HEALTH LITERACY QUESTIONNAIRE: REPORT ON THE EXPERIENCE OF RESEARCHERS IN PRIMARY CARE^*

ABSTRACT

Objective:

To analyze themes that emerged from the experience of researchers during the application of the Health Literacy Questionnaire in primary health care.

Method:

The experience report is based on the researchers’ field diary, collecting data from 500 primary healthcare users in the Federal District - of Brazil between May and August 2022. The records were analyzed in the light of Nola Pender’s nursing theory.

Results:

Demands for care emerged as the main category associated with poor quality of care. The perception of a precarious health system was revealed, implying a low level of relevance perceived by users about their cooperation in promoting changes in health services. Final considerations: It was possible to understand the role of the nursing team in involving users in their care and how this directly reflects on health promotion and disease prevention.

Keywords:
Health Literacy; Primary Health Care; Surveys and Questionnaires; Nursing Theory.

RESUMO:

Objetivo:

analisar temas emergidos a partir da experiência de pesquisadores durante a aplicação do instrumento Health Literacy Questionnaire na atenção primária em saúde.

Método:

relato de experiência baseado no diário de campo dos pesquisadores, na coleta de dados com 500 usuários da Atenção Primária em Saúde do Distrito Federal - Brasil, entre maio e agosto de 2022. Os registros foram analisados à luz da teoria de enfermagem de Nola Pender.

Resultados:

as demandas de atendimento emergiram como principal categoria, associadas à baixa qualidade na assistência. Desvelou-se a percepção de um sistema de saúde precário, implicando em baixa relevância percebida pelo usuário em relação à sua cooperação para promover mudanças nos serviços de saúde. Considerações finais: foi possível entender o papel da equipe de enfermagem para o envolvimento do usuário no seu cuidado, e como isso reflete diretamente na promoção da saúde e prevenção de doenças.

Palavras-chave:
Letramento em Saúde; Atenção Primária à; Saúde; Inquérito e Questionários; Teoria de Enfermagem.

RESUMEN:

Objetivo:

analizar los temas surgidos de la experiencia de los investigadores al aplicar el instrumento Health Literacy Questionnaire en la atención primaria.

Método:

informe de experiencia basado en el diario de campo de los investigadores, recogiendo datos de 500 usuarios de Atención Primaria de Salud en el Distrito Federal - Brasil, entre mayo y agosto de 2022. Los registros se analizaron a la luz de la teoría de enfermería de Nola Pender.

Resultados:

las demandas de atención surgieron como la categoría principal, asociada a una mala calidad de la atención. Se puso de manifiesto la percepción de un sistema sanitario precario, lo que implica un bajo nivel de relevancia percibido por los usuarios en relación con su cooperación para promover cambios en los servicios sanitarios.

Conclusión:

fue posible comprender el papel del equipo de enfermería a la hora de implicar a los usuarios en sus cuidados, y cómo esto se refleja directamente en la promoción de la salud y la prevención de enfermedades.

DESCRIPTORES:
Alfabetización en Salud; Atención Primaria de Salud; Encuestas y Cuestionarios; Teoría de la Enfermería

HIGHLIGHTS

1. Strategies for developing HL in primary care.

2. Promoting awareness of health improvements.

3. Evaluation to implement HL improvements for future research.

INTRODUCTION

Health literacy (HL) is the cognitive skills required to obtain knowledge, understand, evaluate, and make daily decisions related to the individual’s health. It enables them to take responsibility for their health care, aiming to maintain quality of life¹. Health literacy empowers citizens individually and allows them to get involved in collective health promotion actions². Health promotion is fundamentally concerned with action to address the full range of potentially modifiable determinants of health - not only those that are related to the actions of individuals but also the social determinants of health (e.g., income and access to resources, education, employment, and working conditions), access to adequate health services and the environmental determinants of health³.

In the Shanghai Declaration 2020/2030, we have three pillars for health promotion: good governance, healthy cities, and health literacy. HL was widely discussed at the Shanghai Conference. Improving HL through better access to information enables people to make more informed decisions about their health and the health of their families. It empowers them to advocate more effectively to their political leaders and policymakers².

Knowledge of HL is fundamental, as it contributes to health promotion and is highly relevant in Primary Health Care (PHC) for promoting preventive care, avoiding health problems, developing accessible interventions, and fostering good communication in the exchange of information between patients and health professionals⁴.

Most HL research has considered it unidimensional, focusing mainly on reading ability or functional health literacy. However, with the evolution of the HL field, it has become clear that HL encompasses multiple dimensions and is quite complex and heterogeneously constructed. While recognizing that the range of definitions is largely overlapping, each definition also highlights specific aspects of HL that help broaden understanding⁵.

In this multidimensional context, one instrument used to identify the level of HL in the population is the Health Literacy Questionnaire (HLQ), which assesses the understanding of these individuals concerning decision-making and self-carecommands⁶.

This article describes the researchers’ experience with the multidimensional HLQ. We, therefore, have the following guiding question: What experiences can researchers have when applying the HLQ in primary health care? To answer the guiding question, the study’s general objective was to analyze themes that emerged from the experience of researchers during the application of the HLQ in primary health care.

METHOD

This is a report on the experience of researchers who took part in the data collection stage of the research entitled ‘Validation of educational material to increase the health literacy of the population assisted in primary health care’.

Seven researchers, sixthand seventh-semester undergraduates in the nursing course linked to a higher education institution recognized by the Ministry of Education, carried out the experience between May and August 2022. The setting was a Basic Health Unit (BHU) comprising 11 family health teams.

We included adult users of both sexes aged between 18 and 60 registered on the BHU health map. The exclusion criteria were users registered on the health map but who did not use the BHU service under study. The sample was selected by convenience (non-random). Users were contacted in the BHU corridors while waiting to be seen and invited to participate in the study.

The multidimensional instrument used to identify the potential and limitations of HL in the population was the HLQ-Br, which comprises nine scales with a total of 44 items in two parts. The first part consists of five scales (1. Understanding and support from health professionals; 2. Enough information to take care of your health; 3. Active health care; 4. Social support for health; and 5. Evaluation of health information) and the second part consists of four scales (6. Ability to interact actively with health professionals; 7. Navigating the health system; 8. Ability to find good health information; and 9. Understanding health information and knowing what to do)⁷.

The answers are distributed on a Likert scale and scored from 1 to 4: disagree = 1, disagree = 2, agree = 3, and totally agree = 4. Part 2 consists of four scales and asks the participant to indicate how easy or difficult it is to carry out the proposed activities. The answers are distributed on a Likert-type scale, scored from 1 to 5: can’t do it or always difficult = 1, usually difficult = 2, sometimes difficult = 3, usually easy = 4, and always easy = 58.

Before data collection, we obtained authorization from the Australian university to use the HLQ instrument in its Brazilian version (e-mail [e-mail]). The researchers then met with the author, who validated the HLQ instrument in Brazil, for a practical training session. Tests were carried out to apply the instrument before the collection began, followed by a pilot test.

At the same time as the data was collected, the HLQ was applied to 500 BHU users, and a field diary was used, which is an instrument for recording any important information perceived by the researchers during the data collection⁹. At the end of each collection day, the team met and compiled the information to include in the general field diary.

The material was then analyzed and categorized in the light of Nola Pender’s nursing theory, which focuses on preventive actions and the aim of minimizing the prevalence and incidence of diseases¹⁰; based on three points: individual characteristics and experiences, feelings and knowledge about the behavior to be achieved, and desirable health-promoting behavior¹¹, as shown in Figure 1.

Figure 1
Nola Pender’s health promotion model¹¹. Brasília, DF, Brazil, 2023

Regarding ethical aspects, it should be noted that this report was approved by the Ethics and Research Committee of the University of Brasilia, opinion number 5.214.953.

RESULTS

Based on the experience of the researchers during the application of the HLQ, information was gathered about the difficulties of understanding the LS, participation in the evaluation and access to the health system expressed by PHC users, obtaining content that related to questions about the place of care, users, perspectives, challenges, approaches to interviewees, positive and negative reports regarding the basic health unit and its care.

According to Nola Pender’s theory of individual characteristics and experiences, the researchers identified that the BHU was easily accessible and had a high demand for patients, which favored the participants’ adherence to the survey in a short space of time. It was also an organized, clean place with a multi-professional team that always strives to offer the best care.

About the second point of nursing theory, feelings and knowledge about the behavior we want to achieve, some facilitators were observed at the beginning of the collection approach: the availability of the participant due to the waiting time to be seen and the strategy used by the researchers when approaching people, reinforcing that this was evaluative research, offering active listening.

We also approached people who chose not to take part in the survey. This behavior revealed a belief on the part of users that the health system is precarious and, therefore, there is no solution for improving the work process. Pender addresses the aspect of specific health behaviors, which are influenced by past experiences and generate barriers, an association linked to the non-participation of people in the survey for data collection.

In the third aspect that reflects Nola Pender’s theory, “desirable health promotion behavior”, users had difficulties filling out the questionnaire due to their level of education. The difficulty used to be in interpreting the questionnaire. On several occasions, the researcher needed to interpret the questions so the interviewee could answer the health information questions since the term used made it difficult for the participants to understand.

Another factor that hindered data collection was the length of the questionnaire. The process became tiresome as they answered the questions, and finishing the interview was discouraging. However, communication and empathy make the care environment more welcoming, thus improving care and the relationship between professional and patient.

The use of Nola Pender’s model and theory helps in the development of care in the context of promoting knowledge, contributing to the understanding of the community’s empowerment process, aiming at their quality of life, identifying factors that influence healthy behaviors from the biopsychosocial context, and thus allowing intervention and analysis of their needs¹⁰.

DISCUSSION

While applying the HLQ instrument, the researchers reported aspects of the research site, such as easy access, high patient demand, and a very helpful multi-professional team. Nola Pender’s nursing theory can help identify facilitators and hindrances to action, such as cognition and affect specific to behavior. As with LS, which requires the patient’s involvement in self-care, Pender reinforces these aspects in the context of health promotion¹².

The high patient demand made it easier for the collection team to administer the questionnaire while waiting to be seen without interfering with the usual running of the unit, which favored the approach and the exchange of experience between the researcher and the target audience.

However, it can be a problem in PHC care, as there is a reduction in the number of professionals, causing a deficit in welcoming clients, which has been perceived by the team as work overload, stress, and tiredness, generating conflicts within the team, negatively impacting on qualified listening and the care provided to individuals¹³, which reflects the influences of situations that Nola Pender describes for achieving health promotion.

The general perception that the researchers obtained when applying the questionnaire is that HL is an individual’s ability to make health decisions through the information they receive. Therefore, health professionals must pass on information to patients simply and easily. In this way, the behavioral result listed in Pender’s theory, which involves a commitment to the action plan and health-promoting behavior, will be achieved.

In this context, Pender reveals dimensions of health-promoting behaviors such as spiritual growth, responsibility for health, physical activity, nutrition, interpersonal relationships, and stress management, which are tools in conjunction with HL for developing aspects of health promotion¹⁴.

FINAL CONSIDERATIONS

During this study, the members of the collection team, who are undergraduate nursing students, were able to contact PHC users and establish the beginnings of an interpersonal relationship that favors active listening. In addition, by applying the instrument that assesses health literacy, it was possible to understand the role of the nursing team in involving users in their care and how this directly reflects on health promotion and disease prevention.

For future research, we suggest developing strategies to help raise awareness and change users’ perceptions of their contributions to scientific research, increasing collaboration with researchers.

• *
  Article extracted from doctoral thesis project: “Validação de material educativo para ampliação do letramento em saúde de usuários da atenção primária”, Universidade de Brasília, Brasília, DF, Brasil, 2023.

• HOW TO REFERENCE THIS ARTICLE:

  Cavalcanti E de O, Brito AK da SS, Góis MIB, Bezerra JD da R, Ramos ABS, Paranaguá TT de B. Health Literacy Questionnaire: report on the experience of researchers in primary care. Cogitare Enferm. [Internet]. 2024 [cited “insert year, month and day”]; 29. Available from: https://dx.doi.org/10.1590/ce.v29i0.94450.

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Edited by

Associate editor: Dra. Maria Helena Barbosa

Publication Dates

• Publication in this collection
  21 June 2024
• Date of issue
  2024

History

• Received
  12 June 2023
• Accepted
  14 Dec 2023