***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background Developing accessible Web-based material s to support diabetes self-management in people with lower levels of health literacy is a continuing challenge . Objective The objective of this international study was to develop a Web-based intervention promoting physical activity among people with type 2 diabetes to determine whether audiovisual presentation and interactivity ( quizzes , planners , tailoring ) could help to overcome the digital divide by making digital interventions accessible and effective for people with all levels of health literacy . This study also aim ed to determine whether these material s can improve health literacy outcomes for people with lower levels of health literacy and also be effective for people with higher levels of health literacy . Methods To assess the impact of interactivity and audiovisual features on usage , engagement , and health literacy outcomes , we design ed two versions of a Web-based intervention ( one interactive and one plain-text version of the same content ) to promote physical activity in people with type 2 diabetes . We r and omly assigned participants from the United Kingdom , Austria , Germany , Irel and , and Taiwan to either an interactive or plain-text version of the intervention in English , German , or M and arin . Intervention usage was objective ly recorded by the intervention software .  Self-report measures were taken at baseline and follow-up ( immediately after participants viewed the intervention ) and included measures of health literacy , engagement ( website satisfaction and willingness to recommend the intervention to others ) , and health literacy outcomes ( diabetes knowledge , enablement , attitude , perceived behavioral control , and intention to undertake physical activity ) . Results In total , 1041 people took part in this study . Of the 1005 who completed health literacy information , 268 ( 26.67 % ) had intermediate or low levels of health literacy . The interactive intervention overall did not produce better outcomes than did the plain-text version . Participants in the plain-text intervention group looked at significantly more sections of the intervention ( mean difference –0.47 , 95 % CI –0.64 to –0.30 , P<.001 ) , but this did not lead to better outcomes . Health literacy outcomes , including attitudes and intentions to engage in physical activity , significantly improved following the intervention for participants in both intervention groups . These improvements were similar across higher and lower health literacy levels and in all countries . Participants in the interactive intervention group had acquired more diabetes knowledge ( mean difference 0.80 , 95 % CI 0.65 - 0.94 , P<.001 ) . Participants from both groups reported high levels of website satisfaction and would recommend the website to others . Conclusions Following established practice for simple , clear design and presentation and using a person-based approach to intervention development , with in-depth iterative feedback from users , may be more important than interactivity and audiovisual presentations when developing accessible digital health interventions to improve health literacy outcomes . Clinical Trial International St and ard R and omized Controlled Trial Number ( IS RCT N ) : 43587048 ; http://www.is rct n.com/IS RCT N43587048 . ( Archived by WebCite at http://www.webcitation.org/6nGhaP9bv OBJECTIVES The association between the use of telehomecare technology and functional health literacy is rather unexplored in the current literature . This relationship could prove important in the future management of chronic diseases , as technology has become a more integrated part of modern healthcare systems . Therefore , the purpose of this study was to explore how the use of telehomecare technology affects the level of functional health literacy over a period of 10 months . STUDY DESIGN R and omized controlled trial . METHODS Our sample comprised 116 patients diagnosed with chronic obstructive pulmonary disease . A face-to-face interview and an objective test of functional health literacy were conducted with each patient at baseline and again at follow-up after 10 months . Twenty-six patients were lost to follow-up and thus , providing a total of 47 chronic obstructive pulmonary disease patients in the intervention group and 43 in the control group for this follow-up study . The level of functional health literacy was assessed with the Danish Test of Functional Health Literacy in Adults . The difference from baseline to follow-up , in both the functional health literacy score and the mean response time to the entire Danish Test of Functional Health Literacy in Adults ( TOFHLA ) , was tested for statistical significance between the intervention group and the control group . RESULTS A significant increase in functional health literacy is observed in both the groups from baseline to follow-up , but there is no statistical difference between groups ( P-value = 0.62 ) . CONCLUSIONS A significant increase in the functional health literacy score was observed in both groups , but the findings of this present study provide no information on what causes the increase , so further research is needed to explore the increase in functional health literacy score more thoroughly and establish if the use of telehomecare technology is a part of the explanation Background Mobile phone apps are increasingly used to deliver health interventions , which provide the opportunity to present health information via different communication modes . However , scientific evidence regarding the effects of such health apps is scarce . Objective In a r and omized controlled trial , we tested the efficacy of a 6-month intervention delivered via a mobile phone app that communicated either textual or auditory tailored health information aim ed at stimulating fruit and vegetable intake . A control condition in which no health information was given was added . Perceived own health and health literacy were included as moderators to assess for which groups the interventions could possibly lead to health behavior change . Methods After downloading the mobile phone app , respondents were exposed monthly to either text-based or audio-based tailored health information and feedback over a period of 6 months via the mobile phone app . In addition , respondents in the control condition only completed the baseline and posttest measures . Within a community sample ( online recruitment ) , self-reported fruit and vegetable intake at 6-month follow-up was our primary outcome measure . Results In total , 146 respondents ( ranging from 40 to 58 per condition ) completed the study ( attrition rate 55 % ) . A significant main effect of condition was found on fruit intake ( P=.049 , partial η2=0.04 ) . A higher fruit intake was found after exposure to the auditory information , especially in recipients with a poor perceived own health ( P=.003 , partial η2=0.08 ) . In addition , health literacy moderated the effect of condition on vegetable intake 6 months later ( P<.001 , partial η2=.11 ) . A higher vegetable intake was found for recipients with high health literacy after exposure to the textual or auditory intervention compared to the control condition ( contrasts P=.07 and P=.004 , respectively ) . In the case of relatively low health literacy , vegetable intake was the highest in the control condition ( contrasts text control : P=.03 ; audio control : P=.04 ) . Conclusions This study provides evidence -based insight into the effects of a mobile health app . The app seems to have the potential to change fruit and vegetable intake up to 6 months later , at least for specific groups . We found different effects for fruit and vegetable intake , respectively , suggesting that different underlying psychological mechanisms are associated with these specific behaviors . Based on our results , it seems worthwhile to investigate additional ways to increase fruit and vegetable intake in recipients with low health literacy . Clinical Trial International St and ard R and omized Controlled Trial Number ( IS RCT N ) : 23466915 ; http://www.is rct n.com/IS RCT N23466915 ( Archived by WebCite at http://www.webcitation.org/6hTtfSvaz OBJECTIVE To determine the effectiveness of a pictorial ' mind map ' together with the Arthritis Research Campaign ( ARC ) booklet for imparting knowledge to participants with rheumatoid arthritis ( RA ) . Also , we wished to relate this to their reading ability . METHODS We studied 363 participants with RA . Reading ability was assessed using the REALM , and knowledge was assessed using the Knowledge Scale Question naire ( KSQ ) . Information on educational attainment , disease state and levels of anxiety and depression was also collected . Participants were r and omly assigned to receive either the ARC booklet alone or the booklet and the mind map together . RESULTS A significant minority ( 15 % ) of participants were functionally illiterate .  There was a statistically significant increase in knowledge across both groups from baseline to re assessment after they were given the literature , but there was no difference in attainment between the groups . The more literate participants gained more knowledge regardless of the information they were given . They were also significantly less anxious and less depressed . CONCLUSIONS The ARC booklet with or without the mind map was associated with a significant increase in knowledge .  Poor readers had poor educational attainment and poor knowledge acquisition . The information on the mind map was not more accessible to them . Different educational strategies will be necessary to educate these patients Abstract Background Behavioural change interventions for persons with chronic illness draw on a variety of theoretical approaches including motivational interviewing and shared decision making . Health literacy provides an additional , potentially powerful explanatory framework to guide research and practice . Objective To examine the changes in the depth and detail of diabetes‐related knowledge and confidence for persons with type 2 diabetes . Design Two‐year , prospect i ve , observational study , using question naire data at two time points ( baseline and 2 years later ) and in‐depth interviews with a theoretically selected sub sample . Setting and participants A total of 319 patients initially recruited from a deprived urban area in north‐west Engl and Intervention Dedicated tele‐carer education and support , tailored to the individual circumstances of the patient . Main outcome measures Perceptions of confidence , levels of empowerment , learning for self‐care and most helpful aspects of the intervention . Results Over 90 % expressed confidence in keeping their blood sugar controlled , and high levels of perceived empowerment ( mean = 4.25 ; 95 % CI , 4.17–4.33 ) were found . Changes in the depth and detail of diabetes‐related knowledge and confidence , from the specific to the more general , were observed and enhanced competence in translating knowledge into practice . Discussion and conclusions The intervention , built within a developed working partnership between tele‐carer and patient , operated at two levels : health literacy , enhancing knowledge , developing personal skills and enabling self‐control ; and socio‐psychological behavioural change , tailored to individuals within their socio‐economic environments , enabling increased motivation and supportive problem‐solving . Both approaches find reflection in the findings and provide powerful explanatory lenses to interrogate the data Objective To assess the efficacy of patient-centered label ( PCL ) instructions on the knowledge and comprehension of prescription drug use compared to st and ard instructions . Methods A total of 94 participants recruited from an outpatient clinic in Irel and were each r and omly assigned to receive : ( 1 ) st and ard prescription instructions written as times per day ( usual care ) , ( 2 ) PCL instructions that specify explicit timing with st and ard intervals ( morning , noon , evening , bedtime ) or with mealtime anchors ( both PCL ) , or ( 3 ) PCL instructions with a graphic aid to visually depict dose and timing of the medication ( PCL + Graphic ) . The outcome was correct interpretation of the instructions . Results PCL instructions were more likely to be correctly interpreted than the st and ard instructions [ adjusted relative risk ( RR ) 1.08 , 95 % confidence interval ( CI ) 0.98–1.18 ] . The inclusion of the graphic aid ( PCL + Graphic ) decreased the rates of correct interpretation compared to PCL instructions alone ( RR 0.98 , 95 % CI 0.91–1.05 ) . There was a significant interaction between instruction type and health literacy ( p = 0.01 ) . Those with limited health literacy were more likely to correctly interpret the PCL labels ( 91 % ) than the st and ard labels ( 66 % ) , and those with adequate health literacy performed equally well . Conclusion The PCL approach may improve patients  ’ underst and ing and use of their medication regimen Background Processing Web-based health information can be difficult , especially for people with low health literacy . Presenting health information in an audiovisual format , such as animation , is expected to improve underst and ing among low health literate audiences . Objective The aim of this paper is to investigate what features of spoken health animations improve information recall and attitudes and whether there are differences between health literacy groups . Methods We conducted an online experiment among 231 participants aged 55 years or older with either low or high health literacy . A 2 ( spoken vs written text ) x 2 ( illustration vs animation ) design was used . Participants were r and omly exposed to one of the four experimental messages , all providing the same information on colorectal cancer screening . Results The results showed that , among people with low health literacy , spoken messages about colorectal cancer screening improved recall ( P=.03 ) and attitudes ( P=.02 ) compared to written messages . Animations alone did not improve recall , but when combined with spoken text , they significantly improved recall in this group ( P=.02 ) . When exposed to spoken animations , people with low health literacy recalled the same amount of information as their high health literate counterparts ( P=.12 ) , whereas in all other conditions people with high health literacy recalled more information compared to low health literate individuals . For people with low health literacy , positive attitudes mediated the relationship between spoken text and the intention to have a colorectal cancer screening ( b=.12 ; 95 % CI 0.02 - 0.25 ) . Conclusions We conclude that spoken animation is the best way to communicate complex health information to people with low health literacy . This format can even bridge the information processing gap between audiences with low and high health literacy as the recall differences between the two groups are eliminated . As animations do not negatively influence high health literate audiences , it is concluded that information adapted to audiences with low health literacy suits people with high health literacy as well This study was conducted as part of a r and omized , controlled trial , and explored whether the introduction of a Danish telehomecare intervention , referred to as ' the Telekit ' , and its associated educational components affect functional health literacy . The study sample consisted of 60 chronic obstructive pulmonary disease patients in the intervention group who received the Telekit , and 56 
    Output:
    
Three types of interventions were identified ; aim ed at improving health literacy  , tailored to different health literacy levels and aim ed at improving health outcomes in general that differentiated in effects for people with different health literacy levels .
Most interventions identified in the review focus on the functional level of health literacy or numeracy .
Conclusions Promising interventions were tailored to the needs of patients , addressing functional , interactive and critical skills and use not difficult animated spoken text .