Community based health literacy interventions in India: A scoping review

Health literacy (HL) is the degree to which individuals can obtain, process, and understand basic health information and services needed to make appropriate health decisions. Low HL is associated with poorer preventive behaviors, weaker adherence, poor self-care, higher readmissions, and unnecessary emergency care. In India, an estimated nine out of ten individuals lack HL, compounded by high general illiteracy, poverty, frequent hospital visits due to unhealthy lifestyles, and low health insurance coverage, especially in rural areas. Community-level literacy and India’s linguistic diversity further affect HL, underscoring the need for clear, culturally and linguistically appropriate communication. This scoping review asks: What community-based interventions improve HL in India? The objectives were to map such interventions and document reported health outcomes, addressing a gap in systematic syntheses focused on the Indian context.

Prior work indicates that community-based HL interventions using traditional, multimedia, face-to-face, and technology-based approaches can improve patient–provider communication and health outcomes in low- and middle-income countries. Creative and innovative approaches have shown benefits, yet evidence specific to India remains limited. Existing literature has largely focused on educational interventions among adults and adolescents, with no prior systematic reviews centered on Indian community-based HL interventions identified by the authors. India’s cultural and linguistic diversity also highlights the need for tailored, interpreter-supported communication strategies.

Design: Scoping review using Arksey and O’Malley methodology; reported per PRISMA-ScR 2018. A protocol was developed a priori. PICCO (Population–Intervention–Context–Concept–Outcome) framework informed eligibility. Eligibility: Participants included adolescents and adults (≥18 years for adult-focused, studies including adolescents also considered), excluding those with cognitive impairments and healthcare professionals. Interventions aimed to improve HL at the community level (e.g., brochures/print materials, workshops, videos/audio/media campaigns, e-health, tele-care education/support, behavior change interventions, digital health/m-health). Context: Community settings in India (including educational institutes), excluding inpatient institutional settings and multi-country comparisons. Concept: HL defined per Berkman et al.; digital HL (DHL) included per the European definition. Outcomes: Not restricted; categorized post hoc using Berkman’s framework. Study types: RCTs and quasi-randomized/quasi-experimental designs published 01/01/2000–05/31/2022; English only. Search: Databases included MEDLINE (PubMed), EBSCO CINAHL Complete, ProQuest Central, Web of Science, MEDLINE (Ovid), and Scopus. Searches conducted June 27–28, 2022. Screening and Data Extraction: Records imported into Rayyan; duplicates removed; title/abstract and full-text screening by independent reviewers with consensus resolution. PRISMA flow diagram documented selection. Data extraction in Microsoft Excel; intervention details captured using TIDieR. No formal quality assessment (scope was mapping). Synthesis via narrative approach. Yield: 5324 records retrieved; 164 duplicates removed; 5160 screened at title/abstract; 28 full-text assessed; 22 excluded (publication type n=13, design n=4, outcome n=1, population n=4); hand-search added 3; total included studies n=9.

• Included studies (n=9) spanned urban slums and rural communities; most participants were women; delivery agents included project staff, healthcare workers, ASHAs, and peer/youth leaders.
• Interventions: traditional education (lectures, audiovisuals, booklets), art-based (street theatre, puppet shows, wall paintings, picture cards, storytelling), interactive learning (group discussions, role play, demonstrations, question–answer), and technology-based (SMS campaigns, tape-recorded instructions), often multi-component.
• Behavior change outcomes:
  • Reduced tobacco use among disadvantaged youth following a 2-year, multi-component, community-based program with peer-led activities and SMS (Harrell et al., 2016).
  • Improved essential newborn-care practices (Kumar et al., 2008).
  • Evidence of behavior change around antenatal and perinatal care with community mobilization (More et al., 2012).
  • Reduced unprotected marital sex through the RHANI Wives intervention (Raj et al., 2013) with RR 0.83 (95% CI 0.75–0.93) at follow-up.
• Health outcomes and HL-related competencies:
  • Neonatal mortality reduction with essential newborn-care intervention arms: rate ratio 0.46 (95% CI 0.35–0.60) and 0.48 (95% CI 0.35–0.66); p<0.0001 (Kumar et al., 2008).
  • Neonatal mortality lower with participatory learning and action via ASHAs: 30 vs 44 per 1000 live births; OR 0.69 (95% CI 0.53–0.89) (Tripathy et al., 2016).
  • Trends toward increased live births and declines in stillbirths and maternal deaths (More et al., 2012).
  • Increased competence in breast self-examination and awareness after structured education (Rao et al., 2005).
  • Improved knowledge and behaviors for anemia in pregnancy; higher knowledge gains and improved food selection ability; hemoglobin improved alongside education and supplementation (Noronha et al., 2013).
  • Pictograms and multimodal education improved understanding and adherence to cataract postoperative regimens; higher test scores associated with greater medication consumption (Braich et al., 2011).
  • Increased access and use of contraception through multi-channel community family planning efforts including art-based components (Leon et al., 2014).
• Moderators: socioeconomic status, education. Mediators: health behavior, use of health services, knowledge on care-seeking.
• Overall: Five studies showed clear behavior change; four showed improved HL/knowledge; delivery by healthcare workers and community agents was common and effective.

The review maps community-based HL interventions in India and shows that multi-component, culturally resonant approaches—including traditional education, interactive learning, and art-based strategies—can improve knowledge, behaviors, and selected health outcomes. These findings address the research question by identifying effective models (e.g., ASHA-facilitated participatory learning, peer-led youth programs, pictogram-supported instructions) that translate HL improvements into measurable outcomes such as reduced neonatal mortality, safer sexual practices, and better self-care. The results underscore the importance of involving healthcare workers and community stakeholders, tailoring content to linguistic and socio-cultural contexts, and employing both low-tech and digital tools while assessing digital literacy. The studies rarely defined HL explicitly, suggesting a need for theoretical grounding and standardized HL measures. Sustainability and community ownership are crucial for long-term impact; integrating equity considerations and frameworks (e.g., Country Health Rankings Model; Berkman’s HL framework) can strengthen design and evaluation. Scaling up, standardizing indicators, and ensuring inclusivity (e.g., underserved regions like Northeast India) are needed to broaden impact and reduce inequities.

Few community-based HL interventions have been studied in India, but available evidence shows improvements in health-related knowledge, behaviors, and outcomes when interventions are culturally and contextually tailored and delivered by community-linked providers. Empowering communities to make informed health decisions requires integrating healthcare workers in design and implementation, producing local-language content, coordinating public–private efforts, securing sustained funding, and fostering community ownership. Future research should expand to underrepresented regions and vulnerable groups, incorporate digital HL considerations, use theoretically informed designs, and measure both HL and health outcomes over longer time horizons.

• No grey literature search was conducted.
• No formal quality assessment of included studies (consistent with scoping review purpose).
• English-language restriction may have excluded relevant studies.
• Limited number of eligible studies; some regions (e.g., Northeast India) underrepresented.
• Many interventions were small-scale; few captured long-term outcomes; varying time-points and heterogeneity limited comparability.
• Some included studies did not explicitly define HL, complicating synthesis across HL constructs.