
==== Front
PLoS One
PLoS One
plos
PLOS ONE
1932-6203
Public Library of Science San Francisco, CA USA

10.1371/journal.pone.0309806
PONE-D-24-22935
Research Article
Medicine and Health Sciences
Health Care
Health Education and Awareness
Social Sciences
Economics
Health Economics
Medicine and Health Sciences
Health Care
Health Economics
Medicine and Health Sciences
Public and Occupational Health
Behavioral and Social Aspects of Health
People and places
Geographical locations
Europe
European Union
Portugal
Medicine and Health Sciences
Public and Occupational Health
Health Promotion
Research and Analysis Methods
Research Design
Survey Research
Surveys
Research and Analysis Methods
Research Design
Survey Research
Questionnaires
Medicine and Health Sciences
Health Care
Health Care Providers
Physicians
People and Places
Population Groupings
Professions
Medical Personnel
Physicians
Health literacy and its determinants among higher education students in the Alentejo region of southern Portugal—A cross-sectional survey
Health literacy and its determinants among higher education students—A cross-sectional survey
https://orcid.org/0000-0001-9178-3773
Rosário Jorge Writing – original draft 1 2 3 *
https://orcid.org/0000-0001-6782-7481
Dias Sara Simões Writing – original draft 3 4 5
Dias Sónia Writing – original draft 6
Pedro Ana Rita Writing – original draft 6
1 Polytechnic Institute of Beja, Beja, Portugal
2 Institute for Research and Advanced Training, University of Évora, Évora, Portugal
3 Comprehensive Health Research Centre, CHRC, University of Évora, Évora, Portugal
4 ciTechCare - Center for Innovative Care and Health Technology, Polytechnic of Leiria, Leiria, Portugal
5 School of Health Sciences, Polytechnic of Leiria, Leiria, Portugal
6 NOVA National School of Public Health, Public Health Research Centre, Comprehensive Health Research Center, CHRC, NOVA University Lisbon, Lisbon, Portugal
Ramalho André Editor
FMUP: Universidade do Porto Faculdade de Medicina, PORTUGAL
Competing Interests: The authors have declared that no competing interests exist.

* E-mail: Jorge.olhoazul@ipbeja.pt
24 9 2024
2024
19 9 e03098065 6 2024
19 8 2024
© 2024 Rosário et al
2024
Rosário et al
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Introduction

The capacity of higher education students to comprehend and act on health information is a pivotal factor in attaining favourable health outcomes and well-being. Assessing the health literacy of these students is essential in order to develop targeted interventions and provide informed health support. The aim of this study was to identify the level of health literacy and to analyse its relationship with determinants such as socio-demographic variables, chronic disease, perceived health status, and perceived availability of money for expenses among higher education students in the Alentejo region of southern Portugal.

Methodology

An observational, descriptive and cross-sectional study was conducted between 22 June and 12 September 2023. An online structured questionnaire consisting of the Portuguese version of the European Health Literacy Survey Questionnaire—16 items (HLS-EU-PT-Q16), including socio-demographic data, presence of chronic diseases, perceived health status, and availability of money for expenses. Data were analysed using independent samples t-test, one-way ANOVA, post-hoc Gabriel’s test, and multivariate logistic regression analyses at a significance level of 0.05. Regression models were used to investigate the relationship between health literacy and various determinants. The study protocol was approved by the Ethics Committee of the University of Évora, and all participants gave written informed consent.

Results

Analysis of the HLS-EU-PT-Q16 showed that 82.3% of the 1228 students sampled had limited health literacy. The mean health literacy score was 19.3 ± 12.8 on a scale of 0 to 50, with subscores of 19.4 ± 13.9 for health care, 19.1 ± 13.1 for disease prevention, and 19.0 ± 13.7 for health promotion. Significant associations were found between health literacy and several determinants. Higher health literacy was associated with the absence of chronic diseases. Regression analysis showed that lower health literacy was associated with not attending health-related courses, not living with a health professional, perceiving limited availability of money for expenses, and having an unsatisfactory health status.

Conclusion

This study improves the understanding of health literacy levels among higher education students in Alentejo, Portugal, and identifies key determinants. Higher education students in this region had relatively low levels of health literacy, which may have a negative impact on their health outcomes. These findings highlight the need for interventions to improve health literacy among higher education students and to address the specific needs of high-risk subgroups in the Alentejo.

Foundation for Science and Technology (FCT, Portugal) LA/P/0117/2020 This research was funded by the Foundation for Science and Technology (FCT, Portugal) through national funds for the REAL Associated Laboratory in Translation and Innovation for Global Health (LA/P/0117/2020). No additional external funding was received for this study. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Data AvailabilityAll relevant data are within the manuscript.
Data Availability

All relevant data are within the manuscript.
==== Body
pmcIntroduction

Health Literacy (HL), as defined by Sørensen et al. (2012), refers to individuals’ knowledge, motivation, and competencies to access, understand, evaluate, and apply health information in order to make informed judgements and decisions in everyday life concerning healthcare, disease prevention, and health promotion aimed at maintaining or improving quality of life throughout their lives [1]. It is associated with the cognitive and social skills, essentials to the motivations and ability of individuals to access, understand and use information in ways that promote and maintain good health [2]. Recognising its pivotal role, both the United Nations and the World Health Organization (WHO) highlight the importance of health literacy in achieving the Sustainable Development Goals (SDG3) on health and promoting community well-being [3, 4]. The European Health Literacy Project (HLS-EU) emphasises health literacy as a determinant of health, integrating public health perspectives and individual approaches [1].

These global perspectives are based on the dimensions of health literacy described by Nutbeam (2000): functional, interactive and critical [5]. The functional dimension pertains to the capacity to read and comprehend health-related information and sometimes includes numeracy skills, such as the application of mathematics in daily life [5]. The interactive literacy integrates advanced literacy and cognitive skills with social skills, enabling individuals to actively engage with health information and adapt to changing circumstances [5]. Critical literacy comprises the most advanced skills, allowing individuals to critically analyse information and use it to exert greater control over significant events and situations [5].

In order to gain further insight into the pathways linking health literacy to health behaviours and outcomes, Sørensen et al. (2012) developed the Integrated Model of Health Literacy. This theoretical framework delineates the pathways linking health literacy to health behaviours and outcomes. The model identifies the determinants and factors influencing health literacy levels (the antecedents) and their subsequent health outcomes (the consequences) [1]. This theoretical framework, predominant in Europe, describes four core competencies of health literacy: access (the ability to seek, find, and obtain health information), understand (the ability to comprehend accessed health information), appraise (the ability to interpret, filter, judge and evaluate the health information that was assessed) and apply (the ability to communicate and utilise the information to make decision to maintain and improve health). The four competencies, namely accessing, understanding, appraising and applying, can be applied across the three domains of the health continuum, including healthcare, disease prevention and health promotion [1].

An understanding of these competencies, serve to highlight the dynamic and holistic nature of health literacy. This encompasses not only the abilities of individuals, but also the inherent complexity of health systems. This framework facilitates comprehension and improvement of health literacy across heterogeneous populations and healthcare settings. The empowerment of individuals through the acquisition of these skills fosters autonomy and informed decision-making in matters pertaining to health [6] thereby enhancing social participation and well-being. Furthermore, the structural organisation and availability of resources have a significant impact on health literacy levels and individuals’ ability to make informed health decisions, which in turn affect personal and community health [7].

Recent European surveys on health literacy show that levels of health literacy vary across the population and highlight the links between higher health literacy and better health outcomes, reduced health inequalities and reduced economic burden [8–11]. Health literacy outperforms many socioeconomic factors as a predictor of health status [12, 13], and is recognised as a key determinant within health systems [14, 15]. Low levels of health literacy are associated with an increased risk of mortality [16, 17], more frequent use of hospital emergency services, primary care centres, and general practitioner consultations [18–20], lower use of preventive services [21], and lower quality of life [22].

In the context of Portugal, studies have shown significant differences in health literacy among higher education students. Amaral et al. (2021) reported that 61% of students in Viseu, an interior region of Portugal, exhibited problematic or inadequate health literacy [23], while Pedro et al. (2022) found that 44% of higher education students nationally faced similar challenges [24]. Higher health literacy tends to be associated with higher family income and parental education levels.

Given their pivotal role, higher education students are crucial in shaping health knowledge and practice [25–27]. Therefore, it is crucial to implement targeted training initiatives to improve health literacy among higher education students [28]. Their knowledge, attitudes, and behaviours not only impact their personal lives but also have societal implications. The level of knowledge among higher education students regarding health issues can significantly influence the efficacy of health education [25, 26]. Understanding the health literacy among higher education students in certain regions, such as Alentejo, is critical due to educational and health inequalities.

Transitioning from a national perspective to a more focused regional context, the Alentejo faces particular challenges. It has the lowest percentage of tertiary educated and high drop-out rates [29]. The Alentejo region in southern of Portugal, which is classified both as a Territorial Level 2 (TL2) and a Nomenclature of Territorial Units for Statistics II (NUTS II) region, covers an area of 31,605 km2, about 30% of the national territory. This region has a low population density and is threatened by depopulation due to a decreasing young population, an increasing elderly population and low immigration [30, 31]. Addressing these inequalities requires promoting health literacy and healthy behaviours from an early age, particularly in rural areas facing demographic challenges [32, 33].

The regional focus not only demonstrates the existence of educational and health inequalities but also emphasis the pressing necessity to conduct research and implement solutions at the local level. By elucidating the health literacy levels of higher education students in Alentejo, this research can provide insights into regional inequalities and inform policies aimed at reducing these disparities, ultimately benefiting both individual and community health outcomes.

It is therefore imperative to assess the level of health literacy among higher education students and investigate its association with various determinants. To the best of our knowledge, the current level of health literacy among higher education students in Alentejo is unknown, which makes it challenging to design effective health interventions.

This study will address the following research questions: What is the level of health literacy among higher education students in the Alentejo region of southern Portugal? What is the relationship between health literacy and determinants such as socio-demographic variables, the presence of chronic disease, perceived health status, and perceived availability of money for expenses among higher education students in the Alentejo region? The responses to these questions will facilitate the implementation of targeted interventions and policies designed to reduce inequalities and enhance health outcomes in this region. Health students, older students, those living with health professionals and those with enough money for expenses are expected to have higher health literacy. The objective of this study is to identify the level of health literacy and to analyse its relationship with determinants such as socio-demographic variables, the presence of chronic disease, perceived health status, and perceived availability of money for expenses among higher education students in the Alentejo region of southern Portugal. This study aims to respond to the significant gap in knowledge about health literacy among higher education students in the Alentejo region.

Materials and methods

Study design and setting

An online survey was conducted between 22 June and 12 September 2023. Four public higher education institutions (academic institutions) in Alentejo (a region in the south of Portugal) were selected, corresponding to the statistical territorial unit (NUT II), namely the Polytechnic Institute of Beja, Polytechnic Institute of Portalegre, Polytechnic Institute of Santarém, and University of Évora. Following the necessary authorizations from the University of Évora’s rectorate and the presidencies of each institute, an email invitation to participate in the study (including the questionnaire link) was disseminated by them to all undergraduate and integrated master’s degree students.

Study population and sample size

The study population comprised all students enrolled in undergraduate and integrated master’s degree programs. Students from all academic years were considered. Postgraduate students were excluded. A total of 13135 students were enrolled for the 2022–2023 academic year [34].

A minimum sample size of 384 was determined based on sample size calculation using a 95% confidence level, a population proportion of 50%, an estimated population size of 13135 (enrolments in the academic year 2022/2023), and a margin of error of 5%. To reduce the margin of error to 3%, a sample of 952 elements was determined, increased by 20% to account for potential non-responses (1143). The sample comprised 1228 students, exceeding the required size to achieve a 3% margin of error. Based on the calculations outlined, the sample of 1228 students was considered representative. This sample size was initially set to achieve a 3% margin of error, thus exceeding the minimum requirements set for statistical confidence and ensuring the robustness of the study’s findings regarding higher education students in the Alentejo region.

Study participants and data collection

The Portuguese version of the 16-item European Health Literacy Survey Questionnaire (HLS-EU-Q16), which used to assess health literacy levels and a basic demographic survey were distributed through a hyperlink using an online survey platform. The survey hyperlink was included in the study invitation. The questionnaire was designed to be completed only once per participant, with no option for multiple submissions to ensure data integrity.

Institutional approval and promotion

The governing body of each institution was contacted via email to explain the aims and importance of the study, and to request their approval. Once approval was granted, the institution promoted the link to the questionnaire, along with the consent form, to students via their official social media platforms and email lists. To reinforce and encourage participation, course coordinators were asked to highlight the importance of the survey in emails and meetings. This multi-channel approach was designed to ensure high visibility and maximise response rates.

Survey administration

Responses were collected electronically using an online survey tool that automatically recorded and securely stored data. The tool ensured anonymity and confidentiality in line with ethical research standards. Regular reminders were sent to students to maximise participation, and technical support was provided to resolve any problems encountered when completing the survey. The survey was designed to be mobile-friendly, ensuring accessibility on various devices, including smartphone or tablets. It was conciseness to minimise the time required for completions.

Addressing potential biases

The potential biases inherent in the online data collection method were recognised, including the exclusion of students without internet access, electronic devices or familiarity with digital technologies. To mitigate these concerns, the survey was made accessible on various devices available at higher education institutions, and participants were provided with technical support available at institutions where necessary. In addition, the multi-channel promotion strategy aimed to widen participation across different student populations, thus ensuring a more diverse and representative sample.

Measurements

The first section of the questionnaire comprised the presentation of the study’s participation conditions and the request for informed, voluntary, and clear consent along with confirmation of age over 16 years. Only after affirmative responses to these two requests, it would be possible to proceed to answer the remaining sections of the questionnaire.

The second section consisted of the HLS-EU-PT-Q16 scale and another set of questions relating to sociodemographic characteristics. It consisted of 31 questions, with an estimated response time of 10 minutes.

Health Literacy—HL (dependent variable)

The Portuguese version of the European Health Literacy Survey Questionnaire with 16 items (HLS-EU-Q16) was utilized to assess health literacy. This measure is related to the difficulty/ease of access, comprehension, appraisal, and application of information in the domains of healthcare (7 items), disease prevention (5 items), and health promotion (4 items) [35–37].

Each item on the scale has four possible responses (very easy, easy, difficult, and very difficult) and also the option “don’t know/refusal”. Each response corresponds to a numerical value: 1—very difficult, 2—difficult, 3—easy, 4—very easy, and 5—don’t know/refusal. The score of each item of the scale was calculated only if at least 80% of the items contained valid responses (between options 1 and 4). The option 5 (don’t know), it was considered missing. The mean score was calculated for all items on the scale, subsequently converted into a health literacy index score, respecting the guidelines of the European Health Literacy Consortium.

The calculation of the health literacy index score was performed according to the following formula: (mean-1)*(50/3), where mean corresponds to the average of items on the scale, 1—the minimal value of the mean, 3—the range of the mean, and 50—the chosen maximum value of the new index scores [38–41]. Health literacy levels were created based on the cut-offs: excellent (>42–50), sufficient (>33–42), problematic (>25–33), and inadequate (0–25) [39–41]. Subsequently, the levels were dichotomized into limited (combining inadequate and problematic health literacy levels) and adequate health literacy (combining sufficient and excellent health literacy levels). A pretest was conducted with 32 representative individuals from the target population, with no need for correction of questions or formatting.

The Cronbach’s alpha coefficient for HLS-EU-PT-Q16, which indicates internal consistency, was 0.89 overall, and 0.783 for the health care subdomain, 0.724 for the disease prevention subdomain, and 0.703 for the health promotion subdomain [35].

Independent variables

Sociodemographic variables, academic background, chronic disease, self-perceived health status, and perceived availability of money for expenses were considered.

Sociodemographic variables such as age, gender, country where secondary education was completed, district (inside or outside Alentejo) of secondary education conclusion, displacement from usual place of residence to attend the course, cohabitation with a healthcare professional (father, mother, or person with whom they reside being a healthcare professional), highest educational level of parents or the person with whom the student lived, according to the International Standard Classification of Education—ISCED [42], were included. For analysis, we grouped the education variables as following: no formal education and primary, lower, secondary and university.

Academic background included academic institution, academic year, being a finalist, completion a previous course in the health field, and frequenting a health-related course.

The presence of chronic diseases and self-perceived health status were included [43, 44]. Participants were asked to rate their current health status on a 5-point scale, which was initially classified into six categories: very bad, bad, fair, good, very good, and prefer not to answer. It was then reclassified into satisfactory (good and very good) and unsatisfactory (very bad, bad and fair) health status.

The perceived availability of money for expenses was categorized as rarely, sometimes, almost always, always, or prefer not to answer [37]. Subsequently, it was recategorized into bad (rarely and sometimes) and good (almost always and always).

Data analysis

The statistical analysis was performed using the IBM-SPSS version 29. Descriptive analysis was conducted: mean and standard deviation (SD) to quantitative variables and frequencies (absolute and percentages) to qualitative variables. A t-test was used for comparing health literacy differences between two groups, since normal distribution and homogeneity of the variances was presented. One-way ANOVA was used for comparing the health literacy differences among multiples groups since there was normal distribution and homogeneity of the variances. After finding a significant result in the overall ANOVA test, Gabriel’s test was used to determine which specific groups differ significantly from each other. A multiple linear regression analyses was computed to identify the determinants of health literacy. A statistical significance level of p < .05 was considered.

Ethical considerations

The study was approved by the Ethics Committee of the University of Évora (Document number 22091) and approved by the Scientific Council. All students were informed of the study objectives, which were outlined in a written statement of voluntary and informed consent in the first section of the self-administered questionnaire. Written digital informed consent was obtained from study participants prior to completing the survey form by filling in the appropriate space on the first page. Students who did not consent to participate did not have access to the questionnaire content. Confidentiality, anonymity, and data anonymisation are ensured.

Results

Socio-demographic characteristics

The sample comprised 1228 students with an average age of 21.34 ± 2.9 years. Of these students, 54.2% identified as female, 36.5% as male and 9.3% did not specify their gender. Most of the students had completed secondary education in Portugal (97.0%), in an Alentejo district (65.6%), had been displaced from their place of residence (76.1%), had not cohabited with a health professional (94.4%), and had parents who had completed secondary education (39.4%). Only 4.7% of students had completed a health course prior to this study.

In terms of the higher education institution attended, 36.6% of students were affiliated to the Polytechnic Institute of Beja, 34.9% to the University of Évora, 17.5% to the Polytechnic Institute of Santarém, and 11.0% to the Polytechnic Institute of Portalegre. A significant proportion of students were in their third year (31.0%), followed by those in their second (25.0%), fourth (24.7%) and first (15.1%), with the smallest proportion in their fifth year (4.2%). The largest group of students were not finalists (68.0%), had not completed a health-related course before (95.3%), and had not attended a health-related course (66.8%).

Regarding their health status, 68.5% of the students had no chronic diseases. In addition, 76.3% of students reported that their perceived health status was unsatisfactory. The perceived availability of money for expenses (food, housing, education and health) was rated as bad by 77% of the students. Table 1 summarises the differences between the characteristics of higher education students and the mean of the health literacy index.

10.1371/journal.pone.0309806.t001 Table 1 Differences between the characteristics of higher education students and the mean of the health literacy index (N = 1228).

Characteristics of the higher education students—independent variables	N	%	Mean (SD) [0;50]	p	
Age	[16;20]	502	40.9	19.8 (13.1)	< .001Ω	
[21;25]	566	46.1	18.1 (12.3)	
[26;30]	160	13.0	22.5 (13.2)	
Gender (n = 1113)	Feminine	665	59.7	22.6 (12.1)	< .001†	
Masculine	448	40.3	17.1 (12.9)	
Country of completion of secondary education	Portugal	1191	97.0	24.6 (12.6)	< .01†	
Outside of Portugal	37	3.0	19.2 (12.8)	
District in Portugal where secondary education was completed (n = 1191)	Inside Alentejo	781	65.6	19.5 (13.0)	.135 †	
Outside Alentejo	410	34.4	18.6 (12.3)	
Displaced from usual residence to attend the course	Yes	934	76.1	18.1 (12.6)	< .001†	
No	294	23.9	23.2 (12.8)	
Cohabitation with a health professional	Yes	69	5.6	28.5 (8.8)	< .001†	
No	1159	94.4	18.8 (12.8)	
Level of education of the student’s parents or the person with whom the student lived	No formal education/primary	31	2.5	18.6 (16.3)	.092 Ω	
Lower	394	32.1	19.7 (12.7)	
Secondary	484	39.4	20.1 (12.9)	
University	319	26.0	17.8 (12.4)	
Academic institution	Polytechnic Institute of Beja	450	36.6	26.5 (11.1)	< .001Ω	
Polytechnic Institute of Portalegre	135	11.0	29.9 (13.1)	
Polytechnic Institute of Santarém	215	17.5	16.3 (11.0)	
University of Évora	428	34.9	12.6 (11.1)	
Academic year	First	186	15.1	29.0 (9.1)	< .001Ω	
Second	307	25.0	19.1 (12.6)	
Third	381	31.0	13.6 (11.0)	
Fourth	303	24.7	21.2 (13.5)	
Fifth	51	4.2	17.7 (10.9)	
Finalist	Yes	393	32.0	20.6 (12.8)	< .01†	
No	835	68.0	18.7 (12.8)	
Previous completion of a course in healthcare	Yes	58	4.7	22.3 (11.0)	< .001†	
No	1170	95.3	19.2 (12.9)	
Healthcare-related course	Yes	408	33.2	30.0 (7.8)	< .001†	
No	820	66.8	14.0 (11.5)	
Chronic disease	Yes	387	31.5	15.2 (12.4)	< .001†	
No	841	68.5	21.2 (12.6)	
Perceived health status (n = 1222)	Satisfactory	290	23.7	31.2 (7.4)	< .001†	
Unsatisfactory	932	76.3	15,6 (11.9)	
Perceived availability of money for expenses	Good	283	23.0	31.6 (7.1)	< .001†	
Bad	945	77.0	15.7 (11.9)	
SD—Standard Deviation,

Ω—ANOVA;

†—t student

Health literacy

Table 2 presents the distribution of observed frequencies, percentages, means and standard deviations of responses to each item on the HLS-EU-PT-Q16 scale. When analysing the absolute and relative frequencies in per cent of the individual response items of the scale, predominant occurrences of "very difficult" responses were observed in item 15 "understand information in the media about how to get healthier?" with 37.0%. Responses categorized as “difficult” were predominantly observed in item 5 “judging when you might need to get a second opinion from another doctor with 43.2%. Conversely, the highest frequencies of "easy" responses were found in item 7 "follow the instructions of your doctor or pharmacist" with 33.5%. Among the options classified as "very easy," the most prevalent selection was observed in item 9 "follow instructions from your doctor or pharmacist?" with 19.5%.

10.1371/journal.pone.0309806.t002 Table 2 Distribution of observed frequencies, percentages, mean and standard deviation of responses to each item on the HLS-EU-PT-Q16 scale (N = 1228).

Area	On a Scale from Very Easy to Very Difficult, How Easy Would You Say It Is To	1—“Very difficult”
(n, %)	2—“Difficult”
(n, %)	3—“Easy”
(n, %)	4—“Very easy”
(n, %)	Mean (SD)
[1;4]	5—“Don’t know/
Refusal”
(n, %)
[missing]	
HC	1. find information on treatments of illness that concern you	432; 35.2	297; 24.2	364; 29.6	122; 9.9	2.1 (1.0)	13; 1.1	
HC	2. find out where to get professional help when you are ill?	390; 31.8	433; 35.3	315; 25.7	86; 7.0	2.0 (0.9)	4; 0.3	
HC	3. understand what your doctor says to you?	375; 30.5	327; 26.6	396; 32.2	123; 10.0	2.2 (0.9)	7; 0.6	
HC	4. understand your doctor’s or pharmacist’s instruction on how to take a prescribed medicine	374; 30.5	287; 23.4	352; 28.7	212; 17.3	2.3 (1.0)	3; 0.2	
HC	5. judge when you may need to get a second opinion from another doctor?	372; 30.3	530; 43.2	271; 22.1	37; 3.0	1.9 (0.8)	18; 1.5	
HC	6. use information the doctor gives you to make decisions about your illness?	331; 27.0	469; 38.2	342; 27.9	60; 4.9	2.1 (0.8)	26; 2.1	
HC	7. follow instructions from your doctor or pharmacist?	326; 26.2	313; 25.2	411; 33.5	178; 14.6	2.3 (1.0)	0; 0	
DP	8. find information on how to manage mental health problems like stress or depression?	370; 30.1	523; 42.6	267; 21.7	51; 4.2	2.0 (0.8)	17; 1.4	
DP	9. understand health warnings about behaviour such as smoking, low physical activity and drinking too much?	368; 30.0	310; 25.2	304; 24.8	240; 19.5	2.3 (1.1)	6; 0.5	
DP	10. understand why you need health screenings?	351; 28.6	341; 27.8	313; 25.5	215; 17.5	2.3 (1.0)	8; 0.7	
DP	11. udge if the information on health risks in the media is reliable?	386; 31.4	501; 40.8	273; 22.2	55; 4.5	2.0 (0.8)	13; 1.1	
DP	12. decide how you can protect yourself from illness based on information in the media?	351; 28.6	472; 38.4	342; 27.9	56; 4.6	2.0 (0.8)	7; 0.6	
HP	13. ind out about activities that are good for your mental well-being?	348; 28.3	414; 33.7	344; 28.0	115; 9.4	2.1 (0.9)	7; 0.6	
HP	14. understand advice on health from family members or friends?	419; 34.1	342; 29.9	386; 31.4	75; 6.1	2.1 (0.9)	6; 0.5	
HP	15. understand information in the media on how to get healthier?	454; 37.0	314; 25.6	387; 31.5	73; 5.9	2.0 (0.9)	0; 0.0	
HP	16. judge which everyday behaviour is related to your health?	367; 29.9	338; 27.5	399; 32.5	121; 9.9	2.2 (0.9)	3; 0.2	
HC—Healthcare, DP—Disease Prevention; HP—Health Promotion; SD—Standard Deviation.

In terms of mean scores (ranging from very easy = 4 to very difficult = 1), the highest score (2.3 ± 1.0) was observed in four items regarding: item 4; item 7; item 9 and item 10. The item with the lowest mean score (1.9 ± 0.8) was item 5.

Fig 1 (Fig 1) displays the distribution of health literacy levels by percentage across general health literacy and domains. It was observed that 62.4% of the students had inadequate levels for general health literacy, while 2.4% had excellent levels. Processing information related to health promotion appears to be more challenging for students, with 66.4% having inadequate levels compared to 63.2% for disease prevention and 60.3% for healthcare.

10.1371/journal.pone.0309806.g001 Fig 1 Distribution of HL levels by percentage across HL and domains.

Following the categorisation of health literacy levels into two distinct groups, it was found that 82.3% of the students exhibited limited health literacy while 17.7% demonstrated adequate health literacy. In terms of the healthcare domains, limited health literacy was observed to have a higher percentage in disease prevention (78.2%), while adequate health literacy was observed to have a higher percentage in health promotion (25.7%).

The mean general health literacy index was 19.3 ± 12.8, with a range from 0 to 50. The domains of health literacy pertaining to healthcare, disease prevention, and health promotion were observed to be 19.6 ± 13.9, 19.2 ± 13.1, and 19.0 ± 13.7, respectively. The scores for the health literacy index ranged from a minimum of 0 to a maximum of 50.

The frequency analysis of the ability to process health-related information shows a higher percentage of students in the lower literacy levels. Finding and appraising information were considered the most complex aspects, while applying and understanding were considered the most accessible aspects. Inadequate levels were reported by 70.4% of the students for finding information and 69.5% for appraising, compared to 61.6% for applying and 58.2% for understanding.

Table 3 presents the distribution of the mean and standard deviation of the health literacy index (on a scale 0 to 50) according to the competencies of health literacy: finding/accessing, understanding, appraising, and applying. The highest value of the health literacy index was observed in the understanding competency at the level of disease prevention (22.4 ± 17.3) and healthcare (21.4 ± 16.9). The lowest scores were observed in the appraising competencies of health care (17.0 ± 14.6), disease prevention (17.1 ± 15.0), and finding in disease prevention (17.3 ± 14.9). With regard to the health promotion dimension, it is not possible to assess the competence to apply. In the healthcare dimension, students exhibited greater difficulty in appraising (17.0 ± 14.6). In the domain of disease prevention, it is more challenging to appraise (17.1 ± 15.0) or find information (17.3 ± 14.9) than in the domain of health promotion, where the focus is on understanding (18.1 ± 14.9).

10.1371/journal.pone.0309806.t003 Table 3 Distribution of the mean and standard deviation of the health literacy index according to the competencies of health literacy: Access, understand, appraisal, and apply (on a scale of 0 to 50).

Health literacy dimensions	Health literacy competencies and health literacy index	
Find/Access	Understand	Appraise	Apply	All	
Healthcare	18.8 ± 15.4	21.4 ± 16.9	17.0 ± 14.6	21.1 ± 15.3	19.6 ± 13.9	
Disease Prevention	17.3 ± 14.9	22.4 ± 17.3	17.1 ± 15.0	18.3 ± 14.7	19.2 ± 13.1	
Health Promotion	20.0 ± 16.2	18.1 ± 14.9	20.5 ± 16.5	Not available, no data existing	19.0 ± 13.7	
All	18.2 ± 14.1	20.8 ± 16.2	17.5 ± 13.6	19.5 ± 14.8	19.3 ± 12.8	

Differences between independent variables and health literacy

Table 1 highlights significant differences between the characteristics of higher education students and their mean health literacy index. Analysis revealed that students aged 21–25 had a lower mean health literacy index than those aged 26–30. Moreover, students in the 26–30 age group had a higher mean health literacy index compared to those in the 16–20 and 21–25 age groups (p < .001). The Gabriel post-hoc test confirmed that students aged 21–25 exhibit a lower mean health literacy index than those aged 26–30. Additionally, students aged 26–30 demonstrate a higher mean health literacy index compared to those aged 16–20 and 21–25 (p < .01).

The mean health literacy index was significantly higher among female students compared to male students (p < .001). Additionally, students who completed secondary education in Portugal had a higher mean health literacy index than those who completed it outside Portugal (p < .001). However, no significant differences were observed between the mean health literacy index of students who completed secondary education in Alentejo and those who did not (p > .05).

Students who were displaced from their usual residence to attend the course scored lower on the mean health literacy index compared to non-displaced students (p < .001). Additionally, students with a father, mother, or cohabitant who was a health professional scored higher on the mean health literacy index than those without such a background (p < .001). However, the difference in the mean health literacy index based on the educational level of the students’ parents or cohabitants was not statistically significant (p = .092). In the context of higher education institutions, students from the Polytechnic Institute of Portalegre exhibited the highest mean health literacy index, followed by those from the Polytechnic Institutes of Beja, Santarém, and the University of Évora (p < .001). The Gabriel post-hoc Test indicated that students from the Polytechnic Institute of Beja had a higher mean health literacy index compared to students from the Polytechnic Institutes of Portalegre and Santarém, and the University of Évora (p < .001).

Students in the first year of the course had a higher mean of the health literacy index than students in second, third, fourth or fifth academic years (p < .001), and the Gabriel post-hoc Test revealed that first year students had higher mean of the health literacy index than the others. Finalists had higher mean of the health literacy index than non-finalists (p < .001).

Students with a previous healthcare degree achieved higher mean of the health literacy index than those without (p < .001). Additionally, students enrolled in health-related courses had a higher mean of the health literacy index compared to those in non-health-related courses (p < .001).

In relation to the perception of health condition, students with chronic conditions had a lower mean health literacy index than those without (p < .001). Additionally, students who reported a satisfactory perception of their health status had a higher mean health literacy index compared to those with an unsatisfactory perception (p < .001). Concerning perceived availability of money for expenses, students who reported good financial availability had a higher mean health literacy index than those who reported bad availability (p < .001).

The relationship between health literacy and student characteristics using multiple linear regression

The multiple linear regression model presented in Table 4 shows the relationship between health literacy and several independent variables among higher education students in the Alentejo region. The independent variables included were age, presence of chronic disease, attendance in health-related courses, living with a health professional, availability of money for expenses, perceived health status, and academic institution. The intercept represents the baseline health literacy score.

10.1371/journal.pone.0309806.t004 Table 4 Multiple linear regression model.

Variables	β	Standard Error	CI 95%	Wald Chi-Square	Sig.	
Lower	Higher	
Intercept	38.5	1.67	35.2	41.7	527.9	< .001	
Age	[16;20]	-3.5	.85	-5.2	-1.8	17.2	< .001	
[21;25]	-3.4	.83	-5.0	-1.7	16.8	< .001	
[26;30]	Ref	.	.	.	.	.	
Chronic disease (no)	1.8	.60	.6	3.0	9.1	.002	
Healthrelated course (no)	-9.8	.69	-11.2	-8.5	201.6	< .001	
Cohabitation healthprofissional (no)	-4.2	1.17	-6.5	-1.9	13.2	< .001	
Availabilty Money for expenses (bad)	-6.7	.83	-8.4	-5.1	66.4	< .001	
Perceived Health status (unsatisfactory)	-4.3	.86	-6.0	-2.6	25.6	< .001	
Academic Institution	Beja	2.8	.79	1.3	4.4	12.8	< .001	
Portalegre	3.9	.94	2.0	5.8	17.2	< .001	
Santarém	2.0	.80	.4	3.5	6.3	.012	
Évora	Ref	.	.	.	.	.	
Ref—Reference.

The results show that younger students, particularly those aged 16–20 and 21–25, had significantly lower health literacy scores than those aged 26–30, with differences of 3.5 and 3.4 points respectively (p < 0.001). The absence of chronic disease was associated with a higher health literacy score of 1.8 points (p = 0.002), suggesting better health literacy among students without chronic disease. Not attending a health-related course was associated with a significantly lower health literacy score of 9.8 points (p < 0.001), highlighting the impact of health education on health literacy levels.

The data also show that not living with a health professional was associated with a lower health literacy score of 4.2 points (p < 0.001), suggesting that living with health professionals has a positive impact on health literacy. Poor availability of money for expenses was associated with a lower health literacy score by 6.7 points (p < 0.001), highlighting the role of economic factors in health literacy. In addition, perceiving one’s health status as unsatisfactory was associated with a lower health literacy score by 4.3 points (p < 0.001), indicating a relationship between self-perceived health and health literacy.

Finally, differences in health literacy were observed between academic institutions were observed. Students from Beja had a higher health literacy score by 2.8 points higher than those from Évora (p < 0.001), students from Portalegre had a score 3.9 points higher (p < 0.001), and students from Santarém had a score 2.0 points higher (p = 0.012).

Discussion

Summary of findings

This study assessed the level of health literacy among higher education students in Alentejo, located in the south of Portugal, and analysed its relationship with several determinants. The results showed that a significant proportion of students had limited health literacy, which is consistent with previous research on Portuguese populations and highlights the critical need for targeted interventions. This pioneering study of health literacy in the region included 1228 students enrolled in either licentiate or integrated masters programmes, which exceeded the minimum sample size required for the analysis.

Health literacy levels

The results of the HLS-EU-PT-Q16 questionnaire indicated that 82.3% of students had a limited level of health literacy, while 17.7% had an adequate level. This result is consistent with previous studies [15, 23, 24] that reported a limited level of health literacy among Portuguese higher education students [23, 24]. The level observed in the Alentejo higher education student was almost double that found in studies conducted in Nepal and Ghana [15, 44].

Previous studies conducted in Portugal with the Portuguese population have indicated that there is a limited level of health literacy, with unsatisfactory levels of health literacy observed. A study published by Arriaga et al. identified a general health literacy index of 63.8 ± 11.5 in the general Portuguese population, on a standardised scale of 0 to 100 [37]. Of the participants, 65.0% were classified as having an adequate level of health literacy, while and 22.0% were classified as having a problematic level [37]. A higher proportion of students in higher education in Alentejo exhibited inadequate and problematic health literacy, as evidenced by the observed percentages of 62.4% and 19.9%, respectively, which were higher than those observed in the mainland Portuguese population. A lower level of health literacy is associated with a range of adverse health outcomes, including suboptimal health choices, limited understanding of health conditions, difficulties in reading and comprehending medical information, and the inability to engage in preventive health measures [19, 23]. It can be posited that students enrolled in higher education in the Alentejo region may be more susceptible to adverse health outcomes and suboptimal health decisions due to their limited health literacy.

Subdomain analysis

The mean health literacy index score for students enrolled in higher education institutions in the Alentejo region was 19.3 ± 12.8 (on a scale of 0 to 50). The mean values for the subdomains were 19.4 ± 13.9 for healthcare, 19.1 ± 13.1 for disease prevention, and 19.0 ± 13.7 for health promotion. The observed values in this study were found to be lower than those reported in previous studies of Portuguese nursing students [23] and students from other disciplines [24].

In terms of processing health-related information, such as finding, understanding, appraising, and applying it, students demonstrated a high health literacy index for understanding information about disease prevention but a lower index for appraising information about healthcare and disease prevention. To the best of our knowledge, no previous studies allow for a comparison of the health literacy index of skills among higher education students in the Alentejo region. However, compared to the general population, Alentejo higher education students exhibited lower scores [37].

Determinants of health literacy

Socio-demographic variables

Most students were aged between 21 and 25 years, with a mean age of 21.3 ± 2.9 years. Interestingly, the highest level of health literacy was observed among the oldest students, a finding consistent with previous studies assessing health literacy levels among higher education students [23, 24, 27, 45–47]. In terms of gender, 46.1% of students were male, and 54.2% were female. Although there was a statistically significant difference in the mean health literacy index by gender, it did not emerge as an influencing factor on the score. These findings align with previous studies by Kühn et al. and Evans et al., which have demonstrated a relationship between gender and health literacy [25, 44].

A high proportion of students (97.0%) completed their secondary education in Portugal, with 65.6% specifically in the Alentejo region. The proportion of students who completed secondary education outside Portugal is below the expected level, highlighting the challenge of internationalizing higher education institutions. However, this study’s findings do not provide evidence to support the impact of internationalization on health literacy.

A discrepancy in health literacy was identified among students who completed secondary education in Portugal, emphasizing the need for further investigation into the health literacy of students who completed secondary education abroad and the factors associated with it. These data indicate the necessity for health literacy interventions for students who completed secondary education outside of Portugal and are currently pursuing higher education in Portugal. Those with limited health literacy may be more susceptible to making poor health decisions.

No statistically significant differences were observed between students who completed their secondary education in Alentejo and those who completed it outside of Alentejo. It was determined that this phenomenon was not limited to a specific region but rather a national one, and that it was not confined to a particular demographic. The mean health literacy index score for displaced students was found to be lower than that of non-displaced students. It was demonstrated that students who cohabited with health professionals exhibited a higher mean health literacy index score. It was concluded that health literacy interventions should be promoted in the academic context due to the health vulnerability associated with low health literacy. This may be related to the need of students to live temporarily or permanently in another district due to course frequency, without the support of family and friends.

The results of this study indicate that there were no statistically significant differences between the mean health literacy score and the educational level of the students’ parents or the person with whom the students lived. This association was contrary to that identified by Zhang et al. (2016) in a study with nursing students [12] or by Cheong et al. (2024) developed with health science students [46, 48] or by Kühn et al. (2022) in a systematic review of the literature that identified it as a determinant of health literacy [25].

The mean health literacy index score for students from the Polytechnic Institute of Portalegre was found to be higher than that of students from other academic institutions. First-year students from all academic institutions exhibited a higher mean health literacy index score. The mean health literacy index score for finalists was found to be higher than that of non-finalists. It is our understanding that it is not possible to make a comparison of these scores due to the lack of studies on health literacy among higher education students in the Alentejo region. However, the outcomes were comparable to those observed in other studies conducted with higher education students [24, 45, 46].

Students enrolled in health-related courses exhibited higher health literacy index values compared to students enrolled in non-related courses. Attending a health-related course is associated with a higher level of health literacy [23, 25, 46]. In a comparative study of higher education Portuguese students in nursing and other areas, Amaral et al. (2021) observed that 61% of students had a problematic or inadequate level of general health literacy [23]. The majority of respondents reported sufficient or problematic levels across all domains of the questionnaire, with nursing students exhibiting a higher level of health literacy and student workers a lower level [23]. This finding was consistent with those observed in other countries [47], including Ghana [44], China [13, 48] and the United States of America [49]. The incorporation of health-related themes in their courses may explain this result, which could positively influence students’ health literacy. Therefore, it is crucial to implement health literacy interventions in higher education to enhance students’ healthcare, disease prevention and health promotion knowledge, as these factors have a positive impact on their health outcomes [25, 50]. Since the inception of health-related programmes, students have been exposed to health literacy interventions. These interventions seek to familiarise students with health-related knowledge, the healthcare environment, the importance of disease prevention, and health promotion. In this context, it was observed that there were differences in health literacy between students who had previously taken a health-related course and those who had not.

Chronic disease

Students with chronic disease exhibited a lower mean health literacy index score than students those without, and students with bad perceived health status also exhibited lower scores than students with good perceived health status. The results were found to be inconsistent with those reported in the study by Pedro et al. (2022), which was carried out with higher education students in Portugal [24]. With regard to the correlation between perceived health status and the average score on the health literacy index, the results were found to be consistent with those observed by Bánfai-Csonka et al. (2022) in a study of university health science students of different nationalities [51].

Perceived availability of money for expenses and health status

The findings of this study indicate that students who perceive limited availability of money for expenses exhibit lower levels of health literacy. It is important to recognise that social and economic inequalities have a significant impact on health literacy, and therefore require particular attention [12, 15, 25, 50–52]. It is important to note that health literacy interventions can be tailored to meet the specific needs of students in relation to the various health literacy subdomains. Health literacy interventions have been demonstrated to impact health outcomes [25, 50].

Regression analysis showed that lower levels of health literacy were associated with several factors, including not attending health-related courses, not living with a health professional, perceiving bad availability of money for expenses, and having an unsatisfactory health status. Other authors have also identified similar outcomes, indicating that students with higher levels of health literacy were enrolled in health-related courses, resided with a healthcare professional, had convenient access to financial resources for expenses, and demonstrated satisfactory health status [25, 45].

Strengths and limitations

A critical evaluation of the study’s findings reveals several potential biases, limitations and implications for future research. One potential bias is sampling bias, where the sample, although representative with a margin of error of 3%, may not fully represent the diversity of the higher education student population in the Alentejo region. Although efforts were made to reach a wide audience through multiple dissemination channels, inherent biases in voluntary response rates may persist.

In addition, response bias could be an issue as students who chose to participate may have different characteristics to those who did not, potentially skewing the results. Mitigation efforts included regular reminders and incentives to increase participation to reduce non-response bias. Another concern is the digital divide, where differences in access to digital resources may have affected the participation rates and the representativeness of the sample. Although the survey was designed to be mobile-friendly and institutions provided access to the necessary technology, some inequality may still exist.

The focus of the study on the Alentejo region limits the generalisability of the findings to other regions, highlighting geographical specificity as a limitation. Future studies should consider a broader geographical scope to increase the applicability of the results. In addition, the reliance on self-reported data may introduce social desirability bias.

It is important to recognise that the study had some limitations. The results should be interpreted with caution. The baseline level of health literacy was found to be low, and the study design (cross-sectional) does not allow to establish causal relationships, as only some of the potential determinants/factors associated with the level of health literacy among higher education students in Alentejo were analysed. Nevertheless, it is possible to identify a potential health vulnerability. Previous research has shown that health literacy interventions in higher education can significantly improve students’ ability to make informed health-related decisions, thereby reducing their vulnerability to poor health outcomes. [50]. The implementation of training programmes focused on healthcare, disease prevention and health promotion could significantly improve the health literacy of higher education students in Alentejo.

Despite these limitations, the study provides valuable insights into the health literacy of higher education students in Alentejo. By addressing these biases and limitations in future research, we can improve the accuracy and applicability of the findings, ultimately leading to more effective health literacy interventions.

Future research and interventions

The findings highlight the urgent need for health literacy interventions in higher education, particularly for students at risk of making poor health decisions. Educational programmes focused on healthcare, disease prevention and health promotion could significantly improve health literacy.

Future studies should incorporate qualitative methods to gain deeper insights into the factors that influence health literacy. Policy makers should use these findings to develop targeted strategies to address gaps, particularly among underrepresented groups. Although this study provides valuable insights, it must be interpreted with caution due to potential biases and limitations. Addressing these issues in future research will improve understanding and lead to more effective health literacy strategies.

As expected, health students, older students, those living with health professionals and those with enough money for expenses showed higher levels of health literacy.

Conclusions

The study identified lower levels of health literacy among higher education students in the Alentejo during the 2022/2023 academic year, highlighting significant challenges and thus answering the first research question. Key determinants of health literacy were identified, including age, presence/absence of chronic disease, course type, living with health professionals, availability of money for expenses and perceived health status. Younger students, those with chronic conditions, those not enrolled in health-related courses, those not living with a health professional, those with limited financial resources and those who perceived their health as unsatisfactory had lower levels of health literacy. These findings answered the second research question. The deficits identified may affect their wellbeing and future health outcomes. Understanding these determinants is crucial for the development of targeted interventions and educational programmes to improve health literacy and promote better health outcomes among higher education students in the region.

Given their significant social influence, higher education students, play a vital role in shaping health-related decisions for themselves and their communities, particularly in a region facing a growing ageing population that poses challenges to health care and social cohesion. The results show significant differences in health literacy, indicating difficulties in understanding health information and making informed decisions. Comparison of these findings with data from other countries can further inform strategies to improve the health and well-being of higher education students. Improving socio-economic support, reducing inequalities and preventing student attrition are essential steps in addressing these challenges.

Overall, the study indicates the need for higher education institutions to prioritise the improvement of health literacy. By identifying specific factors influencing health literacy levels in this population, the study enriches the existing literature and provides important information for educators, policy makers and health professionals involved in decision-making processes within higher education. Efforts should focus on promoting all domains of health literacy: health care, disease prevention and health promotion. This study emphasises the need to integrate health literacy into educational curricula and policy frameworks to effectively address these gaps.

Based on the results of the study, targeted health literacy interventions should be implemented to meet the identified needs of higher education students in the Alentejo region. For example, the implementation of interactive workshops on navigating health systems and promoting healthy lifestyles could improve students’ understanding and decision-making about their health. In addition, policy changes should prioritise the integration of health literacy into higher education curricula to ensure comprehensive health education.

The limitations of the study highlight the need for caution in interpreting the results. Reliance on self-reported data and potential bias in participant selection may have influenced the results. Future research should use longitudinal approaches to track changes in health literacy over time and assess the effectiveness of different intervention strategies. These findings are essential to refine health literacy interventions and ensure that they meet the diverse needs of higher education students.

In conclusion, the results of this study highlight the urgent need to address the low levels of health literacy among higher education students in the Alentejo region. To mitigate the risks associated with low health literacy, it is essential to implement targeted interventions that foster informed decision-making and promote healthier lifestyles. Educational institutions should consider developing comprehensive curricula that include health literacy as a core competency, as well as offering practical workshops and establishing support networks involving health professionals.

In addition, future research should aim to use mixed methods to gain deeper insights into the dynamics of health literacy, expand geographically to improve comparability, and use longitudinal approaches to track changes over time. By prioritising health literacy in education and public health policy, we can empower the students with the skills necessary to improve health outcomes and ultimately contribute to a healthier society.

10.1371/journal.pone.0309806.r001
Decision Letter 0
Ramalho André Academic Editor
© 2024 André Ramalho
2024
André Ramalho
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submission Version0
25 Jun 2024

PONE-D-24-22935Health literacy and its determinants among higher education students in the Alentejo region of southern Portugal - a cross-sectional surveyPLOS ONE

Dear Dr. Rosário,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Aug 09 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

André Ramalho, PhD

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at 

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and 

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. We note that your Data Availability Statement is currently as follows: 

"All relevant data are within the manuscript and its Supporting Information files."

Please confirm at this time whether or not your submission contains all raw data required to replicate the results of your study. Authors must share the “minimal data set” for their submission. PLOS defines the minimal data set to consist of the data required to replicate all study findings reported in the article, as well as related metadata and methods (https://journals.plos.org/plosone/s/data-availability#loc-minimal-data-set-definition).

For example, authors should submit the following data:

- The values behind the means, standard deviations and other measures reported;

- The values used to build graphs;

- The points extracted from images for analysis.

Authors do not need to submit their entire data set if only a portion of the data was used in the reported study.

If your submission does not contain these data, please either upload them as Supporting Information files or deposit them to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of recommended repositories, please see https://journals.plos.org/plosone/s/recommended-repositories.

If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially sensitive information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. If data are owned by a third party, please indicate how others may request data access.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The text has been described the relevants contexts. The aims is conected with methodology and results. The discussion is conected with results and presents a complete text. Congratulations for the authors.

Reviewer #2: Detailed Section-by-Section Review of the Manuscript

Manuscript Title:

Health literacy and its determinants among higher education students in the Alentejo region of southern Portugal - a cross-sectional survey

1. Introduction

• Lack of Contextual Background: The introduction provides general information on health literacy but lacks a detailed context specific to the Alentejo region or higher education students in Portugal.

• Limited Discussion on Previous Research: While there is a mention of health literacy's importance, there is sparse discussion of previous studies directly comparing or contrasting this study's findings with existing data.

• Theoretical Framework Missing: The introduction lacks a theoretical framework or model that guides the investigation of health literacy determinants.

• Insufficient Justification for Study: The rationale for why this study is needed in the Alentejo region is not adequately justified.

• Lack of Hypotheses: No hypotheses are presented, which makes it challenging to understand the expected outcomes or the direction of the research.

2. Methodology

• Unclear Sampling Method: The sampling method is not described in detail, making it difficult to assess the representativeness of the sample. Provide a more detailed explanation of the sampling process, including any stratification or weighting applied to ensure representativeness.

• Lack of Detail on Data Collection: The data collection process is not fully detailed, including how the survey was administered and how responses were recorded.

Discuss potential biases introduced by the online collection method and steps taken to mitigate these issues.

3. Results

Problems:

• Overemphasis on Descriptive Statistics: The results section heavily focuses on descriptive statistics without sufficient emphasis on inferential statistics that address the research questions. More detailed analysis, including regression models and other inferential statistics, is needed to identify determinants of health literacy.

• Lack of Contextual Interpretation: Results are presented without sufficient interpretation in the context of the study's aims and existing literature.

4. Discussion

• Overgeneralization: The discussion tends to generalize the findings without acknowledging the specific context of the Alentejo region or higher education students.

• Lack of Critical Evaluation: There is insufficient critical evaluation of the study's findings, including potential biases, limitations, and implications for future research.

5. Conclusion

• Overly General Conclusions: The conclusions drawn are too general and do not adequately reflect the specific findings of the study.

o Example: "This study will contribute to the existing literature by elucidating the health literacy level among higher education students in Alentejo, Portugal, and its determinants."

• Lack of Specific Recommendations: The conclusion does not provide specific recommendations for interventions or policy changes based on the findings.

Recommendations:

• Provide a concise summary of the key findings and their implications.

• Offer specific recommendations for health literacy interventions and policy changes based on the findings.

• Summarize the study's limitations and discuss their implications for future research and practice.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

10.1371/journal.pone.0309806.r002
Author response to Decision Letter 0
Submission Version1
23 Jul 2024

Response to reviewer 1:

Dear reviewer,

Manuscript title: Health literacy and its determinants among higher education students in the Alentejo region of southern Portugal - a cross-sectional survey

Thank you very much for your feedback on our manuscript. We appreciate your acknowledgement of our work, entitled “Health literacy and its determinants among higher education students in the Alentejo region of southern Portugal: a cross-sectional study”. Below we outline the main improvements we have made to further improve the manuscript:

1. Introduction

• Contextual background: We extended the contextual background to include the specific challenges and characteristics of the Alentejo region and the higher education context in Portugal.

• Literature Review: The discussion of previous studies on health literacy was expanded to provide a more comprehensive overview.

• Theoretical framework: A theoretical framework based on Sørensen et al. (2012) was introduced to better guide the investigation of the determinants of health literacy.

• Rationale: The rationale for the study was strengthened by highlighting gaps in the current literature and the specific challenges faced in the Alentejo region.

• Research questions: We have added specific research questions to clarify the expected outcomes and direction of our research.

2. Methodology

• Sampling procedure: A more detailed explanation of the sampling process was provided, including the selection criteria for higher education institutions in the Alentejo region.

• Data Collection: We have expanded the description of the data collection process, detailing the administration of the online survey and the measures taken to mitigate potential biases.

• Sample robustness: We clarified the robustness of the sample, including the margin of error, which is 3%.

3. Results section

• Inferential statistics: The results section has been expanded to include more detailed inferential statistics, to address the research questions and identify determinants of health literacy more comprehensively.

• Interpretation: We provided a more robust interpretation of the results in relation to the study aims and existing literature.

4. Discussion

• Contextual analysis: The discussion was broadened to avoid over-generalisation, focusing specifically on the context of the Alentejo region and higher education students.

• Comparative analysis: We have enriched the discussion by making explicit comparisons with other relevant studies on health literacy.

• Implications: The discussion of practical and policy implications was extended, with a focus on the Alentejo region.

• Limitations and future research: We included a critical evaluation of the study's limitations and potential biases, as well as suggestions for future research directions.

5. Conclusion

• Summary and recommendations: The conclusion has been revised to provide a clearer summary of the main findings and their implications for health literacy promotion and policy development in the Alentejo region. We have included specific recommendations for interventions and policy changes based on the study findings to ensure actionable and relevant conclusions for stakeholders.

We hope that these improvements will further enhance the clarity, context and impact of our manuscript. Thank you once again for your encouraging feedback.

Sincerely,

Jorge Rosário

Sara Simões Dias

Sónia Dias

Ana Rita Pedro

Response to reviewer 2:

Dear reviewer,

Manuscript Title: Health literacy and its determinants among higher education students in the Alentejo region of southern Portugal - a cross-sectional survey

Thank you for your detailed and constructive feedback on our manuscript. We have made significant revisions based on your comments:

1. Introduction

• Lack of Contextual Background: The introduction provides general information on health literacy but lacks a detailed context specific to the Alentejo region or higher education students in Portugal.

We appreciate your comment about the need for more specific contextual background in relation to the Alentejo region and higher education students in Portugal. In response, we have expanded the introduction to provide a more detailed context that situates our study within the regional and educational contexts of the Alentejo.

The following information has been added:

“Transitioning from a national perspective to a more focused regional context, the Alentejo faces particular challenges. It has the lowest percentage of tertiary educated and high drop-out rates (29). The Alentejo region in southern of Portugal, which is classified both as a Territorial Level 2 (TL2) and a Nomenclature of Territorial Units for Statistics II (NUTS II) region, covers an area of 31,605 km², about 30% of the national territory. This region has a low population density and is threatened by depopulation due to a decreasing young population, an increasing elderly population and low immigration (30,31). Addressing these inequalities requires promoting health literacy and healthy behaviours from an early age, particularly in rural areas facing demographic challenges (32,33).

The regional focus not only demonstrates the existence of educational and health inequalities but also emphasis the pressing necessity to conduct research and implement solutions at the local level. By elucidating the health literacy levels of higher education students in Alentejo, this research can provide insights into regional inequalities and inform policies aimed at reducing these disparities, ultimately benefiting both individual and community health outcomes.

It is therefore imperative to assess the level of health literacy among higher education students and investigate its association with various determinants. To the best of our knowledge, the current level of health literacy among higher education students in Alentejo is unknown, which makes it challenging to design effective health interventions.”

• Limited Discussion on Previous Research: While there is a mention of health literacy's importance, there is sparse discussion of previous studies directly comparing or contrasting this study's findings with existing data.

We have revised the introduction to include a more comprehensive discussion of previous studies on health literacy, specifically addressing how our findings compare and contrast with existing data in the field.

• Theoretical Framework Missing: The introduction lacks a theoretical framework or model that guides the investigation of health literacy determinants.

A theoretical framework guiding our investigation of the determinants of health literacy has been included in the introduction, providing a clearer basis for our study

The following information has been added:

“In order to gain further insight into the pathways linking health literacy to health behaviours and outcomes, Sørensen et al. (2012) developed the Integrated Model of Health Literacy. This theoretical framework delineates the pathways linking health literacy to health behaviours and outcomes. The model identifies the determinants and factors influencing health literacy levels (the antecedents) and their subsequent health outcomes (the consequences) (1). This theoretical framework, predominant in Europe, describes four core competencies of health literacy: access (the ability to seek, find, and obtain health information), understand (the ability to comprehend accessed health information), appraise (the ability to interpret, filter, judge and evaluate the health information that was assessed) and apply (the ability to communicate and utilise the information to make decision to maintain and improve health). The four competencies, namely accessing, understanding, appraising and applying, can be applied across the three domains of the health continuum, including healthcare, disease prevention and health promotion (1).

An understanding of these competencies, serve to highlight the dynamic and holistic nature of health literacy. This encompasses not only the abilities of individuals, but also the inherent complexity of health systems. This framework facilitates comprehension and improvement of health literacy across heterogeneous populations and healthcare settings. The empowerment of individuals through the acquisition of these skills fosters autonomy and informed decision-making in matters pertaining to health (6) thereby enhancing social participation and well-being. Furthermore, the structural organisation and availability of resources have a significant impact on health literacy levels and individuals' ability to make informed health decisions, which in turn affect personal and community health (7).”

• Insufficient Justification for Study: The rationale for why this study is needed in the Alentejo region is not adequately justified.

We have strengthened the rationale for our study in the Alentejo region by highlighting specific gaps in the current literature and emphasising the unique regional challenges that justify our research focus.

The following information has been added:

“It is therefore imperative to assess the level of health literacy among higher education students and investigate its association with various determinants. To the best of our knowledge, the current level of health literacy among higher education students in Alentejo is unknown, which makes it challenging to design effective health interventions. “

• Lack of Hypotheses: No hypotheses are presented, which makes it challenging to understand the expected outcomes or the direction of the research.

We included the following research questions:

• “What is the level of health literacy among higher education students in the Alentejo region of southern Portugal?

• What is the relationship between health literacy and determinants such as socio-demographic variables, the presence of chronic disease, perceived health status, and perceived availability of money for expenses among higher education students in the Alentejo region?

The responses to these questions will facilitate the implementation of targeted interventions and policies designed to reduce inequalities and enhance health outcomes in this region. It is expected that health students, younger students who live with health professionals and have enough money for expenses will have higher health literacy.”

2. Methodology

• Unclear Sampling Method: The sampling method is not described in detail, making it difficult to assess the representativeness of the sample. Provide a more detailed explanation of the sampling process, including any stratification or weighting applied to ensure representativeness.

For a better understanding, we have explained our sampling method. Our sample was selected from higher education institutions in the Alentejo region, specifically in Portalegre, Santarém, Évora and Beja. We identified our target population as students enrolled in higher education institutions in the Alentejo region.

We didn't use any stratification or weighting in our study. However, our sampling method was designed to capture a broad and diverse subset of students. Our aim remained to gain an overall understanding of the student population in the Alentejo region.

No stratification or weighting was applied in our sampling process, as the objectives of our study are specifically centred on this region and its higher education institutions. Our aim is not to generalise the results beyond this context. We don't intend to generalise the results to every student at every institution. The sample has a margin of error of 3%, which is low in most cases and guarantees the robustness of our results.

• Lack of Detail on Data Collection: The data collection process is not fully detailed, including how the survey was administered and how responses were recorded.

Discuss potential biases introduced by the online collection method and steps taken to mitigate these issues.

We have expanded the description of our data collection process, including how the survey was administered online and the steps taken to mitigate potential bias introduced by this method.

The following information has been added:

“Institutional Approval and Promotion

The governing body of each institution was contacted via email to explain the aims and importance of the study, and to request their approval. Once approval was granted, the institution promoted the link to the questionnaire, along with the consent form, to students via their official social media platforms and email lists. To reinforce the importance of participation, and encourage participation, course coordinators were asked to highlight the importance of the survey in emails and meetings. This multi-channel approach was intended to ensure high visibility and maximise response rates.

Survey Administration

Responses were collected electronically using an online survey tool that automatically recorded and securely stored data. The tool ensured anonymity and confidentiality in line with ethical research standards. Regular reminders were sent to students to maximise participation, and technical support was provided to resolve any problems encountered when completing the survey. The survey was designed to be mobile-friendly, ensuring accessibility on various devices, including smartphone or tablets. It was conciseness to minimise the time required for completions.

Addressing Potential Biases

The potential biases inherent in the online data collection method were recognised, including the exclusion of students without internet access, electronic devices or familiarity with digital technologies. To mitigate these concerns, the survey was made accessible on various devices available at higher education institutions, and participants were provided with technical support available at institutions where necessary. In addition, the multi-channel promotion strategy aimed to widen participation across different student populations, thus ensuring a more diverse and representative sample. “

3. Results

Problems:

• Overemphasis on Descriptive Statistics: The results section heavily focuses on descriptive statistics without sufficient emphasis on inferential statistics that address the research questions. More detailed analysis, including regression models and other inferential statistics, is needed to identify determinants of health literacy.

In response to your feedback, we have enhanced the results section with more detailed inferential statistics, such as regression models, to better address the research questions and identify determinants of health literacy.

It was added the following information:

“The multiple linear regression model presented in Table 4 shows the relationship between health literacy and several independent variables among higher education students in the Alentejo region. The independent variables included were age, presence of chronic disease, attendance in health-related courses, living with a health professional, availability of money for expenses, perceived health status, and academic institution. The intercept represents the baseline health literacy score.

The results show that younger students, particularly those aged 16-20 and 21-25, had significantly lower health literacy scores than those aged 26-30, with differences of 3.5 and 3.4 points respectively (p < 0.001). The absence of chronic disease was associated with a higher health literacy score of 1.8 points (p = 0.002), suggesting better health literacy among students without chronic disease. Not attending a health-related course was associated with a significantly lower health literacy score of 9.8 points (p < 0.001), highlighting the impact of health education on health literacy levels.

The data also show that not living with a health professional was associated with a lower health literacy score of 4.2 points (p < 0.001), suggesting that living with health professionals has a positive impact on health literacy. Poor availability of money for expenses was associated with a lower health literacy score by 6.7 points (p < 0.001), highlighting the role of economic factors in health literacy. In addition, perceiving one's health status as unsatisfactory was associated with a lower health literacy score by 4.3 points (p < 0.001), indicating a relationship between sel

Attachment Submitted filename: Response to reviewer 2.docx

10.1371/journal.pone.0309806.r003
Decision Letter 1
Ramalho André Academic Editor
© 2024 André Ramalho
2024
André Ramalho
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submission Version1
20 Aug 2024

Health literacy and its determinants among higher education students in the Alentejo region of southern Portugal - a cross-sectional survey

PONE-D-24-22935R1

Dear Dr. Rosário,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

André Ramalho, PhD

Academic Editor

PLOS ONE

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: (No Response)

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: Yes: Bruno Filipe Coelho da Costa

**********

10.1371/journal.pone.0309806.r004
Acceptance letter
Ramalho André Academic Editor
© 2024 André Ramalho
2024
André Ramalho
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
13 Sep 2024

PONE-D-24-22935R1

PLOS ONE

Dear Dr. Rosário,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team.

At this stage, our production department will prepare your paper for publication. This includes ensuring the following:

* All references, tables, and figures are properly cited

* All relevant supporting information is included in the manuscript submission,

* There are no issues that prevent the paper from being properly typeset

If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps.

Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

If we can help with anything else, please email us at customercare@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Prof. Dr. André Ramalho

Academic Editor

PLOS ONE
==== Refs
References

1 Sørensen K , Van Den Broucke S , Fullam J , Doyle G , Pelikan J , Slonska Z , et al . Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health [Internet].2012 Jan 25;12 (1 ). Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-12-8010.1186/1471-2458-12-80 22276600
2 Nutbeam D. Health Promotion Glossary. Health Promotion International. 1998 Jan 1; 13 (4 ): 349–64.
3 Kickbusch I, Pelikan JM, Apfel F, Tsouros AD, editores. Health literacy: the solid facts. Copenhagen: World Health Organization Regional Office for Europe; 2013.
4 Nations U. Health Literacy and Sustainable Development [Internet]. United Nations. https://www.un.org/en/chronicle/article/health-literacy-and-sustainable-development
5 Nutbeam D. Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century. Health Promotion International [Internet]. 2000 Sep 1;15 (3 ):259–67. Available from: https://academic.oup.com/heapro/article/15/3/259/551108
6 Nutbeam D. The evolving concept of health literacy. Social Science & Medicine. [Internet]. 2008 Dec;67 (12 ):2072–8. Available from: https://pubmed.ncbi.nlm.nih.gov/18952344/ doi: 10.1016/j.socscimed.2008.09.050 18952344
7 Nutbeam D, Muscat DM. Advancing Health Literacy Interventions. Health Literacy in Clinical Practice and Public Health [Internet]. 2020 [cited 2024 Feb 4];115–27. https://ebooks.iospress.nl/volumearticle/54533
8 Kinoshita S , Hirooka Nobutaka , Kusano T , Saito K , Aoyagi R . Does health literacy influence health-related lifestyle behaviors among specialists of health management? A cross-sectional study. BMC Primary Care. 2024 Jan 20;25 (1 ). doi: 10.1186/s12875-024-02263-1 38245688
9 Diederichs C , Jordan S , Domanska O , Neuhauser H . Health literacy in men and women with cardiovascular diseases and its association with the use of health care services—Results from the population-based GEDA2014/2015-EHIS survey in Germany. Devleesschauwer B , editor. PLOS ONE. 2018 Dec 6;13 (12 ):e0208303. doi: 10.1371/journal.pone.0208303 30521588
10 Wagner C v. , Knight K , Steptoe A , Wardle J . Functional health literacy and health-promoting behaviour in a national sample of British adults. Journal of Epidemiology & Community Health. 2007 Dec 1;61 (12 ):1086–90.18000132
11 The HLS19 Consortium of the WHO Action Network M-POHL. International Report on the Methodology, Results, and Recommendations of the European Health Literacy Population Survey 2019–2021 (HLS19) of M-POHL. [Internet]. Austrian National Public Health Institute, Vienna; 2021. https://m-pohl.net/sites/m-pohl.net/files/inline-files/HLS19%20International%20Report.pdf
12 Zhang Y , Zhang F , Hu P , Huang W , Lu L , Bai R , et al . Exploring Health Literacy in Medical University Students of Chongqing, China: A Cross-Sectional Study. Montazeri A , editor. PLoS ONE. 2016 Apr 6;11 (4 ):e0152547. doi: 10.1371/journal.pone.0152547 27050169
13 Wang W , Hou Y , Hu N , Zhang D , Tao J , Man Y , et al . A cross-sectional study on health-related knowledge and its predictors among Chinese vocational college students. BMJ Open. 2014 Oct;4 (10 ):e005182. doi: 10.1136/bmjopen-2014-005182 25311037
14 Watson R. Europeans with poor «health literacy» are heavy users of health services. BMJ (Clinical research ed) [Internet]. 2011 Nov 29;343 : d7741. Available from: https://pubmed.ncbi.nlm.nih.gov/22127773/ doi: 10.1136/bmj.d7741
15 Bhusal S , Paudel R , Gaihre M , Paudel K , Adhikari TB , Pradhan PMS . Health literacy and associated factors among undergraduates: A university-based cross-sectional study in Nepal. Nazif-Munoz JI , editor. PLOS Glob Public Health. 2021 Nov 8;1 (11 ):e0000016. doi: 10.1371/journal.pgph.0000016 36962072
16 Fan Z ya , Yang Y , Zhang F . Association between health literacy and mortality: a systematic review and meta-analysis. Archives of Public Health. 2021 Jul 1;79 (1 ). doi: 10.1186/s13690-021-00648-7 34210353
17 Berkman ND , Sheridan SL , Donahue KE , Halpern DJ , Crotty K . Low Health Literacy and Health Outcomes: An Updated Systematic Review. Annals of Internal Medicine [Internet]. 2011 Jul 19;155 (2 ):97. Available from: https://pubmed.ncbi.nlm.nih.gov/21768583/ doi: 10.7326/0003-4819-155-2-201107190-00005 21768583
18 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. American Journal of Public Health. 2002 Aug;92 (8 ):1278–83. doi: 10.2105/ajph.92.8.1278 12144984
19 Cho YI , Lee SYD , Arozullah AM , Crittenden KS . Effects of health literacy on health status and health service utilization amongst the elderly. Social Science & Medicine. 2008 Apr;66 (8 ):1809–16. doi: 10.1016/j.socscimed.2008.01.003 18295949
20 Ana Rita Pedro. Doentes crónicos com baixo nível de literacia em saúde recorrem mais às urgências. [Internet]. 2019. https://www.dn.pt/vida-e-futuro/doentes-cronicos-com-baixo-nivel-de-literacia-em-saude-recorrem-mais-as-urgencias--11605073.html/
21 Goto E , Ishikawa H , Okuhara T , Kiuchi T . Relationship of health literacy with utilization of health-care services in a general Japanese population. Preventive Medicine Reports. 2019 Jun;14 :100811. doi: 10.1016/j.pmedr.2019.01.015 30815332
22 Ishikawa H , Kato M , Kiuchi T . Declines in health literacy and health-related quality of life during the COVID-19 pandemic: a longitudinal study of the Japanese general population. BMC Public Health. 2021 Nov 27;21 (1 ):2180. doi: 10.1186/s12889-021-12092-x 34837972
23 Amaral O , Pedro AR , Veiga N , Escoval A , Ferreira M . Literacia em saúde em estudantes do ensino supeior: comparaçã entre estudantes de enfermagem e estudantes de outras áreas literacia em saúde em estudantes do ensino superior de viseu. Revista INFAD de Psicología International Journal of Developmental and Educational Psychology. 2021 Aug 8;2 (1 ):97–106.
24 Pedro A , Rosário R , Monteiro I , Cerqueira M , Roque S , Assunção V , et al . Health literacy in higher education students: findings from a Portuguese study. European Journal of Public Health. 2022 Oct 1;32 (Supplement_3 ).
25 Kühn L , Bachert P , Hildebrand C , Kunkel J , Reitermayer J , Wäsche H , et al . Health Literacy Among University Students: A Systematic Review of Cross-Sectional Studies. Front Public Health. 2022 Jan 21;9 .
26 Dashti S , Abadibavil D , Roozbeh N . Evaluating e-health literacy, knowledge, attitude and practice regarding COVID-19 prevention and Self-Protection among Iranian students: a cross-sectional online survey. BMC Med Educ. 2022 Mar 5;22 (1 ). doi: 10.1186/s12909-022-03210-3 35248025
27 Almeida S , Pinto E , Correia M , Veiga N , Almeida A . Evaluating E-Health Literacy, Knowledge, Attitude, and Health Online Information in Portuguese University Students: A Cross-Sectional Study. IJERPH. 2024 Feb 27;21 (3 ):271. doi: 10.3390/ijerph21030271 38541272
28 Solak M. The Health Literacy Among Turkish University Students. HRJ. 2024 Jan 9;10 (1 ):40–50.
29 Fundação José Neves. Alentejo é a região de Portugal Continental com menos diplomados [Internet]. https://www.joseneves.org/artigo/alentejo-e-a-regiao-de-portugal-continental-com-menos-diplomados
30 OECD. Delivering Quality Services to All in Alentejo: Preparing Regions for Demographic Change, OECD Rural Studies, OECD Publishing. 1st ed. Paris: Organization for Economic Cooperation & Development; 2022.
31 PORDATA. Onde há mais e menos pessoas, em média, por km2? [Internet]. Densidade populacional segundo os Censos. https://www.pordata.pt/municipios/densidade+populacional+segundo+os+censos-591
32 Keating N. A research framework for the United Nations Decade of Healthy Ageing (2021–2030). Eur J Ageing. 2022 Jan 12;19 (3 ):775–87. doi: 10.1007/s10433-021-00679-7 35035341
33 World Health Organization. UN Decade of Healthy Ageing: Plan of Action 2021–2030 [Internet]. 2020. https://cdn.who.int/media/docs/default-source/decade-of-healthy-ageing/decade-proposal-final-apr2020-en.pdf?sfvrsn=b4b75ebc_28
34 Direção-Geral de Estatísticas da Educação e Ciência (DGEEC). Inscritos em estabelecimentos de Ensino Superior—2022/2023. 2023; https://www.Direção-Geral de Estatísticas da Educação e Ciência (DGEEC)dgeec.medu.pt/art/ensino-superior/estatisticas/vagas-e-inscritos/652fba6bbd5c2b00958292c4#artigo-6576f80c5f39ee77721e9e66
35 Pedro AR , Raposo B , Luís L , Amaral O , Escoval A , Simões Dias S . Portuguese Version of the HLS-EU-Q6 and HLS-EU-Q16 Questionnaire: Psychometric Properties. International Journal of Environmental Research and Public Health. 2023 Feb 7;20 (4 ):2892. doi: 10.3390/ijerph20042892 36833587
36 Pedro AR , Amaral O , Escoval A . Literacia em saúde, dos dados à ação: tradução, validação e aplicação do European Health Literacy Survey em Portugal. Revista Portuguesa de Saúde Pública [Internet]. 2016 Sep 1;34 (3 ):259–75. Available from: https://www.sciencedirect.com/science/article/pii/S0870902516300311
37 Arriaga M , Francisco R , Nogueira P , Oliveira J , Silva C , Câmara G , et al . Health Literacy in Portugal: Results of the Health Literacy Population Survey Project 2019–2021. International Journal of Environmental Research and Public Health. 2022 Apr 1;19 (7 ):4225. doi: 10.3390/ijerph19074225 35409905
38 Pelikan JM, Ganahl K. Measuring Health Literacy in General Populations: Primary Findings from the HLS-EU Consortium’s Health Literacy Assessment Effort. Iospressnl [Internet]. 2017 [cited 2024 Aug 23];34–59. https://ebooks.iospress.nl/publication/47672
39 Sørensen K , Van Den Broucke S , Pelikan JM , Fullam J , Doyle G , Slonska Z , et al . Measuring health literacy in populations: illuminating the design and development process of the European Health Literacy Survey Questionnaire (HLS-EU-Q). BMC Public Health. 2013 Oct 10;13 (1 ):948. doi: 10.1186/1471-2458-13-948 24112855
40 Sørensen K , Pelikan JM , Röthlin F , Ganahl K , Slonska Z , Doyle G , et al . Health literacy in Europe: comparative results of the European health literacy survey (HLS-EU). The European Journal of Public Health [Internet]. 2015 Apr 5;25 (6 ):1053–8. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4668324/ 25843827
41 Pelikan JM, Röthlin F, Ganahl K. Measuring comprehensive health literacy in general populations: validation of instrument, indices and scales of the HLS-EU study [Internet]. 6 th Annual Health Literacy Research Conference; 2014 nov 3; Bethesda, Maryland, Hyatt Regency Bethesda. https://www.bumc.bu.edu/healthliteracyconference/files/2014/06/Pelikan-et-al-HARC-2014-fin.pdf
42 OECD, Eurostat, for I. ISCED 2011 Operational Manual Guidelines for Classifying National Education Programmes and Related Qualifications. OECD Publishing; 2015.
43 OECD. Health at a Glance 2023: OECD Indicators [Internet]. OECD iLibrary. Paris: Organisation for Economic Co-operation and Development; 2023. https://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2023_7a7afb35-en
44 Evans AY , Anthony E , Gabriel G . Comprehensive Health Literacy Among Undergraduates: A Ghanaian University-Based Cross-Sectional Study. HLRP: Health Literacy Research and Practice. 2019 Oct 1;3 (4 ):e227–37. doi: 10.3928/24748307-20190903-01 31637363
45 Juvinyà-Canal D , Suñer-Soler R , Boixadós Porquet A , Vernay M , Blanchard H , Bertran-Noguer C . Health Literacy among Health and Social Care University Students. International Journal of Environmental Research and Public Health [Internet]. 2020 Mar 27;17 (7 ). Available from: https://pubmed.ncbi.nlm.nih.gov/32230985/ doi: 10.3390/ijerph17072273
46 Cheong KY , Syed Mahmud SMB , Chng NW , Kwek GJ , Yan CC , Yeung MT . Cross-sectional survey of health literacy among health science students in Singapore. The Journal of Medicine Access. 2024 Jan 1;8 . doi: 10.1177/27550834231222382 38306366
47 Jürgensen IN , Koch P , Otto R , Nock AM , Petersen-Ewert C . Subjective Health Status, Health-Related Behavior, and Health Literacy of Health Professional Students: Results from a Cross-Sectional Study. Healthcare (Basel). 2024 Jan 22;12 (2 ):277–7. doi: 10.3390/healthcare12020277 38275556
48 Zhang Y , Zhang F , Hu P , Huang W , Lu L , Bai R , et al . Exploring health literacy in nursing students of Chongqing, China: a cross-sectional survey using the health literacy questionnaire. The Lancet. 2016 Oct;388 :S99.
49 Joseph R , Fernandes S , Hyers L , O’Brien K . Health literacy: a cross-disciplinary study in American undergraduate college students. Journal of InformationLiteracy. 2016 Dec 1;10 (2 ):26.
50 Rosário J , Raposo B , Santos E , Dias S , Pedro AR . Efficacy of health literacy interventions aimed to improve health gains of higher education students—a systematic review. BMC Public Health. 2024 Mar 22;24 (1 ). doi: 10.1186/s12889-024-18358-4 38515114
51 Bánfai-Csonka H , Bánfai B , Jeges S , Betlehem J . Understanding Health Literacy among University Health Science Students of Different Nationalities. International Journal of Environmental Research and Public Health [Internet]. 2022 Jan 1;19 (18 ):11758. Available from: https://www.mdpi.com/1660-4601/19/18/11758 36142030
52 Sarhan MBA , Fujii Y , Kiriya J , Fujiya R , Giacaman R , Kitamura A , et al . Exploring health literacy and its associated factors among Palestinian university students: a cross-sectional study. Health Promotion International. 2021 Aug 24;36 (3 ):854–65. doi: 10.1093/heapro/daaa089 33141166
