Title: A scoping review of the outcome measures assessed in community-targeted health literacy education interventions.

Introduction: In England, 28.5% of adults possess inadequate health literacy [2], and a recent review suggests children hold low-to-moderate health literacy levels internationally [3]. Education interventions are an integral strategy for improving health literacy and reducing negative outcomes associated with poor health literacy, like physical and psychological quality of life [4], and numerous protocols for education interventions are currently in development [1]. Three direct levels of health literacy exist: Functional, Communicative and Critical health literacy. There is a lack of consensus about outcomes for health literacy education interventions, and no standardised outcomes framework is available to guide research.

Aim: To conduct a scoping review to identify the outcomes used to assess community-targeted health literacy education interventions.

Methods: We searched CINAHL, Embase, ERIC, PsycINFO, PubMed, Scopus, and Web of Science from 2010 to 2020. A six-step modified Arksey and O’Malley scoping review framework underpinned the review process [5]. Studies were included if health literacy was a significant outcome of interest, if they sampled community, non-clinical participants, and if an education intervention was applied to improve a person’s health literacy.

Results: Seventy-two studies met inclusion criteria, and full-text screening revealed 31 eligible papers. Several types of outcomes assessment were extracted, with the majority of studies solely assessing Functional health literacy. Studies assessing health literacy typically used questionnaires designed to evaluate Functional health literacy, neglecting Communicative and Critical health literacy. Common Functional health literacy measures were the newest vital sign, test of functional health literacy in adults, and rapid estimate of adult literacy in medicine. Secondary outcomes were frequently assessed, utilising patient activation, healthy lifestyle behaviours, physical strength tests and interviews to achieve a holistic evaluation of health literacy.

Discussion: Consistency in measuring health literacy is absent, overlooking Communicative and Critical health literacy outcomes. Secondary measures, which provide a more complete overview of a person’s health literacy, vary considerably, and the field may benefit from an outcomes framework designed for community health literacy education interventions.