Journal of Health Communication

International Perspectives

ISSN: 1081-0730 (Print) 1087-0415 (Online) Journal homepage: https://www.tandfonline.com/loi/uhcm20

Knowledge and Perceptions of Health Literacy

Among Nursing Professionals

Aurelia Macabasco-O'Connell & Eileen K. Fry-Bowers

To cite this article: Aurelia Macabasco-O'Connell & Eileen K. Fry-Bowers (2011) Knowledge and
Perceptions of Health Literacy Among Nursing Professionals, Journal of Health Communication,
16:sup3, 295-307, DOI: 10.1080/10810730.2011.604389

To link to this article: https://doi.org/10.1080/10810730.2011.604389

Copyright Taylor and Francis Group, LLC

Published online: 27 Sep 2011.

Submit your article to this journal

Article views: 8986

View related articles

Citing articles: 57 View citing articles

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=uhcm20
Journal of Health Communication, 16:295–307, 2011
Copyright # Taylor & Francis Group, LLC
ISSN: 1081-0730 print=1087-0415 online
DOI: 10.1080/10810730.2011.604389

Knowledge and Perceptions of Health Literacy

Among Nursing Professionals

AURELIA MACABASCO-O’CONNELL
School of Nursing, University of California Los Angeles, Los Angeles,
California, USA

EILEEN K. FRY-BOWERS
School of Nursing and School of Public Health, Loma Linda University,
Loma Linda, California, USA

Low health literacy affects nearly half of the U.S. population. Health care profes-
sionals may not recognize low health literacy in their patients nor understand its
impact on health outcomes. The purpose of this pilot study was to describe nurses’
knowledge and perceptions of low health literacy on patients, their practice, and
the health system. This cross-sectional, descriptive study used a web-based survey
to assess the knowledge and perceptions of health literacy among nursing profes-
sionals. Registered nurses licensed by the State of California were randomly selected
and invited to participate in the study. Data analysis included descriptive statistics to
describe nursing professionals’ general knowledge and perceptions. Qualitative tex-
tual analysis was done on participant responses to a survey question that asks part-
icipants to define health literacy using their own words. Results of this study revealed
that nursing professionals’ knowledge of health literacy and their understanding on
the role health literacy plays on patient health outcomes is limited. Health literacy
was also reported to be a low priority among providers and organizations. Nursing
plays an important role in direct patient care and in the delivery of health services.
Educating nurses on health literacy and improving patient communication and
understanding can improve health outcomes.

According to the 2003 National Adult Literacy Survey, 36% of Americans possess
below basic or basic literacy skills and, as such, lack adequate ability to read, com-
prehend, act on medical information, and interact with the health care system
(Nielsen-Bohlman, Panzer, & Kindig, 2004; Schwartzberg, VanGeest, & Wang,
2005). This ability, formally labeled ‘‘health literacy,’’ comprises numerous skills
beyond those of reading and writing, and includes numeracy, speaking and listening,
and relies on cultural and conceptual knowledge (Nielsen-Bohlman et al., 2004).
Importantly, low health literacy appears to be strongly associated with low edu-
cational attainment, race, ethnicity, age, and English-speaking ability (Institute of
Medicine, 2004; Keller, Wright, & Pace, 2008).
Substantial evidence reveals that individuals with low health literacy possess
poor knowledge of chronic conditions (Williams, Baker, Honig, Lee, & Nowlan,

Address correspondence to Aurelia Macabasco-O’Connell, UCLA School of Nursing,

700 Tiverton Ave., 4-242 Factor Bldg., Los Angeles, CA 90095, USA. E-mail: aoconnel@
sonnet.ucla.edu

295
296 A. Macabasco-O’Connell and E. K. Fry-Bowers

1998; Williams, Baker, Parker, & Nurss, 1998), lack ability to navigate an increas-
ingly complex health care system (Bade, Evertsen, Smiley, & Banerjee, 2008), have
an increased risk of hospitalization (Baker, Parker, Williams, & Clark, 1998) and
an increased risk of mortality (Baker et al., 2007) when compared with those with
higher levels of health literacy. Moreover, persons with poor health literacy incur
higher medical costs and use a less efficient combination of services than their more
literate counterparts (Howard, Gazmararian, & Parker, 2005). Specifically, the Insti-
tute of Medicine (IOM, 2004) estimates that additional health care expenditures
because of low health literacy skills approximate $73 billion, and Vernon and collea-
gues (2007) place total costs to the U.S. economy between $106 and $238 billion per
year (Vernon, Trujillo, Rosenbaum, & DeBuono, 2007).

Health Care Provider Knowledge of Health Literacy

Given the reciprocal nature of health communication, patient-provider communicat-
ive interactions play an important role in care, particularly among patients with low
literacy (J. B. Brown, Stewart, & Ryan, 2003). In addition, provider knowledge
regarding the prevalence of patient characteristics associated with low health literacy
may influence these interactions. Lack of knowledge among providers regarding
issues related to health literacy can substantially alter patient-provider communi-
cation and hinder benefits expected from medical care. In fact, researchers suggest
that discordance in estimation of patient’s literacy level may be an important source
of disparities in health care (Kelly & Haidet, 2007).
Jukkala and colleagues (2009) surveyed 240 health care providers and students,
who were attending a university-sponsored educational session on health literacy,
regarding their general knowledge of the issue and its impact on individual patients
and the health care system (Jukkala, Dupree, & Graham, 2009). Fewer than 12% of
the participants correctly estimated the prevalence of health literacy among adults in
the United States. In addition, participants believed that level of health literacy
could be determined by specific demographic characteristics. Results further sug-
gested that some participants erroneously believed that persons with higher levels
of education were not at risk for limited health literacy. Finally, and most discon-
certing, 16% of participants reported having not heard of health literacy prior to
the educational offering, with nurses having the highest rate of no prior knowledge
at 17.1% (Jukkala et al., 2009). Brown and colleagues (2004) also surveyed 36 allied
health care providers and found that one third of respondents were unaware of the
issues regarding health literacy, including the impact of inadequate health literacy
on patient care, and had no knowledge of health literacy resources (D. L. Brown
et al., 2004).
Several studies further reveal that providers are often unable to correctly identify
patients with low health literacy (Bass, Wilson, Griffith, & Barnett, 2002; Rodgers,
Wallace, & Weiss, 2006). Bass and associates (2002) assessed whether resident phy-
sicians could identify patients with poor literacy skills based on clinical interactions
during a continuity clinic visit. Investigators administered the Rapid Estimate of
Adult Literacy in Medicine-Revised (REALM-R) to patients to screen them for
potential health literacy problems. The research team then queried residents about
whether they felt that the patients had literacy problems. The residents believed that
only 10% of the patients screened had literacy problems based on their clinical inter-
actions. However, of the 90% of patients the residents perceived as having adequate
 Knowledge and Perceptions of Health Literacy 297

literacy, 36% failed the literacy screen. Only three patients passing the literacy screen
were incorrectly identified as at risk for literacy.
Similarly, Rogers and colleagues (Rogers et al., 2006) investigated whether
family-medicine residents at a university-based family medicine clinic could identify
patients with limited health literacy. Patient health literacy was assessed using the
short form of the Test of Functional Health Literacy in Adults (S-TOFHLA). After
the patients completed their office visits with a physician, investigators asked the
family-medicine residents to rate the patients’ ability to understand medical infor-
mation. Of the 140 patients who met with 18 family-medicine resident physicians,
24% had low literacy skills based on testing with the S-TOFHLA. Of those, residents
identified only about half of these patients accurately as having poor or below
average understanding of medical information.
In one of only two studies measuring provider communication methods with low
literate patients, Schwartzberg and associates (2007) explored the self-reported tech-
niques used by 307 providers (99 physicians, 87 nurses and 121 pharmacists) attend-
ing state and national conferences. Using simple language (94.7%), providing printed
materials (70.3%), speaking slowly (67.3%), and reading instructions aloud (59.1%)
were the most commonly employed techniques (Schwartzberg, Cowett, VanGeest,
& Wolf, 2007). Unfortunately, less than 40% routinely used methods promoted by
health literacy experts such as ‘‘teach-back.’’ No significant differences by profession
were noted. Although limited by self-report and convenience sampling, this
study reveals that health care professionals have not routinely incorporated into
practice appropriate methods of communication with low health literate patients
(Schwartzberg et al., 2007).
Schlichting and colleagues (2007) surveyed 333 providers, including 144 physi-
cians, 67 nurse practitioners, 35 physician’s assistants, 48 dentists and dental hygie-
nists, and 36 other professionals, such as registered nurses, in midwestern urban and
rural community health centers for techniques used when caring for clients with lim-
ited health literacy (Schlichting et al., 2007). Again, most common techniques
reported as used always or often by all clinicians included asking a patient’s under-
standing (96%), reviewing instructions carefully (95%), using layman’s terms (95%),
and providing printed health education materials (86%). Using teach-back was
employed by 66% of the clinicians but only 35% provided health materials designed
for low health literate patients. Interestingly, when queried about barriers to provid-
ing formal support for this patient population, 62% of providers considered health
literacy to be a low priority compared with other patient needs. Unfortunately,
the researchers did not analyze the data for differences among the providers for tech-
niques used and, as in many studies, these findings are limited given their reliance on
self-report. Even so, they are cause for concern given that many such health centers
serve low-income, racial=ethnic minority, and elderly clients, all of whom are at risk
for limited health literacy.

Nursing and Health Literacy

Nursing professionals compose the single largest group of health care providers
(Sanders, Thompson, & Wilkinson, 2007). It is essential that nursing’s general
understanding of health literacy be explored. To date, nurse researchers have
examined the prevalence of low health literacy in an urban primary care clinic
(Artinian, Lange, Templin, Stallwood, & Hermann, 2002), knowledge of health
298 A. Macabasco-O’Connell and E. K. Fry-Bowers

literacy among students and health care providers (Jukkala et al., 2009), the read-
ability of patient education materials (Wilson, 2009), the information needs of
mothers over age 35 years (Carolan, 2007), predicting completion of advance
directives (Campbell, Edwards, Ward, & Weatherby, 2007), HIV medication
adherence (Holzemer et al., 2006), and the self-efficacy of parents=guardians of
African American children with asthma within the context of health literacy
(Wood, Price, Dake, Telljohann, & Khuder, 2010). However, thus far, no studies
have been conducted to assess the knowledge of nursing professionals across edu-
cational preparation, role, or practice specialty, regarding nursing knowledge of
health literacy, its impact on patient outcomes, or nursing use of resources to
facilitate communication with individuals with low health literacy. Nursing’s per-
ception of health literacy remains largely unexplored, yet, health promotion activi-
ties and patient education have always been independent and intrinsic components
of nursing care (Mason, 2001). Because such little health literacy research has been
conducted with or by nursing professionals, however, the profession knows little
about how it interacts or influences the phenomenon. At present, evidence indi-
cates that low health literacy is substantially related to a myriad of health indica-
tors. Given nursing’s role in direct patient care and its responsibility in the delivery
and management of health services, what nurses know about health literacy must
be vigorously explored.
Thus, the purposes of this pilot study were as follows:
1. To describe nursing professionals’ knowledge and perceptions of the impact of
limited health literacy on individual patients, their practice, and the health
system.
2. To survey self-reported communication techniques used by nursing professionals
to facilitate the care of individuals with limited health literacy.
3. To examine nursing professionals’ perceptions of the effectiveness of, or barriers
to, implementation of health literacy provider and staff education at their places
of practice.
4. To explore nursing professionals’ perceptions of the effectiveness of, or barriers
to, implementation of health literacy programs for patients at their places of
practice.
An improved understanding of what nursing professionals currently know about
health literacy can guide and facilitate continuing education regarding the issue and
can identify practical barriers to improving care of the low health literate patient at
the point of nurse-patient contact.

Methods
A descriptive, cross-sectional web-based survey (SurveyMonkeyTM) was used to
assess nursing professionals’ knowledge and perceptions of health literacy. Parti-
cipants were randomly selected from a publicly available database of registered
nurses (RN) and advanced practice registered nurses (APRN) licensed in the state
of California. We sent 270 surveys in the first mailings for this pilot study. Nurses
were informed in the cover letter that the survey was confidential and that their indi-
vidual responses or names would not be disclosed to anyone other than the research
team. Study information with a survey link to a website where the survey could be
anonymously completed was also provided in the letter. Nurses who participated
 Knowledge and Perceptions of Health Literacy 299

in the survey were eligible to enter a drawing to win a $100 gift card to a major online
retailer.

Nursing Professional Health Literacy Survey

Specifically, participants’ knowledge and perceptions of health literacy were assessed
using the Nursing Professional Health Literacy Survey (NPHLS), a 47 item,
web-based survey developed by the investigators specifically for this study from
questionnaires used in previous investigations of professional awareness of literacy
(Jukkala et al., 2009; Schlichting et al., 2007). In particular, general health literacy
knowledge questions were adapted from the Limited Literacy Impact Measure (Juk-
kala et al., 2009) and questions regarding professional use of health literacy interven-
tions and perceived effectiveness were informed by prior investigation of practices of
community health clinics (Schlicting et al., 2007). Adaptation was conducted follow-
ing correspondence with the above noted investigators. Content validity was estab-
lished through examination of the instrument by experts in the field of nursing.
The NPHLS asked 10 general-knowledge questions regarding health literacy
including a short-answer question where participants are asked to define health lit-
eracy in their own words. Additional questions explored individual nurse awareness
and use of techniques for communicating with patients with low health literacy,
including an assessment of barriers encountered when implementing such techni-
ques. Finally, the survey requested demographic, professional, and work character-
istics information. Demographic information included race=ethnicity; professional
characteristics included level of nursing education, years of nursing practice, primary
position, current practice setting and patient population and certification status;
work-related characteristics included full-time, part-time, or not working status.
Instrument completion took approximately 15–20 minutes. The study was approved
by the Institutional Review Board. Completion of the survey implied informed
consent to participate.

Data Analysis
Data were collected over a 3-month period (June-August 2010). A total sample of 76
respondents was included in the analysis. Data analysis included descriptive statistics
(frequency counts for categorical variables) to describe nursing professionals’ general
knowledge of health literacy, their self-reported use of communication techniques,
and their perceptions of effectiveness of and=or barriers to implementation of health
literacy provider and staff education at their place of practice. Qualitative textual
analysis was conducted on participant responses to a survey question that asked
participants to define health literacy using their own words.

Results
Study respondents (n ¼ 76) were mostly White (60%), and worked as RN Staff nurses
(47%), Nurse Practitioners (NP; 33%), Clinical Nurse Specialists (CNS; 9%), or RN
Managers (8%). Sixty-four percent reported working full-time, with 31% of them
having worked as nurses for longer than 20 years. Most participants worked in acute
care settings (59%) or hospital-based clinics (14%), primarily with adult (52%) and
geriatric (21%) patients. A majority of the participants held advanced nursing
300 A. Macabasco-O’Connell and E. K. Fry-Bowers

Table 1. Key study findings

. 80% of nursing professionals have heard of the term ‘‘health literacy’’ (HL) and
75% report they know a moderate amount to great deal about HL. However, 59%
have never received any formal training on HL
. 48% perceived that low HL greatly interfered with patients’ ability to understand
health information,
. 38% perceived HL interfered with patients’ ability to obtain appropriate health
services,
. 45% perceived HL interfered with patients’ ability to follow through on
recommended treatment
. 65% reported they ask patients to repeat instructions back to them either often or
always
. 77% reported that they ask patients if they understand instructions or have any
questions
. Only 30% reported they ask patients if they have difficulty reading medical
information or completing medical forms
. More than 80% report they never or rarely formally assess HL with a validated
questionnaire; instead 60% reported they use their ‘‘gut feeling’’ to assess a
patient’s level of HL
. 56% report that low HL is viewed as a low priority compared to other patient
problems

degrees (Masters or PhD; 60%), with 51% of the NP and CNS being nationally
board certified, and 39% of the RNs certified in their respective specialties.
Many respondents (38%) reported that they did not have a health literacy pro-
gram at their practice site or did not know if one existed (34%; see Table 1).
Although 51% of nurses reported their practice site has health education materials
designed for patients with low health literacy, only 21% believed them to be effective.
Few practice sites (22%) had health education programs designed for low health lit-
eracy patients or a health literacy specialist (4%) available. Of those that had health
education programs, only 14% of respondents believed they were effective.

Knowledge and Perceptions of Nurses

Eighty percent of respondents reported that they had heard of the term health liter-
acy and 75% reported knowing a moderate or great deal about it. Yet, a large pro-
portion of nurses (59%) had never had any formal education or training pursuant to
health literacy. Many reported that demographics such as educational level (99%),
socioeconomic status (96%), race=ethnicity (79%), and age (71%) were the main fac-
tors associated with health literacy. Approximately 15% reported that individuals
with high levels of education are not at risk for low health literacy. Only 17% knew
the financial impact low health literacy has on the U.S. economy. Furthermore, only
48% of nurses perceived that low health literacy interferes with a patient’s ability to
understand health information; 38% perceived it interferes with a patient’s ability to
obtain appropriate health services, and 45% perceived it interferes with a patient’s
ability to follow through or perform recommended treatments.
 Knowledge and Perceptions of Health Literacy 301

To gain qualitative data on nurses’ knowledge of the term health literacy, we

asked them to describe what health literacy means to them. Some referred to health
literacy as ‘‘the ability or inability to understand medical language or terminology,’’
‘‘the ability to understand and follow instructions given by the health care provider,’’
‘‘being able to receive and thoroughly understand information pertaining to an indi-
vidual’s health,’’ ‘‘what you understand about taking care of yourself and your
health care needs.’’ Whereas others stated, ‘‘it is understanding patient education
materials, pamphlets, instructions, consents, etc.,’’ ‘‘it is understanding the disease
process and the treatments that goes along with it. Again, only within the context
of disease.’’

Health Literacy Training and Use of Communication Techniques

A large number of respondents (72%) were not aware if their practice site had a
health literacy program in place and only 42% of nurses provided their patients with
educational material designed for low health literacy. When asked how often nurses
assess health literacy in their patients, more than 80% reported that they never or
rarely formally assess health literacy with a validated instrument. Further, 27% never
or rarely ask whether a patient has difficulty reading medical information or
completing medical forms. Instead, 60% of respondents stated they use their ‘‘gut
feeling’’ to assess the patient’s health literacy, often or always.
Techniques most often used by nurses to assist patients with low health literacy
included asking patients if they understand the instructions given or have any ques-
tions (77%), asking patients to repeat instructions back to them (65%), and asking if
patients have difficulty reading medical information or completing medical forms
(30%).

Barriers to Health Literacy Education for Health Care Providers

Health literacy was reported to be a low priority as compared with other problems
(53%), thus creating barriers to implementing a formal health literacy program
designed for health care providers. Other barriers to educating health care providers
include (a) not having time to take part in a health literacy training program (38%),
(b) that it would be too costly (32%), or (c) that it would be too difficult to
implement a program for various types of providers (25%), and (d) lack of support
from their organizational leaders (12%) for developing such a program. Interest-
ingly, 7% of respondents believed that health literacy is not a major problem at their
place of work and 7% reported that a health literacy program for providers and staff
would not improve patient outcomes.

Barriers to Implementing a Health Literacy Program for Patients

Similarly, many respondents (53%) believed that implementing a health literacy pro-
gram for patients is a low priority and would be too expensive (37%). Thirty-two per-
cent also reported that it would be too difficult to implement a program for patients
at sites where patients speak many different languages or to implement one that is
culturally competent (19%).
302 A. Macabasco-O’Connell and E. K. Fry-Bowers

Barriers to Screening for Low Health Literacy in Patients

Lack of knowledge about low health literacy among providers was reported as the
major barrier in screening for low health literacy in patients (63%). Many also
reported that screening patients for low health literacy would take too much time
(37%) or believed that good health literacy screening tools were not available (31%).

Discussion
Findings from this study reveal that nursing professional’s knowledge of health lit-
eracy and their understanding of the role health literacy plays on patient health out-
comes is limited. Although a majority of respondents reported having heard of the
term health literacy, still 20% (n ¼ 15) reported never having heard about it. Overall,
when asked to describe health literacy in their own words, it appears that nurses have
a limited scope of the definition of health literacy. Many responses referred to some
level of understanding medical language or terminology in the context of disease or
chronic illness. However, many did not speak about or make any reference to acting
on information or using the information to make medical decisions. Moreover, as a
result of the incomplete understanding that health literacy is solely about understand-
ing information, then nurses run the risk of developing interventions focusing mainly
on ‘‘readability’’ of educational materials instead of addressing ways to help activate
patients or ways to improve processes to assist patients in self-managing their
illnesses.
Another important aspect revealed from this study is that although many nurses
were aware of the high prevalence of low health literacy, many were not aware of its
economic impact on the United States, nor were they aware of how low health liter-
acy affects the patient’s ability to understand health information, obtain appropriate
health services, and follow through or perform the recommended treatments. These
results provide for a great opportunity to educate nurses on health literacy and how
it gravely impacts health outcomes for the patient.
Techniques used by nurses to assist with low health literacy, such as asking
patients if they understand instructions given or have any questions, or using the
teach-back method by having patients repeat instructions in order to check their
understanding, were consistent with the previous studies conducted with other health
care providers (Schlichting et al., 2007; Jukkala et al., 2009). Although these techni-
ques have been shown to be effective, reliance on these methods may not be the most
effective method for patients. There are many other strategies for improving health
literacy and communication that can be used in the clinical settings by nurses. For
example, seeking out patient education materials written at a 5th-grade reading level
or lower, and using pictorials and=or visuals, can improve patient recall and compre-
hension (National Work Group on Literacy and Health, 1998). In addition, creating
a trustful environment to empower and encourage patients to ask questions and to
participate in their own health care can enhance understanding and self-care
(Williams, Davis, Parker, Weiss, 2002; Kountz, 2009). Other important strategies
should include the use of a medical translator, asking open-ended questions, and
ensuring clear communications when making medical appointments (Kountz, 2009).
Low health literacy can provoke shame and may not be reported by patients and
families (Wolf et al., 2007). As a result, patients with low health literacy are often
unrecognized by health care clinicians, and the issue of health literacy remains
 Knowledge and Perceptions of Health Literacy 303

underappreciated by health policy makers (Institute of Medicine, 2004). Currently,

many nurses report that there is no mechanism of formally evaluating patient’s
health literacy in their practice setting. A large proportion of nurses reported on
using their gut feeling to assess or evaluate whether a patient has low health literacy.
Although many believed that health literacy could be determined based on race, eth-
nicity, age, educational level, and socioeconomic status, there were no formal assess-
ments done with patients to validate their level of health literacy. This gut feeling
approach is problematic because nurses may erroneously classify patients with
higher levels of education as not being at risk for having low health literacy. More-
over, previous reports indicate that health care providers are not able to properly
identify patients with limited health literacy (Bass et al., 2002; Rogers et al., 2006).
Screening tests such as the REALM (Davis et al., 1993) and the TOFHLA
(Parker, Baker, Williams, & Nurss, 1995) have been shown to effectively identify
patients with low literacy skills, however, these tools are generally practicable for
research use only. The Newest Vital Sign (NVS) is one of several new tools now
available for the screening and assessment of health literacy. Briefly, the NVS is
based upon a nutrition label from an ice cream container and asks six questions that
assess an individual’s prose literacy, numeracy, and document literacy, each a dis-
tinct component of health literacy and necessary for interacting with today’s health
care system. The tool can be administered within three minutes and is available in
English (NVS-E) and Spanish (NVS-S) (Weiss et al., 2005). Even a brief screening
tool however, may be perceived as a test by patients. The Single Item Literacy
Screener (SILS) avoids testing and simply asks, ‘‘How often do you need to have
someone help you when you read instructions, pamphlets, or other written material
from your doctor or pharmacy?’’ with possible responses ranging from 1 (never) to 5
(always). Answering 2 or less to this question indicates that respondent is at risk for
low HL and likely needs assistance regarding health-related information. The SILS is
quite effective in detecting inadequate health literacy among diverse populations
(Chew et al., 2008; Cordasco, Idalid, Homeier, & Sarkisian, 2010; Morris, MacLean,
Chew, & Littenberg, 2006).
In addition to screening for low health literacy however, health care providers
need to be willing to tailor communication and health education to the needs of
all patients. While health care organizations should have low health literacy inter-
vention programs and=or materials in place for patients identified with low health
literacy, many experts now advocate Universal Precautions for health literacy
(DeWalt et al., 2011). This approach assumes that everyone can have difficulty
understanding medical information and requires that health care providers and orga-
nizations structure their services and patient interactions to minimize the risk that
any one of their patients will not understand the health information they are given.
Clear communication practices can improve care for all patients regardless of their
level of health literacy (DeWalt et al., 2011).
Importantly, substantial barriers to increasing nursing education on health liter-
acy exist. Many nurses believed that their health care organization viewed health lit-
eracy as a low priority and were concerned about the time and costs of implementing
a health literacy program, particularly in settings with great cultural and ethnic
diversity. These barriers are consistent with those reported in previous studies
(Schlichting et al., 2007; Jukkala et al., 2009). To improve recognition and knowl-
edge of health literacy by health care providers in diverse health care systems, health
care organizations must make it a priority and make educational programs
304 A. Macabasco-O’Connell and E. K. Fry-Bowers

accessible to their staff. Such education also may assist in the identification and
appropriate education of patients with low health literacy and translate into better
health outcomes for our patients.
To overcome some of these organizational barriers, and to improve nursing edu-
cation about health literacy, health literacy education should become part of nursing
school curriculum. Nurses comprise the largest segment of the health care force and
are responsible for ensuring that patients are educated about their self-care. Nursing
educators must include health literacy during educational preparation at every level
to adequately prepare student nurses for the increasing challenges of the diverse
clinical settings. For example, the University Health System Consortium (2008)
and the American Association of Colleges of Nursing have developed a program
aimed for nursing at the baccalaureate level. This partnership created a residency
program for BSN graduates that supports further education addressing health liter-
acy and patient teaching in university hospitals throughout the country (Jukkala
et al., 2009). Further, given the large number of advanced practice nurses in this
study and in the United States, the Nursing Organization of Nurse Practitioner Fac-
ulties (NONPF; 2006) recommends that nursing schools include a greater emphasis
on health literacy within the nurse practitioner curriculum. Training of health care
providers, specifically nurses, can improve provider communication skills to opti-
mize patient understanding, promote shared decision-making, and enhance self-care
behaviors that can translate into improved quality and safety (Rothman, Yin,
Mulvaney, Co, Homer, & Lannon, 2009).

Limitations
This research used a small convenience sample of individuals who were willing to
complete the survey. Although, we randomly selected potential participants, selec-
tion bias may be possible given the low response rate. Further, nurses who decided
to participate in the survey may be those most sensitive to the issues surrounding
health literacy, thus significantly reducing the generalizability of these findings.

Future Directions
Low health literacy is common. Given the increasing diversity of the patients within
our health care settings, and the demands and complexity of health information and
tasks, allowing poor health literacy will become even more problematic. The IOM
health literacy report acknowledges that poor health literacy has become an epi-
demic problem resulting from the way health information is communicated to
patients (Parker & Ratzan, 2010). Future directions and research should focus on
developing and testing interventions on ways to improve communication and health
outcomes. In addition, targeting interventions to those with different cultural beliefs
and values are greatly needed because these factors, independent of health literacy
status, also contribute to impaired communication and comprehension of health
information (Kountz, 2009).
At the health care systems level, examining how health literacy in their patient=
family population is determined and what programs are in place to address low lit-
eracy is needed. Further, we must study the role of rapid health literacy screening
tools to assess literacy for large populations and determine if this approach is effec-
tive in improving quality of care. Additionally, health care systems need to facilitate
 Knowledge and Perceptions of Health Literacy 305

and support continuing education regarding health literacy for nurses and other
health care providers.
Nursing education should also include a greater emphasis on integrating health
literacy within nursing school curriculum. Future research should address testing
educational strategies for nurses and how increasing knowledge and understanding
of health literacy can improve patient health outcomes.

References
Artinian, N. T., Lange, M. P., Templin, T. N., Stallwood, L. G., & Hermann, C. E. (2002).
Functional health literacy in an urban primary care clinic. Internet Journal of Advanced
Nursing Practice, 5(2), 11.
Bade, E., Evertsen, J., Smiley, S., & Banerjee, I. (2008). Navigating the health care system: A
view from the urban medically underserved. Wisconsin Medical Journal, 107(8), 374–379.
Baker, D. W., Parker, R. M., Williams, M. V., & Clark, S. (1998). Health literacy and the risk
of hospital admission. Journal of General Internal Medicine, 13(12), 791–798.
Baker, D. W., Wolf, M. S., Feinglass, J., Thompson, J. A., Gazmararian, J. A., & Huang, J.
(2007). Health literacy and mortality among elderly persons. Archives of Internal
Medicine, 167, 1503–1509.
Bass, P. F., Wilson, J. F., Griffith, C. H., & Barnett, D. R. (2002). Residents’ ability to identify
patients with poor literacy skills. Academic Medicine, 77(10), 1039–1041.
Brown, D. L., Ludwig, R., Buck, G. A., Durham, D., Shumard, T., & Graham, S. S. (2004).
Health literacy: Universal precautions needed. Journal of Allied Health Professions, 33(2),
150–155.
Brown, J. B., Stewart, M., & Ryan, B. L. (2003). Outcomes of patient-provider interaction. In
T. L. Thompson, A. M. Dorsey, K. I. Miller, & R. Parrott (Eds.), Handbook of health
communication (pp. 141–162). Mahwah, NJ: Lawrence Erlbaum.
Campbell, M. J., Edwards, M. J., Ward, K. S., & Weatherby, N. (2007). Developing a parsi-
monious model for predicting completion of advance directives. Journal of Nursing
Scholarship, 39(2), 165–171.
Carolan, M. (2007). Health literacy and the information needs and dilemmas of first-time
mothers over 35 years. Journal of Clinical Nursing, 16(6), 1162–1172.
Chew, L. D., Griffin, J. M., Partin, M. R., Noorbaloochi, S., Grill, J. P., Snyder, A., et al.
(2008). Validation of screening questions for limited health literacy in a large VA
outpatient population. Journal of General Internal Medicine, 23(5), 561–566.
Cordasco, K. M., Idalid, F., Homeier, D. C., & Sarkisian, C. (2010). Sensitivities of three single
item literacy screener questions in geriatric monolingual Spanish-speaking patients. Paper
presented at the Second Annual Health Literacy Research Conference, Bethesda, MD.
Davis, T. C., Jackson, R. H., Mayeaux, E. J., George, R. B., Murphy, P. W., & Crouch, M. A.
(1993). Rapid estimate of adult literacy in medicine: A shortened screening instrument.
Family Medicine, 25, 391–395.
DeWalt, D. A., Broucksou, K. A., Hawk, V., Brach, C., Hink, A., Rudd, R., et al. (2011).
Developing and testing the health literacy universal precautions toolkit. Nursing Outlook,
59(2), 85–94.
Holzemer, W. L., Bakken, S., Portillo, C. J., Grimes, R., Welch, J., Wantland, D., et al.
(2006). Testing a nurse-tailored HIV medication adherence intervention. Nursing
Research, 55(3), 189–197.
Howard, D. H., Gazmararian, J., & Parker, R. M. (2005). The impact of low health literacy on
the medical costs of Medicare managed care enrollees. The American Journal of Medicine,
118(4), 371–377.
Institute of Medicine. (2004). Health literacy: A prescription to end confusion. Washington,
D.C.: National Academies Press.
306 A. Macabasco-O’Connell and E. K. Fry-Bowers

Jukkala, A., Dupree, J. P., & Graham, S. (2009). Knowledge of limited health literacy at an
academic health center. The Journal of Continuing Education in Nursing, 40(7), 298–302.
Keller, D. L., Wright, J., & Pace, H. A. (2008). Impact of health literacy on health outcomes in
ambulatory care patients: A systematic review. Annals of Pharmacotherapy, 42(9),
1272–1281.
Kelly, P. A., & Haidet, P. (2007). Physician overestimation of patient literacy: A potential
source of health care disparities. Patient Education and Counseling, 66(1), 119–122.
Kountz, D. S. (2009). Strategies for improving low health literacy. Postgraduate Medicine,
121(5), 171–177.
Mason, D. J. (2001). Promoting health literacy. American Journal of Nursing, 101(2), 7.
Morris, N. S., MacLean, C. D., Chew, L. D., & Littenberg, B. (2006). The single item literacy
screener: Evaluation of a brief instrument to identify limited reading ability. BioMed Cen-
tral Family Practice, 7(21). Retrieved from http://www.biomedcentral.com/1471-2296/
7/21. doi:10.1186=1471-2296-7-21
National Organization of Nurse Practitioner Faculties. (2006). Health literacy in nurse prac-
titioner education: The NONPF perspective. Victoria Weill, MSN, CRNP, National
Organization of Nurse Practitioner Faculties, University of Pennsylvania, School of
Nursing, 9=14=2006. Available at http://www.iom.edu/~/media/Files/Activity%20Files/
PublicHealth/HealthLiteracy/13WeillWeillHealthLiteracyStrategiesforNursepracticioners.
pdf
National Work Group on Literacy & Health. (1998). Communicating with patients who
have limited literacy skills: Report of the National Work Group on Literacy and Health.
Journal of Family Practice, 46, 168–176.
Nielsen-Bohlman, L., Panzer, A. M., & Kindig, D. A. (Eds.). (2004). Health literacy: A pre-
scription to end confusion. Washington, DC: National Academies Press.
Parker, R. M., Baker, D. W., Williams, M. V., & Nurss, J. (1995). The test of functional health
literacy in adults: A new instrument for measuring patients’ literacy skills. Journal of
General Internal Medicine, 10, 537–541.
Parker, R., & Ratzan, S. C. (2010). Health literacy: A second decade of distinction for
Americans. Journal of Health Communication, 15(Suppl 2), 20–33.
Rodgers, E. S., Wallace, L. S., & Weiss, B. D. (2006). Misperceptions of medical understand-
ing in low-literacy patients: Implications for cancer prevention. Cancer Control, 13(3),
225–229.
Rothman, R. L., Yin, H. S., Mulvaney, S., et al. (2009). Health literacy and quality: Focus on
chronic illness care and patient safety. Pediatrics, 124(Suppl 3), S315–S326.
Sanders, L. M., Thompson, V. T., & Wilkinson, J. D. (2007). Caregiver health literacy and the
use of child health services. Pediatrics, 119(1), e86–92.
Schlichting, J. A., Quinn, M. T., Heuer, L. J., Schaefer, C. T., Drum, M. L., & Chin, M. H.
(2007). Provider perceptions of limited health literacy in community health centers.
Patient Education & Counseling, 69(1–3), 114–120.
Schwartzberg, J. G., Cowett, A., VanGeest, J. B., & Wolf, M. S. (2007). Communication tech-
niques for patients with low health literacy: A survey of physicians, nurses, and pharma-
cists. American Journal of Health Behavior, 31(Supp), S96–S104.
Schwartzberg, J. G., VanGeest, J. B., & Wang, C. C. (Eds.). (2005). Understanding health lit-
eracy: Implications for medicine and public health. Washington, D.C.: AMA Press.
Vernon, J. A., Trujillo, A., Rosenbaum, S., & DeBuono, B. (2007). Low health literacy: Impli-
cations for national health policy. George Washington University, Center for Health
Policy Research.
Weiss, B. D., Mays, M. Z., Martz, W., Castro, K. M., DeWalt, D. A., Pignone, M. P., et al.
(2005). Quick assessment of literacy in primacy care: The newest vital sign. Annals of
Family Medicine, 3(6), 514–522.
Williams, M. V., Baker, D. W., Honig, E. G., Lee, T. M., & Nowlan, A. (1998). Inadequate
literacy is a barrier to asthma knowledge and self-care. Chest, 114(4), 1008–1015.
 Knowledge and Perceptions of Health Literacy 307

Williams, M. V., Baker, D. W., Parker, R. M., & Nurss, J. R. (1998). Relationship of func-
tional health literacy to patients’ knowledge of their chronic disease: A study of patients
with hypertension and diabetes. Archives of Internal Medicine, 158(2), 166–172.
Williams, M. V., Davis, T., Parker, R. M., et al. (2002). The role of health literacy in patient-
physician communication. Family Medicine, 34, 383–389.
Wilson, M. (2009). Readability and patient education materials used for low-income popula-
tions. Clinical Nurse Specialist, 23(1), 33–40.
Wolf, M. S., Williams, M. V., Parker, R. M., Parikh, N. S., Nowlan, A. W., & Baker, D. W.
(2007). Patients’ shame and attitudes toward discussing the results of literacy screening.
Journal of Health Communication: International Perspectives, 12(8), 721–732.
Wood, M. R., Price, J. H., Dake, J. A., Telljohann, S. K., & Khuder, S. A. (2010). African
American parents’=guardians’ health literacy and self-efficacy and their child’s level of
asthma control. Journal of Pediatric Nursing, 25, 418–427.

Appendix: Suggested Resources

Health Literacy Universal Precautions Toolkit
Based on the principles of universal precautions, this toolkit gives providers exam-
ples of specific actions they can take to make health information more understand-
able for all patients. It may be used by all levels of staff in practices providing
primary care for adults and=or pediatric patients. A copy of the toolkit may be
downloaded from: http://www.ahrq.gov/qual/literacy/.

Websites
Agency for Healthcare Research and Quality, Health Literacy and Cultural Compe-
tency, available at http://www.ahrq.gov/browse/hlitix.htm#Literacy
NC Program on Health Literacy, available at http://www.nchealthliteracy.org/
Health Literacy Missouri, available at http://www.healthliteracymissouri.org/
GroupHealth Research Institute, Program for Readability in Science and Medicine
(PRISM), available athttp://www.grouphealthresearch.org/capabilities/readability/
readability_home.html