Document Type : Original Article
Authors
Abstract
BACKGROUND AND AIM: Given the complexities of the health care system and the importance
of the subject and effects of health literacy in all aspects of care, defining specific health literacy in
this context seems necessary. The purpose of this research was to explain the concept of hospital
health literacy (HHL), its definition, and the related dimensions using the qualitative research method.
MATERIALS AND METHODS: An exploratory qualitative design was used. Exploratory, open‑ended,
and face‑to‑face interviews based on the interview guide were used to elicit participants’ perspectives
between July 2021 and January 2022. By using the content analysis method, researchers coded
transcripts and collated these codes into sub‑categories and then merged them into the main category
and explored the dimensions of the concept.
RESULTS: A total of 23 service providers and 25 service recipients were included in the study.
Analysis of qualitative data led to the identification of 6 categories and 25 sub‑categories including
cognitive literacy, functional (basic) literacy, communicative literacy, behavioral literacy, media
literacy, and emotional literacy.
CONCLUSION: The findings of the present study provide a deep understanding of the concept
of HHL that could be applied to develop valid and reliable measurement tools for assessing HHL
among a variety of populations. Also, it is hoped that the present attempt can be useful to guide
future research and interventions as well as to provide a clear base for planning, implementing, and
evaluating interventions aimed at promoting individuals’ health literacy in health settings.
Keywords
1. Kickbusch I, Pelikan JM, Apfel F, Tsouros A. Health literacy: WHO
Regional Office for Europe; 2013.
2. Nutbeam D. The evolving concept of health literacy. Soc Sci Med
2008;67:2072‑8.
3. Karimi N, Saadat‑Gharin S, Tol A, Sadeghi R, Yaseri M,
Mohebbi B. A problem‑based learning health literacy intervention
program on improving health‑promoting behaviors among girl
students. J Educ Health Promot 2019;8:251‑62.
4. Stormacq C, Van den Broucke S, Wosinski J. Does health literacy
mediate the relationship between socioeconomic status and health
disparities? Integrative review. Health Promot Int 2018;34:e1‑17.
5. Nutbeam D, Lloyd JE. Understanding and responding to health
literacy as a social determinant of health. Ann Rev Public Health
2021;42:159‑73.
6. Mackey LM, Blake C, Casey M‑B, Power CK, Victory R,
Hearty C, et al. The impact of health literacy on health outcomes
in individuals with chronic pain: A cross‑sectional study.
Physiotherapy 2019;105:346‑53.
7. See YKC, Smith HE, Car LT, Protheroe J, Wong WC, Bartlam B.
Health literacy and health outcomes in patients with low back
pain: A scoping review. BMC Med Inform Decis Mak 2021;21:1‑19.
8. Wu W‑L, Yu L‑W, Wu L. Health literacy and health outcomes in
China’s floating population: Mediating effects of health service.
BMC Public Health 2021;21:1‑11.
9. Mahmoodi R, Hassanzadeh A, Rahimi M. Health literacy and its
dimensions in elderly people in Farsan city, Iran. J Educ Health
Promot 2021;10:362‑6.
10. Wigfall LT, Tanner AH. Health literacy and health‑care
engagement as predictors of shared decision‑making among
adult information seekers in the USA: A secondary data analysis
of the health information national trends survey. J Cancer Educ
2018;33:67‑73.
11. Taylor DM, Bradley JA, Bradley C, Draper H, Dudley C,
Fogarty D, et al. Limited health literacy is associated with reduced
access to kidney transplantation. Kidney Int 2019;95:1244‑52.
12. Magnani JW, Mujahid MS, Aronow HD, Cené CW, Dickson VV,
Havranek E, et al. Health literacy and cardiovascular disease:
Fundamental relevance to primary and secondary prevention:
A scientific statement from the American Heart Association.
Circulation 2018;138:e48‑74.
13. Tavakoly SanySB, BehzhadF, FernsG, PeymanN. Communication
skills training for physicians improves health literacy and medical
outcomes among patients with hypertension: A randomized
controlled trial. BMC Health Serv Res 2020;20:60.
14. Palumbo R. Examining the impacts of health literacy on
healthcare costs. An evidence synthesis. Health Serv Manage Res
2017;30:197‑212.
15. Persell SD, Karmali KN, Lee JY, Lazar D, Brown T, Friesema EM,
et al. Associations between health literacy and medication
self‑management among community health center patients
with uncontrolled hypertension. Patient Prefer Adherence
2020;14:87‑95.
16. Nutbeam D. Health literacy as a public health goal: A challenge
for contemporary health education and communication strategies
into the 21st century. Health Promot Int 2000;15:259‑67.
17. Edwards M, Wood F, Davies M, Edwards A. The development of
health literacy in patients with a long‑term health condition: The
health literacy pathway model. BMC Public Health 2012;12:130.
18. Dumenci L, Matsuyama R, Riddle DL, Cartwright LA, Perera RA,
Chung H, et al. Measurement of cancer health literacy and
identification of patients with limited cancer health literacy.
J Health Commun 2014;19(Suppl 2):205‑24.
19. Yuen EY‑N, Dodson S, Batterham RW, Knight T, Chirgwin J,
Livingston P. Development of a conceptual model of cancer
caregiver health literacy. Eur J Cancer Care 2016;25:294‑306.
20. Liu C, Wang D, Liu C, Jiang J, Wang X, Chen H, et al. What is the
meaning of health literacy? A systematic review and qualitative
synthesis. Fam Med Community Health 2020;8:e000351.
21. Griese L, Berens E‑M, Nowak P, Pelikan JM, Schaeffer D.
Challenges in navigating the health care system: Development of
an instrument measuring navigation health literacy. Int J Environ
Res Public Health 2020;17:5731.
22. Kilfoyle KA, Vitko M, O’Conor R, Bailey SC. Health literacy and
Women’s reproductive health: A systematic review. J Womens
Health 2016;25:1237‑55.
23. MacLeod S, Musich S, Gulyas S, Cheng Y, Tkatch R, Cempellin D,
et al. The impact of inadequate health literacy on patient
satisfaction, healthcare utilization, and expenditures among older
adults. Geriatr Nurs 2017;38:334‑41.
24. Jaffee EG, Arora VM, Matthiesen MI, Meltzer DO, Press VG.
Health literacy and hospital length of stay: An inpatient cohort
study. J Hosp Med 2017;12:969‑73.
25. Kanejima Y, Shimogai T, Kitamura M, Ishihara K, Izawa KP.
Impact of health literacy in patients with cardiovascular diseases:
A systematic review and meta‑analysis. Patient Educ Couns 2021.
doi: 10.1016/j.pec. 2021.11.021.
26. Boyle J, Speroff T, Worley K, Cao A, Goggins K, Dittus RS, et al.
Low health literacy is associated with increased transitional care
needs in hospitalized patients. J Hosp Med 2017;12:918‑24.
27. Sterling MR, Safford MM, Goggins K, Nwosu SK, Schildcrout JS,
Wallston KA, et al. Numeracy, health literacy, cognition, and
30‑day readmissions among patients with heart failure. J Hosp
Med 2018;13:145‑51.
28. Sim D, Yuan SE, Yun JH. Health literacy and physician‑patient
communication: A review of the literature. Int J Commun Health
2016;10:101‑14.
29. Groene RO, Rudd RE. Results of a feasibility study to assess
the health literacy environment: Navigation, written, and oral
communication in 10 hospitals in Catalonia, Spain. Journal of
Communication in Healthcare 2011;4:227‑37.
30. Speziale HS, Streubert HJ, Carpenter DR. Qualitative Research
in Nursing: Advancing the Humanistic Imperative. Lippincott
Williams & Wilkins; 2011.
31. Cypress BS. Rigor or reliability and validity in qualitative
research: Perspectives, strategies, reconceptualization, and
recommendations. Dimens Crit Care Nurs 2017;36:253‑63.
32. Lee S‑YD, Arozullah AM, Cho YI. Health literacy, social support,
and health: A research agenda. Soc Sci Med 2004;58:1309‑21.
33. Schulz PJ. The concept of health literacy. In: Zeyer A,
Kyburz‑Graber R, editors. Science | Environment | Health:
Towards a Renewed Pedagogy for Science Education. Dordrecht:
Springer Netherlands; 2012. p. 69‑84.
34. Paakkari L, Paakkari O. Health literacy as a learning outcome in
schools. Health Educ 2012;112:133‑52.
35. Murphy‑Knoll L. Low health literacy puts patients at risk: The
Joint Commission proposes solutions to national problem. J Nurs
Care Qual 2007;22:205‑9.
36. Costa VRS, Costa P, Nakano EY, Apolinário D, Santana ANC.
Functional health literacy in hypertensive elders at primary health
care. Rev Brasil Enferm 2019;72:266‑273.
37. Wittink H, Oosterhaven J. Patient education and health literacy.
Musculoskelet Sci Pract 2018;38:120‑7 38. Haverfield MC, Giannitrapani K, Timko C, Lorenz K.
Patient‑centered pain management communication from the
patient perspective. J Gen Intern Med 2018;33:1374‑80.
39. Solan LG, Beck AF, Shardo SA, Sauers‐Ford HS, Simmons JM,
Shah SS, et al. Caregiver perspectives on communication during
hospitalization at an academic pediatric institution: A qualitative
study. J Hosp Med 2018;13:304‑10.
40. Marca‑Frances G, Frigola‑Reig J, Menéndez‑Signorini JA,
Compte‑Pujol M, Massana‑Morera E. Defining patient
communication needs during hospitalization to improve
patient experience and health literacy. BMC Health Serv Res
2020;20:131‑40.
41. Jessup RL, Osborne RH, Buchbinder R, Beauchamp A. Using
co‑design to develop interventions to address health literacy
needs in a hospitalised population. BMC Health Serv Res
2018;18:989‑1002.
42. Epstein RM, Street RL. The values and value of patient‑centered
care. Ann Fam Med 2011;9:100‑3.
43. Kralik D, Price K, Telford K. The meaning of self‐care for people
with chronic illness. Journal of Nursing and Healthcare of Chronic
Illness 2010;2:197‑204.
44. Urpí‑Fernández A‑M, Zabaleta‑Del‑Olmo E, Tomás‑Sábado J,
Tambo‑Lizalde E, Roldán‑Merino J‑F. [Adapting and validating
a questionnaire to measure the self‑care practices in healthy child
population residing in Spain]. Aten Primaria 2020;52:297‑306.
45. Paasche‑Orlow MK, Wolf MS. The causal pathways linking
health literacy to health outcomes. Am J Health Behav
2007;31:S19‑26.
46. Freund KM, Battaglia TA, Calhoun E, Darnell JS, Dudley DJ,
Fiscella K, et al. Impact of patient navigation on timely cancer
care: The patient navigation research program. J Natl Cancer Inst
2014;106:115‑23.
47. Thoman E, Jolls T. Literacy for the 21st century: An overview
and orientation guide to media literacy education. Theory
CML MedicaLit Kit: Center for Media Literacy; 2008.
Available from: https://www.medialit.org/reading‑room
/literacy‑21st‑century‑overview‑orientation‑guide‑
media‑literacy‑education [Last accessed on 2021 Dec 20].
48. Levin‑Zamir D, Bertschi I. Media health literacy, eHealth literacy,
and the role of the social environment in context. Int J Environ
Res Public Health 2018;15:1643.
49. Manganello JA. Health literacy and adolescents: A framework
and agenda for future research. Health Educ Res 2007;23:840‑7.
50. Steiner C. Emotional Literacy: Intelligence with a Heart:
Personhood Press; 2003.
51. Sørensen K, Van den Broucke S, Fullam J, Doyle G, Pelikan J,
Slonska Z, et al. Health literacy and public health: A systematic
review and integration of definitions and models. BMC Public
Health 2012;12:1‑13.
52. Hillson D, Murray‑Webster R, editors. Managing risk attitude using
emotional literacy. PMIR Global Congress 2006 EMEA,presented
in Madrid, Spain, 9 May.
53. Safari‑Moradabadi A, Rakhshanderou S, Ramezankhani A,
Ghaffari M. Explaining the concept of oral health literacy: Findings
from an exploratory study. Community Dent Oral Epidemiol
2022;50:106‑14.
Regional Office for Europe; 2013.
2. Nutbeam D. The evolving concept of health literacy. Soc Sci Med
2008;67:2072‑8.
3. Karimi N, Saadat‑Gharin S, Tol A, Sadeghi R, Yaseri M,
Mohebbi B. A problem‑based learning health literacy intervention
program on improving health‑promoting behaviors among girl
students. J Educ Health Promot 2019;8:251‑62.
4. Stormacq C, Van den Broucke S, Wosinski J. Does health literacy
mediate the relationship between socioeconomic status and health
disparities? Integrative review. Health Promot Int 2018;34:e1‑17.
5. Nutbeam D, Lloyd JE. Understanding and responding to health
literacy as a social determinant of health. Ann Rev Public Health
2021;42:159‑73.
6. Mackey LM, Blake C, Casey M‑B, Power CK, Victory R,
Hearty C, et al. The impact of health literacy on health outcomes
in individuals with chronic pain: A cross‑sectional study.
Physiotherapy 2019;105:346‑53.
7. See YKC, Smith HE, Car LT, Protheroe J, Wong WC, Bartlam B.
Health literacy and health outcomes in patients with low back
pain: A scoping review. BMC Med Inform Decis Mak 2021;21:1‑19.
8. Wu W‑L, Yu L‑W, Wu L. Health literacy and health outcomes in
China’s floating population: Mediating effects of health service.
BMC Public Health 2021;21:1‑11.
9. Mahmoodi R, Hassanzadeh A, Rahimi M. Health literacy and its
dimensions in elderly people in Farsan city, Iran. J Educ Health
Promot 2021;10:362‑6.
10. Wigfall LT, Tanner AH. Health literacy and health‑care
engagement as predictors of shared decision‑making among
adult information seekers in the USA: A secondary data analysis
of the health information national trends survey. J Cancer Educ
2018;33:67‑73.
11. Taylor DM, Bradley JA, Bradley C, Draper H, Dudley C,
Fogarty D, et al. Limited health literacy is associated with reduced
access to kidney transplantation. Kidney Int 2019;95:1244‑52.
12. Magnani JW, Mujahid MS, Aronow HD, Cené CW, Dickson VV,
Havranek E, et al. Health literacy and cardiovascular disease:
Fundamental relevance to primary and secondary prevention:
A scientific statement from the American Heart Association.
Circulation 2018;138:e48‑74.
13. Tavakoly SanySB, BehzhadF, FernsG, PeymanN. Communication
skills training for physicians improves health literacy and medical
outcomes among patients with hypertension: A randomized
controlled trial. BMC Health Serv Res 2020;20:60.
14. Palumbo R. Examining the impacts of health literacy on
healthcare costs. An evidence synthesis. Health Serv Manage Res
2017;30:197‑212.
15. Persell SD, Karmali KN, Lee JY, Lazar D, Brown T, Friesema EM,
et al. Associations between health literacy and medication
self‑management among community health center patients
with uncontrolled hypertension. Patient Prefer Adherence
2020;14:87‑95.
16. Nutbeam D. Health literacy as a public health goal: A challenge
for contemporary health education and communication strategies
into the 21st century. Health Promot Int 2000;15:259‑67.
17. Edwards M, Wood F, Davies M, Edwards A. The development of
health literacy in patients with a long‑term health condition: The
health literacy pathway model. BMC Public Health 2012;12:130.
18. Dumenci L, Matsuyama R, Riddle DL, Cartwright LA, Perera RA,
Chung H, et al. Measurement of cancer health literacy and
identification of patients with limited cancer health literacy.
J Health Commun 2014;19(Suppl 2):205‑24.
19. Yuen EY‑N, Dodson S, Batterham RW, Knight T, Chirgwin J,
Livingston P. Development of a conceptual model of cancer
caregiver health literacy. Eur J Cancer Care 2016;25:294‑306.
20. Liu C, Wang D, Liu C, Jiang J, Wang X, Chen H, et al. What is the
meaning of health literacy? A systematic review and qualitative
synthesis. Fam Med Community Health 2020;8:e000351.
21. Griese L, Berens E‑M, Nowak P, Pelikan JM, Schaeffer D.
Challenges in navigating the health care system: Development of
an instrument measuring navigation health literacy. Int J Environ
Res Public Health 2020;17:5731.
22. Kilfoyle KA, Vitko M, O’Conor R, Bailey SC. Health literacy and
Women’s reproductive health: A systematic review. J Womens
Health 2016;25:1237‑55.
23. MacLeod S, Musich S, Gulyas S, Cheng Y, Tkatch R, Cempellin D,
et al. The impact of inadequate health literacy on patient
satisfaction, healthcare utilization, and expenditures among older
adults. Geriatr Nurs 2017;38:334‑41.
24. Jaffee EG, Arora VM, Matthiesen MI, Meltzer DO, Press VG.
Health literacy and hospital length of stay: An inpatient cohort
study. J Hosp Med 2017;12:969‑73.
25. Kanejima Y, Shimogai T, Kitamura M, Ishihara K, Izawa KP.
Impact of health literacy in patients with cardiovascular diseases:
A systematic review and meta‑analysis. Patient Educ Couns 2021.
doi: 10.1016/j.pec. 2021.11.021.
26. Boyle J, Speroff T, Worley K, Cao A, Goggins K, Dittus RS, et al.
Low health literacy is associated with increased transitional care
needs in hospitalized patients. J Hosp Med 2017;12:918‑24.
27. Sterling MR, Safford MM, Goggins K, Nwosu SK, Schildcrout JS,
Wallston KA, et al. Numeracy, health literacy, cognition, and
30‑day readmissions among patients with heart failure. J Hosp
Med 2018;13:145‑51.
28. Sim D, Yuan SE, Yun JH. Health literacy and physician‑patient
communication: A review of the literature. Int J Commun Health
2016;10:101‑14.
29. Groene RO, Rudd RE. Results of a feasibility study to assess
the health literacy environment: Navigation, written, and oral
communication in 10 hospitals in Catalonia, Spain. Journal of
Communication in Healthcare 2011;4:227‑37.
30. Speziale HS, Streubert HJ, Carpenter DR. Qualitative Research
in Nursing: Advancing the Humanistic Imperative. Lippincott
Williams & Wilkins; 2011.
31. Cypress BS. Rigor or reliability and validity in qualitative
research: Perspectives, strategies, reconceptualization, and
recommendations. Dimens Crit Care Nurs 2017;36:253‑63.
32. Lee S‑YD, Arozullah AM, Cho YI. Health literacy, social support,
and health: A research agenda. Soc Sci Med 2004;58:1309‑21.
33. Schulz PJ. The concept of health literacy. In: Zeyer A,
Kyburz‑Graber R, editors. Science | Environment | Health:
Towards a Renewed Pedagogy for Science Education. Dordrecht:
Springer Netherlands; 2012. p. 69‑84.
34. Paakkari L, Paakkari O. Health literacy as a learning outcome in
schools. Health Educ 2012;112:133‑52.
35. Murphy‑Knoll L. Low health literacy puts patients at risk: The
Joint Commission proposes solutions to national problem. J Nurs
Care Qual 2007;22:205‑9.
36. Costa VRS, Costa P, Nakano EY, Apolinário D, Santana ANC.
Functional health literacy in hypertensive elders at primary health
care. Rev Brasil Enferm 2019;72:266‑273.
37. Wittink H, Oosterhaven J. Patient education and health literacy.
Musculoskelet Sci Pract 2018;38:120‑7 38. Haverfield MC, Giannitrapani K, Timko C, Lorenz K.
Patient‑centered pain management communication from the
patient perspective. J Gen Intern Med 2018;33:1374‑80.
39. Solan LG, Beck AF, Shardo SA, Sauers‐Ford HS, Simmons JM,
Shah SS, et al. Caregiver perspectives on communication during
hospitalization at an academic pediatric institution: A qualitative
study. J Hosp Med 2018;13:304‑10.
40. Marca‑Frances G, Frigola‑Reig J, Menéndez‑Signorini JA,
Compte‑Pujol M, Massana‑Morera E. Defining patient
communication needs during hospitalization to improve
patient experience and health literacy. BMC Health Serv Res
2020;20:131‑40.
41. Jessup RL, Osborne RH, Buchbinder R, Beauchamp A. Using
co‑design to develop interventions to address health literacy
needs in a hospitalised population. BMC Health Serv Res
2018;18:989‑1002.
42. Epstein RM, Street RL. The values and value of patient‑centered
care. Ann Fam Med 2011;9:100‑3.
43. Kralik D, Price K, Telford K. The meaning of self‐care for people
with chronic illness. Journal of Nursing and Healthcare of Chronic
Illness 2010;2:197‑204.
44. Urpí‑Fernández A‑M, Zabaleta‑Del‑Olmo E, Tomás‑Sábado J,
Tambo‑Lizalde E, Roldán‑Merino J‑F. [Adapting and validating
a questionnaire to measure the self‑care practices in healthy child
population residing in Spain]. Aten Primaria 2020;52:297‑306.
45. Paasche‑Orlow MK, Wolf MS. The causal pathways linking
health literacy to health outcomes. Am J Health Behav
2007;31:S19‑26.
46. Freund KM, Battaglia TA, Calhoun E, Darnell JS, Dudley DJ,
Fiscella K, et al. Impact of patient navigation on timely cancer
care: The patient navigation research program. J Natl Cancer Inst
2014;106:115‑23.
47. Thoman E, Jolls T. Literacy for the 21st century: An overview
and orientation guide to media literacy education. Theory
CML MedicaLit Kit: Center for Media Literacy; 2008.
Available from: https://www.medialit.org/reading‑room
/literacy‑21st‑century‑overview‑orientation‑guide‑
media‑literacy‑education [Last accessed on 2021 Dec 20].
48. Levin‑Zamir D, Bertschi I. Media health literacy, eHealth literacy,
and the role of the social environment in context. Int J Environ
Res Public Health 2018;15:1643.
49. Manganello JA. Health literacy and adolescents: A framework
and agenda for future research. Health Educ Res 2007;23:840‑7.
50. Steiner C. Emotional Literacy: Intelligence with a Heart:
Personhood Press; 2003.
51. Sørensen K, Van den Broucke S, Fullam J, Doyle G, Pelikan J,
Slonska Z, et al. Health literacy and public health: A systematic
review and integration of definitions and models. BMC Public
Health 2012;12:1‑13.
52. Hillson D, Murray‑Webster R, editors. Managing risk attitude using
emotional literacy. PMIR Global Congress 2006 EMEA,presented
in Madrid, Spain, 9 May.
53. Safari‑Moradabadi A, Rakhshanderou S, Ramezankhani A,
Ghaffari M. Explaining the concept of oral health literacy: Findings
from an exploratory study. Community Dent Oral Epidemiol
2022;50:106‑14.
)