August, 2009 - SUPPORT Summary of a systematic review | print this article |

Do printed educational materials have any effect on professional practice and health care outcomes?

Printed educational materials are widely used passive-dissemination strategies to improve knowledge, awareness, attitudes, skills, professional practice, and patient outcomes. Traditionally they are presented in paper format such as monographs, publication in peer-reviewed journals, and clinical guidelines and appear to be the most frequently adopted method for disseminating information.


Key messages

  • Printed educational materials may lead to little or no difference in professional practice.
  • The effect of printed educational materials on patient out-comes is uncertain.
  • Printed educational materials may be optimised if implemented alongside other quality improvement strategies with proven effectiveness.
  • All the studies included in the review were conducted in high-income settings. Rigorous studies from low- and middle-income countries are needed to fully assess the impact of printed educational materials on professional practice and health outcomes.


Effectiveness of printed educational materials (PEMs) aimed at changing provider behaviour may be influenced by at least four factors: (1) characteristics of the intervention, (2) characteristics of the provider, (3) characteristics of the behaviour that the intervention is trying to change, and (4) characteristics of the organisation and context. Important characteristics of PEMs include: the source of the information, the content and the channel by which it is delivered. There is limited research on which characteristics of PEMs influence clinical practice. Post-dissemination compliance with clinical guidelines may be higher when recommendations are compatible with existing norms and values, are easy to follow, or are supported with evidence and do not require skills and knowledge

This summary is based on a systematic review published in 2008 by Farmer and colleagues on the effects of printed educational materials on professional practice and health care outcomes.

About the systematic review underlying this summary

Review Objectives: To determine the effectiveness of printed educational materials in improving process outcomes (including the behaviour of healthcare professionals) and patient outcomes.
/What the review authors searched forWhat the review authors found
Interventions Randomised controlled trials (RCTs), con-trolled clinical trials (CCTs), controlled be-fore and after studies (CBAs), and inter-rupted time series analyses (ITS) assess-ing the effects of printed educational materials such as clinical practice guidelines, journals, and monographs.
23 studies: 12 randomised controlled trials, one con-trolled before and after study, and 10 interrupted time series analyses.
Any health care professionalsNewborn infants with suspected late onset sepsis, 
Any health care professionals.
Mostly physicians.
Settings Studies originating from any setting.

United States (7), United Kingdom (7), Canada (7), Nether-land (1) and Denmark (1).
General family or community-based practice (14), managed be-havioural healthcare organisation (1), obstetrics (2), and hospitals (4).

Outcomes Any objective measure of performance (such as number of tests ordered) or patient health outcomes.
Prescribing behaviour (12 studies), prevention and general man-agement conditions (6 studies), test ordering (3 studies), surgical rates (2 studies).
Date of most recent search: March 2007
Limitations: This is a good quality systematic review with only minor limitations.

Farmer AP, Légaré F, Turcot L, Grimshaw J, Harvey E, McGowan JL, Wolf F. Printed educational materials: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD004398. 
See in Cochrane Library

Summary of findings

The review included 23 studies conducted in high-income countries: 12 randomised controlled trials, 1 controlled before and after study, and 10 interrupted time series, were included in the review. Only randomised controlled trials are summarised in the table below.

The randomised controlled trials show that:

  • Printed educational materials may lead to little or no difference in professional performance.
  • The effect of printed educational materials on patient out-comes is uncertain.

Printed educational materials

Patient or population: Health care professionals
: Mostly general practice settings in high-income countries
: Printed educational materials
: No intervention

Adjusted absolute risk difference
Median (Interquartile range)*

Number of Participants
Quality of the evidence
Categorical process outcomes
Median increase of +4.3%
(Range -8.0% to +9.6%)
6 studies
Continuous process outcomes
Median increase of +13.6%
(Range -5.0% to +26.6%)
4 studies
Categorical patient outcomes Median -4.3%
(Range -4.6% to -0.4%)
3 studies
Continuous patient outcomes Two studies reported deteriorations in continuous patient outcome data (e.g. depression score, smoking cessation attempts) of -20.5% and -10.0% 2 studies
GRADE: GRADE Working Group grades of evidence (see explanations)
*Across the board for both professional and patient outcomes, the studies are small and there is heterogeneity of both interventions and outcome measures

Relevance of the review for low-income countries

  • The studies included covered a variety of settings in high-income countries. There were no included studies from low-income settings.
  • The applicability of the findings to low-income countries is limited because of the marked differences in health systems between the two settings.
  • No information was provided regarding differential effects of the interventions for disadvantaged populations.
  • Resources needed for printed educational materials may be less available in disadvantaged populations, and use of these materials may exacerbate health inequities.
  • The studies did not provide information on the costs of printed educational materials used.
  • The cost of printed educational materials is likely to be highly variable and must be estimated based on specific local conditions outside research settings.
  • Where such data are not available, further primary studies may be needed to inform decision-making.
  • The studies should aim to collect data on costs of resources used as well as implementation costs.
  • No information was provided on monitoring and evaluation of use of printed educational materials.
  • Although printed educational materials are widely used for dissemination purposes in several low- and middle-income countries, rigorous impact evaluations using objective measures of professional practice and patient outcomes should be planned and undertaken prior to continue using this strategy in new initiatives.
  • The cost-effectiveness of printed educational materials in such settings should be evaluated after demonstrating their effectiveness on relevant outcomes.

*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low- and middle-income countries. For additional details about how these judgements were made see:

Additional information

Related literature

Freemantle N,Harvey EL,Wolf F, Grimshaw JM, Grilli R, Bero LA. Printed educa-tional materials: effects on professional practice and health care outcomes. Coch-rane Database of Systematic Reviews 1997, Issue 2. [DOI: 10.1002/14651858. CD000172].


Grimshaw J, Shirran L, Thomas R, Mowatt G, Fraser C, Bero L, et al. Changing provider behavior: an overview of systematic reviews of interventions. Medical Care 2001;39 (Suppl 8):II2–II45.


Ockene J, Zapka J. Provider education to promote implementation of clinical prac-tice guidelines. Chest 2000;118(Suppl 2):33S–39S.


de Vos M, Graafmans W, Kooistra M, Meijboom, van Der Voort P, Westert G. Us-ing quality indicators to improve hospital care: a review of the literature. Interna-tional Journal for Quality in Health Care 2009:21(2); 119-29.


This summary was prepared by

Charles I. Okwundu & Charles Shey Wiysonge, South African Medical Research Council, Cape Town, South Africa


Conflict of interest

None declared. For details, see: Conflicts of Interest



This summary has been peer reviewed by: Fernando Althabe, Argentina & Newton Opiyo, Kenya


This summary should be cited as

Okwundu CI, Wiysonge CS. Do printed educational materials have any effects on professional practice and health care outcomes? A SUPPORT Summary of a sys-tematic review. May 2009.


This summary was prepared with additional support from:


The South African Medical Research Council aims to improve health and quality of life in South Africa, through promoting and conducting relevant and responsive health research.


The South African Cochrane Centre, the only centre of the inter-national Cochrane Collaboration in Africa, aims to ensure that health care decision making in Africa is informed by high quality, timely and relevant research evidence.