Healthcare professionals’ views health literacy

Nursing and allied health professionals’ views about using health

literacy screening tools and a universal precautions approach to
communication with older adults: a qualitative study

Brooks, Charlotte1,2, Ballinger, Claire3, Nutbeam, Don1,4, Mander Clare5 and

Adams, Jo1

Affiliations
1Faculty of Health Sciences, University of Southampton, Southampton, UK
2University Hospitals Southampton NHS Foundation Trust, Southampton, UK
3Faculty of Medicine, University of Southampton, Southampton UK
4School of Public Health, University of Sydney, Sydney, Australia
5Solent NHS Trust, Southampton, UK

Corresponding author at:

Dr Charlotte Brooks
Building 67, Nightingale Building
Highfield Campus
University of Southampton
SO17 1BJ
Telephone: +44 7917643206
E-mail: C.Brooks@soton.ac.uk

Word count: 4758 words

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Healthcare professionals’ views health literacy

Nursing and allied health professionals’ views about using health

literacy screening tools and a universal precautions approach to
communication with older adults: a qualitative study

Abstract

Purpose: Health literacy describes individuals’ abilities to access, understand and

use health information. Lower health literacy is associated with poor health
outcomes, is more common among older adults and impacts on the effectiveness of
rehabilitation/self-management interventions. This research explored nursing and
allied healthcare professionals’ views about identifying and responding to older
adults’ health literacy needs.
Methods: Qualitative focus groups were conducted with a purposive sample of 22
UK nursing and AHPs working with older adults. Focus groups were audio-recorded,
transcribed verbatim and analysed using framework approach.
Results: Participants used a variety of practices to identify older patients’ health
literacy levels, but primarily relied on subtle cues. Participants lacked knowledge and
confidence in identifying and addressing health literacy needs. Participants
expressed concerns about patient reactions and described practical barriers to using
recommended health literacy strategies.
Conclusions: Participants recognised the importance of addressing patients’ health
literacy needs, but do not routinely use health literacy strategies, lack confidence and
have reservations about recommended health literacy strategies. This impacts on
healthcare professionals’ abilities to support patients to self-manage and participate
in rehabilitation. Health literacy education for health professionals should consider
barriers to using health literacy strategies and be tailored to accommodate variation
in teams and professions.

Keywords:
Communication; health literacy; measurement; universal precautions; older adults;
healthcare professionals

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Healthcare professionals’ views health literacy

1. Introduction

The past 25 years have seen remarkable growth in interest in health literacy.
Governments around the world have adopted national policies and programs to
improve health literacy, and have begun to require health services to respond
systematically to the challenge of low health literacy among patients and populations
[1, 2, 3, 4, 5, 6, 7]. Research into how best to meet these challenges has grown
steadily with a number of studies reporting on interventions to address the practical
challenges of low health literacy in clinical settings, and describing approaches to
improving health literacy in different clinical and community populations [8, 9, 10].

Despite increasing interest in the issue, the consequences of inadequate health

literacy remain poorly understood, and practical responses to this challenge have not
been established. One in three older adults (aged 52 and over) has inadequate
health literacy [11]. In practical terms, this means that they have difficulty in
interpreting and understanding even basic medicine information such as dose and
frequency. After adjusting for personal and sociodemographic characteristics, lower
health literacy is associated with increased mortality and morbidity, increased risk of
admission to hospital and reduced ability to self-manage long-term conditions [8, 11,
12]. Lower health literacy is associated with reduced adherence to healthcare
professionals’ instructions/recommendations, reduced knowledge, self-management
behaviours and mobility and poorer overall health, with clear implications for self-
management and rehabilitation [13, 14]. Health literacy has been defined and
conceptualised in multiple ways [15], but almost all definitions of health literacy in
common use have the same core elements describing the skills and social resources
that enable individuals to obtain, understand and use health information. Health
literacy represents an observable set of skills that will differ from individual to
individual.

Patient understanding of health information is influenced by differences in healthcare

professionals’ use of communication methods, media and educational content and
the environment in which patient-healthcare professional interactions occur [15]. For
these reasons, significant responsibility lies with healthcare professionals and the

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Healthcare professionals’ views health literacy

health service organisation in which they operate to be responsive to the health

literacy needs of patients. Rehabilitation professionals aim to assess patients
holistically and are particularly concerned with patients’ abilities to self-manage.
Therefore, it is important for rehabilitation professions to consider a patients’ ability to
access, understand and use health information [16]. However, previous research
indicates healthcare professionals, including nurses and allied health professionals,
are frequently using medical jargon, do not clarify medical jargon used, rarely use
recommended health literacy strategies such as the “Teach-Back” technique and
lack knowledge about health literacy [17, 18, 19, 20, 21]. Little research has explored
how healthcare professionals respond to the issue of health literacy in clinical
practice and the reasons why healthcare professionals are currently seldom using
recommended health literacy strategies.

Broadly speaking, two alternative strategies have been used to meet patients’ health
literacy needs. The first is to actively screen a patient to make an assessment of
their health literacy and to adjust communications to fit with the individual need [22,
23, 24]. The second is to adopt “universal precautions”, which involves using the
same communication strategies with patients of all health literacy levels, including
clear health communication, the Teach-Back technique (confirmation of patient
understanding through asking the patient to teach content back to the clinician) and
multimodal education delivery [22, 25, 26]. Both health literacy screening and use of
universal precautions is promoted and used in clinical practice [22, 24, 25, 26].

Healthcare professionals frequently overestimate their patients’ health literacy [18,

27, 28], and those advocating screening have developed, tested and validated
simple screening tools for use in clinical environments to provide a practical solution
to this problem. Examples of health literacy screening tools include the Test of
Functional Health Literacy in Adults (TOFHLA), Rapid Estimate of Adult Literacy in
Medicine (REALM), Newest Vital Sign (NVS), All Aspects of Health Literacy Scale
(AAHLS) and Single Screening Question (SSQ) [24]. There has been much interest
in developing and testing screening tools in the USA and they have been found to be
a useful adjunct to the personal experience of the clinician. Several studies that have
used these screening instruments have revealed that most participants felt
comfortable with health literacy screening [29, 30]. Other studies, however, have
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Healthcare professionals’ views health literacy

revealed that some patients may feel shame arising from low literacy or health
literacy, are uncomfortable in disclosing their difficulties to healthcare professionals
and may go to significant lengths to hide such difficulties [31, 32, 33, 34]. Whilst
these issues may provide justification for screening, others have argued that health
literacy screening could result in harm to patients through causing shame or anxiety
[26, 35, 36]. In response to these concerns the use of universal precautions has
been recommended [22, 26], recognising that all patients would benefit from clear
and simple healthcare communication regardless of their health literacy level [37].

To increase the likelihood of healthcare professionals adopting health literacy

strategies, it is necessary to explore their views on existing strategies for meeting
health literacy needs. Previous studies have examined healthcare professionals’
perceptions regarding health literacy [20, 38, 39], but none to date have explored
healthcare professionals’ views regarding using health literacy screening and
universal precautions in a UK setting using qualitative methodology, which is useful
for illuminating complex issues. Given the differences in healthcare systems and
training of healthcare professionals, exploring this issue in a UK context is important.
Exploring this issue from a nursing and allied health professional perspective also
offers useful insights. This paper describes a study exploring nursing and allied
health professionals’ practices for identifying and responding to differences in older
adults’ health literacy skills and their views about using screening tools and universal
precautions in clinical practice.

2. Materials and methods

2.1. Study design

Because there are known differences in opinion on how best to identify and manage
inadequate health literacy in clinical practice [15, 40], focus groups were used to
provide a methodology to enable healthcare professionals to explore and debate
these issues, gain a range of different perspectives and identify group norms [41, 42,
43].

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Healthcare professionals’ views health literacy

2.2. Participants

Participants were recruited from one community and mental health NHS Trust in the
South of England. Purposive sampling was used to recruit a range of nursing and
allied health professional teams who work with older adults in different areas of
clinical practice [44]. To gain heterogeneous focus group composition and insight
into how clinical teams approach health literacy [42, 44], pre-existing multidisciplinary
clinical teams were recruited. Participants were included if they worked clinically with
older adults and were excluded if they had a close working relationship with the
researcher (CBr) or worked in mental health services to reduce the likelihood of
participants having more health literacy knowledge gained through working with the
researcher and resulting from different mental healthcare approaches. Clinical teams
who were likely to work with older adults were retrieved from the NHS Trust website.
An e-mail was sent to managers of potentially eligible teams, who then applied the
inclusion criteria and shared the invitation, participant information sheet and consent
form with their colleagues as applicable. Focus groups were arranged with teams of
interested individuals who signed a written consent form before participating. Study
design and documentation received ethical approval from the Faculty of Health
Sciences ethics committee at the host University (Reference: 12154). Recruitment to
focus groups stopped when data saturation had been reached [45].

2.3. Data collection

Four focus groups were conducted in meeting rooms in the participants’ offices and
facilitated by author CBr, a doctoral researcher and occupational therapist at the time
with previous experience of conducting qualitative research. All data were audio-
recorded and transcribed verbatim. A note taker attended each focus group to log
the order in which participants spoke to assist with transcription. A focus group topic
guide (see supplementary materials) was used flexibly and open questions were
asked in order to explore healthcare professionals’ practices and views about
identifying and responding to variations in older adults’ health literacy levels. Specific
views were also sought about using health literacy screening tools and universal
precautions in clinical practice. The topic guide was developed using focus group
guidance [41, 43] and structured around the functional, interactive and critical health
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Healthcare professionals’ views health literacy

literacy framework and causal model linking health literacy to health outcomes [40,
46, 47]. The focus group topic guide was piloted with two clinical colleagues and a
public contributor; changes were made to wording and order of questions. Printed
paper copies of the REALM, NVS-UK, SSQ and AAHLS were used to facilitate
discussions regarding the use of screening in clinical practice [48, 49, 50, 51]. These
tools are widely used in the literature and assess different components of health
literacy [23]. After the groups, health literacy resources were provided. Field notes
were made after the focus groups.

2.4. Data analysis

Author CBr transcribed the data from the focus groups and interrogated the
transcripts using Gale’s stages of framework analysis [52]. Qualitative data analysis
software QSR NVivo 10 was used to analyse the data. Findings were shared with
participants who were given an opportunity to comment as a method of validating the
researcher’s interpretation of responses.

3. Results

3.1. Participant characteristics

Eleven clinical teams were invited to participate in this research. Three teams were
unable to participate due to clinical time restraints or low staffing levels. Another
team did not respond to the researcher’s invitation. Seven different clinical teams
from one NHS Trust participated in four focus groups. All focus groups consisted of
clinical teams who usually work together with older adults. Focus groups were
conducted between January and March 2015. Focus group composition and
demographic data are presented in Supplementary Table 1.

INSERT SUPPLEMENTARY TABLE 1 ABOUT HERE

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Healthcare professionals’ views health literacy

3.2. Main findings

The mean focus group length was 62 minutes (range: 51-74 minutes). Three main
themes were identified: (1) identifying older adults’ health literacy levels; (2) current
practices and barriers to responding to variations in older adults’ health literacy
levels and (3) views about using health literacy screening and universal precautions.
Context is provided for the quotes by denoting the focus group number (e.g. FG1),
participant number within the group (e.g. P1) and participant profession (e.g. nurse).

3.2.1. Identifying older adults’ health literacy levels

Practices participants described using for identifying health literacy varied according
to individuals, professions and teams; there was no standard practice. Many
participants discussed using verbal and non-verbal indicators of low health literacy,
interpreted as tacit cues about health literacy. Participants primarily focused on the
identification of literacy abilities, which appeared to be linked to their understanding
of health literacy. Practices were often ones which could be routinely integrated into
standard treatment processes by individual professions or clinical teams. For
instance, it was only nurses who discussed picking up cues regarding patients’
reading ability during medication reviews (nurses being the only healthcare
profession interviewed who routinely completed medication reviews):

I think that us nurses, because we always go through the patient's drug list...
that’s a very big indicator… that the patients can't read or… have very poor
reading skills. And many of the drug names sound the same… and patients
often get them muddled up (FG1, P2, nurse, 35 years clinical experience).

Participants also inferred their patients’ health literacy levels using indicators such as
patients’ use of simple language, body language, facial expressions or level of
interaction.

If they're not looking engaged, then you probably know they're not getting
everything… and you can do assessments and sort of ask and check. But it’s

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Healthcare professionals’ views health literacy

more just a looking [P5: you can tell]… if they’ve sort of got a frown, or you
know whatever, then you know (FG3, P4, psychologist, 4 years clinical
experience).

This quote illustrates a greater reliance on picking up cues based on body language
and facial expressions than assessing understanding.

Only participants in the neurological service focus group reported asking about
reading and writing as part of their standard assessments, which may make it more
acceptable to ask about functional literacy abilities. Contrastingly, participants in the
chronic fatigue and persistent pain service and palliative care focus group advised
that they do not ask patients about literacy: ‘I mean we don’t ask specifically’ (FG3,
P3, physiotherapist, 19 years clinical experience). Participants appeared to feel
uncomfortable about asking patients directly about their literacy abilities. One
participant described how asking about literacy is a bit ‘taboo’, possibly as a result of
societal attitudes. The participant below discussed avoiding directly asking about
literacy abilities by asking if patients require reading glasses.

I always wonder when we’re asking our patients to fill in our questionnaires,
whether they can actually read it… so I usually curb the subject of simply
asking them, ‘Can you read?’ by asking them, ‘Do you need reading glasses?’
Rather than just simply ask, because I feel there’s an embarrassment (FG3,
P2, physiotherapist, 8 years clinical experience).

Participants also used techniques to assess patients’ understanding, which

appeared to be integrated into their standard practice. Nurses in the palliative care
focus group discussed routinely asking patients about their understanding of their
diagnosis while allied health professionals in the chronic fatigue service/persistent
pain service focus group reported using routine follow-up calls with patients to check
their understanding of education sessions. No participants mentioned the Teach-
Back technique by name or discussed tailoring information based on assessing
understanding.

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Healthcare professionals’ views health literacy

Participants felt having more clinical experience and time with patients assisted with
making the ‘clues’ about low health literacy more noticeable. A nurse participant (P5,
21 years clinical experience) in the palliative care focus group self-identified as
‘experienced’ and discussed how ‘if you’re experienced, you would pick it [the clues
about low health literacy] up’. However, later she admitted that there have been
instances where a patient’s low literacy levels were not identified, resulting in him
missing appointments. She reflected: ‘we didn’t actually pick up on it straightaway’.
Participants noted the following barriers to identifying older adults’ health literacy:
uncertainty about how to identify health literacy levels and embarrassment/shame
which patients may feel about their health literacy.

3.2.2. Current practices for and barriers to responding to variations in older

adults’ health literacy levels

Both nursing and allied health professionals felt the most important strategy for
meeting older adults’ health literacy needs was to build relationships and trust with
older adults to encourage them to open up about their health literacy needs:

We had to build a good rapport with him to start with, because he was very
cagey about… he didn’t want to kind of admit that he had literacy problems
(FG2, P4, occupational therapist, 10 years clinical experience).

Participants identified a range of practices they use for responding to variations in

health literacy such as tailoring education to the individual by providing information in
alternative formats, making more time for individuals with lower health literacy,
repeating information and establishing information preferences. Despite this,
participants rarely mentioned having discussions with patients about their health
literacy needs. Participants also discussed barriers to tailoring information such as
having to look harder for information in different formats and group education
programmes; in these instances they described pitching sessions at what they
perceived to be an average ability. As illustrated below, a barrier to tailoring
information discussed in all focus groups was time pressures.

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Healthcare professionals’ views health literacy

It would be nice if we had the time to assess each person’s learning style
[several participants’ agreement] and level of kind of literacy and ability. But
feasibly I don’t think we do, so I think it is more just about trying to have
information in different formats so that some of it’s verbal, some of it’s written
and with pictures (FG3, P5, psychologist, 5 years clinical experience).

When discussing tailoring written information to different health literacy levels, a

nurse participant (P2, 35 years clinical experience) in the palliative care focus group
commented, ‘I don’t think that’s practical’ and an occupational therapist (P7, 20 years
clinical experience) agreed suggesting that it is too costly and time consuming given
that information is always needing updating. Resulting from time pressures,
healthcare professionals reported using older adults’ social networks to fill gaps in
the service and mitigate the risk of low health literacy.

…the pressures of the NHS, and time creep in [several participants: yeah],
and… If I’m not able to provide an audio recording or something like that, I
would usually maybe involve the family in and maybe more significant others
even more so, to try and involve them and use their input (FG2, P1,
psychologist, 7 years clinical experience).

Participants also identified a lack of knowledge and confidence in knowing how to

respond to variations in health literacy levels. This applied to both individuals with
low and high health literacy. Across all focus groups, there was uncertainty about
what practices to use with individuals with low health literacy and the perception that
individuals with higher health literacy pose ‘different challenges’. Whilst there is
much focus in the literature on developing patients’ health literacy abilities, both
nursing and allied healthcare professionals in this study felt individuals with higher
health literacy could be ‘challenging’ and ‘intimidating’, have ‘got their own opinions
on things’, often come to sessions ‘armed with’ articles and questions and have high
expectations about information provided.

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Healthcare professionals’ views health literacy

3.2.3. Views about using health literacy screening and universal

precautions

No participants reported having used health literacy screening tools. Positive views
about using health literacy screening tools included the possibility of increasing
literacy disclosure and creating a more ‘literacy friendly’ environment. One
participant discussed the potential of using health literacy screening tools to begin a
collaborative dialogue with patients about their health literacy needs.

I like this [AAHLS]… in terms of being able to gauge with them, and actually
allow that discussion… actually I could use some of those questions. It’s kind
of beginning that dialogue with them (FG4, P2, occupational therapist, 13
years clinical experience).

Participants in all focus groups expressed reservations about the concept of using
health literacy screening tools in clinical practice. In three focus groups, participants
reached a consensus about health literacy screening being unnecessary in their
service or not adding anything new. Palliative care focus group participants felt the
nature of their patients’ conditions rendered health literacy screening irrelevant and
an unnecessary stress for the patients. They also suggested that they were able to
gauge their patients’ health literacy levels without screening.

Participants in all focus groups revealed concerns about patients’ reactions to

screening tools, such as feeling ‘anxious’ or ‘insulted’. Both nursing and allied health
professionals also perceived health literacy screening as being akin to ‘testing’ the
patient.

Moderator: What would be your thoughts about using screening tools?

FG1, P1, nurse, 15 years clinical experience: I wouldn’t want to.
Moderator: Why is that?
FG1, P1: I think I would feel as if I was testing them.
FG1, P7, occupational therapist, 20 years clinical experience: As if you’re
testing them.

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Healthcare professionals’ views health literacy

FG1, P1: Yeah! As if you’re testing them and… I feel as if they may be
insulted.

Finally, some nursing and allied health professional participants viewed health
literacy screening tools as an administrative and time burden, or as one nurse (FG1,
P5, 21 years clinical experience) commented: ‘[it would be] another hurdle to try and
get through when you go and do an assessment… another bit of paperwork’.
Participants discussed how finding out patients’ health literacy is redundant unless
healthcare can then be meaningfully tailored to patients’ needs, which has time
implications.

Several participants discussed how most patients desire simple information,

therefore using universal precautions could benefit the majority of people and may
only upset a few patients. However, many participants expressed concerns about
some patients (especially their highly literate patients) feeling offended or patronised
by providing accessible information to all patients. Participants used terminology
such as ‘basic’ and ‘childlike’ when referring to simple and clear messages or using
pictures and were concerned about patients’ reactions to this.

They say the average reading age of adults is about six years… I know we’ve
got to put all of our literature through the… whatever team it is. Sometimes
when it comes back I’m thinking it’s a bit almost offensive to some people.
Because we do have some intelligent and literate patients and I would be
uncomfortable perhaps giving some things to them (FG1, P2, nurse, 35 years
clinical experience).

Some participants also appeared to have concerns about patients questioning their
professional status and knowledge levels if information is simplified.

…there could be a detriment for people who have quite a good understanding,
when you start to simplify a lot of the information. They could start to think, why
is this physio here? He doesn’t know anything (FG4, P1, physiotherapist, 10
years clinical experience).

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Healthcare professionals’ views health literacy

Many participants felt a strategy intended to suit everyone would not work. They
argued that patients have different information needs/preferences and thus,
information should be tailored appropriately.

4. Discussion

This study offers new insights into nursing and allied healthcare professionals’
perspectives about how to respond to the variable health literacy needs of patients,
as well as specific responses to the feasibility and desirability of using universal
precautions or health literacy screening in a clinical environment.

In this study we found that both nursing and allied health professionals strongly
relied on picking up subjective indicators of low health literacy, including verbal and
non-verbal cues. This is similar to previous work by Smith, Petrak [39] with
oncologists and suggests that the participants in this study have confidence in their
professional experience to make the necessary judgements about their patients, and
adjust their communications accordingly. However, none of the participants reporting
seeking feedback to confirm the accuracy of their judgements. None of the
participants in this study had used health literacy screening tools, and there was little
enthusiasm for their adoption in routine practice.

Most participants discussed and appeared to understand health literacy in terms of

patients’ literacy skills (reading and writing abilities). This is as opposed to
considering health literacy as a broader set of skills, including comprehension,
listening and speaking. This conceptualisation influenced the practices they
suggested for identifying and managing patients with lower health literacy. This
functional conception of health literacy is not untypical in a clinical environment, but
is less comprehensive than current thinking about health literacy. As indicated earlier,
health literacy is understood to mean more than functional literacy abilities [15], and
includes knowledge, comprehension, the ability to discriminate between sources of
information, interactive and critical appraisal abilities [47] – those skills that enable
patients to play a more active role in shared decision-making and self-management
of long term conditions.

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Healthcare professionals’ views health literacy

Participating nursing and allied health professionals used practices for identifying
health literacy levels which could be routinely integrated into their practice, such as
assessing patients’ baseline understanding of conditions, assessing understanding
during follow-up calls or picking up indicators of low literacy during medication
reviews. These findings suggest that, for these participants, some reflection about
the integration of appropriate health literacy strategies into their usual professional
activities might be useful. For instance, nurses, who frequently conduct medication
reviews, could be encouraged and supported to use these activities to assess health
literacy. Allied health professionals could consider checking health literacy
requirements before inviting patients to group education, always assessing baseline
understanding and checking understanding during follow-up telephone calls.

Although no participants had practical experience in using available screening tools,

they were perceived as time consuming, an administrative burden and participants
expressed concerns about testing being redundant if there is no time to meaningfully
tailor information. Similar to previous studies [38, 39], both nursing and allied health
professionals in this study perceived health literacy screening tools as potentially
anxiety-inducing, embarrassing, stigmatising or offensive for patients. Participants
felt screening would not add anything new, partly reflecting a general view that they
assessed health literacy intuitively by being attuned to verbal and non-verbal
indicators through the course of a consultation. This sits in contrast to previous
research (and the admission of some of our participants) that healthcare
professionals regularly inaccurately identify patients’ heath literacy [18, 53].

Surprisingly, both nursing and allied health professionals in this study were equally
dubious about the concept of using universal precautions, expressing concern about
the potential of offending or patronising highly literate patients by providing simplified
information. Interestingly, some suggested that using universal precautions may
result in patients questioning their professional status and knowledge levels,
suggesting that some may be concerned about their expert status being questioned.

We know from previous research that patients have a broad range of information
preferences which may differ according to their circumstances, and that asking
patients about their information and communication preferences will enable higher
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Healthcare professionals’ views health literacy

quality and more productive clinical interactions [54, 55, 56]. Previous research
indicates older adults prefer clear and accessible (easy to understand) verbal and
written information irrespective of their assessed health literacy level [57, 58, 59].
Our study identified a gap between what older adults desire in provider-patient
interactions and healthcare professionals’ perceptions of these interactions. This
research suggests this may be due to healthcare professionals’ concerns about how
patients will react or perceive them as a professional if they simplify communication,
with potential implications for professional identity. Professional education regarding
health literacy should focus on addressing healthcare professionals’ concerns and
barriers to providing clear and accessible communication.

To date, the majority of health literacy research and guidance focusses on reducing
the “risks” of low health literacy [37, 40, 60, 61]. This research suggests that
healthcare professionals are aware of a range of different needs in clinical practice
but need to be better equipped to respond to this variation. Participants reported
using practices such as building trust, tailoring interactions and involving social
networks to meet varying health literacy needs. This is supported by previous
research findings indicating these factors are important for older adults with varying
health literacy levels [59]. Building trust and involving social networks to meet
patients’ health literacy needs are not routinely recommended health literacy
strategies. These strategies are more focussed on treating patients holistically and
benefit from further consideration in the health literacy field. In the UK and USA,
there is a policy drive towards empowering patients to meaningfully engage with their
healthcare [1, 62, 63]. One way of doing this is through healthcare professionals
tailoring information to individuals’ needs. However, achieving this goal may be
problematic if healthcare professionals lack confidence in engaging with patients with
higher health literacy and different information needs, as this study has
demonstrated.

There are a number of limitations to this research. The sample was relatively small
and limited to nurses and allied health professionals, therefore findings may not be
transferable to different healthcare professions. However, nurses and allied health
professionals typically have more time during consultations than doctors and GPs,
therefore similar barriers may be seen. Only three males participated in the focus
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Healthcare professionals’ views health literacy

groups, but this may be indicative of more females working as healthcare

professionals [64]. Use of “naturally occurring” groups enabled participation of a
range of healthcare professionals who normally work together. However, there could
be “clustering” effects in the form of group norms that may limit the transferability of
the results. Although the study was conducted in one country, studies from other
countries are reporting similar barriers to identifying and meeting health literacy
needs [20, 39]. Finally, the researcher was conducting her doctoral studies on health
literacy and had an interest in this topic, therefore there was a possibility of bias or
interpreting the results in a certain way. However, a reflexive diary and use of
teamwork was used to reduce this.

These findings challenge those advocating the routine use of health literacy
screening and/or universal precautions in clinical practice. Further research should
focus on the acceptability and effectiveness of both these approaches. Our findings
strongly support the application of health literacy strategies that respond to the
individual needs of the patient and are built on the individual relationship between a
healthcare professional and their patient. There is a need to address the barriers that
healthcare professionals identify in meeting patients’ health literacy needs, including
uncertainty about how to identify patients’ health literacy, lack of confidence in
meeting patients’ needs, the perception that patients feel shame and embarrassment
about their health literacy levels, concerns about simplifying communication and a
reluctance to ask about literacy. A tailored approach to health literacy education,
targeted at healthcare professionals, which considers the individual needs of
different healthcare professions and teams may increase the likelihood of healthcare
professionals implementing communication and education strategies that meet
patients’ needs. Supporting and encouraging nursing and allied health professionals
to work collaboratively with patients to identify and meet their health literacy needs is
more likely to result in patients becoming actively engaged as partners in their
healthcare.

Acknowledgements

Thanks are due to Solent NHS Trust who funded this clinical academic doctoral
fellowship, all the healthcare professionals who participated in this research study

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and those who assisted with note-taking during focus groups: Annabel Rule, Chantel
Ostler and Sian Kilmister. No external funding.

Declaration of interest statement

The authors report no conflicts of interest.

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Supplementary Table 1. Focus group composition and

demographic data

Focus Team Focus Focus group Focus Number of Number of

group group composition by group years of participants
number composition profession composition clinical in focus
by gender by Agenda experience group
for Change (years)
grade*
(Bands 3-8)
1 Palliative 6 females; 5 nurses; 5 Band 6s; Range: 13- 7
care service 1 male 2 occupational 2 Band 7s 38
therapists Mean: 24.9
SD: 10

2 Community 5 females 2 occupational 3 Band 6s; Range: 4.5- 5

neurological therapists; 1 Band 8; 9.5
service and 1 clinical 1 Band 3 Mean: 6.6
in-patient psychologist; 1 SD: 1.9
neurological physiotherapist;
service 1 occupational
therapy assistant
3 Chronic 7 females 3 clinical 3 Band 8s; Range: 4-16 7
fatigue psychologists; 2 Band 6s; Mean: 11.3
service and 2 1 Band 7; SD: 5.6
persistent physiotherapists; 1 Band 5
pain service 1 occupational
therapist;
1 exercise
rehabilitation
instructor
4 Pulmonary 2 males; 2 3 Band 6s Range: 6-13 3
rehabilitation 1 female physiotherapists; Mean: 9.7
and home 1 occupational SD: 3.5
oxygen therapist
service
Key Total: 22
*Agenda for Change Pay Grades [65]

Supplementary Table 1 Focus group composition and demographic data

24