Ph.D. candidate hopes her research in health literacy and hypertension can save lives

Nurse and WSU Ph.D. candidate Donulae Knuckles says resolving health literacy deficits is crucial: "If people don't understand what they're taking or why, then we're putting them at risk for those poor outcomes like stroke and heart attack."

At first glance, Nurse Donulae Knuckles' research sounds technical - dense with phrases like "basic conditioning factors" and "antihypertensive medication adherence." But at its core, her work is about something far more human: Why do people struggle to take care of themselves, even when the stakes are life and death?

A Ph.D. candidate in the College of Nursing at Wayne State University, Knuckles brought that question to the WSU Graduate Research Symposium through a study focused on hypertension - one of the most persistent and unequal public health crises in the United States. Her goal was simple but urgent: understand what helps - or prevents -people from managing high blood pressure.

Hypertension, she explains, is not just common - it's devastating. Roughly 60% of Black Americans are diagnosed with it, yet only about a quarter have it under control. Left untreated, it leads to stroke, heart attack, kidney disease and premature death.

"We can count our money," Knuckles says when promoting increased health literacy. "That means we can count our calories. It's just a matter of understanding."

"Hypertension is also the precursor for other cardiovascular diseases," she explains. "But many people don't believe the diagnosis when doctors say you have high blood pressure. And even for those who do believe the diagnoses, they have a hard time managing their high blood pressure for a multitude of reasons."

In exploring these reasons, Knuckles' study zeroed in on a concept that often gets overlooked: health literacy. It's not just whether someone can read, she says - it's whether they can understand and use the health information they're given. That includes everything from interpreting prescription instructions to making sense of a nutrition label.

To explore this, she conducted a cross-sectional study of 190 Black adults in the metro Detroit area, all diagnosed with hypertension and prescribed medication. The participants ranged widely in age and education, with some having advanced degrees. On paper, it was a well-informed group.

But what Knuckles found was startling. Using a tool called the Newest Vital Sign - a six-question assessment based on interpreting a nutrition label - she discovered that only about half of participants even attempted to complete it. And among those who did, not a single person demonstrated adequate health literacy.

Even more striking was her discovery that education didn't protect against this gap. Participants with graduate-level education performed slightly better but still fell into low-literacy categories.

The finding challenges a common assumption - that more schooling automatically translates into better health understanding. "It's not about reading," Knuckles explains. "It's about understanding the health information that's given to us."

And that gap, she warns, has real consequences when it comes to life-saving treatment. "We've gone through the process of saying, 'Okay, your blood pressure is high.' We're past lifestyle changes - now you need medication," she says. "But if people don't understand what they're taking or why, then we're putting them at risk for those poor outcomes like stroke and heart attack."

Her study also examined medication adherence and whether patients actually take their prescribed drugs. For hypertension, at least 80% adherence is needed for treatment to be effective, she explains. Yet even in the best cases, adherence rates fall short.

Surprisingly, Knuckles found no strong statistical link between health literacy and medication adherence in her sample. That doesn't mean literacy doesn't matter - it means the problem is more complex than a single factor.

And complexity is exactly what her research highlights.

People don't always take medication simply because a doctor tells them to. Some don't trust the diagnosis. Others worry about side effects. Some follow instructions without fully understanding why. Still others rely on family habits and cultural traditions that shape how they approach health.

Knuckles' broader research model includes all these variables: medical mistrust, patient-provider communication and medication beliefs. Health literacy is just one piece of a larger puzzle.

But it's a critical one.

Because if patients can't interpret something as basic as a nutrition label, the entire health care system begins to break down. Public health campaigns, dietary guidelines, medication instructions - all of it assumes a level of understanding that may not exist.

Knuckles sees this gap firsthand in her work beyond academia. As the founder of Knuckles Health Education Services, she conducts community trainings that translate abstract health concepts into everyday language. She teaches people what a "gram" looks like. She breaks down grams into teaspoons. She meets people where they are.

A longtime and popular cardiovascular health expert in Detroit, Nurse Knuckles's professional focus sharpened after she suffered a stroke at age 39 due to a congenital condition.

"We can count our money," she says. "That means we can count our calories. It's just a matter of understanding."

That idea of grounding science in real life is what drives her research, she says. Her work doesn't just identify a problem; it points toward solutions rooted in education, accessibility and cultural awareness.

For Knuckles, this mission also is deeply personal. Years before her doctoral research, she suffered a stroke at age 39 caused by a congenital hole in her heart - an event that reshaped her life and sharpened her focus on cardiovascular health. "I was Nurse Knuckles - I was out here teaching, doing everything - and I was the one that had the stroke," she recalls, underscoring the irony that still drives her work today. Today, fully recovered, she channels that experience into both her scholarship and her advocacy.

Her research may live in charts, models and statistical analyses. But its impact is measured in something far more immediate: lives extended, disparities reduced and communities better equipped to take control of their health.

At Wayne State's Graduate Research Symposium, Knuckles didn't just present findings. She issued a quiet but urgent call - to rethink how we communicate health, and to recognize that understanding, not just access, may be the missing link in saving lives.