Determinants of inadequate health literacy among Faculty of Technical Medical Sciences students in Albania
Abstract

Background: Health literacy of nursing students is important so that tomorrow’s nursing professional deliver high quality healthcare and enhance patient education and communication.
Objective: The aim of this study was to assess the HL level of nursing students in order to shed light on this under-researched topic in Albanian settings.
Methods: A cross-sectional study involving 193 nursing students of various study branches was carried out during 22-29 June 2022, in the premises of the Nursing Faculty, in Tirana, Albania. The international HL-EU-Q standardized questionnaire, validated in Albanian language, was used t (Preprint)
Authors: Rustami Etleva 
Published: February 2023

BACKGROUND

Introduction
Health literacy (HL) refers to the people’s ability to find, understand and use health information in order to make appropriate health decisions [1], in an increasingly complex health care system [2]. Despite the many types and definitions of health literacy (for example, one recent systematic review identified more than 250 different health literacy definitions) [3], virtually all experts and studies agree that poor HL is a risk factor for sub-optimal health; on the other hand, health literacy is largely considered a modifiable risk factor thus opening new perspectives to address illness and disease (3).
Many determinants of HL have been identified, including demographic (age, gender, education level, socio-economic status, etc.), as well as other psychosocial and cultural factors (4). The level of individual HL at a specific time and place is determined by many factors; indeed, scientific evidence shows that there is a strong link between literacy, education, health literacy and health status (5). In this context, health literacy might be the result of a life-long process, being built incrementally as one ages, learns (formally and informally) and interacts with the environment and other people. On the other hand, the consequences of poor health literacy are very diverse, at the individual and community level, and range from higher mortality and morbidity rates, higher engagement in risky health behaviors, lower health care service utilization at all levels and lower participation in screening programs (4). Health literacy is everybody’s business because we all, at some point in our lives, will need to find, understand and use health information and services (6).
It is obvious that HL is important for every individual and, consequently, groups of society. This is even more critical for health professionals and especially for the young generation of students that will become the health professionals of tomorrow. This is because in order to be able to educate patients and inform them about health risk factors, health behaviors and their related benefits, first young professionals need to be health literate themselves (7). Balmer and colleagues argue that “the health literacy responsiveness of health organizations interacts with the health literacy of patients and their health outcomes”; in this context, a health organization first needs to have a health literate workforce in order to create health services that support the development of HL among service users (patients) [8]. As a consequence, it is important for academic institutions that train future health professionals to be aware of the health literacy level of their students, since the later will be an additional factor for building, supporting and developing the health literacy of the population as well [8].
In this context, we carried out a health literacy survey among undergraduate students of the Faculty of Nursing in Albania aiming to determine the actual HL literacy level among nursing students and the associated factors.

OBJECTIVE

Objective: The aim of this study was to assess the HL level of nursing students in order to shed light on this under-researched topic in Albanian settings.

METHODS

Methods

Study population
A cross-sectional survey was carried out among students of the Faculty of Medical Technical Sciences (Faculty of Nursing) in Tirana, Albania, during 22-29 June, 2022. The Faculty of Nursing is part of the University of Medicine, a publicly funded academic institution preparing the next generations of health professionals in Albania.
The nursing students were recruited during the exams’ season. More specifically, all nursing students of all branches (nursing, midwifery, physiotherapy, and laboratory technician), of the first and second year of study, giving the exam on various subjects, were invited to participate in this study once they had finished their exam.
Out of 247 students giving their exams on selected days and invited to participate, 53 students declined to do so because they didn’t have time. We didn’t collect any basic socio-demographic information about the non-participating students. Ultimately, 193 students participated in the survey yielding a response rate of 78.1% (193/247).

Data collection
The international full version of the HLS-EU-Q instrument (9) validated in the Albanian language (10) was used to assess the health literacy level of the participants. In line with the recommendations, the HLS-EU-Q instrument was administered face-to-face, using paper and pencil.
Apart from HL questions, the questionnaire included the section of basic socio-demographic information requiring the respondents to report their age, gender, branch of study, employment status, marital status, social status and economic status.
Before the interview, each participating student was explained in detail the purpose of the survey; subsequently, they were invited to read and sign an informed consent form. All participating students signed this form.
This study was approved by the Committee of Bio-Medical Ethics of the Faculty of Medicine.

Statistical analysis
The HLS-EU-Q instrument contains a total of 47 items, each one rated on a Liker scale with 4 levels (very easy, fairly easy, fairly difficult, and very difficult) [9]. The HL items’ coding was reversed in order for higher scores to indicate better health literacy; a general health literacy index was calculated, summing up all 47 items, and standardized on a scale ranging from 0 to 50, in line with instrument developers’ recommendation (9).
General health literacy was categorized into the following categories: inadequate health literacy (score 0-25), problematic health literacy (>25-33), sufficient health literacy (>33-42) and excellent health literacy (>42-50) [9].
The chi-square test was used to assess the distribution of HL levels by basic socio-demographic and health behavior variables.
For our purposes, inadequate and problematic health literacy was collapsed into one single category denoting limited HL, versus sufficient and excellent HL that denotes appropriate HL. This newly created variable was used in binary logistic regression models to assess the association of limited HL with independent socio-demographic variables. Two models of binary logistic regression were employed: first, crude (unadjusted) odds ratios (ORs) were reported (Model 1 in binary regression analysis); subsequently, we controlled for the potential confounding effects of gender, age, branch of study, social and economic status of the students (Model 2 in binary regression analysis).
All associations with a p-value <0.05 were regarded as statistically significant. The analysis was carried out using the Statistical Package for Social Sciences (SPSS) software, version 15.

RESULTS

Results
The average HL score was 37.2, ranging from 16.7 to 50.0. Less than one in twenty students had inadequate HL, about one in five students had problematic HL, more than half (51.3%) had sufficient HL and about one in four students had excellent HL (Table 1).

Table1. Distribution of general health literacy score among study participants

Variable	Value
General health literacy score
Mean
Standard deviation
Median
Interquartile Range
Minimum
Maximum
37.20
6.69
37.59
33.33 – 41.84
16.70
50.0
General health literacy level [n (%)]*
Inadequate
Problematic
Sufficient
Excellent
9 (4.7)
38 (19.7)
99 (51.3)
47 (24.4)
*Discrepancies in the totals are due to the missing values.

The overwhelming majority of participants were female (93.8%), more than half were in the first year of study (20 years old), and more than 90% were studying in the nursing branch (nursing and midwifery). More than four in five students were not working (only studying) at the time of the survey, about 98% were single, about 90% had middle social class and about half had average economic status (Table 2). The prevalence of inadequate and problematic HL was significantly higher among boys and students with low social and economic status, whereas no significant differences were noted with regard to the remaining socio-demographic factors (Table 2).

Table 2. Distribution of health literacy levels by socio-demographic characteristics ofstudy participants

Variable	Total
Health literacy	P
Inadequate	Problematic	Sufficient	Excellent
Gender
Male
Female
12 (6.2)*
181 (93.8)
3 (25.0) *
6 (3.3)
3 (25.0)
35 (19.3)
4 (33.3)
95 (52.5)
2 (16.7)
45 (24.9)	0.005†
Age-group
20 years old
21 years old
112 (58.0)
81 (42.0)
3 (2.7)
6 (7.4)
24 (21.4)
14 (17.3)
58 (51.8)
41 (50.6)
27 (24.1)
20 (24.7)	0.443
Branch of study
Nursing
Midwives
Physiotherapy
Lab. technician
97 (50.3)
79 (40.9)
7 (3.6)
10 (5.2)
4 (4.1)
5 (6.3)
0 (0.0)
0 (0.0)
17 (17.5)
17 (21.5)
0 (0.0)
4 (40.0)
51 52.6()
37 (46.8)
5 (71.4)
6 (60.6)
25 (25.8)
20 (25.3)
2 (28.6)
0 (0.0)	0.456
Employment status
Working student
Not working student

26 (13.5)
167 (86.5)

2 (7.7)
7 (4.2)

3 (11.5)
35 (21.0)

15 (57.7)
84 (50.3)

6 (23.1)
41 (24.6)
0.601
Marital status
Not married‡
Married
189 (97.9)
4 (2.1)
9 (4.8)
0 (0.0)
38 (20.1)
0 (0.0)
97 (51.3)
2 (50.0)
45 (23.8)
2 (50.0)	0.552
Social status
Low
Middle
High
6 (3.1)
173 (89.6)
14 (7.3)
3 (50.0)
6 (3.5)
0 (0.0)
1 (16.7)
35 (20.2)
2 (14.3)
2 (33.3)
92 (53.2)
5 (35.7)
0 (0.0)
40 (23.1)
7 (50.0)	<0.001
Economic status
Very bad/bad
Average
Good/very good
3 (1.6)
95 (49.2)
95 (49.2)
1 (33.3)
4 (4.2)
4 (4.2)
1 (33.3)
23 (24.2)
14 (14.7)
1 (33.3)
53 (55.8)
45 (47.4)
0 (0.0)
15 (15.8)
32 (33.7)	0.016
* Absolute numbers and percentages in parentheses (row percentages for the health literacy categories, but column percentages for the totals). Discrepancies in the total numbers are due to the missing values.

† P-values from the chi-square test.

‡ Single, divorced and widowed.

Table 3 shows the socio-demographic factors associated with inadequate/problematic general health literacy. In multivariable adjusted analysis (Model 2), the only demographic factor that statistically increased the likelihood of inadequate/problematic HL was male gender with male students being 8.13 times more likely to report inadequate/problematic HL compared to female students (Table 4). The associations with the remaining socio-demographic factors were not significant. Nevertheless, there was a tendency for the likelihood of limited HL to be decidedly higher among students with low social status (OR=6.28 vs. high social status students) and students with bad economic status (OR=3.59 vs. good/very good economic status students).

Table 3. The association of inadequate/problematic general health literacy with basic socio-demographic factors – ORs from Binary Logistic Regression
Variable	Model 1 *	Model 2 **
OR (95%CI)	P-value	OR (95%CI)	P-value
Gender
Male
Female
3.42 (1.01-11.16)
1.00 (Reference)
0.042
8.13 (1.68-39.39)
1.00 (Reference)
0.009
Age-group
20 years old
21 years old
1.00 (Reference)
1.03 (0.53-2.01)
0.926
1.00 (Reference)
1.11 (0.50-2.46)
0.805
Branch of study
Nursing
Midwives
Physiotherapy
Lab. Technician
1.00 (Reference)
1.40 (0.70-2.78)
- (-)
2.41 (0.62-9.35)	0.562 (3) ⁋
Reference
0.342
-
0.202
1.00 (Reference)
1.62 (0.73-3.60)
- (-)
2.77 (0.62-12.36)	0.507 (3)
Reference
0.235
-
0.181
Employment status
Working student
Not working student

1.00 (Reference)
1.41 (0.50-3.98)

0.515

1.00 (Reference)
1.57 (0.50-4.94)

0.438
Social status
Low
Middle
High
12.00 (1.25-115.4)
1.86 (0.40-8.67)
1.00 (Reference)	0.073 (2)
0.031
0.427
Reference
6.28 (0.49-80.79)
1.74 (0.34-8.86)
1.00 (Reference)	0.361 (2)
0.159
0.507
Reference
Economic status
Good/very good
Average
Very bad/bad

1.00 (Reference)
1.70 (0.86-3.35)
8.56 (0.74-99.61)	0.102 (2)

0.127
0.087
Reference

1.00 (Reference)
1.69 (0.80-3.56)
3.59 (0.16-80.97)	0.309 (2)

0.169
0.421
Reference
* Model 1: Crude (unadjusted) ORs, from univariate analysis.
** Model 2: Multivariable adjusted ORs, controlled for gender, age, branch of study, social and economic status.
⁋ Overall P-value and degrees of freedom (in parenthesis).

CONCLUSIONS

Conclusion
Our findings might support policy-makers and education professionals to design and implement gender-specific interventions in order to reduce the gender gap in health literacy among nursing students in Albania. On a broader perspective, such targeted interventions need to be implemented in lower education levels and extra school environments as well, taking into account the socio-demographic determinants of health literacy.

CLINICALTRIAL

N/A