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Patient Education and Counseling 71 (2008) 356–364
Understanding the impact of family caregiver cancer literacy
on patient health outcomes§
Jennifer L. Bevan a,*, Loretta L. Pecchioni b
Department of Communication Studies, Chapman University, One University Drive, Orange, CA 92866, United States
Department of Communication Studies, Louisiana State University, United States
Received 4 February 2008; received in revised form 21 February 2008; accepted 22 February 2008
Objective: Family caregivers play a significant role in the diagnosis, treatment, and recovery of individuals with cancer. This position paper
reviews and links the research on family caregiving and health information with the importance of cancer literacy.
Method: Review of literature obtained through searching in Academic Search Premier, EBSCO, Communication and Mass Media Complete,
PsychArticles, PsycInfo, and Health Source: Nursing/Academic Edition library databases.
Results: Family members are important sources of health information, informal caregivers who learn and enact medical procedures, and influential
aspects of patients’ healthcare and treatment decision-making, but are not seriously considered by healthcare practitioners or researchers in terms
of assessing and improving health literacy. Further, very few studies have directly examined or acknowledged the potential importance of family
caregiver health literacy.
Conclusion: The extent to which family caregivers can comprehend the health information they receive along with the patient is crucial for the
patient to achieve the most successful health outcome.
Practice implications: To acknowledge the impact that family caregiver health literacy could have on patient health outcomes, targeted practical
recommendations for understanding family caregiver health literacy in the cancer context are proposed: (1) family member health literacy should
be assessed; (2) close relational partners should be trained as peer health educators; (3) written cancer information should be provided directly to
family caregivers; (4) health interactions between family caregivers and patients should be improved; (5) theoretical perspectives into the
understanding of family caregiver health literacy should be integrated into practice; and (6) patient and family caregiver health literacy should be
# 2008 Elsevier Ireland Ltd. All rights reserved.
Keywords: Vulnerable audiences; Health literacy; Cancer; Family caregivers
Well, when the doctor gave us the news, you know, about my
husband’s lung cancer, we were both stunned. It took us a
good while, a few days, really, before we could really start to
process what this meant, or might mean, and. . .well. . .(long
pause)—Agnes, 54, wife of cancer survivor
Research consistently highlights the vital importance that
health literacy plays in individuals’ negotiation of the
healthcare process. Health literacy involves ‘‘the evolving
skills and competencies needed to find, comprehend, evaluate,
This manuscript combines information from individual papers presented at
the Health Literacy across the Continuum of Cancer Care Symposium at
Chapman University, Orange, CA.
* Corresponding author. Tel.: +1 714 532 7768; fax: +1 714 628 7237.
E-mail address: [email protected] (J.L. Bevan).
0738-3991/$ – see front matter # 2008 Elsevier Ireland Ltd. All rights reserved.
and use health information and concepts to make educated
choices, reduce health risks, and improve quality of life’’ (1: p.
119). Going beyond basic literacy skills, health literate
individuals must apply health terms and knowledge to novel
circumstances and take part in conversations regarding
medicine, health, scientific knowledge, and culture [1].
Inadequate health literacy skills are linked to patient
misunderstanding of essential health information and low rates
of compliance with physician recommendations [2].
When considered in the context of a serious illness such as
cancer, health literacy takes on particular importance and those
with low health literacy can be vulnerable to cancer health
disparities. Namely, being unable to comprehend or understand
information related to preventative cancer procedures could
delay an individual’s cancer diagnosis [3,4]. Individuals with
lower health literacy, however, are more influenced by their
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support networks to seek screening [3]. However, network
members can also be considered a vulnerable audience, as they
often do not have sufficient access to the patients’ health
information and may also not be health literate, and thus may
not provide accurate or useful information to the patient.
Even though they play a significant role in all aspects of care
provision [3], third party influence on patient care and health
outcomes has not been a primary concern of health literacy
researchers. The family caregiver literature overwhelmingly
indicates that close family members who care for patients
receive information from healthcare providers, provide patient
information to physicians, aid in treating and caring for the
patient, and weigh in on treatment decisions. Each of these
important caregiving dimensions can surely be impeded by
inadequate family caregiver health literacy. As such, it is crucial
to understand all aspects of both patients’ and family
caregivers’ health literacy. This position paper thus offers an
overview of literature that examines the importance of family
caregivers in cancer treatment and outcomes from the
perspective of health literacy as well as targeted recommendations for including the family caregiver in treatment protocols
and research on health literacy in the cancer context. The
overarching goal is to initially gain insight into the importance
of family caregivers’ health literacy and its role in cancer care
in hopes of encouraging researchers to recognize the potential
significance of family caregiver health literacy levels in terms
of cancer outcomes.
1. The family caregiver
Because humans are social creatures, we experience the
events of our lives within a web of relationships. When these
events are potentially life threatening, such as a cancer
diagnosis, we are even more likely to turn to our support
network for help. Research conducted by a wide range of
disciplines over a variety of life challenges consistently finds
that people cope better when they report having a strong
support network [10–12]. Although any number of close
relational partners can care for an individual who is diagnosed
with cancer, the family role in caregiving and social support
provision during a cancer crisis is of primary interest in this
position paper.
The family is an interpersonal ‘‘context with the most
immediate effects on disease management and with the greatest
implications for intervention’’ (5: p. 8). Further, the family
setting is where most disease management occurs [5]. Indeed,
as cancer patients and their families know, ‘‘cancer is a disease
of the family rather than of an individual’’ (6: p. 157). Any
serious health diagnosis, especially one regarding cancer,
impacts the entire family network in a myriad of ways [7]. As
such, family members play substantial psychological and
biomedical roles in cancer patient care and subsequent health
outcomes [5]. Specifically, families serve as a ‘‘constant
support system’’ to the cancer patient (8: p. 8), and both observe
and actively participate in the patient’s care [9].
Family caregivers are defined as unpaid individual family
members who aid in patients’ physical care and disease process
coping [13]. This aid, typically referred to as social support,
covers three dimensions: informational, instrumental, and
emotional. Informational support involves sharing knowledge
about a problem or issue and, thus, is most directly related to
health literacy. Provision of this type of support helps the cancer
patient to access, process, and act upon the health-related
information that he or she is receiving. Instrumental support is
related to tasks. Provision of this type of support includes such
behaviors as driving the cancer patient to a doctor’s
appointment, preparing meals, and cleaning the house.
Emotional support is directly tied to coping with fear and
the unknown. Provision of this type of support helps the cancer
patient to feel valued, cared for, and loved.
The amount of social support provided by families is
inestimable. There are approximately 15 million family
caregivers in the United States [14]. Further, the average
duration of caregiving for clinic cancer patients is approximately 29 months [13]. Of particular interest to the topic of
cancer health literacy is how family caregivers manage
information related to the patient’s illness.
1.1. Family caregivers and health information
Healthcare professionals recognize that patients need health
information, but are less likely to realize that the families also
have information needs. Families want to be involved in healthrelated decision-making, but they also require health-related
information to provide adequate and appropriate support to the
cancer patient [7]. Family caregivers provide more hands-on,
day-to-day care than do any other individuals and need not only
access to information, but also the ability to process and act
upon that information in order to provide the best quality care.
Family caregivers fulfill a wide range of functions from
exchanging information among all parties; interpreting
language; offering additional viewpoints, explanations, and
interpretations of medical diagnoses; collaborating to offer
personal care to the patient and learning technical procedures;
taking part in therapeutic regimens; and, encouraging patients
to comply with their medical treatments [15–18]. Despite this,
family caregivers often battle for healthcare providers’ respect
and to be treated as a full partner in the patient’s care [17].
In the specific context of cancer care, the family caregiver
and how he/she manages information takes on a particularly
significant role. Beach and Good [19] describe the importance
of the family caregiver when treating a cancer patient:
As laypersons, family members can exhibit a remarkable
ability to learn technical/medical information. Terms,
applications, and explanations about how the body functions
and is impacted by an illness are invoked during condensed
and over extended periods. Such information may not be
‘technically correct,’ at least by medical experts’ standards,
but is nonetheless utilized when attempting to understand
and discern the appropriateness, and potential consequences,
of diagnosis and treatment options. (p. 17)
Family caregiving is thus particularly notable in three
aspects of cancer prevention and treatment: (a) preventative
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screenings such as mammograms, (b) caregiving behaviors
upon diagnosis, including information management and aid in
medical decision-making, and (c) interacting with healthcare
providers to best treat the patient. Each of these aspects of
cancer communication, in turn, involves sufficient levels of
health literacy.
In terms of prevention, family plays a significant role in
encouraging healthy behaviors in general [7]. When an
individual experiences symptoms, he or she usually turns first
to a loved one who then encourages the individual to seek
medical advice [20–22]. Even without symptoms, individuals
report a greater likelihood of undergoing screening procedures
when recommended by a family member. Almost one-third of
women indicate that they would be likely to get a mammogram
if a relative recommended it [3].
Once diagnosed, a caregiver’s role is central in the patient’s
treatment of and long-term adaptation to cancer [23]. Many
individuals diagnosed with cancer are overwhelmed by the
amount and complexity of required decisions [24]. Upon
diagnosis, patients employ multiple health information sources,
including friends, family, and knowledgeable acquaintances,
with family and friends being the most important sources
[22,25]. This is particularly true for low-income patients, a
group who traditionally struggles with health literacy [26].
Cancer patients and their family members actively seek out
individuals who have some sort of medical expertise, whether
through formal training or prior cancer experience. Interviews
conducted by the second author reveal that cancer patients and
their primary family caregivers repeatedly report turning to
relatives and friends who are nurses, pharmacists, or other kinds
of health professionals to help them access and process the
abundant information that they have accumulated. In addition,
they turn to individuals who have already experienced cancer to
learn more from their first hand accounts. While these cancer
survivors can provide valuable information that can only come
from personal experience, the information they have may be
inappropriate or inaccurate. If this individual has a different
kind of cancer, the information may not be relevant to this
second case. Even when the diagnosis is the same, if this
individual was diagnosed and treated more than 5 years ago,
treatment protocols may have changed dramatically. If the
current cancer patient and the cancer survivor do not carefully
assess these issues, the information may do more harm than
good. Those with low health literacy may either be more
predisposed to turn to their personal network in order to process
information or may be less inclined for fear of being ‘‘found
out’’ as struggling to understand health-related information.
While individuals trust these interpersonal information sources
because they are motivated by personal concern, those with low
health literacy may be more likely to trust this information
because of the personal relationship that exists. If members of
the social support network do not have adequate health literacy
themselves, greater misunderstandings may arise.
Finally, family caregivers and other family members
actively seek information about the illness from the patient’s
healthcare providers [9,27]. Notably, healthcare providers give
more cancer information to the family than to the patient [28].
Further, family members consistently report that many of their
most important and supportive interactions with healthcare
providers involve information exchange (e.g., [8,9]). Examples
of family caregiver information needs from healthcare
providers include offering information on the patient’s
prognosis, side effects, test results, and how to manage the
patient’s pain while at home. Therefore, healthcare professionals need to answer questions in a straightforward manner
and schedule meetings with family members to discuss the
illness [9].
Even though some family members may be given
considerable information, not all have easy access. Due to
privacy laws, medical information cannot be shared with just
anyone who demonstrates concern. A niece will not likely
receive information about her aunt’s condition directly from the
aunt’s oncologist unless the aunt has provided written consent.
If a family member does not have direct access to the treating
physician, but has a strong desire to gather information, he or
she is likely to pursue other sources. Individuals who are not
primary caregivers frequently use the Internet to find
information on a loved one’s cancer [22]. The impact of this
information on the decision-making process is unknown, but an
individual with low health literacy may not be able to
adequately assess the quality of information being provided by
a loved one who has gathered information through the Internet.
In essence, family caregivers play a significant role in aiding
the cancer patient in learning about and managing cancer
information. Accordingly, understanding the impact of this
vitally important role in the context of cancer literacy is long
overdue. Though no research has specifically examined family
caregiver health literacy levels, some studies have examined
how well family caregivers comprehend health information.
Further, health literacy scholars have begun to recognize that
third parties can be influential in understanding patient health
literacy. To begin specifically linking the family caregiver role
with health literacy in the cancer context, we now turn to this
2. Health information-seeking and decision-making
I spent so much time researching treatment options and
trying to understand, so, you know, we could talk about what
we were going to do, and all. I knew he needed me to do this
for him because he felt so bad so much of the time, but,
frankly, I needed to do it for myself, too—Agnes
Information, defined as ‘‘stimuli from a person’s environment that contribute to his or her knowledge or beliefs’’ (29: p.
259), is a vital aspect of health communication. Specifically,
informed patients feel a sense of control, can cope with
uncertainty about their health, follow their plans of care more
closely, and recover faster and more thoroughly compared with
less informed patients [25]. Further, ‘‘informed patients not
only have better outcomes, but they also truly communicate
with those who provide health services’’ (30: p. 117). Though
patients and healthcare providers are the main focus of health
information management, social networks can also play an
integral role. Namely, one’s social network (particularly family
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members) can be involved in two essential aspects of health
information management: (a) as assistants in information
provision and decision-making and (b) as active seekers of
information from healthcare providers to best aid in patient
care. How each is important in the context of cancer literacy is
detailed below.
[27]. Further, nurses delegate as much home healthcare as
possible to family members [18]. Family members who assist
with care or in making health decisions for cancer patients
should thus be a primary focus of health literacy researchers, as
their potential inability to comprehend health information will
likely influence what choices they make and the actual
implementation of the cancer patient’s care.
2.1. Family as information providers and decision-makers
2.2. Family as active information seekers
Cancer patients and their families have information needs
and have vital information to offer to healthcare providers. As
cancer patients typically manage their treatment within the
context of their social support network, others will be
intimately involved across the continuum of care. Further,
family members are important health information sources for
both patients and healthcare providers. Specifically, informal
caregivers who accompany patients to medical appointments
serve as information sources for a physician [17], which tends
to be a positive experience for all involved. Namely, physicians,
patients, and patients’ companions all believe that the
companion’s presence is helpful in increasing understanding
of the patient’s medical problem, diagnosis, and appropriate
treatment [31].
While family members can provide important information
across the continuum of care, most (81%) cancer patients prefer
receiving their diagnosis alone with the doctor and a notable
minority (37%) does not directly share their diagnosis with any
member of their social network [32]. Individuals who do not
share their diagnosis or related fears and concerns report lower
levels of social support [33]. With the consistent findings that
social support enhances well-being and coping, those who are
reluctant to share their medical condition with others are at
greater risk for poor outcomes and limit effective information
exchange by the formal and informal healthcare team. Most
cancer patients, however, do share their condition with
significant others. When they learn of the condition, social
support members are highly motivated to seek relevant
information so that they can contribute to managing this health
crisis effectively [22].
When cancer information is exchanged between relational
partners, it is typically provided by family members and
targeted toward patients. For example, patients prefer receiving
nutrition information from family members, followed by
friends and neighbors, then finally from doctors and
nutritionists [34]. Further, cancer patients, among others, rate
useful informational social support from spouses, romantic
partners, friends, and acquaintances as helpful [35]. Once
patients are diagnosed with prostate cancer, wives and adult
children ensure that patients have knowledge of the disease and
treatment options [36].
This information provision can often translate into family
caregiver’s assistance with medical decision-making and actual
physical care. In the context of cancer care where treatment
options are increasing, family member involvement in
decision-making is particularly likely [37]. Family members
of those in palliative/hospice stages of cancer take an active
health decision-making role and physically care for the patient
A second important information role of family caregivers is
seeking information about the patient’s illness from healthcare
providers. Indeed, both patients and their spouses believe that
spousal information needs are important [38] and cancer
patients’ spouses are accordingly viewed as ‘‘primary
information gatherers’’ (36: p. 148). Despite the central
information-seeking role of family members, healthcare
providers and family members each tend to downplay the
family member information-seeking role [27] and may find
barriers to accessing healthcare professionals regarding their
loved one’s condition.
Family members tend to be frustrated about how healthcare
providers share information with them. In fact, difficulty
learning information is the fourth-most mentioned problem for
next-of-kin of adult cancer patients [39] and unsatisfactory
communication by healthcare providers (including too little
information, too much information, and/or abrupt or blunt
sharing of information) is named the second highest reason for
suffering by cancer patients and their families [40]. Family
members complain that they are provided with too many details
upon receiving the diagnosis by healthcare providers and thus
are unable to process most of the information [17,28] or that
they have difficulty acquiring diagnosis, prognosis, treatment,
and recovery information from healthcare providers [17,27,38].
2.3. Linking family caregiver information roles with cancer
In terms of information sharing, low health literacy can
impact patients’ sharing of medical history with physicians
[41]. Failing to share vital information is especially troubling
when considering that approximately 70% of a patient’s prior
medical history is provided via direct communication [41].
Patient information sharing can be affected by low health
literacy in specific ways, including incorrectly understanding
what information physicians seek, not grasping health
vocabulary in a way that allows for accurate reporting of
symptoms, and sharing information out of sequence or
illogically [41]. The above statistics paint a grim portrait of
information management between patient and healthcare
provider and further emphasize the significance of family
caregiver health literacy assessment. However, one problem
that can arise is that different individuals may remember the
‘‘facts’’ differently, thus providing the healthcare professional
with conflicting information.
Although an individual with low health literacy may be
hiding this fact from significant others and may attend
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appointments without a companion, healthcare providers
should consider the possible reasons when a companion is
present. Indeed, many patients with low literacy skills report
having a family member attend medical appointments in order
to serve as a ‘‘surrogate reader’’ [42]. Though not a primary
focus of health literacy researchers, a family member’s
presence at a medical appointment could be a practical clue
for healthcare providers that the patient may not be health
literate (e.g., [26,34]), although it may also signal other issues,
such as cognitive impairment. When a family member or
companion assists in the reading of medical forms and
documents [34] or acts as a linguistic translator who clarifies
information for the patient [17], this can indicate that the patient
does not have adequate levels of health literacy. The fact that
minimal education, a typical correlate of low health literacy,
positively predicts bringing a companion to the doctor’s office
also fits this pattern [43]. The importance of health literacy is
also highlighted when considering how much patients rely on
their social networks for health information, decision-making,
and physical care. Namely, those with low literacy skills tend to
consult their families for nutrition information [34]. Further,
caregivers may be lacking in health literacy themselves. For
example, more than half of Bahrainian caregivers (53%) know
that the patient suffers from a mental disorder but cannot
correctly specify which disorder [44]. In an interaction analysis
of a father giving bad news to his son about his mother’s cancer
prognosis, the father has difficulty articulating all of the
diagnosis and treatment options to his son [19]. Finally, some
family caregivers feel scared, upset, and overwhelmed that
medical duties delegated to them by home healthcare nurses are
too technical or difficult [18]. Therefore, healthcare providers
should be vigilant not only in assessing their patients’ literacy
levels but that of the patients’ caregivers as well.
When patients’ social network members offer inadequate
information or advice, patients see such communication as
unhelpful [35]. Cancer misinformation, in particular, is
perpetuated by fear and a reliance on informal information
networks [25]. This misinformation can be a result of
inadequate family caregiver health literacy levels. Failing to
consider family caregiver health literacy, especially in the
context of cancer care, can result in a number of potentially
negative outcomes, such as frustration and increased stress,
concern and confusion regarding the quality of information
being provided, and the higher possibility that vital information
will not be shared with the healthcare professionals.
Family caregivers may become frustrated at not being useful
sources of health information and subsequently may feel as if
they are not adequately fulfilling the caregiver role. Though a
highly valued role in most families, providing care to a family
member can be stressful and demanding, leading to a lack of
sleep, financial concerns, and worry over the patient’s wellbeing [45–47]. Certainly, concerns about whether or not
caregivers feel that they have adequate information to guide and
support the cancer patient can only add to caregivers’ stress.
The patient may grow concerned about the quality of
information provision by the family caregiver and be uncertain
how to employ that knowledge when making health decisions.
This confusion over the quality of information is highly likely
to occur when multiple sources of information are being
accessed. Family members may feel particularly compelled to
suggest any and all measures to help ‘‘save’’ a loved one [7]. In
addition, it may be difficult for cancer patients to label
information provided by a loved one as inaccurate because of
the emotional entanglements and consequences of ‘‘accusing’’
a loved one of providing ‘‘bad’’ information. For cancer
patients and their family members with low health literacy,
accessing and assessing the quality of information from
conflicting sources may be especially problematic.
Finally, healthcare providers may be unable to gather
sufficient information from the family caregiver when
diagnosing and treating the patient. Just as a patient with
low health literacy may not understand what the doctor is
asking or how to share relevant information, a family member
with low health literacy will have problems providing relevant
and accurate information to the doctor. Any or all of these
circumstances can potentially lead to less effective cancer
treatments and outcomes.
Individuals with low health literacy feel overwhelmed by
their medical diagnosis and make fewer inquiries compared
with those with high health literacy [41]. Thus, the presence of
family members at medical appointments is vital. Approximately one-third of appointments with physicians include a
companion [43,48]. These companions are most likely patients’
family members and they fill various roles, including
communicating patient concerns to the doctor, aiding patients
in recalling physician recommendations, helping patients make
decisions [31], and learning information [49].
3. Conclusions
Health communication scholars underscore the importance
of acknowledging and including multiple perspectives,
including the relationship between the physician, the patient,
and the family caregiver (e.g., [2]) but this has not been
extended to the relatively new subject of health literacy. As this
position paper shows, family caregivers play a significant role
in the diagnosis, treatment, and recovery of individuals with
cancer. Thus, the extent to which family caregivers can
comprehend the health information they receive along with the
patient is crucial for the patient to achieve the most successful
health outcome.
4. Practice implications
This position paper has thus far linked research on family
caregiving and health information with the importance of
cancer literacy. In doing so, it has depicted a disturbing pattern
where family members are important sources of health
information, informal caregivers who learn and enact medical
procedures, and influential aspects of patients’ healthcare and
treatment decision-making, yet are not seriously considered by
practitioners and researchers in terms of the assessment and
improvement of health literacy. To acknowledge the impact that
family caregiver health literacy could have on patient health
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outcomes, health literacy scholars should assess family
caregiver health literacy. Specifically, targeted practical
recommendations for understanding family caregiver health
literacy in the cancer context are described below.
4.1. Assess family member health literacy
Because low levels of health literacy have a negative
impact on medical outcomes, healthcare professionals should
assess the literacy levels of their patients as well as that of
their family members. While such assessments should start
with the patient, family caregivers will likely be highly
involved in care provision. Because one sign that patients are
not health literate is when they bring family members to
medical appointment to both provide and seek information
from healthcare providers (e.g., [41,42]), assessing family
members’ health literacy is the most crucial recommendation
regarding family caregivers. Williams et al. [41] recommend
that relatives of low health literacy patients be included in
patient medical interviews and information sessions; this
inclusion should also involve health literacy assessment.
Measuring family member health literacy can be done by
healthcare providers in much the same way that patients are
assessed, including informally posing open-ended questions
or requests to read written health information, and/or the
formal administration of short surveys, tests, or interviews
[42,50]. If healthcare providers determine that patients and
their family members possess similar health literacy levels,
they can adapt their communication to both parties accordingly, and/or seek additional help for the family through
formal social services or informally through the larger social
support network. If the family member has higher levels of
health literacy than the patient, the healthcare provider can
focus on patient comprehension, while occasionally ensuring
that the family member also understands the information.
While assessing levels of health literacy remains challenging
and time consuming, quality care cannot be achieved without
such assessments. Considering the unique challenges of
assessing multiple parties, healthcare providers need more
tools and strategies to improve this process. One specific
strategy is for healthcare providers to preface health literacy
assessment requests by stating that because the family member
is important in the healthcare process, they are going to ask both
parties to answer questions and provide information. Caregivers
seek healthcare provider respect and want to provide
information to assist the patient but often are treated
dismissively [17]. Thus, if the healthcare provider includes
family members in the assessment of health literacy in this
manner, it will hopefully aid in the family member feeling as if
he or she is usefully assisting both the patient and the healthcare
4.2. Train close relational partners to be peer health
Davis et al. [26] recommend recruiting community members
to serve as peer educators and information sources to improve
health literacy. Macario et al. [34] also suggest creating
nutrition interventions that incorporate low literacy patients’
social networks. This suggestion could extend to eliciting the
aid of patients’ close relational partners in a similar manner.
Not only would this second suggestion require relational
partners’ health literacy assessment, patients who receive
health information from a personalized source may feel
increased comfort. This evaluation process in turn may make
patients more likely to seek health information or advice and be
willing to indicate what they do and do not understand. Due to
the numerous duties that a family caregiver typically takes on in
caring for the patient, another individual who is close to the
patient should instead be chosen for this training to not
overwhelm the family caregiver.
4.3. Provide cancer information directly to family
Upon receiving the patient’s acute leukemia diagnosis,
many relatives feel that receiving written information about
leukemia would be helpful [28]. Thus, as our third suggestion,
healthcare providers may want to provide family members
with their own set of written cancer materials that replicates
what is provided to the patient and direct them to additional
resources, such as trusted websites or support groups or
providing relevant medical information through audiovisual
means [42]. Ensuring that family members have needed
information shows that healthcare providers recognize the
importance of family members in the healthcare process and
provides an additional informational resource to the patient. In
other words, if written or audiovisual materials are distributed
to the patient and family members, the likelihood that at least
one of them will read or view and attempt to understand this
vital health information increases. Further, such materials may
be an innocuous route to initiating a dialogue about cancer
between the patient and the family member that could
ultimately improve later discussions of treatment options
and other medical decisions.
4.4. Improve health interactions between family caregivers
and patients
The fourth recommendation seeks to improve interpersonal communication between the cancer patient and family
member. Though patients’ social support is consistently
linked with improved mental and physical health outcomes
[12], cancer-related communication between patients and
family members is often characterized by avoidance and
difficult interactions [51] that can create additional marital
stress [37]. Couples who openly and directly communicate
may have difficulty sharing their feelings about cancer
[33,52]. Further, when partners’ willingness to discuss cancer
mismatch, difficulty in each individual’s adjustment to the
illness can result [51]. If healthcare providers design and
implement techniques for facilitating cancer-related communication between patients and family members, not only
will the patient’s health outlook improve, but patients may be
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encouraged to employ family members as additional
informed cancer resources. This should increase the likelihood that the information shared is accurate.
In particular, the topic of health literacy should be
encouraged in an interpersonal context. Individuals with low
health literacy levels are typically ashamed [42] and 67% do
not admit it to their spouses [53]. Further, more than half of
low health literate individuals do not inform their
children and almost 20% have never told anyone. Obviously,
failing to disclose low health literacy to close relational
partners means that they cannot assist in the healthcare
process. Thus, one fundamental communicative aspect of
health literacy research should be to create practical methods
for close relational partners to initiate and manage
conversations about health communication in general and
health literacy in particular that are simultaneously effective
and that maintain the dignity of the individual with low
health literacy.
4.5. Integrate theoretical perspectives into the
understanding of family caregiver health literacy
The fifth recommendation is to understand family caregiver
health literacy from a theoretical viewpoint. Obviously, the
theory that is most applicable to both the family and health
contexts is systems theory. Although systems theorists struggle
to effectively integrate the study of family into the context of
health [54] there is hope for what the future holds [55] as these
spheres become better integrated.
Communication Privacy Management (CPM) theory [56]
can also shed light on how family caregivers’ health literacy can
impact cancer outcomes. In particular, topic avoidance
processes are of interest to CPM theory scholars. Because
cancer patients and family members tend to avoid healthrelated interactions [51], how they do so would be a worthwhile
topic to pursue through a CPM theoretical lens. One of this
approach’s great strengths is its acknowledgment that relational
interactions involve multiple goals beyond information
exchange. Thus, CPM is a theoretical lens that helps researchers
examine how to achieve multiple, potentially conflicting, goals
so that, for example, being open about low health literacy does
not become face-threatening.
Finally, communication-centered uncertainty theories may
be fruitful for a greater theoretical understanding of family
caregiver health literacy. Uncertainty and communication in
the context of health is theoretically approached via
uncertainty management (e.g., [29]), problematic integration
(e.g., [57]), and the Theory of Motivated Information
Management (e.g., [58]). Each approach highlights the
importance of effectively managing uncertainty about an
illness or diagnosis, which is certainly inherent in the
concept of health literacy. Further, recent research on
uncertainty within families (e.g., [59]) suggests a natural
extension of these uncertainty theoretical approaches in the
context of family caregiver health literacy and to understanding why families may want to remain uncertain about
potential outcomes.
4.6. Improve patient and family caregiver health literacy
The final recommendation is for healthcare providers to
improve multiple aspects of patient and family caregiver
health literacy. Further, they should expand the conceptualization of health literacy assessment to include cultural and
conceptual knowledge and listening and speaking skills in
addition to written/reading skills and numeracy. Namely,
understanding the ways in which cultural beliefs impact how
individuals and their family members manage health information provides another facet to increasing cancer knowledge and
comprehension (e.g., [60]). Including family members in
understanding cultural/conceptual knowledge of health literacy is also relevant because family interactions provide
cultural assimilation.
Essentially, communication is paramount throughout –
communication between healthcare providers and patients,
healthcare providers and family caregivers, patients and the
family caregivers, and health communication researchers and
healthcare providers – to establish valid, reliable assessments of
multiple facets of health literacy that can be administered with
little time commitment and face threat. In initiating these
multiple dialogues, this position paper hopes to not only focus
research attention on the role of the family caregiver but also to
improve both patients’ and their health literacy levels. Because
‘‘adequate health literacy is a critical ingredient of quality
health in America’’ (30: p. 117), doing so can only improve the
experiences of those who are diagnosed with cancer and their
The 5-year mark is this summer, God-willing, we’ll be
cancer survivors. . .—Agnes
There was no financial support provided for this review of
literature to either author.
Conflict of interest
There is no actual or potential conflict of interest for either
[1] Zarcadoolas C, Pleasant A, Greer DS. Elaborating a definition of health
literacy: a commentary. J Health Commun 2003;8:119–20.
[2] Duggan A. Understanding interpersonal communication processes across
health contexts: advances in the last decade and challenges for the next
decade. Health Commun 2006;11:93–108.
[3] Davis TC, Arnold C, Berkel HJ, Nandy I, Jackson RH, Glass J. Knowledge
and attitude on screening mammography among low-literate, low-income
women. Cancer 1996;78:1912–20.
[4] Guerra CE, Dominguez F, Shea JA. Literacy and knowledge, attitudes,
and behavior about colorectal screening. J Health Commun
[5] Weihs K, Fisher L, Baird M. Families, health, and behavior. Fam Syst
Health 2002;20:7–46.
Author's personal copy
J.L. Bevan, L.L. Pecchioni / Patient Education and Counseling 71 (2008) 356–364
[6] Sharf BF, Freimuth VS. The construction of illness on entertainment
television: coping with cancer on thirtysomething. Health Commun
[7] Pecchioni LL, Thompson TL, Anderson DJ. Interrelations between family
communication and health communication. In: Turner LH, West R,
editors. The family communication sourcebook. Thousand Oaks, CA:
Sage; 2006. p. 447–68.
[8] Kristjanson LJ. Indicators of quality of palliative care from a family
perspective. J Palliat Care 1986;2:8–17.
[9] Kristjanson LJ. Quality of terminal care: salient indicators identified by
families. J Palliative Care 1989;5:21–30.
[10] Albrecht TL, Adelman MB. Communicating social support: a theoretical
perspective. In: Albrecht TL, Adelman MB, editors. Communicating
social support. Newbury Park, CA: Sage; 1987. p. 18–39.
[11] Albrecht TL, Burleson BR, Goldsmith D. Supportive communication. In:
Knapp ML, Miller GR, editors. Handbook of interpersonal communication. 2nd ed., Newbury Park, CA: Sage; 1994. p. 419–49.
[12] Albrecht TL, Goldsmith DJ. Social support, social networks, and
health. In: Thompson TL, Dorsey AM, Miller KI, Parrott R, editors.
Handbook of health communication. Mahwah, NJ: Erlbaum; 2003 . p.
[13] Harrington V, Lackey NR, Gates MF. Needs of caregivers of clinic and
hospice cancer patients. Cancer Nurs 1996;19:118–25.
[14] Biegel DE, Schulz R. Caregiving and caregiver interventions in aging and
mental illness. Fam Relat 1999;48:345–54.
[15] DiMatteo MR, DiNicola DD. Social science and the art of medicine:
from Hippocrates to holism. In: Friedman HR, DiMatteo MR, editors.
Interpersonal issues in health care. New York: Academic Press; 1982 .
p. 9–31.
[16] Li H, Stewart BJ, Imle MA, Archbold PG, Felver L. Families and
hospitalized elders: a typology of family care actions. Res Nurs Health
[17] Petronio S, Sargent J, Andea L, Reganis P, Cichocki D. Family and friends
as healthcare advocates: dilemmas of confidentiality and privacy. J Soc
Pers Relat 2004;21:33–52.
[18] Ward-Griffin C, McKeever P. Relationships between nurses and family
caregivers: partners in care? Adv Nurs Sci 2000;22:89–103.
[19] Beach WA, Good JS. Uncertain family trajectories: interactional consequences of cancer diagnosis, treatment, and prognosis. J Soc Pers Relat
[20] Adams M, Kerner J. Evaluation of promotional strategies to solve the
problem of underutilization of a breast examination center in a New
York City Black community. In: Mettlin C, Murphy GE, editors. Issues
in cancer screening and communications. New York: Alan R. Liss;
1982 .
[21] Freimuth VS, Stein JA, Kean TJ. Searching for health information: the
Cancer Information Service model. Philadelphia: University of Pennsylvania Press; 1982.
[22] Pecchioni LL, Sparks L. Health information sources of individuals with
cancer and their family members. Health Commun 2006;21:1–9.
[23] Hodges LJ, Humphris GM, Mcfarlane G. A meta-analytic investigation of
the relationship between the psychological distress of cancer patients and
their carers. Soc Sci Med 2005;60:1–12.
[24] Dunkel-Schetter C, Wortman CB. The interpersonal dynamics of cancer:
problems in social relationships and their impact on the patient. In:
Friedman HS, DiMatteo MR, editors. Interpersonal issues in health care.
New York: Academic Press; 1982. p. 69–100.
[25] Matthews AK, Sellergren SA, Manfredi C, Williams M. Factors influencing medical information seeking among African American cancer
patients. J Health Commun 2002;7:205–19.
[26] Davis TC, Williams MV, Marin E, Parker RM, Glass J. Health literacy and
cancer communication. CA: Cancer J Clin 2002;52:134–49.
[27] Kristjanson LJ, Ashcroft T. The family cancer’s journey: a literature
review. Cancer Nurs 1994;17:1–17.
[28] Gould H, Toghill PJ. How should we talk about acute leukemia to adult
patients and their families? Br Med J 1981;282:210–2.
[29] Brashers DE. Communication and uncertainty management. J Commun
[30] Parker RM, Gazmararian JA. Health literacy: essential for health communication. J Health Commun 2003;8:116–8.
[31] Campbell TL, McDaniel SH, Cole-Kelly K, Hepworth J, Lorenz A.
Family interviewing: a review of the literature in primary care. Fam
Med 2002;34:212–8.
[32] Kim MK, Alvi A. Breaking the bad news: the patient’s perspective.
Larynogoscope 1999;109:1064–7.
[33] Figueiredo MI, Fries E, Ingram KM. The role of disclosure patterns and
unsupported social interactions in the well-being of breast cancer patients.
Psychooncology 2004;13:96–105.
[34] Macario E, Emmons KM, Sorensen G, Hunt MK, Rudd RE. Factors
influencing nutrition education for patients with low literacy skills. J Am
Diet Assoc 1998;98:559–64.
[35] Martin R, Davis GM, Baron RS, Suls J, Blanchard EB. Specificity in social
support: perceptions of helpful and unhelpful provider behaviors among
irritable bowel syndrome, headache, and cancer patients. Health Psychol
[36] Arrington MI. She’s right behind me all the way’’: an analysis of prostate
cancer narratives and changes in family relationships. J Fam Commun
[37] Manne S. Couples coping with cancer: research issues and recent findings.
J Clin Psychol Med S 1994;1:317–30.
[38] Rees CE, Bath PA, Lloyd-Williams M. The information concerns of
spouses of women with breast cancer: patients’ and spouses perspectives.
J Adv Nurs 1998;28:1249–58.
[39] Wright K, Dyck S. Expressed concerns of adult cancer patients’ family
members. Cancer Nurs 1984;7:371–4.
[40] Stedeford A. Couples facing death II: unsatisfactory communication. Br
Med J 1981;283:1098–101.
[41] Williams MV, Davis T, Parker RM, Weiss BD. The role of health literacy
in patient-physician communication. Fam Med 2002;34:83–9.
[42] Baker DW, Parker RM, Williams MV, Pitkin K, Parikh NS, Coates W,
et al. The health care experience of patients with low literacy. Arch Fam
Med 1996;5:329–34.
[43] Botelho RJ, Bee-Horng L, Fiscella K. Family involvement in routine
health care: a survey of patients’ behaviors and preferences. J Fam Pract
[44] Al-Faraj AM, Al-Ansari AM. What family caregivers of schizophrenic
and non-psychotic in-patients in Bahrain believe about mental illness.
Arab J Psychiatry 2002;13:26–30.
[45] Kuyper MB, Wester F. In the shadow: the impact of chronic illness on the
patient’s partner. Qual Health Res 1998;8:237–53.
[46] Lidell E. Family support: a burden to patient and caregiver. Eur J
Cardiovasc Nurs 2002;2:149–52.
[47] Rabow MW, Hauser JM, Adams J. Supporting family caregivers at the end
of life: ‘‘they don’t know what they don’t know. J Am Med Assoc
[48] Medalie JH, Zyzanski SJ, Langa D, Strange KC. The family in family
practice: is it a reality? J Fam Pract 1998;46:390–6.
[49] Labrecque MS, Blanchard CG, Ruckdeschel JC, Blanchard EB. The
impact of family presence on the physician-patient cancer interaction.
Soc Sci Med 1991;33:1253–61.
[50] Bernhardt JM, Cameron KA. Accessing, understanding, and applying
health communication messages: the challenge of health literacy. In:
Thompson TL, Dorsey AM, Miller KI, Parrott R, editors. Handbook of
health communication. Mahwah, NJ: Erlbaum; 2003. p. 583–605.
[51] Kornblith AB, Regan MM, Kim Y, Greer G, Parker B, Bennett S, et al.
Cancer-related communication between female patients and male partners
scale: a pilot study. Psychooncology 2006;15:780–94.
[52] Grootenhuis MA, Last BF. Adjustment and coping by parents of children
with cancer: a review of the literature. Support Care Cancer 1997;5:466–
[53] Parikh NS, Parker RM, Nurss JR, Baker DW, Williams MV. Shame and
health literacy: the unspoken connection. Patient Educ Couns 1996;27:33–9.
[54] Steinglass P. The future of family systems medicine: challenges and
opportunities. Fam Syst Health 2006;24:396–411.
[55] Fiese BH. Opportunities for the future in family systems medicine. Fam
Syst Health 2006;24:412–5.
Author's personal copy
J.L. Bevan, L.L. Pecchioni / Patient Education and Counseling 71 (2008) 356–364
[56] Petronio S. Boundaries of privacy: dialectics of disclosure. Albany, NY:
State University of New York Press; 2002.
[57] Babrow AS. Communication and problematic integration: understanding
diverging probability and value, ambiguity, ambivalence, and impossibility. Commun Theory 1992;2:195–230.
[58] Afifi WA, Weiner JL. Toward a theory of motivated information management. Commun Theory 2004;14:167–90.
[59] Bevan JL, Stetzenbach KA, Batson E, Bullo K. Factors associated with
general partner and relational uncertainty within early adulthood sibling
relationships. Commun Quart 2006;54:367–81.
[60] Buki LP, Borrayo EA, Fiegal BM, Carrillo IY. Are all Latinas the same?
Perceived breast cancer screening barriers and facilitative conditions.
Psychol Women Quart 2004;28:400–11.