733775

research-article2017
RSH0010.1177/1757913917733775The perspective of healthcare providers and patients on health literacy: a systematic review of the quantitative and qualitative studiesThe perspective of healthcare providers and patients on health literacy: a systematic review of the quantitative and qualitative studies

PEER REVIEW

The perspective of healthcare providers and patients on health literacy: a systematic review of the quantitative and qualitative studies

The perspective of healthcare

providers and patients on health
literacy: a systematic review of the
quantitative and qualitative studies
Authors
Abstract
Retha Rajah
Pharmacy Department,
Aim: Health literacy (HL) is a multifaceted concept, thus understanding the perspective of healthcare
Hospital Seberang Jaya,
Penang, Malaysia providers, patients, and the system is vital. This systematic review examines and synthesises the
Discipline of Social and available studies on HL-related knowledge, attitude, practice, and perceived barriers.
Administrative Pharmacy,
School of Pharmaceutical
Methods: CINAHL and Medline (via EBSCOhost), Google Scholar, PubMed, ProQuest, Sage
Sciences, Universiti Sains Journals, and Science Direct were searched. Both quantitative and/or qualitative studies in the
Malaysia, 11800 Penang, English language were included. Intervention studies and studies focusing on HL assessment
Malaysia tools and prevalence of low HL were excluded. The risk of biasness reduced with the
Email: rethamuthu@gmail.
com involvement of two reviewers independently assessing study eligibility and quality.
Mohamed Azmi Ahmad
Results: A total of 30 studies were included, which consist of 19 quantitative, 9 qualitative, and 2
Hassali mixed-method studies. Out of 17 studies, 13 reported deficiency of HL-related knowledge
Discipline of Social and among healthcare providers and 1 among patients. Three studies showed a positive attitude of
Administrative Pharmacy, healthcare providers towards learning about HL. Another three studies demonstrated patients
School of Pharmaceutical
Sciences, Universiti Sains feel shame exposing their literacy and undergoing HL assessment. Common HL communication
Malaysia, Penang, Malaysia techniques reported practiced by healthcare providers were the use of everyday language, teach-
Lim Ching Jou
back method, and providing patients with reading materials and aids, while time constraint was
Discipline of Social and the most reported HL perceived barriers by both healthcare providers and patients.
Administrative Pharmacy, Conclusion: Significant gaps exists in HL knowledge among healthcare providers and patients
School of Pharmaceutical
Sciences, Universiti Sains that needs immediate intervention. Such as, greater effort placed in creating a health system
Malaysia, Penang, Malaysia that provides an opportunity for healthcare providers to learn about HL and patients to access
Muthu Kumar Murugiah
health information with taking consideration of their perceived barriers.
Pharmaceutical Services
Division, Penang, Malaysia

Corresponding author: Introduction medication administration and appointment

Retha Rajah, as above Health literacy (HL), commonly cited as
individuals ability to read, understand, and apply
Keywords health information to make healthcare-related
public health; health
decisions,1 is increasingly gaining recognition as a
promotion; public health
policy critical determinant of patients health outcomes.
Patients with limited health literacy (LHL) were
often linked with difficulty in managing chronic
diseases,2 lower rate of medication adherences,3,4
increased emergency care use, and risk of
hospitalisation.3,5,6
Prevalence of LHL is considerably high in
developed countries like the United States,
Europe, and Australia.79 In the United States,
26% of the population has difficulty with common
health tasks such as complying with directions of
dates, filling out forms, and understanding health
information.7 The European Health Literacy
Survey (HLS-EU) reports the prevalence of LHL
between 29% and 62% among eight European
countries,8 whereas the Australian adult literacy
and life skills survey shows more than half of the
respondents have less than minimum life skill.9
Many countries have recognised the impact of
HL on the health system, and considerable efforts
are made to address this silent epidemic.
International collaboration, national policy, and
legal regulations are some steps taken to reduce
the risk of LHL (European Commission 2013;
World Health Organization 2011). HL is
multifaceted, involving participation of not only the

Copyright Royal Society for Public Health 2017 Month 2017 Vol XX No X l Perspectives in Public Health 1
SAGE Publications
ISSN 1757-9139 DOI: 10.1177/1757913917733775
 PEER REVIEW
The perspective of healthcare providers and patients on health literacy: a systematic review of the quantitative and qualitative studies
healthcare providers (HCPs) or the
healthcare system but also patients and
other supporting organisations.
Therefore, the key to effectively address
issues of HL is through an overall
understanding of HL from the
perspective of HCPs and patients, which
this article aims to provide. A systematic
review was conducted on available
studies that report on HL-related
knowledge, attitude, practice, and
perceived barriers. Insight into this
valuable information will be an important
step to help policy makers and
stakeholders to take active measures to
address HL issues, which will
subsequently optimise patient care and
health outcomes.
Methods
Search protocol
This systematic review was developed in
accordance with Preferred Reporting
Items for Systematic Reviews and Meta-
Analyses (PRISMA) guideline.10 An
extensive search of literature published
from 1990 to February 2016 was
undertaken using electronic databases:
CINAHL and Medline (via EBSCOhost),
Google Scholar, PubMed, ProQuest,
Sage Journals, and Science Direct.
Some of the keywords used were health
literacy and low health literacy
combined with other terms such as
practice, knowledge, attitude,
barriers, communication, techniques,
perception, perspective,
understanding, health system, and
impact. In addition, the bibliography of
retrieved articles was screened for
relevant titles.
Study selection
All studies were screened initially for title
and abstract by the main reviewer (R.R.)
for any duplication. The reviewer further
assessed publication titles and abstracts
against pre-determined inclusion and
exclusion criteria. A second reviewer
(M.K.K.) independently assessed the
included abstracts for eligibility, and any
disagreements were discussed until
consensuses were reached.
Inclusion criteria comprised the
following: (1) articles published in the
English language; (2) studies that
2 Perspectives in Public Health l Month 2017 Vol XX No X
contained both qualitative and/or
quantitative descriptions of HL-related
knowledge, attitude, practice, and
perceived barriers. No restriction was
placed to include only those studies
reporting all our outcomes, but studies
that provide useful data for any of these
findings were included.
Exclusion criteria comprised the
following: (1) interventional studies on HL
and health HL outcome studies; (2)
studies investigating HL assessment
tools and prevalence of LHL; and (3)
editorials, reviews, notes, comments,
conference proceedings, and letters.
The main focus of this systematic
review was on functional HL, which is
defined as a skill to read, understand,
and comprehend medical information
and instructions.11
Quality assessment
Quality assessment of eligible studies
was performed independently using a set
of quality criteria by two reviewers (R.R.
and L.C.J.).12 Discussion resolved
disagreements between the reviewers,
and the third reviewer (M.A.A.H.) was
involved when necessary. A total of 16
items for qualitative studies which include
8 items for each section of reporting
clarity and robustness of the study
methods, respectively; meanwhile, 13
items for quantitative studies with 8 items
for reporting clarity and 5 items for
robustness of the study methods were
determined. A score of 1 is given if the
specific criteria are met and 0 if not met.
Items that are not applicable were
excluded from the final score. Qualitative
studies were categorised as high quality
if they met 13 or more criteria and
medium quality if met between 10 and
12 criteria. Quantitative studies were
categorised as high quality if they met 11
or more criteria and medium quality if
they met 10 criteria. Mixed-method
studies were assessed by quantitative
and qualitative study items separately
and then determined whether both
aspects of qualitative and quantitative
studies are met.
Synthesis of results
A narrative synthesis was adapted to
analyse the studies due to their
methodology heterogeneity, which
includes study types, population, and
research questions. The data extracted
were categorised into four outcomes
addressing our research questions: HL
knowledge, attitude, practice, and
perceived barriers. HL knowledge was
further classified into basic facts of HL,
consequences of HL, and HL screening
knowledge. For this review purpose,
attitude towards HL was defined as the
opinion of HCPs or patients about HL
screening and intervention. HL practice
was classified as a screening of HL and
application of HL strategies or
communication in the LHL population.
Perceived barriers were defined as
factors hindering HL screening and
implementation of HL strategies from the
perspective of HCPs and patients.
Results
The initial database search yielded 307
studies, of which 30 studies consisting of
19 quantitative studies, 9 qualitative
studies, and 2 mixed-method studies
met the selection criteria and were
included in the final analysis. Figure 1
describes the flow of studies through
searching and screening for inclusion by
the PRISMA guideline.
Study characteristics
Of the reviewed 19 quantitative studies, 11
were rated as high quality, and 8 studies
were rated as medium quality. Of the nine
qualitative studies, four studies were rated
as high-quality and five studies were
categorised as medium quality. Both the
mixed-method studies fulfilled the criteria
for high-quality studies for both the
qualitative and quantitative aspects. Table
1 provides a summary of included studies
characteristics and quality assessment.
HL-related knowledge
The review identified and categorised
HL-related knowledge into basic facts of
HL, knowledge of HL or LHL
consequences, and knowledge of HL
screening. As for the basic fact of HL,
the majority of studies reported that
HCPs had inadequate knowledge and
understanding of HL definition,22,23,34,37,41
and only qualitative study results support
that HCPs demonstrated adequate
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The perspective of healthcare providers and patients on health literacy: a systematic review of the quantitative and qualitative studies

Figure 1.

Flow chart for study screening and selection according to PRISMA guidelines.

knowledge in defining HL.35 The
prevalence of LHL was mostly
responded incorrectly by HCP.14,16,18,22
Overall, the major factors perceived by
HCPs to determine patients HL were
socioeconomic characteristics,2123
age,22,23 and education level.14,18,22,23 As
for knowledge about consequences of
HL and LHL, both patients and HCPs
agreed upon the impact of HL on
disease management, improving patient
outcomes, and delivery of health
information.21 Besides studies reviewed
reported the majority of HCPs
acknowledging the consequences of
LHL.14,15,28,29,37,38,42,43 These comprise
the ability to understand information,
obtain appropriate health services, follow
through with recommended treatments,
adhere to medication instructions,
manage treatment adverse events, and
assess preventive health screening.
Contrary to this finding, two quantitative
studies have found that a relatively lower

Month 2017 Vol XX No X l Perspectives in Public Health 3

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The perspective of healthcare providers and patients on health literacy: a systematic review of the quantitative and qualitative studies

Table 1

Summary of included studies and quality assessment

Authors, year Study method (design, duration) Sample and sampling Outcome Quality
of the study assessment
score

Quantitative studies (n=19)

Ali etal.13 Questionnaire paper-pencil version Convenience sampling, Attitude towards HL 8

medical residents and Practice of HL
students (n=40)

Atcherson Questionnaire survey via online participation Convenience sampling; Knowledge of HL 9

etal.14 and paper-pencil version during a formal Audiologists and Speech
presentation; adapted from Jukkala etal. Therapists (n=198)
and modified
2weeks

Cafiero15 Questionnaire survey via online participation Convenience sampling, Knowledge of HL 11

and paper-pencil version during an annual nurse practitioners Practice of HL
educational conference, the survey was (n=470)
adapted from Health literacy knowledge
and health literacy experience (HL-KES)
and Health Literacy Strategies Behaviour
Intention

Cormier and Questionnaire paper-pencil version, survey Convenience sampling, Knowledge of HL 11

Kotrlik16 was developed with a review of literature nurses (n=360) Practice of HL

Devraj and Postal survey, instrument was designed Systematic sampling, HL perceived barriers 12
Gupchup17 using multiple sources such as focus pharmacists (n=701)
group, literature reviews, and pilot testing

Devraj and Postal survey, instrument was designed Random sampling, Knowledge of HL 12
Gupchup18 using multiple sources such as focus pharmacist (n=701) HL perceived barriers
group, literature reviews, and pilot testing.

Dickens Interviewer-administered Single Item Convenience sampling; Attitude towards HL 11

etal.19 Questions (SIL) and HL assessment tool patients (n=65) and
(NVS) nurses (n=not stated)

Du20 Interviewer-administered survey and HL Convenience sampling, Attitude towards HL 11

assessment tools (REALM & FACT-G), cancer patients (n=97)
1year

Harrington Questionnaire survey via online participation Convenience sampling, Knowledge of HL 8

and Engelke21 US healthcare providers Attitude towards HL
working with CKD Practice of HL
paediatric patients HL perceived barriers
(n=147)

Jukkala Questionnaire paper-pencil version, survey Convenience sampling, Knowledge of HL 8

etal.22 was developed by study investigator different healthcare
providers (n=230)

Macabasco- Questionnaire survey via online Random sampling, Knowledge of HL 10

OConnell and participation, survey developed by the nursing professionals Attitude towards HL
FryBowers23 study investigators based on previous (n=76)) Practice of HL
studies (Jukkala etal. and Schlichting etal.) HL perceived barriers
(Continued)

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The perspective of healthcare providers and patients on health literacy: a systematic review of the quantitative and qualitative studies

Table 1 (Continued)

Summary of included studies and quality assessment

Authors, year Study method (design, duration) Sample and sampling Outcome Quality
of the study assessment
score

Parikh etal.24 Interviewer-administered survey and HL Convenience sampling, Attitude towards HL 12

assessment tools (TOFHLA) Emergency Department
and acute care patients
(n=202)

Schillinger Postal survey, instrument was designed Convenience sampling, Knowledge of HL 12

etal.25 based on the experience of MidWest different healthcare Attitude towards HL
Clinicians Network Committee members providers (n=701) Practice of HL
and a review of the literature

Schwartzberg Questionnaire paper-pencil version, Convenience sampling, Practice of HL 8

etal.26 designed by the American Medical different healthcare
Association providers (n=307)

Seurer and Postal survey Convenience sampling, Knowledge of HL 8

Vogt27 physicians (n=22) Attitude towards HL
Practice of HL

Torres and Questionnaire paper-pencil version, survey Convenience sampling, Knowledge of HL 9

Nichols28 was adapted from HL-KES survey (20) nursing students (n=391)

Turner etal.29 Postal survey developed through American Random sampling; Knowledge of HL 12
Academy of Pediatricians (AAP) Periodic paediatricians (n=848) Attitude towards HL
Survey of Fellow Perceived barriers

Weatherspoon Postal survey, questionnaire was adapted Random sampling, Practice of HL 10

etal.30 from Horowitz AM etal. and Maybury C paediatricians and family
etal. practice physicians
(n=294)

Wolf etal.31 Interviewer-administered survey and HL Convenience sampling, Attitude towards HL 12

assessment tools (REALM) patients (n=283)

Qualitative studies (n=9)

Baker etal.32 Individual interview face to face and focus Focus group (n=49 Attitude towards HL 15
group patients in 10 separate
focus group)
Individual interview (n=11
patients)

Jordan etal.33 Semi-structured interview face to face or Grounded theory, n=48 HL perceived barriers 14
via telephone patients; chronic disease
(n=20), general population
(n=14), ED (n=14), face
to face (n=23), via
telephone (n=25)

Lambert Individual interview face to face and focus Thematic analysis Knowledge of HL 14
etal.34 group Focus group (one focus HL perceived barriers
group)
Individual interview (n=24
healthcare providers)
(Continued)

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The perspective of healthcare providers and patients on health literacy: a systematic review of the quantitative and qualitative studies

Table 1 (Continued)

Summary of included studies and quality assessment

Authors, year Study method (design, duration) Sample and sampling Outcome Quality
of the study assessment
score

Sadeghi Individual interview face to face and focus Coded using framework HL knowledge 11
etal.35 group method and synthesised HL perceived barriers
using themes, COPD
patients (n=12) and
healthcare providers
(n=20)

Shaw etal.36 Individual interview face to face Thematic analysis HL perceived barriers 11
Patients (n=321)

Smith etal.37 Individual interview Thematic analysis Knowledge of HL 11

Radiation therapists Practice of HL
(n=25) HL perceived barriers

Smith etal.38 Semi-structured interview face to face or Coded using framework Knowledge of HL 12
via telephone method and synthesised Practice of HL
within a set of thematic
matrix radiation
oncologists (n=26)

Wood and Telephone interview Coded using framework HL knowledge 12

Gills39 method and synthesised HL perceived barriers
using themes, dietitians,
and nutritionists (n=9)

Zanchetta Individual interview face to face and focus Thematic analysis, Practice of HL 13
etal.40 group Focus group (three focus HL perceived barriers
groups)
Individual interview (n=3
nursing students)

Mixed-method studies (n=2)

Lewis etal.41 Questionnaire survey via online participation Convenience sampling: Knowledge of HL 13
(closed-ended and open-ended questions physicians and patient Practice of HL
analysed with thematic analysis) care at paediatric hospital
Physicians (n=145) and
patient care (n=891)
Ross etal.42 Qualitative: Focus group using thematic Convenience sampling, Knowledge of HL 12
analysis nursing students (n=262) Practice of HL
Quantitative: Questionnaire paper-pencil HL perceived barriers
version

HL: health literacy; REALM: Rapid Estimate of Adult Literacy in Medicine; TOFHLA: Test of Functional Health Literacy; COPD: chronic obstructive
pulmonary disease; CKD:Chronic Kidney Disease; ED:Emergency Department.

percentage of HCPs believed HL
interferes with patients ability to obtain
health information (48%)23 and as an
obstacle in their practice (32%).27 For the
category of knowledge on HL screening,
two quantitative studies reported a lack
of HCPs familiarity with the HL
assessment tools of the Rapid Estimate
of Adult Literacy in Medicine (REALM)
and the Test of Functional Health Literacy
(TOFHLA).15,28 However, HCPs were
reported adequately knowledgeable of
recognition of low HL behaviour and
higher risk groups.16,18,41,42 High
awareness about HL screening improving

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The perspective of healthcare providers and patients on health literacy: a systematic review of the quantitative and qualitative studies

Table 2

A summary of health literacy communication reported in the studies

HL communication techniques References

Everyday language 25, 26, 29, 30, 37, 38, 40

Teach back techniques 16, 2527, 29, 30, 37, 38, 42

Patients requested to be assisted by family/friends 2527, 30, 37, 38

Repeating key information 23, 29

Call after visit 26, 29, 30, 37, 38

Patient material and aids 15, 25, 27, 30, 37, 40

Indicating key points on written educational materials 25, 26, 29

Ask patient on comprehension of information delivered 23, 37, 42

Limit the number of information provided 26, 30, 37, 38

Speaking more slowly 26, 28, 40

Draw pictures 26, 27

Use of analogies to explain complex concept and risks 37, 38

Prepost test 16

Use of multimedia 40
Creating a sensitive environment 37

HL: health literacy.

healthcare teaching to patients was
demonstrated by one quantitative study
conducted among 360 senior nursing
students,16 and the majority of the same
population showed a sound knowledge
of the effective HL screening approach.28
Attitude towards HL
Generally, positive attitudes were
demonstrated by HCPs in learning more
about HL and training to provide effective
communication to LHL patients.21,27,29 As
for screening of patients HL using an
objective HL assessment tool, a mixed
attitude was reported. A study found that
the majority (92%) of respondents were
interested in conducting formal HL
assessment,21 whereas overestimation of
patients HL due to the use of subjective
assessment was reported in another
study among nurses.19 Only one study
reported on HCPs attitude towards
HL intervention that is low percentage
(14%) of HCPs believed HL intervention
programme was beneficial.23
A qualitative study exploring difficulties
faced by patients dealing with the
healthcare system identified patients deep
sense of shame and embarrassment upon
the need to reveal their reading problems
to HCPs.32 Similarly, a quantitative study
reported that almost half (47.8%) of the
patient population reading at or below
third-grade level admitted feeling shame
and embarrassment about their reading
difficulties.31 Over two-thirds (67.2%) of
these patients never even told their
spouse. Negative attitudes like anxiety and
stress were also shown by patients
towards HL screening, even though the
majority of patients acknowledge the
importance of HCPs being aware of their
reading abilities and having their literacy
documented in their medical records.20
The practice of HL
The practice of HL was categorised into
HL communication techniques and HL
screening. Table 2 summarises the HL
communication techniques used by
HCPs in the reviewed studies.
As for HL screening, HCPs were
reported not utilising HL assessment tools
to determine patients HL.21,23,27,43 Several
studies reported that HCPs often depend
on their gut feelings to determine patients
HL.23,27,43 The majority of the HCPs
claimed to have not received any formal
training about HL13,43 and less than 10%
felt confident about their HL knowledge or
skills to identify LHL patients.13

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The perspective of healthcare providers and patients on health literacy: a systematic review of the quantitative and qualitative studies

materials or resources to address patients

Table 3 with LHL, as reported by two quantitative
and four qualitative studies,
A summary of the perceived barriers from healthcare providers and patients respectively.21,29,34,37,39,40 Only one
perspective quantitative and three qualitative studies
showed a lack of organisational/
Perceived barriers from healthcare providers References
leadership support.23,35,3739 As for
perspectives
patient-related factors, their language
Healthcare systemrelated barriers especially non-English-speaking patients
were HCPs main perceived barriers
Time constraint 18, 21, 23, 29, 35, 36, 39, 40 towards improving patients HL, besides
patients culture and socioeconomic
Lack of education material or resources 21, 29, 34, 37, 39, 40 status.18,34,39,40 Patients characteristics,
such as their education level,35 age,34 and
Lack of organisation/leadership support 23, 35, 3739
attitudes like self-consciousness and
Patient-related barriers feeling shame,35,42 are some other
perceived barriers raised by HCPs.34,39,40
Non-English-speaking/language barriers 18, 34, 39, 40 In the category of HCP-related barriers,
almost 50% of HCPs agreed on the lack
Culture 34, 39, 40 of commitment to enhance HL.18 Three
quantitative studies reported their lack of
Socioeconomic status 34, 40
knowledge and skills as barriers towards
Age 34 HL.18,21,23 Two qualitative studies have
identified a lack of trust and rapport
Education level 35 between HCPs and patients as a barrier
to good health information delivery to
Patients attitude 35, 42 patients.34,40 Besides, three other studies
Shame
supported the claim by HCPs on the lack
Self-consciousness
of reliable and flexible HL assessment
Healthcare providersrelated barriers tools.17,21,23

Lack of skills 21, 23 Patients perspective

Lack of knowledge
Lack of interest
Lack of physicianpatient rapport
No flexible and easy to use HL assessment tool
Perceived barriers from patients perspective
Lifestyle commitment, education, and socioeconomic 33
background and family support
Time constraint
Medical jargon
HL: health literacy.
Perceived barriers towards HL
HCPs perspective
Three main categories of perceived
barriers identified from the perspective of
HCPs were healthcare system barriers,
patient-related barriers, and HCP-related
Only three qualitative studies have
18
explored perceived barriers towards HL
18 from patients perspective.33,35,36 Some
of the findings by Jordan etal.33 are
34, 40 lifestyle commitment, education, and
socioeconomic background and family
17, 23, 21 support.33 The use of medical jargon by
HCPs and time constraints were
References
reported in all the three studies.33,35,36
Table 3 provides a detailed summary of
the perceived barriers from HCPs and
patients perspective.
35, 36
35, 36 Discussion
This study is the first of its kind to
synthesise the available literature on
HL-related knowledge, attitudes,
practice, and perceived barriers to
barriers. At the top of the list of healthcare provide an overview of HL from all
systemrelated perceived barriers was aspects, especially the main players in
time constraint. Four quantitative studies the system, HCPs, and patients.
and three qualitative studies have Quality assessment revealed the
highlighted this barrier.18,21,23,29,35,39,40 This majority (60%) of the studies fulfilled the
is followed by the lack of educational determined quality criteria. This suggests

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The perspective of healthcare providers and patients on health literacy: a systematic review of the quantitative and qualitative studies
that the overall quality of the studies
included in this review was at an
acceptable level. However, there were
some weaknesses identified, especially
regarding the robustness of both the
qualitative and quantitative studies. Most
of the qualitative studies failed to provide
information relating to the
comprehensiveness of sampling strategy
and the reliability of the data collection
methods. While for quantitative studies,
the majority failed to provide data on the
sufficiency of the sample size and
response rate, undermining the
representability of the study findings. In the
aspect of clarity, two criteria were not
fulfilled by some of the qualitative studies.
These include insufficient data provided to
describe the design of the study to
achieve the study goals and strategies
involved to recruit the sample. Assessment
of the quantitative studies showed that
some failed to provide an adequate
description of the study population and
lacked clarity in the data analysis method.
Future research in the same field should
take measures to address the aspect
highlighted in the studies.
HCPs lack of awareness of HL
definition and understanding of the
concept presents a huge deterrent
towards establishing HL in the healthcare
system. Clearly, HCPs must be trained in
HL, and there is no better way than
integrating a HL course in their curriculum
and/or during residency. Numerous
studies have shown the positive outcome
of such exposure to HCPs.4446 Apart
from HCPs, a great knowledge deficiency
on the definition of HL was demonstrated
by patients.35 This study finding was not
surprising because the term and concept
are jargon to them since they had no
previous knowledge or exposure to it.
Importantly, evidence from the studies
showed both HCPs and patients
acknowledge the consequences of HL or
LHL. This awareness is important
because it will create a learning interest
about HL. Objectively assessing patients
HL using validated and established tools
earlier can help HCPs to recognise
patients with LHL and deliver the
appropriate intervention. However, this
cannot be achieved if HCPs themselves
are not well versed with available HL
tool.15,28 Although studies have shown
that HCPs are knowledgeable on
subjective assessment such as body
gesture, language, socioeconomic status,
and education level, it can be misleading
at times.
It is evident that HCPs were keen on
learning about HL and conducting HL
assessment to deliver health information
effectively to their patients.21,27,29 There is
plenty of room for health institutes to
start HL training to equip their staff to
handle the needy population in the sense
of HL.However, it is important to ensure
the designed training or programme is
substantial and impactful to both HCPs
and patients considering feedback that
reported existing programmes were
perceived as not beneficial.23,25 On the
contrary, negative attitudes were shown
by patients towards HL and HL
screening.20,31,32 It is important to point
out that patients negative feeling will
affect their acceptances of HL
intervention. Thus, efforts should aim to
create a more sensitive and conducive
environment that provides patients with
equitable access to health information.
HCPs should adopt a more impartial and
less judgemental manner which will not
embarrass or discourage patients from
revealing their HL or seek assistances.
Several studies highlighted that HCPs
do not regularly use formal HL
assessment tools in their
practice.21,23,27,43 Lack of knowledge and
skills on existing HL tools can be one of
the factors leading to the lack of
practice. Two studies reported that
HCPs claimed to have not received any
formal training on HL.13,43 There is
currently no best practice established to
indicate the frequency of assessing
patients HL level. However, it is unfair to
pinpoint that HCPs do not practice HL
screening at all because studies
reported they use other assessments
such as the verbal cues, non-verbal
cues, and their gut feelings.16,18,22,27,38
Although this evaluation can serve as a
quick and convenient way to assess HL;
it may result in different and variable
interpretation according to the individual
HCPs subjective perception of the
patients. The study by Dickens etal.19
revealed nurses overestimating patients
HL level without using a validated HL
tool. Various HL communication
Month 2017 Vol XX No X l Perspectives in Public Health 9
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techniques utilised by HCPs have been
identified in this study. However, the
rationale of the communication
techniques adapted and any studies did
not evaluate the effectiveness of each
strategy. Studies have suggested that
reimbursement or appreciation to
healthcare HCPs are some of the
strategies to encourage them to
implement HL screening or
communication techniques in healthcare
settings.29,47
There were many perceived barriers
mentioned by HCPs and patients across
the studies, but one that concerned both
was time constraints. It is a known fact
that the work burden is tremendous in
busy clinical settings, and the number of
patients waiting will restrict HCPs from
spending sufficient time to cater to LHL
patients. Thus, the best coping strategy
is involving other supporting team
members or referring to other recourses,
such as local support teams and specific
education classes. Moreover, as
mentioned by previous studies,2527,30,37,38
patients are encouraged to bring family
members or friends. This will provide
extra help to explain information imparted
by HCPs to patients, especially those
with language barriers. Assigning an
interpreter or certified navigators is
another option that needs serious
consideration in identified clinical settings.
Effective communication with adequately
knowledgeable and skilled HCPs on HL is
considered paramount in building trust in
patients. Strong organisational support
with sufficient staff to carry out HL
intervention is also equally important.
Strengths and limitations
The strengths of this review include the
multi-database search strategy, inclusion
of both quantitative and qualitative studies
and involvement of dual reviewers at every
phase that includes screening of articles,
assessing eligibility and quality of included
articles. However, few limitations need to
be acknowledged in this review. First, it
only included articles published in the
English language, so some relevant
studies in other languages may have been
missed. Furthermore, the study
specifically focused on functional H. which
may affect the generalisability of the study
findings. Another limitation is the challenge
 PEER REVIEW
The perspective of healthcare providers and patients on health literacy: a systematic review of the quantitative and qualitative studies
to extract study findings according to the
established definition of little bias. Finally,
the heterogeneous nature of the included
studies also reduces the ability to
summarise the key trends of the
HL-related knowledge, attitudes, practice,
and perceived barriers.
Conclusions
It is evident from the findings of this
systematic review that there is a lack of
knowledge among both HCPs and
patients that needs to be addressed
immediately. Emphasis should be placed
on educating and training the HCPs to
improve the practice of HL screening
and communication. Fundamentally, it is
important to ensure that all materials and
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Conflict Of Interest
The author(s) declared no potential
conflicts of interest with respect to the
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Ethical Review
The protocol of this study was registered
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The author(s) received no financial support
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