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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


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
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 dates, filling out forms, and understanding health
individuals ability to read, understand, and apply information.7 The European Health Literacy
Keywords health information to make healthcare-related Survey (HLS-EU) reports the prevalence of LHL
public health; health
decisions,1 is increasingly gaining recognition as a between 29% and 62% among eight European
promotion; public health
policy critical determinant of patients health outcomes. countries,8 whereas the Australian adult literacy
Patients with limited health literacy (LHL) were and life skills survey shows more than half of the
often linked with difficulty in managing chronic respondents have less than minimum life skill.9
diseases,2 lower rate of medication adherences,3,4 Many countries have recognised the impact of
increased emergency care use, and risk of HL on the health system, and considerable efforts
hospitalisation.3,5,6 are made to address this silent epidemic.
Prevalence of LHL is considerably high in International collaboration, national policy, and
developed countries like the United States, legal regulations are some steps taken to reduce
Europe, and Australia.79 In the United States, the risk of LHL (European Commission 2013;
26% of the population has difficulty with common World Health Organization 2011). HL is
health tasks such as complying with directions of 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

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

healthcare providers (HCPs) or the contained both qualitative and/or methodology heterogeneity, which
healthcare system but also patients and quantitative descriptions of HL-related includes study types, population, and
other supporting organisations. knowledge, attitude, practice, and research questions. The data extracted
Therefore, the key to effectively address perceived barriers. No restriction was were categorised into four outcomes
issues of HL is through an overall placed to include only those studies addressing our research questions: HL
understanding of HL from the reporting all our outcomes, but studies knowledge, attitude, practice, and
perspective of HCPs and patients, which that provide useful data for any of these perceived barriers. HL knowledge was
this article aims to provide. A systematic findings were included. further classified into basic facts of HL,
review was conducted on available Exclusion criteria comprised the consequences of HL, and HL screening
studies that report on HL-related following: (1) interventional studies on HL knowledge. For this review purpose,
knowledge, attitude, practice, and and health HL outcome studies; (2) attitude towards HL was defined as the
perceived barriers. Insight into this studies investigating HL assessment opinion of HCPs or patients about HL
valuable information will be an important tools and prevalence of LHL; and (3) screening and intervention. HL practice
step to help policy makers and editorials, reviews, notes, comments, was classified as a screening of HL and
stakeholders to take active measures to conference proceedings, and letters. application of HL strategies or
address HL issues, which will The main focus of this systematic communication in the LHL population.
subsequently optimise patient care and review was on functional HL, which is Perceived barriers were defined as
health outcomes. defined as a skill to read, understand, factors hindering HL screening and
and comprehend medical information implementation of HL strategies from the
and instructions.11 perspective of HCPs and patients.
Search protocol
This systematic review was developed in Quality assessment Results
accordance with Preferred Reporting Quality assessment of eligible studies The initial database search yielded 307
Items for Systematic Reviews and Meta- was performed independently using a set studies, of which 30 studies consisting of
Analyses (PRISMA) guideline.10 An of quality criteria by two reviewers (R.R. 19 quantitative studies, 9 qualitative
extensive search of literature published and L.C.J.).12 Discussion resolved studies, and 2 mixed-method studies
from 1990 to February 2016 was disagreements between the reviewers, met the selection criteria and were
undertaken using electronic databases: and the third reviewer (M.A.A.H.) was included in the final analysis. Figure 1
CINAHL and Medline (via EBSCOhost), involved when necessary. A total of 16 describes the flow of studies through
Google Scholar, PubMed, ProQuest, items for qualitative studies which include searching and screening for inclusion by
Sage Journals, and Science Direct. 8 items for each section of reporting the PRISMA guideline.
Some of the keywords used were health clarity and robustness of the study
literacy and low health literacy methods, respectively; meanwhile, 13 Study characteristics
combined with other terms such as items for quantitative studies with 8 items Of the reviewed 19 quantitative studies, 11
practice, knowledge, attitude, for reporting clarity and 5 items for were rated as high quality, and 8 studies
barriers, communication, techniques, robustness of the study methods were were rated as medium quality. Of the nine
perception, perspective, determined. A score of 1 is given if the qualitative studies, four studies were rated
understanding, health system, and specific criteria are met and 0 if not met. as high-quality and five studies were
impact. In addition, the bibliography of Items that are not applicable were categorised as medium quality. Both the
retrieved articles was screened for excluded from the final score. Qualitative mixed-method studies fulfilled the criteria
relevant titles. studies were categorised as high quality for high-quality studies for both the
if they met 13 or more criteria and qualitative and quantitative aspects. Table
medium quality if met between 10 and 1 provides a summary of included studies
Study selection
12 criteria. Quantitative studies were characteristics and quality assessment.
All studies were screened initially for title
categorised as high quality if they met 11
and abstract by the main reviewer (R.R.)
or more criteria and medium quality if HL-related knowledge
for any duplication. The reviewer further
they met 10 criteria. Mixed-method The review identified and categorised
assessed publication titles and abstracts
studies were assessed by quantitative HL-related knowledge into basic facts of
against pre-determined inclusion and
and qualitative study items separately HL, knowledge of HL or LHL
exclusion criteria. A second reviewer
and then determined whether both consequences, and knowledge of HL
(M.K.K.) independently assessed the
aspects of qualitative and quantitative screening. As for the basic fact of HL,
included abstracts for eligibility, and any
studies are met. the majority of studies reported that
disagreements were discussed until
consensuses were reached. HCPs had inadequate knowledge and
Inclusion criteria comprised the Synthesis of results understanding of HL definition,22,23,34,37,41
following: (1) articles published in the A narrative synthesis was adapted to and only qualitative study results support
English language; (2) studies that analyse the studies due to their 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 HL and LHL, both patients and HCPs the ability to understand information,
prevalence of LHL was mostly agreed upon the impact of HL on obtain appropriate health services, follow
responded incorrectly by HCP.14,16,18,22 disease management, improving patient through with recommended treatments,
Overall, the major factors perceived by outcomes, and delivery of health adhere to medication instructions,
HCPs to determine patients HL were information.21 Besides studies reviewed manage treatment adverse events, and
socioeconomic characteristics,2123 reported the majority of HCPs assess preventive health screening.
age,22,23 and education level.14,18,22,23 As acknowledging the consequences of Contrary to this finding, two quantitative
for knowledge about consequences of LHL.14,15,28,29,37,38,42,43 These comprise studies have found that a relatively lower

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


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

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

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

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)

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

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

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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

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

assessment tools (TOFHLA) Emergency Department
and acute care patients

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

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

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
Individual interview (n=24
healthcare providers)

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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

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

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
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

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 two quantitative studies reported a lack (TOFHLA).15,28 However, HCPs were
interferes with patients ability to obtain of HCPs familiarity with the HL reported adequately knowledgeable of
health information (48%)23 and as an assessment tools of the Rapid Estimate recognition of low HL behaviour and
obstacle in their practice (32%).27 For the of Adult Literacy in Medicine (REALM) higher risk groups.16,18,41,42 High
category of knowledge on HL screening, and the Test of Functional Health Literacy 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 study among nurses.19 Only one study importance of HCPs being aware of their
demonstrated by one quantitative study reported on HCPs attitude towards reading abilities and having their literacy
conducted among 360 senior nursing HL intervention that is low percentage documented in their medical records.20
students,16 and the majority of the same (14%) of HCPs believed HL intervention
population showed a sound knowledge programme was beneficial.23
of the effective HL screening approach.28 A qualitative study exploring difficulties The practice of HL
faced by patients dealing with the The practice of HL was categorised into
healthcare system identified patients deep HL communication techniques and HL
Attitude towards HL sense of shame and embarrassment upon screening. Table 2 summarises the HL
Generally, positive attitudes were the need to reveal their reading problems communication techniques used by
demonstrated by HCPs in learning more to HCPs.32 Similarly, a quantitative study HCPs in the reviewed studies.
about HL and training to provide effective reported that almost half (47.8%) of the As for HL screening, HCPs were
communication to LHL patients.21,27,29 As patient population reading at or below reported not utilising HL assessment tools
for screening of patients HL using an third-grade level admitted feeling shame to determine patients HL.21,23,27,43 Several
objective HL assessment tool, a mixed and embarrassment about their reading studies reported that HCPs often depend
attitude was reported. A study found that difficulties.31 Over two-thirds (67.2%) of on their gut feelings to determine patients
the majority (92%) of respondents were these patients never even told their HL.23,27,43 The majority of the HCPs
interested in conducting formal HL spouse. Negative attitudes like anxiety and claimed to have not received any formal
assessment,21 whereas overestimation of stress were also shown by patients training about HL13,43 and less than 10%
patients HL due to the use of subjective towards HL screening, even though the felt confident about their HL knowledge or
assessment was reported in another majority of patients acknowledge the 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
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
supported the claim by HCPs on the lack
of reliable and flexible HL assessment
Healthcare providersrelated barriers tools.17,21,23

Lack of skills 21, 23 Patients perspective

Only three qualitative studies have
Lack of knowledge 18
explored perceived barriers towards HL
Lack of interest 18 from patients perspective.33,35,36 Some
of the findings by Jordan etal.33 are
Lack of physicianpatient rapport 34, 40 lifestyle commitment, education, and
socioeconomic background and family
No flexible and easy to use HL assessment tool 17, 23, 21 support.33 The use of medical jargon by
HCPs and time constraints were
Perceived barriers from patients perspective References
reported in all the three studies.33,35,36
Lifestyle commitment, education, and socioeconomic 33 Table 3 provides a detailed summary of
background and family support the perceived barriers from HCPs and
patients perspective.
Time constraint 35, 36
Medical jargon 35, 36 Discussion
This study is the first of its kind to
HL: health literacy.
synthesise the available literature on
HL-related knowledge, attitudes,
practice, and perceived barriers to
Perceived barriers towards HL barriers. At the top of the list of healthcare provide an overview of HL from all
HCPs perspective systemrelated perceived barriers was aspects, especially the main players in
Three main categories of perceived time constraint. Four quantitative studies the system, HCPs, and patients.
barriers identified from the perspective of and three qualitative studies have Quality assessment revealed the
HCPs were healthcare system barriers, highlighted this barrier.18,21,23,29,35,39,40 This majority (60%) of the studies fulfilled the
patient-related barriers, and HCP-related 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 that HCPs are knowledgeable on techniques utilised by HCPs have been
included in this review was at an subjective assessment such as body identified in this study. However, the
acceptable level. However, there were gesture, language, socioeconomic status, rationale of the communication
some weaknesses identified, especially and education level, it can be misleading techniques adapted and any studies did
regarding the robustness of both the at times. not evaluate the effectiveness of each
qualitative and quantitative studies. Most It is evident that HCPs were keen on strategy. Studies have suggested that
of the qualitative studies failed to provide learning about HL and conducting HL reimbursement or appreciation to
information relating to the assessment to deliver health information healthcare HCPs are some of the
comprehensiveness of sampling strategy effectively to their patients.21,27,29 There is strategies to encourage them to
and the reliability of the data collection plenty of room for health institutes to implement HL screening or
methods. While for quantitative studies, start HL training to equip their staff to communication techniques in healthcare
the majority failed to provide data on the handle the needy population in the sense settings.29,47
sufficiency of the sample size and of HL.However, it is important to ensure There were many perceived barriers
response rate, undermining the the designed training or programme is mentioned by HCPs and patients across
representability of the study findings. In the substantial and impactful to both HCPs the studies, but one that concerned both
aspect of clarity, two criteria were not and patients considering feedback that was time constraints. It is a known fact
fulfilled by some of the qualitative studies. reported existing programmes were that the work burden is tremendous in
These include insufficient data provided to perceived as not beneficial.23,25 On the busy clinical settings, and the number of
describe the design of the study to contrary, negative attitudes were shown patients waiting will restrict HCPs from
achieve the study goals and strategies by patients towards HL and HL spending sufficient time to cater to LHL
involved to recruit the sample. Assessment screening.20,31,32 It is important to point patients. Thus, the best coping strategy
of the quantitative studies showed that out that patients negative feeling will is involving other supporting team
some failed to provide an adequate affect their acceptances of HL members or referring to other recourses,
description of the study population and intervention. Thus, efforts should aim to such as local support teams and specific
lacked clarity in the data analysis method. create a more sensitive and conducive education classes. Moreover, as
Future research in the same field should environment that provides patients with mentioned by previous studies,2527,30,37,38
take measures to address the aspect equitable access to health information. patients are encouraged to bring family
highlighted in the studies. HCPs should adopt a more impartial and members or friends. This will provide
HCPs lack of awareness of HL less judgemental manner which will not extra help to explain information imparted
definition and understanding of the embarrass or discourage patients from by HCPs to patients, especially those
concept presents a huge deterrent revealing their HL or seek assistances. with language barriers. Assigning an
towards establishing HL in the healthcare Several studies highlighted that HCPs interpreter or certified navigators is
system. Clearly, HCPs must be trained in do not regularly use formal HL another option that needs serious
HL, and there is no better way than assessment tools in their consideration in identified clinical settings.
integrating a HL course in their curriculum practice.21,23,27,43 Lack of knowledge and Effective communication with adequately
and/or during residency. Numerous skills on existing HL tools can be one of knowledgeable and skilled HCPs on HL is
studies have shown the positive outcome the factors leading to the lack of considered paramount in building trust in
of such exposure to HCPs.4446 Apart practice. Two studies reported that patients. Strong organisational support
from HCPs, a great knowledge deficiency HCPs claimed to have not received any with sufficient staff to carry out HL
on the definition of HL was demonstrated formal training on HL.13,43 There is intervention is also equally important.
by patients.35 This study finding was not currently no best practice established to
surprising because the term and concept indicate the frequency of assessing Strengths and limitations
are jargon to them since they had no patients HL level. However, it is unfair to The strengths of this review include the
previous knowledge or exposure to it. pinpoint that HCPs do not practice HL multi-database search strategy, inclusion
Importantly, evidence from the studies screening at all because studies of both quantitative and qualitative studies
showed both HCPs and patients reported they use other assessments and involvement of dual reviewers at every
acknowledge the consequences of HL or such as the verbal cues, non-verbal phase that includes screening of articles,
LHL. This awareness is important cues, and their gut feelings.16,18,22,27,38 assessing eligibility and quality of included
because it will create a learning interest Although this evaluation can serve as a articles. However, few limitations need to
about HL. Objectively assessing patients quick and convenient way to assess HL; be acknowledged in this review. First, it
HL using validated and established tools it may result in different and variable only included articles published in the
earlier can help HCPs to recognise interpretation according to the individual English language, so some relevant
patients with LHL and deliver the HCPs subjective perception of the studies in other languages may have been
appropriate intervention. However, this patients. The study by Dickens etal.19 missed. Furthermore, the study
cannot be achieved if HCPs themselves revealed nurses overestimating patients specifically focused on functional H. which
are not well versed with available HL HL level without using a validated HL may affect the generalisability of the study
tool.15,28 Although studies have shown tool. Various HL communication findings. Another limitation is the challenge

Month 2017 Vol XX No X l Perspectives in Public Health 9


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 communications with patients are Conflict Of Interest
established definition of little bias. Finally, tailored in a way that is easy to be The author(s) declared no potential
the heterogeneous nature of the included administered and at a level that conflicts of interest with respect to the
studies also reduces the ability to everybody can benefit. It is equally research, authorship, and/or publication of
summarise the key trends of the critical to create a positive attitude this article.
HL-related knowledge, attitudes, practice, among patients towards HL screening
and perceived barriers. and strategies to promote HL
interventions. The findings of perceived Ethical Review
barriers from the perspective of HCPs The protocol of this study was registered
Conclusions with the Malaysian Medical Research
and patients will be valuable insights to
It is evident from the findings of this Register (NMRR-15-2208-28623) and
stakeholders to implement policies and
systematic review that there is a lack of approved by the Medical Research Ethics
guidelines to encourage HL practices in
knowledge among both HCPs and Committee.
patients that needs to be addressed
immediately. Emphasis should be placed
on educating and training the HCPs to Acknowledgements Funding
improve the practice of HL screening We wish to thank Ministry of Health, The author(s) received no financial support
and communication. Fundamentally, it is Malaysia and Universiti Sains Malaysia for for the research, authorship, and/or
important to ensure that all materials and the support. publication of this article.

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