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Demographic Predictors of Health Literacy Among Hospitalized Patients

1,2,3 Božica Lovrić

2,4,5 Tihomir Jovanović

1,2Marin Mamić

1 Sanja Hlubuček Čingel

1 Tomislav Paun

1 Željka Jukić

1 Bruno Dokozić

1 Brankica Andromako Matković

1 Ljilja Obradović Šebalj

1 Domagoj Dokozić

1,5Ivan Vukoja

¹ Požega General County Hospital, Croatia

2 Josip Juraj Strossmayer University of Osijek, Faculty of Dental Medicine and Health, Croatia

3 University of Applied Sciences Ivanić-Grad, Croatia

4 Pakrac General County Hospital and Croatian Veterans Hospital, Croatia

5 Josip Juraj Strossmayer University of Osijek, Faculty of Medicine Osijek, Croatia

Article received: 27. 07. 2025.

Article accepted: 14. 11. 2025.

DOI: 10.24141/2/10/1/3

Author for correspondence:

Marin Mamić Tome Matica 20

34000 Požega, Croatia

E-mail: mmamic@fdmz.hr

Keywords: health literacy, demographic characteristics, hospitalized patients, Croatia

Abstract

Introduction. One definition of health literacy de- scribes it as the ability to access, understand, and evaluate health information with the aim of preserv- ing and improving health. Limited health literacy represents a significant but unequal burden in differ- ent parts of the world. The results of many previous studies have found that older age, lower education level, and poor socioeconomic status significantly contribute to lower health literacy.

Aim. The objectives of this study were to examine health literacy among hospitalized patients, inves- tigate differences in health literacy according to so- ciodemographic variables, and identify sociodemo- graphic predictors of health literacy.

Methods. The research was conducted as a cross- sectional study. The study included adult hospital- ized patients in the Požega General County Hospital in the period from July to October 2020. The criteria for inclusion in the study were as follows: respond- ents older than 18 years of age, respondents hos- pitalized in hospital wards, respondents who speak and understand the Croatian language, respondents voluntarily participating in the study.

A questionnaire containing demographic data was used as a research instrument, while the second re- search instrument was the Croatian version of the SAHLCA-50 functional health literacy test. A health illiterate person is one who had 42 or fewer correct answers.

Results. A total of 173 (34.6%) respondents had ad- equate health literacy, whereas 327 (65.4%) showed inadequate health literacy. Women were more likely to have adequate health literacy than men. Of the total of 289 (58%) women, 118 (68%) showed ade- quate health literacy (p = 0.001). Respondents aged 61 and older were significantly less health literate than younger respondents (p < 0.001). Age ≥61 was the strongest predictor of health illiteracy (OR = 8.17). Other significant predictor included complet- ed primary school (OR = 113.3), incomplete primary school (OR = 550.8) and being retired rather than employed (OR = 6.54). Those respondents living in the city (101; 58%) p < 0.001) and those who were married, 128 of them (74%) (p < 0.001), were more likely to have adequate health literacy. Regarding the number of children, respondents without children or with only one child had higher health literacy than those with more children (p < 0.001).

Conclusion. In the study, we identified demographic factors that are significantly associated with health literacy levels. Future research should focus on longi- tudinal designs to determine the causes, outcomes, and consequences, as well as the possible impact of health status on changes in health literacy. This data can be used to develop effective public health strate- gies that take into account the diverse needs of dif- ferent population groups. Public health interventions should particularly target men, people from rural areas, older people, and those with lower levels of education to improve their health literacy and ensure equitable access to health information.

Introduction

Health literacy is a concept that combines knowledge in the field of literacy and health, both of which are important determinants of overall well-being. There- fore, health literacy is the basis of good function- ing, and has a direct impact on individual’s ability to manage their own health and that of the wider community (1). In recent decades, health literacy has been highlighted as an important topic worldwide, especially for the prevention of chronic diseases (2). Inadequate health literacy has been linked to poorer disease management, non-adherence to treatment recommendations, frequent hospitalizations, and improper use of prescribed medications by patients or caregivers (3). Limited health literacy represents a significant but unequal burden in different parts of the world. Unfortunately, the research conducted so far shows a worrying proportion of insufficient health literacy of the population. A survey conduct- ed in eight European countries found a low level of health literacy in as many as 47% of the population

(4). The phenomenon of insufficient health literacy in Europe is significant and poses a challenge to public health (5). The results of many previous studies have shown that older age, lower level of education and poor socioeconomic status are significant predictors of low health literacy (6-9). Gender differences in health-related attitudesas well as the use of health services have been repeatedly documented (10-13). While there is great interest in studying health liter- acy worldwide due to its direct impact on the health of individuals and society as a whole, research in Croatia in this area is insufficient and has been con- ducted on subpopulation groups (14-15). Thus, the study by the Croatian Institute of Public Health on the mental health literacy among educational work- ers showed that more than half of the respondents (57,6%) did not recognize that the described case in- dicated a depressive disorder (16). A national survey conducted by Bobinac et al. showed that the level of health literacy in the Croatian population is on the borderline between problematic and adequate, with older people, people with lower education and lower incomes achieving worse results (17). These results confirm the importance of further research into health literacy in Croatia. In order for healthcare providers and policymakers to act effectively to raise

health literacy levels, it is essential to identify the various factors influencing health literacy before planning health information access activities and de- signing adequate interventions (18).

Aim

The objectives of this study were to:

• Examine health literacy among hospitalized patients.

• Investigate differences in health literacy ac- cording to sociodemographic variables.

• Identify sociodemographic predictors of health literacy.

Methods

The research was conducted as a cross-sectional study. The study included all adult hospitalized pa- tients at the Požega General County Hospital during the period from July to October 2020.

The inclusion criteria were as follows: respondents aged 18 or older, patients hospitalized in hospital wards, individualss who speak and understand the Croatian language, and individuals who voluntarily agreed to participate in the study. The exclusion cri- teria were: cognitive impairments, vision and/or hear- ing difficulties, illiteracy, unconsciousness, confirmed COVID-19 infection, or suspected COVID-19 infection.

A total of 500 participants took part in the study, of whom 289 were women (57.8%) and 211 were men (42.2%). The largest age group consisted of par- ticipants aged 61 years and older, numbering 278 (55.6%).

Instruments

Demographic questionnaire – This section was specif- ically designed for the purposes of this study and in-

cluded seven items (gender, age, place of residence, marital status, number of children, education level, and employment status). All questions were closed- ended, and respondents could select one of the pro- vided answer options.

Short Assessment of Health Literacy for Croatian Adults – 50 items (SAHLCA-50) – The Croatian ver- sion of the SAHLCA-50 functional health literacy test, which has been analyzed and validated, was used (19). The questionnaire consists of fifty closed- ended items. For each question, participants could choose one of three response options: “Correct,” “In- correct,” or “I don’t know.” The total score represents the sum of all correct answers and can range from 0 to 50. Health literacy level was treated as a dichoto- mous variable. Scores of 42 or higher were classified as adequate health literacy, while scores of 41 or lower indicated low health literacy. The reliability of the SAHLCA-50 was 0.91 (19).

Ethics

The research was conducted after the approval of the Ethics Committee of the Požega General County Hos- pital (Reg. No.: 02-7/1-1/1-4- 2020). All participants were previously informed in detail about the aim and nature of the research, and after receiving the nec- essary explanations, they provided written informed consent. The research was conducted anonymously.

Statistics

Categorical variables were summarized using absolute and relative frequencies, and differences between groups were assessed using the chi-square (χ²) test with adjusted residual analysis. The normality of the distribution for continuous variables (health literacy) was evaluated using the Shapiro–Wilk test, which in- dicated that the variable was not normally distributed. Continuous data are presented as medians with inter- quartile ranges (IQR). Homogeneity of variance was also not confirmed; therefore, nonparametric tests were applied in subsequent analyses. Comparisons between two independent groups were performed using the Mann–Whitney U test, while comparisons involving more than two independent groups were conducted using the Kruskal–Wallis test followed by Conover’s post hoc test. The impact of multiple predic- tors on the likelihood of health literacy was examined through logistic regression (both univariate and mul- tivariate, stepwise selection). All p values were two-

tailed, and statistical significance was set at α = .05. Analyses were performed using MedCalc® Statistical Software, version 20.111 (MedCalc Software Ltd., Os- tend, Belgium) and IBM SPSS Statistics for Windows, Version 23.0 (IBM Corp., Armonk, NY, 2015).

Table 1. Basic characteristics of the subjects (N = 500)

Results

The study was conducted on 500 hospitalized pa- tients, of which 211 (42.2%) were men and 289

(57.8%) were women. There were 278 (55.6%) re- spondents aged 61 and over. A total of 293 (58.6%) respondents lived in rural areas, and 313 (62.6%) were married (Table 1).

To determine differences in health literacy according to sociodemographic variables, the Mann–Whitney U test and the Kruskal–Wallis test were used. There was a significant difference in health literacy scores across several sociodemographic groups. Women were significantly more health-literate than men (U

= 25902,50, p = 0.004). Respondents aged 61 years and older had significantly lower health literacy scores than all younger age groups (H(4) = 123.4, p

< 0.001). Widowed respondents demonstrated sig- nificantly lower health literacy than those who were married, cohabiting, or living alone (H(3) = 55.5, p < 0.001). Participants with three or more children had lower health literacy than those with fewer children, while respondents with one child scored higher than those with two children (H(3) = 27.7, p < 0.001). Regarding education, respondents with a university degree or higher scored significantly higher than those with secondary, primary, or incomplete primary education (H(4) = 246.1, p < 0.001). Finally, retired respondents had significantly lower health literacy than employed and unemployed respondents (H(3) = 113.3, p < 0.001) (Table 2).

The results of the SAHLCA-50 test showed that the median total health literacy score was 37 (IQR = 25–44). To determine differences in the distribution between health-literate and health-illiterate partici- pants, a χ² test was used. The analysis revealed a statistically significant difference (χ²(1) = 47.43; p < 0.001), with a significantly higher number of health- illiterate participants in the sample (n = 327; 65.4%) (Table 3).

The χ² test analysis showed that all examined soci- odemographic variables (gender, age, place of resi- dence, marital status, number of children, education, and employment status) were significantly associ- ated with the level of health literacy (p ≤ 0.001 for

all). The strongest associations were observed for education, age, and employment status. Adjusted residual analysis (Table 4) revealed that participants with higher health literacy were significantly more likely to be women, younger, urban residents, mar- ried, have fewer children, possess higher education, and be employed. In contrast, individuals with lower health literacy were more frequently men, older, ru- ral residents, widowed, have more children, possess lower education, and be retirees (Table 5).

Logistic regression was conducted to identify predic- tors of health literacy based on several sociodemo- graphic factors among hospitalized patients. The bivar- iate regression analysis indicated that age, education, and employment status had the strongest effects. Re- spondents aged 61 years and older were significantly less likely to be health-literate compared to those aged up to 30 years (OR = 8.17, 95% CI [4.55–14.68]). Participants with completed primary education (OR = 113.3, 95% CI [32.5–395.18]) or unfinished primary

education (OR = 550.8, 95% CI [62.01–4892.6]) were markedly less likely to be health-literate compared to those with a university degree or higher. Additionally, retired respondents were less likely to be health-lit- erate than employed respondents (OR = 6.54, 95% CI [4.14–10.34]) (Table 5).

Discussion

The results of this study indicate that women, indi- viduals with higher education, married respondents, those with fewer children, residents of urban areas,

and employed individuals demonstrate higher levels of health literacy compared to men, those with low- er education, unmarried respondents, parents with more children, rural residents, and retirees. These dif- ferences can be explained by a combination of social, educational, and lifestyle factors.

Women and married individuals are often more in- volved in managing family health, communicate more frequently with healthcare providers, and are more exposed to health-related resources (3, 20–23), while individuals with higher education possess stronger cognitive, communication, and digital skills (20, 24, 25). Empirical evidence consistently shows a signifi- cant association between lower levels of education and poorer health literacy, with educational status recognized as a key determinant of health literacy

1. These findings confirm that better-educated individuals are more capable of understanding and internalizing health information, and that education represents a fundamental prerequisite for health lit- eracy (27).

   The analysis also revealed that age and employment status are strong predictors of health literacy. Older participants, particularly those aged over 60, exhib- ited significantly lower health literacy compared to younger groups. This result can be explained by low- er formal education levels among older generations, reduced digital competence, age-related cognitive changes, and limited access to modern health infor- mation sources. These findings are consistent with previous research showing that older age is associat- ed with a higher risk of low health literacy (3, 37, 38).

   
   

   Employed participants demonstrated higher health literacy than unemployed and retired individuals. A possible explanation is that those who are employed have more opportunities for social interaction, easier access to information, and more developed skills for managing their own health. In contrast, retirees and unemployed individuals may experience social iso- lation and lower motivation to actively seek health information, which can lead to poorer health literacy.

   A smaller number of children and living in urban ar- eas were also associated with higher levels of health literacy, which can be explained by better access to health and digital resources, more developed infra- structure, and more available time for health-relat- ed activities (31, 32). The study also found higher health literacy among married participants, which is consistent with previous research (33–36). This find- ing can be explained by reduced motivation and a lack of social and emotional support among divorced or widowed individuals, or by marriage serving as a possible protective factor.

   These findings align with international literature showing a strong association between health liter- acy, education, age, gender, urban living, and social support (3, 37, 38). Systematic reviews emphasize that rural populations often exhibit lower health lit- eracy due to limited access to health information, weaker digital infrastructure, and lower socioeco- nomic resources. However, local context and cultural factors may modify these general trends (39).

   
   

   

   Conclusion

   
   

   

   
   

   This study identified demographic factors that serve as key determinants of health literacy. The great- est impact on health literacy was observed among respondents aged 61 years and older, followed by educational attainment—where completion of only primary school significantly contributed to health il- literacy—and employment status, with retirees show- ing notably lower literacy levels.

   As the research was conducted among hospitalized patients, the generalizability of the findings to the wider population may be limited. Hospitalized indi-

   viduals may display a distinct health literacy profile due to acute health conditions, frequent interactions with healthcare professionals, and direct exposure to medical information.

   In practical terms, these findings underscore the need for targeted educational and public health in- terventions aimed at groups with lower health liter- acy—particularly men, single individuals, those with lower education, rural residents, and parents with larger families. Such programs should include compo- nents of digital education, access to reliable health information, communication strategies tailored to varying literacy levels, and mechanisms to strength- en social support and family involvement in health management.

   Future research, especially longitudinal and interven- tional studies, is needed to establish causal relation- ships and to evaluate the effectiveness of targeted interventions designed to improve health literacy among vulnerable populations.

   
   

   Author contributions

   Conceptualization (BL, TJ, MM, SHČ); Methodology (BL, TJ, MM, TP); Investigation (BL, ŽJ, BD, BAM); Writ- ing—original draft preparation (TJ, LJOŠ, DD, IV); Writ- ing—review and editing (IV, TJ, MM, BL). All authors have approved the final manuscript.

   
   

   Conflict of interest

   The authors declare no conflicts of interest.

   
   

   Acknowledgments

   The authors would like to thank all the participants.

   
   

   Funding

   This research did not receive any specific grant from funding agencies in the public, commercial or not for- profit sectors.

   
   

   
   

   

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