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Original Research
Article history: Objectives: The aim of conducting this study is to measure health literacy (HL) and to
Received 17 March 2017 investigate the factors associated with inadequate HL in a sample of outpatient clinics
Received in revised form attendees (i.e. patients and companions) at Ain Shams University (ASU) Hospitals.
23 June 2017 Study design: It is a cross-sectional study.
Accepted 28 June 2017 Methods: The study was conducted on 805 attendees of the outpatient clinics at El-
Demerdash University Hospital of ASU Hospitals. The Arabic versions of the Swedish
Functional Health Literacy Scale and the European Health Literacy Survey Ques-
Keywords: tionnairedshort versiondwere used to assess HL. The level of HL and factors influencing it
Functional health literacy were analyzed using correlation and binary logistic regression tests.
Comprehensive health literacy Results: It was found that 81% of the participants had limited comprehensive health literacy
Egypt (CHL; 34.3% inadequate and 46.7% problematic), while only 18.9% had sufficient CHL.
Ain Shams University Hospitals Regarding functional health literacy (FHL), it was found that 84% had limited FHL (50.6%
S-FHL inadequate and 33.4% problematic), while only 16.1% had sufficient FHL. Females were
HLS-EU-Q16 more likely to have inadequate FHL. On the other hand, males, individuals with low
educational levels, and attendees identified as patients as well as participants with inad-
equate FHL were more likely to have inadequate CHL.
Conclusion: The majority of our study population has limited HL. Extensive research is
warranted to explore the extent of the problem on multi-institutional and national levels
and to investigate more explanatory factors.
© 2017 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
* Corresponding author.
E-mail address: ranya.almaleh@gmail.com (R. Almaleh).
1
Equally contributed.
http://dx.doi.org/10.1016/j.puhe.2017.06.024
0033-3506/© 2017 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
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about individuals' ability to read health-related information2 explanatory phrases for each question were agreed upon
and comprehensive health literacy (CHL) which represents among all interviewers to meet different cultural backgrounds
individuals' ability to obtain, understand, appraise, and apply of different participants. Aside from our study population, 121
health-related information to promote health or prevent dis- attendees were approached but they refused to participate in
eases.3 Limited HL has been established as a growing problem the study as they were either not interested in participation or
affecting both individuals and the general population. It is now were in a hurry.
linked to increased rates of hospital admission,4,5 poorer
physical and mental health,6,7 some psychological problems The European Health Literacy Survey Questionnairedshort
such as deep sense of shame and so individuals are unwilling version (HLS-EU-Q16 questionnaire)
to disclose their problem to healthcare providers,8,9 and lower
use of preventive health services, such as vaccinations and The Arabic version of the modified European Health Literacy
screening tests.10 All these lead to higher healthcare costs.11e14 Survey Questionnairedshort version (HLS-EU-Q16)20,21 was
Health literacy and factors influencing its level like edu- used to assess CHL (Supplementary file 1). It was chosen
cation have become an important aspect of global research.15 because it is simple and easily understood. It consists of 16
Despite reporting high level of illiteracy16 and its low ranking items taken from the longer European Health Literacy Survey
in the Global Competitiveness Report 2015e2016 regarding Questionnairedoriginal matrix-related version (HLS-EU-
both primary and higher education,17 Egypt has lagged behind Q47).22 Both versions were developed by the European Health
in researching HL. To date, minimal data regarding measuring Literacy (HLS-EU) consortium as a part of the European
HL in Egypt exist. Only one study was conducted among Health Literacy (HLS-EU) project.22 It covers the conceptual
elderly caregivers in the Geriatrics Medicine Department of model of CHL proposed by Sorensen et al.3 by investigating
Ain Shams University (ASU) Hospitals. Results showed that the ability of individuals to access/obtain, understand, pro-
about 75% of elderly caregivers have limited HL.18 cess, and use health information. Valid answer categories
The aim of conducting this study is to measure the prev- were ‘very easy’, ‘fairly easy’, ‘fairly difficult’, and ‘very
alence of limited HL among attendees (i.e. patients and com- difficult’ with the option to give an answer of ‘do not know’
panions) of the outpatient clinics of El-Demerdash University that was analyzed in the same way as not answering the
Hospital (DUH) of ASU Hospitals. Determination of socio- question.21 The scoring consisted of dichotomizing the valid
economic factors associated with inadequate HL is also a answer categories of the 16 items; both categories ‘very easy’
core purpose of the study. and ‘fairly easy’ got the value of ‘one’, while categories ‘fairly
difficult’ and ‘very difficult’ got ‘zero’. A sum score was
calculated only for valid questionnaires, i.e. having 14 or
Methods more valid answers; therefore, questionnaires with more
than two unanswered questions were treated as ‘missing’.20
Study design and setting The respondent could score between 0 and 16 points, in
which zero represented the lowest possible HL and 16 rep-
An observational cross-sectional study was carried out from resented the highest possible one.
April 2015 to March 2016 using a convenience sample. The Then, participants' scores were categorized into ‘suffi-
study took place at the outpatient clinics of DUH located in cient’, ‘problematic’, and ‘inadequate’ HL. Scores equal to or
Cairo. It is a locally and regionally renowned tertiary health more than 13 denoted sufficient HL, scores from nine to 12
facility with a high flow of patients throughout the year. In denoted problematic HL, and scores less than or equal to eight
2013, the number of visits made to the outpatient clinics of denoted inadequate HL.20
DUH was about 261,894.19 Ethical approval was sought from
the Ethical Committee of Research in ASU. Approvals from The Swedish functional health literacy scale (S-FHL scale)
both the Head of Administration of ASU Hospitals and the
Head of Outpatient Clinics were obtained. The Arabic version of the S-FHL scale was used. It consists of
five items that assess FHL, i.e. the ability to read health-related
Study participants and data collection information to maintain and improve health (Supplementary
file 2). The scale is short, easy to analyze and has a validated
The study population comprised 805 attendees of the outpa- translated Arabic version which made it convenient for our
tient clinics of DUH. Participants must be able to speak and study setting.
comprehend Arabic. Attendees younger than 15 years of age Being aware of the poor quality of the Egyptian primary ed-
were excluded for being highly unlikely to make health- ucation17 and that primary school graduates are not necessarily
related decisions on their own. Interview questionnaires capable of reading, we performed a preliminary exploration
were used with all participants who have verbally consented prior to data collection. The aim was to estimate the level at
to participate. Interviews were performed by eight medical which attendees have sufficient reading skills. Thus, of the HLS-
students of ASU in which a single interviewer approached an EU-Q16 participants, only the ones with educational level of
attendee at a time. Data from each attendee were collected in preparatory school or higher, the level at which attendees
a single interview. It was stated that participation is voluntary observed to demonstrate reading capability, were offered to
and that participants can withdraw from the interview at any complete the S-FHL scale. This condition was specifically applied
time with no subsequent consequences. All data were to ensure that participants were capable of reading because FHL
collected anonymously. In order to minimize interviewer bias, is concerned with reading health-related information.
p u b l i c h e a l t h 1 5 1 ( 2 0 1 7 ) 1 3 7 e1 4 5 139
Fig. 1 e Prevalence of different levels of comprehensive health literacy. Std.Dev., standard deviation.
Analysis of missing values know’ for more than two questions (see Methods section). To
determine the factors that were associated with being
HLS-EU-Q16 excluded from the analysis, we created a logistic regression
According to the previously mentioned criteria, 165 ques- model with the included vs excluded cases as dependent
tionnaires were excluded from the analysis out of which 147 variables. We found that being in the lower education groups
cases were excluded because they gave the response of ‘do not is a risk factor for being excluded (Supplementary file 4). To
Table 2 e CHL categories by gender, age group, marital status, and highest level of education.a
Number of subjects ¼ 640 CHL categories
Inadequate 220 Problematic 299 Sufficient 121
n (%) n (%) n (%)
Gender P ¼ 0.981 Male 140 (34.7) 188 (46.5) 76 (18.8)
Female 79 (33.9) 110 (47.2) 44 (18.9)
Age (years) P ¼ 0.045 15e19 18 (42.9) 20 (47.6) 4 (9.5)
20e39 134 (38.2) 147 (41.9) 70 (19.9)
40e59 54 (27.7) 101 (51.8) 40 (20.5)
60e85 13 (28.3) 27 (58.7) 6 (13.0)
Marital status P ¼ 0.022 Married 140 (31.2) 224 (49.9) 85 (18.9)
Non-married 79 (42) 74 (39.4) 35 (18.6)
Nature of visit P ¼ 0.007 Patient 126 (39.6) 142 (44.7) 50 (15.7)
Companion 91 (28.7) 155 (48.9) 71 (22.4)
Highest level of education P < 0.001 No education 45 (40.5) 51 (45.9) 15 (13.5)
Preprimary or primary education 44 (41.1) 50 (46.7) 13 (12.1)
Preparatory school 38 (40.4) 40 (42.6) 16 (17)
High school or associate degree 71 (31) 117 (51.1) 41 (17.9)
Collegeþ 19 (20.2) 40 (42.6) 35 (37.2)
Table 3 e FHL categories by gender, age group, marital status, and highest level of education.a
Number of subjects ¼ 422 FHL categories
Inadequate 213 Problematic 141 Sufficient 68
n (%) n (%) n (%)
Gender P < 0.001 Male 109 (41.1) 104 (39.2) 52 (19.6)
Female 104 (66.2) 37 (23.6) 16 (10.2)
Age (years) P ¼ 0.088 15e19 23 (62.2) 11 (29.7) 3 (8.1)
20e39 122 (45.5) 95 (35.4) 51 (19)
40e59 62 (60.2) 29 (28.2) 12 (11.7)
60e85 4 (40) 5 (50) 1 (10)
Marital status P ¼ 0.88 Married 144 (50.7) 96 (33.8) 44 (15.5)
Non-married 69 (50) 45 (32.6) 24 (17.4)
Nature of visit P ¼ 0.46 Patient 98 (49) 65 (32.5) 37 (18.5)
Companion 114 (51.6) 76 (34.4) 31 (14)
Highest level of education P ¼ 0.009 Preparatory school 57 (60.6) 26 (27.7) 11 (11.7)
High school or associate degree 121 (51.5) 81 (34.5) 33 (14)
Collegeþ 35 (37.6) 34 (36.6) 24 (25.8)
Table 5 e Odds ratios (ORs) of having inadequate CHL in the study population.a
Variables Model 1 Model 2
P-value OR (95% CI) P-value OR (95% CI)
Gender Male 0.38 1.18 (0.82e1.69) 0.03 1.85 (1.08e3.16)
Female 1 1
Age (years) 15e19 0.22 1.86 (0.69e5.03) 0.69 0.71 (0.13e3.94)
20e39 0.03 2.28 (1.11e4.7) 0.93 1.07 (0.24e4.8)
40e59 0.67 1.17 (0.46e1.08) 0.26 0.4 (0.08e1.94)
60e85 1 1
Marital status Married 0.1 0.7 (0.46e1.08) 0.28 0.73 (0.4e1.29)
Non-married 1 1
Nature of visit Patient 0.03 1.49 (1.05e2.11) 0.06 1.61 (0.99e2.62)
Companion 1
Highest level of education No education <0.001 3.93 (2e7.7)
Primary or preprimary <0.001 3.74 (1.92e7.32)
Preparatory school 0.003 2.86 (1.42e5.76) 0.001 3.77 (1.71e8.31)
High school or associate degree 0.04 1.89 (1.04e3.4) 0.04 2 (1.04e3.74)
College þ 1 1
FHL Not inadequate (problematic þ sufficient) <0.001 0.37 (0.22e0.62)
Inadequate 1
Model 1: the first postulated binary logistic regression model in which all of the socioeconomic factors’ association with inadequate CHL was
assessed.
Model 2: the second binary logistic regression model in which FHL level was considered as an independent variable in addition to the other
variables included in model 1.
CI, confidence interval; CHL, comprehensive health literacy; FHL, functional health literacy.
a
Missing data not included.
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Table 6 e Odds ratios (ORs) of having inadequate FHL in the study population.a
Variables P-value OR (95% CI)
Gender Male <0.001 0.36 (0.23e0.55)
Female 1
Age (years) 15e19 0.61 1.51 (0.32e7.18)
20e39 0.84 1.15 (0.3e4.42)
40e59 0.23 2.35 (0.59e9.38)
60e85 1
Marital status Married 0.53 0.85 (0.51e1.41)
Non-married 1
Nature of visit Patient 0.29 0.8 (0.53e1.21)
Companion 1
Highest level of education Preparatory school 0.08 1.79 (0.93e3.45)
High school or associate degree 0.11 1.52 (0.91e2.53)
Collegeþ 1
assess whether the results of excluded cases could have remaining answered one to four questions only. The primary
altered our main results, we postulated two regression reason explaining a questionnaire with no responses is that
models. In the first, missing values were considered as ‘diffi- the interviews were held in the outpatient clinics while in-
cult’, while in the second, missing values were considered as terviewees waited for their turn with physicians, and some-
‘easy’. In the second model, in which the results were delib- times an interviewee's turn would be due before the
erately pushed towards the ‘not inadequate HL’ outcome, conclusion of an interview.
males demonstrated potential to move to a higher level of HL.
Meanwhile, attendees' level of education remained to be of a
significant association with HL (Supplementary file 5). Discussion
S-FHL The aim of our study was to provide an initial assessment of the
Questionnaires with less than five answered questions were current HL status among attendees of outpatient clinics in ASU
excluded. These were 65 questionnaires, among which 40 Hospitals, as well as to determine factors associated with
participants did not respond to any of the questions, while the inadequate HL. The results showed that the majority of our
study population had both limited (i.e. inadequate and prob- outpatient clinics attendees. Another limitation is that 432
lematic) FHL and CHL. Gender was the only significant factor participants refused to provide any information regarding
affecting the level of FHL, whereas CHL was impacted, in addi- their monthly income and others displayed a wide range of
tion to gender, by education. We also found that limited FHL was inaccuracy regarding their income which prohibited us from
associated with limited CHL; nonetheless, many participants assessing the impact of economic level on HL.
held limited FHL and simultaneously, sufficient CHL. Moreover, Notwithstanding these limitations, our study is one of the
questions pertaining to prevention of mental health problems first to be conducted in Egypt on the topic of HL. It was con-
and promotion of mental well-being demonstrated the highest ducted in a locally and regionally renowned health facility
frequency of perceived difficulty among participants. that covers a wide variety of the population. A relatively large
The European health literacy survey is employed to assess sample was obtained to overcome the shortcomings of con-
CHL in eight European countries in which the prevalence of venience sampling. Furthermore, face-to-face interviews
inadequate CHL was 12.4%23 compared to 34.3% among our were used instead of self-administration to ensure the com-
study population. The former investigates a wider scope of plete understanding of the questions. This facilitated the in-
potential explanatory factors such as poor health status and clusion of uneducated people and subsequently, realistically
socio-economic level. While education is the most important reflected the current situation. Also, in order to minimize
predictor of CHL in our study, it ranks third after economic interviewer bias, explanatory phrases for each question were
deprivation and social status in the European countries.23 agreed upon among all interviewers to meet different cultural
Gender seems to play a minimal role in predicting CHL backgrounds for different participants.
levels of European countries,23 while it significantly affects
CHL level of our study population when adjusted for other Implications
factors, including FHL level in model 2 as mentioned before.
Although females have substantially lower FHL, their CHL is Problem identification is the first step to its reduction.
significantly better than their male counterparts when Therefore, this study could serve as an initial step for estab-
adjusting for other variables (i.e. age, highest level of educa- lishing a national HL surveying system. From a practical point
tion, marital status, and level of FHL). This surprisingly, of view, these results are sufficient to start applying in-
somewhat paradoxical impact of gender could be attributed to: terventions to improve HL such as: plain language initiatives
that aim at raising the level of HL through making health
1 Poorer quality of education that females receive compared materials more comprehensible and accessible to the lay
to males at the same educational level expressed by: public24 and training healthcare providers on how to
explicit undermining of the importance of education to deliver health-related information to people suffering inad-
girls, social phenomena discouraging girls' education, equate HL.
higher rates of absenteeism, and lower financial invest- Inadequate HL may be the root of most cases of non-
ment in girls' education. compliance. An individual with inadequate HL may not
adhere to instructions due to not comprehending them rather
This attitude is rooted within Egyptians of lower socio- than not wanting to adhere to them. Repeating instructions,
economic classes which represent most of DUH attendees, simplifying instructions, and forming engaging groups to
including DUH outpatient clinics. This explanation is sug- encourage discussion and feedback processes may all help in
gested by experts' opinions on gender-based discrimination in decreasing non-compliance.25
developing countries. Aside from non-compliance to therapy, inadequate HL
may also be the root of the lack of utilization of recommended
2 Better CHL among females may be traced to frequent screenings. In turn, this would lead to higher rates of relatively
exposure of females to healthcare services, as they are, in late hospital admissions. Combining multiple strategies with
most cases, the caregivers of family members. More the aim of improving HL, i.e. educational interventions
exposure and therefore more experience contributed to addressing specific health topics like cancer screening,
females being more familiar with medical information and intensive self-management, and adherence interventions,
presenting fewer perceived difficulties in matters related to can help in reducing emergency department visits and hos-
disease prevention and health promotion. This explana- pitalizations while increasing the utilization of cancer
tion is conjectural and has no supporting published data. screening services.26
This study was conducted in the outpatient clinics of a
Furthermore, the prevalence of inadequate CHL among major tertiary health facility in Cairo that serves a huge vari-
patients is higher than that of their companions, presumably ety of people, many of whom are economically deprived and
because they generally exhibit higher levels of education uneducated. With taking the aforementioned fact into
(Fig. 2). Notably, there is a remarkable discrepancy between consideration, these results could be used to extrapolate the
the prevalence of inadequate CHL and the prevalence of level of HL in similar strata of the Egyptian society. Further
inadequate FHL (34.3% and 50.6%, respectively). research using random sampling is warranted in order to
corroborate these results in ASU Hospitals. Also, our findings
Strengths and limitations should prompt public health scholars in Egypt to study the
issue on a national level in addition to investigating other
A convenience sample was used instead of random sampling potential factors such as, economic deprivation, residence,
due to the lack of an established registration system of and the presence of a chronic illness.
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