Key literature: Measuring the impact of health literacy initiatives Overall, trials examining the relationship between health literacy and health outcomes tend to focus on health knowledge and health behaviours. A 2009 systematic review of complex interventions to improve the health of people with limited literacy found that nearly half of the identified reviews (seven out of 15) had not reported any clinical outcomes.84 Instead, knowledge and self-efficacy – the belief in one’s capabilities to achieve a goal or outcome – were found to be the classes of outcome most likely to improve with increased health literacy skills.84 It is acknowledged that although improvements in factors such as knowledge and confidence are important, they do not necessarily translate into changes in health.