Health literacy is important in health care, particularly in improving communication skills and achieving positive health outcomes ( Nutbeam, & Lloyd, 2021). Thus, health literacy should be enhanced in the undergraduate nursing education. The current study examined the alterations in the health literacy levels of undergraduate nursing students in a four-year prospective longitudinal study. It was revealed via the present study that, the health literacy levels of nursing students were lowest in the first year, at the initiation of the education program; started to increase from the second education year, and reached the highest level in the fourth year by increasing throughout the education period. Health literacy levels of the students are thought to increase over time, thanks to the gained professional knowledge, experience, and clinical practice occasions. In the studies, which compare the health literacy levels of freshman and senior nursing students, the health literacy level of the seniors was found to be higher than that of the freshmen (Ayaz-Alkaya & Terzi, 2019; González-López & Rodríguez-Gázquez, 2022; Munangatire et al., 2022). Generally, these results of the literature show the changes in health literacy levels of the students compared to their grades during the professional education programs. However, there could not be reached any other study, which was conducted to explore the alterations in the health literacy levels of the nursing students over time throughout the education period the same student cohort. Future nurses will exactly have more opportunities to gain and integrate their health-related knowledge into the care, if the nursing curriculum focuses on the health literacy issue (Koduah, Amoah, Nkansah, & Leung, 2021). Although most of the nursing curriculums have patient education and counselling topics, they do not specifically point out health literacy (Akça & Ayaz-Alkaya, 2021). Therefore, the health literacy subject should be integrated into the nursing curriculum to competently prepare the students for practicing nursing care in the clinical settings.
Internet use was an important factor, which contributes positively to health literacy. The internet and the new digital tools for seeking, communicating, and using information have become embedded in the social actions of people (Huhta, Hirvonen, & Huotari, 2018). The Internet may be a preferential communication channel for helping advance health literacy (Sinan et al., 2023). The LMM analyses in the present study revealed that the internet use was one of the significant factors related to the alterations in health literacy. Several studies found that the health literacy level of nursing students was higher who use the internet (Ayaz-Alkaya & Terzi, 2019; Park & Lee, 2015). The Internet is one of the main sources of the knowledge, which enables users to have access to a larger volume of information on various sectors. Moreover, the Internet has become an important source for health information (Shiferaw & Mehari, 2019). It is thought that the Internet is a useful tool in advancing health literacy, students who use the Internet have more opportunities to access various health resources, and the use of the Internet during education has positive effects on health literacy. The use of smartphone applications may be an effective approach to provide health information and services to students with limited health literacy level.
Another significant factor related to the alteration in the health literacy was the place of residence of the students in this study. Namely, health literacy was higher in the nursing students who lived longer in the urban areas than that of the rural area residents. This result can be explained by the fact that students have more opportunities to access health-related information due to the more advanced information and communication technologies in urban areas. Ergün determined that the health literacy level of nursing students who lived longer in a metropolitan area was higher than those who lived in rural area (Ergün, 2017). Likewise, in the studies, conducted on different groups other than the nursing students, inadequate health literacy level was more frequently identified among individuals who lived in the rural areas (Maricic et al., 2021; Todorovic et al., 2019). It is clear that living in the urban areas can positively affect the health literacy level. Therefore, opportunities, to which ease to improve the health literacy level of the rural area residents, should be provided. Those individuals, whose health literacy level is low or limited, can feel themselves incompetent in the self-management of health problems, and this situation would pave the way for having chronic health problems (Golboni, Nadrian, Najafi, Shirzadi, & Mahmoodi, 2018). It is thought that additional practices (teaching how to use internet-based health services, additional research activities, asking simple questions, using basic language when explaining a health problem) should be practiced to increase the health literacy level of nursing students who are the rural area residents.
In this study, LMM analyses showed that having any visual impairment was a significant factor related to the alterations in health literacy. Unlike, in the study of Ayaz-Alkaya and Terzi (2019), visual impairment was found as an ineffective factor of the health literacy levels of the nursing students. This difference may stem from the diversity of methodologies of the studies. Since only one measurement was performed in the cross-sectional study, the visual impairment factor may not have affected the health literacy level (Ayaz-Alkaya & Terzi, 2019). Yet, health literacy levels of the nursing students were measured in different phases of the education in this prospective-longitudinal study, visual impairment may have detected as a predictor of the health literacy. In the literature, which were conducted with the nursing students, the relationship between visual impairment and the health literacy was not investigated (Ergün, 2017; Özen, Bal-Özkaptan, Coşkun, & Terzioglu, 2019; Tuğut, Yılmaz, & Yeşildağ-Çelik, 2021). Different from the cohort of current study, a study conducted with women found that the health literacy level of women having a visual problem and wearing glasses was found lower (Ayaz-Alkaya & Özturk, 2021). It is thought that individuals with visual problems are more likely at the risk group in terms of low health literacy and developing poor communication skills.
Implications for practice
According to the Healthy People 2030 targets, HL is a high-priority public health issue. Appropriate strategies could develop developed to increase the level of health literacy during undergraduate nursing education. Appropriate mentoring programs should be designed for the nursing students to improve their HL skills. A nursing manager or nurse leader may be more capable of assisting nursing students during their clinical education to integrate their HL skills into the students' professional careers as nurses. Nurse leaders can collaborate with stakeholders such as health care providers, ministry of health, nursing school managers, non-governmental organizations etc. to develop policies to improve health literacy level. Nurse managers, educators and leaders can develop strategies for the implementation of these policies. For the future, interventional studies could be planned to improve HL of both nursing students and clinical nurses.
Strengths and limitations
The results of the current study are remarkable because of showing the positive effects of nursing education on the health literacy levels of the students. Different from the literature, following-up an undergraduate nursing student cohort from the beginning of their nursing education process and being a first study, which was explored to the alterations in the health literacy levels of the students within four years, are the other strengths of the present study.
There are some limitations in this study. Firstly, any possible confounding variables were not considered at different time points during nursing education program. Therefore, the potential effective factors associated with the alterations in the health literacy in various time points are recommended to be investigated in the future studies. Secondly, since the study was conducted in one nursing school, the generalizability of the results is limited to this cohort.