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The Concept of Health Literacy


Limited health literacy has been noted among some patients in the US and therefore health literacy has gained significant recognition in the last two decades. The purpose of this formal concept analysis paper is to explore a chosen concept in nursing theory. The methodology applied in this concept analysis was obtained from Walker and Avant 2010. The model consists of eight stages identified in table 1. Health literacy as a nursing concept was selected for this analysis. Health literacy refers to the extent to which individuals have the ability to acquire, process and comprehend primary health information and services required to make appropriate health decisions (Hepburn, 2012). There is no a single explanatory or theoretical approach to health literacy. Instead, the concept is noted across other disciplines such as social sciences, psychology, public health, applied linguistics, medicine, psychiatry and nursing (Hepburn, 2012, p. 229).

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Table 1: Eight steps of concept analysis of Walker and Avant 2010

1 Select a concept
2 Determine the purpose of the analysis
3 Identify all uses of the concept
4 Determine the defining attributes
5 Construct a model case
6 Construct a borderline and contrary case
7 Identify antecedents and consequences
8 Define empirical referents

Aims or Purpose

The paper focuses on concept analysis of health literacy in order to determine, clarify, eliminate vagueness of the concept and enhance consistency when the concept is used in nursing profession and other related studies.

The Institute of Medicine (IOM) defines health literacy as the “ability to obtain, understand, and act on healthcare information and instructions” (as cited in Sand-Jecklin, Murray, Summers, & Watson 2010). Still, Healthy People 2020 defines health literacy as “the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions” (as cited in Hepburn, 2012).

Although these definitions are slightly different, they tend to include various activities, which include understanding of medication instructions, adhering to prescriptions, offering informed consent, observing self-care instructions and reading medication instructions among others.

Literature Review

Various scholars concur that health literacy is a relatively new concept but has attracted much attention in the last two decades (Hepburn, 2012; Sand-Jecklin et al., 2010; Sykes, Wills, Rowlands, & Popple, 2013). The concept, however, is critical for improving healthcare and self-care in patients.

These studies acknowledged the differences that existed in the actual concept of health literacy and its application in research. Further, they showed that health literacy had huge potential to affect healthcare outcomes. Therefore, it is imperative to ensure that a concept analysis helps researchers and healthcare providers to integrate various elements of health literacy when formulating effective health promotion, patient information, vulnerable populations and finally enhancing health outcomes. Moreover, it is necessary to maintain the uniqueness and usefulness of the concept of health literacy by focusing on its core meaning and avoiding ambiguities. These researchers conducted thorough literature searches of several databases and experimental studies to explore the concept. These methodologies were effective for getting reliable conclusions.

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In the experimental study, a convenience sample of patients was selected, another study noted that it was not possible to obtain a conclusive interpretation of the concept (Hepburn, 2012; Sand-Jecklin et al., 2010; Sykes et al., 2013). Overall, studies were highly scientific in methodologies in order to provide reliable conclusions.

Uses of Health Literacy

The concept is applied in health science research, discourses and professional care as a factor that affects treatments directly in relation to treatment adherence, self-care and patient empowerment (Dennison, et al., 2011). On this note, several definitions have emerged to guide the use of the concept.

Apart from the previously mentioned definitions by Healthy People 2020 and the IOM, American Medical Association (AMA) considers health literacy as skills related to reading and numeracy skills for functioning in the healthcare environment. In addition, the World Health Organization (WHO) sees the concept as a form of patient empowerment.

In a broader view, health literacy may reflect outcomes associated with health education endeavors and promotions with effects on individuals and social aspects. It reflects improved cognitive skills, communication, critical thinking, problem solving, decision-making, analytical tendencies alongside other social skills to empower patients and improve individual health status and communities’ health.

Defining Attributes

The adopted analysis methodology presents defining attributes as those features of a concept, which are usually associated with a given concept and occur in several instances in reference to the concept. The defining attributes include reading, conception, numeracy abilities, decision-making abilities and effective functioning in healthcare environments.

Overall, individuals with adequate health literacy skills are much informed and capable of making positive health decisions. This has notably been the objective of health education endeavors, and it shows an important attribute among people with adequate health literacy skills.

Model Cases

Based on the methodology, a model case reflects all the defining attributes of the concepts and shows the real application of the concept (Hepburn, 2012).

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In this regard, a patient with health literacy skills exhibit functional reading and numeracy skills that support treatment (Hepburn, 2012). Such patients follow treatments, medications and physicians’ advice. They make informed decisions on behaviors and lifestyles to support the recommended preventive interventions. In addition, they successfully operate well in healthcare environments by informing their healthcare providers of their actions and notable changes. Finally, such patients also show high-levels of self-care. For instance, Dennison et al. (2011) have demonstrated that “adequate health literacy was associated with higher heart failure knowledge and self-care confidence in hospitalized patients” (p. 359). In addition, Hepburn (2012) had shown the application of health literacy in the Barbershop Health Outreach Program (BBHOP) to promote screening, lifestyle recommendations, self-care and interventions.

Alternative Cases

Borderline Case

A borderline case reflects another case of a concept application, but the case leaves out many defining attributes of the concept. In this regard, researchers would be able to understand what the concept does not include or what the concept is not. For instance, a patient may be highly literate, but exhibits limited health literacy. That is, a patient could be able to read, sign informed consent forms, but unable to understand the relevance of the form or potential medical procedures. The patient may not sufficiently requirements, instructions and therefore does not adhere to instructions and may use interventions inappropriately. A patient who decides to ignore instructions shows limited comprehension of treatment or severity of the problem. Therefore, such a patient fails to function well in health environments.

Related Case

A case that shows similarities with defining attributes, but is inconsistence. For instance, patients may understand importance of treatment but does not follow nurse’s recommendations.

Contrary Case

A contrary case fails to show any attributes of health literacy due to a lack of any of the attributes associated with the concept. In this case, a patient would demonstrate a complete lack of health literacy. For instance, such patients have limited reading and numeracy skills, might tell the care providers that they understand instructions while in essence they do not, ignore medication instructions and cannot make sound decisions. In addition, such patients may not change their behaviors and continue to exhibit health-threatening lifestyles and therefore not functioning well in health environments.

Invented Case

The concept attributes do not exist but a patient may make them up to respond to questions. Further, the patient could fail to make any healthcare decisions.

Illegitimate Case

The notable attributes do not reflect the defining attributes. Hence, a patient shows a complete lack of health literacy and display unknown behaviors, not following instructions or engaging in different behaviors that do not support interventions e.g. becoming angry or abusive when told sign informed consent forms.

Antecedents & Consequences

Based on methodology, antecedents are occurrences that must come first before the concept (Hepburn, 2012). In health literacy, antecedents include literacy and certain health-related cases (Sykes et al., 2013). Literacy shows ability to use written information to meet daily needs of society, attain one’s desires and develop self-knowledge and personal potential. Further, a literate person demonstrates meta-cognitive abilities related to reading, writing, comprehension and numeracy skills.

Patients may have some earlier experiences with diseases and healthcare provision systems or exposure to medical related terms. These aspects may show health-related experiences in patients. At the same time, the patient must reflect some logical elements of healthcare information within his or her mental framework. In other words, people with sufficient health literacy skills must have acquired such experiences from healthcare environments, experienced healthcare language use and developed mental framework to enhance understanding and logic in healthcare information received.

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Consequences are events or occurrences that take place because of the occurrence of the concept. For instance, researchers have reported several consequences that have resulted from health literacy. They include increased health knowledge, increased self-care and adherence, reduce d costs of care among others (Dennison, et al., 2011).

Empirical Referents

According to the selected methodology, empirical referents are elements that show the real phenomena because of the availability or existence to show the incidence of the concept itself. Empirical referents offer observable incidence to researchers, nurses, physicians and others to evaluate the extent of health literacy in a given patient or to locate certain risk factors in identified populations.

The Test of Functional Health Literacy in Adults (TOFHLA) has been touted as the most reliable and valid measure of health literacy in patients.

Another empirical referent for health literacy concept is the National Assessment of Adult Literacy (NAAL) from the National Centre for Education Statistics of the US Department of Education.

These empirical referents show health literacy index scores of patients on their ability to read and understand primary health-related information.


The concept analysis was done to determine the definition of health literacy, elucidate, eliminate vagueness and enhance uniformity when the concept is used in medical profession, studies and other related areas. As a result, this concept analysis of health literacy has offered a methodical and meticulous analysis of the definition and application of the concept of health literacy in different contexts within healthcare environments by using Walker and Avant methodology of 2010.

It is imperative to understand concepts to aid in describing and accounting for various phenomena and other occurrences from different areas. This approach helps to underpin and explain various situations demonstrated in a concept, which could be poorly understood.

It is therefore necessary to educate nurses and patients on the relevance of health literacy and its role in healthcare outcomes. In addition, researchers must continue with empirical studies to demonstrate effectiveness of the concept and its need in society, particularly for vulnerable patients.


Dennison, C., McEntee, M., Samuel, L., Johnson, B., Rotman, S., Kielty, A., Russell, S. (2011). Adequate health literacy is associated with higher heart failure knowledge and self care confidence in hospitalized patients. Journal of Cardiovascular Nursing, 26(5), 359–367.

Hepburn, M. (2012). Health Literacy, Conceptual Analysis for Disease Prevention. International Journal of Collaborative Research on Internal Medicine & Public Health, 4(3), 228-238.

Sand-Jecklin, K., Murray, B., Summers, B., & Watson, J. (2010). Educating Nursing Students about Health Literacy: From the Classroom to the Patient Bedside. OJIN: The Online Journal of Issues in Nursing, 15(3).

Sykes, S., Wills, J., Rowlands, G., & Popple, K. (2013). Understanding critical health literacy: a concept analysis. BMC Public Health, 13, 150.

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