Social Health and Behavior

: 2019  |  Volume : 2  |  Issue : 4  |  Page : 139--144

Predictors of health literacy in community-dwelling elderly

Sima Seifollahzadeh1, Seyedeh Ameneh Motalebi2, Jamileh Amirzadeh Iranagh3, Maryam Mafi4, Fatemeh Mohammadi2,  
1 Department of Nursing, Students' Research Committee, School of Nursing and Midwifery, Qazvin University of Medical Sciences, Qazvin, Iran
2 Social Determinants of Health Research Center, Qazvin University of Medical Sciences, Qazvin, Iran
3 Department of Public Health, Urmia University of Medical Sciences, Urmia, Iran
4 Department of Nursing and Biostatistics, School of Nursing and Midwifery, Qazvin University of Medical Sciences, Qazvin, Iran

Correspondence Address:
Dr. Fatemeh Mohammadi
Social Determinants of Health Research Center, Qazvin University of Medical Sciences, Qazvin


Introduction: Health literacy is an essential factor for self-care of chronic conditions and maintenance of health and wellness. This research examines whether or not sociodemographic factors predict health literacy in community-dwelling elderly adults. Methods: The sample of this cross-sectional study consisted of 250 elderly individuals residing in Qazvin, Iran, who were selected by cluster sampling method. Data were collected using the sociodemographic and Health Literacy for Iranian Adults questionnaires. A multivariate regression model was used for analyzing the data. Results: The mean age of 250 elderly people participated in the study was 69.42 ± 6.81 years. Based on the findings of the current study, the majority of the elderly participants had insufficient (n = 79, 31.6%) or not enough (n = 69, 27.6%) health literacy. The results also indicated that good economic status (B = 5.75, standard error (SE) = 2.19, P = 0.009) and living with a spouse (B = −8.75, SE = 3.36, P = 0.010) were associated with higher health literacy. However, having no formal education (B = −26.73, SE = 3.42, P < 0.001) or under diploma education (B = −8.03, SE = 2.53, P = 0.002) and being homemaker (B = −10.58, SE = 3.02, P = 0.001) or unemployed (B = −5.22, SE = 3.13, P = 0.036) were associated with lower health literacy. Conclusion: The findings of this study highlight the importance of using appropriate strategies for promoting the health literacy of elderly people.

How to cite this article:
Seifollahzadeh S, Motalebi SA, Amirzadeh Iranagh J, Mafi M, Mohammadi F. Predictors of health literacy in community-dwelling elderly.Soc Health Behav 2019;2:139-144

How to cite this URL:
Seifollahzadeh S, Motalebi SA, Amirzadeh Iranagh J, Mafi M, Mohammadi F. Predictors of health literacy in community-dwelling elderly. Soc Health Behav [serial online] 2019 [cited 2020 Aug 5 ];2:139-144
Available from:

Full Text


Aging is a critical, inevitable, and irreversible process experiencing by all human beings.[1] The aging population is increasing fast due to the reduction of mortality and fertility rates, increase of the life expectancy, and improvement in health status.[2],[3] There is about 60 million elderly in the world that it is expected to be doubled by 2025. It will also increase to 2 billion elderly by 2050.[4] Iran is no exception. It is projected that the population aged 65 years or over would reach 8.7% of the total population of Iran by 2025 and 30% by 2050.[5]

The elderly face different problems and issues related to the physical, mental, and social health.[2],[6] As people age, they become more susceptible to chronic diseases, such as diabetes, arthritis, cardiovascular, pulmonary, renal diseases, and disability.[7] Nearly 92% of elderly people suffer from at least one chronic illness,[8] while more than half of them have three or more chronic conditions.[9] Such problems turn the elderly to the major consumers of healthcare services.[7] The increase in healthcare expenditure per capita in older age groups creates a challenge for their families and governments.[10] Therefore, it is required attention to be paid to the appropriate interventions to reduce the treatment costs.[11],[12]

Health literacy is an important factor in the promotion of health of the elderly.[13] Limited health literacy is predictive of poor health.[14] Health literacy is defined as the cognitive and social skills to have better access, understanding and use of the information, and health services for promoting and maintaining good health.[15],[16] Health literacy is considered as a key factor for effective preventive medicine and healthy behaviors.[17] It is documented that it has an important role in preventing and controlling chronic diseases.[18] As Panagioti et al. showed that the increase of health literacy improved self-care abilities of the patients suffering from chronic diseases.[15] Insufficient health literacy can be an indicator of low health status, inappropriate use of the medicines, less participation in treatment decision-making, less worry about the health, and low referring to the physicians.[14] The majority of elderly people have a low level of health literacy affecting their abilities to participate in healthcare appropriately.[11]

Lower health literacy is a public health issue. Determinants of the limited health literacy consisted of older age, lower educational level, lower income, perceived poor health, and lack of access to the internet.[19] Likewise, Schaeffer et al. introduced the increasing age, poor social status, and low educational level as demographic factors affecting the limited health literacy.[20] According to Palumbo et al., the poor financial situation is the predictor of insufficient health literacy.[21] Liu et al. also reported that the lower educational level, poor financial situation, older age, sedentary lifestyle, smoking, and lack of access to health information are the predictors of the limited health literacy.[22] Furthermore, Borji et al.[23] showed a significant association between age, gender, level of education, job, place of living, suffering from chronic diseases, history of hospitalization, and health literacy among a sample of Iranian elderly.

Low health literacy along with the aging-related physiological changes can make the elderly vulnerable and have a negative effect on their healthy behavior.[24] Given the remarkable increase in the aging population and an increase in the incidence of chronic diseases, there is a need for studies to address the limited health literacy and health-related behaviors of the elderly.[25] Furthermore, there is a scarcity of research in this filed in Iran, so this study was aimed to investigate the predictors of health literacy in a sample of Iranian elderly.


Study design and participants

In this cross-sectional study, a random cluster sampling method was used. At first, Qazvin city was divided into five districts: north, south, east, west, and center. Then, one mosque and park were selected randomly from each district. The available and qualified elderly persons were selected from these public places. In addition, the samples were chosen from two daily elderly care centers that have members from all districts. Inclusion criteria were aged 60 years and over, oral communication ability, and being voluntary to participate in the study. The elderly people who suffered from diagnosed mental and cognitive diseases (Alzheimer and severe depression) and severe physical illnesses that were barriers to effective communication excluded from the study.

To determine the sample size, by considering 52% prevalence of insufficient health literacy (P = 0.52) extracted from results of Mohseni et al.[26] among elderly in Kerman city, Iran, alpha level = 0.05, and the degree of precision d = 0.13 × p, a total sample size was calculated at 216. By considering 20% nonresponsive rate, 250 subjects were finalized for this study.


Data were collected through face-to-face interview from December 2017 to April 2018 by health literacy questionnaires and demographic characteristic form. Demographic characteristics included age, gender, marital status, number of children, educational level, place of residence, financial status, and hospitalization history.

Health Literacy for Iranian Adults questionnaire was used to measure the elderly participants' health literacy. This questionnaire was designed by Montazeri. It includes 33 items and five subscales consisting of access (6 items), reading skill (4 items), understanding (7 items), assessment (4 items), and decision-making and the application of health information (12 items). The items of the questionnaires are scored on a five-point Likert scale.[27] The total values were converted to a range of 0–100. Health literacy was classified into four levels: inadequate (0–50), insufficient (51–66), adequate (67–84), and excellent (85–100). To calculate the total score, the score of the subscales (on a range of score from 0 to 100) is added and is divided by the number of the subscales.[5] The content and face validity and reliability of this questionnaire were confirmed by Montazeri.[27]

Ethical consideration

The study was approved by the Ethics Committee of Qazvin University of Medical Sciences, Qazvin, Iran (IR.QUMS.REC.1396.366). Participants were informed about the purpose and procedure of the study. Furthermore, the participants were informed that they can participate in the study voluntarily, and they were ensured that their information was kept confidentially. The confidentiality of the participant's responses was guaranteed. Informed consent was obtained from all elderly participants before completing the questionnaires.

Statistical analysis

Statistical Package for the Social Sciences, version 24.0 (IBM Corp, Armonk, NY, USA) was used to analyze the data. Demographic variables were described using frequencies and percentages for categorical variables and mean and standard deviations for continuous variables. The linear regression model was used to investigate the sociodemographic variables as predictors of health literacy.

To assess multicollinearity issues, variance inflation factor of each independent variable was computed. Variance inflation factor of all variables was below 2 (ranged from 1.099–1.936), indicating no multicollinearity issue. Durbin Watson statistic was computed to detect autocorrelation. Durbin Watson close to 2 indicates linear regression residuals are uncorrelated. Furthermore, no autocorrelation was detected in the sample evidenced by Durbin Watson static of 1.869. Normality distribution of the residuals was assessed by Kolmogorov–Smirnov test, skewness, and kertosis as well. The statistical significance level was set at P < 0.05.


[Table 1] describes the demographic profiles of the respondents. The mean age of the elderly people participated in the study was 69.42 ± 6.81 years and 57.2% (n = 143) of them were female. The elderly respondents were predominately married (n = 160, 64.0%), had <2 children (n = 184, 73.6%), and lived with their spouse (n = 164, 65.6%). Nearly one-fourth of the sample (n = 61, 24.4%) reported no formal education and 69.6% (n = 174) reported low- to middle-range income. The majority of them were retired or homemaker (n = 211, 84.4%) and had personal house (n = 229, 91.6%). More than 80% of the elderly reported at least one chronic diseases, and 64% of them (n = 160) had history of hospitalization.{Table 1}

As depicted in [Table 2], the majority of the elderly participants had insufficient (n = 79, 31.6%) or not enough (n = 69, 27.6%) health literacy.{Table 2}

Predictors of health literacy

Multivariate analyses showed that educational status, job, economic status, and living arrangement were statistically significant predictors for health literacy [Table 3]. Compared to subjects with medium, the good economic status (B = 5.75, SE = 2.19, P = 0.009) was positively associated with health literacy. Homemakers (B = −10.58, SE = 3.02, P = 0.001) and unemployers (B = −5.22, SE = 3.13, P = 0.036) reported lower health literacy compared to retired subjects. The elderly people with no formal education (B = −26.73, SE = 3.42, P < 0.001) or in under diploma (B = −8.03, SE = 2.53, P = 0.002) reported lower health literacy compared to elderly people with diploma or higher education level. The elderly who were alone had the lowest health literacy compared to those who lived with spouse or spouse and children (B = −8.75, SE = 3.36, P = 0.010).{Table 3}


Elderly people with limited health literacy have less information about their own health condition and receive less preventive cares.[28] In such a way that it puts them at risk of deviation from health.[25] Hence, this study was conducted to determine the health literacy level and its predictors in an Iranian elderly sample.

The results of this study showed that the majority of elderly participants had insufficient health literacy. This is consistent with national and international studies.[19],[23],[25],[26],[29] The determinants of this result can be low educational level, inappropriate financial status, age-related diseases, low cognitive situation, and barriers to access to the health centers in the elderly. However, Tiller et al. showed an increase in health literacy by advancing age among the German elderly people.[18] These inconsistent findings can be related to the study place and the type of questionnaire used.

In the current study, there was a statistically significant positive relation between educational level and health literacy in a sample of Iranian elderly. Importantly, this study introduced educational level as the strongest predictor of health literacy (B = −26.73). Obviously, this finding demonstrates the significance and importance of education in shaping an individual's health literacy. Considering that the most information in health systems and social networks is in writing form, therefore, a higher level of education is needed to receive and understand this information.[30] In literature, the authors have also reported that people with lower education have lower health literacy skills in comparison with people with higher education.[23],[31],[32] In this regard, van der Heide et al.[33] reported that health literacy is a pathway by which level of education affects health. Furthermore, illiteracy is one of the important barriers for communication that makes these people less likely to have access to health and education information.[34] However, the majority of Iranian elderly are illiterate or in low educational level, may negatively influence their understanding of health information affecting on their health literacy level.

In the current study, economic status was a predictor of health literacy. Specifically, elderly people with higher economic status were more likely to have higher health literacy. This finding is consistent with results of the previous studies.[18],[22] The elderly people with a higher income have easier access to healthcare facilities, and medical services, as a result, become more familiar with healthcare issues that can increase their health literacy.[29] Conversely, Borji et al. and Molakhalili et al. (2014) reported that the level of income did not predict health literacy among elderly people.[23],[31] This contradictory results can be related to the difference in the economic status of the elderly participants in different areas of Iran.

The findings of this study indicated that the health literacy of the retired elderly is higher than the homemakers and unemployers. In this regard, Khodabakhshi-Koolaee (2016) reported that health literacy of the retired elderly women residing in Tehran is higher than homemakers.[35] This result can be explained in such a way that retired elderly people have been linked with different people due to their previous job and have wider interactions, information exchange, and relationships than homemaker elderly people. These relationships and interactions will be widened through the retirement centers causing the retired elderly to have more comprehensive information about the prevention and control of diseases.[26] Askelson et al. also stated that individuals with a higher social network use the interpersonal relationship to search health information than those with a lower social network.[36] However, Mollakhalili et al. could not find a significant relationship between health literacy and the job of the hospitalized elderly.[31] The reason for this contradictory can be the sample of the study and the used questionnaire.

In this study, the health literacy of the elderly living alone was less than the elderly living with their spouse. This finding is consistent with Hosieni et al. (2016), who found that living with spouse significantly increased the elderly people's health literacy.[37] In this regard, the authors found a direct and significant relationship between health literacy and social relation.[38],[39] Likewise, Geboers et al. (2016) considered low social participation an important factor in the limited health literacy.[28]


This study was conducted on the community-dwelling elderly people, and thus, it is difficult to generalize the results to the institutionalized elderly people. The other limitation of the study is that only the elderly of the public places were studied, and other elderly who were not present in these places due to different reasons such as disability were not examined.


The results of the present study showed that most of the elderly participants had limited health literacy. Low educational level and economic status, living alone, and being homemaker or unemployed were the predictors of limited health literacy. Given the incidence of chronic diseases and the need for self-care skill in this vulnerable group, the need to pay more attention to the promotion of health literacy in the elderly is very important.


We would extend our thanks to the Qazvin University of Medical Sciences, Iran, for the generous cooperation at the time of sampling. We would like to express our gratitude to the elderly people who helped make this research possible.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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