3.1. Characteristics of the Study Population
Two hundred and nineteen students (187 women (85.4%) and 32 men 14.6%) took part in the study. The average age was 24.9 years (SD 5.2) (the youngest was 19 and the oldest 60), with no differences according to sex (women’s average age was 24.8; men’s average age was 25.3; p = 0.629).
The majority of students (64.4%) were studying a degree in Social Work (n: 141); 23.7% (n: 52) were studying a degree in Nursing; 5.9% (n: 13) a degree in Primary Education, and also 5.9% (n: 13) a degree in Special Education. In addition, 78.2% of the participants combined work and studies and 4.1% (n: 9) reported having another degree.
3.2. Health Literacy Results
shows the scores for each item on the HLS-EU-Q16 questionnaire based on the type of degree participants were studying, with descriptions obtained from the original scores (very difficult = 1, difficult = 2, easy = 3 and very easy = 4).
The highest mean scores corresponded in most of the 16 items to Nursing students with significant differences, except in item 2 (—find out where to get professional help when you are ill?), 10 (—understand why you need health screenings?), and 15 (—understand information in the media on how to get healthier?), in which the scores obtained by students of the four degrees were not statistically significant.
shows the average scores by subdomains of the HLS-EU-Q16 questionnaire. In the total sample, the highest scores corresponded to the healthcare subdomain. By type of studies, Nursing students had significantly higher scores in the three subdomains (p
The total average score obtained from the participants’ health literacy index was 11. 1 (± 3.2) using the HLS-EU-Q16 questionnaire, after recoding answers and transforming each item into a dichotomous response (difficult and very difficult = 0; easy and very easy = 1).
By gender, the average health literacy index score was 11.1 (±3.1) for women and 10.8 (±3.6) for men (Student’s t-test; p = 0.593). By university degree, the average health literacy index score for Nursing student participants was 13.2 (± 4); 10.5 (± 2.9) for Social Work students; 10.1 (± 2.8) for Primary Education students, and 10.1 (± 2.7) for Special Education students (ANOVA analysis; p < 0.001).
Participants who reported having another degree presented higher average health literacy index scores (12.3 versus 11.1; (Student’s t-test; p = 0.255).
shows the classification of the participants’ levels of health literacy (insufficient, problematic or sufficient) in the total sample and by type of degree. Almost 7 out of 10 participants in the Nursing group and almost 3 out of 10 in the Social Work group obtained this level, while approximately a quarter of the Primary Education and Special Education students were in this category.
On studying the variables associated with health literacy levels using the binary multiple regression model adjusted for sex and age (Table 3
), it was observed that the university degree variable was associated with health literacy. Thus, participants studying Social Work, Primary and Special Education were less likely to be classified at a sufficient level of health literacy than participants studying Nursing (Social Work OR 0.15 IC 95% 0.07–0.31; p
< 0.001; Primary Education OR 0.10 IC 95% 0.02–0.46; p
< 0.003; Special Education OR 0.05 IC 95% 0.00–0.31; p
= 0.001). In addition, having another degree was also related to health literacy so participants with another university degree were more likely to have sufficient health literacy (OR 0.19 IC 95% 0.03–0.99; p
In this study, we defined the health literacy levels of undergraduate students in the fields of health, Social Work and Education in two universities in Spain and in a Social Work training institute in France. Among the sociodemographic variables, it is worth noting the large number of women participating in the study, as well as the average age of 25 years, which was similar for both sexes. This can be accounted for by the type of degree and the highly feminized fields of health and education covered by this research.
The average health literacy score of the participants was 11.1 and they had very differentiated and significant results depending on the degree they were studying. Thus, the average level of literacy was clearly higher among Nursing students (13.2) and lower among Social Work students (10.5) and Primary and Special Education students (10.1). The fact that participants with another degree had higher health literacy levels (12.3) would suggest that their age was related, favouring greater contact with the health system and its professionals [2
Women had slightly higher literacy scores than men, although not significantly. The related literature offers mixed evidence for the relationship between gender and health literacy of college students. In a study by Garcia-Codina et al., women showed slightly higher percentages of inadequate/problematic health literacy in a much larger sample with a tendency to statistical significance [3
], the same was observed in the study by Rababah et al. [16
] and in the study by Vamos et al., in Texas [20
]. However, other authors have not found these differences [21
The fact that Nursing and Medical students have better literacy outcomes has been found in several studies conducted in the university environment, such as the one carried out by Rababah et al., which also highlighted the influence of demographic characteristics, such as age, gender, field of study and academic year, on the literacy level of college students. Health Science students, women and non-smokers had better health literacy [16
]. Other authors, such as Mather at al. in a study conducted among students in Tasmania, have identified the importance of these variables together with the parents’ level of education. They highlighted the literacy deficiencies of Health Science students and pointed out the need to incorporate health literacy in secondary and tertiary curricula in order to promote it among the general population and especially among future care providers [22
It is worth highlighting that although one third of the participants were ranked sufficient in health literacy, the Nursing group had more students at this level (seven out of ten). This ratio decreased to more than half of the participants in the Social Work and Education groups. Thus, Nursing students obtained the highest average scores in all the aspects covered in the questionnaire except those related to finding out where to get professional help when you are ill, understanding why you need health screenings, and understanding information in the media on getting healthier, in which the scores obtained by students of the four degrees were not statistically significant. The fact that participants studying to become nurses obtained these results could be due to the learning objectives themselves and degree competencies and contents. However, it is necessary to take into account the importance of personal background (family and social environment, previous health-related experiences, etc.) and the students’ educational trajectories so a good approximation can be made to their health literacy levels. In this way, both specific and cross-curricular literacy-related training and curricular activities can be planned, as illustrated by Elsborg et al., in a study conducted among Danish students enrolled in health-related study programs [21
Nursing students had similar results in limited (inadequate and problematic) health literacy to the general population of Spain [17
], but not of Catalonia [3
] and Valencia [18
] (30.8% versus 34.4%, 15.6% and 12.8% respectively). Students of Special Education, Primary Education and Social Work had less favourable health literacy results than the reference populations. In addition, the number of students (over 70%) with very high limited literacy levels was striking. The results show the need for cross-cutting lines of action to be implemented for the enhancement and empowerment of university students in health-related matters. Studies such as the one by Ozen et al. [5
] endorse the effectiveness of improving health literacy among Nursing students by including it in the education program. Bröder et al., stated that the more health literate students are, the greater the influence they will have on people in their professional lives in terms of health management and healthier decision-making [23
]. Nurses need to be able to tailor care to people with low levels of health literacy, making it essential to integrate health literacy into Nursing studies. Authors such as Mosley and Taylor have assessed literacy needs and identified points for improvement in order to construct a health literacy plan integrated in the Nursing curriculum that includes learning activities based on evaluation and effective communication [24
Nursing students reported having fewer difficulties carrying out healthcare, health promotion and disease prevention actions than students of Primary Education and Special Education and Social Work. However, training that goes well beyond knowledge of healthcare and caring for people with health problems is needed. Self-care competencies should be incorporated and reinforced in Nursing programs to enable Nursing students to transmit this knowledge in their future professional careers. This is also an essential requirement for graduates in education and community work. Ayaz-Alkaya and Terzi, have highlighted the importance of health literacy especially for Nursing students given that nurses are key players in addressing the problem of low health literacy by improving the health outcomes of the people they care for through health education and health promotion. Health education is a fundamental responsibility for nurses, and it is imperative they have sufficient health literacy skills [25
In general, actions such as judging when you need to get a second opinion from your doctor, finding information on how to manage mental health problems and judging if the information on health risks in the media is reliable were considered the most difficult to perform. This may be related to the generational component.
This study reaffirms that gender is not related to health literacy levels. However, it contradicts the belief that people’s educational level is a protective factor given that the sample corresponded to university students and that 63.5% of these students had limited health literacy, which was well above the percentage in the reference populations. This result conflicts with the findings of the study on health literacy determinants conducted by Garcia et al., among the general population in Catalonia [3
The average age of the sample in relation to the general populations of the reference studies in Spain and Catalonia may have influenced the lower levels of limited literacy, since younger people are less likely to have limited literacy levels, as pointed out in studies carried out by Sørensen et al. [2
]. However, Bröder et al. [26
] argued that young people have unique characteristics in terms of needs, assets and perspectives, and therefore should be considered a specific group regarding health literacy and its determinants. They proposed a six-dimensional model including, among other determinants, not only young people’s sociodemographic characteristics, but also their health perspectives and the digital world in which they have grown [26
As far as study limitations are concerned, the sample size, especially of the Primary and Special Education groups, may be biased due to lack of representation. Accordingly, the results should be treated with caution. In addition, the cross-sectional design does not allow for causal relationships to be established, since only some possible factors associated with literacy levels in a population of university students have been analysed. Nonetheless, despite the scant literature on health literacy among college students, we consider it of great interest to study health literacy in university students in order to work on preventing the potential effects that the low literacy levels observed may have on these people.
4.2. Practical Implications
The results of this study have shown the need to improve health literacy levels by incorporating additional cross-cutting actions in training programs aimed at health care, disease prevention and health promotion. Not only are these actions needed in Nursing studies but also in Social Work and Education degrees, given the importance of incorporating literacy in the early stages of education and through healthcare education and contact with the community.