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Limited cancer health literacy may be attributed to various factors. Although these factors play decisive roles in identifying individuals with limited cancer health literacy, they have not been sufficiently investigated, especially in China. There is a pressing need to ascertain the factors that effectively identify Chinese people with poor cancer health literacy.
This study aimed to identify the factor associated with limited cancer health literacy among Chinese people based on the 6-Item Cancer Health Literacy Test (CHLT-6).
We first categorized Chinese study participants according to the answers provided for cancer health literacy as follows: people who provided ≤3 correct answers were labeled as having limited cancer health literacy, whereas those who provided between 4 and 6 correct answers were labeled as having adequate cancer health literacy. We then adopted logistic regression to analyze the factors that were closely related to limited cancer health literacy among at-risk study participants.
The logistic regression analysis identified the following factors that effectively predicted limited cancer health literacy: (1) male gender, (2) low education attainment, (3) age, (4) high levels of self-assessed general disease knowledge, (5) low levels of digital health literacy, (6) limited communicative health literacy, (7) low general health numeracy, and (8) high levels of mistrust in health authorities.
Using regression analysis, we successfully identified 8 factors that could be used as predictors of limited cancer health literacy among Chinese populations. These findings have important clinical implications for supporting Chinese people with limited cancer health literacy through the development of more targeted health educational programs and resources that better align with their actual skill levels.
Cancer is a leading cause of death and a major public health concern in China owing to population growth and aging, as well as sociodemographic changes in the country [
Health literacy is becoming an essential factor for improving health [
Given the extensive human suffering and other costs of cancer diagnosis and care [
To the best of our knowledge, few studies have explored the various factors predicting cancer health literacy status. A recent study examined the roles of age, education attainment, and financial resources in predicting health literacy skills [
This study aimed to identify the factors associated with limited cancer health literacy in the Chinese population based on the CHLT-6, by including self-assessed disease knowledge; functional, communicative, and critical health literacy [
We first designed a survey questionnaire and then categorized the study participants into varying cancer health literacy groups based on the survey data collected. Afterwards, we adopted logistic regression to analyze the factors that were closely related to limited cancer health literacy measured by the study participants’ responses.
To achieve our objective, we designed the questionnaire through panel discussions among all researchers. The questionnaire comprised the following 2 sections: demographics and the measure (CHLT-6). The section of population demographics covered age, gender, education, self-assessed disease knowledge, the All Aspects of Health Literacy Scale (AAHLS) [
Among the currently available tools, the Cultural Cancer Screening Scale was designed to conduct breast and cervical cancer screening among Latino and Anglo women [
The CHLT-6 (
We used randomized sampling to recruit Chinese participants from Qilu Hospital affiliated to Shandong University, China. Those included in this study satisfied the following criteria: (1) being aged 17 years or older, (2) having primary education or above to understand the questionnaire items, and (3) participating in the survey voluntarily. The questionnaire survey lasted 1 month from August 1, 2022, to August 31, 2022. The questionnaire was administered via
We categorized Chinese study participants into 2 contrastive cancer health literacy groups: people who provided ≤3 correct answers were labeled as having limited cancer literacy, whereas those who provided between 4 and 6 correct answers were labeled as having adequate cancer health literacy.
Logistic regression was used to analyze the factors closely associated with limited cancer health literacy among the study participants. Specifically, it was used to statistically explore relations between various factors (age, gender, education, self-assessed disease knowledge, digital health literacy, general health numeracy, and communicative health literacy determined through the demographics section of the questionnaire) and differing cancer health literacy levels (the 2 groups of limited and adequate health literacy). We used 0.3 as the threshold to divide study participants (people who provided ≤3 correct answers in the CHLT-6 were labeled as having limited cancer health literacy, and those who provided between 4 and 6 correct answers were labeled as having adequate cancer health literacy). The predicted outcome of the dependent variable was the limited cancer health literacy class. The independent variables of self-assessed disease knowledge, the AAHLS, the eHEALS, and the GHNT were measured through Likert scales based on their respective question items. In regression modeling, the reference values of the categorical predictor variables were female (gender), postgraduate (education), little (self-assessed knowledge level), often (functional, communicative, and critical health literacy items of the AAHLS), strongly disagree (eHEALS), and wrong response (GHNT). The model fit was assessed using the collinearity statistics (the tolerance and its reciprocal variance inflation factors [VIFs]) of the predictor variables.
This study was approved by the Ethics Review Board of Qilu Hospital of Shandong University, China (number: KYLL-202208-026). The study data were anonymous to protect the privacy and confidentiality of the study participants. Since the participants took part in the survey voluntarily for supporting and promoting academic research, no compensation was provided, as per the common practice in China.
Descriptive statistics.
Variable | Value (N=849) | ||
Age (years), min-max; mean (SD) | 17-68; 43.68 (11.37) | ||
Female gender, n (%) | 441 (51.9) | ||
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Year 6 | 140 (16.5) | |
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Year 9 | 215 (25.3) | |
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Year 12 | 157 (18.5) | |
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Diploma | 156 (18.4) | |
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Bachelor’s degree | 138 (16.3) | |
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Postgraduate | 43 (5.1) | |
Self-Assessed Disease Knowledgea, min-max; mean (SD) | 1-4; 2.40 (0.98) | ||
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FHL Item 1 | 1-3; 2.05 (0.76) | |
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FHL Item 2 | 1-4; 2.18 (0.98) | |
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FHL Item 3 | 1-3; 2.08 (0.75) | |
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FHL_SUM | 3-10; 6.30 (1.38) | |
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COHL Item 1 | 1-3; 1.78 (0.77) | |
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COHL Item 2 | 1-3; 1.88 (0.75) | |
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COHL Item 3 | 1-3; 1.90 (0.75) | |
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COHL_SUM | 3-9; 5.56 (1.47) | |
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CRHL Item 1 | 1-3; 1.98 (0.74) | |
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CRHL Item 2 | 1-3; 1.94 (0.73) | |
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CRHL Item 3 | 1-3; 1.94 (0.75) | |
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CRHL Item 4 | 1-3; 2.00 (0.74) | |
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CRHL Item 5 | 1-3; 1.97 (0.74) | |
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CRHL Item 6 | 1-3; 1.58 (0.49) | |
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CRHL_SUM | 6-18; 11.41 (1.97) | |
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eHEALS Item 1 | 1-3; 2.80 (1.20) | |
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eHEALS Item 2 | 1-3; 2.80 (1.19) | |
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eHEALS Item 3 | 1-3; 2.81 (1.18) | |
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eHEALS Item 4 | 1-3; 2.92 (1.18) | |
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eHEALS Item 5 | 1-3; 2.75 (1.22) | |
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eHEALS Item 6 | 1-3; 2.86 (1.23) | |
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eHEALS Item 7 | 1-3; 2.87 (1.20) | |
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eHEALS Item 8 | 1-3; 2.84 (1.20) | |
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eHEALS_SUM | 8-24; 22.65 (4.91) | |
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GHNT Item 1 | 1-3; 1.53 (0.50) | |
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GHNT Item 2 | 1-3; 1.15 (0.36) | |
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GHNT Item 3 | 1-3; 1.18 (0.39) | |
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GHNT Item 4 | 1-3; 1.92 (0.27) | |
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GHNT Item 5 | 1-3; 1.86 (0.35) | |
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GHNT Item 6 | 1-3; 1.79 (0.41) | |
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GHNT_number of total correct answers | 0-6; 2.57 (1.13) | |
Limited cancer health literacy, n (%) | 526 (62.0) |
aThe Self-Assessed Disease Knowledge scale allows participants to report their general disease knowledge based on the following Likert scale: 1=very well, 2=a lot, 3=some, and 4=very little.
bThe Functional Health Literacy Scale includes 3 items (
cThe Communicative Health Literacy Scale includes 3 items (
dThe Critical Health Literacy Scale includes 6 items (
eThe Electronic Health Literacy Scale includes 8 items (
fThe General Health Numeracy Test includes 6 items (
Collinearity statistics of the predictor variables.
Predictor variable | Collinearity statistics | |
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Tolerance | VIFa |
Age | 0.83 | 1.21 |
Gender | 0.95 | 1.06 |
Education | 0.79 | 1.27 |
Self-Assessed Disease Knowledge | 0.98 | 1.02 |
FHL_SUMb | 0.99 | 1.01 |
COHL_SUMc | 0.85 | 1.18 |
CRHL_SUMd | 0.93 | 1.07 |
eHEALS_SUMe | 0.80 | 1.26 |
GHNT_SUMf | 0.96 | 1.05 |
aVIF: variance inflation factor.
bFHL_SUM: sum of Functional Health Literacy Scale scores.
cCOHL_SUM: sum of Communicative Health Literacy Scale scores.
dCRHL_SUM: sum of Critical Health Literacy Scale scores.
eeHEALS_SUM: sum of Electronic Health Literacy Scale scores.
fGHNT_SUM: sum of General Health Numeracy Test scores.
Logistic regression analysis (threshold=0.3) for the predicted outcome of limited cancer health literacy.
Variable | B | SE | Wald |
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Exp(B) | 95% CI for Exp(B) | |||
Lower | Upper | ||||||||
Age | 0.04 | 0.01 | 38.64 | 1 | <.001 | 1.04 | 1.03 | 1.05 | |
Male gender (reference: female) | 0.41 | 0.18 | 5.39 | 1 | .02 | 1.51 | 1.07 | 2.13 | |
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Postgraduate (reference) | N/Aa | N/A | 24.99 | 5 | <.001 | N/A | N/A | N/A |
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Year 6 | 2.48 | 0.81 | 9.33 | 1 | <.001 | 11.94 | 2.43 | 58.59 |
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Year 9 | 2.78 | 0.80 | 11.94 | 1 | <.001 | 16.09 | 3.33 | 77.77 |
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Year 12 | 2.72 | 0.81 | 11.33 | 1 | <.001 | 15.25 | 3.12 | 74.54 |
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Diploma | 2.59 | 0.80 | 10.43 | 1 | <.001 | 13.36 | 2.77 | 64.41 |
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Bachelor’s degree | 1.71 | 0.80 | 4.59 | 1 | .03 | 5.55 | 1.16 | 26.65 |
COHL_SUMb | 0.22 | 0.07 | 11.02 | 1 | <.001 | 1.24 | 1.09 | 1.42 | |
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Little (reference) | N/A | N/A | 16.08 | 2 | <.001 | N/A | N/A | N/A |
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Often | 0.95 | 0.24 | 15.93 | 1 | <.001 | 2.60 | 1.63 | 4.15 |
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Sometimes | 0.50 | 0.21 | 5.64 | 1 | .02 | 1.64 | 1.09 | 2.47 |
CRHL Item 6d for education (reference: health facilities) | −0.41 | 0.18 | 5.35 | 1 | .02 | 0.66 | 0.47 | 0.94 | |
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Strongly agree (reference) | N/A | N/A | 13.77 | 4 | .01 | N/A | N/A | N/A |
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Strongly disagree | −0.45 | 0.42 | 1.14 | 1 | .29 | 0.64 | 0.28 | 1.45 |
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Disagree | −0.43 | 0.38 | 1.25 | 1 | .26 | 0.65 | 0.31 | 1.38 |
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Unsure | −1.06 | 0.35 | 8.99 | 1 | <.001 | 0.35 | 0.17 | 0.69 |
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Agree | −0.82 | 0.37 | 4.77 | 1 | .03 | 0.44 | 0.21 | 0.92 |
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Strongly agree (reference) | N/A | N/A | 18.88 | 4 | <.001 | N/A | N/A | N/A |
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Disagree | 0.83 | 0.45 | 3.41 | 1 | .06 | 2.29 | 0.95 | 5.51 |
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Unsure | −0.57 | 0.34 | 2.93 | 1 | .09 | 0.56 | 0.29 | 1.09 |
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Agree | −0.40 | 0.31 | 1.62 | 1 | .20 | 0.67 | 0.37 | 1.24 |
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Strongly agree | 0.05 | 0.34 | 0.02 | 1 | .89 | 1.05 | 0.54 | 2.04 |
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Strongly agree (reference) | N/A | N/A | 11.42 | 4 | .02 | N/A | N/A | N/A |
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Disagree | −1.07 | 0.41 | 6.82 | 1 | .01 | 0.34 | 0.15 | 0.76 |
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Unsure | −1.21 | 0.39 | 9.86 | 1 | <.001 | 0.30 | 0.14 | 0.63 |
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Agree | −1.15 | 0.36 | 10.35 | 1 | <.001 | 0.32 | 0.16 | 0.64 |
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Strongly agree | −0.99 | 0.38 | 6.99 | 1 | .01 | 0.37 | 0.18 | 0.77 |
eHEALS_SUMg | −0.09 | 0.03 | 7.89 | 1 | <.001 | 0.92 | 0.86 | 0.97 | |
GHNTh Item 6i for correct (reference: wrong) | −1.07 | 0.23 | 21.27 | 1 | <.001 | 0.34 | 0.22 | 0.54 | |
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Little (reference) | N/A | N/A | 26.80 | 3 | <.001 | N/A | N/A | N/A |
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Very well | 0.10 | 0.26 | 0.16 | 1 | .69 | 1.11 | 0.67 | 1.83 |
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Well | −0.17 | 0.24 | 0.52 | 1 | .47 | 0.84 | 0.53 | 1.34 |
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Some | −0.80 | 0.23 | 11.90 | 1 | <.001 | 0.45 | 0.29 | 0.71 |
Constant | 0.47 | 1.43 | 0.11 | 1 | .74 | 1.60 | N/A | N/A |
aN/A: not applicable.
bCOHL_SUM: sum of Communicative Health Literacy Scale scores.
cCRHL: Critical Health Literacy Scale.
dThe Critical Health Literacy Scale includes 6 items (
eeHEALS: Electronic Health Literacy Scale.
fThe Electronic Health Literacy Scale includes 8 items (
geHEALS_SUM: sum of Electronic Health Literacy Scale scores.
hGHNT: General Health Numeracy Test.
iThe General Health Numeracy Test includes 6 items (
Interestingly, when an individual reported lower levels of self-assessed disease knowledge, the odds of that individual being in the limited cancer health literacy group decreased significantly, questioning the reliability of this self-report scale among participants (some self-assessed disease knowledge: OR 0.45, 95% CI 0.29-0.71;
The odds of an individual being in the limited cancer health literacy group decreased significantly when the individual reported overall higher levels of eHealth literacy (eHEALS_SUM). We coded the responses to the 8 items of the eHEALS in an ascending order as follows: 1=strongly disagree, 2=disagree, 3=not sure, 4=agree, and 5=strongly agree. An increase in the sum score thus indicated a higher level of confidence in seeking and using online health information. The results showed that the odds of a study participant being in the limited cancer health literacy group decreased significantly when the self-reported eHealth literacy level increased (eHEALS_SUM: OR 0.92, 95% CI 0.86-0.97;
The results also revealed the limited discrimination effect of some questions of the eHEALS among the Chinese study participants. For example, there were no significant changes among the 5 categories of eHEALS Item 4 (strongly agree, agree, unsure, strongly disagree, and disagree). Moreover, regardless of the response to eHEALS Item 6, the odds of being in the limited cancer health literacy group dropped significantly across the study population.
Limited communicative health literacy and general health numeracy were statistically significant predictors of limited cancer health literacy among the participants (COHL_SUM: OR 1.24, 95% CI 1.09-1.42;
An important finding of this study was that a higher level of mistrust in health professionals was a significant predictor of limited cancer health literacy (“Are you the sort of person who might question your doctor’s or nurse’s advice based on your own research?”; CRHL Item 4 [often]: OR 2.6, 95% CI 1.63-4.15;
Responses to questions in the Critical Health Literacy Scale (CRHL).
Limited cancer health literacy prevents patients from fully benefiting from cancer treatment, causing negative health outcomes [
The results of our study showed that this principal finding applied to the 2-class and 3-class latent class analysis models alike. It reinforces the findings in some previous studies that females tended to have higher health literacy than males [
However, this finding does not align with the finding reported by Chan et al that the limited and adequate cancer health literacy labels assigned to each class indeed refer to the same class regardless of patient gender [
This principal finding aligns well with the finding of Lee et al, who reported that a higher health literacy status was associated with a higher education attainment [
Health literacy has been expanded to include knowledge about health management and care pathway navigation specific to diseases [
Considering the previous findings, we need to further verify our counter-intuitive finding concerning self-assessed disease knowledge and ascertain the underlying causes in future studies on the one hand, and seek possible clinical explanations on the other hand. As reported in a very recent study, although patients self-assessed their disease knowledge as high and those who attended outpatient clinics or were hospitalized in wards claimed to know much about specific diseases, they actually had very little knowledge, and worse still, much of their claimed knowledge was incorrect [
Many existing studies found that age is a significant predictor of health literacy. Lorini et al found that health literacy levels were significantly associated with age classes (ie, the proportion of people with low health literacy increased with age) [
With the growing adoption of eHealth services, people are increasingly expected to engage in appropriate self-care and self-management of their health conditions through eHealth [
Health literacy skills include the following 3 subsets of skills: (1) functional: practically applying the literacy skills needed to function effectively in daily circumstances; (2) interactive: cognitive and literacy skills used to actively participate in daily activities and apply new information to changing situations; and (3) critical: cognitive skills used to critically analyze information and impose better control over life events and situations [
Some studies have documented the significance of numeracy in health. Schwartz et al discovered that participants’ numeracy skills were closely related to the accuracy of applying quantitative information about the benefit of mammography to the perceived risk of death [
An important finding of this study was that a higher level of mistrust in health professionals was a significant predictor of limited cancer health literacy. The odds of being in the limited cancer health literacy group increased significantly when study participants
The association between mistrust in health professionals and limited cancer health literacy may be explained by the patients’ claimed higher levels of disease knowledge. Diversified sources of health information that is not evidence-based, particularly web-based misinformation or myths about health and disease, might have misled our study participants. In China, over 80% of individuals experiencing a specific disease have sought web-based information about their condition [
This study may add to the limited body of evidence that supports the need to ascertain the factors associated with limited cancer health literacy. The findings have important implications for medical education and training, health policy, research, and practice. Given that the majority of study participants were classified into the limited cancer health literacy group, related education and training should be conducted among the general public in China to improve the overall cancer health literacy status across the country. Screening of the most prevalent cancers needs to be carried out regularly, because there is a high prevalence of cancer in China, and a high proportion of the population with limited cancer health literacy is likely to fall victim to cancer. Furthermore, researchers can draw on the methodology and results of this study to identify more factors related to limited cancer health literacy in the Chinese population or different factors in other sociocultural and ethnic groups. As such, fresh insights could be provided into the significant predictors of limited cancer health literacy. In terms of clinical practice, the factors identified in this study could have important implications for identifying people with limited cancer health literacy and even those at risk in high cancer health literacy populations.
This study has some limitations. First, the data collected for this study cannot be considered representative of the overall Chinese population, since we only recruited participants from a single hospital in Shandong Province, China. The study participants may represent people in Shandong Province, a highly populated province in middle east China having relatively low socioeconomic development, but not necessarily people in the whole of China. As a result, the generalizability of the study results and principal findings to Chinese populations may be limited to some extent. Second, we could not explain some principal findings convincingly in this study (eg, principal finding 3) owing to the limited number of relevant previous studies that we could identify in the existing literature. Third, there was an issue regarding principal finding 8. Higher critical health literacy has been measured by an increase in the frequency of patients questioning the validity of health advice and recommendations given by health professionals. However, our study found that a higher level of engagement with health professionals in discussions of their health advice was a significant predictor of limited cancer health literacy among the study participants. Further research needs to be conducted to ascertain whether this finding is widely present among Chinese patients and determine the implications of defining and assessing critical health literacy in a culturally more sensitive way among Chinese populations given their traditional health cultures and the relationships between patients and health authorities.
By performing regression analysis on Chinese study participants with varying cancer health literacy, we successfully identified 8 factors that could be used as predictors of limited cancer health literacy among Chinese populations. These findings have important clinical implications for identifying those with limited cancer health literacy and developing more targeted cancer educational programs and resources.
Items of the scales used in the study.
Translation of the 6-Item Cancer Health Literacy Test (CHLT-6) to Mandarin Chinese.
All Aspects of Health Literacy Scale
6-Item Cancer Health Literacy Test
30-Item Cancer Health Literacy Test
Cancer Health Literacy Test-30-Spanish
Critical Health Literacy Scale
Electronic Health Literacy Scale
General Health Numeracy Test
odds ratio
sum of item scores
variance inflation factor
None declared.