p u b l i c h e a l t h 1 5 1 ( 2 0 1 7 ) 1 3 7 e1 4 5

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Public Health

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Original Research

Assessment of health literacy among outpatient

clinics attendees at Ain Shams University
Hospitals, Egypt: a cross-sectional study

R. Almaleh a,1,*, Y. Helmy a,1, E. Farhat a, H. Hasan a, A. Abdelhafez a,b

a
Faculty of Medicine, Ain Shams University, Lotfy Al-Sayed Street, Abbasyia District, Cairo Governorate, Egypt
b
Department of Public Health, Ain Shams University Faculty of Medicine, Egypt

article info abstract

Article history: Objectives: The aim of conducting this study is to measure health literacy (HL) and to
Received 17 March 2017 investigate the factors associated with inadequate HL in a sample of outpatient clinics
Received in revised form attendees (i.e. patients and companions) at Ain Shams University (ASU) Hospitals.
23 June 2017 Study design: It is a cross-sectional study.
Accepted 28 June 2017 Methods: The study was conducted on 805 attendees of the outpatient clinics at El-
Demerdash University Hospital of ASU Hospitals. The Arabic versions of the Swedish
Functional Health Literacy Scale and the European Health Literacy Survey Ques-
Keywords: tionnairedshort versiondwere used to assess HL. The level of HL and factors influencing it
Functional health literacy were analyzed using correlation and binary logistic regression tests.
Comprehensive health literacy Results: It was found that 81% of the participants had limited comprehensive health literacy
Egypt (CHL; 34.3% inadequate and 46.7% problematic), while only 18.9% had sufficient CHL.
Ain Shams University Hospitals Regarding functional health literacy (FHL), it was found that 84% had limited FHL (50.6%
S-FHL inadequate and 33.4% problematic), while only 16.1% had sufficient FHL. Females were
HLS-EU-Q16 more likely to have inadequate FHL. On the other hand, males, individuals with low
educational levels, and attendees identified as patients as well as participants with inad-
equate FHL were more likely to have inadequate CHL.
Conclusion: The majority of our study population has limited HL. Extensive research is
warranted to explore the extent of the problem on multi-institutional and national levels
and to investigate more explanatory factors.
© 2017 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

motivation and ability of individuals to gain access to, under-

Introduction stand and use information in ways which promote and
maintain good health.’1 Health literacy comprises two main
The World Health Organization defines health literacy (HL) as domains: functional health literacy (FHL) that is concerned
‘The cognitive and social skills which determine the

* Corresponding author.
E-mail address: ranya.almaleh@gmail.com (R. Almaleh).
1
Equally contributed.
http://dx.doi.org/10.1016/j.puhe.2017.06.024
0033-3506/© 2017 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
138 p u b l i c h e a l t h 1 5 1 ( 2 0 1 7 ) 1 3 7 e1 4 5
about individuals' ability to read health-related information2
and comprehensive health literacy (CHL) which represents
individuals' ability to obtain, understand, appraise, and apply
health-related information to promote health or prevent dis-
eases.3 Limited HL has been established as a growing problem
affecting both individuals and the general population. It is now
linked to increased rates of hospital admission,4,5 poorer
physical and mental health,6,7 some psychological problems
such as deep sense of shame and so individuals are unwilling
to disclose their problem to healthcare providers,8,9 and lower
use of preventive health services, such as vaccinations and
screening tests.10 All these lead to higher healthcare costs.11e14
Health literacy and factors influencing its level like edu-
cation have become an important aspect of global research.15
Despite reporting high level of illiteracy16 and its low ranking
in the Global Competitiveness Report 2015e2016 regarding
both primary and higher education,17 Egypt has lagged behind
in researching HL. To date, minimal data regarding measuring
HL in Egypt exist. Only one study was conducted among
elderly caregivers in the Geriatrics Medicine Department of
Ain Shams University (ASU) Hospitals. Results showed that
about 75% of elderly caregivers have limited HL.18
The aim of conducting this study is to measure the prev-
alence of limited HL among attendees (i.e. patients and com-
panions) of the outpatient clinics of El-Demerdash University
Hospital (DUH) of ASU Hospitals. Determination of socio-
economic factors associated with inadequate HL is also a
core purpose of the study.
Methods
Study design and setting
An observational cross-sectional study was carried out from
April 2015 to March 2016 using a convenience sample. The
study took place at the outpatient clinics of DUH located in
Cairo. It is a locally and regionally renowned tertiary health
facility with a high flow of patients throughout the year. In
2013, the number of visits made to the outpatient clinics of
DUH was about 261,894.19 Ethical approval was sought from
the Ethical Committee of Research in ASU. Approvals from
both the Head of Administration of ASU Hospitals and the
Head of Outpatient Clinics were obtained.
Study participants and data collection
The study population comprised 805 attendees of the outpa-
tient clinics of DUH. Participants must be able to speak and
comprehend Arabic. Attendees younger than 15 years of age
were excluded for being highly unlikely to make health-
related decisions on their own. Interview questionnaires
were used with all participants who have verbally consented
to participate. Interviews were performed by eight medical
students of ASU in which a single interviewer approached an
attendee at a time. Data from each attendee were collected in
a single interview. It was stated that participation is voluntary
and that participants can withdraw from the interview at any
time with no subsequent consequences. All data were
collected anonymously. In order to minimize interviewer bias,
explanatory phrases for each question were agreed upon
among all interviewers to meet different cultural backgrounds
of different participants. Aside from our study population, 121
attendees were approached but they refused to participate in
the study as they were either not interested in participation or
were in a hurry.
The European Health Literacy Survey Questionnairedshort
version (HLS-EU-Q16 questionnaire)
The Arabic version of the modified European Health Literacy
Survey Questionnairedshort version (HLS-EU-Q16)20,21 was
used to assess CHL (Supplementary file 1). It was chosen
because it is simple and easily understood. It consists of 16
items taken from the longer European Health Literacy Survey
Questionnairedoriginal matrix-related version (HLS-EU-
Q47).22 Both versions were developed by the European Health
Literacy (HLS-EU) consortium as a part of the European
Health Literacy (HLS-EU) project.22 It covers the conceptual
model of CHL proposed by Sorensen et al.3 by investigating
the ability of individuals to access/obtain, understand, pro-
cess, and use health information. Valid answer categories
were ‘very easy’, ‘fairly easy’, ‘fairly difficult’, and ‘very
difficult’ with the option to give an answer of ‘do not know’
that was analyzed in the same way as not answering the
question.21 The scoring consisted of dichotomizing the valid
answer categories of the 16 items; both categories ‘very easy’
and ‘fairly easy’ got the value of ‘one’, while categories ‘fairly
difficult’ and ‘very difficult’ got ‘zero’. A sum score was
calculated only for valid questionnaires, i.e. having 14 or
more valid answers; therefore, questionnaires with more
than two unanswered questions were treated as ‘missing’.20
The respondent could score between 0 and 16 points, in
which zero represented the lowest possible HL and 16 rep-
resented the highest possible one.
Then, participants' scores were categorized into ‘suffi-
cient’, ‘problematic’, and ‘inadequate’ HL. Scores equal to or
more than 13 denoted sufficient HL, scores from nine to 12
denoted problematic HL, and scores less than or equal to eight
denoted inadequate HL.20
The Swedish functional health literacy scale (S-FHL scale)
The Arabic version of the S-FHL scale was used. It consists of
five items that assess FHL, i.e. the ability to read health-related
information to maintain and improve health (Supplementary
file 2). The scale is short, easy to analyze and has a validated
translated Arabic version which made it convenient for our
study setting.
Being aware of the poor quality of the Egyptian primary ed-
ucation17 and that primary school graduates are not necessarily
capable of reading, we performed a preliminary exploration
prior to data collection. The aim was to estimate the level at
which attendees have sufficient reading skills. Thus, of the HLS-
EU-Q16 participants, only the ones with educational level of
preparatory school or higher, the level at which attendees
observed to demonstrate reading capability, were offered to
complete the S-FHL scale. This condition was specifically applied
to ensure that participants were capable of reading because FHL
is concerned with reading health-related information.
 p u b l i c h e a l t h 1 5 1 ( 2 0 1 7 ) 1 3 7 e1 4 5 139

Each of the S-FHL's five items has five response options:

Table 1 e Characteristics of the study population.a
‘never’, ‘seldom’, ‘sometimes’, ‘often’, and ‘always’. Accord-
ing to responses, the participants were divided into three Variables (N ¼ 805) n (%)
categories of FHL: sufficient, problematic (the label categories: Gender Male 484 (60.6)
inadequate, problematic, and sufficient are the terms used by Female 315 (39.4)
the developers of both the HLS-EU-Q16 and the S-FHL scales. Age (years) 15e19 51 (6.4)
20e39 427 (53.9)
Whilst potentially overly subjective, they have been used to
40e59 254 (32.1)
maintain consistency with the instruments used), and inad- 60e85 60 (7.6)
equate. Participants who respond by ‘often’ or ‘always’ at least Marital status Married 572 (71.6)
once are categorized as having inadequate FHL, while partic- Single 194 (24.3)
ipants who respond only by ‘never’ or ‘seldom’ to all questions Divorced 11 (1.4)
are categorized as having sufficient FHL. Otherwise, partici- Widowed 22 (2.8)
Nature of visit Patient 397 (49.3)
pants are categorized as having problematic FHL, i.e.
Companion 398 (49.4)
responding to at least one question by ‘sometimes’ and no
Highest level of No Education 171 (21.5)
responses with ‘often’ or ‘always’.21 Questionnaires with at education Preprimary or Primary education 138 (17.3)
least one unanswered question were treated as ‘missing’. Preparatory school 115 (14.4)
High school or associate degree 268 (33.7)
Characteristics Collegeþ 104 (13.1)
a
Missing data not included.
The following socio-economic factors were investigated: age,
gender, marital status, nature of visit (i.e. patient or com-
panion), and level of education. Monthly income was initially
HLS-EU-Q16.20 We found that 34.3% of them have inadequate
considered for investigation. However, since most partici-
CHL, 46.7% and 18.9% have problematic and sufficient CHL,
pants refused to provide accurate answers, the authors
respectively (Fig. 1). Factors that had a statistically significant
decided not to include it in the analysis.
effect on the results of CHL were age, highest level of educa-
Statistical analysis tion, nature of visit, as well as marital status (Table 2).
It is worth noting that 75.4% of respondents perceived
The statistical analysis was carried out using the Statistical difficulty and expressed unease with the question related to
Package for Social Science (SPSS), version 20 (SPSS Inc., Chi- prevention of mental health problems (i.e. Q8) and 67.7% with
cago, IL, USA). Sample characteristics were summarized as the question related to mental health promotion (i.e. Q13).
frequency and percentage. Chi-squared test was used to These two questions display the highest frequency of
assess the association of each explanatory factor with the perceived difficulty in HLS-EU-Q16 (Supplementary file 3).
outcome. Spearman's correlation test was used to estimate
the degree of association between FHL, CHL, and other
Functional health literacy
various variables (non-parametric data). Binary logistic
A total of 422 questionnaires were analyzed. Inadequate FHL
regression was then performed in which HL outcome cate-
gories were dichotomized into inadequate and not inade- represented around half (50.6%). Problematic and sufficient
quate (problematic and sufficient). This approach has been FHL constituted 33.4% and 16.1%, respectively. Gender and
utilized previously.21 The first models for CHL and FHL highest level of education had the only significant impact on
included gender, age, education, and marital status. The FHL (Table 3).
second model for CHL included the same variables plus FHL.
Factors associated with inadequate health literacy
Results were expressed in terms of odds ratios with 95%
confidence intervals and P-value. P-value <0.05 was consid-
There were significant associations among potential explan-
ered statistically significant.
atory variables inferred from Spearman correlation analysis
illustrated in Table 4. Nonetheless, all of them were observed
to be weak associations (i.e. absolute value of rs < 0.3).
Results
The first postulated model for CHL indicates that having
low education, being in the second age group, and being a
A detailed description of the study population is presented in
patient are associated with inadequate CHL. When the
Table 1. Males comprise about two thirds of the study popula-
dichotomized results of FHL were added (model 2), males,
tion (60.6%). Patients represent half of the sample. The sample is
participants with inadequate FHL, and participants with lower
quite heterogenic regarding the highest level of education.
levels of education reported inadequate CHL (Table 5).
Comprehensive health literacy The postulated multivariate model for FHL indicates that,
only the gender is significantly associated with the level of FHL
Out of 805 questionnaires, 640 were analyzed; the rest were in which males were less likely to have inadequate FHL
considered ‘missing’ according to the instruction manual of (OR ¼ 0.38) (Table 6).
140 p u b l i c h e a l t h 1 5 1 ( 2 0 1 7 ) 1 3 7 e1 4 5

Fig. 1 e Prevalence of different levels of comprehensive health literacy. Std.Dev., standard deviation.

Analysis of missing values
HLS-EU-Q16
According to the previously mentioned criteria, 165 ques-
tionnaires were excluded from the analysis out of which 147
cases were excluded because they gave the response of ‘do not
know’ for more than two questions (see Methods section). To
determine the factors that were associated with being
excluded from the analysis, we created a logistic regression
model with the included vs excluded cases as dependent
variables. We found that being in the lower education groups
is a risk factor for being excluded (Supplementary file 4). To

Table 2 e CHL categories by gender, age group, marital status, and highest level of education.a
Number of subjects ¼ 640 CHL categories
Inadequate 220 Problematic 299 Sufficient 121
n (%) n (%) n (%)
Gender P ¼ 0.981 Male 140 (34.7) 188 (46.5) 76 (18.8)
Female 79 (33.9) 110 (47.2) 44 (18.9)
Age (years) P ¼ 0.045 15e19 18 (42.9) 20 (47.6) 4 (9.5)
20e39 134 (38.2) 147 (41.9) 70 (19.9)
40e59 54 (27.7) 101 (51.8) 40 (20.5)
60e85 13 (28.3) 27 (58.7) 6 (13.0)
Marital status P ¼ 0.022 Married 140 (31.2) 224 (49.9) 85 (18.9)
Non-married 79 (42) 74 (39.4) 35 (18.6)
Nature of visit P ¼ 0.007 Patient 126 (39.6) 142 (44.7) 50 (15.7)
Companion 91 (28.7) 155 (48.9) 71 (22.4)
Highest level of education P < 0.001 No education 45 (40.5) 51 (45.9) 15 (13.5)
Preprimary or primary education 44 (41.1) 50 (46.7) 13 (12.1)
Preparatory school 38 (40.4) 40 (42.6) 16 (17)
High school or associate degree 71 (31) 117 (51.1) 41 (17.9)
Collegeþ 19 (20.2) 40 (42.6) 35 (37.2)

CHL, comprehensive health literacy.

a
Missing data not included.
 p u b l i c h e a l t h 1 5 1 ( 2 0 1 7 ) 1 3 7 e1 4 5 141

Table 3 e FHL categories by gender, age group, marital status, and highest level of education.a
Number of subjects ¼ 422 FHL categories
Inadequate 213 Problematic 141 Sufficient 68
n (%) n (%) n (%)
Gender P < 0.001 Male 109 (41.1) 104 (39.2) 52 (19.6)
Female 104 (66.2) 37 (23.6) 16 (10.2)
Age (years) P ¼ 0.088 15e19 23 (62.2) 11 (29.7) 3 (8.1)
20e39 122 (45.5) 95 (35.4) 51 (19)
40e59 62 (60.2) 29 (28.2) 12 (11.7)
60e85 4 (40) 5 (50) 1 (10)
Marital status P ¼ 0.88 Married 144 (50.7) 96 (33.8) 44 (15.5)
Non-married 69 (50) 45 (32.6) 24 (17.4)
Nature of visit P ¼ 0.46 Patient 98 (49) 65 (32.5) 37 (18.5)
Companion 114 (51.6) 76 (34.4) 31 (14)
Highest level of education P ¼ 0.009 Preparatory school 57 (60.6) 26 (27.7) 11 (11.7)
High school or associate degree 121 (51.5) 81 (34.5) 33 (14)
Collegeþ 35 (37.6) 34 (36.6) 24 (25.8)

FHL, functional health literacy.

a
Missing data not included.

Table 4 e Spearman correlation among potential explanatory factors.

Variables Minimum Maximum 1 2 3 4
a
Age 1 4 1
Highest level of educationb 1 5 0.266** 1
CHLc 1 3 0.087* 0.182** 1
FHLc 1 3 0.047 0.166** 0.2** 1

CHL, comprehensive health literacy; FHL, functional health literacy.

*
Correlation is significant at the 0.05 level (2-tailed).
**
Correlation is significant at the 0.01 level (2-tailed).
a
1 ¼ 15e19 years, 4 ¼ 60e85 years.
b
1 ¼ no education, 5 ¼ college or above.
c
1 ¼ inadequate CHL/FHL, 3 ¼ sufficient CHL/FHL.

Table 5 e Odds ratios (ORs) of having inadequate CHL in the study population.a
Variables Model 1 Model 2
P-value OR (95% CI) P-value OR (95% CI)
Gender Male 0.38 1.18 (0.82e1.69) 0.03 1.85 (1.08e3.16)
Female 1 1
Age (years) 15e19 0.22 1.86 (0.69e5.03) 0.69 0.71 (0.13e3.94)
20e39 0.03 2.28 (1.11e4.7) 0.93 1.07 (0.24e4.8)
40e59 0.67 1.17 (0.46e1.08) 0.26 0.4 (0.08e1.94)
60e85 1 1
Marital status Married 0.1 0.7 (0.46e1.08) 0.28 0.73 (0.4e1.29)
Non-married 1 1
Nature of visit Patient 0.03 1.49 (1.05e2.11) 0.06 1.61 (0.99e2.62)
Companion 1
Highest level of education No education <0.001 3.93 (2e7.7)
Primary or preprimary <0.001 3.74 (1.92e7.32)
Preparatory school 0.003 2.86 (1.42e5.76) 0.001 3.77 (1.71e8.31)
High school or associate degree 0.04 1.89 (1.04e3.4) 0.04 2 (1.04e3.74)
College þ 1 1
FHL Not inadequate (problematic þ sufficient) <0.001 0.37 (0.22e0.62)
Inadequate 1

Model 1: the first postulated binary logistic regression model in which all of the socioeconomic factors’ association with inadequate CHL was
assessed.
Model 2: the second binary logistic regression model in which FHL level was considered as an independent variable in addition to the other
variables included in model 1.
CI, confidence interval; CHL, comprehensive health literacy; FHL, functional health literacy.
a
Missing data not included.
142 p u b l i c h e a l t h 1 5 1 ( 2 0 1 7 ) 1 3 7 e1 4 5

Table 6 e Odds ratios (ORs) of having inadequate FHL in the study population.a
Variables P-value OR (95% CI)
Gender Male <0.001 0.36 (0.23e0.55)
Female 1
Age (years) 15e19 0.61 1.51 (0.32e7.18)
20e39 0.84 1.15 (0.3e4.42)
40e59 0.23 2.35 (0.59e9.38)
60e85 1
Marital status Married 0.53 0.85 (0.51e1.41)
Non-married 1
Nature of visit Patient 0.29 0.8 (0.53e1.21)
Companion 1
Highest level of education Preparatory school 0.08 1.79 (0.93e3.45)
High school or associate degree 0.11 1.52 (0.91e2.53)
Collegeþ 1

CI, confidence interval; FHL, functional health literacy.

a
Missing data not included.

assess whether the results of excluded cases could have
altered our main results, we postulated two regression
models. In the first, missing values were considered as ‘diffi-
cult’, while in the second, missing values were considered as
‘easy’. In the second model, in which the results were delib-
erately pushed towards the ‘not inadequate HL’ outcome,
males demonstrated potential to move to a higher level of HL.
Meanwhile, attendees' level of education remained to be of a
significant association with HL (Supplementary file 5).
remaining answered one to four questions only. The primary
reason explaining a questionnaire with no responses is that
the interviews were held in the outpatient clinics while in-
terviewees waited for their turn with physicians, and some-
times an interviewee's turn would be due before the
conclusion of an interview.
Discussion

S-FHL The aim of our study was to provide an initial assessment of the
Questionnaires with less than five answered questions were current HL status among attendees of outpatient clinics in ASU
excluded. These were 65 questionnaires, among which 40 Hospitals, as well as to determine factors associated with
participants did not respond to any of the questions, while the inadequate HL. The results showed that the majority of our

Fig. 2 e Levels of education among patients and companions.

 p u b l i c h e a l t h 1 5 1 ( 2 0 1 7 ) 1 3 7 e1 4 5
study population had both limited (i.e. inadequate and prob-
lematic) FHL and CHL. Gender was the only significant factor
affecting the level of FHL, whereas CHL was impacted, in addi-
tion to gender, by education. We also found that limited FHL was
associated with limited CHL; nonetheless, many participants
held limited FHL and simultaneously, sufficient CHL. Moreover,
questions pertaining to prevention of mental health problems
and promotion of mental well-being demonstrated the highest
frequency of perceived difficulty among participants.
The European health literacy survey is employed to assess
CHL in eight European countries in which the prevalence of
inadequate CHL was 12.4%23 compared to 34.3% among our
study population. The former investigates a wider scope of
potential explanatory factors such as poor health status and
socio-economic level. While education is the most important
predictor of CHL in our study, it ranks third after economic
deprivation and social status in the European countries.23
Gender seems to play a minimal role in predicting CHL
levels of European countries,23 while it significantly affects
CHL level of our study population when adjusted for other
factors, including FHL level in model 2 as mentioned before.
Although females have substantially lower FHL, their CHL is
significantly better than their male counterparts when
adjusting for other variables (i.e. age, highest level of educa-
tion, marital status, and level of FHL). This surprisingly,
somewhat paradoxical impact of gender could be attributed to:
1 Poorer quality of education that females receive compared
to males at the same educational level expressed by:
explicit undermining of the importance of education to
girls, social phenomena discouraging girls' education,
higher rates of absenteeism, and lower financial invest-
ment in girls' education.
This attitude is rooted within Egyptians of lower socio-
economic classes which represent most of DUH attendees,
including DUH outpatient clinics. This explanation is sug-
gested by experts' opinions on gender-based discrimination in
developing countries.
2 Better CHL among females may be traced to frequent
exposure of females to healthcare services, as they are, in
most cases, the caregivers of family members. More
exposure and therefore more experience contributed to
females being more familiar with medical information and
presenting fewer perceived difficulties in matters related to
disease prevention and health promotion. This explana-
tion is conjectural and has no supporting published data.
Furthermore, the prevalence of inadequate CHL among
patients is higher than that of their companions, presumably
because they generally exhibit higher levels of education
(Fig. 2). Notably, there is a remarkable discrepancy between
the prevalence of inadequate CHL and the prevalence of
inadequate FHL (34.3% and 50.6%, respectively).
Strengths and limitations
A convenience sample was used instead of random sampling
due to the lack of an established registration system of
143
outpatient clinics attendees. Another limitation is that 432
participants refused to provide any information regarding
their monthly income and others displayed a wide range of
inaccuracy regarding their income which prohibited us from
assessing the impact of economic level on HL.
Notwithstanding these limitations, our study is one of the
first to be conducted in Egypt on the topic of HL. It was con-
ducted in a locally and regionally renowned health facility
that covers a wide variety of the population. A relatively large
sample was obtained to overcome the shortcomings of con-
venience sampling. Furthermore, face-to-face interviews
were used instead of self-administration to ensure the com-
plete understanding of the questions. This facilitated the in-
clusion of uneducated people and subsequently, realistically
reflected the current situation. Also, in order to minimize
interviewer bias, explanatory phrases for each question were
agreed upon among all interviewers to meet different cultural
backgrounds for different participants.
Implications
Problem identification is the first step to its reduction.
Therefore, this study could serve as an initial step for estab-
lishing a national HL surveying system. From a practical point
of view, these results are sufficient to start applying in-
terventions to improve HL such as: plain language initiatives
that aim at raising the level of HL through making health
materials more comprehensible and accessible to the lay
public24 and training healthcare providers on how to
deliver health-related information to people suffering inad-
equate HL.
Inadequate HL may be the root of most cases of non-
compliance. An individual with inadequate HL may not
adhere to instructions due to not comprehending them rather
than not wanting to adhere to them. Repeating instructions,
simplifying instructions, and forming engaging groups to
encourage discussion and feedback processes may all help in
decreasing non-compliance.25
Aside from non-compliance to therapy, inadequate HL
may also be the root of the lack of utilization of recommended
screenings. In turn, this would lead to higher rates of relatively
late hospital admissions. Combining multiple strategies with
the aim of improving HL, i.e. educational interventions
addressing specific health topics like cancer screening,
intensive self-management, and adherence interventions,
can help in reducing emergency department visits and hos-
pitalizations while increasing the utilization of cancer
screening services.26
This study was conducted in the outpatient clinics of a
major tertiary health facility in Cairo that serves a huge vari-
ety of people, many of whom are economically deprived and
uneducated. With taking the aforementioned fact into
consideration, these results could be used to extrapolate the
level of HL in similar strata of the Egyptian society. Further
research using random sampling is warranted in order to
corroborate these results in ASU Hospitals. Also, our findings
should prompt public health scholars in Egypt to study the
issue on a national level in addition to investigating other
potential factors such as, economic deprivation, residence,
and the presence of a chronic illness.
144 p u b l i c h e a l t h 1 5 1 ( 2 0 1 7 ) 1 3 7 e1 4 5
Conclusion
The majority of our study population had limited HL (inade-
quate and problematic). Gender played a paradoxical role in
predicting HL level since it was noted that females are more
likely to have inadequate FHL; whereas, many females had
sufficient CHL, unlike males. Education seemed to be the salient
predictor of CHL level. Most participants perceived high diffi-
culty with questions covering the mental health domain. This
should draw researchers' attention for further investigation.
Author statements
Acknowledgments
The authors would like to thank Josefin Wångdahl, Social
Medicine, Department of Public Health and Caring Science,
Uppsala University for providing them with the validated
Arabic version of the HLS-EU-Q16 and the S-FHL scale as well
as the instruction manual for the HLS-EU-Q16 scoring system.
They would also like to thank Dr. Maha Eljafari, Depart-
ment of Community Medicine, Faculty of Medicine Ain Shams
University for the revision of the statistical work of this study.
Ethical approval
Ethical approval was obtained from the Ethical Committee of
Research in ASU. Informed verbal consent was obtained from
participants.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Competing interests
None declared.
Collaborators
Muhammed A. El-Gabbas, Hossam K. Elroby, Muhammed K.
Mahmoud and Muhammed A. Muhammed participated in the
data collection.
Authors' contributions
RA and YH, who equally contributed, were responsible for
researching health literacy domains to be investigated,
implementing, and coordinating data collection, writing the
background and the methodology, performing statistical
analysis on the collected data, and interpreting and discussing
the results.
EF was responsible for setting and writing the background
and research methodology, implemented data collection, and
participated in writing the discussion as well as the final
editing and writing of the manuscript.
HH was responsible for setting and writing the background
and research methodology, implemented data collection, and
participated in writing the discussion as well as the final
editing and writing of the manuscript.
AA had the original idea for the article, provided ques-
tionnaire materials, and supervised data analysis process.
All authors have contributed to researching the literature,
read, and approved the final manuscript.
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Appendix A. Supplementary data
Supplementary data related to this article can be found at
http://dx.doi.org/10.1016/j.puhe.2017.06.024.