Knowledge and Perceptions of Health Literacy Among Nursing Professionals

Journal of Health Communication International Perspectives ISSN: 1081-0730 (Print) 1087-0415 (Online) Journal homepage: http://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: 3954 View related articles Citing articles: 26 View citing articles Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalinformation?journalcode=uhcm20 Download by: [37.44.193.113] Date: 30 December 2017, At: 11:20

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 professionals 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 professionals. 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 textual analysis was done on participant responses to a survey question that asks participants 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, comprehend, 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 educational 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 increasingly 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 Institute of Medicine (IOM, 2004) estimates that additional health care expenditures because of low health literacy skills approximate $73 billion, and Vernon and colleagues (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 communicative 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 communication 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 suggested that some participants erroneously believed that persons with higher levels of education were not at risk for limited health literacy. Finally, and most disconcerting, 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 physicians 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 interactions. 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 information. 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 techniques used by 307 providers (99 physicians, 87 nurses and 121 pharmacists) attending 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 physicians, 67 nurse practitioners, 35 physician s assistants, 48 dentists and dental hygienists, and 36 other professionals, such as registered nurses, in midwestern urban and rural community health centers for techniques used when caring for clients with limited health literacy (Schlichting et al., 2007). Again, most common techniques reported as used always or often by all clinicians included asking a patient s understanding (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 providing 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 techniques 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 readability 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 educational 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 perception of health literacy remains largely unexplored, yet, health promotion activities 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 indicates that low health literacy is substantially related to a myriad of health indicators. 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 (SurveyMonkey TM ) was used to assess nursing professionals knowledge and perceptions of health literacy. Participants 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 individual 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 (Jukkala et al., 2009) and questions regarding professional use of health literacy interventions and perceived effectiveness were informed by prior investigation of practices of community health clinics (Schlicting et al., 2007). Adaptation was conducted following correspondence with the above noted investigators. Content validity was established 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 literacy 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 techniques. Finally, the survey requested demographic, professional, and work characteristics 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 program 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 literacy 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 literacy and 75% reported knowing a moderate or great deal about it. Yet, a large proportion 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 factors 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 individual 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 questions (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. Interestingly, 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 program for patients is a low priority and would be too expensive (37%). Thirty-two percent 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 literacy and their understanding of the role health literacy plays on patient health outcomes 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 understanding 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 literacy 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 techniques 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 comprehension (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, ethnicity, age, educational level, and socioeconomic status, there were no formal assessments 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. Moreover, 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 distinct 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 intervention 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 organizations 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 literacy exist. Many nurses believed that their health care organization viewed health literacy 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 knowledge 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 education 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 literacy 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 Faculties (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 optimize 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, selection 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 epidemic 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 literacy 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 effective 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 parsimonious 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 Central 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 practitioner 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 prescription 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 understanding 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 techniques for patients with low health literacy: A survey of physicians, nurses, and pharmacists. American Journal of Health Behavior, 31(Supp), S96 S104. Schwartzberg, J. G., VanGeest, J. B., & Wang, C. C. (Eds.). (2005). Understanding health literacy: Implications for medicine and public health. Washington, D.C.: AMA Press. Vernon, J. A., Trujillo, A., Rosenbaum, S., & DeBuono, B. (2007). Low health literacy: Implications 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 functional 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 patientphysician communication. Family Medicine, 34, 383 389. Wilson, M. (2009). Readability and patient education materials used for low-income populations. 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 examples of specific actions they can take to make health information more understandable 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 Competency, 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