The rapid spread of COVID-19 and the high number of deaths cause countries where the outbreak occurs to implement strict isolation measures. Separating uninfected groups from those who are infected, suspected, and carrying the virus effectively disrupts the chain of transmission and protects at-risk groups.Reference Turk 1 Increasing individuals’ awareness levels and taking personal measures are the most necessary interventions to prevent the disease’s transmission chain. Mortality caused by COVID-19 is reduced by increasing individuals’ awareness of the disease and developing healthy behaviors.Reference Çopurlar and Kartal 2
Positive health behaviors can be acquired by increasing individuals’ health literacy levels.Reference Tuzun, Demirköse and Özkan 3 WHO defines health literacy (HL) as “gaining access to, understand, and use health information in ways that promote and maintain good health.”Reference Güven 4 A low level of health literacy is an essential public health problem in developed and developing countries.Reference Duong, Nguyen and Pham 5 A study conducted in China with individuals aged 15-69 years reported that 28.8% had health literacy below the primary level. The infectious diseases literacy, ranging from 0-7 points, was 3.68.Reference Nie, Li and Li 6 A study by the Ministry of Health in Turkey (2018) reported that 38% of individuals had a problematic-limited HL level. Considering that 7 of every 10 people have inadequate or limited levels of HL, the importance of increasing HL levels in protecting and promoting health becomes clear. 7 Health literacy is considered a fundamental element of social responsibility in reducing and controlling pandemics.Reference Daşlı, Bakırer and Mısırlıoğlu 8 In the literature review, it was observed that people with limited health literacy were not personally prepared for the COVID-19 pandemic, were more likely to accept conspiracy beliefs, and used preventive health services inadequately.Reference Shaukat, Asghar and Naveed 9 , Reference Nguyen and Do 10
Individuals should develop conscious behaviors and increase their awareness to protect themselves from COVID-19 and maintain their health. This awareness is also related to their HL levels.Reference Mansur and Ertaş 11 As the spread of COVID-19 increased, various platforms began to publish information lacking scientific evidence, which caused the public to worry and harmed public health.Reference Akbal and Gökler 12 Increasing individuals’ HL levels is necessary to distinguish between correct and incorrect information about COVID-19 and to use health-related information effectively.Reference Hızal 13 Paying attention to the link between health literacy and COVID-19 awareness may be a suitable strategy to support preventive activities during the outbreak of such infectious diseases in the community.
The present study contributes to the literature as it is the first to examine the relationship between awareness of COVID-19 and health literacy in Turkey. This study aims to determine individuals’ COVID-19 awareness and health literacy levels in eastern Turkey and the relationship between them.
Methods
This study utilized a descriptive and correlational design. It was conducted with 762 individuals aged 18-65 years who sought treatment at the emergency service of a public hospital in a province in eastern Turkey (Erzurum) between July 15, 2021-December 15, 2021.
Target Population and the Sample
The study’s target population was individuals seeking treatment in the health institution between the dates mentioned above and meeting the research criteria. The study’s Inclusion criteria were being 18-65 years old, seeking treatment in the emergency department, having no communication problems, and being literate.
The minimum number of individuals to be included in the sample of the study was determined by using the sample of unknown population formula (n = t 2.p.q/d 2) at the 95% confidence interval (d = 0.05), t = 1.96, P = 0.5, q = 0,5. The minimum number of individuals to be included in the sample was 384. During the data collection process, the responses from the participants were accepted to be included in the data analysis according to the eligibility criteria, and the study was completed with 762 participants. The power of our study was calculated as 99% with a medium effect size at the 95% confidence level in the post hoc power analysis performed with the G*Power 3.1 statistical package software.Reference Cohen 14 STROBE guidelines were used in reporting this study.Reference Vandenbroucke, von Elm and Altman 15
Data Collection Tools
A single researcher administered data collection forms to individuals who applied to the emergency service through face-to-face interviews. Data collection tools included the Personal Information Form, the COVID-19 Awareness Scale, and the Health Literacy Scale. Data for 1 person was collected in approximately 8-10 minutes.
Personal Information Form
The researcher developed the Personal Information Form in line with the literature to determine the socio-demographic characteristics of the respondents.Reference Çopurlar and Kartal 2 , Reference Suka, Odajima and Kasai 16 These questions aimed to collect data about the participants’ gender, age, marital status, occupation, education level, and monthly income.
COVID-19 Awareness Scale
The COVID-19 Awareness Scale was developed by BilginReference Bilgin 17 in 2020 as a valid and reliable measurement tool to measure the awareness levels of individuals in Turkish society about COVID-19. The COVID-19 Awareness Scale (CAS) consists of 17 items responded on a 5-point Likert scale ranging from never (1)-always (5).
Awareness of transmission measures sub-scale, one of the sub-scales of the scale, includes 9 items, and a maximum of 45 points can be obtained from the scale. Awareness of following current developments and awareness of hygiene measures consist of 4 items, and a maximum score of 20 points can be obtained. Higher total scores indicate a higher level of awareness. Higher scores obtained from the sub-scales indicate a higher level of awareness. The sub-scales include awareness of transmission measures (1-2-3-4-5-6-7-8-9), awareness of following current developments (10-11-12-13), and awareness of hygiene measures (14-15-16-17).
Cronbach’s alpha reliability coefficients were 0.93 for the awareness of transmission measures sub-scale, 0.87 for the awareness of current developments sub-scale, and 0.82 for the awareness of hygiene measures sub-scale. This study found Cronbach’s alpha reliability coefficients of the scale as .92 for the awareness of transmission measures sub-scale, .86 for the awareness of following current developments sub-scale, and .65 for the awareness of hygiene measures sub-scale. Cronbach’s alpha value was found to be 0.91 for the total score.
Health Literacy Scale (HLS)
Turkish validity and reliability of the scale, which Suka14 developed, were conducted by Türkoğlu and KılıçReference Turkoğlu and Kılıç 18 in 2021. The scale consists of 14 items that responded on a 5-point Likert scale. Total scores from the scale range between 14-70 points, with options ranging from strongly disagree (1)-strongly agree (5).
Higher scores obtained from the scale indicate a higher level of health literacy. The 3 sub-scales of the scale include Functional Health Literacy (1-2-3-4-5), Communicative Health Literacy (6-7-8-9-10), and Critical Health Literacy (11-12-13-14). Cronbach’s alpha reliability coefficient of the scale was reported to be 0.85. Cronbach’s alpha reliability coefficient was found to be 0.84 in this study.
Data Analysis
The SPSS 21 package program was utilized to analyze the data obtained from the study. The conformity of the outcome variable to normal distribution was assessed with skewness and kurtosis coefficients. It was determined that the Skewness and Kurtosis values were between -0.405/-0.126 for the Health Literacy Scale and 0.041/-0.780 for the COVID-19 Awareness Scale. Because the Skewness and Kurtosis values obtained from the scales and their sub-dimensions were within the ± 3 range, it was determined that all scales and their sub-dimensions showed normal distribution. The descriptive characteristics of the participants and the scale score averages were evaluated with descriptive statistics (number, standard deviation, percentage, mean, minimum, and maximum values), and the suitability of the data set for normal distribution was evaluated with skewness and kurtosis coefficients. In comparing the scale scores with the descriptive characteristics of the participants, t test and one-way analysis of variance (ANOVA) were used in independent groups, and Welch ANOVA and Bonferroni tests were used for Post Hoc analyses when group variances were not homogeneous. Correlation analysis was used to examine the relationship between the 2 scales. Statistical significance was accepted as P < 0.05.
Ethical Considerations
This study followed the principles of the Declaration of Helsinki. Ethics approval of the study was obtained from the Medical Ethics Committee of Atatürk University (Ethics committee number: B.30.2.ATA.0.01.00/41 and date: 03.4.2021). Written permission was obtained from the hospital where the study was conducted.
Before the data collection tools were administered, the participants were informed about the purpose of the study, the estimated time to complete the survey, and the benefits to be obtained from the study. Written and verbal consent were obtained from the participants.
Results
According to the findings obtained from 762 participants, 30.4% were aged 26-35, 54.2% were female, 27% were primary school graduates, and 60.8% were married. Furthermore, 72.4% of the participants were employed, and 45.9% had less income than expenses (Table 1).
Descriptive characteristics of participants
The participants’ total mean score was 50.71 ± 14.93, and they were found to score 27.92 ± 9.77 in the awareness of transmission measures sub-scale, 11.38 ± 4.53 in the awareness of following current developments sub-scale, and 11.41 ± 3.71 in the awareness of hygiene measures sub-scale. The participants’ HLS total mean score was 45.03 ± 10.57, and they were found to score 13.57 ± 5.07 in the Functional HL sub-scale, 17.28 ± 5.03 in the Communicative HL sub-scale, and 14.17 ± 4.00 in the Critical HL sub-scale (Table 2). Compared to other groups, individuals in the 36-45 age group had a higher awareness of transmission measures sub-scale score, awareness of hygiene measures sub-scale score, and COVID-19 Awareness Scale total scale scores. Women were found to have higher awareness of hygiene measures scores than men on the COVID-19 Awareness Scale (P < 0.05). Compared to women, men were found to have higher scores in the awareness of transmission measures sub-scale, awareness of following current developments sub-scale, and the total scale scores (P < 0.05). Compared to other groups, the participants who had high school and university education and above were found to have higher scores in all sub-scales and total scale scores (P < 0.05). Those who had income less than expenses were found to have lower scores in the awareness of transmission measures, awareness of following current developments sub-scales, and total scale scores (P < 0.05) (Table 3).
Distribution of the participants’ COVID-19 awareness and Health Literacy Scale mean scores
Comparison of the participants’ descriptive characteristics according to the COVID-19 Awareness Scale mean scores
* Welch ANOVA test values were taken in cases where group variances were not homogeneous.
Compared to the older age groups, participants aged 18-45 were found to have higher functional HL sub-scale and total scores (P < 0.05). Women had higher scores in the functional HL sub-scale than men (P < 0.05). Men scored higher in the critical HL sub-scale than women (P < 0.05). Communicative, critical sub-scale, and total scale scores of participants with a university education and above were higher than the other groups (P < 0.05). Single participants had higher critical HL sub-scale and total scores than married participants (P < 0.05). The employed participants’ functional, communicative, and critical HL sub-scale scores were higher than those unemployed (P < 0.05). Those whose income was less than their expenses had lower scores in all sub-scales and total scales (Table 4).
Comparison of the participants’ descriptive characteristics according to the HL Scale and its sub-scales mean scores
A positive relationship was detected between the participants’ health literacy levels and COVID-19 awareness sub-scales and total scores, and this relationship was found to be moderate. The scores obtained from the Health Literacy Scale were found to significantly increase with the increase in the participants’ COVID-19 awareness scores (P < 0.001) (Table 5).
Relationship between the participants’ CAS and HLS scores
*P < 0.05, **P < 0.001.
Discussion
In this section, the findings obtained from the research conducted to examine individuals’ COVID-19 awareness and health literacy levels and the relationship between them are discussed considering other research findings and literature. This research is essential because it is a study conducted on individuals in society, where the COVID-19 Awareness and Health Literacy scales were used together, and the relationship between them was investigated.
The COVID-19 Awareness total score and the sub-scale scores show that the scores are above the average (50.71 ± 14.93), indicating a good level of COVID-19 awareness. AlkanReference Alkan 19 found the COVID-19 awareness scale’s total mean score to be 69.00. High mean scores in our study, similar to the study conducted by Alkan, indicate parallel results with the literature. Studies have shown that individuals’ lack of knowledge about COVID-19 can be reduced, protective measures can be taken against the disease, and COVID-19 awareness can be increased thanks to the information and training provided by health professionals.Reference Qazi, Qazi and Naseer 20 , Reference Çın, Emre and Altunbaş 21 The fact that the health literacy level in our study findings was above average supports this finding. In addition, COVID-19 awareness was found to be reasonable in this study, which may be because the study was conducted with individuals who applied to health institutions.
The participants’ Health Literacy Scale total mean score was 45.03 ± 10.57. Higher total scores obtained from the scale indicate an increase in health literacy. Both the total score of the scale and the scores of its sub-dimensions are above average and considering that 7 of every 10 people in Turkey have insufficient or limited health literacy levels, 7 these results show that the participants’ health literacy levels are good. This is because the sample group did not include elderly individuals.
Compared to other age groups, people in the 36-45 age group had higher scores in the awareness of transmission and hygiene measures sub-scale scores in the COVID-19 Awareness Scale and total scale scores. AlkanReference Alkan 19 found that while awareness of transmission measures increased with age, awareness of following current developments and awareness of hygiene measures decreased. Alahdal et al.Reference Alahdal, Basingab and Alotaibi 22 reported that the awareness level of people aged 18-49 in Saudi Arabia is higher than that of other groups. High levels of awareness among people aged 36-45 are considered to result from the fact that younger individuals survive COVID-19 with milder symptoms, and older individuals have lower education and health literacy levels.
This study found that while women had higher mean scores in the awareness of hygiene measures sub-scale of the COVID-19 Awareness Scale compared to men, men had higher mean scores in the awareness of transmission measures, awareness of following current developments sub-scales, and total mean scores (P < 0.05). A study in Saudi Arabia reported that women’s awareness levels are higher than men’s. The study conducted by AlkanReference Alkan 19 reported no differences in any of the gender and awareness levels sub-scales. In their study conducted in Saudi Arabia, Alrefaei et al.Reference Alrefaei, Almaleki and Alshehrei 23 found that women had less awareness than men. It is thought that the high level of awareness of hygiene measures in women is due to the sensitivity of women in Turkish culture to cleanliness and hygiene issues related to their housewifery duties at home.
This study found that the COVID-19 Awareness Scale mean scores increased with the increase in individuals’ education level (P < 0.05). Similar to our study, the study conducted by Liu et al.Reference Liu, Li and Lv 24 in China also reported that awareness increased with increased education level. Unlike the present study, the study conducted by AlkanReference Alkan 19 found that the awareness of transmission measures scores of primary school graduates were statistically significantly higher than those of graduates of high school, university, and above. People’s COVID-19 awareness is high because they have better health knowledge and the ability to interpret this information.
This study found that those with income less than expenses had lower awareness of transmission measures and awareness of following current developments sub-scales and COVID-19 Awareness Scale total scores (P < 0.05). AlahdalReference Alahdal, Basingab and Alotaibi 22 also found that higher income levels were positively associated with COVID-19 awareness levels. Our study is in line with the literature. The higher COVID-19 awareness levels of individuals with higher income levels are due to their more significant opportunities to access information on the subject, benefit from health services, and reach health personnel.
The HLS functional sub-scale and total scores were higher in individuals aged 18-45 years than in the other older age groups (P < 0.05). The study conducted by Daşlı et al.Reference Daşlı, Bakırer and Mısırlıoğlu 8 using a different measurement tool (Turkey Health Literacy Scale) found that the level of health literacy decreased with age, and a significant difference was reported between the 18-35 age group and the 53+ age group. The study conducted in Denmark using the HLS-EU scale with people aged over 25 reported that, unlike the results of the present study, people aged 25-44 years had a lower level of health literacy compared to people in the other groups,Reference Svendsen, Bak and Sørensen 25 which may be because the literacy rate and education level decrease with age about the development levels of these countries.
Compared to men, women in this study had higher mean scores in the functional HL sub-scale of the HLS and lower mean scores in the critical HL sub-scale of the HLS (P < 0.05). This result shows us that women have better basic health literacy than men. It shows that critical health literacy, seen as a high literacy level, is lower in women than in men. In a study conducted in Denmark, it was seen that women have higher health literacy levels than men.Reference Svendsen, Bak and Sørensen 25 Limited health literacy research conducted in the US with the REALM test reported that women had a higher health literacy level than menReference Davis, Wischhusen and Sutton 26. Daşlı et al.Reference Daşlı, Bakırer and Mısırlıoğlu 8 found no statistically significant difference between gender groups and health literacy. These differences indicate the need for further research to determine the relationship between gender and health literacy level. It is thought that the fact that general literacy rates are lower among women than men in Turkish society impacts health literacy levels.Reference Kurumu 27
This study found that people with university and higher education levels had higher communicative and critical HL sub-scale and total HLS scores; the mean score was found to increase with the increase in the level of education (P < 0.05). Similar to our study, in their study conducted with older adults, Ayaz AlkayaReference Ayaz-Alkaya and Dülger 28 found that health literacy increased with the increase in the level of education. In this study, the level of HL was in line with the level of education; the level of health literacy increased as the level of education increased. The study findings are similar to those of the literature.Reference Can Özdemir, Işık and Nazik 29 , Reference Bakan and Yıldız 30 As individuals’ education levels increase, accessing, understanding, and evaluating information on health-related issues becomes easier.
This study found that the critical HL sub-scale and total HLS scale scores were higher in single than married individuals (P < 0.05). Similar to our study, a study conducted in Denmark found that married individuals had lower health literacy levels.Reference Svendsen, Bak and Sørensen 25 This similarity is in line with the findings of the present study.
In all sub-scales and the total HLS, the mean scores of unemployed people and people whose income level was less than their expenses were found to be lower (P < 0.05). Daşlı et al.Reference Daşlı, Bakırer and Mısırlıoğlu 8 found that health literacy levels increased with the increase in income level. A study conducted in Denmark reported that people with annual income levels below the national average had lower health literacy scores.Reference Svendsen, Bak and Sørensen 25 A study conducted in Turkey investigated the health literacy levels of people who sought treatment in public and private individuals accessing hospital care the HLS-EU scale and reported that people with lower income levels had lower health literacy levels.Reference Durmuş 31 Similar to other studies in the literature, income level and health literacy level were found to be positively correlated. A high economic situation can increase health literacy by allowing individuals to access health services and resources faster and easier and receive better education.
This study found a moderate positive correlation between the HLS and the COVID-19 Awareness Scale (r = 0.350). The participants’ COVID-19 awareness scores were found to significantly increase with the increase in their health literacy scale scores (P < 0.001). The data obtained in this study indicate a relationship between COVID-19 awareness and health literacy levels. The health literacy level of society is considered necessary in combating the pandemic. Similarly, in the study conducted by Panahi and Ghalavand, it was determined that health literacy has a significant effect on individuals’ intentions and attitudes toward behavior.Reference Panahi and Ghalavand 32 A cross-sectional study conducted in Germany with people aged 16 years and older reported that participants with low health literacy levels had significant confusion about COVID-19, and it was recommended that individuals’ health literacy levels be increased.Reference Okan, Bollweg and Berens 33 Effective behaviors in the prevention of infections, such as hand hygiene and immunization, are associated with the HL level.Reference Cohen 14 Societies with a low level of HL may need help understanding and applying what they read in their lives. COVID-19 is a relatively new term that has led to new and unfamiliar situations, which causes inadequacy in people’s awareness and measures taken during the pandemic in societies with low HL levels.
Limitations
The data used in the study are limited to the participants’ self-reports. The data is limited to individuals accessing hospital care and cannot be generalized to the entire population.
Conclusion
It was found that the level of COVID-19 awareness increased as individuals’ health literacy levels increased (P < 0.001). To increase the Turkish society’s awareness of COVID-19, interventional studies should be carried out to increase health literacy levels. The higher the level of education and income of individuals, the higher the awareness of COVID-19 and the level of health literacy. Based on this result, it is recommended that the education and income levels of individuals in Turkey be increased. Future studies to increase COVID-19 awareness should be planned by considering the factors of education and income, and intervention studies should be conducted on this subject.
Acknowledgements
The authors thank all participants who so willingly participated in this study.
The study was presented orally as a summary presentation at the Third International Fourth National Public Health Nursing Congress in Turkey on January 11-13, 2023.
Author contribution
MMO, HYB contributed to project conception and did the data acquisition and analysis; HYB did the statistical analysis; MMO did the literature review; MMO, HYB, wrote the manuscript and HYB critically revised the successive drafts. All authors read and approved the final manuscript.
Funding statement
None.
Competing interest
The authors declare that they have no conflicts of interest. This study is a master’s thesis.
Ethical standard
Ethical committee approval was received from the Ethics Committee of Atatürk University (Date of approval: 03.4.2021 and Number: B.30.2.ATA.0.01.00/41).
