Clear Conversations: A mixed methods evaluation of a verbal health literacy initiative for health service providers

Clear Conversations: A mixed methods evaluation of a verbal health literacy initiative for health service providers | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clear Conversations: A mixed methods evaluation of a verbal health literacy initiative for health service providers Cheryl Grindell, Jo Hall, Laura Connolly, Jane Hawley, Alicia O’Cathain This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8252432/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Understanding health information can be difficult. Consequently, people may struggle to know how to manage their health. This may negatively impact on healthy practices leading to poorer health outcomes. This study aimed to evaluate a verbal health literacy training initiative, incorporating Teach-back, Chunk and Check, Open Questions and Simple Language alongside implementation support from a health literacy officer, to enable clear conversations between health service providers and users. Methods A mixed methods evaluation was conducted across two health programmes serving a geographical region of a million people in the United Kingdom: A Pulmonary Rehabilitation Programme delivered by five physiotherapists in a hospital setting, and a Weight Management Programme delivered by 12 health improvement advisors in a regional government authority. The five evaluation components were: 1. A survey of 110 service providers’ perceptions of the training. 2. Observations of service delivery by 11 service providers before and after training. 3. Two focus groups with 11 service providers six months post-training. 4. Change in 73 service users’ health literacy levels over time. 5. Change in service users’ health and wellbeing outcomes. Results Service providers found the initiative useful. Changes in communication practice, such as increased use of Chunk and Check and Open Questions, were observed post-training. Both programmes were delivered in group settings where Teach-back was reported to be challenging to apply but beneficial in one-to-one interactions in wider practice. Implementation support from the health literacy officer was perceived as helpful but difficult to deliver to busy teams. The health literacy levels of service users improved by the end of their programme but there was no evidence that the initiative improved health and wellbeing outcomes. Conclusions The verbal health literacy initiative was well received and enhanced service providers’ communication skills. The techniques within the initiative may be easier to apply in one-to-one consultations with service users than in group-delivered care. Strengthened implementation support may improve adoption and effectiveness in practice. Further evaluation of a strengthened initiative should focus on controlled before and after designs on larger samples to measure the effect on service users’ health literacy levels and health and wellbeing outcomes. Verbal health Literacy implementation support health and wellbeing outcomes Figures Figure 1 Background Health literacy is important so that everyone has the ability to access and receive high quality healthcare ( 1 ). Health literacy has been defined as a person’s ability to understand and use information to make decisions about their health so they can be active partners in their care ( 2 ). People with low health literacy struggle to read and understand health information, communicate with health professionals, and know how to act on the information they receive ( 3 ). If health literacy is improved this can positively affect treatment adherence, and lead to reduced numbers of cancelled appointments, and improved satisfaction and outcomes ( 4 ). Improving health service providers’ communication skills is important and has the potential to positively impact on service users ( 5 – 8 ). Evidence suggests that effective health conversations can potentially increase adherence to treatment, patient safety, quality of life and health outcomes ( 5 , 6 ). In the United Kingdom (UK) health care is provided by the National Health Service (NHS) free at the point of delivery. National agencies advocate the use of clear communication, both spoken and written, to help address health literacy ( 9 , 10 ). These agencies have developed toolkits and guides where they recommend the use of: Teach-back techniques ( 9 , 10 ); Chunk and Check techniques ( 9 , 10 ); Open Questions; and Simple Language ( 10 ). A recent study in the United States of America found that if health service providers improved communication by slowing speech, using more understandable words, and intentionally allowing more time for patients to speak and ask questions then this could help to improve patient understanding ( 11 ). Verbal health literacy techniques such as using simpler language have been evaluated internationally ( 6 , 7 , 12 , 13 ). The Teach-back technique improved service users’ knowledge recall, as well as hospital re-admissions and quality of life ( 13 ). There were inconsistent results related to knowledge retention, and implementation in routine practice was rarely considered ( 13 ). A training session on Teach-back alone was not considered to be adequate for sustained translation into practice ( 12 , 13 ), indicating the need for additional implementation support. In a study in the UK, pharmacists received a one-off training session on Teach-back, Chunk and Check, and Simple Language. In qualitative interviews the pharmacists found Chunk and Check harder to use than Teach-back and reported that it was easy to revert to jargon and habitual use of more complicated language ( 14 ). At the time we designed this study, the evidence base for verbal health literacy was limited so there was a need to evaluate initiatives to improve health service providers’ communication skills, particularly measuring whether such initiatives improve service user outcomes in the short and longer term. The aim of this study was to evaluate a verbal health literacy initiative offered to different types of service providers aiming to improve service users’ health and wellbeing. Methods Setting Derbyshire is a region of the UK with a population of a million people. Six out of ten people are estimated to be below the UK average for health literacy and numeracy ( 15 ). Joined Up Care Derbyshire brings together services provided by the NHS, regional government authorities (known as local authorities), and the voluntary sector to deliver better care to whole communities in Derbyshire ( 16 ). In 2022 a regional agency Joined Up Care Derbyshire appointed a health literacy officer, a role that is not commonly provided in the UK. This health literacy officer offers support and training to service providers to improve health literacy within their services. The programmes Two programmes were selected to participate in the evaluation. First, the Pulmonary Rehabilitation Programme provided within the NHS, which aims to improve patients’ exercise tolerance and respiratory health. This programme provides a six week rolling face-to-face programme for adults aged 18 and over. 15 members of staff - a mixture of physiotherapists, healthcare assistants, and specialist nurses - offer supervised exercise and education and advice to groups of people who are limited by their respiratory condition. The 5 physiotherapists lead the group sessions. Up to 12 service users attend two sessions a week over the six week period. Second, Live Life Better Derbyshire Tier 2 Weight Management Programme, which aims to help adults aged 18 or over lose weight. The service provides online and face-to-face group education and advice programmes that run for one session a week over a rolling 12 week period. 12 Health Improvement Advisors offer advice to groups of up to 25 people who need to lose weight. The verbal health literacy initiative The verbal health literacy initiative is part of a wider initiative called ‘Quality Conversations’, an evidence-based communications skills programme for health service providers, developed by the Derbyshire Psychological Insights team and Public Health Derbyshire, to support the implementation of Making Every Contact Count in Derbyshire ( 17 ). It is informed by the COM-B behaviour change model ( 18 ) and is focused on addressing health inequalities through the promotion of ‘ compassionate and curious conversations’ ( 17 ). A health literacy officer works with teams to support them to take evidence-based steps to provide more health literacy friendly services. The initiative consists of a verbal health literacy training package for health service providers to enable clearer health conversations. It is a two-hour interactive and experiential session delivered by the health literacy officer, focusing on how service providers can learn, practice and implement four key verbal health literacy techniques: Teach-back, a method of making sure patients understand the health information they receive ( 12 ); Chunk and Check, where information is broken down into smaller chunks rather than giving it all at once, then checking it is understood before moving onto the next ‘chunk’( 10 ); the use of Simple Language; and the use of Open Questions. The health literacy officer then offers service providers implementation support to help them use the techniques within their practice. This might consist of a meeting with teams to discuss any issues they may be having implementing the techniques and providing advice on how to overcome them. All five physiotherapists from the Pulmonary Rehabilitation Programme received the training because they are the team members that spend most time with service users. Half of the health improvement advisors from the Weight Management Programme (6/12) received the training to allow for a controlled before and after comparison of outcomes for this service. These physiotherapists and health improvement advisors are referred to as service providers. Study design A mixed methods evaluation was undertaken consisting of a process evaluation to assess acceptability, feasibility and implementation of the initiative ( 19 ), and a concurrent pre-test post-test measurement of outcomes ( 20 , 21 ). The research team The research team consisted of the head of the Derbyshire Psychological Insights team which had designed the initiative, the health literacy officer providing the initiative, a public health practitioner from Derbyshire County Council who was involved in the development and delivery of the initiative, and two university researchers (one of whom is an academic physiotherapist). Ethics Ethics approval was given by Camden and Kings Cross NHS Research Ethics committee (REC reference: 24/LOC/0324). Patient and Public Involvement and Engagement A project partnership advisory group of 7 service users were recruited from the services and existing patient and public panels. The group met online three times to help develop easy read versions of service user research documents, and provide advice about recruitment, analysis and interpretation of results. Payment was offered based on national guidance for public contributors’ payment recommendations (the NIHR’s) ( 22 ). Components of the evaluation There were five components of the evaluation. 1.Survey of service providers’ views of the initiative The health literacy officer undertakes an online survey of attendees at the training session at three time points: at baseline where current knowledge of verbal health literacy techniques is assessed; immediately after training where the utility of the training and knowledge and confidence to use the techniques is assessed; and at 12–20 weeks post-training where support for implementation is assessed. Anonymised data on all service providers undergoing training in a 26 week period (July 2023 - January 2024) were provided to the research team. This data included the 11 service providers in this evaluation. Service provider data was only included in this research if individual consent was given. 2.Observation of service delivery before and after training To assess if there was a change in the frequency with which service providers used the techniques they learnt, the lead researcher (CG) observed a consultation with service users for each of the 11 service providers in the evaluation, both before and 4–6 months after training. The lead researcher recorded the extent to which the techniques (Teach-back, Chunk and Check, Simple Language and Open Questions) occurred in each consultation on a 7-item checklist using the response set of ‘never, sometimes, most of the time, all of the time’. 3.Focus groups of service providers’ views of the initiative Two focus groups were undertaken with the 11 service providers who received training (Kitzinger, 1995). A focus group was undertaken for each programme to allow discussion of issues important to their area of practice. The focus groups were online for the Pulmonary Rehabilitation Programme and face-to-face for the Weight Management Programme. The focus groups were facilitated by CG. They lasted 90 minutes and were recorded and transcribed verbatim. 4.Survey of change in service users’ health literacy levels Service users who attended the two programmes in the period after the service providers were trained were consented to participate in the evaluation. This meant that data were available in the post-test period only, so changes could not be assessed between service users receiving programmes before the verbal health literacy training and after the training. For the Pulmonary Rehabilitation Programme, physiotherapists approached service users to request sharing their contact details with the lead researcher. The lead researcher then contacted service users for written informed consent. For the Weight Management Programme, written consent was taken via an electronic link when service users enrolled on the programme. If service users gave consent, they completed a questionnaire of two domains of the validated Health Literacy Questionnaire (Osborne et al; 2013) at two time points: baseline (before they attended the programme) and at the end of their 6 weeks (Pulmonary Rehabilitation) or 12 weeks (Weight Management) programme. The domains were whether they felt they had sufficient information to manage their health, and whether they felt they were actively managing their health. They were asked to consider the questions in relation to the programme they were about to, or had, attended. They completed them electronically or by telephone with the lead researcher. 5.Routine data to assess health and wellbeing outcomes Individual service user data The two programmes collect data about service user outcomes as part of their routine service. Data for individual service users was shared with researchers for service users who gave written informed consent (see section above). For the Pulmonary Rehabilitation Programme, assessments were carried out at baseline and on completion of the programme at six weeks, after attendance at 8–12 sessions. The primary outcome was change in quality of life measured by the four domains of the Chronic Respiratory Disease Questionnaire (CRDQ) ( 23 ). Secondary outcomes were measured using the incremental shuttle walking test in metres ( 24 ), Lung Information Needs Questionnaire (LINQ) ( 25 ), Generalised Anxiety Disorder Assessment (GAD − 7) ( 26 ), Patient Health Questionnaire 9 (PHQ-9) ( 27 ) and strength tests at 0 and 6 weeks ( 28 ). For the Weight Management Programme, service users completed routine service assessments at baseline, 12 and 26 weeks. The primary outcome was change in weight in kilograms. Weight was self-reported for those attending the programme online. Those attending the programme face-to-face were weighed by the service providers weekly. Due to time constraints for the research, the primary outcome was weight change between 0 and 12 weeks only. The secondary outcome of well-being was measured by the short form Warwick and Edinburgh Mental Health and Wellbeing Scale ( 29 ) at 0 and 12 weeks. Programme level data Because use of individual level data required informed consent from service users, with likely partial sign up, it was important to assess aggregated programme level data from each of the two programmes. The Pulmonary Rehabilitation Programme provided data for the six month period after the training (July 2024-December 2024), and the same six month period in the year before the training (July 2023-December 2023) to reduce seasonal effects. The Weight Management Programme leaders were concerned that changes they had made to the programme the previous year would detrimentally affect a similar analysis. Therefore, they provided a three-month period post-training (September -November 2024), and the three month period immediately before training (May-July 2024). The data was attendance numbers, programme completion numbers, and outcomes described in the individual level outcomes section earlier in terms of means and standard deviations for the periods pre and post-training. For the Weight Management Programme, the data was divided into courses led by the 6 verbal health literacy trained service providers and a control group of courses led by 6 service providers who had not attended the training to allow a controlled pre-test post-test comparison. Proposed theory of change The research team developed a theory of change for the initiative (see Fig. 1). Figure 1 Theory of change for the verbal health literacy initiative Expected sample size for outcomes For the Pulmonary Rehabilitation Programme, the research team estimated that 96–144 service users might enrol in the post-training period. With an expected response rate of 50% for giving consent, individual outcomes were expected for around 70 service users in the post-test period. Data was not available to the research team to undertake a formal sample size calculation. For the Weight Management Programme, the research team estimated that 495–825 service users might enrol in the post-training period. With a response rate of 50% for giving consent, individual outcomes were expected for 330 service users. Approximately 165 service users would have attended course led by trained service providers and 165 courses led by providers who had not attended the training. A sample size calculation was undertaken using data from 2023 where the mean starting weight was 103.68kg. The mean weight on completion of the course was 99.60kg. So, the mean weight loss was 4.08 kg for this cohort. If the initiative resulted in an extra 10% increase in mean weight loss at 12 weeks, with an estimated pooled standard deviation of 1.6, a sample size of 252 would be required in each group to detect this size of difference with 80% power at a 5% level of significance. Data analysis For the service provider survey of the initiative, data were entered into SPSS ( 30 ) and descriptive statistics calculated at each of the three time points e.g. how staff rated their knowledge of the techniques (baseline, post-training and at follow up), % staff who found the training helpful (post-training), and % staff who used the techniques in practice (two to four months post-training). For the observations of the use of the verbal health literacy techniques in practice by the 11 service providers in the evaluation, scores were allocated to the categories in the response set (‘all of the time’= 3 to ‘never’ 0) to create a total score for each service provider before and after training. Data was entered into SPSS ( 30 ). A paired t-test was undertaken to measure change within individual service providers between pre and post-training. For the two focus groups, the audio and videocall were transcribed. The two transcripts were analysed using the ‘framework approach’. The four stages of familiarisation, identification of a thematic framework, charting (coding the data to the thematic framework), and then mapping (making connections between themes) ( 31 ) were carried out. For the Health Literacy Questionnaire ( 3 ) for service users, data were entered into SPSS ( 30 ), and scores calculated for the two domains of the Health Literacy Questionnaire at baseline and the end of the course. Mean change over time was calculated and a paired t-test undertaken. T-tests are robust to non-normal distributions, but a Wilcoxen test was also undertaken. For the Weight Management Programme, there was an intervention group and a control group so changes in health literacy scores were compared for these two groups using a t-test. For the individual level outcomes, data were entered into SPSS ( 30 ) and descriptive statistics calculated for each outcome measure. Mean change over time was compared using a paired t-test for the Pulmonary Rehabilitation Programme, and difference in mean change over time between intervention and controls was assessed using a t-test for the Weight Management Programme. For the aggregated data, the mean change in an outcome was calculated in the pre-test and in the post-test periods and compared using a t-test. For the Weight Management Programme, the difference in mean change over time between intervention and controls was assessed using a t-test. Results Participants All five physiotherapists from the Pulmonary Rehabilitation Programme received the training and participated in the evaluation. Six of the twelve Weight Management Programme advisors received the training, with six acting as controls. The six receiving the training participated in the evaluation. All 11 service providers (5 physiotherapists and 6 health improvement advisors) participated in the observation and the focus groups. 110 service providers completed the pre-training survey, including the 11 who were part of the evaluation. 69 completed the post-training survey, including the 11 staff. 23 completed the final survey, including 7/11 in the evaluation (3 from Pulmonary Rehabilitation Programme, 4 from Weight Management Programme). For the Pulmonary Rehabilitation Programme, 49 service users who attended the programme consented to take part: 45% (22/49) male, 96% white (47/49), mean age 69 (range 46 to 85), 6% (3/49) in the quintile with the worst social derivation using the Index of Multiple Deprivation (ref). This was lower than the expected 70 participants. For the Weight Management Programme 34 service users consented to take part: 18% (6/34) male, 94% (32/34) white, mean age 52, and 21% (7/34) in the quintile with the worst social deprivation. This was lower than the expected 160 participants. Service providers’ views of the initiative 68% (47/69) service providers found the verbal health literacy training to be very useful and 26% (18/69) useful. For the 11 in the evaluation, 100% (5/5) of the Pulmonary Rehabilitation Programme team found the training to be very useful compared to 33% (2/6) of the Weight Management Programme team. See supplementary file 1 for details. Reported knowledge of the verbal health literacy techniques was poor to adequate for the majority of service providers pre-training, especially for Teach-back (82% − 90/110) and Chunk and Check (74% − 82/110). Reported knowledge improved post-training and was sustained for the smaller numbers completing the survey at 4–6 months post-training. This pattern was also evident for the two sets of service providers in the evaluation (see Table 1). Reported confidence to use the verbal health literacy techniques followed a similar pattern (supplementary file 2), as did how often the service providers reported using the verbal health literacy techniques in practice (supplementary file 3). Table 1 Service providers’ reported knowledge of the verbal health literacy techniques Observed use of the techniques before and after training Based on observation of sessions delivered to service users, more frequent use of verbal health literacy techniques was observed post-training than pre-training. The maximum score on the observation checklist was 21. The mean score for the 11 service providers in the evaluation increased from 4.5 at pre-training to 9.4 at post-training (p < 0.001). The improvements were similar for each team: 4.4 to 9.0 (p = 0.019) for the Pulmonary Rehabilitation Programme and 4.5 to 9.7 (p < 0.001) for the Weight Management Programme. Some verbal health literacy techniques were not used at all in the pre-training period (Chunk and Check) but were used sometimes in the post-training period. Service providers’ views of the initiative Based on the focus groups, there were four themes relating to: the training (relevant and worthwhile), the ability to make changes to materials they used (varied ability), implementing the techniques in routine practice (limitations of the group setting), and the post-training implementation support (more needed). The training was relevant and worthwhile Overall, the training was received favourably by both teams. The physiotherapists and health improvement advisors described how they found the training enjoyable, relevant, and worthwhile. They liked the varied and interactive content which they found engaging. They felt that it should be offered to all staff and used in undergraduate level education. They suggested minor changes to the training such as more time to practice the techniques and tailoring the techniques for use in group settings and specific scenarios. ‘Other health professionals teaching the [courses], they could all do with this training, couldn't they? I'd advise anyone to go on it that hasn't done the training that's in health care, definitely. We could have done with it at university couldn't we?’ (Physiotherapist 4) I'd ask for more group-based examples. I think it felt like the training was set up for one-to-one situations perhaps more than groups a little bit more. Or maybe just if there's time to get to know some of the nuances of the service and the practice of the professionals to be able to get really useful specific examples that are hyper-appropriate, that would be what I would add to it . (Health Improvement Advisor 10) Ability to make changes to materials used with service users Both teams reported they were actively trying to use the techniques in their practice. The physiotherapists described being unfamiliar with the techniques and how they did not use them at all prior to the training. They had changed the PowerPoint slides they used with service users as a result of the training to help them incorporate the verbal health literacy techniques into routine practice. In contrast, the health improvement advisors reported being more familiar with the techniques, and how they used them in small ways before the training e.g. use of online quizzes and ‘take home’ messages. They therefore felt more confident to use the techniques in their practice but had little control over making changes to their session slides which were developed by the management team. ‘I think the Chunk and Check is just something I've never even heard of or done before. So, it's quite a big change to include that in your education sessions. And the slides (that physiotherapist 1 has incorporated into the PowerPoints) have really helped me. So, after we'd done the training, I can honestly admit that I then did another education session and I didn't do it. But the new slides do help. They just remind us.’ (Physiotherapist 4) ‘ I feel like we were using a lot of them anyway, I don't know if anybody else thinks that? And I think maybe that's why it made it easier.’ (Health improvement advisor 8) Implementing the techniques is challenging in a group setting For both teams the use of the techniques was limited by having to deliver their courses to groups of service users rather than one-to-one. They described how difficult it was to use Teach-back and Chunk and Check in a group setting but physiotherapists described how they used the techniques in one-to-one interactions with service users outside the programme in the evaluation e.g. wider respiratory clinics. ‘I feel like using Simple Language can work for anyone in any position whether it's one-to-one or a group. But I struggle sometimes when it's a group setting to use ‘Chunk and Check.’ (Health improvement advisor 10) ‘Teach-back’ is more useful on a one-to-one basis really and when you teach inhaler techniques and things like that it's like ‘right you show me now’. And like [colleague in the focus group] said you do think ‘oh my [goodness] what are they doing!’. So that is really useful.’ ( Physiotherapist 1 ) More post-training implementation support needed The implementation support from the health literacy officer after the training session appeared to have the potential to improve implementation. Unfortunately, not all the service providers in the evaluation received the support offered due to time constraints. Those that did receive it found it valuable. Suggestions for other kinds of implementation support were made, such as the health literacy officer observing their practice and telling them where to improve use of the techniques, or time to reflect on their practice as a team. ‘Or even after we've had the training, like shadow us and then give us feedback in terms of like ‘’oh I notice you said this’’, ‘’you could have turned it into an open question by saying this’’ would have been really specific and pinpointed where we can get stuff in and what exactly we can do differently. Because it does take practice with these things for it to become normal .’ (Health improvement adviser 10) ‘I think you need prompting because everything's so busy and, like we said, it's not just this project we're doing, is it? How many other things are going on at the same time? We feel like we're split in many pieces. So, I think that's helpful, the prompting and the time to chat and reflect.’ (Physiotherapist 3) Change in service users’ health literacy levels In the post-test period there was an improvement in subjective health literacy for service users in both programmes between the beginning and end of their contact with service providers (Table 2 ). At the end of the course, service users were more likely to feel they had sufficient information to manage their health, and more likely to feel able to manage their health (p < 0.001 for all comparisons). This indicates the utility of the programmes at improving health literacy, rather than the effect of the verbal health literacy initiative. For the Weight Management Programme, some service users attended programmes led by health-literacy-trained staff, and some service users attended programmes led by staff who had not attended the training (a control group), allowing comparison of the initiative with a control. However, numbers of service users in the control group were small (n = 6) and the statistical power for this comparison was low. There was no statistically significant difference in change in health literacy levels between initiative and control service users mean difference=-0.1 (-0.78 to 0.90, p = 0.88) for sufficient information and mean difference 0.2 (-0.76 to 0.35, p = 0.44) for actively managing health (Table 2 ). Table 2 Changes in service users’ health literacy levels (two domains of the Health Literacy Questionnaire) Service +Sufficient information BASELINE Sufficient information END Change +Actively managing health BASELINE Actively managing health END Change Mean Mean Mean (95% CI) Mean Mean Mean (95% CI) N* Pulmonary Rehabilitation Programme 2.8 3.6 0.8 (0.6–1.1) 2.8 3.3 0.5 (0.3 to 0.7) 40 Weight Management Programme (all) 2.6 3.4 0.8 (0.5–1.2) 2.6 3.1 0.5 (0.3 to 0.8) 20 Weight Management Programme (attended sessions with health literacy trained staff) 2.6 3.4 0.8 (0.3–1.3) 2.6 3.3 0.6 (0.3 to 0.9) 14 Weight Management Programme (attended sessions with control staff) 2.4 3.3 0.9 (0.2–1.6) 2.5 2.9 0.4 (-0.2 to 1.0) 6 + higher scores indicate higher levels of subjective health literacy *There was loss to follow-up. 40/49 people completed the Health Literacy Questionnaire at the end of the course for the Pulmonary Rehabilitation Programme, and 20/34 for the Weight Management Programme Changes in health outcomes Primary health outcomes for individual service users who gave consent for their data to be used are shown in Table 3 . Secondary outcomes are in supplementary files 4–7. There were improvements in the scores for the Pulmonary Rehabilitation Programme and the Weight Management Programme, showing the impact of the programmes rather than the verbal health literacy training. There was no statistically significant difference between the primary outcome for service users attending the health-literacy-trained group compared with the control group for the Weight Management Programme − 0.2 (-2.3 to 1.9) p = 0.84. Table 3 Change in primary outcomes for individual service users giving consent Service BASELINE END CHANGE N p-value Mean score Mean score Mean change (95% CI) Pulmonary Rehabilitation Programme (CRDQ score) Dysnoea Fatigue Emotional function Mastery 2.79 3.65 4.37 4.48 3.37 4.15 4.88 5.10 0.58 (0.11 to 1.10) 0.50 (0.17 to 0.83) 0.51 (0.20 to 0.81) 0.63 (0.27 to 0.99) 41 41 41 41 0.016 0.004 0.002 0.001 Weight Management Programme (Weight in kg) 105.5 102.9 -2.6 (-3.5 to -1.7) 27 < 0.001 Weight Management Programme (attended sessions with health literacy trained staff) 108.8 106.2 -2.6 (-3.6 to -1.5) 20 < 0.001 Weight Management Programme (attended sessions with control staff) 95.6 92.9 -2.8 (-5.1 to -0.5) 7 0.024 Aggregated routine data allowed comparison of outcomes for service users attending programmes in time periods before and after the service providers had the training. For the Pulmonary Rehabilitation Programme, the completion rate of the course (completed 8 or more sessions) pre-training was 57% (97/169) and post-training was 62% (69/111). There was no indication that the verbal health literacy training had improved completion rates (chi-square, p = 0.43). There was no indication that the verbal health literacy training had improved service user outcomes (see Table 4 for primary outcome and additional file 6, Table 10 for secondary outcomes). For the Weight Management Programme the completion rate for the courses run by health-literacy-trained advisors (completed 9 weeks or more) pre-training was 50% (219/438) and post-training was 56% (215/383) compared with controls pre-training 62% (76/123) and post-training 67% (79/118). There was no indication that the verbal health literacy training had improved service user outcomes. Standard deviations differed largely between time periods and groups, indicating problems with this data (see supplementary files 4–7) for primary and secondary change in outcomes and secondary outcomes for those completing the programme only for both services). Table 4 Change in primary outcomes before and after training (based on aggregated routine data for service users completing the programmes) Service Primary outcome Mean change (SD) BEFORE Mean change (SD) AFTER Différence in mean changes (95%CI) p-value Pulmonary Rehabilitation Programme CRDQ score Dysnoea Fatigue Emotional function Mastery 0.93 (1.47) 0.74 (1.11) 0.46 (0.98) 0.64 (1.32) 0.71 (1.23) 0.56 (1.15) 0.44 (1.11) 0.54 (1.15) -0.22 (-0.71 to 0.27) -0.18 (-0.59 to 0.23) -0.02 (-0.39 to 0.36) -0.10 (-0.55 to 0.35) 0.37 0.38 0.92 0.66 N 63 58 Weight Management Programme (attended sessions with health literacy trained staff) Weight in kg -3.16 (0.54) -3.30 (0.51) -0.14 (-0.23 to -0.04) 0.006 219 215 Weight Management Programme (attended sessions with control staff) Weight in kg -1.58 (3.06) -3.38 (0.03) -1.80 (-2.4 to -1.1) 0.0001 N 76 79 Discussion Summary of findings Service providers found the verbal health literacy training useful because they learned new communication techniques. Changes in communication practice were observed in both the Pulmonary Rehabilitation and Weight Management Programmes, with the physiotherapists and health improvement advisors making increased use of Chunk and Check and Open Questions when communicating with service users. Both programmes worked with groups of service users rather than on a one-to-one basis. Service providers reported that Teach-back was difficult to use in group settings but was useful in one-to-one sessions in their wider practice. They also found the implementation support from the health literacy officer helpful but wanted more opportunities to meet as teams to reflect on how to improve their use of the new techniques. The health literacy levels of service users improved by the end of their course. However, this improvement was due to the course rather than the verbal health literacy initiative. There was no evidence that the verbal health literacy initiative improved health outcomes for service users. Context of other research The service providers in this study felt they learnt new communication techniques and changes in practice were observed. Despite this, both teams found Teach-back more difficult to implement than Chunk and Check in their group-based courses. Cork and White’s (2022) study exploring community pharmacists' views of a health literacy training initiative, found the opposite. Pharmacists reported that they found Chunk and Check more difficult to implement than Teach-back ( 14 ). Perhaps this was because community pharmacists interact with service users in a more instructive way and on a one to one basis, for example teaching medication use, rather than the information-based group sessions offered in our evaluation. Incorporating health literacy techniques into information-based group sessions has been found to be successful in improving service users’ knowledge ( 32 , 33 ). However, in Gharachourlo et al’s (2018) study they did not describe their health literacy intervention approach and neither study explored service providers’ ability or perception of using health literacy strategies when delivering information sessions to service users ( 32 , 33 ). This suggests that further research exploring the use of verbal health literacy techniques in a group setting is warranted. Difficulty implementing Teach-back into practice has been highlighted in two more recent American studies ( 8 , 34 ). They found that in order to overcome issues such as communication habits, time, role constraints and uncertainty on how to use health literacy techniques in practice, changes to the way Teach-back is taught, conceptualised and implemented is needed ( 8 , 34 ). In our evaluation, the verbal health literacy initiative for service providers was delivered by a health literacy officer working within the same organisation. The implementation support they offered after the initiative was delivered was limited but valued by the teams. Several studies have explored the use of external health literacy facilitators as well as the use of health literacy champions (clinicians/ team members) trained in health literacy techniques, to support and sustain implementation ( 8 , 35 , 36 ). It has been proposed that champions from multiple levels within an organisation working in a coordinated way may be more effective than solo champions ( 35 ). The evidence suggests that a more bottom-up approach where a ‘community of practice’ of health literacy champions is fostered and existing staff are trained to deliver and sustain initiatives, rather than a top-down hierarchical approach, may give staff the autonomy and confidence to make and sustain changes at a practice level ( 8 , 35 , 36 ). The service providers in our evaluation suggested alternative implementation support strategies. These included prompt sheets and having regular protected time to review and reflect on how they were using the verbal health literacy techniques in their practice. In the wider literature, implementation support methods include the use of flyers ( 36 ), ‘lunch and learn’ sessions to discuss what is and is not working ( 8 , 36 ), five minute booster sessions during breaks ( 8 , 36 ), weekly emails ( 8 ), staff induction ( 36 ) and standardised document templates to record the use of techniques such as Teach-back in clinical notes ( 36 ). A range of support methods that can be easily incorporated into busy clinical days could be considered, including the development of health literacy champions within service user facing teams to support and embed implementation, in any future delivery of this verbal health literacy initiative. Despite increasing research into verbal health literacy initiatives few studies evaluate service providers health literacy knowledge and ability to apply that knowledge in practice. Research that evaluates service user health literacy and health and wellbeing outcomes, as in this study, is lacking. Strengths and limitations This was a mixed methods evaluation, using a range of qualitative and quantitative methods to address the acceptability and effectiveness of a new initiative in a real-world setting. A strength was the measurement of health outcomes using a controlled before and after design for one of the programmes implementing the new initiative. There were three limitations. First, the controlled before and after design was not possible for one of the programmes, which instead relied on a before and after design which is lower in the hierarchy of evidence of effectiveness. Second, the consent process to include data from individual service users was challenging. Physiotherapists worked hard to gain consent and did well in recruiting service users. The electronic approach to recruitment for the Weight Management Programme yielded a very low consent rate. Small numbers limited the statistical power to detect changes in individual service user data. The included individual data was also likely not to be representative of service users in that more educated or affluent service users may have completed the consent process. Third, there was drop out of service users over time, with some service users not completing their end of course outcome measures. The team consisted of people invested in the initiative (LWT, JoH, JaH) and independent researchers (AOC, CG). This could be viewed as a strength in that the team consisted of people with a range of relevant expertise. It could be viewed as a limitation if the service providers felt they had to be positive about the initiative, or interpretation of results was biased towards the positive. Only CG, an independent researcher, collected data so this reduced the potential for bias. During team discussions about interpretation of the findings, all members of the team took an open and curious approach, genuinely interested in whether this initiative had the intended impact, and open to recommendations for improvements to the initiative. Implications This verbal health literacy initiative has potential to improve service user outcomes. Service providers valued the training and could see the potential of the learnt techniques to improve communication with patients. The initiative would have to have a more intense approach to supporting implementation of the verbal health literacy techniques, as well as a managerial component if service providers have to use materials developed by their managers and do not have control over making changes to those materials. Any similar initiative might fare better in the context of one-to-one consultations, although further adaptation of the training to group delivery might also be useful. Future mixed methods evaluations should include controlled before and after measurement of patient reported outcomes measures with larger sample sizes to better understand the impact these kinds of verbal health literacy initiatives can have on health outcomes. If this type of comparison relies on service user consent, it will likely lead to small, biased samples; the use of aggregated routine data could offer a better option. Conclusions This verbal health literacy initiative evaluated here has potential. It was appreciated by service providers and enabled clear conversations with service users. The communication techniques within the initiative may be easier to apply in one-to-one consultations with service users than in the group settings evaluated here. More focus on supporting implementation of techniques in practice, and opportunity for team reflection, might improve the potential effectiveness of the initiative. Future research should focus on a more intense initiative and use controlled before and after designs on larger samples to measure the effect on service users’ health literacy levels and health and wellbeing outcomes. Declarations Ethics approval and consent to participate The research was conducted in accordance with the Declaration of Helsinki. Ethics approval was obtained from HRA and Health Care Research Wales. REC reference 24/LO/0324. All participants provided written consent to participate in the study. Consent for publication Not applicable Competing interests One author LC was the health literacy officer who produced the training. One author JoH established the health literacy officer role. Funding Professor Alicia O’Cathain is a National Institute for Health Research (NIHR) Senior Investigator. Funds related to this award were used to fund a researcher to undertake this research. The views expressed in this article are those of the author and not necessarily those of the NIHR, or the Department of Health and Social Care. Author Contribution LC and JoH and JH developed the intervention. CG and AOC designed the research and it’s methodology. CG was the primary researcher and collected all the data. CG and AOC analysed the data. CG wrote the original draft manuscript. AOC, LC ,JoH and JH reviewed and edited the draft manuscript. CG made final edits. All authors read and approved the final manuscript. Acknowledgement The authors wish to thank Dr Vera Fibisan for administrative support, the Clear Conversations PPI group for their invaluable contributions and the two services that took part. Data Availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. References World Health Organization. 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The effect of a health literacy approach to counselling on the lifestyle of women with gestational diabetes: A clinical trial. F1000Research. 2018;7:282. Anderson K, Rojas-Alvarado E, Aragon L, Bradshaw J, Fontana E, Hernandez F, et al. Innovating a Teach-Back Model for Community Health Workers Led Health Literacy Practice to Improve COVID-19 Health Equity. Health Lit Res Pract. 2025;9(2):e56–63. Ayre J, Zhang M, Mouwad D, Zachariah D, McCaffery KJ, Muscat DM. Systematic review of health literacy champions: who, what and how? Health Promot Int. 2023;38(4):daad074. Gibson C, Smith D, Morrison AK. Improving Health Literacy Knowledge, Behaviors, and Confidence with Interactive Training. Health Lit Res Pract. 2022;6(2):e113–20. Supplementary. file 1- Table S1. How useful was the training. Supplementary file 2- Table S2. Service provider confidence to use the Verbal Health Literacy techniques. Supplementary file 3- Table S3. Service provider reported frequency of use of the verbal health literacy techniques in practice. Supplementary file 4 -Table S4. Change in primary and secondary outcomes for individual service users in Pulmonary Rehabilitation Programme. Supplementary file 5- Table S5. Change in secondary outcome of WELL-BEING for individual service users in Weight Management Programme. Supplementary file 6- Table S6. Pulmonary Rehabilitation Programme secondary health outcomes (those completing the programme only). Supplementary file 7- Table S7. Weight Management Programme Wellbeing secondary outcome (those completing the programme only). Tables Table 1 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1Serviceprovidersreportedknowledgeoftheverbalhealthliteracytechniques.docx Supplementaryfile1TableS1Howusefulwasthetraining.docx Supplementaryfile2TableS2ServiceproviderconfidencetousetheVerbalHealthLiteracytechniques.docx Supplementaryfile3TableS3Serviceproviderreportedfrequencyofuseoftheverbalhealthliteracytechniquesinpractice.docx Supplementaryfile4TableS4ChangeinprimaryandsecondaryoutcomesforindividualserviceusersinPulmonaryRehabilitationProgramme.docx Supplementaryfile5TableS5ChangeinsecondaryoutcomeofwellbeingforindividualserviceusersinWeightManagementProgramme.docx Supplementaryfile6TableS6PulmonaryRehabilitationProgrammesecondaryhealthoutcomesthosecompletingtheprogrammeonly.docx Supplementaryfile7TableS7WeightManagementProgrammeWellbeingsecondaryoutcomethosecompletingtheprogrammeonly.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 19 Jan, 2026 Reviews received at journal 18 Jan, 2026 Reviews received at journal 30 Dec, 2025 Reviewers agreed at journal 22 Dec, 2025 Reviewers agreed at journal 22 Dec, 2025 Reviewers invited by journal 12 Dec, 2025 Editor invited by journal 10 Dec, 2025 Editor assigned by journal 09 Dec, 2025 Submission checks completed at journal 09 Dec, 2025 First submitted to journal 01 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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1","display":"","copyAsset":false,"role":"figure","size":99607,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTheory of change for the verbal health literacy initiative\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1Clearconversationsprojecttheoryofchange.png","url":"https://assets-eu.researchsquare.com/files/rs-8252432/v1/ac659d13f80f199ddb1a2b7a.png"},{"id":98774677,"identity":"6bbbdd9e-9411-46cd-b339-3381327646bc","added_by":"auto","created_at":"2025-12-22 12:10:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1674912,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8252432/v1/90d399cb-596b-45a1-ab3a-5d2dbc729ec6.pdf"},{"id":98623716,"identity":"1f3c733d-ccb2-43c1-a3df-c57b83bcbc7a","added_by":"auto","created_at":"2025-12-19 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19:19:10","extension":"docx","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":15243,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile6TableS6PulmonaryRehabilitationProgrammesecondaryhealthoutcomesthosecompletingtheprogrammeonly.docx","url":"https://assets-eu.researchsquare.com/files/rs-8252432/v1/2d606d49944cf4092069be8a.docx"},{"id":98622807,"identity":"f723dfc5-5a3e-4dd2-82d0-c56b4b7013ca","added_by":"auto","created_at":"2025-12-19 17:02:34","extension":"docx","order_by":8,"title":"","display":"","copyAsset":false,"role":"supplement","size":14650,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile7TableS7WeightManagementProgrammeWellbeingsecondaryoutcomethosecompletingtheprogrammeonly.docx","url":"https://assets-eu.researchsquare.com/files/rs-8252432/v1/0c9e0a855a3ad13188f8ec94.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clear Conversations: A mixed methods evaluation of a verbal health literacy initiative for health service providers","fulltext":[{"header":"Background","content":"\u003cp\u003eHealth literacy is important so that everyone has the ability to access and receive high quality healthcare (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Health literacy has been defined as a person\u0026rsquo;s ability to understand and use information to make decisions about their health so they can be active partners in their care (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). People with low health literacy struggle to read and understand health information, communicate with health professionals, and know how to act on the information they receive (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). If health literacy is improved this can positively affect treatment adherence, and lead to reduced numbers of cancelled appointments, and improved satisfaction and outcomes (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eImproving health service providers\u0026rsquo; communication skills is important and has the potential to positively impact on service users (\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Evidence suggests that effective health conversations can potentially increase adherence to treatment, patient safety, quality of life and health outcomes (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In the United Kingdom (UK) health care is provided by the National Health Service (NHS) free at the point of delivery. National agencies advocate the use of clear communication, both spoken and written, to help address health literacy (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). These agencies have developed toolkits and guides where they recommend the use of: Teach-back techniques (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e); Chunk and Check techniques (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e); Open Questions; and Simple Language (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA recent study in the United States of America found that if health service providers improved communication by slowing speech, using more understandable words, and intentionally allowing more time for patients to speak and ask questions then this could help to improve patient understanding (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Verbal health literacy techniques such as using simpler language have been evaluated internationally (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The Teach-back technique improved service users\u0026rsquo; knowledge recall, as well as hospital re-admissions and quality of life (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). There were inconsistent results related to knowledge retention, and implementation in routine practice was rarely considered (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). A training session on Teach-back alone was not considered to be adequate for sustained translation into practice (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), indicating the need for additional implementation support. In a study in the UK, pharmacists received a one-off training session on Teach-back, Chunk and Check, and Simple Language. In qualitative interviews the pharmacists found Chunk and Check harder to use than Teach-back and reported that it was easy to revert to jargon and habitual use of more complicated language (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e At the time we designed this study, the evidence base for verbal health literacy was limited so there was a need to evaluate initiatives to improve health service providers\u0026rsquo; communication skills, particularly measuring whether such initiatives improve service user outcomes in the short and longer term. The aim of this study was to evaluate a verbal health literacy initiative offered to different types of service providers aiming to improve service users\u0026rsquo; health and wellbeing.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSetting\u003c/h2\u003e \u003cp\u003eDerbyshire is a region of the UK with a population of a million people. Six out of ten people are estimated to be below the UK average for health literacy and numeracy (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Joined Up Care Derbyshire brings together services provided by the NHS, regional government authorities (known as local authorities), and the voluntary sector to deliver better care to whole communities in Derbyshire (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). In 2022 a regional agency Joined Up Care Derbyshire appointed a health literacy officer, a role that is not commonly provided in the UK. This health literacy officer offers support and training to service providers to improve health literacy within their services.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eThe programmes\u003c/h3\u003e\n\u003cp\u003eTwo programmes were selected to participate in the evaluation. First, the Pulmonary Rehabilitation Programme provided within the NHS, which aims to improve patients\u0026rsquo; exercise tolerance and respiratory health. This programme provides a six week rolling face-to-face programme for adults aged 18 and over. 15 members of staff - a mixture of physiotherapists, healthcare assistants, and specialist nurses - offer supervised exercise and education and advice to groups of people who are limited by their respiratory condition. The 5 physiotherapists lead the group sessions. Up to 12 service users attend two sessions a week over the six week period. Second, Live Life Better Derbyshire Tier 2 Weight Management Programme, which aims to help adults aged 18 or over lose weight. The service provides online and face-to-face group education and advice programmes that run for one session a week over a rolling 12 week period. 12 Health Improvement Advisors offer advice to groups of up to 25 people who need to lose weight.\u003c/p\u003e\n\u003ch3\u003eThe verbal health literacy initiative\u003c/h3\u003e\n\u003cp\u003eThe verbal health literacy initiative is part of a wider initiative called \u0026lsquo;Quality Conversations\u0026rsquo;, an evidence-based communications skills programme for health service providers, developed by the Derbyshire Psychological Insights team and Public Health Derbyshire, to support the implementation of Making Every Contact Count in Derbyshire (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). It is informed by the COM-B behaviour change model (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) and is focused on addressing health inequalities through the promotion of \u0026lsquo;\u003cem\u003ecompassionate and curious conversations\u0026rsquo;\u003c/em\u003e (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). A health literacy officer works with teams to support them to take evidence-based steps to provide more health literacy friendly services.\u003c/p\u003e \u003cp\u003eThe initiative consists of a verbal health literacy training package for health service providers to enable clearer health conversations. It is a two-hour interactive and experiential session delivered by the health literacy officer, focusing on how service providers can learn, practice and implement four key verbal health literacy techniques: Teach-back, a method of making sure patients understand the health information they receive (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e); Chunk and Check, where information is broken down into smaller chunks rather than giving it all at once, then checking it is understood before moving onto the next \u0026lsquo;chunk\u0026rsquo;(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e); the use of Simple Language; and the use of Open Questions. The health literacy officer then offers service providers implementation support to help them use the techniques within their practice. This might consist of a meeting with teams to discuss any issues they may be having implementing the techniques and providing advice on how to overcome them.\u003c/p\u003e \u003cp\u003eAll five physiotherapists from the Pulmonary Rehabilitation Programme received the training because they are the team members that spend most time with service users. Half of the health improvement advisors from the Weight Management Programme (6/12) received the training to allow for a controlled before and after comparison of outcomes for this service. These physiotherapists and health improvement advisors are referred to as service providers.\u003c/p\u003e\n\u003ch3\u003eStudy design\u003c/h3\u003e\n\u003cp\u003eA mixed methods evaluation was undertaken consisting of a process evaluation to assess acceptability, feasibility and implementation of the initiative (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), and a concurrent pre-test post-test measurement of outcomes (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eThe research team\u003c/h3\u003e\n\u003cp\u003eThe research team consisted of the head of the Derbyshire Psychological Insights team which had designed the initiative, the health literacy officer providing the initiative, a public health practitioner from Derbyshire County Council who was involved in the development and delivery of the initiative, and two university researchers (one of whom is an academic physiotherapist).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthics\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eEthics approval\u003c/strong\u003e \u003cp\u003e was given by Camden and Kings Cross NHS Research Ethics committee (REC reference: 24/LOC/0324).\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePatient and Public Involvement and Engagement\u003c/h3\u003e\n\u003cp\u003eA project partnership advisory group of 7 service users were recruited from the services and existing patient and public panels. The group met online three times to help develop easy read versions of service user research documents, and provide advice about recruitment, analysis and interpretation of results. Payment was offered based on national guidance for public contributors\u0026rsquo; payment recommendations (the NIHR\u0026rsquo;s) (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eComponents of the evaluation\u003c/h3\u003e\n\u003cp\u003eThere were five components of the evaluation.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e1.Survey of service providers\u0026rsquo; views of the initiative\u003c/span\u003e \u003c/p\u003e \u003cp\u003eThe health literacy officer undertakes an online survey of attendees at the training session at three time points: at baseline where current knowledge of verbal health literacy techniques is assessed; immediately after training where the utility of the training and knowledge and confidence to use the techniques is assessed; and at 12\u0026ndash;20 weeks post-training where support for implementation is assessed. Anonymised data on all service providers undergoing training in a 26 week period (July 2023 - January 2024) were provided to the research team. This data included the 11 service providers in this evaluation. Service provider data was only included in this research if individual consent was given.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e2.Observation of service delivery before and after training\u003c/span\u003e \u003c/p\u003e \u003cp\u003eTo assess if there was a change in the frequency with which service providers used the techniques they learnt, the lead researcher (CG) observed a consultation with service users for each of the 11 service providers in the evaluation, both before and 4\u0026ndash;6 months after training. The lead researcher recorded the extent to which the techniques (Teach-back, Chunk and Check, Simple Language and Open Questions) occurred in each consultation on a 7-item checklist using the response set of \u0026lsquo;never, sometimes, most of the time, all of the time\u0026rsquo;.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e3.Focus groups of service providers\u0026rsquo; views of the initiative\u003c/span\u003e \u003c/p\u003e \u003cp\u003eTwo focus groups were undertaken with the 11 service providers who received training (Kitzinger, 1995). A focus group was undertaken for each programme to allow discussion of issues important to their area of practice. The focus groups were online for the Pulmonary Rehabilitation Programme and face-to-face for the Weight Management Programme. The focus groups were facilitated by CG. They lasted 90 minutes and were recorded and transcribed verbatim.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e4.Survey of change in service users\u0026rsquo; health literacy levels\u003c/span\u003e \u003c/p\u003e \u003cp\u003eService users who attended the two programmes in the period after the service providers were trained were consented to participate in the evaluation. This meant that data were available in the post-test period only, so changes could not be assessed between service users receiving programmes before the verbal health literacy training and after the training. For the Pulmonary Rehabilitation Programme, physiotherapists approached service users to request sharing their contact details with the lead researcher. The lead researcher then contacted service users for written informed consent. For the Weight Management Programme, written consent was taken via an electronic link when service users enrolled on the programme.\u003c/p\u003e \u003cp\u003eIf service users gave consent, they completed a questionnaire of two domains of the validated Health Literacy Questionnaire (Osborne et al; 2013) at two time points: baseline (before they attended the programme) and at the end of their 6 weeks (Pulmonary Rehabilitation) or 12 weeks (Weight Management) programme. The domains were whether they felt they had sufficient information to manage their health, and whether they felt they were actively managing their health. They were asked to consider the questions in relation to the programme they were about to, or had, attended. They completed them electronically or by telephone with the lead researcher.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e5.Routine data to assess health and wellbeing outcomes\u003c/span\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eIndividual service user data\u003c/h2\u003e \u003cp\u003eThe two programmes collect data about service user outcomes as part of their routine service. Data for individual service users was shared with researchers for service users who gave written informed consent (see section above). For the Pulmonary Rehabilitation Programme, assessments were carried out at baseline and on completion of the programme at six weeks, after attendance at 8\u0026ndash;12 sessions. The primary outcome was change in quality of life measured by the four domains of the Chronic Respiratory Disease Questionnaire (CRDQ) (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Secondary outcomes were measured using the incremental shuttle walking test in metres (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), Lung Information Needs Questionnaire (LINQ) (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), Generalised Anxiety Disorder Assessment (GAD \u0026minus;\u0026thinsp;7) (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), Patient Health Questionnaire 9 (PHQ-9) (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) and strength tests at 0 and 6 weeks (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). For the Weight Management Programme, service users completed routine service assessments at baseline, 12 and 26 weeks. The primary outcome was change in weight in kilograms. Weight was self-reported for those attending the programme online. Those attending the programme face-to-face were weighed by the service providers weekly. Due to time constraints for the research, the primary outcome was weight change between 0 and 12 weeks only. The secondary outcome of well-being was measured by the short form Warwick and Edinburgh Mental Health and Wellbeing Scale (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) at 0 and 12 weeks.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eProgramme level data\u003c/h2\u003e \u003cp\u003eBecause use of individual level data required informed consent from service users, with likely partial sign up, it was important to assess aggregated programme level data from each of the two programmes. The Pulmonary Rehabilitation Programme provided data for the six month period after the training (July 2024-December 2024), and the same six month period in the year before the training (July 2023-December 2023) to reduce seasonal effects. The Weight Management Programme leaders were concerned that changes they had made to the programme the previous year would detrimentally affect a similar analysis. Therefore, they provided a three-month period post-training (September -November 2024), and the three month period immediately before training (May-July 2024). The data was attendance numbers, programme completion numbers, and outcomes described in the individual level outcomes section earlier in terms of means and standard deviations for the periods pre and post-training. For the Weight Management Programme, the data was divided into courses led by the 6 verbal health literacy trained service providers and a control group of courses led by 6 service providers who had not attended the training to allow a controlled pre-test post-test comparison.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eProposed theory of change\u003c/h2\u003e \u003cp\u003eThe research team developed a theory of change for the initiative (see Fig.\u0026nbsp;1).\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 1 Theory of change for the verbal health literacy initiative\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eExpected sample size for outcomes\u003c/h2\u003e \u003cp\u003eFor the Pulmonary Rehabilitation Programme, the research team estimated that 96\u0026ndash;144 service users might enrol in the post-training period. With an expected response rate of 50% for giving consent, individual outcomes were expected for around 70 service users in the post-test period. Data was not available to the research team to undertake a formal sample size calculation. For the Weight Management Programme, the research team estimated that 495\u0026ndash;825 service users might enrol in the post-training period. With a response rate of 50% for giving consent, individual outcomes were expected for 330 service users. Approximately 165 service users would have attended course led by trained service providers and 165 courses led by providers who had not attended the training. A sample size calculation was undertaken using data from 2023 where the mean starting weight was 103.68kg. The mean weight on completion of the course was 99.60kg. So, the mean weight loss was 4.08 kg for this cohort. If the initiative resulted in an extra 10% increase in mean weight loss at 12 weeks, with an estimated pooled standard deviation of 1.6, a sample size of 252 would be required in each group to detect this size of difference with 80% power at a 5% level of significance.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eFor the service provider survey of the initiative, data were entered into SPSS (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) and descriptive statistics calculated at each of the three time points e.g. how staff rated their knowledge of the techniques (baseline, post-training and at follow up), % staff who found the training helpful (post-training), and % staff who used the techniques in practice (two to four months post-training).\u003c/p\u003e \u003cp\u003eFor the observations of the use of the verbal health literacy techniques in practice by the 11 service providers in the evaluation, scores were allocated to the categories in the response set (\u0026lsquo;all of the time\u0026rsquo;= 3 to \u0026lsquo;never\u0026rsquo; 0) to create a total score for each service provider before and after training. Data was entered into SPSS (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). A paired t-test was undertaken to measure change within individual service providers between pre and post-training.\u003c/p\u003e \u003cp\u003eFor the two focus groups, the audio and videocall were transcribed. The two transcripts were analysed using the \u0026lsquo;framework approach\u0026rsquo;. The four stages of familiarisation, identification of a thematic framework, charting (coding the data to the thematic framework), and then mapping (making connections between themes) (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) were carried out.\u003c/p\u003e \u003cp\u003eFor the Health Literacy Questionnaire (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) for service users, data were entered into SPSS (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), and scores calculated for the two domains of the Health Literacy Questionnaire at baseline and the end of the course. Mean change over time was calculated and a paired t-test undertaken. T-tests are robust to non-normal distributions, but a Wilcoxen test was also undertaken. For the Weight Management Programme, there was an intervention group and a control group so changes in health literacy scores were compared for these two groups using a t-test.\u003c/p\u003e \u003cp\u003eFor the individual level outcomes, data were entered into SPSS (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) and descriptive statistics calculated for each outcome measure. Mean change over time was compared using a paired t-test for the Pulmonary Rehabilitation Programme, and difference in mean change over time between intervention and controls was assessed using a t-test for the Weight Management Programme.\u003c/p\u003e \u003cp\u003eFor the aggregated data, the mean change in an outcome was calculated in the pre-test and in the post-test periods and compared using a t-test. For the Weight Management Programme, the difference in mean change over time between intervention and controls was assessed using a t-test.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eAll five physiotherapists from the Pulmonary Rehabilitation Programme received the training and participated in the evaluation. Six of the twelve Weight Management Programme advisors received the training, with six acting as controls. The six receiving the training participated in the evaluation. All 11 service providers (5 physiotherapists and 6 health improvement advisors) participated in the observation and the focus groups.\u003c/p\u003e \u003cp\u003e110 service providers completed the pre-training survey, including the 11 who were part of the evaluation. 69 completed the post-training survey, including the 11 staff. 23 completed the final survey, including 7/11 in the evaluation (3 from Pulmonary Rehabilitation Programme, 4 from Weight Management Programme).\u003c/p\u003e \u003cp\u003eFor the Pulmonary Rehabilitation Programme, 49 service users who attended the programme consented to take part: 45% (22/49) male, 96% white (47/49), mean age 69 (range 46 to 85), 6% (3/49) in the quintile with the worst social derivation using the Index of Multiple Deprivation (ref). This was lower than the expected 70 participants. For the Weight Management Programme 34 service users consented to take part: 18% (6/34) male, 94% (32/34) white, mean age 52, and 21% (7/34) in the quintile with the worst social deprivation. This was lower than the expected 160 participants.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eService providers\u0026rsquo; views of the initiative\u003c/h2\u003e \u003cp\u003e68% (47/69) service providers found the verbal health literacy training to be very useful and 26% (18/69) useful. For the 11 in the evaluation, 100% (5/5) of the Pulmonary Rehabilitation Programme team found the training to be very useful compared to 33% (2/6) of the Weight Management Programme team. See supplementary file 1 for details.\u003c/p\u003e \u003cp\u003eReported knowledge of the verbal health literacy techniques was poor to adequate for the majority of service providers pre-training, especially for Teach-back (82% \u0026minus;\u0026thinsp;90/110) and Chunk and Check (74% \u0026minus;\u0026thinsp;82/110). Reported knowledge improved post-training and was sustained for the smaller numbers completing the survey at 4\u0026ndash;6 months post-training. This pattern was also evident for the two sets of service providers in the evaluation (see Table\u0026nbsp;1).\u003c/p\u003e \u003cp\u003eReported confidence to use the verbal health literacy techniques followed a similar pattern (supplementary file 2), as did how often the service providers reported using the verbal health literacy techniques in practice (supplementary file 3).\u003c/p\u003e \u003cp\u003e\u003cb\u003e Table\u0026nbsp;1 Service providers\u0026rsquo; reported knowledge of the verbal health literacy techniques\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eObserved use of the techniques before and after training\u003c/h2\u003e \u003cp\u003e Based on observation of sessions delivered to service users, more frequent use of verbal health literacy techniques was observed post-training than pre-training. The maximum score on the observation checklist was 21. The mean score for the 11 service providers in the evaluation increased from 4.5 at pre-training to 9.4 at post-training (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The improvements were similar for each team: 4.4 to 9.0 (p\u0026thinsp;=\u0026thinsp;0.019) for the Pulmonary Rehabilitation Programme and 4.5 to 9.7 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) for the Weight Management Programme. Some verbal health literacy techniques were not used at all in the pre-training period (Chunk and Check) but were used sometimes in the post-training period.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eService providers\u0026rsquo; views of the initiative\u003c/h2\u003e \u003cp\u003eBased on the focus groups, there were four themes relating to: the training (relevant and worthwhile), the ability to make changes to materials they used (varied ability), implementing the techniques in routine practice (limitations of the group setting), and the post-training implementation support (more needed).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eThe training was relevant and worthwhile\u003c/h2\u003e \u003cp\u003eOverall, the training was received favourably by both teams. The physiotherapists and health improvement advisors described how they found the training enjoyable, relevant, and worthwhile. They liked the varied and interactive content which they found engaging. They felt that it should be offered to all staff and used in undergraduate level education. They suggested minor changes to the training such as more time to practice the techniques and tailoring the techniques for use in group settings and specific scenarios.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;Other health professionals teaching the [courses], they could all do with this training, couldn't they? I'd advise anyone to go on it that hasn't done the training that's in health care, definitely. We could have done with it at university couldn't we?\u0026rsquo;\u003c/em\u003e (Physiotherapist 4)\u003c/p\u003e\u003cp\u003e \u003cem\u003eI'd ask for more group-based examples. I think it felt like the training was set up for one-to-one situations perhaps more than groups a little bit more. Or maybe just if there's time to get to know some of the nuances of the service and the practice of the professionals to be able to get really useful specific examples that are hyper-appropriate, that would be what I would add to it\u003c/em\u003e. (Health Improvement Advisor 10)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eAbility to make changes to materials used with service users\u003c/h2\u003e \u003cp\u003eBoth teams reported they were actively trying to use the techniques in their practice. The physiotherapists described being unfamiliar with the techniques and how they did not use them at all prior to the training. They had changed the PowerPoint slides they used with service users as a result of the training to help them incorporate the verbal health literacy techniques into routine practice. In contrast, the health improvement advisors reported being more familiar with the techniques, and how they used them in small ways before the training e.g. use of online quizzes and \u0026lsquo;take home\u0026rsquo; messages. They therefore felt more confident to use the techniques in their practice but had little control over making changes to their session slides which were developed by the management team.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;I think the Chunk and Check is just something I've never even heard of or done before. So, it's quite a big change to include that in your education sessions. And the slides (that physiotherapist 1 has incorporated into the PowerPoints) have really helped me. So, after we'd done the training, I can honestly admit that I then did another education session and I didn't do it. But the new slides do help. They just remind us.\u0026rsquo; (Physiotherapist 4)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e\u0026lsquo;\u003cem\u003eI feel like we were using a lot of them anyway, I don't know if anybody else thinks\u003c/em\u003e\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003ethat? And I think maybe that's why it made it easier.\u0026rsquo;\u003c/h2\u003e \u003cp\u003e(Health improvement advisor 8)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eImplementing the techniques is challenging in a group setting\u003c/h2\u003e \u003cp\u003eFor both teams the use of the techniques was limited by having to deliver their courses to groups of service users rather than one-to-one. They described how difficult it was to use Teach-back and Chunk and Check in a group setting but physiotherapists described how they used the techniques in one-to-one interactions with service users outside the programme in the evaluation e.g. wider respiratory clinics.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;I feel like using Simple Language can work for anyone in any position whether it's one-to-one or a group. But I struggle sometimes when it's a group setting to use \u0026lsquo;Chunk and Check.\u0026rsquo;\u003c/em\u003e (Health improvement advisor 10)\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;Teach-back\u0026rsquo; is more useful on a one-to-one basis really and when you teach inhaler techniques and things like that it's like \u0026lsquo;right you show me now\u0026rsquo;. And like [colleague in the focus group] said you do think \u0026lsquo;oh my [goodness] what are they doing!\u0026rsquo;. So that is really useful.\u0026rsquo; (\u003c/em\u003ePhysiotherapist 1\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eMore post-training implementation support needed\u003c/h2\u003e \u003cp\u003eThe implementation support from the health literacy officer after the training session appeared to have the potential to improve implementation. Unfortunately, not all the service providers in the evaluation received the support offered due to time constraints. Those that did receive it found it valuable. Suggestions for other kinds of implementation support were made, such as the health literacy officer observing their practice and telling them where to improve use of the techniques, or time to reflect on their practice as a team.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;Or even after we've had the training, like shadow us and then give us feedback in terms of like \u0026lsquo;\u0026rsquo;oh I notice you said this\u0026rsquo;\u0026rsquo;, \u0026lsquo;\u0026rsquo;you could have turned it into an\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eopen question by saying this\u0026rsquo;\u0026rsquo; would have been really specific and pinpointed where\u003c/h2\u003e \u003cp\u003e \u003cem\u003ewe can get stuff in and what exactly we can do differently. Because it does take\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003epractice with these things for it to become normal\u003c/em\u003e.\u0026rsquo; (Health improvement adviser 10)\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;I think you need prompting because everything's so busy and, like we said, it's not just this project we're doing, is it? How many other things are going on at the same time? We feel like we're split in many pieces. So, I think that's helpful, the prompting and the time to chat and reflect.\u0026rsquo;\u003c/em\u003e (Physiotherapist 3)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eChange in service users\u0026rsquo; health literacy levels\u003c/h2\u003e \u003cp\u003eIn the post-test period there was an improvement in subjective health literacy for service users in both programmes between the beginning and end of their contact with service providers (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e). At the end of the course, service users were more likely to feel they had sufficient information to manage their health, and more likely to feel able to manage their health (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for all comparisons). This indicates the utility of the programmes at improving health literacy, rather than the effect of the verbal health literacy initiative. For the Weight Management Programme, some service users attended programmes led by health-literacy-trained staff, and some service users attended programmes led by staff who had not attended the training (a control group), allowing comparison of the initiative with a control. However, numbers of service users in the control group were small (n\u0026thinsp;=\u0026thinsp;6) and the statistical power for this comparison was low. There was no statistically significant difference in change in health literacy levels between initiative and control service users mean difference=-0.1 (-0.78 to 0.90, p\u0026thinsp;=\u0026thinsp;0.88) for sufficient information and mean difference 0.2 (-0.76 to 0.35, p\u0026thinsp;=\u0026thinsp;0.44) for actively managing health (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eChanges in service users\u0026rsquo; health literacy levels (two domains of the Health Literacy Questionnaire)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eService\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e+Sufficient information\u003c/p\u003e \u003cp\u003eBASELINE\u003c/p\u003e\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSufficient information\u003c/p\u003e \u003cp\u003eEND\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChange\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e+Actively managing health BASELINE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eActively managing health END\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eChange\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean (95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePulmonary Rehabilitation Programme\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003cp\u003e(0.6\u0026ndash;1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003cp\u003e(0.3 to 0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWeight Management Programme (all)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003cp\u003e(0.5\u0026ndash;1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003cp\u003e(0.3 to 0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWeight Management Programme (attended sessions with health literacy trained staff)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e2.6\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e3.4\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.8\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e(0.3\u0026ndash;1.3)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003e2.6\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e3.3\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003e0.6\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e(0.3 to 0.9)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003e14\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWeight Management Programme (attended sessions with control staff)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e2.4\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e3.3\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.9\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e(0.2\u0026ndash;1.6)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003e2.5\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e2.9\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003e0.4\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e(-0.2 to 1.0)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003e6\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e+ higher scores indicate higher levels of subjective health literacy\u003c/p\u003e \u003cp\u003e*There was loss to follow-up. 40/49 people completed the Health Literacy Questionnaire at the end of the course for the Pulmonary Rehabilitation Programme, and 20/34 for the Weight Management Programme\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eChanges in health outcomes\u003c/h2\u003e \u003cp\u003ePrimary health outcomes for individual service users who gave consent for their data to be used are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Secondary outcomes are in supplementary files 4\u0026ndash;7. There were improvements in the scores for the Pulmonary Rehabilitation Programme and the Weight Management Programme, showing the impact of the programmes rather than the verbal health literacy training. There was no statistically significant difference between the primary outcome for service users attending the health-literacy-trained group compared with the control group for the Weight Management Programme \u0026minus;\u0026thinsp;0.2 (-2.3 to 1.9) p\u0026thinsp;=\u0026thinsp;0.84.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eChange in primary outcomes for individual service users giving consent\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eService\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBASELINE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEND\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCHANGE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean change (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulmonary Rehabilitation Programme (CRDQ score)\u003c/p\u003e \u003cp\u003eDysnoea\u003c/p\u003e \u003cp\u003eFatigue\u003c/p\u003e \u003cp\u003eEmotional function\u003c/p\u003e \u003cp\u003eMastery\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.79\u003c/p\u003e \u003cp\u003e3.65\u003c/p\u003e \u003cp\u003e4.37\u003c/p\u003e \u003cp\u003e4.48\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.37\u003c/p\u003e \u003cp\u003e4.15\u003c/p\u003e \u003cp\u003e4.88\u003c/p\u003e \u003cp\u003e5.10\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.58 (0.11 to 1.10)\u003c/p\u003e \u003cp\u003e0.50 (0.17 to 0.83)\u003c/p\u003e \u003cp\u003e0.51 (0.20 to 0.81)\u003c/p\u003e \u003cp\u003e0.63 (0.27 to 0.99)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e41\u003c/p\u003e \u003cp\u003e41\u003c/p\u003e \u003cp\u003e41\u003c/p\u003e \u003cp\u003e41\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.016\u003c/p\u003e \u003cp\u003e0.004\u003c/p\u003e \u003cp\u003e0.002\u003c/p\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWeight Management Programme (Weight in kg)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e105.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e102.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-2.6 (-3.5 to -1.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWeight Management Programme (attended sessions with health literacy trained staff)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e108.8\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e106.2\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e-2.6 (-3.6 to -1.5)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003e20\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e\u0026lt;\u0026thinsp;0.001\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWeight Management Programme (attended sessions with control staff)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e95.6\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e92.9\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e-2.8 (-5.1 to -0.5)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003e7\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e0.024\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAggregated routine data allowed comparison of outcomes for service users attending programmes in time periods before and after the service providers had the training. For the Pulmonary Rehabilitation Programme, the completion rate of the course (completed 8 or more sessions) pre-training was 57% (97/169) and post-training was 62% (69/111). There was no indication that the verbal health literacy training had improved completion rates (chi-square, p\u0026thinsp;=\u0026thinsp;0.43). There was no indication that the verbal health literacy training had improved service user outcomes (see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e4\u003c/span\u003e for primary outcome and additional file 6, Table\u0026nbsp;10 for secondary outcomes). For the Weight Management Programme the completion rate for the courses run by health-literacy-trained advisors (completed 9 weeks or more) pre-training was 50% (219/438) and post-training was 56% (215/383) compared with controls pre-training 62% (76/123) and post-training 67% (79/118). There was no indication that the verbal health literacy training had improved service user outcomes. Standard deviations differed largely between time periods and groups, indicating problems with this data (see supplementary files 4\u0026ndash;7) for primary and secondary change in outcomes and secondary outcomes for those completing the programme only for both services).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eChange in primary outcomes before and after training (based on aggregated routine data for service users completing the programmes)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eService\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary outcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean change (SD)\u003c/p\u003e \u003cp\u003eBEFORE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean change (SD)\u003c/p\u003e \u003cp\u003eAFTER\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDiff\u0026eacute;rence in mean changes (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePulmonary Rehabilitation Programme\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCRDQ score\u003c/p\u003e \u003cp\u003eDysnoea\u003c/p\u003e \u003cp\u003eFatigue\u003c/p\u003e \u003cp\u003eEmotional function\u003c/p\u003e \u003cp\u003eMastery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.93 (1.47)\u003c/p\u003e \u003cp\u003e0.74 (1.11)\u003c/p\u003e \u003cp\u003e0.46 (0.98)\u003c/p\u003e \u003cp\u003e0.64 (1.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.71 (1.23)\u003c/p\u003e \u003cp\u003e0.56 (1.15)\u003c/p\u003e \u003cp\u003e0.44 (1.11)\u003c/p\u003e \u003cp\u003e0.54 (1.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.22 (-0.71 to 0.27)\u003c/p\u003e \u003cp\u003e-0.18 (-0.59 to 0.23)\u003c/p\u003e \u003cp\u003e-0.02 (-0.39 to 0.36)\u003c/p\u003e \u003cp\u003e-0.10 (-0.55 to 0.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003cp\u003e0.38\u003c/p\u003e \u003cp\u003e0.92\u003c/p\u003e \u003cp\u003e0.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eN\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWeight Management Programme (attended sessions with health literacy trained staff)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWeight in kg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e-3.16 (0.54)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e-3.30 (0.51)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003e-0.14 (-0.23 to -0.04)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e0.006\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e219\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e215\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWeight Management Programme (attended sessions with control staff)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWeight in kg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e-1.58 (3.06)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e-3.38 (0.03)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003e-1.80 (-2.4 to -1.1)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e0.0001\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eN\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e76\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e79\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec30\" class=\"Section2\"\u003e \u003ch2\u003eSummary of findings\u003c/h2\u003e \u003cp\u003e Service providers found the verbal health literacy training useful because they learned new communication techniques. Changes in communication practice were observed in both the Pulmonary Rehabilitation and Weight Management Programmes, with the physiotherapists and health improvement advisors making increased use of Chunk and Check and Open Questions when communicating with service users. Both programmes worked with groups of service users rather than on a one-to-one basis. Service providers reported that Teach-back was difficult to use in group settings but was useful in one-to-one sessions in their wider practice. They also found the implementation support from the health literacy officer helpful but wanted more opportunities to meet as teams to reflect on how to improve their use of the new techniques. The health literacy levels of service users improved by the end of their course. However, this improvement was due to the course rather than the verbal health literacy initiative. There was no evidence that the verbal health literacy initiative improved health outcomes for service users.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eContext of other research\u003c/h2\u003e \u003cp\u003eThe service providers in this study felt they learnt new communication techniques and changes in practice were observed. Despite this, both teams found Teach-back more difficult to implement than Chunk and Check in their group-based courses. Cork and White\u0026rsquo;s (2022) study exploring community pharmacists' views of a health literacy training initiative, found the opposite. Pharmacists reported that they found Chunk and Check more difficult to implement than Teach-back (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Perhaps this was because community pharmacists interact with service users in a more instructive way and on a one to one basis, for example teaching medication use, rather than the information-based group sessions offered in our evaluation.\u003c/p\u003e \u003cp\u003eIncorporating health literacy techniques into information-based group sessions has been found to be successful in improving service users\u0026rsquo; knowledge (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). However, in Gharachourlo et al\u0026rsquo;s (2018) study they did not describe their health literacy intervention approach and neither study explored service providers\u0026rsquo; ability or perception of using health literacy strategies when delivering information sessions to service users (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). This suggests that further research exploring the use of verbal health literacy techniques in a group setting is warranted.\u003c/p\u003e \u003cp\u003eDifficulty implementing Teach-back into practice has been highlighted in two more recent American studies (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). They found that in order to overcome issues such as communication habits, time, role constraints and uncertainty on how to use health literacy techniques in practice, changes to the way Teach-back is taught, conceptualised and implemented is needed (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn our evaluation, the verbal health literacy initiative for service providers was delivered by a health literacy officer working within the same organisation. The implementation support they offered after the initiative was delivered was limited but valued by the teams. Several studies have explored the use of external health literacy facilitators as well as the use of health literacy champions (clinicians/ team members) trained in health literacy techniques, to support and sustain implementation (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). It has been proposed that champions from multiple levels within an organisation working in a coordinated way may be more effective than solo champions (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). The evidence suggests that a more bottom-up approach where a \u0026lsquo;community of practice\u0026rsquo; of health literacy champions is fostered and existing staff are trained to deliver and sustain initiatives, rather than a top-down hierarchical approach, may give staff the autonomy and confidence to make and sustain changes at a practice level (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe service providers in our evaluation suggested alternative implementation support strategies. These included prompt sheets and having regular protected time to review and reflect on how they were using the verbal health literacy techniques in their practice. In the wider literature, implementation support methods include the use of flyers (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e), \u0026lsquo;lunch and learn\u0026rsquo; sessions to discuss what is and is not working (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e), five minute booster sessions during breaks (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e), weekly emails (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), staff induction (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) and standardised document templates to record the use of techniques such as Teach-back in clinical notes (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). A range of support methods that can be easily incorporated into busy clinical days could be considered, including the development of health literacy champions within service user facing teams to support and embed implementation, in any future delivery of this verbal health literacy initiative.\u003c/p\u003e \u003cp\u003eDespite increasing research into verbal health literacy initiatives few studies evaluate service providers health literacy knowledge and ability to apply that knowledge in practice. Research that evaluates service user health literacy and health and wellbeing outcomes, as in this study, is lacking.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThis was a mixed methods evaluation, using a range of qualitative and quantitative methods to address the acceptability and effectiveness of a new initiative in a real-world setting. A strength was the measurement of health outcomes using a controlled before and after design for one of the programmes implementing the new initiative. There were three limitations. First, the controlled before and after design was not possible for one of the programmes, which instead relied on a before and after design which is lower in the hierarchy of evidence of effectiveness. Second, the consent process to include data from individual service users was challenging. Physiotherapists worked hard to gain consent and did well in recruiting service users. The electronic approach to recruitment for the Weight Management Programme yielded a very low consent rate. Small numbers limited the statistical power to detect changes in individual service user data. The included individual data was also likely not to be representative of service users in that more educated or affluent service users may have completed the consent process. Third, there was drop out of service users over time, with some service users not completing their end of course outcome measures.\u003c/p\u003e \u003cp\u003eThe team consisted of people invested in the initiative (LWT, JoH, JaH) and independent researchers (AOC, CG). This could be viewed as a strength in that the team consisted of people with a range of relevant expertise. It could be viewed as a limitation if the service providers felt they had to be positive about the initiative, or interpretation of results was biased towards the positive. Only CG, an independent researcher, collected data so this reduced the potential for bias. During team discussions about interpretation of the findings, all members of the team took an open and curious approach, genuinely interested in whether this initiative had the intended impact, and open to recommendations for improvements to the initiative.\u003c/p\u003e \u003cdiv id=\"Sec33\" class=\"Section3\"\u003e \u003ch2\u003eImplications\u003c/h2\u003e \u003cp\u003eThis verbal health literacy initiative has potential to improve service user outcomes. Service providers valued the training and could see the potential of the learnt techniques to improve communication with patients. The initiative would have to have a more intense approach to supporting implementation of the verbal health literacy techniques, as well as a managerial component if service providers have to use materials developed by their managers and do not have control over making changes to those materials. Any similar initiative might fare better in the context of one-to-one consultations, although further adaptation of the training to group delivery might also be useful. Future mixed methods evaluations should include controlled before and after measurement of patient reported outcomes measures with larger sample sizes to better understand the impact these kinds of verbal health literacy initiatives can have on health outcomes. If this type of comparison relies on service user consent, it will likely lead to small, biased samples; the use of aggregated routine data could offer a better option.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis verbal health literacy initiative evaluated here has potential. It was appreciated by service providers and enabled clear conversations with service users. The communication techniques within the initiative may be easier to apply in one-to-one consultations with service users than in the group settings evaluated here. More focus on supporting implementation of techniques in practice, and opportunity for team reflection, might improve the potential effectiveness of the initiative. Future research should focus on a more intense initiative and use controlled before and after designs on larger samples to measure the effect on service users\u0026rsquo; health literacy levels and health and wellbeing outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e The research was conducted in accordance with the Declaration of Helsinki. Ethics approval was obtained from HRA and Health Care Research Wales. REC reference 24/LO/0324. All participants provided written consent to participate in the study.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eOne author LC was the health literacy officer who produced the training. One author JoH established the health literacy officer role.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eProfessor Alicia O\u0026rsquo;Cathain is a National Institute for Health Research (NIHR) Senior Investigator. Funds related to this award were used to fund a researcher to undertake this research. The views expressed in this article are those of the author and not necessarily those of the NIHR, or the Department of Health and Social Care.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eLC and JoH and JH developed the intervention. CG and AOC designed the research and it\u0026rsquo;s methodology. CG was the primary researcher and collected all the data. CG and AOC analysed the data. CG wrote the original draft manuscript. AOC, LC ,JoH and JH reviewed and edited the draft manuscript. CG made final edits. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors wish to thank Dr Vera Fibisan for administrative support, the Clear Conversations PPI group for their invaluable contributions and the two services that took part.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Newsroom/Factsheets/Detail/Health Literacy. Health literacy. 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London: Sage.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHosseinifar S, Afkhamzadeh A, Moayeri H, Ghaderi S, Mahmoodi H. Teach back educational strategy on knowledge about breast cancer among low health literate women. BMC Med Educ. 2024;24(1):1420.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGharachourlo M, Mahmoodi Z, Akbari Kamrani M, Tehranizadeh M, Kabir K. The effect of a health literacy approach to counselling on the lifestyle of women with gestational diabetes: A clinical trial. F1000Research. 2018;7:282.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnderson K, Rojas-Alvarado E, Aragon L, Bradshaw J, Fontana E, Hernandez F, et al. Innovating a Teach-Back Model for Community Health Workers Led Health Literacy Practice to Improve COVID-19 Health Equity. Health Lit Res Pract. 2025;9(2):e56\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAyre J, Zhang M, Mouwad D, Zachariah D, McCaffery KJ, Muscat DM. Systematic review of health literacy champions: who, what and how? Health Promot Int. 2023;38(4):daad074.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGibson C, Smith D, Morrison AK. Improving Health Literacy Knowledge, Behaviors, and Confidence with Interactive Training. Health Lit Res Pract. 2022;6(2):e113\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSupplementary. file 1- Table S1. How useful was the training.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSupplementary file 2- Table S2. Service provider confidence to use the Verbal Health Literacy techniques.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSupplementary file 3- Table S3. Service provider reported frequency of use of the verbal health literacy techniques in practice.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSupplementary file 4 -Table S4. Change in primary and secondary outcomes for individual service users in Pulmonary Rehabilitation Programme.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSupplementary file 5- Table S5. Change in secondary outcome of WELL-BEING for individual service users in Weight Management Programme.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSupplementary file 6- Table S6. Pulmonary Rehabilitation Programme secondary health outcomes (those completing the programme only).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSupplementary file 7- Table S7. Weight Management Programme Wellbeing secondary outcome (those completing the programme only).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Verbal health Literacy, implementation support, health and wellbeing outcomes","lastPublishedDoi":"10.21203/rs.3.rs-8252432/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8252432/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eUnderstanding health information can be difficult. Consequently, people may struggle to know how to manage their health. This may negatively impact on healthy practices leading to poorer health outcomes. This study aimed to evaluate a verbal health literacy training initiative, incorporating Teach-back, Chunk and Check, Open Questions and Simple Language alongside implementation support from a health literacy officer, to enable clear conversations between health service providers and users.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA mixed methods evaluation was conducted across two health programmes serving a geographical region of a million people in the United Kingdom: A Pulmonary Rehabilitation Programme delivered by five physiotherapists in a hospital setting, and a Weight Management Programme delivered by 12 health improvement advisors in a regional government authority. The five evaluation components were: 1. A survey of 110 service providers\u0026rsquo; perceptions of the training. 2. Observations of service delivery by 11 service providers before and after training. 3. Two focus groups with 11 service providers six months post-training. 4. Change in 73 service users\u0026rsquo; health literacy levels over time. 5. Change in service users\u0026rsquo; health and wellbeing outcomes.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eService providers found the initiative useful. Changes in communication practice, such as increased use of Chunk and Check and Open Questions, were observed post-training. Both programmes were delivered in group settings where Teach-back was reported to be challenging to apply but beneficial in one-to-one interactions in wider practice. Implementation support from the health literacy officer was perceived as helpful but difficult to deliver to busy teams. The health literacy levels of service users improved by the end of their programme but there was no evidence that the initiative improved health and wellbeing outcomes.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003e The verbal health literacy initiative was well received and enhanced service providers\u0026rsquo; communication skills. The techniques within the initiative may be easier to apply in one-to-one consultations with service users than in group-delivered care. Strengthened implementation support may improve adoption and effectiveness in practice. Further evaluation of a strengthened initiative should focus on controlled before and after designs on larger samples to measure the effect on service users\u0026rsquo; health literacy levels and health and wellbeing outcomes.\u003c/p\u003e","manuscriptTitle":"Clear Conversations: A mixed methods evaluation of a verbal health literacy initiative for health service providers","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-17 19:19:05","doi":"10.21203/rs.3.rs-8252432/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-19T08:36:27+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-18T11:16:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-30T18:46:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"304304007676600217263187997571878969195","date":"2025-12-23T00:09:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"261830959632774748346808681680838935359","date":"2025-12-22T14:29:39+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-12T13:29:05+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-10T08:39:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-09T13:05:10+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-09T13:02:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-12-01T16:02:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7591ff98-48dd-43d7-9d44-57b583bfe042","owner":[],"postedDate":"December 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-30T17:53:40+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-17 19:19:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8252432","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8252432","identity":"rs-8252432","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}