Journal of General Internal Medicine

, Volume 33, Issue 4, pp 510–523 | Cite as

The Effectiveness of Self-Management Interventions for Individuals with Low Health Literacy and/or Low Income: A Descriptive Systematic Review

  • Jamie Schaffler
  • Katerina Leung
  • Sarah Tremblay
  • Laura Merdsoy
  • Eric Belzile
  • Angella Lambrou
  • Sylvie D. Lambert
Review Paper



With the burden of chronic illness increasing globally, self-management is a crucial strategy in reducing healthcare costs and increasing patient quality of life. Low income and low health literacy are both associated with poorer health outcomes and higher rates of chronic disease. Thus, self-management represents an important healthcare strategy for these populations. The purpose of this study is to review self-management interventions in populations with low income or low health literacy and synthesize the efficacy of these interventions.


A systematic review of trials evaluating the efficacy of self-management interventions in populations with low income or low health literacy diagnosed with a chronic illness was conducted. Electronic databases were primarily searched to identify eligible studies. Data were extracted and efficacy summarized by self-management skills, outcomes, and content tailoring.


23 studies were reviewed, with ten reporting an overall positive effect on at least one primary outcome. Effective interventions most often included problem-solving as well as taking action and/or resource utilization. A wide range of health-related outcomes were considered, were efficacious empowerment and disease-specific quality of life were found to be significant. The efficacy of interventions did not seem to vary by duration, format, or mode of delivery or whether these included individuals with low health literacy and/or low income. Tailoring did not seem to impact on efficacy.


Findings suggest that self-management interventions in populations with low income or low health literacy are most effective when three to four self-management skills are utilized, particularly when problem-solving is targeted. Healthcare providers and researchers can use these findings to develop education strategies and tools for populations with low income or low health literacy to improve chronic illness self-management.


self-management chronic disease disease management vulnerable populations health literacy 



We wish to acknowledge Drs. Lisa Merry and Argerie Tsimicalis of McGill University for their guidance and support in the preparation of this systematic review. Preliminary results were presented in the form of an e-poster in a Graduate level class on research methods in Nursing at McGill University, and an abstract was presented (poster presentation) at the Health Literacy Annual Research Conference (HARC) in October 2016 (title: The effectiveness of tailoring self-management interventions for individuals with low health literacy or low income: A systematic review). There has been no significant financial support for this work that could have influenced its outcome. Sylvie Lambert was supported by a Canada Research Chair (Tier 2).

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Supplementary material

11606_2017_4265_MOESM1_ESM.docx (19 kb)
Electronic Supplementary Material S1 (DOCX 19 kb)
11606_2017_4265_MOESM2_ESM.docx (13 kb)
Electronic Supplementary Material S2 (DOCX 13 kb)
11606_2017_4265_MOESM3_ESM.docx (23 kb)
Electronic Supplementary Material S3 (DOCX 22 kb)


  1. 1.
    Wu S-Y, Green A. Projection of chronic illness prevalence and cost inflation. Santa Monica: RAND Health 2000, 18.Google Scholar
  2. 2.
    Walker D, Adebajo A, Heslop P, et al. Patient education in rheumatoid arthritis: the effectiveness of the ARC booklet and the mind map. Rheumatology (Oxford). 2007, 46:1593–1596.CrossRefGoogle Scholar
  3. 3.
    Vogeli C, Shields AE, Lee TA, et al. Multiple chronic conditions: prevalence, health consequences, and implications for quality, care management, and costs. J Gen Intern Med 2007, 22:391-395.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med 2011, 155:97-107.CrossRefPubMedGoogle Scholar
  5. 5.
    Davy C, Bleasel J, Liu H, et al. Effectiveness of chronic care models: opportunities for improving healthcare practice and health outcomes: a systematic review. BMC Health Serv Res 2015, 15:194.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Coleman K, Austin BT, Brach C, Wagner EH. Evidence on the Chronic Care Model in the new millennium. Health affairs (Milwood). 2009, 28:75–85.CrossRefGoogle Scholar
  7. 7.
    Davy C, Bleasel J, Liu H, et al. Effectiveness of chronic care models: opportunities for improving healthcare practice and health outcomes: a systematic review. BMC Health Serv Res 2015, 15:194.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA 2002, 288:1775-1779.CrossRefPubMedGoogle Scholar
  9. 9.
    Adams K, Greiner AC, Corrigan JM. 1st Annual Crossing the Quality Chasm Summit: A focus on communities. Washington DC: National Academies Press, 2004.Google Scholar
  10. 10.
    Lorig KR, Holman HR. Self-management education: History, definition, outcomes, and mechanisms. Ann Behav Med 2003, 26:1-7.CrossRefPubMedGoogle Scholar
  11. 11.
    Beatty L, Lambert S. A systematic review of internet-based self-help therapeutic interventions to improve distress and disease-control among adults with chronic health conditions. Clin Psychol Rev 2013, 33:609-622.CrossRefPubMedGoogle Scholar
  12. 12.
    Boger EJ, Demain S, Latter S. Self-management a systematic review of outcome measures adopted in self-management interventions for stroke. Disabil Rehabil 2013, 35:1415–1428.CrossRefPubMedGoogle Scholar
  13. 13.
    Dorn SD. Systematic review: self-management support interventions for irritable bowel syndrome. Aliment Pharmacol Ther 2010, 32:513-521.CrossRefPubMedGoogle Scholar
  14. 14.
    Du S, Yuan C, Xiao X, et al. Self-management programs for chronic musculoskeletal pain conditions: a systematic review and meta-analysis. Patient Educ Couns 2011, 85:e299-e310.CrossRefPubMedGoogle Scholar
  15. 15.
    Plow MA, Finlayson M, Rezac M. A scoping review of self-management interventions for adults with multiple sclerosis. PM&R 2011, 3:251–262.CrossRefGoogle Scholar
  16. 16.
    Barlow J, Wright C, Sheasby J, Turner A, Hainsworth J. Self-management approaches for people with chronic conditions: a review. Patient Educ Couns 2002, 48:177-187.CrossRefPubMedGoogle Scholar
  17. 17.
    Eichner J, Blumenthal D. Medicare in the 21st Century: Building a Better Chronic Care System. National Academy of Social Insurance; 2003.
  18. 18.
    Warsi A, Wang PS, LaValley MP, Avorn J, Solomon DH. Self-management education programs in chronic disease: a systematic review and methodological critique of the literature. Arch Intern Med 2004, 164:9-23.CrossRefGoogle Scholar
  19. 19.
    Meraviglia M, Stuifbergen A, Parsons D, Morgan S. Health promotion for cancer survivors: adaptation and implementation of an intervention. Holist Nurs Pract 2013, 27:140-147.CrossRefPubMedGoogle Scholar
  20. 20.
    Walker D, Adebajo A, Heslop P, et al. Patient education in rheumatoid arthritis: the effectiveness of the ARC booklet and the mind map. Rheumatology 2007, 46:1593-1596.CrossRefPubMedGoogle Scholar
  21. 21.
    Canadian Public Health Association. Ottawa Charter for Health Promotion. Can J Public Health. 1986; 77:425–430.Google Scholar
  22. 22.
    DeNavas-Walt C, Proctor BD, Smith JC. US Census Bureau, Current population reports, P60–245, income, poverty, and health insurance coverage in the United States: 2012, US Government Printing Office, Washington, DC, 2013.Google Scholar
  23. 23.
    Betancourt MT, Roberts KC, Bennett TL, et al. Monitoring chronic diseases in Canada: the Chronic Disease Indicator Framework. Chronic Dis Inj Can 2014, 34:1-30.PubMedGoogle Scholar
  24. 24.
    Dubay LC, Lebrun LA. Health, behavior, and health care disparities: disentangling the effects of income and race in the United States. Int J Health Serv 2012, 42:607-625.CrossRefPubMedGoogle Scholar
  25. 25.
    World Health Organization. Noncommunicable diseases. Retrieved October 2, 2015 from
  26. 26.
    Mikkonen J, Raphael D. Social determinants of health: The Canadian facts. Toronto: York University School of Health Policy and Management. 2010. Available at
  27. 27.
    Kutner M, Greenburg E, Jin Y, Paulsen C. The Health Literacy of America’s Adults: Results from the 2003 National Assessment of Adult Literacy (NCES 2006-483). U.S. Department ofEducation. Washington, DC: National Center for Education Statistics. 2006.Google Scholar
  28. 28.
    Rootman I, Gordon-El-Bihbety D. A vision for a health literate Canada report of the Expert Panel on Health Literacy. Ottawa: Canadian Public Health Association, 2008.Google Scholar
  29. 29.
    Moher D, Liberati A, Tetzlaff J, Altman DG. Group TP Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement Ann Intern Med 2009, 151:264-269.CrossRefPubMedGoogle Scholar
  30. 30.
    Higgins JP, Green S. Cochrane handbook for systematic reviews of interventions version 5.0.0 [updated February 2008]. The Cochrane Collaboration. 2008. Available: Accessed 15 February 2016.
  31. 31.
    Chambless DL, Hollon SD. Defining empirically supported therapies. J Consult Clin Psychol 1998, 66:7–18.CrossRefPubMedGoogle Scholar
  32. 32.
    Blundell M. Understanding and synthesizing my numerical data. In A. Boland, M. G. Cherry and R. Dickson (eds), Doing a systematic review—A student’s guide. Los Angeles, Sage, 2014.Google Scholar
  33. 33.
    Bos-Touwen I, Jonkman N, Westland H, et al. Tailoring of self-management interventions in patients with heart failure. Current Heart Failure Reports, 2015, 12(3):223-235.
  34. 34.
    Cohen JH. Statistical power analysis for the behavioral sciences (2nd Ed.). Hillsdale: Lawrence Earlbaum Associates, 1988.Google Scholar
  35. 35.
    Arora S, Peters AL, Burner E, Lam CN, Menchine M. Trial to examine text message-based mhealth in emergency department patients with diabetes (TExT-MED): A randomized controlled trial. Ann Emerg Med. 2014, 63:745–754.e746.CrossRefPubMedGoogle Scholar
  36. 36.
    Fischer HH, Eisert SL, Durfee MJ, et al. The impact of tailored diabetes registry report cards on measures of disease control: a nested randomized trial. BMC Med Inform Decis Mak 2011, 11:12.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Fischer HH, Moore SL, Ginosar D, et al. Care by cell phone: text messaging for chronic disease management. Am J Manag Care 2012, 18:e42-47.PubMedGoogle Scholar
  38. 38.
    Frosch DL, Uy V, Ochoa S, Mangione CM. Evaluation of a behavior support intervention for patients with poorly controlled diabetes. Arch Intern Med 2011, 171:2011-2017.CrossRefPubMedGoogle Scholar
  39. 39.
    Gregg JA, Callaghan GM, Hayes SC, Glenn-Lawson JL. Improving diabetes self-management through acceptance, mindfulness, and values: a randomized controlled trial. J Consult Clin Psychol 2007, 75:336-343.CrossRefPubMedGoogle Scholar
  40. 40.
    Piette JD, Weinberger M, McPhee SJ. The effect of automated calls with telephone nurse follow-up on patient-centered outcomes of diabetes care: a randomized, controlled trial. Med Care 2000, 38:218-230.CrossRefPubMedGoogle Scholar
  41. 41.
    Sequeira PA, Montoya L, Ruelas V, et al. Continuous glucose monitoring pilot in low-income type 1 diabetes patients. Diabetes Technol Ther 2013, 15:855-858.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Thom DH, Ghorob A, Hessler D, et al. Impact of peer health coaching on glycemic control in low-income patients with diabetes: a randomized controlled trial. Ann Fam Med 2013, 11:137-144.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Bove AA, Homko C, Santamore W, et al. Managing hypertension in urban underserved subjects using telemedicine: A clinical trial. J Am Coll Cardiol 2013, 1:E1401.CrossRefGoogle Scholar
  44. 44.
    Martin MY, Kim Y, Kratt P, et al. Medication adherence among rural, low-income hypertensive adults: A randomized trial of a multimedia community-based intervention. Am J Health Promot 2011, 25:372-378.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Bennett GG, Warner ET, Glasgow RE, et al. Obesity treatment for socioeconomically disadvantaged patients in primary care practice. Arch Intern Med 2012, 172:565-574.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Krieger J, Song L, Philby M. Community health worker home visits for adults with uncontrolled asthma—the HomeBase trial randomized clinical trial. JAMA Intern Med 2015, 175:109–117.CrossRefPubMedGoogle Scholar
  47. 47.
    Riley KM, Glasgow RE, Eakin EG. Resources for health: A social-ecological intervention for supporting self-management of chronic conditions. J Health Psychol 2001, 6:693-705.CrossRefPubMedGoogle Scholar
  48. 48.
    Rudd RE, Blanch DC, Gall V, et al. A randomized controlled trial of an intervention to reduce low literacy barriers in inflammatory arthritis management. Patient Educ Couns 2009, 75:334-339.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Dewalt DA, Schillinger D, Ruo B, et al. Multisite randomized trial of a single-session versus multisession literacy-sensitive self-care intervention for patients with heart failure. Circulation 2012, 125:2854-2862.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    DeWalt DA, Malone RM, Bryant ME, et al. A heart failure self-management program for patients of all literacy levels: a randomized, controlled trial [ISRCTN11535170]. BMC Health Serv Res 2006, 6:30.CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Kripalani S, Schmotzer B, Jacobson TA. Improving Medication Adherence through Graphically Enhanced Interventions in Coronary Heart Disease (IMAGE-CHD): a randomized controlled trial. J Gen Intern Med 2012, 27:1609-1617.CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Kiser K, Jonas D, Warner Z, et al. A randomized controlled trial of a literacy-sensitive self-management intervention for chronic obstructive pulmonary disease patients. J Gen Intern Med 2012, 27:190-195.CrossRefPubMedGoogle Scholar
  53. 53.
    Wilson FL, Mood D, Nordstrom CK, Risk J. The effect of low literacy on the self-care behaviors of men receiving radiation therapy. Nurs Sci Q. 2010, 23:326–333.CrossRefPubMedGoogle Scholar
  54. 54.
    Cavanaugh K, Wallston KA, Gebretsadik T, et al. Addressing literacy and numeracy to improve diabetes care: two randomized controlled trials. Diabetes Care 2009, 32:2149-2155.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Cordasco KM, Asch SM, Bell DS, et al. A low-literacy medication education tool for safety-net hospital patients. Am J Prev Med 2009, 37:S209-S216.CrossRefPubMedGoogle Scholar
  56. 56.
    Bosworth HB, Olsen MK, Grubber JM, et al. Two self-management interventions to improve hypertension control: a randomized trial. Ann Intern Med. 2009, 151:687–695.CrossRefPubMedPubMedCentralGoogle Scholar
  57. 57.
    Gazmararian J, Jacobson KL, Pan Y, Schmotzer B, Kripalani S. Effect of a pharmacy-based health literacy intervention and patient characteristics on medication refill adherence in an urban health system. Ann Pharmacother 2010, 44:80-87.CrossRefPubMedGoogle Scholar
  58. 58.
    US Department of Health and Human Services. The Poverty Guidelines Updated Periodically in the Federal Register. Washington, DC: US Department of Health and Human Services. 2015, 42.Google Scholar
  59. 59.
    Darnell JS. Free clinics in the United States: a nationwide survey. Arch Intern Med 2010, 170:946-953.CrossRefPubMedGoogle Scholar
  60. 60.
    Battersby M, Von Korff M, Schaefer J, et al. Twelve evidence-based principles for implementing self-management support in primary care. Jt Comm J Qual Patient Saf 2010, 36:561-570.CrossRefPubMedGoogle Scholar
  61. 61.
    Nolte S, Osborne RH. A systematic review of outcomes of chronic disease self-management interventions. Qual Life Res 2013, 22:1805-1816.CrossRefPubMedGoogle Scholar
  62. 62.
    Savery JR. Overview of problem-based learning: Definitions and distinctions. Interdisc J Probl-Based Learn 2006, 1:9–20.Google Scholar
  63. 63.
    King DK, Glasgow RE, Toobert DJ, et al. Self-efficacy, problem solving, and social-environmental support are associated with diabetes self-management behaviors. Diabetes Care 2010, 33:751-753.CrossRefPubMedPubMedCentralGoogle Scholar
  64. 64.
    Primožič S, Avbelj M, Dernovšek MZ, Oblak MR. Specific cognitive abilities are associated with diabetes self-management behavior among patients with type 2 diabetes. Diabetes Res Clin Pract 2012, 95:48-54.CrossRefPubMedGoogle Scholar
  65. 65.
    Auerbach JA, Krimgold BK. Income, socioeconomic status, and health: exploring the relationships. Washington DC: National Policy Association, 2001.Google Scholar
  66. 66.
    Glasgow RE, Fisher L, Skaff M, Mullan J, Toobert DJ. Problem solving and diabetes self-management investigation in a large, multiracial sample. Diabetes Care 2007, 30:33-37.CrossRefPubMedGoogle Scholar
  67. 67.
    Hill-Briggs F, Yeh H-C, Gary TL, et al. Diabetes problem-solving scale development in an adult, African American sample Diab Educ 2007, 33:291-299.CrossRefGoogle Scholar
  68. 68.
    Osborne R, Elsworth G, Whitfield K. The Health Education Impact Questionnaire (heiQ): an outcomes and evaluation measure for patient education and self-management interventions for people with chronic conditions. Patient Educ Couns 2007, 66:192-201.CrossRefPubMedGoogle Scholar
  69. 69.
    Campbell MK, Quintiliani LM. Tailored interventions in public health. Where does tailoring fit in interventions to reduce health disparities? Am Behav Sci 2006, 49: 1–19.Google Scholar
  70. 70.
    Kreuter M, Strecher V, Glassman B. One size does not fit all: The case for tailoring print materials. Ann Behav Med 1999, 21:276-283.CrossRefPubMedGoogle Scholar
  71. 71.
    Short CE, James EL, Plotnikoff RC, Girgis A. Efficacy of tailored-print interventions to promote physical activity: a systematic review of randomised trials. Int J Behav Nutr Phys Act 2011, 8:113.CrossRefPubMedPubMedCentralGoogle Scholar
  72. 72.
    Noar SM, Benac CN, Harris MS. Does tailoring matter? Meta-analytic review of tailored print health behavior change interventions. Psychol Bull 2007, 133:673-693.CrossRefPubMedGoogle Scholar
  73. 73.
    Lin ZC, Effken JA. Effects of a tailored web-based educational intervention on women’s perceptions of and intentions to obtain mammography. J Clin Nurs 2010, 19:1261-1269.CrossRefPubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2018

Authors and Affiliations

  • Jamie Schaffler
    • 1
  • Katerina Leung
    • 1
  • Sarah Tremblay
    • 1
  • Laura Merdsoy
    • 1
  • Eric Belzile
    • 2
  • Angella Lambrou
    • 3
  • Sylvie D. Lambert
    • 1
    • 2
  1. 1.Ingram School of Nursing, McGill UniversityQuebecCanada
  2. 2.St. Mary’s Research CentreQuebecCanada
  3. 3.Schulich Library of Science and Engineering, McGill UniversityQuebecCanada

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