher levels of self-efficacy when using patient portals, as their findings revealed that after the intervention programme, the elderly people believed that they could use the technology and reap benefits from doing so independently. Unexpectedly, and in contrast to the findings of other studies, the study by Chiu et al. (2016) found that the participants expressed lower levels of confidence in using the Internet after participating in a health literacy training course. In addition, Fink and Beck (2015) found no difference in the level of self-efficacy between the intervention and the control group regarding the use of digital health platforms after providing the intervention group participants with educational materials.

Computer efficacy could be viewed as elderly people's level of confidence in using computers to find online health information ( Perestelo-Perez et al. , 2020 ). For example, the studies conducted by Perestelo-Perez et al. (2020) and Xie and Bugg (2009) showed significant improvements in computer efficacy when pre- and post-training efficacy levels were compared. In other studies (e.g. Bertera et al. , 2007 ; Chu et al. , 2009 ), elderly people who participated in a five-week programme on retrieving and evaluating online health information succeeded in enhancing their confidence and self-efficacy levels regarding computer and Internet usage.

In summary, this theme focusses on the extent to which health literacy intervention programmes are useful for (1) reducing elderly people's stress and anxiety levels regarding computer or Internet usage, (2) increasing elderly people's interest, intention, and willingness to use computers and the Internet, (3) enhancing the self-efficacy and confidence of elderly people regarding the use of technology and reaping the benefits of doing so independently. All these factors result in higher intention and ability to locate medical information via digital platforms.

5. Discussion

This review paper analysed the current literature at the nexus of health literacy intervention, elderly people, and the use of digital health services. We performed a systematic literature review of 34 academic articles published from 2000 to 2020. The review results revealed that the dominant part of the literature consists of studies demonstrating the effectiveness of implementing health literacy intervention programmes to enhance the ability of elderly people (65+) to cope effectively with available health information on digital platforms or use digital medical tools. It found that intervention programmes are helpful and enhance the ability of elderly people to better manage their health condition(s) and make appropriate medical decisions. However, while most of the studies reported positive results, the study by Redfern et al. (2020) found no positive outcomes regarding health literacy improvement in elderly people's health-related behaviour. In addition, a study conducted by Chiu et al. (2016) showed negative results regarding elderly people's self-efficacy at the post-intervention stage. Even so, it is possible that there was a positive bias in the reviewed studies.

All the reviewed studies reported health literacy interventions among elderly people (65+). The studies were reviewed for their intervention strategies, study settings, and study designs. The results revealed that the studies employed two different health literacy intervention strategies: collaborative and individualistic. In addition, three studies ( Sarfati et al. , 2018 ; Xie, 2011a , b ) used a mixed strategy. Some scholars argue that owing to age-related changes (e.g. cognitive and physiological impairments), specific intervention strategies (tailored interventions) should be applied to elderly people in a manner that considers their own unique skills, learning abilities, and personal characteristics ( Bosworth et al. , 2009 ; Long and Gambling, 2012 ). In other words, generalised health literacy intervention programmes may not be appropriate for elderly people ( Xie, 2012 ). However, it can be speculated that owing to the difficulties concerning the design of intervention programmes (e.g. monetary and temporal issues), a noticeable percentage (79.41%) of the reviewed studies used untailored intervention strategies.

Five different content mediation styles were used in the reviewed studies. Some of the studies demonstrated the usefulness of communicating educational content through individual uptake and consumption style, while others relied on using traditional teaching methods (lecturing). On the other hand, some authors (e.g. Bertera et al. , 2007 ) believe that elderly people learn better by doing (13 studies used a hands-on style). Three studies used a comprehensive style and only one used the teach-back method, which charges teachers with the responsibility for successful learning. This style needs considerable effort on the part of the teachers and cannot be achieved rapidly; therefore, it is unsurprising that this style is unpopular. Regarding the study setting, educational content was communicated to the participants in the intervention programmes through online and face-to-face channels. Most of the studies used face-to-face channels (64.70%); moreover, the number of studies using ICTs seems to have increased in recent years. Of the 34 studies which were reviewed in this paper, 12 of them reported having used online channels. When employing face-to-face channels, intervention processes were typically implemented in informal learning settings (e.g. libraries and senior centres), universities, or health centres. Among these three, informal learning settings were most commonly used (52.94%). Furthermore, two different research designs were used to implement intervention programmes. While 61.76% of the reviewed studies used one group study design, with all participants in the study participating in the intervention programme, 38.23% of the studies used multiple (at least two) groups: an intervention and a control group. Using one group study design is more popular, as it may be assumed it is easier to have only one group. Also, with a single-group design, there are no group-wise differences to consider in relation to the intervention process ( Fink and Beck, 2015 ).

5.1 Intervention process

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 ).

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.

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.

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. Conclusion

The aim of this systematic review was to provide an updated and comprehensive assessment of the state-of-the-art academic knowledge on the effectiveness of health literacy interventions in relation to the use of digital health services. The object of the research was elderly people (65+), and the overall objective was to assess how intervention programmes enhance their ability to make informed medical decisions. In this review study, 34 articles were retained for analysis; below we describe the main contributions.

Our first contribution concerns the insights provided into several streams of research that focus on elderly people's literacy skills (health literacy, e-health literacy, and digital literacy), attitude, and confidence towards the use of digital health services and their competency at managing their health conditions. Three main themes were extracted. The themes demonstrate that the most significant part of the existing literature has concentrated on the impact of health literacy skills on the ability of elderly people to cope successfully with available online health information and to manage their health conditions. Owing to the speed at which digital health services (e-health and m-health) and digital health platforms are developing, as along with elderly people's appetite for accessing healthcare services and medical information, there is an increasing need to implement additional health literacy intervention programmes.

Furthermore, the reviewed studies report positive change in self-efficacy and attitude towards using digital health services when intervention programmes were implemented. Elderly people were found to have more confidence and a more positive attitude (more interest and less stress) towards using digital health services after participating in training sessions. Such findings answer the first research question.

Secondly, based on the analysis of the literature and the themes that emerged, we propose a research integrative framework. This framework can be used to explain how the health literacy intervention process can empower elderly people's abilities to navigate, find, evaluate, understand, and use available online medical information from digital information sources. The proposed framework is holistic, providing an overall overview and outlook of all the factors that change between the pre- and post-intervention stage (literacy skills, confidence, and attitude towards using digital health services). This framework considers two essential levels (personal and societal levels) to show how the health literacy intervention process can affect individuals and societies in a positive manner.

Thirdly, the results of the literature review enabled us to categorise the intervention strategies and identify the most commonly used intervention method. Our analysis indicates that to implement a health literacy intervention, researchers have applied different strategies – individualistic and collaborative. Both strategies were employed almost equally in the reviewed studies. In other words, intervention designers have had diverse priorities, and different factors have played out in selecting strategies. The two strategies have utilised two different approaches (tailored and untailored). Since an untailored approach was used in most of the reviewed studies (27 studies), we may conclude that the untailored health literacy intervention is the most popular in the reviewed corpus of literature. However, three studies that used both strategies at the same time did not demonstrate any significant differences in the outcome.

In addition, five content mediation styles have been used to communicate educational content to elderly people, which differ in the level of responsibility placed upon the trainees and trainers. Among these five styles, the hands-on method was found to be the most popular (13 studies). Such findings answer the second research question. Finally, despite all the advantages and opportunities offered by health literacy interventions for elderly people, there are several obstacles that have to be considered when planning for the implementation of intervention programmes. These obstacles could impede the process of implementing health literacy intervention programmes for elderly people. Our analysis of the reviewed studies reveals two major categories of obstacles: personal and infrastructural. Personal obstacles mostly relate to the attitudes and perspectives of elderly people and the digital divide issue, while infrastructural obstacles mostly relate to accessibility and affordability aspects. Such findings answer the third research question.

6.1 Practical implications

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.

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.

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.

study literacy intervention

Research model

study literacy intervention

PRISMA flowchart of the selection procedure

study literacy intervention

Integrative health model: integration of societal, personal level obstacles and intervention programme

Selected studies

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Banbury , A. , Nancarrow , S. , Dart , J. , Gray , L. , Dodson , S. , Osborne , R. and Parkinson , L. ( 2019 ), “ Adding value to remote monitoring: Co-design of a health literacy intervention for older people with chronic disease delivered by telehealth - the Telehealth Literacy Project ”, Patient Education and Counselling , Vol.  103 No.  3 , pp.  597 - 606 .

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Bhattarai , P. and Phillips , J.L. ( 2017 ), “ The role of digital health technologies in management of pain in older people: an integrative review ”, Archives of Gerontology and Geriatrics , No.  68 , pp.  14 - 24 , doi: 10.1016/j.archger.2016.08.008 .

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Chiu , C.J. , Hu , Y.H. , Lin , D.C. , Chang , F.Y. , Chang , C.S. and Lai , C.F. ( 2016 ), “ The attitudes, impact, and learning needs of older adults using apps on touchscreen mobile devices: results from a pilot study ”, Computers in Human Behaviour , Vol.  63 C , pp. 189 - 197 , doi: 10.1016/j.chb.2016.05.020 .

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Czaja , S.J. , Sharit , J. , Lee , C.C. , Nair , S.N. , Hernández , M.A. , Arana , N. and Fu , S.H. ( 2013 ), “ Factors influencing use of an e-health website in a community sample of older adults ”, Journal of the American Medical Informatics Association , Vol.  20 No.  2 , pp.  277 - 284 .

Del Giudice , P. , Bravo , G. , Poletto , M. , De Odorico , A. , Conte , A. , Brunelli , L. , Arnoldo , L. and Brusaferro , S. ( 2018 ), “ Correlation between eHealth literacy and health literacy using the eHealth literacy scale and real-life experiences in the health sector as a proxy measure of functional health literacy: cross-sectional web-based survey ”, Journal of Medical Internet Research , Vol.  20 No.  10 , e281, doi: 10.2196/jmir.9401 .

Edwards , M. , Wood , F. , Davies , M. and Edwards , A. ( 2012 ), “ The development of health literacy in patients with a long-term health condition: the health literacy pathway model ”, BMC Public Health , Vol.  12 No.  1 , pp.  1 - 15 .

Faggini , M. , Cosimato , S. , Nota , F.D. and Nota , G. ( 2019 ), “ Pursuing sustainability for healthcare through digital platforms ”, Sustainability , Vol.  11 No.  1 , 165 , doi: 10.3390/su11010165 .

Fink , A. and Beck , J.C. ( 2015 ), “ Developing and evaluating a website to guide older adults in their health information searches ”, Journal of Applied Gerontology , Vol.  34 No.  5 , pp.  633 - 651 .

Goeman , D. , Conway , S. , Norman , R. , Morley , J. , Weerasuriya , R. , Osborne , R.H. and Beauchamp , A. ( 2016 ), “ Optimising health literacy and access of service provision to community dwelling older people with diabetes receiving home nursing support ”, Journal of Diabetes Research , 2483263 , doi: 10.1155/2016/2483263 .

Gross , V.A. , Famiglio , L.M. and Babish , J. ( 2007 ), “ Senior citizen access to trusted stroke information ”, Journal of Consumer Health on the Internet , Vol.  11 No.  2 , pp.  1 - 11 .

Hoffman-Goetz , L. , Friedman , D.B. and Celestine , A. ( 2006 ), “ Evaluation of a public library workshop ”, Journal of Consumer Health on the Internet , Vol.  10 No.  3 , pp.  29 - 43 .

Huang , Y. , Ruan , T. , Yi , Q. , Wang , T. and Guo , Z. ( 2019 ), “ The health literacy questionnaire among the aged in Changsha, China: confirmatory factor analysis ”, BMC Public Health , Vol.  19 No.  1 , doi: 10.1186/s12889-019-7563-x .

Jackson , D.N. , Trivedi , N. and Baur , C. ( 2020 ), “ Re-prioritizing digital health and health literacy in healthy people 2030 to affect health equity ”, Health Communication , Vol.  36 No.  1 , pp.  1 - 8 .

Kim , K.B. , Han , H.R. , Huh , B. , Nguyen , T. , Lee , H. and Kim , M.T. ( 2014 ), “ The effect of a community-based self-help multimodal behavioral intervention in Korean American seniors with high blood pressure ”, American Journal of Hypertension , Vol.  27 No.  9 , pp.  1199 - 1208 .

Liu , Y.B. , Liu , L. , Li , Y.F. and Chen , Y.L. ( 2015 ), “ Relationship between health literacy, health-related behaviours and health status: a survey of elderly Chinese ”, International Journal of Environmental Research and Public Health , Vol.  12 No.  8 , pp.  9714 - 9725 .

Long , A.F. and Gambling , T. ( 2012 ), “ Enhancing health literacy and behavioural change within a tele-care education and support intervention for people with type 2 diabetes ”, Health Expectations , Vol.  15 No.  3 , pp. 267 - 282 .

Manafò , E. and Wong , S. ( 2013 ), “ A tool to promote the eHealth literacy skills of older adults ”, Journal of Consumer Health on the Internet , Vol.  17 No.  3 , pp.  255 - 271 .

Mancuso , J.M. ( 2008 ), “ Health literacy: a concept-dimensional analysis ”, Nursing and Health Sciences , Vol.  10 No.  3 , pp.  248 - 255 .

Martin , A. and Grudziecki , J. ( 2006 ), “ DigEuLit: concepts and tools for digital literacy development ”, Innovation in Teaching and Learning in Information and Computer Sciences , Vol.  5 No.  4 , pp.  249 - 267 .

Martin , L.G. , Schoeni , R.F. and Andreski , P.M. ( 2010 ), “ Trends in health of older adults in the United States: past, present, future ”, Demography , Vol.  47 No.  1 , pp. 249 - 267 .

Masi , C.M. , Suarez-Balcazar , Y. , Cassey , M.Z. , Kinney , L. and Piotrowski , Z.H. ( 2003 ), “ Internet access and empowerment ”, Journal of General Internal Medicine , Vol.  18 No.  7 , pp.  525 - 530 .

Mueller , A.L. , McNamara , M.S. and Sinclair , D.A. ( 2020 ), “ Why does COVID-19 disproportionately affect older people ”, Aging , Vol.  12 No.  10 , pp.  9959 - 9981 .

Nahm , E.S. , Resnick , B. , Brown , C. , Zhu , S. , Magaziner , J. , Bellantoni , M. , Brennan , P.F. , Charters , K. , Brown , J. , Rietschel , M. , An , M. and Park , B.K. ( 2015 ), “ The effects of an online theory-based bone health program for older adults ”, Journal of Applied Gerontology , Vol.  36 No.  9 , pp.  1117 - 1144 .

Nahm , E.S. , Zhu , S. , Bellantoni , M. , Keldsen , L. , Russomanno , V. , Rietschel , M. , Majid , T. and Smith , L. ( 2018 ), “ The effects of a theory-based patient portal e-learning program for older adults with chronic illnesses ”, Telemedicine and E-Health , Vol.  25 No.  10 , pp.  940 - 951 .

Norman , C.D. and Skinner , H.A. ( 2006 ), “ eHealth literacy: essential skills for consumer health in a networked world ”, Journal of Medical Internet Research , Vol.  8 No.  2 , e9 , doi: 10.2196/jmir.8.2.e9 .

Park , N.H. , Song , M.S. , Shin , S.Y. , Jeong , J. and Lee , H.Y. ( 2018 ), “ The effects of medication adherence and health literacy on health-related quality of life in older people with hypertension ”, International Journal of Older People Nursing , Vol.  13 No.  3 , e12196 , doi: 10.1111/opn.12196 .

Parker , S.M. , Stocks , N. , Nutbeam , D. , Thomas , L. , Denney-Wilson , E. , Zwar , N. , Karnon , J. , Lloyd , J. , Noakes , M. , Liaw , S.-T. , Lau , A. , Osborne , R. and Harris , M.F. ( 2018 ), “ Preventing chronic disease in patients with low health literacy using eHealth and teamwork in primary healthcare: protocol for a cluster randomised controlled trial ”, BMJ Open , Vol.  8 No.  3 , e023239 , doi: 10.1136/bmjopen-2018-023239 .

Perestelo-Perez , L. , Torres-Castaño , A. , González-González , C. , Alvarez-Perez , Y. , Toledo-Chavarri , A. , Wagner , A. , Perello , M. , Van Der Broucke , S. , Díaz-Meneses , G. , Piccini , B. , Rivero-Santana , A. and Serrano-Aguilar , P. ( 2020 ), “ IC-health project: development of MOOCs to promote digital health literacy: first results and future challenges ”, Sustainability , Vol.  12 No.  16 , 6642 , doi: 10.3390/su12166642 .

Pita Barros , P. , Bourek , A. , Brouwer , W. , Lehtonen , L. , Barry , M. , Murauskiene , L. , Ricciardi , W. , Siciliani , L. , Wild , C. , Koch , S. and Saranto , K. ( 2019 ), “ Assessing the impact of digital transformation of health services ”, Publications Office of the European Union , doi: 10.2875/644722 .

Redfern , J. , Coorey , G. , Mulley , J. , Scaria , A. , Neubeck , L. , Hsfiz , N. , Pitt , C.H. , Weir , K. , Forbes , J. , Parker , Sh. , Bsmpi , F. , Coenen , A. , Enright , G. , Wong , A. , Nguyen , Th , Hsrris , M. , Zwar , N. , Chow , C. , Rodgers , A. , Heeley , E. , Panaretto , K. , Lau , A. , Hayman , N. , Usherwood , T. and Peiris , D. ( 2020 ), “ A digital health intervention for cardiovascular disease management in primary care (CONNECT) randomized controlled trial ”, NPJ Digital Medication , Vol.  3 No.  117 , pp.  1 - 9 .

Sarfati , D. , McLeod , M. , Stanley , J. , Signal , V. , Stairmand , J. , Krebs , J. , Dowell , A. , Leung , W. , Davies , C. and Grainger , R. ( 2018 ), “ BetaMe: impact of a comprehensive digital health programme on HbA1c and weight at 12 months for people with diabetes and pre-diabetes: study protocol for a randomised controlled trial ”, Trials , Vol.  19 No.  1 , doi: 10.1186/s13063-018-2528-4 .

Serbim , A. , Paskulin , L. and Nutbeam , D. ( 2019 ), “ Improving health literacy among older people through primary health care units in Brazil: feasibility study ”, Health Promotion International , Vol.  35 No.  6 , pp. 1256 - 1266 .

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Teacher training programs don't always use research-backed reading methods

Brianna Atkinson

Ann Doss Helms


Kerry Sheridan

Beth Wallis

Students scale a mountain of books, as a teacher helps them up.

A dozen college students are saying the word "pat" and jotting down notes about the sounds being made.

"Puh - AH - tt"

Pay attention to the shapes your mouths make as you pronounce the word, instructs Robin Fuxa, their education professor at Oklahoma State University.

She asks her students if they can feel the way the words sound as they speak.

"Say it again and see if you feel it in your vocal cords," Fuxa prompts her reading instruction class, held last October.

Fuxa is trying to get her students to pay attention to phonics, the reading method that links a sound to a letter. Extensive research has shown phonics is an effective way to teach kids to read.

But teacher training programs like this one don't always prepare educators to use researched-backed reading methods, like phonics. In a 2023 study , the National Council on Teacher Quality (NCTQ) surveyed nearly 700 teacher training programs across the country. Their findings:

"Only about a quarter of the teachers who leave teacher preparation programs across our nation enter classrooms prepared to teach kids to read [in a way that's] aligned to the science and research on reading," says Heather Peske, president of NCTQ.

The rest, she says, are investing money and time into learning methods like "three- cueing" and "balanced literacy," which aren't backed by research.

Thomas Dee, an education professor and researcher at Stanford University, says this disconnect between research and practice has been a long standing issue in education.

"Things for which there's good evidence of efficacy don't always make it into [the] everyday classroom practice of teachers," Dee says.

This comes at a time when reading proficiency among some school-aged children has been declining.

The National Assessment of Educational Progress, otherwise known as the Nation's Report Card , shows reading scores among 13-year-olds have dropped since 2012, with a sharper dip during and after the pandemic. While test scores for 9-year-olds have mostly held steady since 2012, they too suffered a decline during the pandemic.

What makes the "science of reading" different

Dee is a big proponent of the "science of reading," which incorporates phonics, reading comprehension, vocabulary, and fluency, among other techniques. There is growing evidence that the science of reading is a more effective way to teach students how to read.

More effective than, say, "three-cueing," which is when students rely on context and sentence structure to identify words they don't know.

"Balanced literacy," formerly known as "whole language," is another commonly used method of reading instruction.

"The idea there was that kids sort of learn to read naturally and we just have to surround them with great literature," says Ellen McIntyre, dean of the teachers college at The University of Tennessee, Knoxville.

MyIntyre says balanced literacy had some great ideas about how to get students excited about reading, but she found the model was lacking.

"Really early on, the model didn't include systematic, explicit teaching of phonics or any of the other foundational skills."

Neither three-cueing nor balanced literacy are backed by research.

The 2023 study from NCTQ found 40% of surveyed schools are still teaching methods that "run counter to the research on effective reading instruction."

How teaching programs adopt "science of reading" methods

From 2019-2022, 46 states , including D.C., have passed reading legislation, according to The Albert Shanker Institute, a nonprofit connected to one of the country's largest teacher unions, the American Federation of Teachers.

In North Carolina, for example, a 2021 law requires current teachers to undergo training in the science of reading. To adapt, some colleges and universities with teacher training programs are amending their courses so they're more in line with the latest research.

And they have some guidance: In 2022, the UNC System – the network of public universities in North Carolina – hired an outside company to audit teacher colleges and their use of the science of reading model. The institutions were given an evaluation of "strong," "good," "needs improvement" or "inadequate." Most teacher colleges were labeled as "needs improvement."

Gerrelyn Patterson, chair of educator preparation at North Carolina A&T State University, a historically Black college, says the school was already teaching science of reading concepts, and even though the audit delivered a "good" score, they made additional changes to their curriculum. This included changes to syllabi, course descriptions and a review of the materials used for assignments.

Patterson says she and faculty met for hours at a time to review the courses they were teaching. In the end, the committee revised some courses to be more in-depth when it comes to reading.

"The students would say [the courses were] time intensive... they already felt like the literacy classes are very rigorous," Patterson says. But students told her the revised literacy courses were aligning with other training they got, "so they could see that connection."

The University of North Carolina at Pembroke, the state's only four-year American Indian and Alaska Native-serving institution , was not among the campuses that received a "strong" or "good" score from the audit.

In response to the lower evaluation, the university added two additional classes to the curriculum, increasing the required reading courses for students from three to five.

In 2023, school administrators said that they were planning on hiring an endowed professor of literacy, with a focus on leadership, research and teaching in the science of reading. The person hired in the position will also have funding to conduct literacy research.

However, not all educators have been on board with the changes at Pembroke.

"It's taken some time to kind of get the buy-in," says Gretchen Robinson, an education professor there.

According to Robinson, faculty met last spring for weekly feedback sessions. She said some were skeptical of the changes because they were being asked to teach in a way they weren't used to.

The university ended up losing two faculty members in 2023 as a result of the instruction shift.

Teachers pushback on legislating the classroom

Some educators have been uncomfortable with state legislators making decisions around how reading is taught.

"No collective group of legislators have the knowledge to do that," said Jenifer Jasinski Schneider, a professor of literacy studies at the University of South Florida.

She said USF is not changing their way of teaching reading because they've always incorporated principles like phonics and vocabulary into their lessons.

She acknowledges that there are a lot of K-12 students who are not learning to read, but she thinks there are bigger issues that state legislators should address before taking a critical stance on reading.

"We have internet access issues...We have kids that have food insecurity," Jasinski Schneider said.

"If they want to legislate something, legislate that every kid gets to eat three meals a day, instead of banning a teaching method, right? If they really want to help... make sure schools are over-resourced not under-resourced."

Elissa Nadworny contributed to this report. Edited by Nicole Cohen.

  • science of reading

Investigating the Impact of Collaborative Strategic Reading on Reading Comprehension and Reading Anxiety Among High School EFL Lower Attainers


  • Original Paper
  • Published: 16 February 2024

Cite this article

  • Ying Xiong   ORCID: orcid.org/0000-0002-8346-3478 1  

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Compared to foreign language (FL) communication anxiety, less is known about FL reading anxiety, especially among novice EFL readers. This is a notable limitation given that previous research has shown that FL reading anxiety can negatively influence the cognitive abilities of learners during reading according to Katzir et al., ( Frontiers in psychology, 9 (1180), 1-13, 2018 ). Collaborative Strategic Reading (CSR) is one approach that combines cooperative learning and reading comprehension strategies that can address the negative effects of FL reading anxiety by Klingner and Vaughn ( 1999 ). However, most previous research on CSR has focused on learners of mixed abilities and examined its impact on reading comprehension only. Using questionnaires, reading tests, and semi-structured interviews, the present study explores the efficacy of CSR in both improving reading comprehension and alleviating reading anxiety through a 7-week intervention study with 60 low-performing EFL students in a Chinese high school. No significant difference in reading test results was found between the control group and the experimental group; however, learners in the experimental group reported lower FL reading anxiety after intervention. In addition, reading test results negatively correlated with FL reading anxiety levels. Group interviews indicated that CSR enhanced the reading engagement of participants. These findings that CSR appeared to reduce FL anxiety and improve reading engagement among novice EFL learners have important implications for language pedagogy and teacher training.

和外語 (FL) 溝通焦慮相比, 外語閱讀焦慮較不為人知, 尤其是在新手EFL讀者間。這是一個顯著的局限性, 因為先前的研究顯示, 外語閱讀焦慮會對學習者閱讀過程中的認知能力產生負面影響 (Katzir et al. 2018 )。 合作策略閱讀 (CSR) 是一種將合作學習和閱讀理解策略相結合的方法, 可以處理外語閱讀焦慮的負面影響 (Klingner & Vaughn, 1999 ); 然而, 以往大多數的CSR研究都聚焦在不同能力的學習者身上, 並只探究CSR對閱讀理解的影響。本研究採問卷調查、閱讀測驗和半結構式訪談, 對中國一所高中60名英語低成就的學生進行為期七週的介入性研究, 探討了CSR在提升閱讀理解能力和舒緩閱讀焦慮的功效。研究結果顯示, 對照組和實驗組閱讀測驗的結果並沒有顯著差異; 然而, 實驗組的受試者接受干預後的外語閱讀焦慮降低了。此外, 閱讀測驗的結果和閱讀焦慮的層度呈現負相關, 小組訪談結果顯示, CSR提高了受試者的閱讀投入度。這些研究結果顯示, CSR似乎減輕了新手EFL讀者的焦慮, 提高了其閱讀投入度, 這些結果對語言教學和教師培訓上有重要的啟示。

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Xiong, Y. Investigating the Impact of Collaborative Strategic Reading on Reading Comprehension and Reading Anxiety Among High School EFL Lower Attainers. English Teaching & Learning (2024). https://doi.org/10.1007/s42321-024-00168-x

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The effectiveness of a reading and cognitive task-based Web delivered intervention program for children with reading difficulties


  • 1 Laboratory of Digital Neuropsychological Assessment, Department of Informatics and Telecommunications, University of Thessaly, Lamia, Greece.
  • 2 Department of Special Education, University of Thessaly, Volos, Greece.
  • 3 Laboratory of Cognitive Neuroscience, Department of Psychology, Aristotle University of Thessaloniki, Greece.
  • PMID: 38340140
  • DOI: 10.1080/21622965.2024.2313637

The present study aimed to investigate the improvement of reading ability and cognitive performance of children with reading difficulties through a Web application named "Poke the Reading Ability" (PtRA). PtRA is designed to assist the intervention of reading difficulties in Greek, a language that is more transparent than English. Sixty (60) children between nine (9) to twelve (12) years old (mean age 10.18 years). The baseline assessment consisted of two batteries of reading and cognitive abilities tests. Test-A, a Greek standardized psychometric tool and Askisi, a newly developed neuropsychological battery of tests are adopted to assess reading and cognitive performance. Both tools, were used in order to screen children's reading and cognitive performance before and after implementing the PtRA. The PtRA Web intervention consists of (a) tasks that focus on improving visual and auditory working memory, (b) tasks that improve phonological awareness and decoding, (c) tasks that are adopted to strengthen visual discrimination ability and (d) tasks that improve reading comprehension ability. Following the Web delivered intervention program the results revealed that the reading and cognitive abilities of children with reading difficulties were statistically significant improved in all 9 reading and all 3 cognitive abilities tasks.

Keywords: Children with reading difficulties; intervention program; online learning; poke the reading ability; reading ability; reading skills; web-based application.

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Early dementia diagnosis: blood proteins reveal at-risk people

  • Miryam Naddaf

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Coloured CT scan of a coronal section through the brain of a patient with Alzheimer's disease.

A computed-tomography scan of a brain affected by Alzheimer’s disease, the most common cause of dementia. Credit: Vsevolod Zviryk/Science Photo Library

An analysis of around 1,500 blood proteins has identified biomarkers that can be used to predict the risk of developing dementia up to 15 years before diagnosis.

The findings, reported today in Nature Aging 1 , are a step towards a tool that scientists have been in search of for decades: blood tests that can detect Alzheimer’s disease and other forms of dementia at a very early, pre-symptomatic stage.

Researchers screened blood samples from more than 50,000 healthy adults in the UK Biobank, 1,417 of whom developed dementia in a 14-year period.

They found that high blood levels of four proteins — GFAP, NEFL, GDF15 and LTBP2 — were strongly associated with dementia.

“Studies such as this are required if we are to intervene with disease-modifying therapies at the very earliest stage of dementia,” said Amanda Heslegrave, a neuroscientist at University College London, in a statement to the Science Media Centre in London.

Late diagnosis

According to the World Health Organization, more than 55 million people worldwide currently live with dementia.

People are often diagnosed only when they notice memory problems or other symptoms. At that point, the disease might have been progressing for years. “Once we diagnose it, it’s almost too late,” says study co-author Jian-Feng Feng, a computational biologist at Fudan University in Shanghai, China. “And it’s impossible to reverse it.”

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Dementia risk linked to blood-protein imbalance in middle age

By screening 1,463 proteins in blood samples from 52,645 people, the authors found that increased levels of GFAP, NEFL, GDF15 and LTBP2 were associated with dementia and Alzheimer’s disease. For some participants who developed dementia, blood levels of these proteins were outside normal ranges more than ten years before symptom onset.

GFAP, a protein that provides structural support to nerve cells called astrocytes, has already been proposed as a diagnostic marker for Alzheimer’s disease 2 , as has GDF15 .

The latest study finds that people with high levels of GFAP in their blood are more than twice as likely as people with normal levels to develop dementia, and are nearly three times as likely to develop Alzheimer’s.

The authors used machine learning to design predictive algorithms, combining levels of the four protein biomarkers with demographic factors such as age, sex, education level and family history. They trained the model on information from two-thirds of the study participants, and tested its performance using data from the remaining 17,549 people.

The model predicted the incidence of three subtypes of dementia, including Alzheimer’s disease, with about 90% accuracy, using data from more than ten years before participants were officially diagnosed.

The authors say their findings could be used to develop blood tests that identify people at risk of developing dementia. Other researchers caution that the new biomarkers need further validation before being used as clinical screening tools.

The study “needs to be replicated and biomarkers that enable us not only to screen for disease risk but also to differentiate between diseases should be a priority”, said Heslegrave.

doi: https://doi.org/10.1038/d41586-024-00418-9

Guo, Y. et al. Nature Aging https://doi.org/10.1038/s43587-023-00565-0 (2024).

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Shir, D. et al. Alzheimers Dement. 14 , e12291 (2022).

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  • Margo Barr 1 * , PhD   ; 
  • Sharon M Parker 1 * , MPH   ; 
  • Alamgir Kabir 1 * , PhD   ; 
  • Annie Y S Lau 2 * , PhD   ; 
  • Siaw-Teng Liaw 3 * , PhD   ; 
  • Nigel Stocks 4 * , MD   ; 
  • Mark F Harris 1 * , MD  

1 Centre for Primary Health Care and Equity, University of New South Wales, Sydney, Australia

2 Australian Institute of Health Innovation, Macquarie University, Sydney, Australia

3 School of Population Health, University of New South Wales, Sydney, Australia

4 Adelaide Medical School, University of Adelaide, Adelaide, Australia

*all authors contributed equally

Corresponding Author:

Margo Barr, PhD

Centre for Primary Health Care and Equity

University of New South Wales

AGSM Building

High Street, Kensington Campus

Sydney, 2052

Phone: 61 290656041

Email: [email protected]

Background: The Health eLiteracy for Prevention in General Practice trial is a primary health care–based behavior change intervention for weight loss in Australians who are overweight and those with obesity from lower socioeconomic areas. Individuals from these areas are known to have low levels of health literacy and are particularly at risk for chronic conditions, including diabetes and cardiovascular disease. The intervention comprised health check visits with a practice nurse, a purpose-built patient-facing mobile app (mysnapp), and a referral to telephone coaching.

Objective: This study aimed to assess mysnapp app use, its user profiles, the duration and frequency of use within the Health eLiteracy for Prevention in General Practice trial, its association with other intervention components, and its association with study outcomes (health literacy and diet) to determine whether they have significantly improved at 6 months.

Methods: In 2018, a total of 22 general practices from 2 Australian states were recruited and randomized by cluster to the intervention or usual care. Patients who met the main eligibility criteria (ie, BMI>28 in the previous 12 months and aged 40-74 years) were identified through the clinical software. The practice staff then provided the patients with details about this study. The intervention consisted of a health check with a practice nurse and a lifestyle app, a telephone coaching program, or both depending on the participants’ choice. Data were collected directly through the app and combined with data from the 6-week health check with the practice nurses, the telephone coaching, and the participants’ questionnaires at baseline and 6-month follow-up. The analyses comprised descriptive and inferential statistics.

Results: Of the 120 participants who received the intervention, 62 (52%) chose to use the app. The app and nonapp user groups did not differ significantly in demographics or prior recent hospital admissions. The median time between first and last app use was 52 (IQR 4-95) days, with a median of 5 (IQR 2-10) active days. App users were significantly more likely to attend the 6-week health check (2-sided Fisher exact test; P<. 001) and participate in the telephone coaching (2-sided Fisher exact test; P=. 007) than nonapp users. There was no association between app use and study outcomes shown to have significantly improved (health literacy and diet) at 6 months.

Conclusions: Recruitment and engagement were difficult for this study in disadvantaged populations with low health literacy. However, app users were more likely to attend the 6-week health check and participate in telephone coaching, suggesting that participants who opted for several intervention components felt more committed to this study.

Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12617001508369; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373505

International Registered Report Identifier (IRRID): RR2-10.1136/bmjopen-2018-023239


Problem statement.

Obesity is a major contributor to disease burden, increasing the risk of chronic conditions, including ischemic heart disease, stroke, diabetes mellitus, chronic kidney disease, and hypertensive heart disease [ 1 ]. According to the Global Burden of Disease Study 2017 [ 2 ], high BMI was the cause of 4.72 million deaths and 148 million disability-adjusted life-years worldwide, making it the fourth leading risk for mortality in 2017. In 2017 to 2018, an estimated 36% of the Australian adult population were overweight (ie, BMI 25.0-29.9) and 31% of them had obesity (ie, BMI≥30.0) [ 3 ]. The proportion of people who are overweight or hose with obesity is higher in populations from lower socioeconomic backgrounds [ 3 ]. In 2017-2018, 72% of Australian adults residing in the lowest socioeconomic areas were overweight or had obesity compared to 62% from the highest, after adjusting for age [ 3 ]. People from the lowest socioeconomic areas were 1.9 times more likely to have diabetes in 2020 and 1.6 times more likely to have self-reported coronary heart disease in 2017-2018 than those from the highest socioeconomic areas [ 4 ].

Rationale for the Study

Other research has shown that mobile app-based interventions can facilitate weight loss in individuals who are overweight and those with obesity, but it requires regular app use. For example, Patel et al [ 5 ] reported that consistent weight self-monitoring via a mobile app could lead to clinically meaningful weight loss. However, the study classified only a quarter of participants as consistent trackers, which they defined as self-monitoring weight and diet on at least 6 days per week for at least 75% of the study weeks [ 5 ]. Their study highlighted that consistent tracking was crucial, but only a minority of participants did so. Similarly, Laing et al [ 6 ] found that providing access to a weight loss app to primary care patients who are overweight and those with obesity did not lead to significant weight loss compared to usual care. Only one-third of them logged into the app in the sixth month of the intervention, in which the median number of logins was 0 (IQR 0-2). The authors concluded that prescribing self-monitoring apps for caloric counting may be successful in primary care patients who are particularly motivated to lose weight [ 6 ]. Chin et al [ 7 ] analyzed user data from a popular commercial weight loss app and found that in a multivariate logistic regression model, the frequency of entering body weight and consumption of dinner particularly was associated with successful weight loss in app users. Considering other studies, the focus of this study was understanding how participants used a mobile app within the Health eLiteracy for Prevention in General Practice (HeLP-GP) trial and if its use led to improvements in health literacy and diet.

Description of the Intervention

The HeLP-GP trial was a behavior change intervention developed for implementation in Australian general practices aimed at Australians who are overweight and those with obesity from lower socioeconomic areas to help them reduce their weight. The intervention was based on the 5As framework (assess, advise, agree, assist, and arrange) [ 8 ]. It included health check visits with a practice nurse based on the 5As framework, the use of a purpose-built patient-facing mobile app called mysnapp , and referral to health coaching via the “Get Healthy” information and coaching service [ 9 ]. The mysnapp is based on a web-based platform developed by Lau et al [ 10 ].

The trial was a pragmatic, 2-arm, unblinded cluster randomized controlled trial, which continued for 12 months. Primary outcomes included changes in weight, blood pressure, health literacy, and eHealth literacy [ 11 , 12 ]. Secondary outcomes included lipids, diet (fruit and vegetable intake), level of physical activity, quality of life, advice received, and referral for diet, physical activity, and weight loss [ 12 ]. Participants who received the intervention could choose to use the mobile app and access the telephone coaching program. The HeLP-GP trial assessed the intervention’s effectiveness [ 12 ]. The intervention led to significant improvements at 6 months compared to the controls for health literacy (mean DiD 0.22, 95% CI 0.01-0.44) and diet (mean DiD 0.98, 95% CI 0.50-1.47). There were no associations with any of the other outcomes [ 12 ].

The overall aim of this study, within the HeLP-GP trial, was to assess mysnapp app use, engagement, its association with other intervention components, and its association with study outcomes shown to have significantly improved (health literacy and diet) at 6 months.

Our objectives were to (1) explore differences in demographics and hospital admissions between participants who used the app and those who did not, (2) examine the duration and frequency of app use (app engagement) by participants overall and by module, (3) assess the association among app use, app engagement, and participation in other intervention components, and (4) examine the association between app use and app engagement on study outcomes that were shown to be significantly improved at 6 months (ie, health literacy and diet).

Ethical Considerations

The University of New South Wales Human Research Ethics Committee (HC17474) approved the trial. The University of Adelaide Human Research Ethics Committee ratified this approval. All participants provided consent to take part in this study.


The methodology of the randomized controlled trial, of which this study is a subanalysis, was published previously [ 13 ] and prospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12617001508369). In 2018, a total of 22 general practices were recruited from 2 Australian states, New South Wales (South West and Central Sydney) and South Australia (Adelaide), and randomized by cluster to the HeLP-GP intervention (11 practices) or usual care (11 practices). General practices were recruited through the local Primary Health Networks. Practices were located in local government areas with Socio-Economic Indexes for Areas scores [ 14 ] equal to or below the eighth decile. The Australian Bureau of Statistics reported that these are usually associated with lower health literacy levels in the population [ 15 ], with health literacy being defined by the Australian Institute of Health and Welfare in their latest Health Literacy Report as “how people access, understand and use health information in ways that benefit their health” [ 16 ]. In total, 4 strata based on the practice size (<5 general practice [GPs] and ≥5 GPs) and the state were created and then we randomly allocated practices to each stratum’s intervention or usual care group. The intervention comprised a practice nurse–led health check; additionally, participants could choose whether to take up a lifestyle app, a telephone coaching program, or both. Potential participants were identified using the GPs’ software. The general practitioners of the intervention sites also assessed their patients for eligibility. The eligible patients were provided with trial information and consent forms by the reception staff. Recruitment occurred between October 2018 and September 2019.

At the baseline health check, the practice nurses helped participants with the mysnapp setup and access the coaching program. They entered the participant’s height, weight, waist circumference, and blood pressure into the app and set the health goals with the participant. For 6 weeks, the participants received a nutrition-related and a physical activity–related text message weekly. These were preprepared to be sent automatically each week and provided direct advice and a web link for further information. In addition, the telephone coaching program provided free, confidential health support to participants to reach personalized lifestyle goals concerning diet, physical activity, alcohol, and body weight [ 17 ]. The coaching was available in multiple languages through an interpreter service. The practice nurses conducted a 6-week health check in which they reviewed and revised the participants’ health goals. Additionally, general practitioners conducted a 12-week health review. Text messages reminded participants to attend these follow-up visits.


Individuals were eligible for this study if they were aged 40-74 years, had a BMI of ≥28 and blood pressure levels recorded in the clinical software within the last 12 months, spoke English or Arabic, and had access to a smartphone or tablet. Potential participants were ineligible if they fulfilled any of the following exclusion criteria: recent weight loss (ie, >5% in the past 3 months), taking weight loss drugs (ie, orlistat or phentermine), diagnosed with insulin-dependent diabetes or cardiovascular disease (ie, angina, myocardial infarction, heart failure, heart valve disease, or stroke), cognitive impairment, or physical impairment disallowing them to perform moderate physical activity.

mysnapp Design

The mysnapp content was based on a web-based platform designed to help individuals control and maintain their health data and information to manage their health [ 10 ]. Research by Webb et al [ 18 ] and DiFilippo et al [ 19 ] into behavior change through mobile and electronic platforms informed the app design, including goal setting and self-monitoring, and additional methods to interact with individuals, mainly text messaging. The mysnapp app consisted of 4 core modules that allowed users to (1) set physical activity– and diet-based goals, (2) monitor their progress over the past 6 weeks, (3) take notes in a diary, and (4) learn about healthy eating and physical activity. Users could choose from the following goal options: set daily servings of fruits or vegetables or physical activity minutes; aim to drink fewer soft drinks, eat smaller portions, or eat fewer snacks or takeaway foods. In the self-monitoring module, they entered how many days of the week they achieved their goals. The educational material consisted of short text summaries and fact sheets about healthy foods, portion sizes, discretionary beverage consumption, physical activity benefits in English or Arabic, and links to simple exercise videos on YouTube.

Study Measures

App use measure.

Data were collected on app use, specifically, when the study participants in the intervention group had an app account set up.

App Engagement Measures

Data were collected on the participants’ app use directly through mysnapp . Each month, a cumulative data report was created about app logins and interactions with the different app modules from each participant for 12 months. App engagement included active days, duration of app use, and frequency of accessing app modules.

Other Intervention Component Measures

The data from the 6-week health check with the practice nurses (ie, occurrence) and the telephone coaching (ie, occurrence and completion status) were the other intervention component measures.

Outcome Measures

The participants’ questionnaires at baseline and 6-month follow-up (ie, self-reported fruit and vegetable intake, and health literacy) were used.

Specifically, the diet questions were as follows: (1) How many servings of fruit do you usually eat each day? A serving is 1 medium-sized fruit such as an apple or 2 small-sized fruits or 1 cup of fruit pieces. (2) How many servings of vegetables do you usually eat each day? One serving is half a cup of cooked vegetables or 1 cup of salad vegetables. With the diet score being the portions of fruit intake (between 0 and a maximum of 2 per day) plus portions of vegetable intake (between 0 and a maximum of 5 per day) with a range of 0 to 7 based on the sum of fruit and vegetable scores. This diet measure has been validated against food frequency questionnaires [ 20 ].

Specifically, the Health Literacy Questionnaire domain 8 questions were the following [ 11 ]: please indicate how difficult or easy the following tasks are for you now: (1) find information about health problems; (2) find health information from several different places; (3) get information about health so you are up to date with the best information; (4) get health information in words you understand; and (5) get health information by yourself. There is a 5-point response option scale for each question (cannot do or always difficult, usually difficult, sometimes difficult, usually easy or always easy). The scores are reported as averages for the domain (with a range between 1 and 5) with high scores representing higher health literacy.

Table 1 contains definitions for study measures. Duration of app use, active days, and consistent use had preset maximum values (365 days or 52 weeks); the values were capped when they exceeded the maximum.

Data Analysis

Descriptive and inferential analyses in RStudio (with the programming language R ; R Foundation for Statistical Computing) using a significance level of .05 for all statistical tests were conducted. Normally distributed continuous variables were summarized using the mean and SD, and nonnormally distributed continuous variables with median and IQR. Box plots compared continuous variables across the categories of nonnumerical variables [ 21 ]. Normality was tested using the Shapiro-Wilk normality test [ 22 - 24 ]. The 2-sided Welch t test was performed to compare the means of continuous variables between 2 subgroups (eg, participants using mysnapp versus those not using it) for normally distributed continuous variables [ 25 ]. Alternatively, the Wilcoxon signed rank test with continuity correction comparing the medians of nonnormally distributed continuous variables between 2 subgroups was used [ 26 , 27 ]. The Kruskal-Wallis rank-sum test was performed for more than 2 subgroups and nonnormally distributed continuous variables [ 28 ]. Pearson chi-square test with Yates continuity correction was used to test for associations between 2 categorical variables and the 2-sided Fisher exact test was used when there were less than 5 participants in any cell of the contingency table of expected frequencies [ 29 - 31 ].

For objective 4, we used 1-sided tests to assess whether app use versus nonapp use, or app engagement was associated with health literacy or diet between baseline and 6-month follow-up. Correlations between the app engagement and health literacy or diet score were measured with the Kendall rank correlation test (if variables did not follow a normal distribution) or Pearson product-moment correlation test (if they followed a normal distribution) [ 32 , 33 ].

In total, 120 participants received the intervention, of which 62 (52%) people chose to use mysnapp . Among the 62 app users, 38 (61%) also opted for telephone coaching. Table 2 shows the results for the first objective, comparing the demographic characteristics of the participants who chose not to use mysnapp to those who decided to use it. There were no significant differences between app users and nonapp users.

a OR: odds ratio.

App Engagement

The median duration of app use was 52 (IQR 4-95) days. Further, 2 participants used mysnapp weekly throughout the 12 months ( Table 3 ). Active days ranged from 1 to 117 days, with a median of 5 (IQR 2-10) days. The median number of weeks participants consistently used mysnapp from baseline was 1 (IQR 1-2). Of the 62 app users, 60 (97%) opened the goal setting module, 55 (89%) the education module, 39 (63%) the progress tracking module, and 25 (39%) the diary. Table 3 shows the consistency of app use and how many modules the app users accessed over the entire period of the intervention. Of the 19 app users who had opened 3 of the 4 modules, 17 (89%) had accessed the goal setting, progress tracking, and education modules. Among the 16 who had opened 2 modules, 14 (88%) had accessed the goal setting and education modules.

Association With Other Intervention Components

The difference in telephone coaching uptake between the app and nonapp users was statistically significant (Freeman-Halton extension of 2-sided Fisher exact test P <.001, Table 4 ). The median number of days using mysnapp for the app users who completed the telephone coaching was 3.5 (IQR 1-7) days, for the app users who did not complete the telephone coaching it was 7 (IQR 2.5-9.5) days, and for the app users who did not undertake the telephone coaching it was 3.5 (IQR 2-9) days ( Figure 1 ). The difference in median active days by telephone coaching completion status was not statistically significant ( χ 2 19 =13.2, P =.83).

study literacy intervention

The difference in the attendance rate of the 6-week health check between app users and nonusers was significant (2-sided Fisher exact test P =.007, Table 4 ). Those app users who attended the 6-week health check with the practice nurse did not have significantly more active days using mysnapp (median active days for 6-week health check attendees: 6, IQR 2-10 days, and for nonattendees: 4, IQR 2-10 days; W =374, P =.46).

Impact of App Use and App Engagement on Behavioral and Biomedical Outcome Measures

Differences in outcome measures between app users and nonusers, and app engagement were not significant ( Tables 5 and 6 ) for study outcomes which were shown to be significantly improved at 6 months (ie, health literacy and diet).

a Test for greater change in app users versus nonapp users from baseline to 6 months.

b HLQ: Health Literacy Questionnaire.

c N/A: not applicable.

a HLQ: Health Literacy Questionnaire.

Principal Results

The overall aim of this study was to assess mysnapp app use within the HeLP-GP trial and its association with study outcomes shown to have significantly improved (health literacy and diet) at 6 months. With regard to the specific objectives, (1) there were no significant differences in demographics between participants who used mysnapp and those who did not; (2) among app users, the median duration of app use was 52 days, with a median of 5 active days; (3) more participants who chose to use mysnapp also attended the 6-week health check with the practice nurse and opted for telephone coaching; and (4) there was no association between app use and study outcomes shown to have significantly improved (health literacy and diet) at 6 months.

Length and Frequency of App Use and Module Access

Turner-McGrievy et al [ 34 ] aimed to identify the best criteria for defining adherence to dietary self-monitoring with mobile devices when predicting weight loss. They found that adherence, defined as the number of days participants tracked at least 2 meal times, explained the most variance in weight loss at 6 months [ 34 ]. We were not able to measure this because the diary, available for recording meals, could also be used for other reasons such as activities, appointments, plans for the future, and thoughts about progress. In the study by Jacobs et al [ 35 ], they analyzed data from 7680 users of a commercial weight loss app; high adherence to self-monitoring (ie, logging at least 1 food event within a reasonable time after a meal) was associated with increased weight loss. However, they also found that app users with higher adherence rates had significantly lower body weight at baseline than those with lower adherence rates [ 35 ]. The analysis only comprised people who entered data in the app at least once a week for 12 weeks. In our study, 4.9% (n=3) of the app users were still entering data at week 12. Analyzing data from the same commercial app, Carey et al [ 36 ] found significant differences in 7 different engagement measures (ie, number of articles read, meals logged, steps recorded, messages to coach, exercise logged, weigh-ins, and days with 1 meal logged per week) between app users with moderate or high weight loss (ie, 5%-10% or >10% body weight loss, respectively) and individuals with no change in body weight (ie, ±1% body weight). Their analysis indicated that people with moderate to high weight loss engaged with all app sections [ 36 ]. In our study, only 34% (n=21) of the app users had accessed all of the modules.

Other studies showed promising results for weight loss apps, for example, Carter et al [ 37 ], Patel et al [ 5 ], and Antoun et al [ 38 ]. Specifically, Carter et al [ 37 ] conducted a pilot study of 128 volunteers who are overweight comparing a smartphone app (My Meal Mate) with a website and paper diary. They found the mean weight loss over 6 months for the app was higher (4.6 kg, 95% CI 3.0-6.2) than for the diary group (2.9 kg, 95% CI 1.1-4.7) or the website group (1.3 kg, 95% CI 0.1-2.7). Antoun et al [ 38 ] in their review of 34 studies that evaluated the use of smartphones for weight loss found an overall mean loss of 2.8 kg (95% CI 2.6-3.0) at 6 months. Patel et al [ 5 ] found that consistent tracking was associated with greater weight loss than inconsistent tracking at 6 months (2.1 kg, 95% CI 0.3-4.0). A difference between these studies and ours was that they did not specifically target disadvantaged populations with low health literacy. Therefore, their apps were more complex than ours. In contrast, Lanpher et al [ 39 ] developed a weight loss intervention suitable for individuals with low health literacy. A computer algorithm automatically allocated the self-monitoring goals (eg, no sugary drinks, no snacking after dinner, eating 5 fruits and vegetables a week). Participants reported whether they achieved the goals via interactive voice response calls [ 39 ]. The algorithm decided which goals to assign next based on previous adherence to goals so that individuals would rather receive goals to which they were receptive [ 40 ]. They also received tailored skills training through verbal calls and materials, one-on-one counseling calls, and a membership at the gym [ 39 ]. The results showed that the intervention group maintained or lost weight over 12 months, independent of their level of health literacy [ 38 ].

Bennett et al [ 40 ] extended the intervention to comprise a mobile app. They evaluated its effectiveness in a randomized controlled trial including socioeconomically disadvantaged patients with increased cardiovascular risk by comparing the intervention to usual care [ 40 ]. The app used interactive voice responses or text messaging to simplify self-monitoring, like in the previous study. Additionally, participants received in-person coaching and personalized feedback messages immediately after entering data [ 40 ]. The intervention group achieved meaningful weight loss, with more than 40% of participants reducing their body weight by at least 5% compared to 17% of participants in the usual care group [ 39 ]. Comparing this intervention to ours raises the question of whether the way people had to select and track their goals in our app contributed to the low engagement and the nonsignificant findings. Locke and Latham [ 41 ] explained that goal commitment, goal importance, self-efficacy, feedback, and task complexity act as moderators between goals and performance. Potentially, the app did not sufficiently address all 5 moderators.

This study showed that mysnapp users were more likely to attend the 6-week face-to-face health check with the practice nurse and to participate in the telephone coaching program than nonusers. Potentially, these individuals were more motivated to lose weight and, therefore, more willing to engage in the other intervention components. Another explanation could be that participants who opted for several intervention components felt more committed to study participation and, therefore, made more use of the individual intervention components. Griauzde et al [ 42 ] proposed a similar hypothesis in their mobile health–based prediabetes intervention study; they assumed that participants who received a more robust intervention were more committed to the study and subsequently more likely to complete the 12-week survey. Hutchesson et al [ 43 ] concluded that adding nondigital components, such as face-to-face visits and telephone coaching, to mobile health interventions can improve participants’ accountability even though these additional features may not be necessary for the intervention’s effectiveness.


The plan for the randomized controlled trial was to recruit 800 study participants; however, only 215 individuals were able to be recruited (120 in the intervention and 95 in the control group) [ 13 ]. Further, despite targeting low socioeconomic areas, this study failed to recruit many participants with low health literacy. One needs to be cautious when interpreting the results of this study due to the small sample size and the high dropout. Despite considerable efforts and additional time to recruit participating practices and patients, the anticipated sample size was not achieved. Research by Perkins et al [ 44 ] has shown an ongoing issue with recruitment through Australian general practices. Another problem with the study was that the uptake of intervention components was determined by the clinician and patient. Thus, some chose to just have the app and others to just have the phone coaching. Additionally, the study may not be generalizable to other settings. Since recruitment was from 2 Australian urban areas, results could differ in rural areas or other urban areas. Diet score and health literacy level were self-reported, posing a risk of bias. Further, caution is required when interpreting the results in the context of low health literacy because the baseline health literacy levels were higher than anticipated [ 12 ]. According to data from the National Health Survey 2018, the health literacy level in this study’s sample was comparable to that of Australians who are overweight or those with obesity in the general population [ 45 ]. A potential explanation is that this study’s requirements (randomization, completing the questionnaire, and undertaking the health check) stopped people with low health literacy from participating. This rationale is in line with results from Kripalani et al [ 46 ], who found that people with low health literacy or numeracy were significantly less interested in participating in research.


There was no association between app use and study outcomes shown to have significantly improved (health literacy and diet) at 6 months. Recruitment and engagement were difficult for this study in disadvantaged populations with low health literacy. A potential explanation could be related to the self-selection of the goals and the weekly submission of the goal achievements. The practice nurses assisted participants at the beginning with the selection of goals. However, these may not have been relevant to participants, and nurses did not receive specific training in selecting meaningful goals for individuals.

However, app users were more likely to attend the 6-week health check and participate in telephone coaching, suggesting that participants who opted for several intervention components felt more committed to this study.


The authors would like to acknowledge the contribution to this research by An Tran, Carmel McNamara, Elizabeth Denney-Wilson, Katrina Paine, and Shoko Saito. We also acknowledge Louise Thomas for contributing to the trial protocol and early development. We are grateful for the partnership and support of the South Western Sydney, Adelaide and Nepean and Blue Mountains Primary Health Networks and the Australian Institute of Health Innovation. We would like to acknowledge the general practices and their staff and patients for participating in the research and consumers affiliated with Adelaide PHN for piloting mysnapp . This work was supported by the National Health and Medical Research Council of Australia (grant APP1125681, 2017).

Conflicts of Interest

None declared.

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Edited by L Buis; submitted 22.01.23; peer-reviewed by L Bell, J Job; comments to author 20.04.23; revised version received 21.08.23; accepted 19.12.23; published 09.02.24.

©Vera Helen Buss, Margo Barr, Sharon M Parker, Alamgir Kabir, Annie Y S Lau, Siaw-Teng Liaw, Nigel Stocks, Mark F Harris. Originally published in JMIR mHealth and uHealth (https://mhealth.jmir.org), 09.02.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR mHealth and uHealth, is properly cited. The complete bibliographic information, a link to the original publication on https://mhealth.jmir.org/, as well as this copyright and license information must be included.

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Interventions for Improving Reading Comprehension in Children with ASD: A Systematic Review

Associated data.

No new data were created or analyzed in this study. Data sharing is not applicable to this article.

Children with autism spectrum disorder (ASD) often have comorbid learning difficulties in reading comprehension, an essential skill in accessing any area of the curriculum. The aim of this systematic review is to analyze the effectiveness of reading comprehension interventions in students with ASD. We conducted a search for scientific articles published from 2000 to 2019 using the keyword “autis*” in combination with the terms “reading comprehension” and “intervention” or “instruction” in Psyc Info and Scopus databases. After applying inclusion and exclusion criteria, a total of 25 studies were selected. The content analysis of these studies shows that when specific interventions are carried out, students with ASD are able to take advantage of the instruction they receive and compensate for difficulties. Understanding inferences and the main idea of the text are the most common reading comprehension topics, and direct instruction is the most widely-used intervention method in the reviewed studies. Nonetheless, it must be kept in mind that some of the reviews do not specify which sub-processes are addressed in the intervention. Future work should include this aspect, consider the importance of the interventions being implemented by teachers, and take specific aspects of ICT into account that can contribute to improving reading comprehension.

1. Introduction

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by the presence of persistent difficulties in communication and social interaction in several contexts, as well as the presence of restrictive and repetitive patterns of behavior, interests, or activities [ 1 ]. In addition to these core aspects of ASD, people with this diagnosis usually have other comorbid difficulties that are highly significant in their daily quality of life [ 2 ].

One of these common comorbidities consists of learning difficulties in reading comprehension [ 3 , 4 ], probably one of the most relevant academic skills learned in the school context. In fact, reading comprehension in the initial stages of schooling is a good predictor of later academic success and even variables related to behavioral adjustment [ 5 , 6 , 7 ].

Theoretically, reading comprehension is a complex task that basically requires two phases: the decoding of the graphemes and the extraction of linguistic meanings [ 8 ]. Many studies show that people with ASD have difficulties with understanding texts, taking into account their reading decoding ability [ 9 ].

In addition, reading comprehension is conditioned by pragmatic characteristics and language comprehension, such as understanding metaphors, jokes, and ironies, making inferences, understanding idioms, or understanding meanings whose interpretation depends on the context. These issues are challenging for students with ASD, even for those with preserved linguistic and cognitive abilities, as in Asperger Syndrome (AS) (level 1 ASD, according to the DSM-5 criteria) [ 10 ].

Due to the great heterogeneity in the presentation of the clinical forms of autism, the possible comorbid difficulties, or the age of onset of the first signs and their evolution [ 11 , 12 ], the reading comprehension difficulties can vary in their severity and intensity in students with ASD [ 13 ]. Some possible explanations for these difficulties in reading comprehension are the classic theoretical explanations for ASD [ 14 ]. For instance, the theory of weak central coherence [ 15 ] states that people with ASD have difficulties integrating elements they perceive in isolation into a whole, an essential skill for construction meaning in reading comprehension; the theory of executive dysfunction [ 16 ] explains some of the characteristics of ASD based on difficulties in processes such as inhibition, working memory, or planning, key processes in reading comprehension; also, the theory of mind [ 17 ] explains some of the difficulties people with ASD have in attributing intentions or mental states in others, a key skill for understanding narrative texts.

Given the reading comprehension difficulties of children with ASD, and considering the relevance of this learning, a large amount of research has been carried out in recent years to evaluate the efficacy of interventions designed to improve reading comprehension in these children.

In this line, a review study of 11 intervention studies published between 1986 and 2006 included seven studies focused on the teaching of vocabulary and four studies aimed at improving text comprehension processes [ 18 ]. Another review study [ 19 ], which included 11 interventions published between 2000 and 2011 focused on evaluating the effectiveness of computer-assisted interventions. The results of this study showed that computer use can provide effective support for improving reading comprehension in children with ASD through interventions based on solution strategies and making questions related to the comprehension, identification of the structure of the text, and cooperative learning.

A review study that analyzed a total of 12 intervention studies published between 1980 and 2012 [ 14 ] found that providing strategies from a cognitive approach, the use of group methodologies, and direct instruction are useful proposals for improving the reading comprehension of students with ASD. Specifically, three of the studies included in this review found that peer tutoring shows benefits in reading comprehension, as well as in social and emotional development. The authors concluded that the implementation of these strategies can be quite beneficial, not only for children with ASD, but also for all students, especially those who present reading and learning difficulties.

Finally, in a review analyzing 15 reading comprehension interventions in students with ASD published between 1989 and 2015 [ 20 ], researchers found that only four of the interventions were potentially highly effective, whereas four other interventions obtained an acceptable-high improvement. These interventions agreed on the need to use cooperative learning and graphic organizers, and that it is not advisable to use electronic supports without supervision and it is preferable to design personalized interventions. Additionally, this review also showed that the skills learned in the interventions are transferable to texts that students with ASD face for the first time.

Considering the literature described above, the aim of the present systematic review is to analyze the effectiveness of reading comprehension interventions in students with ASD, considering studies published between 2000 and 2019. Specifically, we aim to answer the following research questions:

1. What results did the educational interventions to improve reading comprehension in children with ASD published between 2010 and 2019 obtain? 2. Which reading sub-processes have these studies focused on? And 3. What are the main characteristics of the interventions regarding methodologies, duration, implementing agents, and context of intervention?

This review expands and updates the previous conclusions of other literature reviews: it covers an updated period of time and includes empirical work carried out to evaluate the effectiveness of any type of reading comprehension intervention (not specific ones). This objective is relevant because it can help to determine which intervention strategies have been effective to improve reading abilities in students with ASD, and so it can help to guide current and future interventions.

2. Materials and Methods

2.1. eligibility criteria.

The inclusion criteria used in the review were: (a) empirical studies that evaluate the effectiveness of an intervention to improve reading comprehension; (b) studies that include participants with ASD as the main diagnosis; and (c) studies that include participants between the ages of 5 to 18.

The research was limited to scientific articles published in peer review journals (therefore other types of publications were excluded), from 2000 to 2019.

2.2. Information Sources and Search Strategy

The search for and compilation of analyzed articles was carried out through a sequenced research process in the PsycInfo and Scopus databases. We conducted a search for the keyword “autis*” in combination with the terms “reading comprehension” and “intervention” or “instruction”, delimiting any field of the bibliographic record except full text. The first search produced a total of 60 publications in PsycInfo and 100 in Scopus.

2.3. Study Selection

After eliminating duplicate studies, two of the authors independently applied the inclusion and exclusion criteria. After that, we included 25 studies in this review. The search and selection process are summarized in Figure 1 .

An external file that holds a picture, illustration, etc.
Object name is behavsci-11-00003-g001.jpg

Flow chart of the search process.

2.4. Data Collection Process and Data Items

All 25 studies were independently reviewed by two of the authors of the present review. In each study, they identified: the number, diagnosis, and age of the participants; the reading comprehension subprocesses trained; the type of intervention carried out; the implementer (e.g., teacher, psychologist, or family member) and the context of the intervention (e.g., school, home, or clinic); and a brief summary of the results was obtained. After independent reviews, cases in which there were some divergences in data collection were discussed and resolved by consensus.

Table 1 includes the information from the 25 selected articles in this review. All of them evaluate the effectiveness of different reading comprehension interventions carried out with children with ASD.

Analysis of the studies included in the review.

Overall, 196 students from 5 to 17 years old participated in the 25 studies included in this review. Regarding the number of participants: two of the studies were individual case studies [ 29 , 37 ]; most of them (a total of 16 articles) were carried out with two to five participants [ 21 , 24 , 25 , 26 , 27 , 28 , 30 , 31 , 33 , 34 , 35 , 36 , 39 , 42 , 43 , 45 ]; in two articles, there were from 10 to 19 participants [ 32 , 40 ]; and, finally, in five studies, there were 20 or more participants [ 22 , 23 , 38 , 41 , 44 ].

Regarding the effect of the interventions, almost all of the studies (except for one [ 22 ] that did not obtain significant results), revealed improvements in the reading comprehension skills of students with ASD. Nonetheless, some positive results obtained in different studies were moderate due to the students’ limited language skills [ 32 , 33 , 37 , 38 ]. In these cases, reading comprehension skills were conditioned by the low language skills of the participants.

Regarding the specific reading comprehension sub-processes trained in the interventions, some studies worked on various sub-processes at the same time, others worked on only one specific sub-process, and others did not specify the reading comprehension sub-processes included in the intervention. Considering the studies that specify the sub-processes addressed: five of the studies focused on understanding inferences [ 29 , 30 , 34 , 35 , 38 ]; five other studies worked on understanding the main idea [ 34 , 38 , 40 , 41 , 43 ]; four studies focused on identifying the structure and relationship between the elements of the text [ 27 , 34 , 40 , 41 ]; three interventions practiced “Wh questions” [ 21 , 25 , 38 ]; three other studies used comprehension skills related to story elements [ 26 , 36 , 45 ]; two studies worked on analogies [ 30 , 31 ]; two other studies used paraphrasing [ 34 , 38 ]; one of the interventions focused on understanding metaphors [ 37 ]; another study worked on reading fluency and section-based and topography-based comprehension tasks [ 24 ]; one study focused on a multicomponent reading comprehension intervention [ 28 ]; one study worked on parts of speech, combining sentences with and, identifying contradictions, and identifying relevant/irrelevant information [ 33 ]; another study worked on question development and anaphoric cueing [ 42 ]; and another study focused on metacognitive and cognitive strategies for improving comprehension [ 39 ].

Regarding the type of intervention used: seven studies used direct instruction [ 27 , 30 , 31 , 32 , 33 , 40 , 41 ]; six studies used collaborative, guided, or shared reading [ 21 , 35 , 36 , 39 , 43 , 44 ]; three studies used answering questions [ 24 , 25 , 45 ]; one study used instruction in the use of digital concept maps of narrative texts read aloud by the researcher [ 26 ]; and another study used the Think While After (TWA) strategy [ 34 ]. Some studies compared two different interventions: group sessions versus direct instruction [ 22 ]; individual sessions versus traditional intervention in school [ 23 ]; direct instruction from the teacher versus instruction assisted by a digital tablet [ 28 ]; and adding content related to the participants’ persistent interests versus texts without these added contents [ 29 ]. Finally, some studies combined several types of activities [ 37 , 38 , 42 ].

The duration of the interventions varied from 1 to 60 sessions. One study conducted a single session intervention [ 33 ]; seven studies conducted 6 to 12 sessions [ 26 , 27 , 34 , 36 , 37 , 42 , 44 ]; two studies conducted 13 to 20 [ 22 , 45 ]; four studies conducted 21 to 29 [ 21 , 23 , 29 , 32 ]; seven studies conducted 30 sessions or more [ 24 , 25 , 35 , 39 , 40 , 41 , 43 ]; and two studies conducted interventions whose duration depended on students’ progress [ 30 , 31 ]. Only two studies did not specify the number of sessions, but the studies lasted four [ 28 ] and six [ 33 ] weeks. The sessions varied from a mean duration of 10 min to an intensive intervention of 70 min per session.

Regarding the people who implement the intervention, most of the interventions were conducted only by teachers [ 22 , 25 , 27 , 30 , 32 , 33 , 43 , 45 ] or only by researchers [ 21 , 23 , 24 , 26 , 28 , 31 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 44 ]. Only one intervention [ 29 ] had mixed implementers: researchers and school counsellors.

Finally, the intervention setting was mainly in the school context [ 21 , 22 , 25 , 26 , 27 , 29 , 30 , 31 , 33 , 35 , 39 , 40 , 41 , 42 , 43 , 44 , 45 ]; only three interventions were carried out in clinical settings [ 34 , 36 , 37 ]; two other interventions took place in a summer camp context [ 28 , 32 ]; and only one intervention was carried out at home [ 23 ]. There were interventions that combined two settings: school and University Centre for Autism Research [ 24 ]; or school and the home context [ 38 ].

4. Discussion

In the present study, we have carried out an updated systematic review of empirical studies that analyzed the effectiveness of interventions in different sub-processes of reading comprehension in children with ASD. Specifically, the study raises three research questions.

The first one refers to what results have been obtained by the reviewed research. The main conclusion is that almost all the interventions analyzed produced positive results in the reading comprehension skills of students with ASD. Only one of the 25 studies reviewed did not show significant improvements [ 22 ]. This result shows that, when specific interventions are carried out, students with ASD are able to take advantage of the instruction they receive and compensate for difficulties. This result leads to the conclusion that teachers and other practitioners should be encouraged to continue to focus and increase efforts in teaching reading comprehension skills in children with ASD. As shown in this review, these efforts can produce positive short-term results in reading comprehension.

Regarding this, it should be taken into account that advances in reading comprehension were moderated by language skills in some studies. For this reason, language ability became a powerful predictor of reading comprehension [ 32 , 33 , 37 , 38 ].

The second research question aims to determine which reading sub-processes have the reviewed studies focused on. Reading comprehension is a complex process involving several sub-processes: vocabulary and syntactic structure knowledge, making inferences, and integration of simple ideas into macro ideas, among others [ 46 ]. The results of this review show that understanding inferences and understanding the main idea of the text were the most common reading comprehension sub-processes included in the reviewed interventions. Understanding the main idea of a text is a key point, according to the theory of weak central coherence, which explains that people with ASD have difficulties integrating the elements they perceive in isolation into a whole [ 10 ]. Despite these initial difficulties, the present review shows that, if specific strategies are explicitly taught and opportunities for practice are provided, students with ASD are able to extract the main idea from the texts they read.

The third research question refers to several characteristics of the interventions, such as methodologies, duration, implementing agents, and context of intervention.

The results show that a large number of studies used direct instruction, some of them as the only technique [ 27 , 30 , 31 , 32 , 33 , 40 , 41 ] and others as a part of the intervention [ 26 ]. Direct instruction consists of a teaching approach based on breaking down tasks into sequences of more concrete steps with the aim that students acquire the different skills worked in sequence. It is an approach that emphasizes the structuring of the teaching processes through scripts that guide the teaching process. The results of this review confirm that, according to previous reviews [ 14 , 20 ], this is a positive methodology for teaching school content to children with ASD, considering that these children need individualized attention, and that this systematic methodology is particularly well adapted to the order and structuring needs of students with ASD.

Nevertheless, direct instruction should not be considered as the only option to teach reading comprehension to students with ASD. Collaborative, guided, and shared reading have also been shown as effective methodologies [ 21 , 35 , 36 , 39 , 43 , 44 ]. These techniques have the value of treating reading as a shared act, highlighting the social value of reading, which can be especially positive for children with ASD. Therefore, given that both direct instruction and shared reading have shown good results, it seems appropriate for practitioners to take both methodological approaches into account when designing educational interventions with their students with ASD, considering the characteristics and particular needs of these students.

Regarding the duration of the interventions, the results show great heterogeneity between the different studies, finding durations from just one session to more than 30. This variety in the length of the interventions is due to the different scope of the objectives of each investigation, as well as the age, skills and previous knowledge of the participants. Reading comprehension training is a process whose results depend to a large extent on reading practice and experience. Therefore, one of the most relevant aspects that we must take into account when designing educational interventions is its ability to be implemented in real contexts. These interventions should have a duration to be feasible over time, considering issues such as the motivation of the students and the availability of time and personal resources to carry them out in natural contexts, either by teachers at school or by families in the home.

If we analyze the ecological validity of the research included in this review, regarding the implementer, the number of interventions carried out by teachers is low (only 7 of the analyzed studies). However, reading comprehension is one of the main forms of learning that take place in school (in fact, it is an instrumental learning, which serves as a base tool for later learning). So, it is necessary to design educational interventions that, once shown to be effective in the field of research, could be applied in schools with the usual resources in this context. To transfer the results of the research to the school environment, it is important to consider: the skills and teachers’ resources, the ratio of students per classroom, and the possibility of implementing interventions following the schools’ schedules.

Some studies have taken these aspects into account, since the interventions have been carried out in school contexts by the teachers (not by researchers) throughout all the research process or at least in a generalization phase [ 22 , 25 , 27 , 30 , 43 , 45 ]. These investigations provide added value to the field, since they furnish greater confidence about the ecological validity of the results obtained.

Nonetheless, there is a large amount of research that has been conducted in different settings other than the school context. In these cases, these educational interventions have demonstrated its effectiveness in improving the reading comprehension of children with ASD under controlled conditions. However, we cannot reliably affirm that teachers in the typical conditions of their classrooms can apply these same intervention procedures carried out in control conditions.

In fact, we found two studies in this review that have used the same intervention procedures (based on ABRA, a free computer-assisted literacy program) in two different contexts. In a first study [ 23 ], ABRA intervention was conducted by a researcher on a 1:1 basis in participants’ homes, obtaining good results also in reading fluency as in reading comprehension. In a later study [ 22 ], ABRA was conducted by teachers at school in a more naturalistic context, obtaining also good results in reading fluency, but not in reading comprehension. The possibility of comparing these two studies, which apply the same intervention in two different settings, obtaining different results, gives us the opportunity to reflect on the importance of designing interventions that can be put into practice in the usual school conditions.

In addition to the necessary school and teacher involvement, reading is an activity that can be carried out at home as a dyadic activity with families. Reading at home with parents can have benefits not only in improving reading skills, but also in improving joint attention and certain aspects related to communication and social interaction [ 47 , 48 ]. For this reason, in addition to designing interventions to carry out in the school context, future research should design interventions that can be implemented in the home context.

Finally, regarding students’ motivation towards reading, this research has shown that some tools and strategies used to carry out interventions are interesting and could be attractive to children with ASD. That is the case of ICT support [ 21 ], the ABRA computer assisted intervention [ 22 , 23 ], and the inclusion of content according to the students’ interests [ 19 ], among other initiatives. Additionally, it is important to consider the use of maps and graphic organizers as tools to enhance the comprehension of text information. In fact, in the articles reviewed that used these aids [ 26 , 27 , 35 , 45 ], and according to a previous review study [ 20 ], the results were highly effective and the improvements in reading comprehension were more noteworthy, compared to studies that did not use visual aids.

4.1. Limitations of the Study

Conclusions about the effectiveness of the interventions analyzed in the present review should be viewed with caution because they could be influenced by publication bias. The 25 studies included in this review have been published. Nevertheless, this review does not include any unpublished studies. Because interventions that do not obtain good results usually remain unpublished, not including any of these studies could skew the conclusions about the effectiveness of these interventions.

In addition, reading comprehension is a complex task that includes a large variety of cognitive and meta-cognitive sub-processes. Some of the studies included in this review did not specify which sub-processes were addressed in their interventions, and most of the studies in which the sub-processes were specified included many different types of activities. Therefore, it is difficult to determine what specific types of interventions are more effective. Future studies should analyze the effectiveness of the interventions while considering the sub-processes that were worked on in each case in greater depth.

4.2. Future Research

Future lines of inquiry should carry out research to identify which specific aspects cause the greatest difficulties for children with ASD, and continue to investigate specific aspects of ICT that can contribute to improving the reading comprehension of children with ASD. These interventions should be implemented by teachers in their ordinary school environment in order to be considered valid.

5. Conclusions

Through our review, we were able to provide an overview of different interventions carried out with students with ASD, confirming that they are effective strategies to improve the reading comprehension of children with ASD. Among the most used intervention strategies, two methodologies with very different characteristics stand out. One of them is direct instruction, a methodology characterized by a high structure, and the existence of exhaustive scripts on the actions to be carried out by teachers and students. The other one that we found was the collaborative, guided and shared reading methodologies, characterized by highlighting the social and communicative aspects of reading.

Both methodological approaches can be considered as being effective, although in different ways. While direct instruction emphasizes mastery of purely cognitive aspects, shared reading brings into play issues of a much more social nature. Since both facets of reading are important, teachers and professionals who are responsible for teaching reading must be aware of the strengths and weaknesses of each method to make well-informed decisions about which strategies employ taking into account the set objectives and the students’ characteristics.

We think this review may be of interest to both researchers and teachers who want their pupils with ASD to improve their reading comprehension skills. Finally, we hope that our work will lead to further research and better and more useful practices.

Author Contributions

Conceptualization, R.T.-M.; methodology, R.T.-M.; writing—original draft preparation, I.G.-M., P.S.-C. and R.T.-M.; writing—review and editing, I.G.-M. and P.S.-C.; funding acquisition, R.T.-M. All authors have read and agreed to the published version of the manuscript.

This research was funded by Agencia Estatal de Investigación (AEI) from Government of Spain and FEDER, grant number EDU-2016-78867R, and received human resources from Ministry of Education (Government of Spain), grant code FPU19/06330. The APC was funded by AEI and FEDER.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Data availability statement, conflicts of interest.

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.


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  14. Providing Reading Interventions for Students in Grades 4-9

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  15. Health Literacy Interventions to Improve Health Outcomes in Low- and

    Quantitative pre-intervention, immediate post-intervention, and 6-month post-intervention questionnaire Ibadan Southwest, Nigeria The study aimed to assess the effect of a school-based mental health awareness program on increasing mental health literacy and reducing negative views about people with mental illness

  16. PDF Self-study Guide for Implementing Early Literacy Interventions

    Self-study is a process of using a guide with predetermined focus areas and questions to collect, share, and discuss data with stakeholders. The process can include teachers, reading coaches, school-based administrators, district administrators, and literacy supervisors knowledge­ able in early literacy interventions.

  17. PDF Impact of Literacy Intervention on Achievement Outcomes of Children

    Nine reading intervention studies were accepted; no writing intervention studies were identified that met the inclusion criteria for this systematic review. Findings were grouped by reading intervention category (e.g., synthetic phonics) and outcome (e.g., spelling). Efficacy was noted for all reading intervention categories for a

  18. Structured Literacy Interventions

    Structured Literacy Interventions Teaching Students with Reading Difficulties, Grades K-6 Edited by Louise Spear-Swerling Hardcover February 22, 2022 ISBN 9781462548798 Price: $59.00 244 Pages Size: 7" x 10" Paperback February 22, 2022 ISBN 9781462548781 Price: $39.00 244 Pages Size: 7" x 10" e-book January 26, 2022 PDF and ePub ? Price: $39.00

  19. Establishing the efficacy of interventions to improve health literacy

    Health literacy. Twelve of the studies showed a significant increase in health literacy in the intervention group compared to the control group [30,31,32, 34, 37,38,39,40,41, 44, 45, 47].Six showed no significant difference [35, 36, 42, 43, 48, 52], three showed an increase in health literacy for some but not all domains or subscales [33, 49, 51] and one was inconclusive due to mixed results ...

  20. Leveled Literacy Intervention Resources

    Leveled Literacy Intervention is a short-term, supplementary intervention system proven to improve literacy achievement of struggling readers with engaging leveled books and fast-paced systematically designed lessons. Explore our intervention offerings below and our intervention resources in the Resource Library .

  21. Health literacy, health literacy interventions and decision-making: a

    Inclusion criteria were as follows: (1) the study had to describe and include a health literacy intervention(s) and use of digital health services; (2) the study participants should include elderly people (65+); and (3) the study had to be published between 2000 and 2020.


    The study develops strategic reading intervention materials to support teachers and students during the remedial programs. The pre-tests revealed that the reading ability of the struggling...

  23. Teacher training programs drop the ball on reading. : NPR

    But teacher training programs like this one don't always prepare educators to use researched-backed reading methods, like phonics. In a 2023 study, the National Council on Teacher Quality (NCTQ ...

  24. Investigating the Impact of Collaborative Strategic Reading ...

    Using questionnaires, reading tests, and semi-structured interviews, the present study explores the efficacy of CSR in both improving reading comprehension and alleviating reading anxiety through a 7-week intervention study with 60 low-performing EFL students in a Chinese high school.

  25. The effectiveness of a reading and cognitive task-based Web ...

    The present study aimed to investigate the improvement of reading ability and cognitive performance of children with reading difficulties through a Web application named "Poke the Reading Ability" (PtRA). PtRA is designed to assist the intervention of reading difficulties in Greek, a language that is more transparent than English.

  26. IJERPH

    The current study used post-intervention surveys, which were administered to Chicago residents who were 18 years or older and had participated in the program. Among the 1499 diverse Chicago residents, improved personal health literacy was associated with greater diffusion intention (ORs = 2.00-2.68, 95% CI [1.27-4.39], p ≤ 0.003).

  27. Early dementia diagnosis: blood proteins reveal at-risk people

    The study "needs to be replicated and biomarkers that enable us not only to screen for disease risk but also to differentiate between diseases should be a priority", said Heslegrave. doi ...

  28. JMIR mHealth and uHealth

    Objective: This study aimed to assess mysnapp app use, its user profiles, the duration and frequency of use within the Health eLiteracy for Prevention in General Practice trial, its association with other intervention components, and its association with study outcomes (health literacy and diet) to determine whether they have significantly ...

  29. Interventions for Improving Reading Comprehension in Children with ASD

    A review study that analyzed a total of 12 intervention studies published between 1980 and 2012 found that providing strategies from a cognitive approach, the use of group methodologies, and direct instruction are useful proposals for improving the reading comprehension of students with ASD. Specifically, three of the studies included in this ...