Lee et al. BMC Public Health 2010, 10:614 http://www.biomedcentral.com/1471-2458/10/614 Health literacy and socio-demographic factors The mean MHLS score of the sample was 39.2. The health literacy level of 69.7% respondents was consid- ered to be adequate, 16.6% marginal, and 13.7% inade- quate. The c2 analysis indicated significant variation in health literacy by age, educational attainment, household income, and residential location. In general, the level of health literacy was lower among adults with older age, fewer years of formal schooling, lower household income, and living in less populated areas. Although males appeared to have a higher average MHLS score than females, the difference was not statistically signifi- cant (Table 1). Health literacy, health status and health service utilization The majority of respondents perceived their physical and mental health to be average or better. Around 64% of respondents reported at least one outpatient visit in the past 3 months, 13.3% had visited an ER, and 6.9% had been hospitalized in the previous year (Table 2). The c2 tests showed that health literacy level was posi- tively associated with self-rated physical and mental health status and negatively associated with outpatient visits and hospitalization. No significant association was found between health literacy level and ER utilization (Table 2). Page 4 of 8 Excluding 313 observations with missing information on household income, multinomial logit models were performed on 1,180 observations to further examine the associations of health literacy level with self-rated health status (physical and mental health) and health care utili- zation (outpatient clinic visit, ER visit, and hospitaliza- tion). Two dummy variables (marginal health literacy and inadequate health literacy) were included in the models to represent health literacy level. As results in Table 3 show, health literacy level, in general, was not significantly associated with self-rated health status or health care utilization. There was one exception: com- pared to those with adequate health literacy, Taiwanese adults with inadequate health literacy had poorer self- rated mental health (odds ratio = 0.62; 95% confidence interval = 0.39-0.99). Several covariates were significantly associated with self-rated health status and health care utilization. Older adults were more likely to report better mental health and were less likely to visit an outpatient clinic. Males, compared to females, were more likely to report better physical health and less use of outpatient clinics. Adults with higher educational attainment were more likely to be hospitalized in the previous year. Compared to adults in the lowest household income category, those in the highest household income level were more likely to Table 2 Health Status, Health Care Utilization, and Health Literacy in a National Sample of Adults in Taiwan, 2008 N % Inadequate HL Marginal HL Adequate HL X2-test p-value Self-Reported Physical Health Very poor Poor Average Good Excellent Self-Reported Mental Health Very poor Poor Average Good Excellent Outpatient Clinic Visit Yes No Emergency Room Visit Yes No Hospitalization Yes No 25 175 756 343 194 15 176 593 452 257 957 536 198 1295 103 1390 1.7 11.7 50.6 23.0 13.0 1.0 11.8 39.7 30.3 17.2 64.1 35.9 13.3 86.7 6.9 93.1 a Yates’ correction was used to adjust for small observations in some of the cells. N 7 42 99 39 18 4 40 78 63 20 152 53 34 171 25 180 % 3.4 20.5 48.3 19.0 8.8 2.0 19.5 38.0 30.7 9.8 74.2 25.8 16.6 83.4 12.2 87.8 N 6 28 125 54 34 3 26 100 75 43 157 90 34 213 13 234 % 2.4 11.3 50.6 21.9 13.8 1.2 10.5 40.5 30.4 17.4 63.6 36.4 13.8 86.2 5.3 94.7 N 12 105 532 250 142 8 110 415 314 194 648 393 130 911 65 976 % 1.2 11.1 51.1 24.0 13.6 0.8 10.6 39.9 30.2 18.6 62.2 37.8 12.5 87.5 6.2 93.8 <0.001a <0.01a <0.01 0.277 <0.01