Abstract
Background
Low health literacy is linked to poorer quality of life and health outcomes. However, one-third of healthcare professionals lacked awareness or understanding. This highlights the importance of incorporating health literacy into the education of healthcare professionals. Our study aimed to integrate health literacy into medical clerkship curricula and evaluate the effectiveness of educational programs.
Methods
We recruited fifth-year medical students in the family medicine clerkship from October 2023 to January 2026. The health literacy education program included lectures, simulated case-based videos in the classroom, and observation and hands-on practice in a real-world clinic. The post-lecture quiz was taken to assess foundational health literacy concepts following the lecture course. The Health Literacy Scale specific for Taiwan questionnaires were used to measure the health literacy competencies of pre- and post-survey.
Results
A total of 109 participants demonstrated significant improvements in self-awareness and confidence across all four dimensions, and all changes were statistically significant. The mean score for the Concept and Evaluation Dimension increased from 4.13 to 4.69, representing a 13.48% gain, while the Acceptance and Respect Dimension rose from 4.07 to 4.58, corresponding to a 12.56% increase. The Communication and Interaction Dimension rose from 3.77 to 4.58 (a 21.52% increase), and the Medical Information and Decision-Making Dimension increased from 3.79 to 4.56 (a 20.22% increase). In the multiple-choice questions within the Concept and Evaluation Dimension, the average score improved from 4.11 to 5.30 points, reflecting a 29.02% increase. In the quiz conducted after class, the participants’ average score was 15.55 out of 18.
Conclusions
Comparing pre- and post-surveys results suggested an overall positive impact of the program, with participants reporting improvement in the participants’ competence, self-confidence, familiarity with health literacy, and communication skills. The results demonstrated that health literacy lessons and real-world clinical learning, observation, and practice were effective in improving health literacy competencies for medical students.
Trial registration
This research was approved by the Institutional Review Board of MacKay Memorial Hospital (IRB No. 23MMHIS404e).
Supplementary Information
The online version contains supplementary material available at 10.1186/s12909-026-09593-x.
Keywords: Health literacy, Health literacy competency, Medical humanities, Medical education, Curriculum development, Medical student clerkship
Background
Understanding and effectively using health information is critical to an individual’s health and quality of life [1]. Recognized as a critical element of global health initiatives, health literacy is essential in improving public health outcomes [2]. Furthermore, low health literacy moderately correlated with reduced quality of life and health outcomes [3]. Yet nearly half of the adults struggled with limited health literacy in studies from Taiwan [4]. Despite the critical role of health literacy in patient care, community healthcare providers in Taiwan were not especially familiar with health literacy when implementing it into clinical practice, even though they recognized its importance [5]. Additionally, the average medical student falls into the “problematic” category [6]. Therefore, integrating health literacy training into the education of healthcare professionals is crucial, as it enhances communication, empowers patients, improves patient outcomes, and fosters high-quality, patient-centered care [7–10]. For example, school-based interventions, such as medical simulation videos, role-playing, and board games, enhance health literacy competencies and promote professional development [11].
Many studies have employed didactic and experiential methods. However, these studies often lack detailed reporting on program characteristics or evaluation methods [10]. Nevertheless, previous studies have highlighted various efforts to enhance healthcare providers’ health literacy skills. Educational methods, such as teach-back, jargon-free communication, effective questioning, simulation videos, card-based board games, case-based learning, digital drawing, service-learning experiences, lectures, and standardized patient practice, have significantly enhanced medical students’ competence, confidence, and familiarity with health literacy [11–19].
In recent years, various frameworks defining health literacy competencies for healthcare providers have emerged [8, 20, 21]. In a landmark 2013 study, Coleman and colleagues identified a comprehensive list of 62 competencies [8]. In Taiwan, a similar effort was made by Liu et al., who created a local set of competencies for physician health literacy [22]. Building on these findings, our study aimed to incorporate health literacy into medical education curricula by a program that combined a lecture, a simulated case-based video, followed by a two-week-long observation and practice in the real-world clinic for fifth-year medical students in Taiwan’s family medicine clerkship while access the effectiveness of our educational program.
Methods
Study design and participants
The study population consisted of fifth-year medical students from MacKay Medical College in Taiwan rotating through the Family Medicine clerkship course in MacKay Memorial Hospital. The study was conducted from October 2023 to January 2026. Participants included students who provided written informed consent and completed survey questionnaires. Students with incomplete data were excluded from the study. This research was approved by the Institutional Review Board of MacKay Memorial Hospital (IRB No. 23MMHIS404e) and conducted in accordance with the guidelines of the Helsinki Declaration.
Data collection
The following demographic data were collected in the pre-survey: gender, geographic background, parental education level, socioeconomic background, reported specialty interest, living with grandparents, and prior exposure to health literacy-related lessons. The Health Literacy Scale specific for Taiwan questionnaires were used to measure the health literacy competencies of pre- and post-survey. This scale, developed by Liu et al., is a validated tool designed to measure health literacy for medical professionals in the context of Taiwan’s healthcare system [22]. The survey questions are proposed to assess competencies for physician health literacy in four key dimensions: (1) Concept and Evaluation Dimension (3 items); (2) Acceptance and Respect Dimension (4 items and 7 multiple-choice questions (MCQs)); (3) Communication and Interaction Dimension (7 items); and (4) Medical Information and Decision-Making Dimension (6 items).
Intervention
The health literacy program included 3 parts: the first was class lectures, the second was simulation clinical setting videos, and the third part was the real-world observation, learning, and practicing in the clinical settings. The class lectures were structured to provide a comprehensive understanding of health literacy and its practical applications. These lecture topics included the definition and importance of health literacy for medical students, how healthcare professionals assess patients’ health literacy, how to evaluate the competency of healthcare professionals in health literacy, and strategies for communicating with patients with low health literacy. Then, our participants would view simulation videos of low health literacy patients during the clinical visit. The video demonstrated potential challenges and reactions, such as avoidance, misunderstandings, silence, resistance, and frustration. It illustrated how physicians can identify and interact with such patients using appropriate strategies taught in the lectures. After the class lesson and the simulation video, the participants completed a post-lecture quiz to assess foundational health literacy concepts.
The participants would participate in real-world clinical settings through their clerkship course. After the real-world observation, learning, and practicing, they were given a post-survey identical to the pre-survey without the demographic data.
Statistical analysis
Descriptive statistics were run for categorical and continuous variables. The Wilcoxon Signed-Rank Test was applied to analyze the changes in test scores before and after the intervention. 95% confidence intervals (CI) were estimated using bootstrap methods based on 10,000 resampling iterations with replacement. Subgroup analysis stratified by prior exposure to health literacy-related lessons was performed and test of interaction was conducted by Welch Two-Sample Test.
Results
Between October 2023 and January 2026, 117 fifth-year family medicine clerkship students participated in our program. After excluding 8 participants for missing data, 109 participants were left. Those participants completed the pre-and post-surveys and the lesson quiz. Their demographic data was shown in Table 1. Most participants self-identified as male (75, 68.81%). Most reported growing in the northern region of Taiwan (67, 61.47%). Regarding parental education level, most students had parents with higher educational attainment, including graduate school-educated parents (38, 34.86%) and college-educated parents (58, 53.21%). In terms of family income, most students reported that their families had a middle (64, 58.72%) or average (44, 40.37%) income. Internal medicine was the most frequently reported specialty of interest (92, 84.40%). Most participants did not live with their grandparents (95, 87.16%), and relatively more did not have prior experience of taking health literacy-related lessons (Yes: 46, 42.20%; No: 63, 57.80%).
Table 1.
Demographic Attritubte of Study Participants (N = 109)
| Demographic Attribute | Participants n (%) | |
|---|---|---|
| Gender | Male | 75 (68.81) |
| Female | 34 (31.19) | |
| Geographic background | Northern region | 67 (61.47) |
| Central region | 16 (14.68) | |
| Southern region | 15 (13.76) | |
| Eastern region | 4 (3.67) | |
| Mountainous and offshore islands | 6 (5.50) | |
| Overseas | 1 (0.92) | |
| Parental education level | Graduate school | 38 (34.86) |
| College | 58 (53.21) | |
| Senior high school | 12 (11.01) | |
| Below junior high school | 1 (0.92) | |
| Socioeconomic background | Wealthy | 0 (0.00) |
| Middle-income | 64 (58.72) | |
| Average | 44 (40.37) | |
| Low-income households | 1 (0.92) | |
| Reported specialty interest (multiple selections allowed) | Internal medicine | 92 (84.40) |
| Surgical | 50 (45.87) | |
| Emergency department | 33 (30.28) | |
| Obstetrics and gynecology | 20 (18.35) | |
| Pediatrics | 28 (25.69) | |
| Otorhinolaryngology | 37 (33.94) | |
| Psychiatry | 14 (12.84) | |
| Rehabilitation medicine | 21 (19.27) | |
| Other specialties | 25 (22.94) | |
| Living with grandparents | Yes | 14 (12.84) |
| No | 95 (87.16) | |
| Prior exposure to health literacy-related lessons | Yes | 46 (42.20) |
| No | 63 (57.80) | |
The descriptive analysis of the 18 MCQs quiz administered immediately after the lesson showed that participants had an average score of 15.55, with a standard deviation of 1.87. The median was 16 and the mode was 15.
The results of the pre- and post-surveys are summarized in Table 2. The data analysis revealed statistically significant improvements across all questions (p < 0.001). Specifically, the participants reported increased self-understanding or self-confidence levels in all the four dimensions as shown in Fig. 1: (1) Concept and Evaluation Dimension: mean score increased from 4.13 to 4.69, representing a 13.48% (95% CI: 11.15%-15.78%) gain; (2) Acceptance and Respect Dimension: mean score increased from 4.07 to 4.58, representing a 12.56% (95% CI: 10.08%-15.24%) gain; (3) Communication and Interaction Dimension: mean score increased from 3.77 to 4.58, representing a 21.52% (95%CI: 18.58%-24.77%) gain; and (4) Medical Information and Decision-Making Dimension: mean score increased from 3.79 to 4.56, representing a 20.22% (95% CI: 11.29%-28.97%) gain. Additionally, the analysis of MCQs in the Concept and Evaluation Dimension presented in Fig. 2 showed a statistically significant overall positive change. In average, the participants’ scores increased by 4.11 to 5.3 points, representing a significant 29.02% (95% CI: 21.11%-37.47%) improvement. The subgroup analysis stratified by prior exposure to health literacy-related lessons revealed no significant interaction shown in Supplementary Table 1.
Table 2.
Health Literacy Questionnaire Mean Item Scores Comparison between Pre- and Post-Surveys
| Scores | Average growth rate | |||
|---|---|---|---|---|
| pre-survey | post-survey | P value | % with 95% CI | |
| 1) Concept and Evaluation Dimension | ||||
|
Average of 3 items, 5-pt Likert scale |
4.13 | 4.69 | < 0.001 |
13.48 (11.15–15.78) |
| Sum of 7 MCQs | 4.11 | 5.3 | < 0.001 |
29.02 (21.11–37.47) |
| 2) Acceptance and Respect Dimension | ||||
|
Average of 4 items, 5-pt Likert scale |
4.07 | 4.58 | < 0.001 |
12.56 (10.08–15.24) |
| 3) Communication and Interaction Dimension | ||||
|
Average of 7 items, 5-pt Likert scale |
3.77 | 4.58 | < 0.001 |
21.52 (18.58–24.77) |
| 4) Medical Information and Decision-Making Dimension | ||||
|
Average of 6 items, 5-pt Likert scale |
3.79 | 4.56 | < 0.001 |
20.22 (11.29–28.97) |
CI confidence interval, MCQs multiple choices questions, 5-pt Likert 5-point Likert scale questions
P value was calculated by the Wilcoxon Signed-Rank Test
Fig. 1.
Comparison of Self-awareness and Confidence for Health Literacy Compentence between Pre-survey and Post-Survey
Fig. 2.
Comparison of Scores of Multiple-choice Questions in the Concept and Evaluation Dimension
Discussion
Most of the 109 participants from MacKay Medical College were from northern Taiwan, had parents with higher education levels, and reported a middle-to-average family income, suggesting a relatively homogeneous participant demographic. The pre- and post-surveys results showed statistically significant increases. These findings suggest improvements in confidence and understanding across all four dimensions of health literacy competency in most participants. As regards our lesson, most participants scored 15, averaged 15.55 out of 18 on the quiz administered after the lesson, indicating that both the lecture and simulated case videos positively impacted students’ learning and understanding.
Our health literacy program covered both specific health literacy techniques and provided a thorough overview of health literacy. This lesson included lectures on what health literacy is, how to assess it, its associated competencies, and how to apply these competencies in practice. We provided a case scenario through a simulated clinical video that incorporated the lecture content. The quiz result showed that this lesson was practical for our participants. In addition to the lesson, we designed two weeks of real-world clinical learning, observation, and practice in our program. The pre- and post-surveys comparison was a thorough assessment of the program’s overall effect on the participants, indicating a participants’ reporting improvement in their competence, self-confidence, and familiarity with health literacy. The positive results of our program are consistent with findings from other studies [11–19]. This alignment may be attributed to the inclusion of interactive content and real-world experiences in our program [23].
According to the U.S. Department of Health and Human Services, personal health literacy refers to an individual’s ability to locate, interpret, and apply health information to make informed decisions about their health [24]. It helps people make informed decisions and engage with the healthcare system, and it is linked to quality of life and health outcomes [3]. In Taiwan, nearly half of the adult population struggles with low health literacy, and community healthcare providers were not especially confidence in implementing health literacy into clinical practice [4, 5]. This gap underscores the urgent need to consider health literacy within the health care system and to enhance health literacy competencies [10, 25]. Through school-based interventions to enhance health literacy competency, our study addressed this need by incorporating health literacy education into professional healthcare training.
Several limitations of this study should be considered when interpreting the findings. First, the study lacked a control group, which limits causal inference regarding the observed changes. However, practical and feasibility constraints in educational or clinical settings limited implementation. Withholding educational opportunities from students was ethically inappropriate and a crossover design was not suitable for this type of educational program. Using a pre- and post-test approach, where each participant serves as their own control, can reduce the interference of individual differences on the results. Second, the two-week follow-up period may have been too brief to fully assess the long-term effects of our program. Although the initial plan was to conduct long-term follow-up assessments of evaluation of knowledge retention, behavioral change or impact on patient care, the response rate to the questionnaire survey conducted one year after the completion of the family medicine course was unstable, thus warranting more comprehensive data collection for long-term longitudinal analysis. Finally, prior exposure to health literacy programs, as about two-fifths of the participants self-reported having prior participation in health literacy-related lessons, represents a potential confounding factor. Subgroup analysis indicated that participants without prior lessons experience appeared to demonstrate greater improvement from pre- to post-survey; however, this difference was not statistically significant.
Conclusion
Integrating lectures, simulated video scenarios, and real-world clinical practice effectively enhances medical students’ self-reported competence and confidence in health literacy. This finding suggests that a multifaceted, experiential approach to teaching health literacy may strengthen competence of medical students, supporting its adoption in medical education curricula.
Supplementary Information
Supplementary Material 1: Supplementary Table 1.
Supplementary Material 2: STROBE statement.
Acknowledgements
The authors would like to thank Dr. Chan-Shoun Lee for his support and thank the study participants for their time.
Authors’ contributions
Conceptualization, L.-C.H.; methodology, L.-C.H.; software, T.-T.L. and L.-C.H.; Validation, Y.-T.L. and L.-C.H.; formal analysis, Y.-T.L. and L.-C.H.; investigation, Y.-T.L. and L.-C.H.; resources, Y.-C. C., H.-C. M., W.-H. H. and L.-C.H.; data curation, Y.-T.L. and L.-C.H.; writing - original draft preparation, Y.-T. L.; writing - review and editing, Y.-C. C., H.-C. M., W.-H. H., C.-W. L. and L.-C.H.; visualization, Y.-T. L.; supervision, L.-C.H.; project administration, L.-C.H. All authors have read and agreed to the published version of the manuscript.
Funding
This study is a partial research result of the Higher Education Sprout Project of Taiwan’s Ministry of Education.
Data availability
The datasets generated or analyzed during this study are available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
This research was approved by the Institutional Review Board of MacKay Memorial Hospital (IRB No. 23MMHIS404e) and conducted in accordance with the guidelines of the Helsinki Declaration. Participants provided written informed consent.
Consent for publication
Not Applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.World Health Organization. Health literacy: Fact sheet. https://www.who.int/news-room/fact-sheets/detail/health-literacy. Accessed 29 July 2025.
- 2.de Wit L, Fenenga C, Giammarchi C, di Furia L, Hutter I, de Winter A, et al. Community-based initiatives improving critical health literacy: a systematic review and meta-synthesis of qualitative evidence. BMC Public Health. 2017;18(1):40. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Zheng M, Jin H, Shi N, Duan C, Wang D, Yu X, et al. The relationship between health literacy and quality of life: a systematic review and meta-analysis. Health Qual Life Outcomes. 2018;16(1):201. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Wei MH, Wang YW, Chang MC, Hsieh JG. Development of mandarin multidimensional health literacy questionnaire (MMHLQ). Taiwan J Public Health. 2017;36(6):556–70. [Google Scholar]
- 5.Chang MC, Hsieh JG, Wei MH, Tsai CH, Yu JH, Wang YW. Familiarity, Attitude, and Confidence of Health Literacy Practice among Community Healthcare Providers in Taiwan. Int J Environ Res Public Health. 2021;18(23):12610. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Pesheva P, Velkova A, Georgieva L, Georgieva E, Hristov N, Pravchanska M. Exploring Health Literacy of Medical Students: A Cross-Sectional Study. Acta Med Bulg. 2025;52(1):75–82. [Google Scholar]
- 7.Marshall N, Butler M, Lambert V, Timon CM, Joyce D, Warters A. Health literacy interventions and health literacy-related outcomes for older adults: a systematic review. BMC Health Serv Res. 2025;25(1):319. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Coleman C. Teaching health care professionals about health literacy: a review of the literature. Nurs Outlook. 2011;59(2):70–8. [DOI] [PubMed] [Google Scholar]
- 9.Sharkiya SH. Quality communication can improve patient-centred health outcomes among older patients: a rapid review. BMC Health Serv Res. 2023;23(1):886. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Connell L, Finn Y, Sixsmith J. Health literacy education programmes developed for qualified health professionals: a scoping review. BMJ Open. 2023;13(3):e070734. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Yang HF, Chang CC, Tseng PL, Lai HR, Tasi JS, Huang WH, et al. Effectiveness of innovative instructional module for professional competence in health literacy in medical students. BMC Med Educ. 2022;22(1):210. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Stone M, Bazaldua O, Morrow J. Developing Health Literacy Communication Practices for Medical Students. MedEdPORTAL. 2021;17:11091. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Chang MC, Yu JH, Hsieh JG, Wei MH, Wang YW. Effectiveness of the refined health literacy course on improving the health literacy competencies of undergraduate nursing students: quantitative and qualitative perspectives. Med Educ Online. 2023;28(1):2173042. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.King J, Taylor J. Integration of Case-Based Dialogue to Enhance Medical Students’ Understanding of Using Health Communication to Address Social Determinants of Health. Adv Med Educ Pract. 2023;14:237–44. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Kellner RL, Agathis AZ, Moon JK, Garfinkle S, Appel J, Coakley BA. A new student-led digital drawing course: an initiative to bridge patient health literacy through medical illustrations. J Vis Commun Med. 2022;45(3):182–7. [DOI] [PubMed] [Google Scholar]
- 16.Fox JL, Doolan TD, Gurney TM, McGrail MR. Short-term medical student placements completed consecutively at a rural general practice positively impact chronic disease management. Rural Remote Health. 2023;23(2):7611. [DOI] [PubMed] [Google Scholar]
- 17.Roberts DM, Reid JR, Conner AL, Barrer S, Miller KH, Ziegler C. A replicable model of a health literacy curriculum for a third-year clerkship. Teach Learn Med. 2012;24(3):200–10. [DOI] [PubMed] [Google Scholar]
- 18.Spengler E, Schechter M, Pina P, Rhim HJH. You Can Teach Every Patient: A Health Literacy and Clear Communication Curriculum for Pediatric Clerkship Students. MedEdPORTAL. 2021;17:11086. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Barksdale S, Stark Taylor S, Criss S, Kemper K, Friedman DB, Thompson W, et al. Improving Patient Health Literacy During Telehealth Visits Through Remote Teach-Back Methods Training for Family Medicine Residents: Pilot 2-Arm Cluster, Nonrandomized Controlled Trial. JMIR Form Res. 2023;7:e51541. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Toronto CE. Health Literacy Competencies for Registered Nurses: An e-Delphi Study. J Contin Educ Nurs. 2016;47(12):558–65. [DOI] [PubMed] [Google Scholar]
- 21.Kaper MS, Sixsmith J, Koot JAR, Meijering LB, van Twillert S, Giammarchi C, et al. Developing and pilot testing a comprehensive health literacy communication training for health professionals in three European countries. Patient Educ Couns. 2018;101(1):152–8. [DOI] [PubMed] [Google Scholar]
- 22.Liu CC, Chang CC, Lai HR, Tsai JS, Ming JL, Tung CY. Study of constructing indicators of physician’s professional competence on health literacy by Delphi method. Taiwan J Public Health. 2020;39(3):292–310. [Google Scholar]
- 23.Albertson F, Kennedy AB, Taylor SS, Natafgi N. Evaluating medical learners’ experiences with health literacy at a southeastern medical school. BMC Med Educ. 2025;25(1):23. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Centers for Disease Control and Prevention. Personal health literacy definition. https://www.cdc.gov/health-literacy/php/about/index.html. Accessed 29 July 2025.
- 25.Charoghchian Khorasani E, Tavakoly Sany SB, Tehrani H, Doosti H, Peyman N. Review of Organizational Health Literacy Practice at Health Care Centers: Outcomes, Barriers and Facilitators. Int J Environ Res Public Health. 2020;17(20):7544. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplementary Material 1: Supplementary Table 1.
Supplementary Material 2: STROBE statement.
Data Availability Statement
The datasets generated or analyzed during this study are available from the corresponding author upon reasonable request.