Learning Outcomes
By the end of this section, you should be able to:
- 17.2.1 Define health literacy.
- 17.2.2 Assess the health literacy of a population to guide health promotion and disease prevention activities.
- 17.2.3 Examine one or more health literacy assessment tools.
- 17.2.4 Examine how people learn and the factors that influence learning and knowledge acquisition.
Nurses working in the community regularly use health education to help clients promote, maintain, and restore health. Effective educators assess the individual or community for learning needs and health literacy, understand how people learn, utilize one or more learning theory models, promote factors that influence learning, and attempt to decrease factors that hinder learning and knowledge acquisition. Assessment of individual and community needs for health education may occur during the CHA process, but a more in-depth assessment is often needed. Identifying community health education needs, including personal and organizational health literacy, is a necessary part of assessment. Limited health literacy is associated with greater emergency care use, increased hospitalizations, reduced preventative screening, lower vaccination rates, poorer ability to interpret health-related messages and labels, and poorer ability to take medications appropriately (Berkman et al., 2011).
Health Literacy
Only 12 percent of U.S. adults have the health literacy skills to manage the complex U.S. health care system (Agency for Healthcare Research and Quality, 2020). This leads to mismanagement of client conditions, increased risk for disease and disability, reduced health promotion and disease prevention behaviors, and negative client outcomes. One overarching goal of Healthy People 2030 is to “eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all” (Office of Disease Prevention and Health Promotion, 2021, para 1). Healthy People 2023 defines two types of health literacy, personal and organizational. Personal health literacy is the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others. Organizational health literacy is the degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.
These definitions emphasize an individual’s ability to understand and use health information to make well-informed decisions. Health literacy also involves acting on the understanding of health information in all situations, such as making decisions regarding voting on health-related policy, choosing a health care provider, or even choosing where to live (Santana et al., 2021). The organizational definition acknowledges that organizations are responsible for addressing health literacy and ensuring equity of health literacy.
Conversations About Culture
Five Things to Know About Health Literacy
Health care is a culture with its own language and systems that are unfamiliar to many clients. This includes clients who speak English, those with limited English proficiency, and those who have difficulty reading and using numbers. Health information and health care services may be challenging to find, understand, and use, yet health literacy is key in understanding and applying health information. This video describes populations at greatest risk for health literacy challenges and strategies nurses, other health care professionals, and organizations can use to improve health literacy.
Watch the video, and then respond to the following questions.
- What populations are at greatest risk for literacy challenges?
- What can organizations and health professionals do to improve health literacy?
- What are strategies nurses may use to check that clients understand information?
Population Health Literacy Assessment to Guide Health Promotion and Disease Prevention Activities
Including health literacy assessment as a component of the CHA helps the nurse understand the health education needs of individuals and communities. The health literacy level of individuals, aggregates, and community guides health promotion and disease prevention activities. An aggregate is a specific subgroup of a community or population. Individual, aggregate, and community health literacy skill levels impact health-related decisions and behaviors. Three levels of health literacy include functional, interactive, and critical (Table 17.7) (Nutbeam & Muscat, 2020). Understanding health literacy levels guides the nurse in choosing appropriate health promotion and disease prevention activities that align with the client’s current health literacy level and enhance health literacy by utilizing activities associated with the next level. Health literacy assessment should be ongoing to evaluate the effectiveness of health promotion and disease promotion activities.
| Health Literacy Level | Skills Present | Activities to Enhance Health Literacy | Examples of Activities |
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| Functional health literacy |
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| Interactive health literacy |
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| Critical health literacy |
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Health Literacy Assessment Tools
Including health literacy assessment as a component of the CHA helps the nurse understand the health education needs of individuals and communities. CHA teams can include health literacy assessment questions in CHA surveys, interviews with key community partners, and focus groups. Individual assessment of health literacy of targeted, high-risk populations can occur using a personal health literacy assessment tool. Organization health literacy assessment tools are available to assess community health systems. Including the results of this information in the final CHA report will highlight a community’s educational health literacy needs and changes needed within community health systems to enhance the health literacy of consumers. Health literacy assessment tools are available to assess health literacy skills at the personal and organizational levels.
Personal Health Literacy Assessment Tools
Personal health literacy assessment tools measure an individual’s ability to find, understand, and use health-related information and services and help the nurse determine a client’s health literacy level. The client’s health literacy level will guide interventions, including educational tools the nurse uses to provide health information and to improve health literacy.
Multiple tools are available that measure different aspects of health literacy. For example, The Health Literacy Tool Shed (Boston University, 2023) is an online database that contains information about health literacy assessment tools. Over 200 free and paid tools are available to measure terminology comprehension, application, information seeking and eHealth, and media comprehension of medicine, dentistry, genetic, and general health literacy. Tools are available for adults and youth in a variety of languages and for specific diagnoses such as cancer, diabetes, high blood pressure, HIV, infectious disease, intellectual disability, kidney transplant, mental health, oral health, and vascular surgery.
Organizational Health Literacy Assessment Tools
Organizational health literacy assessment guides health promotion and disease prevention activities at the organizational and systems level. Organizational health literacy assessment tools identify areas of strength and areas for improvement. These findings guide the organization in health literacy improvement efforts at the systems level. Assessment findings should be reported to the organization’s committee that deals with health literacy and key organization administrators. For example, the Health Literacy Environment of Hospitals and Health Centers (HLE2) tool measures organizational policies, institutional practices (resources, staff orientation and development, and expectations), navigation within the organization (signage and staff assistance), culture and language (respect for diversity, language serves, and staff training), and communication (print materials, forms, websites, and patient portals). The HLE2 suggests focusing on percentage scores for each section of the assessment tool as a way to identify strengths and weaknesses, select priority areas, and generate ideas for action (Rudd et al., 2019).
The Agency for Healthcare Research and Quality (2020) created the AHRQ Health Literacy Universal Precautions Toolkit to help organizations take steps to simplify communication and confirm client comprehension, improve navigation of the environment and health care system, and support efforts to improve health. The CDC (2019b) provides additional resources to assess organizational health literacy and tools to train staff, develop client materials, meet the needs of consumers with a range of health literacy skills, improve access to health information and services, and communicate clearly during crises.
Learning Process for Knowledge Acquisition
Disease prevention and health promotion begin with education of the individual and communities. Education is the establishment and arrangement of events to facilitate learning and skill development. Learning is the process of gaining knowledge and skills that lead to behavioral changes. Effective evidence-based community education programs are needed to increase health literacy, decrease health disparities, promote disease prevention, and promote health. Learning theories, health promotion models, and educational principles explain behavior and assist nurses in guiding community health strategies and choosing which intervention will be more likely to increase learning. Nurses should consider the identified health problem, population, and context of the planned program when choosing a learning theory or model. Often disease prevention and health promotion programs utilize one or more theories or models.
Selected Learning Theories
To provide effective health education to individuals and communities, nurses must understand the three domains of learning—cognitive, affective, and psychomotor. The cognitive domain is related to knowledge and includes thinking, memory, recognition, understanding, and application, moving from simple to complex. An example is the learner stating three signs of diabetes. The affective domain is related to perceptions and feelings, including changes in attitudes and development values. An example is a client with diabetes stating they feel as if they can manage their symptoms. The psychomotor domain is the performance of skills that require neuromuscular coordination. Learning in this domain depends on ability, a sensory image of how to carry out the skill, and practice. An example is self-administration of insulin.
Learning theories frequently used in community health education programs include behaviorism, social cognitive learning theory, constructivism, and adult learning theory. Planning Community Health Education discusses learning theories in more detail.
Factors That Influence Learning and Knowledge Acquisition
Nurses must consider factors that influence learning and knowledge acquisition when planning disease prevention and health promotion community educational programs. Age, culture, language, reading and comprehension skills, technology, and learner characteristics and experiences influence learning and knowledge acquisition, as do educator characteristics, experiences, and preparation. Learner characteristics include health literacy, self-efficacy, and motivation. Educator characteristics and preparation are public speaking, teaching or classroom/group management, choice of learning theory and teaching strategy, and planning.
Educator preparation and planning significantly impact the factors that influence learning and knowledge acquisition. Following the steps in the development of community education programs and choosing effective, evidence-based theories and strategies decrease both learner-related and educator-related barriers to learning. The educational method chosen should meet the learning needs of the population and have the greatest impact.
Steps In Developing a Community-Based Education Program
- Identify population learning need.
- Establish goals and objectives.
- Select appropriate educational methods.
- Select learning theories to use.
- Consider educational principles that are most appropriate.
- Examine educational issues/barriers.
- Design and implement the educational program.
- Evaluate the educational process and effects of the program.
Identifying a population’s learning needs occurs with community health assessment; these needs are then prioritized in the analysis phase. Assessment also identifies a population’s age, culture and language, educational level, and potential barriers to learning. Individual learner assessment can be used to clarify those learning needs and identify learner characteristics, including learning style, health literacy, and readiness to learn.
Educational methods should align with the age and developmental level of the target population. Pedagogy, where the teacher holds full responsibility for the teaching-learning process, is appropriate for children. Additionally, younger children require concrete examples, interactive activities, and repetition for knowledge acquisition. In contrast, adults learn best using andragogy, where learners share the responsibility of developing learning goals. This corresponds with the principles of adult learning theory.
When choosing educational methods, nurses should consider the target population's cultural beliefs, language barriers, educational level, health literacy, and motivation. Content and materials should align with cultural beliefs. Multilingual materials (presentation and written) may be needed. Additionally, because more than half the U.S. population ages 16 to 74 reads below a sixth-grade reading level (Schmidt, 2022), written educational materials should use plain language and be no higher than a fourth- to sixth-grade reading level (CDC, 2022). Content and materials should also align with health literacy levels. Refer to Table 17.7 for examples of teaching strategies for functional, interactive, or critical health literacy levels. Finally, aligning a learner’s motivation with the chosen teaching strategy facilitates learning.
Because individuals process information differently, nurses should consider the target population’s learning styles when choosing educational methods. Visual learners think in pictures or images and learn best through seeing and visualization. Appropriate educational methods for visual learners include taking notes and viewing videos, presentations, and pictures or images. Auditory learners process information and learn best through listening; appropriate educational methods are verbal lecture, discussion, music, podcasts, and reading aloud. Tactile-kinesthetic learners process information and learn best through doing and exploration. Appropriate educational methods are learning by trial and error, hands-on or interactive activities, and return demonstration.
Theory should be a foundation for community program planning and development and is consistent with the current emphasis on using evidence-based interventions in public health (Lhachimi et al., 2016) The chosen theory’s assumptions about a behavior, health problem, target population, or environment should be a good fit, logical, consistent with observations, similar to those used in previous successful programs, and supported by research (National Cancer Institute, 2005).
Finally, the educator considers the learning environment. To stimulate learning and reduce barriers, nurses should create a comfortable, distraction-free environment that encourages interaction. The educator needs experience managing a learning environment and the skills to minimize distractions, present content to enhance learner comprehension, evaluate teaching methods throughout the learning process, modify plans as needed to meet learner needs, and manage technology.