Running head: THEORY GUIDING PRACTICE

A Theory Guided Approach to Health Illiteracy Improvements in

Spanish Speaking People in the US
Brittany N. Reynolds
University of Central Florida

Professor: Patricia Lafferty

April 17, 2015

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Abstract

Spanish speaking people in the United States face disparities that lead to poorer outcomes than
non-minorities. Health illiteracy plays a dominant role in their ability to receive information;
thus, a clinical practice problem is present. Spanish, the most commonly spoken non-English
language in the United States is spoken by more than 37 million people in the country. In one
study, patients report difficulties with their doctor appointments and with follow-ups due to the
language barrier. Another study shows that patients with limited English proficiency (LEP)
undergo unnecessary testing due to the misunderstanding between provider and patient. Patients
with LEP were more likely to report being dissatisfied with their healthcare provider. An
additional study reports discharge instructions provided in a hospital were done with no
interpreter or by using a family member as an interpreter in one in four patients interviewed.
Together, the findings of the studies emphasize the need for improvement in communication
between healthcare providers and their Spanish speaking patients. Nola Penders Health
Promotion Model is a conceptual framework used to predict motivating factors that influence a
persons pursuit of healthy behaviors. This model is used in congruence with research articles to
determine what interventions can potentially improve patient outcomes in this demographic of
people. Interventions geared toward group counselling, culturally sensitive approaches to health
education and the use of mass media health communication outlets were shown to improve
patient knowledge and increase behavior modifications. Future research can combine Nola
Penders model with this population to improve patient outcomes and encourage behavior
modification.

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Health Literacy

We live in a diverse society that is constantly evolving; healthcare is evolving as well. As

people gain greater access to healthcare, they are expected to know more about their health and
be empowered to improve their overall health. Unfortunately, healthcare providers take for
granted their patients ability to understand what is expected of them. The Patient Protection and
Affordable Care Act of 2010, Title V, defines health literacy as the degree to which an individual
has the capacity to obtain, communicate, process, and understand basic health information and
services to make appropriate health decisions (Center for Disease Control and Prevention, 2014).
Issues with health literacy could be due to a number of reasons that include the following:
illiteracy, language barriers, cognitive barriers, physical impairments, cultural barriers and so
forth. Health illiteracy presents a pressing problem in health care practice. It is essential that
healthcare providers ensure their patients comprehension of their diagnosis, medications and plan
of action to improve their health and prevent poor patient outcomes. In order to narrow in on a
specific population, this paper will focus on the language barriers that lead to health illiteracy
among Spanish speaking citizens and immigrants of the United States (US).
Statement of Problem
Health disparities faced by ethnic and racial minorities have been well documented
throughout literature. These disparities lead to significant clinical practice problems in todays
healthcare environment. Health Communication and Health Information Technology remain a
current and relevant topic in Healthy People 2020, with objectives and interventions stressing the
importance of improving health literacy among patients (Office of Disease Prevention and
Health Promotion, 2015). Minorities living in the U.S. have been documented to have
disproportionate amounts of people suffering from chronic illnesses, and this population also has

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an increased amount of morbidity and mortality rates related to their chronic diseases (Britigan,
Murland, and Rojas-Guyler, 2009). The National Institute of Health reports that the estimated
cost of health literacy, according to Pfizer is between 106-236 billion dollars annually (National
Institute of Health, 2014). The clinical practice problem is that Spanish speaking people in the
US face disparities in healthcare. These disparities lead to decreased health literacy, and
ultimately, poorer patient outcomes.
Significance
The US is the worlds melting pot and is comprised of people from many different
countries. A vast number of these people speak a language other than English as their primary
language. In particular, Spanish is a language other than English that is commonly spoken
throughout the country. Pew Research Center reports that as of 2011, 37.6 million people in the
US speak Spanish at home- the most spoken non-English language in the country (GonzalezBarrera and Hugo Lopez, 2013).
Supporting Research
Britigan, Murland, and Rojas-Guyler (2009) reported language is a barrier to effective
health communication and leads to patient dissatisfaction, noncompliance, and fewer physician
visits. In their article, A Qualitative Study Examining Latino Functional Health Literacy Levels
and Sources of Health Information, a study was completed to determine where a specific
population of Latinos obtained their health information, as well as their literacy levels and
perceived barriers to obtaining health information. The participants in this study reported
difficulties scheduling their doctor appointments, during their appointments, and with their
follow-up instructions. The respondents reported turning to the Internet to receive their health
information because it is easier to understand in their native language. The lack of ability to

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understand their healthcare providers directly affects the Spanish speaking patients, and increases
the disparities faced in this population. It is essential that patients have their health information
explained to them in a way they can understand in order to optimize their health promotion and
improve their overall health.
According to the article No Comprendo: Practice Considerations When Caring for
Latinos with Limited English Proficiency in the United States Health Care System (Avila,
Sobralske and Katz, 2011), 21 million individuals in the United States of Spanish speaking
background report having limited English proficiency (LEP). The article reports that patients
with LEP undergo more unnecessary diagnostic testing due to their lack of understanding
between patient and provider. They also report being less satisfied with their provider if the
provider is not bilingual. This lack of understanding drives up health-care costs with unnecessary
testing and increases the risk for medication error. Being dissatisfied with your provider can also
lead to poorer outcomes. A lack of trust for their provider can cause a patient to neglect being
upfront and honest with him or her. Despite laws requiring interpreters, this article reports their
underutilization due to cost and longer wait times for patients. It is important that patients
understand their right to an interpreter and that healthcare providers make every effort to use
professionally trained medical interpreters.
A study by Karliner, Auerbach, Napoles, Schillinger, Nickleach, and Perez-Stable, (n.d)
showed how language barriers affect communication between healthcare providers and patients
in a hospital setting. Of the participants, greater than half had LEP, and the patients with LEP
proved to have less understanding of their discharge instructions and medications. One in four
participants of LEP reported having a family member or friend interpret their instructions from
the nurse, and one in four reported having no interpreter present. This study provides compelling

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evidence of the importance of having a trained interpreter available for patients at the time of
discharge. Using appropriate interpreters will improve outcomes and increase patient
compliance.
LEP can be a significant patient safety issue when it comes to prescription drug use. The
article Evaluation of Language Concordant, Patient-centered Drug Label Instructions (Bailey,
Sarkar, Chen, Schillinger, and Wolf, 2012) draws attention to the large number of adverse
medication effects from poor comprehension of prescription bottle labels. In this study, the
participants were divided into two groups- intervention and non-intervention. The group with the
intervention using an evidence-based approach to literacy was able to understand their
prescription instructions far better than the non-intervention group. The study concluded that
there is an imminent need for a standardized, multilingual method to provide patients with
instructions on their medication in a way in which they can understand. Better understanding
leads to better compliance- thus, improving patient outcomes.
Specific Aim
The disparities faced by this demographic of people warrant a significant adjustment in
the delivery of information and education provided to them. A desired outcome would be for a
drastic improvement in the methods used to educate Spanish speaking people in the US. Nursing
interventions geared toward improving health promotion among these patients could potentially
aid in the improvement of a patients health-seeking behavior; especially in health illiterate and
LEP patients. Through proper education of health-care providers and patients alike, patient
outcomes can improve. The disproportionate amounts of morbidity and mortality faced by this
underserved population could be reduced if patients and caregivers collaborate in an effort to
improve this unfortunate fact.

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Model

The Health Promotion Model (HPM) developed by Nola Pender provides an appropriate
framework for improving this clinical practice problem. Originally formulated in 1982, this
theory has been revised several times before reaching its most recent form in 2006. This middlerange theory was developed in order to promote health through disease prevention, rather than
disease management (Pender, 2000). The HPM incorporates behavioral science with nursing to
explore the different motivating factors that lead a person to pursue health enhancement, and is
used as a predictor of health behaviors (McEwen, 2014). There are three major concepts in the
model. The concepts are: 1) individual characteristics and experiences (prior related behavior and
personal factors), 2) behavior-specific cognitions and affect (perceived benefits of action,
perceived barriers to action, perceived self-efficacy, activity-related affect, interpersonal
influences, and situational influences), and 3) behavioral outcomes (commitment to an action
plan, immediate competing demands, and health-promoting behavior) (McEwen, 2014). The
ability this model has to reach patients in a variety of settings and populations emphasizes its
applicability to the development of a plan to improve this clinical practice problem.
Theory Application
As stated prior, the HPM is used to explore motivating factors for disease prevention.
Despite the wide use of the HPM as a predictor to a patients motivation, no studies were found
that directly involved Nola Penders Model combined with Spanish speaking people in the US.
There are, however, several articles pertaining to patient motivation, health promotion, and
interventions used to improve outcomes across this demographic. Further research involving this
specific population would prove beneficial to the growing number of Spanish-speaking people
living in the US.

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Evidence Substantiating Model

In an attempt to improve patients access to preventative healthcare, the Patient Protection
and Affordable Care Act 2010 (ACA) made steps to eliminate the barrier of cost to accessing
quality preventative care (Anderson, Siems, Holloway, Sultana, Braund and Harris, 2012). In
light of this, a project was conducted using group counselling in patients with LEP in an attempt
to improve the quality of care being provided. The project consisted of two groups- Spanish and
English. In the group sessions, participants were educated on disease prevention and provided
reliable resources for continued behavior modification outside of the group. The article Group
Counselling Improves Quality for Patients with Limited Health Literacy (Anderson et. al, 2012)
acknowledges the affect that group support has on improving self-efficacy and behavior
modifications. Perceived self-efficacy is a portion of a major concept in the HPM. It is
noteworthy that 86% of the Spanish-speaking participants were able to meet the behavior
modifications set for themselves. The high success rate of the program is a prime example of the
importance of combining interventions to promote health in a population that has been
underserved.
Strategies for Health Education in North American Immigrant Populations (Zou & Parry,
2012) discusses the barriers to proper receipt of health information among immigrants of the US.
The linguistic barrier ranks high on the barriers to health education, along with health literacy.
This article also acknowledges the impact that cultural differences has on a patients ability and
willingness to pursue health information. Strategies for improving health education expressed in
the article include: a culturally sensitive approach, language facilitating methods, appropriate
technology application, partnership and participation, and appropriate pedagogy. These strategies
would be helpful in promoting health education and understanding of immigrant patients- whose

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population in the US continues to grow. The article also expresses that linguistic barriers cause
patients to be less motivated to seek health information. The HPMs emphasis on motivating
factors can be used to understand Spanish speaking immigrants behaviors, and can be utilized to
tailor interventions toward improving the above statistics.
In an era where the use of technology appears to be everywhere you look, studies still
show that Internet usage among the Hispanic population in the US is around 35%, in regards to
its use for health information (De Jesus, n.d.). The Impact of Mass Media Health Communication
on Health Decision-Making and Medical Advice-Seeking Behavior of US Hispanic Population
(De Jesus, n.d.) set out to determine if mass media exposure improved patient health seeking
behaviors of Hispanic populations, who rely heavily on media outlets to obtain health
information. This study proved that Hispanic populations with lower health literacy reported
depending on media outlets, in particular Television, to influence their health seeking behaviors.
Those with higher health literacy denied heavy reliance on media outlets as a motivator. Once
again, motivation has a large impact on patients and their self-efficacy. Improvements on media
outlets as information sources for health improvement will expand patient accessibility to
resources and motivators to achieve better health outcomes.
Summary
The literature reviewed solidifies the need for improvement in communication with
Spanish speaking patients. A predominant factor in the research is in regards to patient
motivation. Correlations are made between health literacy and patient motivation. Nursing
interventions geared toward patient understanding should be heavily promoted across the
continuum of care. Nurses should properly identify Spanish speaking and LEP patients at
admission and ensure that every effort is made to increase patient understanding of health

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information. Another way to ensure patient understanding is to use the repeat-back method- thus,
identifying areas that the patient needs further education. The literature reiterates the challenges
faced by health illiteracy and language barriers. However, more research needs to be done
regarding the implementation of appropriate and cost-effective interventions to reduce the
amount of health illiterate patients, and methods to improve their comprehension of the materials
provided. With the use of the HPM, motivating factors can be identified, and used for further
research. Bridging the gap for Spanish speaking people in the US will help to ensure patient
safety and compliance. Providing the resources and tools for patients of different cultural, ethnic,
and social backgrounds to better understand health literacy will undoubtedly end in quality
improvement. Implementing the skills learned through evidence-based practices in the healthcare
setting should be of utmost importance in every patients plan of care. With teamwork among
providers, health literacy can improve. This will, in turn, improve patient outcomes- an optimum
goal for nurses.

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References

Anderson, K. M., Siems, L. V., Holloway, S. C., Sultana, N., Braund, W. E., & Harris, L. M.
(2012). Group counselling improves quality for patients with limited health literacy.
Quality In Primary Care, 20(1), 5-13
Avila, J., Sobralske, M., & Katz, J. (2011). No comprendo: practice considerations when caring
for Latinos with limited English proficiency in the United States health care system.
Hispanic Health Care International, 9(4), 159-165. doi: 10.1891/1540-4153.9.4.159
Bailey, S. C., Sarkar, U., Chen, A. H., Schillinger, D., & Wolf, M. S. (2012). Evaluation of
language concordant, patient-centered drug label instructions. Journal Of General
Internal Medicine, 27(12), 1707-1713. doi:10.1007/s11606-012-2035-3
Britigan, D., Murnan, J., & Rojas-Guyler, L. (2009). A qualitative study examining Latino
functional health literacy levels and sources of health information. Journal Of
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Gonzalez-Barrera, A., & Hugo Lopez, M. (August 13, 2013). Spanish is the most spoken nonEnglish language in U.S. homes, even among non-Hispanics. Pew Research Center.
Retrieved from www.pewresearch.com/fact-tank/2013/08/13.

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Karliner, L., Auerbach, A., Napoles, A., Schillinger, D., Nickleach, D., & Perez-Stable, E. (n.d).
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