Abstract
In this westernized culture, maintaining a healthy lifestyle has become a major health concern internationally. Health literacy is an emerging concept and requires effective measures and reform to improve the health status and health of individuals at both national and international levels, and has become one of the important determinants of individual health and healthcare service. This study aimed to assess health literacy among adults in Saudi Arabia. A cross-sectional study was conducted among a randomly selected population using a structured validated questionnaire over 4 months in 2021. The questionnaires designed for the study included 26 items divided into 5 domains assessed on a five-point Likert scale. Data were analyzed using IBM SPSS Statistics 26 (IBM Inc., Chicago, IL, USA) and IBM SPSS 26 (IBM Inc.). The mean score for reading, access to information, understanding, appraisal, and decision-making was 12.01 ± 4.37, 20.16 ± 7.17, 24.84 ± 8.37, 11.85 ± 4.90, and 36.94 ± 10.41 respectively. The mean scores of reading and understanding domains were found to have significant differences concerning gender (P < .05). Additionally, participants’ age was significantly associated with the mean score of reading and decision-making (P < .006 and P < .049). The findings reported a prevalence of inadequate HL in the population of Saudi Arabia was 54.4%, and the determinants associated with the scores of HL were age, gender, and education.
• Health literacy is an emerging concept and requires effective measures and reform to improve the health status and health of individuals.
• Health literacy can assist healthcare professionals in better understanding information about their patient’s health status and disease management
• The findings reported varying levels of Health literacy among Saudi adults. Furthermore, Health literacy was significantly associated with the demographics of individuals. The findings of this study could be used as references to apply strategies to improve health literacy. for the management individual’s health.
Introduction
In this westernized culture, maintaining a healthy lifestyle has become a major health concern internationally.1,2 There was evidence that social, economic, and behavioral factors were the potential in bringing a healthy life. 3 The World Health Organization 3 defines health literacy (HL) as the cognitive and social skills that determine an individual’s motivation and ability to gain access to, understand, and use information in ways that promote and maintain good health. It is evidenced that HL is an emerging concept and requires effective measures and reform to improve the health status and health of individuals at both national and international levels, and has become one of the important determinants of individual health and healthcare service. 4
Health Literacy can be assessed using 4 literacy performance levels: below basic, basic, intermediate, and proficient. 5 Only 12% of adults in the United States are proficient in HL, in Canada, 60% of adults are proficient in HL. 5 According to a recent study in Saudi Arabia, 46% (n = 3557) of the Saudi population estimated with lower rates of HL. 6 According to earlier literature, poor HL leads to poor health outcomes, and this low HL can have a causal role in a high mortality rate. 7 However, patients with low HL are more likely to visit ER and they are more likely to have hospital stays, and are less likely to follow treatment plans. 8 Additionally, literature suggested that Low HL could act as a barrier to effective self-disease management, in the case of chronic diseases such as asthma and heart failure, which require complicated self-care regimes.9,10 According to a national survey of literacy people with limited HL are also more likely to skip required health screening tests and underused preventative health care. 11 However, people with low HL are more likely to have a lower financial status. 12 An earlier study found that adults living below the poverty level have higher rates of low HL, additionally, literature evidenced that disability is also a risk factor for low HL. 12 According to previous reports, individuals irrespective of their educational status also face HL issues such as not being familiar with medical terms and their mechanism, being diagnosed with a serious illness, and being scared and confused. 12 Therefore, health education should empower, raise awareness of HL, and provide more information to address and understand the diagnoses, navigate and use health information and manage their treatments. Middle Eastern countries with high income and education levels, such as Saudi Arabia, face many challenges related to people’s quality of life and health. Furthermore, raising the risk of various diseases, and demanding individuals to pose adequate knowledge and awareness of diseases is warranted.13-20 The earlier literature shows a low level of HL in Saudi society.6,21 As a result, increasing HL can assist healthcare professionals in better understanding information about their patient’s health status and disease management. However, the Saudi government has taken various measures under the Vision 2030 scenario, including the adoption of healthcare education, various national and international collaborations in education and healthcare, the use of technology, and mobile health.6,21 Which may help in the expansion and improvement of the healthcare system in the Kingdom of Saudi Arabia. Among the Saudi population, HL is an important issue for the Saudi healthcare system of a culturally diverse workforce for many international healthcare professionals. 21 As of now, there are limited studies published to measure HL among Saudi adults. Therefore, this study aimed to assess the HL among Saudi adults in Saudi Arabia.
Materials and Methods
A cross-sectional, web-based, non-interventional study was conducted among the Saudi public over 4 months from April 2021 to July 2021, using Google Forms® to collect data on the level of HL by the public in Saudi Arabia. The data collection was carried out using social media platforms. The convenience sampling technique was used to collect the data with no predetermined sample size. The study included Saudi adults aged 18 years or more, able to read and understand the English and Arabic languages, and those who are currently living in the kingdom were included. Illiterate participants rejected to provide informed consent, and Saudis living in other countries were excluded from the study. The present investigation was carried out according to the guidelines of the Checklist for Reporting Results of Internet E-Surveys also study followed the guidelines of the Declaration of Helsinki. 22 Before participating in the questionnaire, participants were provided an electronic consent form with a short introductory paragraph that stated the objective of the research and its importance.
The questionnaires designed for the study included 2 sections.23,24 First, a section focusing on demographic information such as gender, age, educational level, nationality, income, and marital status. The second part was intended to assess the HL and was subdivided into 5-domains. The first domain of HL collected data on the knowledge about reading with a total of the 4-items questionnaire. The second asked about the access to information questionnaire (6 items). The third talked about the understating of HL with a total of 7 items. The fourth domain is appraisal questionnaires (4 items). The last domain of the HL questionnaire consisted of decision-making/behavioral intention questionnaires (12 items). All the 5 domains of HL questionnaires were assessed on a 5-point Likert scale (always/usually). The mean overall HL score were prepared by computing all the domain variables. Furthermore, HL score was divided in to the good HL, and Poor HL, similar to previous study.23,24
A pilot study was conducted among randomly selected 10 participants, to check the accuracy and content of the questionnaires. After which necessary revisions were made by experts, the final study questionnaire was sent for data collection. The results of the pilot study were not included in the main study. Cronbach’s alpha was used to calculate the stability of the scale it was found to be .74 for the HL questionnaire. Before data collection, informed consent was obtained and the importance of the study was explained to the participants were given confidentiality about the information provided, also the participants were assured that the data provided was used for the research purpose only and participants have the right to withdraw from the study at any time during the study period.
Statistical Analysis
The Statistical Package for the Social Sciences version 22.0 (SPSS Inc., Chicago, IL, USA) was used for statistical analysis. Descriptive statics such as numbers and percentages and mean values were presented. The association between demographics and HELIA domains was measured using nonparametric tests. The association between the mean scores and demographics with 2 groups was assessed using Mann–Whitney U test, while demographics with more than 2 groups were assessed by Kruskal–Wallis tests. A P value of less than <.05 was considered statistically significant.
Results
A total of 568 individuals participated in this research. Among those 8 (n = 8) responses were excluded due to incompleteness. Therefore, a total of 560 questionnaires were included in the analysis, giving a response rate of 98.5%. Among the participants 302 (53.9%) of them female, 258 (46.1%) of them were male and 96.6% belonged to Saudi nationals, and 52.1% the individuals in the age range of 18 to 30 years. Regarding socioeconomic status (SES), one-third of the 172 (30.7%) participants were students, slightly less than one-third (25.4%) were working in the government sector, While the majority (69.6%) of them had a university education. In terms of financial status, nearly half of the participants (49.3%) earn less than 5000 Saudi riyals per month. The majority of the participants (54.6%) were married, and 76.3% lived in Saudi Arabia’s western region. Detailed demographic characteristics are presented in Table 1.
Distribution of the Sample According to Their Demographic and Socioeconomic Factors. (n = 560).
To evaluate the HL among adults in Saudi Arabia. The respondents are asked 6 questions regarding reading about the HL. About 236 (42.1%) of the participants reported that they sometimes read educational materials about health for easiness, 184 (32.9%) always, and 95 (17.0%) usually of them reported that they easily understood such information. Of the 560 survey respondents, 227 (40.5%) said it was easy to read written information about the illness from doctors, dentists, and health workers. While 234 (41.8%) of participants said it was sometimes easy for them to read medical forms in hospitals, 166 (29.6%) said it was always easy, and 75 (13.4%) said it was usually easy. Additionally, when surveyed participants were asked about the reading leaflets and instructions for laboratory testing, ultrasound, or radiology 200 (35.7%) responded it is simple, sometimes while 139 (24.8%) responded always felt simple to read this statement.
Regarding access to information, slightly less than half of the participants (47.9%) found health information from different sources when needed. About 40.5% found health information about healthy eating, regarding finding information related to a mental health issue such as depression and stress 33.0% found such information. However, half of the participants (50.9%) found information for some health problems and diseases such as high blood pressure, high blood sugar, and high lipid levels. Furthermore, (58.6%) found health information about the harmful effects of tobacco and smoking. The frequencies of the participants in detail are presented in Table 2.
Participant Responses Toward Reading, Access to Information, and Understanding.
Almost 62.9% of the respondents understand illness by the physician, while 52% of the participants understand the recommendations for a healthy diet. On the other hand, 51.3% of them agreed that by reading medical forms they always understand the meaning. Approximately two third (62.7%) understand signage guidelines in hospitals, clinics, and health centers. When asked about understanding the risks and benefits of drugs prescribed by a physician (53.8%) of the respondents understand this.
Based on the findings, one-third of the respondents evaluate health-related information on the Internet, while (32.3%) evaluate health-related information broadcast on television and radio. one hundred and eight seven of the respondents assess the accuracy of health-related recommendations receive from relatives and friends and communicate trusted health information to others (Table 3). The study results revealed that 45.6% (255) Saudi adults were found to have adequate HL while 54.4% (304) found inadequate HL (Figure 1). The mean overall HL score was 105.82 ± 27.59 (range 0-131).
Levels of health literacy.
Participant Responses Toward Appraisal and Decision-Making.
The mean score (S.D) for reading, access to information, understanding, appraisal, and decision-making was 12.01 (4.37), 20.16 (7.17), 24.84 (8.37), 11.85 (4.90), 36.94 (10.41) respectively. The reading, access to information, understanding, appraisal, and decision-making domain scores did not significantly differ according to marital status, nationality, residential area, and education (P > .05). Furthermore, decision-making alone was found to have significant differences (P < .044) concerning participants’ residential area and age compared with the remaining subscales. The reading and understanding scores were found to have significant differences concerning gender (P < .05). However, participants’ age was significantly associated with reading and decision-making (P < .006 and P < .049). Detailed information is presented in Table 4.
Association Between Demographics and 5 Domains of HL.
Discussion
Health literacy is an important health concept, lack of HL contributes to multiple health problems which are associated with poor health outcomes.25,26 Patients and individuals with limited HL were more likely to skip important preventive measures and use of health services11,27 which results in poor health-related quality of life and health outcomes. However, in this study, the mean HL score was 105.82 ± 27.59 (range 0-131), this indicated an acceptable range of HL among Saudi adults in Saudi Arabia. The mean score of reading, access to information, understanding, and appraisal decision-making was 12.01 ± 4.37, 20.16 ± 7.17, 24.84 ± 8.37, 11.85 ± 4.90, and 36.94 ± 10.41 respectively. While the previous study in Saudi Arabia reported, the Saudi population had a poor knowledge of HL and most of the studied population found intermediate and basic HL levels. 21 Similarly, another recent study revealed limited levels of HL among the Saudi population the most cited factors were identified as poor awareness and beliefs about the specific disease. 28
In this study, 32.9% of the participants reported always-reading educational materials about health, and slightly less than half of the participants always read information written by the physician about their illness. These findings were similar to earlier findings by Namdar et al, 24 but lower than earlier study Abdel-Latif and Saad 21 in Saudi Arabia. According to earlier findings health information for blood pressure, blood sugar level, obesity, and nutrition 47.6% found it easily, while 52.4% of the participants felt difficulty in knowing the information. 21 Additionally, previous findings reported a lack of knowledge in understating health screening tests, while more than one-third of the participants from earlier findings reported a lack of knowledge in understanding diseases and their management. 21 However, in the current study more than half of the participants reported always understanding the explanation from the physician about the disease and recommendation of a healthy diet, drug information on labels, and risk and benefits of the drug prescribed by a physician. This is comparable to a previous population-based study from Iran, 24 where the author reported that 55.1% of the participants were able to understand the health-related information given by their physicians. 24 Although understating the health information is essentially important for achieving better health outcomes and to main a quality of life similar to healthy individuals.
The findings revealed that 54.4% of the participants found inadequate HL. These findings were higher than earlier study in Iran which reported 48.7% of the Iranians had limited HL, 24 a similar study published by Abdel-Latif and Saad 21 reported 40.6% of the participants found to have basic and below basic HL, while 15.6% reported proficient HL. Similarly, another recent study found a prevalence of 46% of low HL in Saudi Arabia. 6 However, our results findings were better than earlier studies conducted in the western region of Saudi Arabia. 21 In this current study, 45.6% of the participants reported adequate HL. The difference in the levels of HL in the current study and previous studies might be due to the use of different criteria to calculate the HL scores or the use of different study tools and the effect of the study population and their culture.
Many previous studies demonstrated the knowledge of HL potentially reflected by age, gender, educational levels language, ethnicity, and dietary habits.25,29,30 In this study participants’ age, gender, and employment status were significantly associated with reading and understanding the decision-making domain of HL, while employment status is associated with understating and access to information. Females scored higher for the reading domain of the HL in comparison to male participants. In addition, participants aged between 31 and 40 years scored higher for the reading domain in comparison to other age categories, while the decision-making score was higher among older individuals (61 and above). The findings of the current study were similar to an earlier study by Abdel-Latif and Saad, 21 who reported gender, age, and educational levels, were potential determinants of HL. similarly, another recent study by Almubark et al 6 reported that older ages, lower income, and education, and having been formerly married were factors associated with low HL. Despite the current findings, previous reports also suggested that the most common justification for the lower levels of HL among individuals were increased age, ethnicity, ethnic minorities, low educational level, and people with low-income levels. 31
It was evidenced that individuals with a lack of HL knowledge might face trouble in understanding everything they read and may not know how to apply medical information in their daily lives to achieve better health outcomes. As a result, patients with low HL frequently lack knowledge or have incorrect information about their illness and disease treatment. Therefore, they may fail to understand the management of chronic diseases, which may influence the lifestyle and health outcomes of every individual. Although a lack of HL is a serious problem among the general public and patients, future research should focus on more specific issues that can help healthcare professionals improve it by addressing the various underlying causes. Furthermore, healthcare professionals and organizations must develop a good health system by providing easy-to-read and understandable health information to patients and other individuals through various educational and awareness programs at the national and international levels.
The current study has some limitations. First, the results were based on a self-completed online questionnaire, which may have increased the possibility of biases such as social desirability bias or recall bias. Second, the results were derived from a single country Saudi Arabia, making them not representative of others and not generalizable globally. Thirdly this study assessed general HL because it does not focus on food or nutrition literacy. In addition to that, each domain shows a different association with the factors, and the total score of HL was not tested to be associated with the variables. Therefore, we recommend further investigations focusing on a larger sample size with the use of specific literacy scales involving both general and food or nutrition literacy instruments.
Conclusion
In conclusion, the current findings revealed a 54.4% prevalence of inadequate HL in the studied population, and the determinants associated with the scores of HL were age and gender. Employment status was significantly associated with access to information and understanding the domain of HL. Future studies with a larger population should be conducted to find out the exact factors and efforts need to improve the low HL among individuals across Saudi Arabia is needed.
Footnotes
Acknowledgements
The authors extend their appreciation to the final year students of Taibah university for assisting in data collection.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethical Approval
Ethical approval was obtained from the college of Pharmacy, Taibah University (COPTU-REC-20-20210526), Madinah, Saudi Arabia
