Document Type : Original Article


Biostatistics and Epidemiology, Faculty of Health, Isfahan University of Medical Sciences, Isfahan, Iran


Background: Health literacy is a measure of an individual’s ability to read, comprehend, and act on
medical instructions. Limited health literacy can reduce the adults’ ability to comprehend and use
basic health-related materials, such as prescription, food labels, health education pamphlets, articles,
appointment slips, and health insurance plans, which can affect their ability to take appropriate and
timely health care action. Nowadays, low health literacy is considered a worldwide health threat. So,
the purpose of this study was to assess health literacy level in older adults and to investigate the
relationships between health literacy and health status, health care utilization, and health preventive
behaviors. Materials and Methods: A cross-sectional survey of 354 older adults was conducted
in Isfahan. The method of sampling was clustering. Health literacy was measured using the Test of
Functional Health Literacy in Adults (TOFHLA). Data were collected using home interviewing. Health
status was measured based on self-rated general health. Health care utilization was measured
based on self-reported outpatient clinic visits, emergency room visits, and hospitalizations, and
health preventive behaviors were measured based on self-reported preventive health services
use. Results: Approximately 79.6% of adults were found to have inadequate health literacy. They
tended to be older, had fewer years of schooling, lower household income, and were females.
Inadequate health literacy was associated with poorer general health (P < 0.001). Health literacy
level was negatively associated with outpatient visits (P = 0.003) and hospitalization (P = 0.01).
No significant association was found between health literacy level and emergency room utilization.
Self-reported lack of PSA (Prostate-Specific Antigen) test (P < 0.001) and fecal occult blood test
(FOBT; P = 0.003) was higher among individuals with inadequate health literacy than those with
adequate health literacy. No significant association was found between health literacy level and
mammogram in the last 2 years. Conclusion: Low health literacy is more prevalent in older adults.
It indicates the importance of health literacy issue in health promotion. So, with simple educational
materials and effective interventions for low health literacy group, we can improve health promotion
in the society and mitigate the adverse health effects of low health literacy.


1. Nielsen-Bohlman L, Panzer AM, Kindig DA. Health Literacy:
A prescription to end confusion. Washington, D.C.: Institute of
Medicine of The National Academies; 2004.
2. Sihota S, Lennard L. Health literacy: Being able to make the most
of health. London: National Consumer Council; 2004: 11. Available
literacy.pdf. [Last accessed on 2012 Jan 24].
3. Nutbeam D, Kickbusch I. Advancing health literacy: A global
challenge for the 21st century. Health Promotion Int 2000;15:183-4.
4. CSDH: Closing the Gap in a Generation: Health Equity through
Action on the Social Determinants of Health. Final Report of the
Commission on Social Determinants of Health. Geneva: World
Health Organization; 2008.
5. Kichbush I, translators: Sarmast H, Moosavian poor M.
Health literacy and discussion on health and education. Publication
of Health Promotion and Healthy Lifestyle Association 2006;2:4.
6. Williams MV, Parker RM, Baker DW, Coates W, Nurss J. The impact
of inadequate functional health literacy on patients’ understanding
of diagnosis, prescribed medications, and compliance. Acad Emerg
Med 1995;2:386.
7. Joint Committee on National Health Education Standards. National
Health Education Standards: Achieving Health Literacy. Atlanta, GA:
American Cancer Society; 1995.
8. Baker DW, Gazmararian JA, Williams MV, Scott T, Parker RM,
Green D, et al. Functional health literacy and the risk of hospital
admission among Medicare managed care enrollees. Am J Public
Health 2002;92:1278-83.
9. Baker DW, Parker RM, Williams MV, Clark WS, Nurss J. The
relationship of patient reading ability to self-reported health and
use of health services. Am J Public Health 1997;87:1027-30.
10. Schillinger D, Grumbach K, Piette J, Wang F, Osmond D, Daher C,
et al. Association of health literacy with diabetes outcomes. JAMA
11. Scott TL, Gazmararian JA, Williams MV, Baker DW. Health literacy
and preventive health care use among Medicare enrollees in a
managed care organization. Med Care 2002;40:395-404.
12. Howard DH, Sentell T, Gazmararian JA. Impact of health literacy
on socioeconomic and racial differences in health in an elderly
population. J Gen Intern Med 2006;21:857-61.
13. Kutner M, Greenberg E, Yin J, Paulsen C, White S. The health
literacy of America’s adults: Results from the 2003 national
assessment of adult literacy. Washington, DC: US Department of
Education; 2006.
14. Tehrani Banihashemi SA, Haghdooost A, Alavian M, Asgharifard H,
Baradaran H, Barghamdi M, et al. Health literacy in five province
and relative effective factors. Strides In Development of Medical
Education, Journal of Medical Education Development Center of
Kerman University of Medical Sciences. 2007;1(4):1-9.
15. Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of
functional health literacy to pationts knowledge of their chronic
disease: A study of patients with hypertension and diabetes. Arch
Intern Med 1998;158:166-72.
16. Kalichman SC, Rompa D. Functional health literacy is associated
with health status and health related knowledge in people living
with HIV-AIDS. J Acquir Immune Defic Syndr 2000;25:337-44.
17. Kalichman SC, Benotsch E, Suarez T, Catz S, Miller J, Rompa D.
Health literacy and health- related knowledge among persons living
with HIV/AIDS. Am J Prev Med 2000;18:325-31.
18. Baker DW, Wolf MS, Feinglass J, Thompson JA, Gazmararian JA,
Huang J. Health literacy and mortality among elderly person. Arch
Intern Med 2007;167:1503-9.
19. White SH, Chen J, Atchison R. Relationship of preventive health
practices, and health literacy. Am J Health Behav 2008;32:227-42.
20. Wolf MS, Gazmararian JA, Baker DW. Health literacy and health risk
behaviors among older adults. Am J Prev Med 2007;32:19-24.
21. Wolf MS, Gazmararian JA, Baker DW. Health literacy and functional
health status among older adults. Arch Intern Med 2005;165:1946-52.
22. Islamic Republic News Agency. (2007). Social; Elderly. [On-line].
Available from: http//www. [Last
accessed on 2007 Jun 03].
23. Hearth-Holmes M, Murphy PW, Davis TC, Nandy I, Elder CG,
Broadwell LH, et al. Literacy in patients with a chronic disease:Systemic lupus erythematosus and the reading level of patient
education materials. J Rheumatol 1997;24:2335-9.
24. Zion AB, Aiman J. Level of reading difficulty in the American College
of Obstetricians and Gynecologists patient education pamphlets.
Obstet Gynecol 1989;74:955-9.
25. Davis TC, Bocchini JA Jr, Fredrickson D, Arnold C, Mayeaux EJ,
Murphy PW, et al. Parent comprehension of polio vaccine
information pamphlets. Pediatrics 1996;97:804-10.
26. Davis TC, Mayeaux EJ, Fredrickson D, Bocchini JA Jr, Jackson RH,
Murphy PW. Reading ability of parents compared with reading level
of pediatric patient education materials. Pediatrics 1994;93:460-8.
27. Wengryn M, Jackson Hester E.Pragmatic Skills Used by Older Adults
in Social Communication and Health Care Contexts: Precursors to
Health Literacy. Contemp Issues Commun Sci Disord 2011;38:41-52.
28. Parikh NS, Parker RM, Nurss JR, Baker DW, Williams MV. Shame
and health literacy: The unspoken connection. Patient Educ Couns
29. Wolf MS, Williams MV, Parker RM, Parikh NS, Nowlan AW, Baker
DW.Patients’ shame and attitudes toward discussing the results of
literacy screening. J Health Commun 2007;12:721-32.
30. Von Wagner C, Knight K, Steptoe A, Wardle J. Functional health
literacy and health-promoting behaviour in a national sample of
British adults. J Epidemiol Community Health 2007;61:1086-90.
31. Paasche-Orlow MK, Parker RM, Gazmararian JA, NielsenBohlman LT, Rudd RR. The prevalence of Limited health literacy. J
Gen Intern Med 2005;20:175-84.
32. Cho YI, Lee SY, Arozullah AM, Crittenden KS. Effects of health
literacy on health status and health service utilization amongst the
elderly. Soc Sci Med 2008;66:1809-16.
33. Gazmararian JA, Baker DW, Williams MV, Parker RM, Scott TL,
Green DC, et al. Health literacy among Medicare enrollees in a
managed care organization. J Am Med Assoc 1999;281:545-51.
34. Lee SY, Tsai TI, Tsai YW, Kuo KN. Health literacy, health status, and
healthcare utilization of Taiwanese adults: Results from a national
survey. BMC Public Health 2010;10:614.
35. Jovic-Veanes A, Bejgovic-Mikanovic V, Marinkovic J. Functional
health literacy among primary health-care patients: Data from the
Belgrade pilot study. J Public Health 2009;31:490-5.
36. Tokuda T, Doba N, Butler JP, Passche-Orlow MK. Health literacy and
physical and psychological wellbeing in Japanese adults. Patient
Educ Couns 2009;75:411-17.
37. Arozullah AM, Lee S-YD, Khan T, Kurup S, Ryan J, Bonner M,
Soltysik R, Yarnold PR: The roles of low literacy and social support
in predicting the preventability of hospital admission. J Gen Intern
Med 2006;21:140-5.
38. Available from:
breast/HealthProfessional. [Last accessed on 2011 Mar 03].
39. Bush TL, Miller SR, Golden AL, Hale WE. Self-report and medical
record report agreement of selected medical conditions in the
elderly. Am J Public Health 1989;79:1554-6.
40. Simpson CF, Boyd CM, Carlson MC, Griswold ME, Guralnik JM,
Fried LP. Agreement between self-report of disease diagnoses and
medical record validation in disabled older women: Factors that
modify agreement. J Am Geriatr Soc 2004;52:123-7.