communication is one of the most important skills for healthcare professionals and service providers in the healthcare system ( 1 ) . although these people tend to establish a clear communication with patients to provide information and education to them , in the process of communication with patients , they usually use specialized terms and jargons , which are familiar to them and are deemed as more accurate . in addition , in communicating with patients , eventually they convey so much information that patients can not process . therefore , the majority of patients , even those with strong language skills and good speaking and communication ability , encounter difficulties in processing information , because most of them are unfamiliar with medical terminology and had difficulty in focusing on the information provided . they often find it hard to understand the information and training offered by health professionals ( 1 - 4 ) . according to studies ; patients remember only 50 percent or less of what health specialists teach them ( 3 ) . poor communication between patients and health care providers leads to frequent problems in the healthcare system such as inability to remember next doctor s visit time , poor self - care , misuse of drugs , delayed access to needed medical care , hospital re - admissions and the like ( 5 ) . according to the literature , a significant proportion of patients facing these problems are people with limited health literacy . in fact , the concept of limited health literacy describes patients who do nt have enough skills and abilities to acquire , interpret and understand health - related information needed for proper decision making and functioning in the health care system ( 6 , 7 ) and therefore , requires information and training provided in a different way than is done for others ( 8) . in general , health literacy includes knowledge , motivation and ability to obtain , understand , evaluate and implement health information in order to judge and make decisions about health care routines , disease prevention and health promotion , which finally affects maintaining and improving quality of life . it is becoming increasingly important in healthcare systems and is related to people s capabilities for satisfying complex health needs in modern societies . poor health literacy negatively affects the communication between health professionals and patients and is rapidly becoming a problem in the healthcare system ( 9 ) . patients with low health literacy often use passive methods of communication , do not participate in partnership decision - making , and , as a result , face several problems in their interaction with therapists ( 10 - 13 ) . effective communication is the foundation of patient - centered health care and health literacy is a key component for effective communication between patients and health professionals ( 14 ) and is thus one of the most important priorities for improving health care system ( 15 , 16 ) . in fact , establishing effective communication between health professionals and patients increases the system s efficacy and patients satisfaction in the service provided in health centers . it improves patient satisfaction as one of the main indicators of quality of health care , which will result in positive health outcomes ( 17 - 19 ) . health literacy is considered by healthy people 2020 as one of the main priorities for improving the quality of health services , and one of the goals related to health literacy in this project is that of improving the communication between patients and health care providers ( 20 ) . in this regard , joint commission and the world health organization also stressed the need to provide information and training in a standard and patient - centered approach to people with inadequate health literacy ( 18 ) . in this regard , sudore and schillinger ( 2009 ) in a study titled interventions to improve care for patients with limited health literacy , introduce best health literacy practices that benefit all patients , especially those with insufficient health literacy . according to these researchers , health literacy strategies include the use of simple and understandable language , limiting the number of points provided in each visit , using multiple modalities , including pictures , encouraging patients to ask questions and finally using simple and understandable media ( 21 ) . in general , if health professionals become familiar with the concept of health literacy strategies , when training patients , they offer materials using language and methods that help patients better understand and achieve a greater ability implement the expert advice ( 22 ) . since health literacy is a multi - faceted issue , which affects almost every aspect of health care ( 23 ) . therefore , all those who have to communicate with patients , their families and other people in clinical environments , in writing or verbally , must have necessary skills and knowledge in the area of health literacy ( 14 ) . nurses , as a group of health care providers who are in the frontline of establishing safe and effective communication with patients and families with different levels of health literacy play a key role in patient education ( 24 - 26 ) . unfortunately , research suggests that this largest group of health care providers do not have enough knowledge , attitudes and skills in the area of health literacy and responding to patients needs and most of them do not use effective communication strategies and methods in teaching and communicating with patients ( 27 , 28 ) . since , according to literature , a variety of factors , including individual , motivational , economic , and organizational factors can affect the performance of health care providers in clinical settings ( 29 ) , behavioral science theories can provide good information on the factors affecting the behavior of this class of people . the theory of planned behavior ( tpb ) as one of the best behavioral science theories has been used in several studies to explain behavior and identify important factors affecting it . in this study , this theory is used as a conceptual research framework , because various studies have shown that it has performed well in predicting the intention and behavior of different groups of healthcare providers ( 30 , 31 ) . tpb is based on the premise that people are reasonable and evaluate consequences before engaging in certain actions ( 32 ) . based on the theory , behavioral intention , which is shaped by attitude toward behavior , subjective norms , and perceived behavioral control , can predict behavior . attitude toward behavior is one s positive or negative evaluation of self - performance of the particular behavior . subjective norm is one s perception about the particular behavior as influenced by social pressures and can lead to doing or abandoning the behavior . perceived behavioral control is one s perceived ease or difficulty of performing the particular behavior . the theory has done well in various studies in predicting the behavior of different groups of healthcare providers , including nurses ( 33 ) . research has been conducted at the alzahra educational hospital which is one of the largest such facilities in iran . it has 950 beds and more than 2600 personnel , and about 970 of them are nurse practitioners . the majority of this hospital s patients are from isfahan and surrounding provinces , which have a variety in ethnicity and races . because of the inexpensive services of educational hospitals and the geographical situation , a large number of patients who referred to this hospital are from low socioeconomic levels , low educated and many of them had difficulties in talking in persian language and low health literate ( 34 , 35 ) . communicating with such in danger of low health literacy patients requires its knowledge and techniques . having this in mind , the present study aims to predict factors influencing the nurses behaviors regarding use of health literacy strategies when communicating and educating low health literacy patients based on tpb . this is a descriptive - analytical cross - sectional study carried out in 2014 on 148 nurses working in al - zahra hospital in isfahan , iran . the sample was selected through simple random sampling from among the nurses of the hospital . criteria for inclusion in the nurse group were having at least a bachelor s degree in nursing and consent to participate in the study . the sample size was determined based on standard deviation taken from a pilot study by researchers on 30 nurses ( =0.64 ) . at the significance level of 0.95 and accuracy of 0.05 , the sample size was estimated as 148 using the formula ( n = z22/d2 ) . research subjects were informed about the purpose of the project and privacy and were ensured that the project would not affect their evaluation . those who consented were included in the study . for data collection , the first part was about demographic characteristics of the participants and included items on age , gender , marital status , level of education , type of employment , experience , organizational position and the ward where they were working . the second part of the questionnaire consisted of items based on tpb and was administered to determine predictors of nurses intention and behavior regarding the use of health literacy strategies . the questionnaire consisted of 11 questions on attitude towards behavior , 9 question on subjective norms , 7 questions on perceived behavioral control and 6 questions on behavioral intention rated based on five - point likert scale anchored at 1 = completely agree and 5 = completely disagree . the use of health literacy strategies in patient education was assessed by 10 items . to investigate the validity of the developed questionnaire , the face and content validity were assessed using a qualitative approach based on comments of a panel of experts and a quantitative approach via comparing the content validity ratio ( cvr ) . according to lawsche table , values of cvr for 10 experts above 0.62 were considered as necessary items in the instrument ( 36 ) . the calculated cvr value for each of the constructs was above the acceptable level , and the mean ratio for the whole instrument was 0.85 indicating the content validity of the questionnaire . to determine the reliability of the instrument , internal consistency method was used . to this end , the questionnaire was completed by 30 participants and cronbach s alpha was used to assess the internal consistency . the alpha value was 0.74 for the attitude scale , 0.78 for subjective norms , 0.68 for perceived behavioral control and 0.81 for behavioral intention . data were analyzed using independent t - test , anova , pearson s correlation coefficient and linear regression via spss v.17 . a total of 148 nurses working in al - zahra hospital with a mean age of 36.75  5.78 participated in the study . 89 percent of participants were female , 80 percent were married , 64.8 percent had completed patient education retraining courses in last year , 37.8 percent of them were contract employees , 87.9 percent was working in the wards and about 12 percent worked as a supervisor the mean score of nurses on use of health literacy strategies for patient education was 21.743.47 . one - way anova showed a significant difference between the mean scores of nurses on use of health literacy strategies for patient education on the basis of variables such as marital status ( p=0.023 ) , attending retraining courses ( p=0.003 ) , type of employment ( p=0.02 ) , work experience ( p=0.004 ) , and organizational position ( p=0.003 ) . , in other words , single nurses with 5 to 10 years of work experience and those with contract employment and attending retraining courses on patient education used more health literacy strategies and techniques for patient education than others did . results of pearson s correlation coefficient show that there is a significant positive correlation between construct of attitude toward behavior , subjective norms , and perceived behavioral control with intent and behavior of nurses regarding use of health literacy strategies for patient education ( table 1 ) . correlation coefficient between constructs of tpb and implementation of health literacy strategies for patient education based on the results of linear regression analysis , perceived behavioral control ( =0.417 ) was the best predictor of intention ( table 2 ) . the results of the regression model showed that ability of tpb constructs to predict nurses use of health literacy strategies in patient education is 0.31 . perceived behavior control was the strongest predictor of behavior and predicted 33% of the behavior change ( table 3 ) . linear regression analysis of effects of tpb constructs on intention to use health literacy strategies in patient education ( dependent variable ) * p < 0.01 linear regression analysis of effects of tpb constructs on behavior of using health literacy strategies in patient education ( dependent variable ) * * p < 0.001*p the purpose of this study is to determine the predictors of nurses intention and behavior regarding use of health literacy strategies and techniques in patient education based on tpb . according to literature , tpb is one of the best theories that explain the behavior of service providers in the healthcare system and can work well in identifying factors affecting the behavior of practitioners in clinical settings ( 30 ) . in this study , variables affecting nurses intention and behavior for use of these techniques based on tpb were identified and analyzed via regression model . identifying and focusing on modifiable factors in nurses behavior is an important step in the selection of appropriate intervention to obtain the best results . it is worth mentioning that this study is the first of its kind on assessing the use of health literacy strategies in patient education by iranian nurses . therefore , similar studies that can be compared with the results of the present study were not at hand . hence , in this section we reviewed the studies that examined the intention and behavior of nurses in similar issues . based on the results , single nurses with 5 to 10 years of work experience and those with contract employment and attending retraining courses on patient education used more health literacy strategies and techniques for patient education than others did . results confirm the fact that patient education retraining courses and nurses familiarity with communication skills enhance the effectiveness of the training they provide to patients ( 37 ) . unlike results of this study , caferio claimed that there is not any statistically significant relationship between demographics , intention and experience of using health literacy strategies among nurse practitioners ( 38 ) . since service providers in clinical environments consider using health literacy techniques in patient education a time - consuming task , it appears that single nurses , who have fewer personal responsibilities and more time , use these techniques in patient education more than others do . in the present study , the constructs of attitude , subjective norms and perceived behavioral control were associated with nurses intention and behavior of using health literacy skills in patient education . in this study , this construct predicted 23 percent of the variance in intention and more than 45% of the variation in behavior . in fact , if nurses perceive the use of these strategies as easy and under their control , they will have a strongest intention to use these strategies in patient education , and eventually they will do so . in addition , they can cope more easily with potential problems during treatment . according to millstein et al . , health professionals with higher perceived behavioral control performed better in training adults in the field of sexually transmitted diseases ( 39 ) . nai - ying et al found perceived behavioral control to be the strongest predictor of nurses intention and volunteering to care for sars patients ( 29 ) . in bunce and birdi , perceived behavioral control predicted the behavior of physicians regarding doctors intentions to request hospital autopsies as a function of job control ( 40 ) . unlike results of this study , renfroe et al found positive attitude toward behavior and subjective norms the best predictors of nurses intention and behavior regarding documentation . based on their study , these two components predicted 46.1 percent of variance in nurses behavioral intention and 15.1 percent of the variance in their behavior ( 41 ) . limitations : although the efficacy of the tpb to predict major factors affecting nurses behavior is well established in clinical settings , since behavior is a complex phenomenon , it is likely that other factors not included in tpb affect their use of health literacy strategies . although the participants were chosen only from al - zahra hospital , which is one of the largest hospitals in isfahan , the results are not generalizable to other clinical settings . whereas , in this study , attitude towards behavior and subjective norms did not predict nurses intention to use health literacy techniques in patient education . it can be argued that the nurses attitude towards the use of health literacy strategies in patient education was positive . therefore , nurses control beliefs and perceived ability to do the behavior and overcome obstacles can lead them towards using health literacy strategies to increase the effectiveness of patient education . this is called perceived behavioral control , which deserves more attention . since the construct of perceived behavioral control was found to be the most important factor affecting nurses intention and behavior of using health literacy strategies , designing and implementing programs and educational interventions based on tpb with a focus on perceived behavioral control can increase nurses participation to provide patient education based on health literacy strategies .
background : health literacy is one of the most important priorities for improving health care quality through enhancing patient - provider communication . implementing health literacy strategies enable nurses to provide information and instructions for patients in a manner that is more commensurate and understandable . 
 the purpose of this study was to investigate the factors affecting nurses intention to implement health literacy strategies in patient education based on theory of planned behavior.methods:a cross - sectional study was done on 148 nurse practitioners of al - zahra educational hospital in isfahan , iran , using a descriptive - analytic method . 
 data collected via a standardized questionnaire based on theory of planned behavior constructed and analyzed by spss v.17 using anova , independent t - test , pearson correlation and linear regression.results:there was statistically significant correlation between using health literacy strategies and marriage status , attending in retraining courses , employment type , job history , and job status . perceived behavioral control was the most powerful predictor of intention ( =0.417 ) and use health literacy strategies in patient education and behavior of nurses ( =0.33).conclusion : according to the findings of this study , perceived behavioral control is a powerful determinant of nurses intention and behavior of using health literacy strategies in patient education . hence we recommend nurse educators to pay special attention to the constructs of this theory mainly perceived behavioral control in retrain courses about patient education and health literacy strategies .