School Nurses’ Assessment of Parental Health Literacy for Students with Chronic Health Conditions

Introduction

Health literacy (HL) is recognised as a fundamental determinant of individual and population health, encompassing the ability to access, understand, evaluate, and use health information to make informed decisions and navigate healthcare systems effectively (Sørensen et al., 2012). Low HL is associated with health disparities and disproportionately affects populations who may experience social, educational or healthcare-related disadvantages (Schillinger, 2021), such as parents of children with disabilities. These parents may face difficulties in interpreting and applying health-related information, which can contribute to suboptimal caregiving practices and, ultimately, poorer health outcomes for their children (de Buhr & Tannen, 2020).

While HL has been extensively studied in adult populations managing chronic diseases, its role in pediatric caregiving -particularly among parents of children with disabilities- has received comparatively limited scholarly attention. Lindly et al. (2020), in a recent systematic review underscored this research gap by analyzing the extent to which HL is associated with health outcomes among children with developmental disabilities, ultimately highlighting the lack of empirical evidence on family HL in this population. Thus far, most existing research has focused on condition-specific contexts such as asthma (Keim-Malpass et al., 2015), or on broader domains like general health promotion, medication management, and emergency decision-making (Morrison et al., 2013).

Yet, regardless of the specific context, an increasing number of studies highlight the clinical relevance of parental HL across diverse care settings. In both high -and low- to middle-income countries, lower parental HL has been associated with poorer child health outcomes, including higher rates of emergency service utilization and medication errors (Lawrence et al., 2021). Consistent with prior research, Zaidman et al. (2023) conducted a systematic review that analyzed the relationship between parental HL and child health outcomes in both high- and low-resource settings. They found that lower parental HL was consistently associated with poorer outcomes among children with chronic conditions. Importantly, the authors highlighted that disease-specific knowledge can serve as an effective target for interventions aiming to improve caregiving. This was considered especially relevant for parents with low HL, particularly mothers, who often serve as primary caregivers in low-resource contexts and may benefit significantly from tailored educational programmes.

Given that many parents of children with disabilities interact closely with school-based health professionals, particularly school nurses, understanding how these professionals perceive and respond to parental HL is of increasing importance. School nurses are frontline providers of health education and support, interacting with students, parents, and school staff to promote students’ health and academic success (Best et al., 2018). Access to school nurses and related services has been shown to improve clinical outcomes and reduce absenteeism among children with chronic health conditions (Leroy et al., 2017). Positioned at the intersection of health and education, school nurses play a key role in ensuring equitable access to educational opportunities, helping to reduce barriers to learning and fostering healthier families and communities (Johnson, 2017). Although previous researchers reported that school nurses can strengthen HL among families (de Buhr et al., 2020), little is known about their ability to accurately identify parents with low HL.

Furthermore, few research studies have focused on healthcare professionals’ ability to identify individuals with limited HL (Storms et al., 2019). This gap in the literature is particularly concerning given the growing body of evidence linking low parental HL with a range of adverse child health outcomes. For example, low HL has been associated with more frequent medication errors, greater reliance on emergency care, and reduced quality and safety of care especially for children with complex medical needs (Lawrence et al., 2021). In line with these observations, a recent systematic review by Louizou et al. (2024) highlighted that healthcare professionals exhibit varying perceptions of patients’ HL levels and ascribe different meanings to the concept. Notably, none of the professionals in the reviewed studies employed standardized tools to assess HL, and there was no consistent approach in managing patients with low HL. Instead, some relied on general communication strategies, such as using simplified language, repeating information, or providing written instructions, which may not be sufficient for addressing the complex needs of individuals with limited HL.

This lack of structured assessment is compounded by limited awareness among professionals regarding the nature and consequences of low HL (Lambert et al., 2014). Without adequate training or tools, even well-intentioned professionals may fail to recognize families who require additional support, potentially perpetuating disparities in care. Understanding parental HL is critical to ensuring effective communication, informed decision-making, and adequate health support for children in school settings.

The significance of parental HL extends beyond basic understanding; it directly impacts a child's health outcomes, ability to participate fully in daily life, and access to necessary services (Akca et al., 2024; Kramer et al., 2018). For children with disabilities, parental HL is particularly crucial as it facilitates engagement in complex healthcare decisions (Downs et al., 2024), navigates environmental barriers to participation (Kramer et al., 2018), and ensures the effective implementation of care plans (Nam et al., 2023). Misjudging a parent's HL, especially for students with additional needs, can therefore have significant implications for managing their health and educational well-being, potentially leading to inequities in care (VanPuymbrouck et al., 2021).

School Nursing Context in Greece

It is important to provide context on how school nursing operates in Greece, as this background influences the interpretation of the study findings. Specifically, the nature and scope of school nursing practice in Greece may affect both the frequency and depth of nurse-parent interactions, which in turn shape the nurses’ capacity to assess parental HL.

Even though the health-related decisions occurring in school contexts may not typically involve acute or high-stakes medical interventions, HL remains central to the ongoing collaboration between school nurses and families. In Greece, school nurses assigned to students with chronic health conditions are authorized to implement individualized care plans that include medication administration according to medical orders, emergency response protocols, and supervision of feeding, hygiene, and safety routines . These responsibilities often require tailored daily adaptations and continuous coordination with parents.

School nurses frequently engage in regular, bidirectional communication with parents regarding the child's health status, adherence to treatment instructions, adjustments to daily care routines, and early identification of warning signs. Although school nurses operate within predefined clinical parameters and are not empowered to alter prescribed care plans, they function as critical intermediaries between families and the broader healthcare system, ensuring continuity of care and facilitating appropriate referrals when needed.

This ongoing relational engagement renders the school environment a particularly relevant context for assessing parental HL -not in terms of initiating or modifying medical regimens, but in terms of understanding, applying, and sustaining prescribed health actions within the educational setting. The quality and intensity of these interactions can vary substantially, influenced by factors such as the child's specific health needs, the parent's availability and involvement, and the nurse's workload. Importantly, school nurses are also responsible for providing first aid and emergency care to the wider school population, including co-located schools, which may constrain their ability to develop deep familiarity with each parent. Nonetheless, even within these limitations, school nurses must make continuous, nuanced judgments regarding a parent's ability to comprehend and act upon health-related information -judgments that shape the nature and adequacy of the support provided.

In the Greek general education system, school nurses are not assigned based on total school population but are instead allocated to provide individualized support to students with officially certified medical needs. Current administrative guidelines and standard practice typically assign school nurses to provide individualized support to up to three students, contingent upon staffing levels, schedules, and school locations. Importantly, these professionals constitute the only healthcare personnel formally embedded in general education settings in Greece with a continuous role in managing students’ daily health needs. While their responsibilities include first aid and emergency care for the broader student population, their designated role in supporting students with complex needs positions them as the most appropriate informants for assessing parental HL. This perspective captures both the structured nature of school-based engagement and the practical constraints shaping how HL is perceived and acted upon within the educational context.

Methods

This study was approved by the Institutional Review Board of the National and Kapodistrian University of Athens, IRB approval number 138172/19.12.2022.

Results

The study included 52 dyads of school nurses and parents. School nurses’ ages ranged from 26 to 47 (median = 34), with 7 male (n = 7, 13.5%) and 45 female school nurses (n = 45, 86.5%). School nurse participants had a median work experience of 18.5 months (Interquartile range: 7.25–35.75; range: 6–168).

Parents of students with chronic health conditions were aged 30–58 years (median = 44.5). The majority were women (n = 49, 94.2%), with men constituting a smaller proportion (n = 3, 5,8%). Regarding employment, 20 parents (38.5%) were private sector employees, 13 (25%) were public servants, 7 (13.5%) were self-employed and 12 (23%) were homemakers. In terms of education, 23.1% of the parents had completed secondary or technical education, 32.7% held a university degree, and 21.2% had completed postgraduate studies; overall, more than half of the parents (53.9%) had attained a university or postgraduate education. The mean score of parents’ HL, was 13.17 (SD = 3.06). Among the parents, 33 (63.5%) were categorized as having adequate HL, 12 (23.1%) as problematic, and 7 (13.5%) as inadequate. In comparison, school nurses’ classified 78.8% of parents as having adequate HL, 15.4% as problematic, and 5.8% as inadequate. The mean estimated HL score was 12.5 (SD = 3.33).

Agreement between the school nurses’ estimations and parents’ actual HL scores varied significantly across HL categories with distinct patterns of overestimation and occasional underestimation as school nurses consistently tended to overestimate parental HL when evaluating parents classified with lower HL (Table 1). Specifically, for parents classified as having Inadequate HL (n = 8), nurses accurately identified 2 cases (25%), while overestimating HL in the remaining 6 cases (75%) and rating them as Adequate. A similar pattern emerged with parents who rated themselves as having Problematic HL (n = 12), where agreement was found in only 2 cases (16.7%), with nurses overestimating HL in 10 parents (83.3%) by rating them as Adequate.

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Table 1.

Cross-Tabulation of Agreement Between School Nurses’ Assessments and Parents’ Self-Reported HL Levels.

School Nurses’ Evaluation	Inadequate HL	Problematic HL	Adequate HL	Total
Inadequate	2 (25%)	0 (0%)	1 (3.1%)	3
Problematic	0 (0%)	2 (16.7%)	6 (18.8%)	8
Adequate	6 (75%)	10 (83.3%)	25 (78.1%)	41
Total	8	12	32	52

Note. HL = health literacy.

Conversely, for parents classified with Adequate HL (n = 32), agreement with nurse evaluations occurred in 25 cases (78.1%). However, there was also an occasional underestimation of HL for these parents: 6 parents (18.8%) were rated as Problematic HL, and 1 parent (3.1%) was rated as Inadequate HL. Findings indicate while nurses generally align with parents exhibiting adequate HL, there is a clear predisposition to overestimate HL in parents classified with lower scores, alongside an occasional tendency to underestimate HL in those demonstrating adequate levels.

Cohen's kappa was calculated to assess the agreement between school nurses’ estimation of parents’ HL level and the objective HL categories (0.06, p = 0.547). The Intraclass Correlation Coefficient (ICC) analysis was used to assess the agreement between school nurses’ subjective evaluations of parents’ HL and the HL score derived by measuring parents’ HL using the HLS-EU-Q16 (−0.018, 95% CI: −0.286 to 0.254, p = 0.55). A Sensitivity-Specificity analysis was conducted to assess the accuracy of school nurses’ evaluations of parents’ HL (Table 2). For this analysis, HL was dichotomized into two categories: adequate and inadequate (with the problematic and inadequate categories merged into the inadequate group). The sensitivity (true positive rate) was 20.0%, and specificity (true negative rate) was 78.1%. The positive predictive value (PPV) was 36.4%, and the negative predictive value (NPV) was 60.98%. The false positive rate (FPR) was 21.9%, while the false negative rate (FNR) was 80.0%

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Table 2.

Classification Outcomes of Parental HL: Counts and Percentages.

HL Category	Correctly Identified	Misclassified
Inadequate HL (n = 20)	TPR: 20.0% (4/20) → Correctly classified as inadequate (sensitivity)	FNR: 80.0% (16/20) → Misclassified as adequate
Adequate HL (n = 32)	TNR: 78.1% (25/32) → Correctly classified as adequate (specificity)	FPR: 21.9% (7/32) → Misclassified as inadequate

Note. HL = health literacy; TPR = true positive rate; FNR = false negative rate; TNR = true negative rate; FPR = false positive rate.

Discussion

In this study, we examined the HL of parents of students with chronic health conditions and school nurses’ ability to accurately assess it. The majority of parents demonstrated adequate HL; however, school nurses frequently overestimated HL among parents with lower HL levels and occasionally underestimated HL in parents with adequate HL. Overall agreement between nurses’ estimations and parents’ self-reported HL was low (Cohen's κ = 0.06, p = 0.547; ICC = −0.018, p = 0.55). Sensitivity-specificity analysis further indicated limited accuracy in nurses’ assessments, with a tendency to misclassify parents, particularly underestimating those with inadequate HL. Accurate assessment of parental HL by school-based health professionals is critical, given the well-documented link between low parental HL and adverse child health outcomes (Zaidman et al., 2023). Children with chronic or complex medical needs, such as those included in this study, are especially vulnerable to miscommunication or misunderstanding in health management (Adams et al., 2021).

Taken together, these findings highlight substantial discrepancies in the accuracy of school nurses’ assessments, carrying important implications for professional practice and the support available to parents in educational contexts. Overall, our results indicate a consistent pattern observed across multiple healthcare settings, where professionals tend to overestimate patients’ HL, leading to potential miscommunication and suboptimal support. This finding is consistent with Dickens et al. (2013), who found almost no agreement between patients’ and nurses’ HL assessments (Kappa = 0.09), as well as with Zawilinski et al. (2019), who similarly reported poor and non-significant agreement between physicians’ perceptions of patients’ HL and patients’ self-reports (Kappa = 0.13, p = 0.42). The overestimation identified in our findings also aligns with Storms et al. (2019), who reported that general practitioners overestimated the proportion of patients with adequate HL by more than 30%, as well as Kelly and Haidet (2007), who observed that overestimations occurred nearly twice as frequently as underestimations. Rogers et al. (2006) further demonstrated that family medicine resident physicians correctly identified only about half of the patients with poor or below-average understanding of medical information. Similarly, in our study, school nurses showed limited accuracy in evaluating parents’ HL, with sensitivity of 20.0% and specificity of 78.1%, indicating a notable discrepancy between observed and actual parental HL. In both cases, healthcare professionals were more likely to misclassify individuals with inadequate HL as adequate rather than the reverse. Collectively, these converging findings underscore a persistent challenge in clinical practice: the frequent overestimation of HL by healthcare professionals, which may result in insufficient support for individuals most in need.

The low sensitivity and high false negative rate (80.0%) found in this study suggest that school nurses frequently overestimate parents’ HL, potentially failing to identify those in need of support. Moreover, the positive predictive value (PPV) of 36.4% demonstrates that even when nurses judged a parent as having inadequate HL, this assessment was often inaccurate. The negative predictive value (NPV) of 60.98% means that if a nurse assessed a parent as having adequate HL, there was almost 40% chance that the parent actually had problematic or inadequate HL. Similarly, Williams et al. (2024) recently described the discrepancy between registered nurses’ predictions of patients’ HL levels and their actual HL levels in a predominantly Hispanic population. They found that nurses consistently overestimated patients’ abilities (mean predicted HL = 4.26 vs. actual HL = 1.71, r_s = .418). Furthermore, Voigt-Barbarowicz and Brütt (2020), who reviewed the literature on the alignment between healthcare professionals’ assessments of patients’ HL and patients’ self-reported HL, identified seven studies that collectively showed healthcare professionals often overestimate patients’ HL, particularly in cases of low HL. These discrepancies, identified through various HL measurement tools, highlight challenges healthcare professionals face in accurately assessing HL, which can potentially lead to communication barriers and inadequate patient support.

The consistent overestimation of HL levels by healthcare professionals, reported in previous studies (Sørensen et al., 2012; Storms et al., 2019), highlights the potential for misjudging patients’ needs, particularly among populations experiencing social, educational, or healthcare-related disadvantages, such as parents of children with disabilities. This pattern of misjudgment may compromise effective health communication and limit the implementation of appropriate support strategies. Consistently, the present findings highlight the importance of enhanced training and the adoption of standardized, evidence-based HL assessment tools to improve accuracy in evaluating parental HL. Adopting such measures would enable school nurses to more effectively identify and address parents’ HL needs, thereby optimizing both educational and health-related support.

Although the findings of this study underscore notable discrepancies in school nurses’ assessments of HL, these results should be interpreted within the context of school-based health practice. Unlike hospital or clinical settings, where HL is often linked to acute, high-stakes medical decision-making, the role of HL in schools is contextually embedded -shaped by the educational environment, the continuity of daily routines, and the collaborative nature of parent–nurse relationships. Within this setting, HL facilitates the ongoing management of chronic health conditions, supports effective communication between home and school, and enables the consistent implementation of individualized care and health education plans (Auld et al., 2020). Although these functions differ in scope from those in clinical contexts, they are equally critical for promoting student well-being and ensuring equitable access to both health and education services.

Within the context of school-based health practice, school nurses play a pivotal role in maintaining continuity of care, collaborating with families to adapt medical guidance to the school environment, and reinforcing treatment adherence during the school day (Council on School Health, 2016). Consequently, parental HL is essential not only for navigating individual health concerns, but also for supporting collaborative processes that promote student health and enable uninterrupted access to education. The discrepancies observed in this study should not be dismissed: rather they should be understood as part of the broader challenge of aligning HL assessment with the structural realities and operational constraints inherent in school-based health practice.

Limitations

The interpretation of this study's findings should be considered in light of several methodological and contextual constraints. All participants were fluent Greek speakers, and no data were collected on cultural or ethnic background. Consequently, the findings may not be generalizable to linguistically or culturally diverse populations, where language and cultural differences could further affect the accuracy of HL assessment. Such miscommunication may compromise health information exchange and result in systematic misjudgments. Moreover, the relatively small sample size and the use of convenience sampling further limit the generalizability of results to broader educational or healthcare contexts.

The recruitment process was indirectly mediated via regional education authorities, hindering precise tracking of how many school nurses and parents ultimately received or reviewed the study invitation. As both members of each dyad were required to provide independent consent, systematic monitoring of invitation delivery, eligibility, acceptance, or refusal was not feasible. Assuming the invitation reached the full pool of 2,425 nurses, an approximate response rate of 2.2% can be inferred, although this likely underestimates actual participation due to the matched-participation requirement and eligibility constraints. This limitation introduces the potential for self-selection bias, as participants may differ systematically from non-participants.

Another important consideration relates to the variability in the nature and quality of nurse–parent interactions. Differences in the child's medical condition, the frequency of communication, and the parent's level of engagement may have influenced nurses’ familiarity with parental communication styles, thus affecting the accuracy of HL assessments.

Additionally, the requirement for school nurses to have been employed continuously for a minimum of six months further restricted the eligible population. Given that many school nurses in Greece are on fixed-term contracts and that the role has only recently been institutionalized within general education, a substantial proportion of the nominal pool may not have satisfied this criterion, introducing potential selection bias and thereby limiting the generalizability of the findings.

Also, a limitation of this study is the use of only two questions to assess school nurses’ perceptions of parental HL. Although designed to minimize respondent burden and aligned with prior literature supporting brief measures, this approach may not fully capture HL's multidimensional complexity. Future research should incorporate more comprehensive tools or mixed-method approaches that combine quantitative and qualitative insights to provide a richer and more holistic understanding of how school professionals assess parental HL.

The dichotomization of HL into ‘adequate’ and ‘inadequate’ categories, although necessary for statistical analysis, may have oversimplified HL and limited interpretative depth. Additionally, the focus on parents of children with chronic health conditions in Greek primary and secondary schools restricts the generalizability of the findings to other demographic groups or educational contexts.

Finally, the cross-sectional design prevents inferences regarding causality or temporal changes. Future research utilizing larger, more diverse samples and longitudinal designs would provide a more thorough understanding of HL assessment in school health contexts.

Implications for School Nursing Practice, Education and Policy

Despite the limitations, the findings of this study underscore the pressing need for school nurses to adopt more accurate and systematic approaches when assessing parental HL, particularly in the context of students with chronic health conditions. The persistent overestimation of parental HL describes a pattern in which informal impressions are insufficient for identifying families who may struggle to comprehend and apply health-related information. Instead, validated HL screening tools -such as brief questionnaires or structured observation checklists- should be adapted for school health contexts to support more objective and equitable judgments (Agency for Healthcare Research and Quality [AHRQ], 2015; Sørensen et al., 2013).

To this end, HL-related competencies should be explicitly embedded in continuing professional development. Training should not only provide content about HL but also cultivate practical patient-education communication techniques, including the use of plain language, pictorial aids, and the teach-back method. These strategies have been shown to enhance understanding, reduce parental anxiety, and improve adherence to care protocols -particularly among families with lower educational attainment or linguistic barriers (Haun et al., 2014; McCarthy et al., 2012). In multicultural school settings, collaboration with interpreters and cultural mediators is essential for reducing miscommunication and building trust with diverse families (Batterham et al., 2016).

Following such training, at a systems level, adopting a ‘universal precautions’ approach to HL -treating all parents as potentially at risk for misunderstanding information- can promote consistency and reduce stigma. This approach entails simplifying health communication, confirming understanding through interactive dialogue, and ensuring that all materials are accessible and actionable (AHRQ, 2015; DeWalt et al., 2011). Schools can also implement structured communication tools (e.g., visual home-school health logs or bilingual health education booklets) to reinforce nurses’ messages and support continuity of care.

Policy-level action is equally critical for enhancing HL in school settings. Ιmproving HL requires coordinated efforts across systems, including the integration of HL competencies into professional training standards, systematic evaluation of communication practices (Baur et al., 2017). In alignment with this approach, educational authorities and health policymakers should support the incorporation of HL competencies into school nurse credentialing requirements, promote regular audits of communication strategies. Moreover, individualized health plans and emergency action plans should be co-developed with families in ways that foster clarity, mutual understanding, and meaningful parental engagement.

The findings support a conceptual shift from viewing HL as a fixed individual trait to understanding it as a relational and context-dependent process that develops through interactions between families and school health personnel. As Sørensen et al. (2021) highlight, HL emerges within supportive systems and collaborative relationships, rather than being solely an individual skill. In this context, school nurses can actively promote parental HL by fostering sustained partnerships with families, providing clear guidance, and reinforcing understanding through interactive communication. With appropriate training, sufficient time allocation, and institutional support, nurses can function not only as care providers but also as advocates for HL, enabling families to make informed decisions that enhance student well-being and promote equity in school health. Embracing this approach strengthens the role of school nurses as facilitators of health literacy, supporting more inclusive and responsive care for families navigating complex educational and health needs.

Conclusion

The researchers described the alignment between school nurses’ assessments of parental HL and objectively measured HL levels in parents of children with chronic health conditions. The results revealed significant discrepancies and limitations in the accuracy of the nurses’ evaluations, which have implications for professional practice and support for parents in educational settings.

Based on the findings of the present study, school nurses tend to overestimate the HL of parents of students with chronic health conditions. This overestimation could potentially impact the accuracy of health interventions and support strategies for these families, as accurate identification of HL levels is crucial for providing appropriate guidance and resources. Similar results were observed in previous studies, where HL was often overestimated by professionals working with populations in need of tailored health support. Healthcare providers’ subjective assessments do not always align with objective measures of HL, which leads to discrepancies in the provision of health-related interventions.