Graduation Date

Spring 5-4-2019

Document Type


Degree Name

Doctor of Philosophy (PhD)



First Advisor

Kathryn Fiandt

Second Advisor

Carol Pullen

Third Advisor

Kelly Gonzales

Fourth Advisor

Lynette Smith


Health literacy is an evolving concept, impacting all areas of health care. There is a need for improved understanding of the concept and its relationship with self-management especially in the United States (US) where health literacy has been limited to functional health literacy consisting of basic reading and writing. Health literacy is defined as the “ability to obtain, understand, and apply health information for healthcare decisions” (Nielsen, 2004, p. 32) and has been expanded into three sub-concepts of functional, communicative, and critical health literacy. The purpose of this dissertation is to explore and better understand the relationship between health literacy and self-management using a health literacy tool modified and evaluated in the US. The specific aims in this study were 1) to evaluate the validity and reliability of the Functional, Communicative, and Critical Health Literacy (FCCHL) tool in a Midwestern, socioeconomically vulnerable or unstable adult population, 2) to determine the efficacy of the FCCHL compared to the Newest Vital Sign (NVS) or Short Form of the Test of Functional Health Literacy in Adults (s-TOFHLA) in relation to self-management, and 3) to determine the relationship between the FCCHL components of functional, communicative and critical health literacy and the self-management components of patient activation, self-regulation, and self-efficacy. The study included a cross-sectional, convenience sample from both urban and rural US locations including a rural health clinic, an urban Federally Qualified Health Center (FQHC), and an urban workplace clinic supporting under-insured employees. A total of 276 participants were recruited for a fully powered study. The FCCHL tool was evaluated using construct, criterion, and concurrent validity, internal consistency and external reliability. The tool was found to be valid and reliable when tested in this population. Additionally, it was determined by correlations that the FCCHL tool measured more than functional health literacy and was different than educational levels suggesting that more than literacy was measured. The relationship between the FCCHL and self-management showed statistically significant and higher correlations for all three self-management components as compared to the relationship between the NVS to self-management and s-TOFHLA to self-management. The relationship between the components of the FCCHL tool and self-management components were all moderately, positively correlated. Additionally, the multiple linear regression showed statistically significant relationships between FCCHL tool components with patient activation, self-efficacy, and self-regulation when adjusting for various demographic variables. These results support the use of the FCCHL tool to measure all three sub-concepts of health literacy and supports the positive relationship between health literacy and self-management. These findings support the use of the FCCHL tool to help determine a patient’s total health literacy. Future studies should include the language and cultural adaptation of this tool to assess limited English proficient communities, describing the relationship of health literacy with health outcomes, testing FCCHL tool with a self-management intervention, and interventions determined by health literacy as measured by the FCCHL tool.