Health literacy for the safety of patients in primary care: scoping review protocol


Euni de Oliveira Cavalcanti1,2, Graziani Izidoro Ferreira1, Moara Ávila de Jesus Moreira1, Thatianny Tanferri de Brito Paranaguá1


1University of Brasília, Brasília, DF, Brazil

2Euro-American University Center, Brasília, DF, Brazil




Objective: To map evidences on the impact of health literacy on the safety of primary health care users. Method: Scoping review protocol according to the method of the Joanna Briggs Institute (JBI). The following inclusion criteria will be used: articles that report the application of the principles of health literacy (concept) in patients treated in primary health care (population) in the context of patient safety (context). The data sources will be: PUBMED, Scopus, CINAHL, BVS, including MEDLINE, LILACS and BDENF, SciELO, Web of Science and Google Scholar. Two reviewers will perform the screening by title and abstracts, read the full texts and extract data from the selected articles. The data will be organized and expressed in categories, according to their content. The results will be disclosed to health services linked to primary care, academic community, policymakers for the development of safety and health promotion.


Descriptors: Health Literacy; Patient Safety; Primary Health Care.



Health literacy (LS) or Literacy in Health is the term used to describe the ability to engage with information in health services. It refers to individual attributes and social resources that are used for the individual and community to have means of access and ability to understand, evaluate and use health information and services, for a decision-making on aspects of their health. It includes the ability to communicate, affirm and act on such decisions(1).

Communication between health professionals and patients is a critical element in patient safety. Effective communication skills can be taught and enhanced through training and awareness. There are many barriers to effective communication, including patient factors, clinicians, and system factors, but there are tools and strategies to address these barriers, improve communication, and engage patients in their care. The LS approach and shared decision making are evidence-based tools that improve communication and increase patient safety(2).

In the Netherlands, a randomized study compared the use of several educational materials to increase literacy in health, with the use of several tools, showed that patient safety is an important topic for citizens who want to be informed and involved(3). Although improvements in the production and legibility of leaflets may be advantageous, the quality of patient-health professional relationships should be emphasized to enable a personalized patient education, which can improve their capacity for engagement and self-management in the context of promotion, prevention and treatment(4).

Health literacy interventions have been implemented in most high-income countries. There are many instruments that have been used to measure LS and assess how well individuals understand health information. Appropriate, community-based health care can lower operational costs, increase team availability, and empower the local community(1).

Study investigated the perception and experiences of the patient in the context of patient safety in primary health care. They identified from the respondents, some aspects that may contribute to patient safety such as: the patient is more active and involved in the care process and has adequate health literacy level; the contact between patient and professional focusing on effective communication and empathy; to solve the problems inherent to the health system, which involves work overload, lack of organization of the system and assistance, difficulty of access, incomplete or wrong patient annotations(5).

In the context of patient safety, "communication is the basis for the development of a partnership relationship. Health services with a safety culture focused on patient and family care should ensure at all levels of care the quality of communication as an integral part of health care"(2).

Thus, patient safety also includes "patient-centered care and family-centered care. The patient should not only be an active participant in his or her own care, but also the link between the health institution and the community"(2). Some strategies for the implementation of health literacy in primary care can be used to better adapt the provision of health care to the needs of patients with low levels of literacy in health, for example, strengthening the skills of health professionals to communicate with these patients, or adapting the organization and design of health services(3).

Study developed in Korea as part of the Comprehensive Patient Safety Plan (2018-2022), analyzed the effectiveness of the use of educational materials on patient safety and improvement of health literacy; it identified that patients with low level of health literacy are not aware of the importance of early detection and treatment of diseases; therefore, less likely to use services related to disease prevention, which are followed in primary care(2).

In this context, using the acronym PCC (population, concept and context) to elaborate the research question, the following question was raised: How can health literacy contribute to the safety of primary health care users/patients?

Based on this question, the objective of the review is to map evidences on the impact of health literacy on the safety of primary health care users. There are many studies in the literature that address health literacy issues at national and international level, however, conducting a research with the descriptors:

"Health literacy", "patient safety" and "primary care", in the summaries of the JBI, Cochrane Library and Pubmed databases, there were no systematic reviews, integrative reviews, narratives or scope that encompass the theme.




Study design

To achieve the proposed objective, based on the research question, we used the scoping review methodology, which is a type of systematic review, mapping concepts and findings related to the topic of interest, available in the main data sources, using the knowledge synthesis approach(6).


Protocol and registration

The elaboration of the basic protocol for the development of the scoping review is in accordance with the guidelines and methodological framework contained in the methodology manual published by Joanna Briggs Institute (JBI) for Scoping Reviews and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoring Reviews (PRISMA-SCR)(7.8). The expected time and duration for the development of the review is 6 months. The protocol was prospectively registered in the Open Science Framework (OSF) (

Prior to the elaboration of the protocol, a search was carried out for review articles already published on the subject to be studied, through the type of studies sought: Systematic review, overview and scoring review; year of publication and search strategy that will be elaborated from descriptors raised in Descritores em Ciência da Saúde (DECS) and Medical Subject Headings (MESH), as described below (Table 1).


Table 1 - Review articles identified in databases. Brasilia, DF, Brazil, 2022



JBI Syntheses



Web of Science

Health Systems Evidence

Google Scholar



Fulfilled the inclusion criteria

Health Literacy AND Patient Safety










0 0

Health Literacy AND Primary Health Care










0 0

Health Literacy OR Information Literacy OR Alfabetización en Salud AND Primary Health Care AND (Patient Safety OR Risk Management)










0 0

Source: Elaborated by the authors, 2022.


Research question

P (population): Primary Health Care Users C (concept): Health literacy C (context): Patient safety

How can health literacy contribute to the safety of primary health care users/patients?


Research strategy

Type of studies sought: Systematic review, overview and scoping review. Descriptors: "Health literacy" AND "Primary health care" AND "Health safety" OR "Risk management".

Filters: Year of publication (last 10 years); Type of study.


Inclusion Criteria



Studies whose participants are users of primary health care services, of any age, who received health care will be included. Studies will be excluded, in which participants received home care.



The central concept of the studies should address care, techniques, protocols, or methods of health literacy used to improve health care.



The context to be observed should be patient safety. The patient’s safety includes not submitting the user to avoidable risks arising from care or care provided, and preventing any complications(8). Thus, all studies that address this context together with the concept and participants described will be included in the search.



Studies published in the last ten years will be eligible, developed in any year and duration.



Considered for inclusion complete articles published in the languages: English, Portuguese and Spanish.


Sources of information and research strategy


1st Step

An initial search in electronic databases, MEDLINE (PubMed) and Virtual Health Library (Biblioteca Virtual em Saúde, BVS). After this initial search, words contained in the title, abstract and keywords of the articles found were analyzed. The descriptors found were compared to the descriptors registered in the databases of descriptors (Figure 1), MeSH for searches in PubMed and DeCS for searches to be performed in the VHL.







Letramento em saúde

Health literacy

Alfabetización en Salud

Health literacy

Atenção Primária à Saúde

Primary Health Care

Atención Primaria de Salud

Primary Health Care

Segurança do paciente

Patient Safety

Seguridad del Paciente

Patient Safety

Gestão da Segurança

Safety Management

Administración de la Seguridad

Risk Management

Source: Elaborated by the authors, 2022.

Figure 1 - Descriptors selected for research strategy. Brasilia, DF, Brazil, 2022




2nd Step

A search will be performed using the keywords and descriptors in the following databases: PubMed, BVS, SciELO (Scientific Electronic Library Online), Web of Science, SCOPUS and CINAHL (Cumulative Index to Nursing and Allied Health Literature) following the search strategy that will be developed (Figure 2).





(((("health literacy"[MeSH Terms] OR "health literacy"[All Fields]) AND "Primary Health Care"[MeSH Terms]) OR "Primary Health Care"[All Fields]) AND "Patient Safety"[All Fields]) OR "Risk Management"[MeSH Terms]

Web of Science

("health literacy" OR "Information Literacy") AND "Primary Health Care" AND ("Patient Safety" OR "Risk Manaqement")


("health literacy" OR "Information Literacy") AND "Primary Health Care" AND ("Patient Safety" OR "Risk Management")


"Letramento em saúde" AND "Atenção primária à saúde" AND ("Segurança do paciente" OR "Gestão da Segurança")


("health literacy" OR "Information Literacy") AND "Primary Health Care" AND ("Patient Safety" OR "Risk Management")


("health literacy" OR "Information Literacy") AND "Primary Health Care" AND ("Patient Safety" OR "Risk Management")

Google Scholar

"Letramento em saúde" AND "Atenção primária à saúde" AND ("Segurança do paciente" OR "Gestão da Segurança")



Source: Elaborated by the authors, 2022.

Figure 2 - Search strategy. Brasilia, DF, Brazil, 2022




3rd Step

A third research, now in the gray literature, through Google Scholar, thus completing the search in seven different search bases. If necessary, the list of references used in all articles selected from the full text and included in the review and/or made contact with authors of primary studies or reviews to obtain more information about the published studies will be raised.

All these steps and care will be carried out to maximize the scope of the search and reach of the important studies to be considered in the review.


Selection of studies

The selection process of the studies will be carried out by two independent researchers and in case of divergences, a third researcher will assist in the final decision to include or not the study.

Thus, the screening of articles during the selection process will be through:

1st) Screening per year of publication;

2nd) Screening by title;

3rd) Screening by abstract;

4th) Full text screening.


Data extraction

The important information that will be mapped can be found in Figure 3 below:


Title of


Year of publication

Objective of the




Design of


Main conclusions

Main findings related to scope review questions

Source: Elaborated by the authors, 2022.

Figure 3 - Data Extraction. Brasília, DF, Brazil, 2022




The data will be extracted following the guidance of the manual, second: title of the article, year of publication, objective of the study, population, design of the study, Main conclusions and the findings that answer the question and objective of this scoping review. The data to be extracted will be observed for certification that all relevant results will be extracted.


Summary of the results

The results will be expressed through narrative synthesis, tables and graphs. When found, research gaps and possible limitations of the review will be pointed out.



The conclusions of this Scoping Review will be the basis for defining the techniques and approaches of health literacy that will be applied as an intervention in safe care to primary care patients. The synthesis of evidence generated may also serve as a guideline for practices that generate greater patient safety during primary health care.



The summary of the results will be published through the publication of scientific articles in databases of free access, through the translation of knowledge to health professionals, in addition to presentation at conferences and scientific events.



The authors have declared that there is no conflict of interests.



1. World Health Organization. Health Promotion Glossary of Terms 2021 [Internet].  Geneva: WHO; 2021 [cited 2023 Jan 24]. Available from:


2. Kim YS, Kim HA, Kim MS, Kim HS, Kwak MJ, Chun J, et al. How to Improve Patient Safety Literacy?. Int J Environ Res Public Health. 2020;17(19).;36(3).


3. Jansen CJM, Van’T Jagt RK, Reijneveld SA, van Leeuwen E, de Winter AF, Hoeks JCJ. Improving health literacy responsiveness: A randomized study on the uptake of brochures on doctor-patient communication in primary health care waiting rooms. Int J Environ Res Public Health. 2021 May;18(9).


4. Durrant LA, Taylor J, Thompson H, Usher K, Jackson D. Health literacy in pressure injury: Findings from a mixed-methods study of community-based patients and carers. Nurs Health Sci. 2019;21(1):37–43.


5. Dineen-Griffin S, Garcia-Cardenas V, Williams K, Benrimoj SI. Helping patients help themselves: A systematic review of self management support strategies in primary health care practice. PLoS ONE. 2019;14(8):e0220116.


6. Peters MDJ, Godfrey C, McInerney P, Munn Z, Tricco AC, Khalil H. Chapter 11: Scoping Reviews (2020 version). In: Aromataris E, Munn Z, editors. JBI Manual for Evidence Synthesis [Internet]. Adelaide: JBI; 2020 [cited 2022 Maio 10]. Available from:


7. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. 2018;169(7):467–73.


8. Aromataris E, Munn Z, editors. JBI Manual for Evidence Synthesis. JBI [Internet].  Adelaide: JBI; 2020 [cited 2023 Jan 24]. Available from:


Submission: 01/16/2023

Approved: 03/23/2023



Project design: Cavalcanti EO, Ferreira GI

Data collection: Cavalcanti EO, Moreira MAJ

Data analysis and interpretation: Cavalcanti EO, Paranaguá TTB

Writing and/or critical review of the intellectual content: Cavalcanti EO, Ferreira GI, Moreira MAJ, Paranaguá TTB

Final approval of the version to be published: Ferreira GI, Paranaguá TTB

Responsibility for the text in ensuring the accuracy and completeness of any part of the paper: Cavalcanti EO, Ferreira GI, Moreira MAJ, Paranaguá TTB