Health Literacy Competence of Health Education Students in Three Universities

Abstract

Introduction. Limited health literacy challenges health care and perpetuates health disparities. Health agencies, such as the U.S. Department of Health and Human Services and the World Health Organization, have recommended health literacy training for all health professionals, but little is known about the health literacy competence of health education professionals. The purpose of this study was to assess the health literacy knowledge and experience of advanced health education students. Method. We used a cross-sectional design to collect data from a sample of 250 juniors and seniors enrolled in health education programs who self-reported an intention to take the certified health education specialists examination. Descriptive and bivariate analyses were conducted. Findings. Results showed most students (84%) scored below 70% on the knowledge component of the test, even though majority of them (94%) reported health literacy training was included in their health educator preparation curriculum. A correlation analysis found health literacy knowledge was not associated with students’ reports of health literacy in their health education curriculum. Prior academic degree was negatively correlated with health literacy knowledge (ρ = −.211, p < .05), and there was a negative correlation between health literacy knowledge and health literacy experience (ρ = −.189, p < .05). Discussion. The study identified weaknesses and gaps in the health literacy knowledge and skills of students, most of who were in the final phase of their professional preparation. The findings have implications for research, practice, and credentialing.

Keywords

health educator health literacy professional preparation competence

While health literacy training is recommended for all health professionals in the United States (U.S. Department of Health and Human Services, 2010), the precise health literacy competence health education specialists should possess is not formally delineated in the literature. Health literacy has received some attention in clinical education (Coleman & Appy, 2012; Coleman, Nguyen, Garvin, Sou, & Carney, 2016; Toronto, 2016) but is not well explored in health education research and teaching. As a result, little is known about the health literacy knowledge and skills of health education professionals, many of whom work in underserved, minority communities that bear disproportionate rates of disease burden.

The clinical literature shows gains in health professionals’ health literacy competence lead to positive shifts in practice behavior and patient outcome (Chen, Noureldin, & Plake, 2013; Evans et al., 2014; Green, Gonzaga, Cohen, & Spagnoletti, 2014; Price-Haywood, Harden-Barrios, & Cooper, 2014). Evans et al. (2014), for example, reported health literacy training that used a faculty dissemination model resulted in improvements in health professionals’ self-reported knowledge, skills, and attitudes related to health literacy and ethnogeriatrics. Similarly, a health literacy intervention for internal medicine residents resulted in improved knowledge, attitude, and practice (Green, Gonzaga, Cohen, & Spagnoletti, 2014). The practice benefits that accrue from health professionals’ health literacy skills make it imperative to ascertain if health educators possess the competence to effectively integrate health literacy into their practice.

In theory, health literacy and health education share a common goal—empowerment. In Nutbeam’s model of health literacy, health literacy is a continuum of cognitive skills that equip individuals to advocate for themselves and their communities and take actions that change the environments that inhibit health (Nutbeam, 2000, 2008). This conceptualization of health literacy parallels the aim of health education. The World Health Organization (1998) asserts health education is not solely about increasing knowledge around personal health behavior. More expansively, it involves developing skills that “demonstrate the political feasibility and organizational possibilities of various forms of action to address social, economic and environmental determinants of health.” Similarly, the Ottawa Charter for Health Promotion emphasized health promotion activities should be grounded in a socioecological approach that helps people gain autonomy over their health (World Health Organization, 1986).

The centrality of empowerment in both health literacy and health education sets up a somewhat reciprocal relationship between the two. Health education activities produce health literacy and gains in individual and community health literacy lead to improved health outcomes (Nutbeam, 2017). Health literacy competence, therefore, is an important and recommended tool for health education specialists, but there is a lack of research about students’ and professionals’ health literacy knowledge. The purpose of this study, therefore, was to assess the health literacy knowledge and experience of health education students in the junior or senior year of their undergraduate program at three universities in Texas. The assessment will highlight knowledge gaps and signal possible weaknesses and strengths in professional preparation.

Method

We used a cross-sectional survey design to assess health literacy knowledge and experience of a sample of health education students. The sample was drawn from three public universities in Texas. Two of the three universities are classified as “Highest” research activity (R1) under the Carnegie Classification of Institutions of Higher Education, and the third is classified “Higher” research activity (R2; Carnegie Classification of Institutions of Higher Education, n.d.). The universities were selected because, among public universities in Texas, they had the three highest enrollments of health education students. Surveys were administered during Fall 2016 and Spring 2017 semesters.

Participant Selection

Purposive sampling was used to recruit students for this study. Eligibility criteria required students to be juniors or seniors enrolled in a health education bachelor of science degree at one of the three Texas public universities in the study. Eligibility was restricted to these two student classifications to ensure participants were exposed to a significant number of preprofessional health core courses. In addition, students had to have the intention to take the certified health education specialists examination.

Instrumentation

A modified version of the Health Literacy Knowledge and Experience Survey (HL-KES; Cormier & Kotrlik, 2009) was used to collect data. The original instrument was validated among nurses and is growing in popularity among nursing researchers (Cafiero, 2012; Knight, 2011; Torres & Nichols, 2014). Validity evidence for the instrument range from Cronbach α = .57 to Cronbach α = .82(Cafiero, 2012; Knight, 2011; Torres & Nichols, 2014).

The original form of the HL-KES is divided into three parts. Part 1 (HL knowledge) has 29 multiple choice items covering five content areas: basic health literacy facts, health literacy screening, consequences of low health literacy, guidelines for writing health care materials, and evaluation strategies for health literacy interventions. Except for Question 1, which has five answer choices, each multiple choice question has three distractors and a single correct response, resulting in 25% probability a correct response is the result of guess rather than a measure of actual knowledge. Part 2 (HL experience) has nine Likert-type scale items divided into two subscales. The items assess how frequently students participate in health literacy learning activities (e.g., use HL screening tools, evaluate reading material, evaluate cultural appropriateness of teaching material). Part 3 has seven demographic questions (Cormier & Kotrlik, 2009) that capture information about race/ethnicity, gender, age, prior education, academic classification, health system use, and school.

The HL-KES was not validated among health education specialists but was considered an appropriate tool to use in this population because the items in the questionnaire cover topics generic to all health professions. Also, the HL-KES is the only available validated instrument that measures health literacy knowledge and experience of health professionals.

In adopting the HL-KES to use among students enrolled in health educator degree programs, slight modifications were made to the wording of the original instrument to make it applicable to the sample in the current study. The word “nursing” or “nurse” was changed to “health educator” or “health” and “patient” was changed to “individual.” In addition, two items (academic classification and name of school) were added to the demographic section of the questionnaire and two items (one queried students’ previous health care certification and the other grade point average) were inadvertently omitted. The instrument was also converted from its original paper and pencil format to an electronic format administered through Qualtrics, which is an online survey platform.

Procedure

Ethics approval was granted by Texas A&M University Institutional Review Board. A message was sent to the official university email address of upper division health education students inviting them to participate in the study. The invitation email outlined purpose and benefits of the study, inclusion criteria, students’ rights as participants, and gave assurance of anonymity. It also contained a link that took students who were willing to participate to a screening page that checked eligibility. Eligible participants were automatically routed to the questionnaire. After completing the questionnaire, students were sent a final thank you note and an electronic Amazon gift card worth $10. Approximately 844 students were enrolled in community health tracks during the study period. The initial study invitation and two follow-up email reminders were sent to all potential participants. Course instructors were also asked to announce the study in their classrooms.

A forced-response format was used to eliminate the problem of missing cases in the data set. In forced-response questionnaires, participants have to answer a question in order to advance to the next question (Albaum, Wiley, Roster, & Smith, 2011; Stieger, Reips, & Voracek, 2007). Forced response has been described as a quality versus quantity tradeoff (Albaum et al., 2011). While the approach improves the completeness of datasets, it also has the potential to compromise data quality. Research shows that forcing responses can cause frustration and result in random and false information, especially when respondents cannot honestly provide an answer or the questions are sensitive (Dillman, Smyth, & Christian, 2014; Stieger et al., 2007). In spite of the possible danger inherent in forced-response, the format was used in this study because it was fiscally prudent and because of the non-sensitive, objective nature of the questions on the HL-KES. The knowledge items had only one correct answer; therefore, students either knew the correct answer or they did not. Not answering a question would be equivalent to supplying the wrong answer. Conversely, forcing responses on a multiple choice test compels respondents to guess when they do not know the correct answers, leading to a possible overestimation of knowledge. The experience questions asked students to report the frequency with which they engaged in different health literacy activities. The response options ranged from “never” to “always” and, therefore, could be answered with ease and a high degree of honesty.

Data Analysis

Data on students’ health literacy knowledge and experience were analyzed using Statistical Package for the Social Science (SPSS) 22.0. Two hundred fifty questionnaires were included in the final analyses. Responses to the 29 knowledge items were recoded as “0” (incorrect) or “1” (correct), and knowledge scores were calculated for each participant. The nominal data captured by the experience items were also recoded as never = 0, sometimes = 1, frequently =2, and always = 3, and a composite HL experience score was calculated for each student.

Descriptive analyses were conducted to capture respondent characteristics, frequency of specific responses, and measures of central tendency. The knowledge data were further disaggregated by the five content foci covered by the HL-KES to highlight areas of strengths and weaknesses in what participants knew about health literacy.

In order to examine the data for relationships, scatterplots were generated. The data did not satisfy assumptions regarding linearity, outliers, and normal distribution, therefore, Spearman’s rho was used instead of Pearson’s R to check for evidence of association.

Results

Across the three universities included in this study, an average of 844 juniors and seniors were enrolled in community health tracks during Fall 2016 to Spring 2017. Of this enrollment, 250 students participated in the survey. This represents a 30% response rate.

Demographics

Most respondents were white females with no prior academic degrees. More than half the students were classified as seniors and more than 90% reported interacting with the health care system for their personal health needs between one and four times per year (see Table 1).

Table 1.

Participants’ Demographics.

Demographics	Frequency	Percentage
Gender
Female	205	82
Male	45	18
Age (years)
18-20	80	32
21-23	139	56
24-26	15	6
>26	16	6
Race/ethnicity
American Indian/Alaska Native	3	1.2
Asian	36	14.4
Black or African American	51	20.4
White	114	45.6
More than one race	31	12.4
Unknown	15	6.0
Education
No prior degree	214	85.6
At least one undergraduate	34	13.6
At least a master’s degree	2	0.8
Classification
Junior	107	42.8
Senior	143	57.2

Health Literacy Knowledge

The descriptive analyses showed students’ composite score on the 29-item knowledge scale ranged between 3 and 28 (M = 15.6; SD = 4.97). Most students (84%) scored less than 70% and approximately 5% of the sample scored more than 80% on the instrument. Item-level analysis revealed majority of students answered one third of the questions incorrectly. The poorest performance was on Knowledge Item 5, which queried the best predictor of health status. Eighty-eight percent of the sample selected one of the three distractors. The most popular distractor was socioeconomic status (68%). Only 12% of respondents selected the correct response, “health literacy.” The question that posed the least difficulty for students was Item 22 that assessed students’ knowledge of recommendations for developing written health care materials. Eighty-two percent of participants selected the correct response.

Domain-level analyses were also conducted to identify patterns in performance across the five content areas that constitute HL-KES knowledge (Table 2).

Table 2.

Mean and Standard Deviation of Knowledge Domains.

Domains	Items	Maximum scores	M	SD
Basic health literacy facts	1-5	5	0.394	0.233
Consequences of low health literacy	6-9	4	0.669	0.282
Health literacy screening	10-17	8	0.589	0.224
Guidelines for writing health care materials	18-25	8	0.532	0.210
Evaluation strategies for health literacy interventions	26-29	4	0.486	0.295

Note. Minimum scores = 0; M and SD values standardized to range between 0 and 1.

Basic Health Literacy Facts

In the basic health literacy facts domain, students performed poorly on three of the five items. The proportion of students who selected wrong responses on the three low scoring items ranged from 62% to 88%. These items asked about the populations most at risk for low health literacy (Items 1 and 2) and the best predictor of health status (Item 5). The other two items had 56% and 64% of students answering them correctly.

Consequences of Low Health Literacy

Overall, students performed best in this domain with majority of students answering all four questions correctly. The proportion of students who selected correct responses to each of the four items ranged from 54% to 79%. Question 8, which fell at the lowest end of the range, asked about coping skills for patients with low health literacy, and Question 6, which fell at the upper end, queried the impact of low health literacy on diagnosis and treatment.

Health Literacy Screening

Health literacy screening was composed of eight items. Proportion of students answering each question correctly ranged from 27% to 79%. Two items (Items 10 and 13) were particularly challenging for most students. Seventy-three percent of the students did not know the purpose of the Test of Functional Health Literacy (Item 13) and approximately 50% of participants did not know what the Rapid Estimate of Adult Literacy in Medicine (Item 10) was used to assess.

Guidelines for Writing Health Care Materials

Eight items also made up this domain. Two items (Items 19 and 24) were answered incorrectly by most students. Almost 75% of the sample did not know the recommended reading level for written health care material and 60% did not know the number of main ideas that should be included in written health care information about specific diseases. Each of the other six items in the domain was answered correctly by approximately 50% of the respondents. Overall, the highest proportion of students answering a question correctly was 61% and the lowest proportion was 26%.

Evaluation Strategies for Health Literacy Interventions

This last domain was made up of four questions, three of which (Items 26, 28, and 29) were problematic for most participants. Most students answered incorrectly the questions on teachback (57%), community involvement in developing health materials (70%), and opportunities for active learning (52%). The fourth question, which was concerned with clarity of health information, was answered correctly by 73% of participants.

Health Literacy Experience

The experience component of the HL-KES was made up of nine questions divided into two domains: core health literacy experience (6 items) and technology health literacy experience (3 items). Table 3 presents participants’ rating of their health literacy experience on a 4-point Likert-type scale that ranged from “never” to “always.”

Table 3.

Response Frequency to HL-KES Experience Scale.

Domains	Questions	Always (%)	Frequently (%)	Sometimes (%)	Never (%)
Core HL experience	Health literacy emphasized in your health education curriculum	12	44	38	6
	Use health literacy screening tool to assess health literacy skills	4	16	47	33
	Evaluate reading level of written health care materials	6	17	44	33
	Evaluate the cultural appropriateness of health care materials	14	30	40	16
	Evaluate the use of illustrations in written health care materials	11	28	45	16
	Use written materials to provide health care information	10	38	37	15
Technology HL experience	Use audiotapes to provide health care information	2	11	30	57
Technology HL experience	Use videotapes to provide health care information	3	18	42	37
	Use computer software to provide health care information	8	26	41	25

Note. HL-KES = Health Literacy Knowledge and Experience Survey.

Most students reported health literacy was emphasized in their health education curriculum either sometimes (38%), frequently (44%), or always (12%). Only 6% of participants said health literacy was never emphasized. Few participants reported “always” or “frequently” engaging in activities such as using health literacy screening tools, evaluating the reading level of health care materials, or evaluating the cultural appropriateness of health care materials.

Relationship Among Variables

Spearman’s rho correlation was computed to test for evidence of relationship between health literacy knowledge and six other variables on the HL-KES. The data in Table 4 indicate four out of six correlations were statistically significant (p < .05).

Table 4.

Correlations Between HL Knowledge and Other Variables.

		Age	Classification	HL experience	Health system use	Prior degree	HL in HE curriculum
HL knowledge	Spearman’s rho coefficient	−.016	.243	−.189	.126	−.211	.065
	Significance (2-tailed)	.801	.000	.003	.046	.001	.307
	N	250	250	250	250	250	250

Note. HL = health literacy; HE = health education. Coefficients in bold are significant (p < .05).

In general, the results suggest health literacy knowledge was neither associated with students’ reports of the emphasis health literacy received in their health education curriculum nor students’ age. On the other hand, students who engaged with the health care system for personal reasons or who were more advanced in the health education program (i.e., seniors) tended to have better health literacy knowledge than their counterparts. Interestingly, prior academic degree was negatively correlated with health literacy knowledge (ρ = −.211, p < .05) and there was a negative correlation between health literacy knowledge and health literacy experience (ρ = −.189, p < .05).

Discussion

The nature and extent of health literacy knowledge and experience of advanced health education students is an unrecognized area in health literacy research. This study, therefore, is an important addition to health literacy literature. The study identified weaknesses and gaps in the health literacy knowledge of students, most of who were in the final phase of their professional preparation. Many students had incomplete knowledge of basic health literacy facts such as prevalence of HL and populations that are most at risk for low HL. Students also demonstrated limited understanding of evaluation strategies and popular screening tools. These findings are consistent with other studies that found many health professionals have inadequate health literacy knowledge (Coleman, 2011; Cormier & Kotrlik, 2009; Lambert et al., 2014).

Deficits in students’ health literacy knowledge will no doubt impact if and how they integrate health literacy into their practice when they enter the workforce. It is unrealistic to expect health education specialists or other health professionals to effectively use a construct they do not fully understand. Social cognitive theory literature suggests action or behavior is contingent on feelings of self-efficacy that arise from repeatedly mastering a task. If students’ health literacy knowledge is inadequate, it may undermine their ability to achieve this mastery status. Furthermore, once students leave their preprofessional preparation programs, it is unclear what mechanisms are available to close the health literacy knowledge gap. Professional development courses are a possible medium through which health literacy can be promoted, but the extent to which health literacy content is routinely included in health professions’ training is frankly unknown.

The implication of this gap is significant for minority and underserved communities that experience severe health disparities and health literacy deficits. The results from this study suggest health education students may not be very clear about how health literacy can be leveraged to achieve the ultimate goal of empowered, activated communities. While health education students reported health literacy was included in professional preparation, other indicators in the study highlight gaps in their knowledge.

These gaps in knowledge may undermine the effectiveness of health education specialist in challenging health disparities. Health literacy is at the heart of health equity (Commission on Social Determinants of Health, 2008). People who have strong health literacy skills have greater ability to engage in personal and social actions that improve health (Nutbeam, 2017). On the other hand, individuals who have difficulty navigating the health system and advocating for themselves have poorer health outcomes, higher health care cost, and experience higher mortality from chronic diseases (Centers for Disease Control and Prevention, 2016; Nielsen-Bohlman, 2004). This link between health literacy and health equity makes it imperative for health educators to fully understand how health literacy complements and informs their practice and fits into the goal of health education.

It was not surprising many students performed well on the questions that assessed recommendations for written health care material and health literacy screening approaches. The knowledge assessed in these items mirrors requirements in National Commission for Health Education Credentialing (NCHEC) Competency 7.2 (NCHEC, 2015). This competency requires health educators be able to develop and tailor messages for different populations. Since classroom instruction is often guided by credentialing requirements, it is likely students had received instruction on developing health care materials and assessing literacy levels of populations.

The parallel between health literacy and some NCHEC competencies may be one explanation for the absence of a statistically significant relationship between students’ health literacy knowledge and their report that health literacy was included in their curriculum. It was expected that any change in reports of health literacy instruction would be accompanied by a parallel change in knowledge, but that was not the case. We found no significance. It is possible students misinterpreted health education content as health literacy inclusion in the curriculum when, really, the focus was not on health literacy. Health literacy includes a broader range of issues than the NCHEC competencies cover.

A finding that was somewhat unexpected was the negative correlation between prior academic degree and health literacy knowledge. Even though there are overlaps between health literacy and education, the extant literature indicates education is not a good predictor of health literacy (U.S. Department of Health and Human Services, 2010). The specialized nature of health information can baffle even well-educated individuals, especially in the stressful context of ill-health (Kickbusch, 2001; Nielsen-Bohlman, 2004). Hence, it was expected there would either be no relationship or a weak positive relationship between prior degrees and HL knowledge. The analysis, however, identified a statistically significant inverse relationship. Since no data were collected about the nature of prior degrees, it is not clear what factors might be driving this relationship or influencing the direction.

Apart from gaps in knowledge, students also reported limited opportunities to develop health literacy experience. The small number of participants who reported always or frequently engaging in different experiences indicates students may need more opportunities to gain practical experience. Health literacy is skills-based, and skills are honed through repeated practice (Ericsson, Krampe, & Tesch-Römer, 1993). On the other hand, students’ seeming lack of experience in a couple areas may be more a reflection of shifts in technology. In an era of Internet and online content, many students may never use audio tapes and video tapes, which are somewhat obsolete, in health education activities. This is not to say they have no experience using technology to deliver aural and visual messages. Future refinement of the instrument should review these questions to ascertain their continued validity.

Limitations

The generalizability of the findings in this study is constrained by the limitations of the research. First, the sample is not a representation of the population of health education students in the United States. It was drawn from three public universities in one state and is disproportionately composed of white females. While there are gender and racial disparities in higher education (U.S. Department of Education, 2018) and even greater disparities in public health–related degrees (Leider et al., 2015), the ratio of women to men and Whites to other racial groups in the sample does not mirror higher education figures nationally. Hence, the findings cannot be used to formulate conclusions about the knowledge and experience of advanced health education students nationally.

Second, the cross-sectional design provides a single set of data at a single point in time. It is plausible the results could vary if the constructs were measured at a different time. Finally, the instrument measured only a narrow range of HL knowledge and experiences. It focused on functional-level HL skills only, leaving students’ interactive- and critical-level knowledge and skills unexplored. In addition, knowledge related to other key areas of health literacy such as numeracy, the health environment, oral exchange, and national and international assessments of population health literacy were not captured. The study, therefore, provides only partial understanding of the health literacy knowledge and experience of advanced health education students.

Conclusion and Recommendations

In spite of the limitations, this study makes an important contribution to what is known about health education students’ health literacy knowledge and experience. A search of the literature identified no other study that examined health literacy of health education students. This study, therefore, offers initial understanding about strengths and weaknesses in health education students’ health literacy competence. The results of the study suggest there are a number of gaps in knowledge and students may have limited opportunities to develop practical health literacy experience.

In response, professional programs may need to review and revise their curricula to identify and address health literacy deficiencies in course offerings. Such a move would need to be bolstered by more robust research to expand the literature on health education students’ health literacy preparation and competence. Future studies could use a nationally representative sample to give a more complete picture of the state of the health literacy in professional preparation. The scholarship could also explore further the inverse relationship between prior academic degrees and health literacy knowledge and the mismatch between students’ health literacy knowledge and their report that health literacy was included in their programs. Such investigation would help clarify how health literacy is taught to health education students and establish the evidence base for curricular, credentialing, and practice changes.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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