Received: 10 July 2019 Revised: 6 February 2020 Accepted: 20 February 2020

DOI: 10.1111/nhs.12698

RESEARCH ARTICLE

Nurses' knowledge of health literacy, communication

techniques, and barriers to the implementation of health
literacy programs: A cross-sectional study

Apiradee Nantsupawat PhD, RN1 | Orn-Anong Wichaikhum PhD, RN1 |

1 1
Kulwadee Abhicharttibutra PhD, RN | Wipada Kunaviktikul PhD, RN |
Mohd Said Bin Nurumal PhD, RN2 | Lusine Poghosyan PhD, RN3

1
Nursing Division, Faculty of Nursing, Chiang
Mai University, Chiang Mai, Thailand Abstract
2
Kulliyyah of Nursing, International Islamic Nurses' health literacy knowledge and communication skills are essential for improv-
University Malaysia, Bandar Indera Mahkota,
ing patients' health literacy. Yet, research on nurses' health literacy knowledge and
Kuantan, Pahang, Malaysia
3
School of Nursing, Columbia University, perception is limited. The study aimed to evaluate nurses' health literacy knowledge,
New York, New York communication techniques, and barriers to the implementation of health literacy
Correspondence interventions. A cross-sectional study was used, and a total of 1697 nurses in
Apiradee Nantsupawat, Faculty of Nursing, 104 community hospitals in Thailand completed self-report measures. Approximately
110/406 Inthawaroros road, Sutep District,
Chiang Mai 50200, Thailand. 55% of the participants had heard about the concept of health literacy; 9% had
Email: [email protected] received formal training specific to interaction with patients with low health literacy.
Funding information About 50% of the nurses were aware of their patients' low health literacy; therefore,
International College of Digital Innovation they applied the recommended communication techniques for them. Delivery of
effective health literacy training was hampered by a lack of assessment tools, health
literacy training and specialists, educational materials, and health provider time. Hos-
pital administrators, nurse managers, health leaders should develop strategies to cre-
ate environments and resources supporting health literacy interventions.

KEYWORDS

health literacy, health promotion, nurse, patient education, Thailand

1 | I N T RO DU CT I O N social equity (Batterham et al., 2016). Limited health literacy affects

many types of health conditions, is a barrier to self-management, and
The concept of health literacy has become the subject of increasing can increase the risk of adverse health outcomes as well as increase
interest over the past two decades, and there has been much discussion costs (Centers for Disease Control and Prevention [CDC], 2016). Those
about the definition (Batterham, Hawkins, Collins, Buchbinder, & with low health literacy are less knowledgeable about their own health
Osborne, 2016; Sykes, Wills, Rowlands, & Popple, 2013). The National status, have limited understanding about the overall importance of pre-
Academy of Medicine defined health literacy as “the degree to which ventive measures in maintaining and managing good health (Argarwal,
individuals have the capacity to obtain, process and understand basic Shah, Stone, Ricks, & Friedlander, 2015; Australian Commission on
health information and services needed to make appropriate health Safety and Quality in Health Care, 2016; Hersh, Salzman, & Snyderman,
decisions” (Somers & Mahadevan, 2010, p. 7). Other definitions empha- 2015), and those who self-report worse health outcomes also has the
size that health literacy is not just an individual trait, but a characteristic most limited literacy, numeracy, and health literacy skills (CDC, 2016).
related to families, communities, and organizations providing health and Hospitalized patients with low health literacy experience more
social services and effectively increasing health literacy can increase adverse outcomes (Australian Commission on Safety and Quality in

Nurs Health Sci.. 2020;1–9. wileyonlinelibrary.com/journal/nhs © 2020 John Wiley & Sons Australia, Ltd 1
2 NANTSUPAWAT ET AL.

Health Care, 2016) and there is an established relationship between medium (30–60 bed capacity); and high (60–90 bed capacity). These
low health literacy and poor outcomes including medication error hospitals offer both inpatient and outpatient services and serve a
(Mixon et al., 2014); 30-day hospitals readmission (Mitchell, Sadikova, diverse Thai population, which varies by socioeconomic characteris-
Jack, & Paasche-Orlow, 2012); mo90rtality (McNaughton et al., 2015); tics, ethnic heritages, and fluency in the Thai language. They also pro-
and the increased cost of health care due to overuse and inappropri- vide health care services to migrant workers from Myanmar, Laos, and
ate use of health care services (Eichler, Wieser, & Brugger, 2009; Cambodia and minority Thai ethnic populations. Many ethnic minori-
Haun et al., 2015). ties and migrant workers have limited abilities to speak Thai. The pri-
Individuals' health literacy is influenced by factors that include mary role of nurses in community hospitals is to provide treatment
reading, comprehension, and writing skills, but organizational policy but is it also offers education to patients and their families. These
and regulations also affect health literacy, and it remains challenging nurses often encounter the challenge of patients with limited health
to embed health literacy principles into routine practice (Batterham literacy.
et al., 2016). Health care systems, where the emphasis is on the qual- The conceptual framework that guided the study was adapted
ity of delivery of health care services through effective communica- from the Health Literacy Skills (HLS) conceptual framework (Squiers,
tion between patients and their health care providers, demonstrate Peinado, Berkman, Boudewyns, & McCormack, 2012). The HLS
more success with improving their patients' health literacy and overall framework hypothesizes that individuals' health literacy and health-
treatment outcomes (Macabasco-O'Connell & Fry-Bowers, 2011; related outcomes have multiple levels of influences, including
Rudd, Groene, & Navarro-Rubio, 2013). Health care providers' ability individual-level, system-level, and social-level factors, and that these
to appropriately and adequately assess the health literacy of their influences interact across different levels (Squiers et al., 2012). At a
patients is the basis of successful health education, health promotion system level, the hospital systems and health care providers support
and community health campaigns (Batterham et al., 2016). Using Nut- patients' health literacy education and implementation in terms of an
beam's (2008) three-tier definition of health literacy, nurses are individual's exposure to and cognitive processing and understanding
expected, to function at the third and highest tier— “critical health lit- of health-related information. At a societal level, community and cul-
eracy.” This is the ability to critically analyze information, increase tural considerations affect patient and family functioning and influ-
awareness and participate in activities to address barriers (Peerson & ence patients' health literacy and self-care abilities. Literature reviews
Saunders, 2009). Nurses play an essential role in the assessment of supported systemic and societal levels to influence individuals' health
the patients' clinical conditions and need to provide education and literacy (Paasche-Orlow & Wolf, 2008; Sørensen et al., 2012). The
disease management based on the patients' ability to understand. It is results of this study are empirical measures at the systemic level that
required that health care professionals have adequate awareness, support the use of the HLS.
knowledge, skills, and attitudes when treating patients with low health Although there has been research into health literacy knowledge
literacy (Institute of Medicine, 2004). However, research suggests that and communication skills of health care professionals (Cafiero, 2013;
health care professionals have limited knowledge and skills about Dickens et al., 2013; Mackert et al., 2011), little is known about health
health literacy assessment and effective communication (Cafiero, literacy among nurses in Thailand. This study collected baseline data
2013; Dickens, Lambert, Cromwell, & Piano, 2013; Mackert, Ball, & to assess nurses' general health literacy knowledge, nurses' perception
Lopez, 2011) and may overestimate patients' health literacy because of health literacy, nurses' communication techniques with patients,
of their own misunderstanding or limited understanding of health lit- and the potential barriers to implementation of health literacy educa-
eracy (Dickens et al., 2013). They may themselves have mistaken tion and interventions in community hospital settings.
health beliefs (e.g. false beliefs from personal experience, family, and
mass media) which they pass on to patients (Guptarak et al., 2019;
Stone et al., 2015). 2 | METHODS
The rapid rise in Thailand's economic development and improve-
ments in health has contributed to an increase in the incidence and 2.1 | Design and sample
prevalence of non-communicable diseases (NCDs). The government
at the national and provincial levels has mandated changes in public This was a cross-sectional study. Stratified random sampling was
health policies and public health services to address the rapid rise of used to select community hospitals with 30–90 beds around the
NCDs in the Thai community, which include policies to improve public country. A total of 104 community hospitals were selected
health literacy through effective health communication strategies (Figure 1). Simple sampling was used to randomly select 20–25
(Thai Steering Committee of Making the 12th National Health Devel- nurses who provided direct care for the patients in units. A sample
opment Plan, 2017). Efforts are being made by many professional size of 20 was chosen based on the minimum number of nurses
organizations and government agencies to increase the awareness of employed in the selected community hospitals. Of 2080 question-
health literacy among health care professionals (Thai National Reform naires distributed, 1817 questionnaires (87.4%) were returned. The
Steering Assembly, 2016). In Thailand, community public hospitals researcher checked for incomplete questionnaires, and 120 ques-
deliver secondary care, which comprises three levels of secondary tionnaires had missing data. Therefore, 1697 questionnaires (81.6%)
care level corresponding to bed numbers: low (30-bed capacity); were used for data analysis.
NANTSUPAWAT ET AL. 3

2.3 | Data collection

Before the data collection, ethics approval was obtained, and permis-
sion was obtained from hospital directors of study hospitals. The fol-
lowing permission, data collection took place between September to
October 2018. The researcher contacted the nursing directors of each
hospital and informed them about the details of the study and asked
for a coordinator to distribute and collect the questionnaires. Prior to
the distribution of the surveys, the researcher provided relevant infor-
mation about the study including the research objectives, the partici-
pants' rights, and data collection methods. Coordinators distributed
the questionnaire package. Participants were asked to respond to the
questionnaires within 2 weeks and returned the completed question-
naires in a sealed envelope in a locked box provided in nursing depart-
ments. Participants were requested to separate consent forms and
questionnaires before submitting them. The coordinator collected the
completed questionnaires and returned them to the researcher.

2.4 | Data analysis

Descriptive statistics were performed to categorize demographic

characteristics and the other attributes, such as knowledge, percep-
tion of health literacy, communication techniques, and barriers to
health literacy assessment. All analyses were conducted using the
SPSS statistical program (SPSS Inc., Chicago, IL).

FIGURE 1 Distribution of study hospitals

2.5 | Ethical statement

The study was approved by the Ethical Committee of the Faculty of

2.2 | Measurement Nursing, Chiang Mai University, Thailand (approval-EXP043). A writ-
ten informed consent form was obtained from participants. All partici-
The Nursing Professional Health Literacy (NPHLS) instrument was pants were informed about the purpose and the methods of the study
used to measure nurses' health literacy. This questionnaire was and that their participation in the study was voluntary, so they could
developed by Macabasco-O'Connell and Fry-Bowers (2011). Permis- refuse to participate or withdraw from the study at any time without
sion was received from the authors to use and translate the instru- being penalized. A statement was attached with a cover letter to guar-
ment. The original NPHLS has 47 items grouped into five parts to antee confidentiality and anonymity of individual responses. Code
collect information on the following: (i) demographic characteristics; numbers were used instead of names. Information provided by the
(ii) general knowledge questions related to health literacy, which participants was only used for the study purposed and kept confiden-
include dichotomous yes/no answers, Likert-scale responses includ- tial. Only aggregated results of the study were presented.
ing: often, always, sometimes, never, rarely, as well as open-ended
questions; (iii) nurses' perceptions related to health literacy using
Likert-scale responses, use of techniques for communicating with 3 | RE SU LT S
patients with low health literacy; and (iv) an assessment of barriers
encountered when implementing such techniques which partici- In Table 1, the distribution of demographic characteristics of partici-
pants can rate with more than one answer. The questionnaire was pants is presented. The mean age was 41 years (range 22–60 years):
translated using the backward-forward translation method following female nurses constituted the majority of the sample (96.3%). About
the WHO guideline (World Health Organization, 2015b). In this 90.2% of the participants had baccalaureate nursing education, and
study, four parts of NPHLS were used besides the demographic 3.7% had completed education at the masters' level. One of the par-
characteristics part was adjusted to be appropriate to this study ticipants held a doctoral degree in nursing sciences. The mean years
sample. The Cronbach's alpha for the nurse's perception related to of professional experience were 18.3 years (range 1–40 years). About
health literacy was 0.81. one-third of the participants (n = 558, 32.9%) worked in inpatient
4 NANTSUPAWAT ET AL.

T A B L E 1 Frequency and percentage of respondents' TABLE 2 General health literacy knowledge

demographic characteristics (1697)
Items N %
Characteristics N % x
Had ever heard the term “health literacy”
Mean age (range 22–50) 41 Yes 939 55.3
22–30 293 17.3 No 758 44.7
31–40 423 25.0 Describe your knowledge level about “health literacy”
41–50 689 40.6 None/A little 380 22.7
51–60 292 17.2 A moderate amount 865 51.7
Gender Quite a bit/A great deal 428 25.6
Female 1634 96.3 Receive formal training specific to dealing with patients with low
Male 63 3.7 health literacy
Education Yes 156 9.4
Bachelor 1531 90.2 No 1511 90.6
Master 165 9.7 The minimum grade level does the average Thai read
Doctoral 1 0.6 Elementary education (G1-6) 1309 85.7
Mean years of practice as an RN 18.3 Lower secondary - upper secondary 219 14.3
(range 1–40) education (G7-12)
Practice setting Percentage of the Thai population has difficulty understanding health
care information or instruction
Out-patient department 480 28.3
0–30% 317 22.4
In-patient department 558 32.9
40–60% 762 53.9
Emergency room 388 22.9
70–100% 335 23.7
Labor room & operating room 271 16.0
Factors associated with the level of
Education level 1606 94.6
services, 28.3% (n = 480) in outpatient services, and 22.9% (n = 388) Socioeconomic status 1357 80.0
in the emergency department.
Age 1225 72.2
Culture 977 57.6
Ethnicity 826 48.7
3.1 | Nurses' health literacy knowledge
Gender 580 34.2
Individuals with high levels of education at risk for low health literacy
In Table 2 more than half of the study participants (55.3%) had heard
the term “health literacy,” and 51.7% rated their level of health liter- Often/Always 494 30.0

acy knowledge as “moderate.” About 90.6% had not received formal Sometimes 938 57.1

training specific to dealing with patients with low health literacy. Never/Rarely 212 12.9
More than 85.7% rated the minimum grade level the average Thai Individuals who speak Thai as a second language at risk for low health
read as elementary education. The majority perceived that 40–60% of literacy

the Thai population had difficulty understanding health care informa- Often/Always 669 39.5
tion or instructions. Most of the nurses believed that the health liter- Sometimes 749 44.2
acy level of patients they treated were affected by education levels Never/Rarely 277 16.3
(94.6%), socioeconomic status (80%), age (72.2%), and culture (57.6%).
Note: Participants could provide more than one answer; Participants could
Approximately 12.9% stated that those with high levels of education decline to answer any of the questions.
were not at risk for low health literacy, and 16.3% reported that those
who spoke Thai as a second language were not at risk for low health
literacy (Tables 2–5). the Thai language, imposed restrictions on understanding health care
information, obtaining appropriate health services, and adhere fully to
recommended treatments. Most participants (74.9%) asked patients
3.2 | Nurse's perception of health literacy about their understanding of their health condition or whether they
had additional questions to ask; while asking patients about whether
In Table 3 nurses clarified the impact of low health literacy on their they have difficulty in reading medical information or completing
patients with no or limited ability to communicate in the Thai lan- medical forms was the second most common (48.3%) applied method
guage. More than half of the participants responded that low health of learning reinforcement. One-fifth of the participants described
literacy among patients with no or limited ability to communicate in using “gut feeling” to assess health literacy.
NANTSUPAWAT ET AL. 5

TABLE 3 Nurse's perception of health literacy

None/a little A moderate amount Quite a bit/a great deal

Items N % N % N %
To what degree does low health literacy interfere with your Thai speaking patients' ability to
Understand health information 372 22.5 391 23.6 891 53.9
Obtain appropriate health services 405 24.4 436 26.2 821 49.4
Follow through on recommended treatments 390 23.4 401 24.0 877 52.6
To what degree does low health literacy interfere with your non-Thai speaking patients' ability to
Understand health information 191 11.5 287 17.3 1181 71.2
Obtain appropriate health services 236 14.2 305 18.4 1116 67.4
Follow through on recommended treatments 188 11.3 272 16.4 1201 72.3
Never/Rarely Sometimes Often/Always
How often do you N % N % N %
Ask a patient if they understand instructions or have any 61 3.6 363 21.5 1267 74.9
questions
Ask a patient if they have difficulty reading medical 261 15.4 616 36.3 818 48.3
information or completing medical forms
Have a patient repeat instruction back to you 211 12.5 761 45.0 721 42.6
Ask a patient for the last grade they completed 714 42.5 461 27.4 505 30.1
Formally assess health literacy with a validated 723 43.6 587 35.4 348 21.0
questionnaire
Use your “gut feeling” as a clinician to assess health literacy 598 35.9 674 40.4 396 23.7

Note: Participants could decline to answer any of the questions.

3.3 | Use of communication techniques and health literacy training (34.8%), and health literacy is seen as a low priority as
literacy training compared to other issues (23.9%). Regarding barriers to screening for
low health literacy, respondents reported that there was a lack of
In Table 4 participants reported multiple methods of communication knowledge about low health literacy among health care providers
with low health literacy patients. The most commonly used method (54.6%), that good health literacy assessment tools were not available
(90.5%) was a description of the medical condition and associated (51.6%), and assessment/screening took too much time (32.2%). In
treatments and instructions in easy to understand terms. About addition, respondents reported that providers do not have time to
85.6% of the participants also verbally reviewed written instructions implement a health literacy program (34.4%), that it was too difficult
with patients. The third most commonly (75.8%) used method was to implement a health literacy program for patients who use many dif-
“teach back” the technique of having the patients repeat back instruc- ferent languages (34%), and too difficult to implement a culturally
tions to check to understand. Participants reported that their practice appropriate health literacy program for minority groups (33.6%).
site had no health literacy training program or intervention in place
(68.5%), did not provide patients with health education materials that
were designed especially for patient with low health literacy (65%), 4 | DI SCU SSION
had no intensive, individualized health education sessions for patients
with low health literacy (45.8%), and did not have a dedicated low The results suggest that many nurses are not familiar with the concept
health literacy specialist (78.9%). of health literacy but were using a number of strategies to ensure
their patients understood the information they were given. Lacking
were organization-level strategies to train frontline staff in the con-
3.4 | Barriers to implementation of health literacy cept of health literacy, health literacy assessment or engagement with
education and intervention groups or the community to increase health literacy.
Although the participants were responsible for patient education,
In Table 5 the majority of respondents reported that barriers to health only 55% were familiar with the concept of health literacy and less
literacy education for health care providers included difficulties of than 10% had received formal training specific to interaction with
having many types of providers involved in health literacy implemen- patients with low health literacy. Our findings concur with previously
tation (47.5%), providers do not have the time to undertake health reported studies suggesting a serious lack of health literacy
6 NANTSUPAWAT ET AL.

TABLE 4 Use of communication techniques and training T A B L E 5 Barriers to implementation of health literacy education
and intervention
Routine use
a
Barriers to health literacy education
Techniques using N % for health care providersa N %
Describe medical conditions, treatments and 1535 90.5 Too difficult to implement a health 806 47.5
instructions in layman's terms literacy program for many types of
Orally review written instructions with 1452 85.6 providers
patient Providers do not have time to take part in 591 34.8
Have patient repeat instructions back to you 1287 75.8 a health literacy training program
to check understanding Health literacy is a low priority as 405 23.9
Encourage patients to bring a family member 1133 66.8 compared to other problems
or friend to appointments Health literacy is not a major problem 347 20.5
Have patient demonstrate instructions back 889 52.4 with the specific population served at
to you to check understanding the place of practice
Provide the patient with health education 873 51.4 Health literacy program for providers and 274 16.6
materials staff would not improve outcomes
Refer patient to other services such as 466 27.5 Senior leadership is not supportive 271 16.0
patient educator Implementing a health literacy training 221 13.0
Provide the patient with health education 409 24.1 program will cost too much money
materials designed specifically for patients Barriers to screening for low health literacy for patientsa
with low health literacy
Lack of knowledge about low health 927 54.6
The practice site has a health literacy program or intervention in place literacy among providers and other
Yes 532 31.5 staff
No/I do not know 1157 68.5 Good health literacy assessment tools are 876 51.6
The practice site provides patient with health education materials that not available
designed especially for patients with low health literacy Assessment/screening takes too much 546 32.2
Yes 592 35.0 time

No /I do not know 1099 65.0 Health literacy is a low priority as 409 24.1
compared to other problems
The practice site has an intensive, individualized health education
session for patients with low health literacy Health literacy is not a major problem 342 20.2
with the specific population served at
Yes 914 54.1 the place of practice
No /I do not know 773 45.8 Assessment/screening will embarrass or 268 15.8
The practice site has a dedicated low health literacy specialist shame patients
Yes 353 21.1 Barriers to implementing a health literacy for patienta
No /I do not know 1323 78.9 Providers do not have time to implement 584 34.4
a
a health literacy program
Participants could provide more than one answer; Participants could
decline to answer any of the questions. Too difficult to implement a health 577 34.0
literacy program for patients who use
many different languages
knowledge among nurses and health care providers (Macabasco-
Too difficult to implement a culturally 570 33.6
O'Connell & Fry-Bowers, 2011). A lack of familiarity with the concept
component health literacy program
of health literacy and lack of formal training likely imposes consider-
Health literacy is a low priority as 361 21.3
able limitations in the implementation of effective health literacy
compared to other problems
interventions including ineffective communication; use of terminology
Health literacy is not a major problem 358 21.1
that is not understood by the patient; provision of instructions that with the specific population served at
are not clear; and allowing inadequate time to check patient under- the place of practice
standing or how they intend to enact the instructions (Cafiero, 2013; Health literacy program for providers and 259 15.3
Coleman, Hudson, & Maine, 2013). staff would not improve outcomes
Nurses in this study reported that they had received little educa- Senior leadership is not supportive 226 13.3
tional input about health literacy. This is similar to previous studies Implementing a health literacy training 216 12.7
that found that the inclusion of health literacy in curricula is not program will cost too much money
widely reported in nursing education and other health professional a
Participants could provide more than one answer; Participants could
programs (Coleman, 2011; Coleman & Appy, 2012). The results imply decline to answer any of the questions.
NANTSUPAWAT ET AL. 7

that health literacy is not being adequately addressed in Thai Nursing evidence to advocate effectively for resources or to implement con-
schools. The health literacy education for nurses has been identified temporary culturally appropriate evidence-based care.
as a priority area. Therefore, improving and promoting health literacy The reported lack of resources and the provider's time were bar-
education for nursing students will prepare their knowledge and expe- riers to the implementation of health literacy education and interven-
riences required to provide health care information to patients with tion. The absence of appropriate health literacy screening tools
low health literacy. More recent studies suggest that nursing educa- prevented nurses from implementing teaching and communication
tion and training can benefit from courses in health literacy and how strategies adapted to each patient. Several tools have been used to
to effectively deploy health literacy concepts into practice measure health literacy and assess how well individuals understand
(Coleman & Fromer, 2015; Hadden, 2015; Kaper et al., 2018). Addi- health information, for instance, the Test of Functional Health Liter-
tionally, training in identifying poor levels of health literacy and how acy in Adults (TOFHLA) (Parker, Baker, Williams, & Nurss, 1995),
to best teach patients to be health literate has been shown to assist which assesses both reading skills and numeracy. The Information and
health care professionals to better communicate with and support Support for Health Actions Questionnaire (ISHA-Q) and Health Liter-
patients with low health literacy (Brach et al., 2012). acy Questionnaire (HLQ) are also being used to better understand the
The evidence of this study suggests that nurses use a variety of health literacy strengths and difficulties of people from a range of
communication techniques to assist patients who have low health lit- socioeconomic and ethnic backgrounds and of people living with a
eracy. These results are consistent with prior studies that investigated disability or with long-term health conditions (WHO, 2015a).
health literacy in other health care providers (Jukkala, Deupree, & Gra- Our study showed that nurses perceived that language and cultural
ham, 2009; Schlichting et al., 2007). It may be that even if nurses differences were obstacles to implementing effective health literacy edu-
report that they do not understand the concept of health literacy that cation and interventions. Currently, educational pamphlets developed by
their teaching does take into account the patients understanding of hospitals are in a standard format and used for a broad spectrum of
their health. Nurse and the way their communication plays a major health conditions and are not adapted for non-Thai speaking or cultural
role in influencing an individual's ability to process health information. minorities. This finding reflects prior studies which found that language
However, the evidence is consistent with other findings, which have and communication barriers were a significant impediment for minority
shown that health literacy specialists and health education materials groups, such as immigrants, to access and utilize health care (Britigan,
designed for patients with low health literacy were rarely used or pro- Munan, & Rojas-Guyler, 2009; Kalengayi, Hurting, Ahlm, & Ahlberg,
vide at practice sites (Macabasco-O'Connell & Fry-Bowers, 2011). A 2012; Priebe et al., 2011). The use of culturally -appropriate and
previous study suggested the well-known guideline such as the Health language-sensitive health literacy interventions is likely to encourage
Literacy Universal Precautions Toolkits would offer a method for sys- individuals to further engage with hospital-based health literacy initia-
tematic evaluation of clinical practices, educational resources for tives (Tsai & Lee, 2016) and health promotion activities. The rec-
health care providers, and the techniques to communicate with ommended tool is the use of professional interpreters when required to
patients in a clear and effective manner (DeWalt et al., 2011). improve overall care and decrease health inequalities (Karliner, Jacobs,
The finding presented that one-fifth of nurses using “gut feeling” Chen, & Mutha, 2007). Education for health care providers should
to assess health literacy. Either this finding is a disturbing indictment include health literacy training as well as cultural sensitivity training.
of nurses not using evidence-base practice - which is unlikely given
the other responses - or perhaps nurses are describing an intuitive
way of knowing. Benner (1982) described as being characteristic of an 4.1 | Study limitations
expert nurse where, because of extensive experience, the nurse has
an intuitive grasp of the situation and as the nurses' level of expertise Our study has strengths and limitations. Two strengths of our study
increases so did the use of intuition in their clinical judgments include its sample size, and the fact that its data was collected from a
(Benner, 1984). “Gut feeling” is intuition, instinct, hunch, or a sixth representative sample of nurses across Thailand who provide health
sense encompasses the ability to understanding something instinc- care services to diverse groups of patients. However, the nurses who
tively, without the need for conscious reasoning (Gore & Sadler- contributed to our study were aware of study objectives, which could
Smith, 2011). Gut feeling or intuition in clinical practice is something have biased their responses. Also, the questionnaire relied on self-
that develops over time and is based on knowledge and experience of reporting and therefore measured nurses' perceptions of health liter-
caring for patients (Ramezani-Badr, Nasrabadi, Yekta, & Taleghani, acy rather than using an objective measure. The descriptive design
2009) and nurses recognize them as a valuable component of limits our ability to make a conclusion about factors leading to these
decision-making. Research evidence would suggest that gut feeling or barriers in the implementation of health literacy.
intuition occurs in response to knowledge, is a trigger for action or
reflection and thus has a direct bearing on analytical processes inpa-
tient/client care or as an important part of the nursing process (Melin- 4.2 | Conclusion
Johansson, Palmqvist, & Ronnberg, 2017). Therefore, it is likely that
experienced nurses used “gut feeling” to assess health literacy. How- This is the first assessment of nurses' knowledge of health literacy,
ever, reliance on gut feeling alone may mean that nurses lack the communication techniques, and barriers to the implementation of
8 NANTSUPAWAT ET AL.

health literacy programs in community hospitals in Thailand. The study Coleman, C. A., & Appy, S. (2012). Health literacy teaching in U.S. medical
found that nursing professionals' knowledge of health literacy was still schools, 2010. Family Medicine, 44, 504–507.
Coleman, C. A., & Fromer, A. A. (2015). Health literacy training intervention for
limited, even though nurses applied a variety of communication tech-
physicians and other health professionals. Family Medicine, 47, 388–392.
niques. Delivery of effective health literacy training was hampered by Coleman, C. A., Hudson, S., & Maine, L. L. (2013). Health literacy practices
a lack of assessment tools, health literacy training and specialists, edu- and educational competencies for health professionals: A consensus
cational materials, and health provider time. Further studies using study. Journal of Health Communication, 18(Suppl 1), 82–102.
DeWalt, D. A., Broucksou, K. A., Hawk, V., Brach, C., Hink, A., Rudd, R., &
objective measures are needed about factors leading to poor health
Callahan, L. (2011). Developing and testing the health literacy univer-
literacy implementation or how poor health literacy among patients sal precautions toolkit. Nursing Outlook, 59(2), 85–94.
impacts their outcomes. Hospital administrators, nurse managers, and Dickens, C., Lambert, B. L., Cromwell, T., & Piano, M. R. (2013). Nurse
health leaders should support the work environment and resources overestimation of patients' health literacy. Journal of Health Communi-
cation, 18(Suppl 1), 62–69.
supporting the delivery of health literacy interventions.
Eichler, K., Wieser, S., & Brugger, U. (2009). The costs of limited health literacy:
A systematic review. International Journal of Public Health, 54, 313–324.
ACKNOWLEDGMENTS Gore, J., & Sadler-Smith, E. (2011). Unpacking intuition: A process and out-
The authors thank all of nurses in Thai community hospitals for their come framework. Review of General Psychology, 15, 304–316.
Guptarak, M., Conway, J., Stone, T. E., Fongkaew, W., Settheekul, S., &
participation in this study. This research was funded by ASEAN+3
Baxter, E. (2019). Health beliefs of nurses in Northern Thailand: A Q-
Cross Border Research, Chiang Mai University, Thailand.
Methodology Study. Journal of Transcultural Nursing. https://doi.org/
10.1177/1043659619865589
AUTHOR CONTRIBUTIONS Hadden, K. B. (2015). Health literacy training for health professions stu-
Study design: A.P., O.W., K.A., W.K., M.B.N., and L.P. dents. Patient Education and Counseling, 98, 918–920.
Haun, J., Patel, N., French, D., Campbell, R., Bradham, D., & Lapcevic, W.
Data collection: A.P., O.W., K.A., and W.K.
(2015). Association between health literacy and medical care costs in
Data analysis: A.P., O.W., K.A., and W.K. an integrated health care system: A regional population-based study.
Manuscript writing and revising for important intellectual content: BMC Health Services Research, 15, 249–260.
A.P., O.W., K.A., W.K., M.B.N., and L.P. Hersh, L., Salzman, B., & Snyderman, D. (2015). Health literacy in primary
care practice. American Family Physician, 92(2), 118–124.
Institute of Medicine. (2004). Health literacy: A prescription to end confu-
ORCID sion. Washington, DC: The National Academies Press. Retrieved from
Apiradee Nantsupawat https://orcid.org/0000-0001-5284-3147 https://doi.org/10.17226/10883
Jukkala, A., Deupree, J. P., & Graham, S. (2009). Knowledge of limited
health literacy at an academic health center. Journal of Continuing Edu-
RE FE R ENC E S
cation in Nursing, 40(7), 298–302.
Argarwal, N., Shah, K., Stone, J., Ricks, C., & Friedlander, R. (2015). Over Kalengayi, F. K. N., Hurting, A. K., Ahlm, C., & Ahlberg, B. M. (2012). It is a
the head of neurosurgical patients: The economic impact of inade- challenge to go it the right way: An interpretive description of care-
quate health. World Neurosurgery, 84(5), 1223–1226. givers' experiences in caring for migrant patients in Northern Sweden.
Australian Commission on Safety and Quality in Health Care. (2016). BMC Health Services Research, 12, 433.
Health literacy. Retrieved from http://www.safetyandquality.gov.au/ Kaper, M. S., Sixsmith, J., Koot, J. A. R., Meijering, L. B., Van Twillert, S.,
our-work/patient-and-consumer-centred-care/health-literacy/ Giammarchi, C., … de Winter, A. F. (2018). Developing and pilot testing
Batterham, R. W., Hawkins, M., Collins, P., Buchbinder, R., & a comprehensive health literacy communication training for health
Osborne, R. H. (2016). Health literacy: Applying current concepts to professionals in three European countries. Patient Education and
improve health services and reduce health inequalities. Public Health, Counseling, 101, 152–158.
132, 3–12. Karliner, L. S., Jacobs, E. A., Chen, A. H., & Mutha, S. (2007). Do profes-
Benner, P. (1982). From novice to expert. AJN The American Journal of sional interpreters improve clinical care for patients with limited
Nursing, 82(3), 402–407. English proficiency? A systematic review of literature. Health Services
Benner, P. (1984). From novice to expert, excellence and power in clinical Research, 42(2), 727–754.
nursing practice. Menlo Park, CA: Addison-Wesley Publishing Macabasco-O'Connell, A., & Fry-Bowers, E. K. (2011). Knowledge and per-
Company. ceptions of health literacy among nursing professionals. Journal of
Brach, C., Keller, D., Hernandez, L. M., Baur, C., Parker, R., Dreyer, B., … Health Communication, 16(Suppl 3), 295–307.
Schillinger D. (2012). Ten Attributes of Health Literate Health Care Mackert, M., Ball, J., & Lopez, N. (2011). Health literacy awareness training
Organizations. NAM Perspectives. (Discussion Paper). Washington, DC: for health care workers: Improving knowledge and intentions to use
National Academy of Medicine. https://doi.org/10.31478/201206a clear communication techniques. Patient Education and Counseling, 85
Britigan, D. H., Munan, J., & Rojas-Guyler, L. (2009). A qualitative study (3), e225–e228.
examining Latino functional health literacy levels and source of health McNaughton, C. D., Cawthon, C., Kripalani, S., Liu, D., Storrow, A. B., &
information. Journal of Community Health, 34(3), 222–230. Roumie, C. L. (2015). Health literacy and mortality: A cohort study of
Cafiero, M. (2013). Nurse practitioners' knowledge, experience, and inten- patients hospitalized for acute heart failure. Journal of the American
tion to use health literacy strategies in clinical practice. Journal of Heart Association, 4(5), e001799.
Health Communication, 18(Suppl 1), 70–81. Melin-Johansson, C., Palmqvist, R., & Ronnberg, L. (2017). Clinical intuition
Centers for Disease Control and Prevention. (2016). What is health liter- in the nursing process and decision-making–A mixed-studies review.
acy? Retrieved from https://www.cdc.gov/healthliteracy/learn/index. Journal of Clinical Nursing, 26(23-24), 3936–3949.
html Mitchell, S. E., Sadikova, E., Jack, B. W., & Paasche-Orlow, M. K. (2012).
Coleman, C. A. (2011). Teaching health care professionals about health lit- Health literacy and 30-day post-discharge hospital utilization. Journal
eracy: A review of the literature. Nursing Outlook, 59(2), 70–78. of Health Communication, 17(Suppl 3), 325–338.
NANTSUPAWAT ET AL. 9

Mixon, A. S., Myers, A. P., Leak, C. L., Jacobsen, J. M. L., Cawthon, C., Squiers, L., Peinado, S., Berkman, N., Boudewyns, V., & McCormack, L.
Goggins, K. M., … Kripalani, S. (2014). Characteristics associated with (2012). The health literacy skills framework. Journal of Health Commu-
postdischarge medication errors. Mayo Clinic Proceedings, 89(8), nication, 17(Suppl 3), 30–54.
1042–1051. Stone, T. E., Kang, S. J., Cha, C., Turale, S., Murakami, K., & Shimizu, A.
Nutbeam, D. (2008). The evolving concept of health literacy. Social Sci- (2015). Health beliefs and their sources in Korean and Japanese
ence & Medicine, 67(12), 2072–2078. nurses: A Q-methodology pilot study. Nurse Education Today, 36,
Paasche-Orlow, M. K., & Wolf, M. S. (2008). Evidence does not support 214–220.
the clinical screening of literacy. Journal of General Internal Medicine, Sykes, S., Wills, J., Rowlands, G., & Popple, K. (2013). Understanding criti-
23, 100–102. cal health literacy: A concept analysis. BMC Public Health, 13(1), 150.
Parker, R. M., Baker, D. W., Williams, M. V., & Nurss, J. (1995). The test of Thai National Reform Steering. (2016). The reform of health literacy and
functional health literacy in adults: A new instrument for measuring health communication: Reform of health literacy and health communica-
patients' literacy skills. Journal of General Internal Medicine, 10, tion. Retrieved from http://library2.parliament.go.th/giventake/
537–541. content_nrsa2558/d111459-03.pdf
Peerson, A., & Saunders, M. (2009). Health literacy revisited: What do we Thai Steering Committee of Making the 12th National Health Develop-
mean and why does it matter? Health Promotion International, 24(3), ment Plan. (2017). Draft of the 12th National Development Plan. Bang-
285–296. kok, Thailand: Ministry of Public Health.
Priebe, S., Sandhu, S., Dias, S., Gaddini, A., Greacen, T., Ioannidis, E., … Tsai, T. I., & Lee, S. Y. D. (2016). Health literacy as the missing link in the
Bogic, M. (2011). Good practice in health care for migrants: Views and provision of immigrants' health care: A qualitative study of Southeast
experiences of care professionals in 16 European countries. BMC Pub- Asia immigrants' women in Taiwan. International Journal of Nursing
lic Health, 11, 187. Studies, 54, 65–74.
Ramezani-Badr, F., Nasrabadi, A. N., Yekta, Z. P., & Taleghani, F. (2009). World Health Organization, Regional Office for South-East
Strategies and criteria for clinical decision making in critical care Asia. (2015a). Health literacy toolkit for low- and middle-income coun-
nurses: A qualitative study. Journal of Nursing Scholarship, 41(4), tries : A series of informationsheets to empower communities and
351–358. strengthen health systems. WHO Regional Office for South-East
Rudd, R. E., Groene, O. R., & Navarro-Rubio, M. D. (2013). On health liter- Asia. https://apps.who.int/iris/handle/10665/205244
acy and health outcomes: Background, impact, and future directions. World Health Organization. (2015b). Process of translation and adaptation
Revista de Calidad Asistencial, 28(3), 188–192. of instruments. Retrieved from http://www.who.int/substance_abuse/
Schlichting, J. A., Quinn, M. T., Heuer, L. J., Schaefer, C. T., Drum, M. L., & research_tools/translation/en/
Chin, M. H. (2007). Provider perceptions of limited health literacy in
community health centers. Patient Education and Counseling, 69(1–3),
114–120.
Somers, S. A., & Mahadevan, R. (2010). Health literacy implications of the How to cite this article: Nantsupawat A, Wichaikhum O-A,
Affordable Care Act. Hamilton, NJ: Center for Health Care Strategies,
Abhicharttibutra K, Kunaviktikul W, Nurumal MSB,
Inc. Retrieved from http://www.iom.edu/~/media/Files/Activity%
20Files/PublicHealth/HealthLiteracy/Commissioned%20Papers/ Poghosyan L. Nurses' knowledge of health literacy,
Health%20Literacy%20Implication%20of%20Health%20Care% communication techniques, and barriers to the
20Reform.pdf implementation of health literacy programs: A cross-sectional
Sørensen, K., Van den Broucke, S., Fullam, J., Doyle, G., Pelikan, J.,
study. Nurs Health Sci. 2020;1–9. https://doi.org/10.1111/
Slonska, Z., … (HLS-EU) Consortium Health Literacy Project European.
(2012). Health literacy and public health: A systematic review and inte- nhs.12698
gration of definitions and models. BMC Public Health, 12, 80.