Assessment of Health Literacy Among Adults Visiting Outpatient Clinics at a Government Tertiary Care Hospital in Urban Bangalore: A Cross-Sectional Study

Introduction

Health literacy is increasingly recognized as a critical determinant of health outcomes, particularly in outpatient settings where patient engagement and informed decision-making are essential. The World Health Organization (WHO) defines health literacy as the cognitive and social skills determining an individual’s motivation and ability to access, understand, and use health information effectively.¹ Inadequacy in health literacy has been associated with poorer health outcomes, including increased hospitalization rates, lower utilization of preventive services, and higher chronic disease burden.²

Urban Bangalore presents a unique context for this research due to its diverse demographic landscape and varying levels of education and socio-economic status. Previous studies have indicated that specific socio-demographic factors, such as age, education, and income, significantly influence health literacy levels.³ By focusing on adults in outpatient clinics, this study seeks to identify populations at risk for low levels of health literacy and explore how these levels correlate with various socio-demographic factors of the study participants.

Understanding the scope of health literacy in this context is vital for developing targeted interventions to improve patient education and engagement. Enhan-ced health literacy can empower individuals to make informed decisions regarding their health care, ultimately leading to better health outcomes and reduced healthcare costs. HL has consequences beyond managing one's health; it also affects the healthcare system’s efficiency and equity by determining how effectively patients navigate services, adhere to treatment plans, and utilize preventive measures. Thus, improving health literacy is crucial for promoting healthier communities and reducing health disparities. The findings from this research could inform policy changes and educational programs within the healthcare system in Bangalore, contributing to a broader understanding of health disparities in urban settings.

This study aims to evaluate health literacy among adults visiting outpatient clinics at a government tertiary care hospital in urban Bangalore, focusing on a cross-sectional analysis that highlights the interplay between health literacy and various socio-demographic factors. By identifying key determinants of health literacy, the research aims to contribute significantly to the field of public health and inform strategies for improving patient care in tertiary healthcare settings.

Materials and Methods

Study Design: This study employed a cross-sectional design to evaluate the health literacy, and the socio-demographic factors associated with adults visiting outpatient clinics at a government tertiary care hospital in urban Bangalore.

Study setting: The study was conducted in the outpatient departments of a government tertiary care facility in urban Bangalore for three months (from May 2024 to July 2024).

Sample Size: The sample size was estimated based on the study by Almaleh et al., which reported a proportion of inadequate HL at 34.3%.⁴ Using this proportion, a sample size of approximately 200 participants was calculated to ensure adequate power for statistical analysis. Consecutive sampling was done to select individuals who met the mentioned inclusion criteria.

Study Population: All patients and/or patient attenders of 18 and above who visited the outpatient clinics and were willing to participate in the study were included, whereas individuals not willing to give informed consent were excluded from the study. Informed consent was obtained from all participants before being included in the study. Participants were informed about the purpose of the study, procedures, potential risks, and their rights to withdraw at any time without consequence.

Research Tools: Data were collected using a pre-tested, semi-structured questionnaire that included socio-demographic factors and the Indian Version of Health Literacy Survey-Europe-Q16 (HLS-EU-Q16) to assess health literacy. The HLS-EU-Q16 is a validated instrument consisting of 16 items designed to measure various dimensions of health literacy, including the ability to access, understand, and apply health information.⁵

Data analysis: The collected data were entered into Microsoft Excel for initial organization and cleaning. Statistical analysis was performed using JAMOVI version 2.4.11, where descriptive statistics were calculated to summarize socio-demographic characteristics and health literacy levels. Inferential statistics explored the associations between HL and numerous socio-demographic factors.

Results

Two hundred individuals aged 18 years and above enrolled and participated in the study. The study participants had a mean age of 38.1 + 14.9 years, with the majority (26.5%) falling in the age group of 26-30 years. Males comprised about three-fourths (75.5%) of the study participants.

Some of the other characteristics of the participants are shown in Table 1.

The health literacy assessment revealed that a substantial proportion of the participants had less than sufficient health literacy levels, with 35% (n=70) categorized as having inadequate health literacy and 30.5% (n=61) as having problematic health literacy. In comparison, only 34.5% (n=69) demonstrated sufficient health literacy. The health literacy status is demonstrated in Figure 1.

The analysis revealed significant associations between health literacy and multiple socio-demographic factors. Age and health literacy showed a borderline association (χ² = 25.7, P = 0.058), with inadequate and problematic health literacy more prevalent in older age groups (50 years and above), while sufficient health literacy was more common in younger adults (18-30 years). Gender was not significantly associated with health literacy (χ² = 0.175, P = 0.916), indicating a similar distribution across males and females. However, religion (χ² = 34.2, P < 0.001), marital status (χ² = 17.6, P = 0.002), and education (χ² = 98.2, P < 0.001) demonstrated strong associations, with lower health literacy more common among certain religious groups, married individuals, and those with lower education levels.

Occupation (χ² = 103, P < 0.001) and monthly household income (χ² = 63.1, P < 0.001) were also significantly associated with inadequate health literacy prevalent among manual workers and low-income groups. Inadequate health literacy was highest among manual workers (73.7%), service workers (55.6%), and self-employed individuals (56.5%). In comparison, insufficient health literacy was most prevalent among those in professional/managerial roles (83.9%), healthcare providers (100%), and clerical/adminis-trative roles (33.3%). Inadequate health literacy was predominantly observed in individuals from the lowest income group, i.e., monthly income below ₹20,000 (51%), while sufficient health literacy was highest among those earning ₹40,001 - ₹60,000 (77.4%) and ₹60,001 - ₹1,00,000 (76.9%).

Addictive habits (χ² = 54.4, P < 0.001) and socio-economic status (χ² = 111, P < 0.001) showed strong correlations, with inadequate health literacy being highest in individuals from lower socio-economic status groups and those with smoking or tobacco habits. In contrast, physical activity was not significantly associated with health literacy (χ² = 9.47, P = 0.149). Individuals with no addictive habits had the highest proportion of sufficient health literacy (44.4%) and the lowest proportion of inadequate health literacy (23.7%). In comparison, inadequate health literacy was notably high among individuals who engaged in tobacco chewing (78.9%) and smoking (46.2%). Sufficient health literacy was almost nonexistent among individuals with multiple addictive habits (e.g., smoking, tobacco chewing, and alcohol use combined). Lower socio-economic status groups (class V and IV- according to the modified Kuppuswamy scale 2024) had the highest proportion of inadequate health literacy (83.3% and 66.7%, respectively). Sufficient health literacy was concentrated in the upper-middle (class II) socio-economic status participants (74.3%).

Table 2 shows the analysis using the Chi-square test to check the association of various socio-demographic factors with health literacy.

Discussion

The present study assessed health literacy among adults attending outpatient clinics in an urban tertiary care hospital. The findings highlight that many participants had less than sufficient health literacy, indicating potential barriers to understanding and utilizing health information effectively.

Socio-demographic analysis revealed that most participants were young adults, predominantly male, and belonged to Hindu religious backgrounds. A considerable proportion was married and had attained at least a secondary level of education. Socio-economic status varied, with participants distributed across different income levels.

The study identified significant associations between health literacy and multiple socio-demographic factors. Lower educational attainment and lower socioeconomic status were strongly linked with inadequate health literacy. As the education level increases, the likelihood of having sufficient health literacy improves significantly. This finding underscores the need for targeted health education programs for individuals with lower educational backgrounds to improve their ability to access, understand, and use health information effectively. Also, individuals in the lowest socio-economic status (class V) had very low representation in sufficient or even problematic health literacy categories, reinforcing the strong link between low socio-economic status and poor health literacy likely due to limited educational opportunities, reduced access to healthcare resources, and lower exposure to health-related information.

Similarly, occupational status played a crucial role, with specific job categories exhibiting lower literacy levels. Individuals in professional, managerial, and healthcare-related roles tend to have better health literacy, likely due to higher education levels and workplace exposure to health information. In contrast, manual laborers, service workers, homemakers, and self-employed individuals may face barriers to accessing and understanding health-related information.

Marital status and religion also showed significant associations, reflecting the influence of social and cultural factors on health literacy. Unmarried individuals, often younger and possibly more educated, have better health literacy. In contrast, married individuals may have more challenges, possibly due to time constraints, household responsibilities, or differing levels of exposure to health education. Religious background may influence health literacy levels due to factors such as education, socio-economic status, cultural beliefs, or access to healthcare information within different communities. Further research may be needed to explore the underlying reasons for this disparity.

Furthermore, addictive habits and lower household income were found to correlate with inadequate health literacy, emphasizing the need for targeted interventions in these groups. While gender did not show a statistically significant association, trends indicated slightly lower literacy levels among specific subgroups. Physical activity levels, however, did not exhibit a strong association with health literacy.

These findings align with previous research high-lighting the impact of educational and socio-economic factors on health literacy.^3,6,7,8,9 The study underscores the need for tailored health education programs that address disparities and enhance comprehension among vulnerable populations. Future research should explore interventions to improve health literacy, particularly among individuals with lower educational backgrounds and those in lower income brackets. The study’s limitations include its cross-sectional nature, which prevents causal inferences, and its hospital-based setting, which may limit generalizability to the broader community. Nevertheless, the study provides valuable insights into the determinants of health literacy and suggests directions for future public health initiatives.

Recommendations

• Policy-level interventions should focus on simplified health communication strategies for populations with lower literacy levels, lower income, and lower socio-economic status (especially class IV and V, according to the modified Kuppuswamy scale).

• Health education campaigns should be designed to cater to people with limited formal education, using visual aids, multilingual materials, and community-based programs.

• Further research is needed to explore the specific barriers to health literacy among less-educated individuals to design more effective interventions.

• Targeted health literacy programs should be developed for manual labor, service industries, and self-employment workers, using workplace-based training, visual aids, and interactive sessions.

• Community-based health interventions can help reach homemakers and unemployed individuals, ensuring they receive simplified, accessible health information.

• Employers in low-literacy sectors should integrate basic health education into workplace policies, promoting preventive healthcare and awareness.

• Digital health initiatives and telemedicine services should be made more accessible to lower-income groups, as they may lack access to smartphones, the internet, or digital literacy.

• Public health campaigns should integrate addiction awareness with health literacy programs, emphasizing the impact of addictive habits on overall well-being.

Conclusion

In conclusion, this study highlights the significant gaps in health literacy among adults visiting outpatient clinics in an urban tertiary care hospital. It underscores the strong associations with various socio-demographic factors. The findings emphasize the need for targeted interventions, such as educational programs and policy measures, to enhance health literacy, particularly among vulnerable groups. Enhancing health literacy can lead to improved health outcomes and greater participation in healthcare, reinforcing the importance of integrating literacy-focused strategies into public health initiatives.

Conflict of Interest

None