Public Health Literacy and Emergency Department Utilization in Saudi Arabia: A Cross-Sectional Study

Introduction

Health literacy (HL) has been defined as occurring “when health information and services created for the public match with people’s capacity to find, understand and use them”.¹ Poor HL leads to greater emergency department (ED) utilization and several consequences.² ED is a crucial part of healthcare services where urgent and serious health concerns are handled. While many people who visit ED have problems requiring urgent care, some patients use ED to treat primary care ailments that might be treated elsewhere, such as at the outpatient clinics. Furthermore, many patients visit the emergency because of complications and problems that may have been avoided with appropriate outpatient care.³ According to estimates, the prevalence of low HL in ED can range widely, reaching as high as 88%, depending on the patient mix and the screening tools used.⁴ Globally, healthcare utilization is increasing rapidly, including ED visits, which is a burden on the healthcare system, especially because many ED visits are unwarranted. Approximately 37% of all ED visits in the United States result from non-urgent conditions. Patient-primary care provider relationships are weakened by ED visits for non-urgent conditions, leading to excessive healthcare spending and unnecessary testing and treatment. Previous studies showed that individuals with inadequate HL have contributed largely to the greater number of ED visits.^5–8

Multiple contributing factors to HL have been reported in Saudi Arabia. These included older age, female sex, unemployment states, low financial income, rural cities, and a low educational level. It is reported that almost half of the participants had low HL.⁹

Another study showed that low HL was associated with male sex, older age, comorbidities, poor health, and lower educational attainment; the low HL is related to decreased patient satisfaction, lower compliance with preventive services, and increased healthcare utilization.⁵

ED may be preferred by people with limited HL as a point of entry into the healthcare system because it is easier and more convenient to access than primary care.

Among ED patients, limited HL is associated with worse health status, a higher rate of healthcare utilization, such as ED relapse, and a higher risk of death.¹⁰

Previous studies are few with lack of studies conducted in Saudi Arabia regarding the association between health literacy level and emergency department utilization. Based on prior evidence and a deficit of local studies, this study aimed to estimate the prevalence, factors, ED service utilization, and outcomes of low HL status in the Kingdom of Saudi Arabia (KSA).

Materials and Methods

This cross-sectional study with a convenience sample was conducted in Saudi Arabia using a self-administered questionnaire collected over a 2-month period (April and May 2023). This design allowed us to compare different variables and assess the relationships between HL and its associated factors.

Determination of sample size was based on previous literature showing that the average acceptable level of HL is 50%–60%. When level of confidence is 95% (alpha = 0.05), the minimum sample size needed for the current study is 846. Furthermore, data collection was continued until 846+6.7% responses were reached to compensate for any incomplete surveys. The target sample comprised 903 participants.

Data were collected using an online survey via Google Forms between February 2023 and April 2023. We crafted the survey constructs after an extensive literature review of relevant previously validated studies.⁹ Participants were contacted via social media and were asked demographic characteristic questions for the variables included in the weighting strategy. Participants were asked if they had any chronic disease, psychiatric disease, relatives with chronic disease, ED utilization during the past year (if yes), the cause and the number of visits, hospitalization during the past year, and whether they were infected with COVID-19, and COVID-19 vaccination. Based on whether their response was ‘yes’ or “no” participants were then asked to complete the HL Instrument for Adults (HELIA) questions. HELIA has five subscales (dimensions), an important aspect of the instrument that covers the fundamental ideas and structures that give HL its meaning. HELIA’s components are also pertinent to healthy lifestyles in general, and public health in particular. The instrument’s fundamental concepts address the three most significant global public health issues, including problems related to cardiovascular diseases (nutrition-related disorders), malignancies, and accidents. People with both minimal literacy and high levels of education were able to respond to questions on these themes with ease. Instead of testing people’s knowledge, this instrument examined abilities related to HL.⁹

Respondents rated the following five subscale statements on a 5-point rating scale: 1 = never, 2 = seldom, 3 = sometimes, 4 = often, and 5 = always.

Ease of Reading

• About educational materials about health.
• Written instructions about their illness, medical and dental forms.

Access to Information

• Information about healthy eating, mental health, specific disease.
• Health problems and diseases, harmful effects of tobacco and smoking.

Understand the Recommendations

• Understanding drug information on the labels.
• Understanding the risks and benefits of drugs prescribed by the physician.

Appraisal

• The ability to evaluate health-related information on the Internet.
• The ability to evaluate health-related information on the television or radio.

Decision Making/ Behavioral

• Regular checkups.
• Ask physician or health care team questions about the disease.

For scoring, we calculated each subscale of the HELIA by first adding the raw scores, and linearly transferred them to a score from 0 to 100 using a specific formula. After calculating all five subscales, we added all five results and divided it by 5. For categorical classification, scores of 0–66 were considered limited and those of 66.1–100 were considered adequate. The formula used is as follows:

Testing was performed to determine the instrument’s reliability and validity. The results indicated that the scale was reliable and valid. Reliability was evaluated by calculating the Cronbach’s alpha coefficient. According to these findings, all the components had satisfactory internal consistency. Institutional Review Board approval for the study was obtained from Princess Noura bint Abdulrahman University before the start of data collection. All participants provided informed consent, in accordance with the Declaration of Helsinki.

SPSS (version 23.0; IBM Corp., Armonk, NY, USA) was used to analyze the data. For the research variables and demographic parameters, frequencies, percentages, means, and standard deviations were calculated. To determine the associations between variables and demographic factors and HL, chi-square (χ²) testing was performed. Statistical significance was set at p <0.05.

Results

Prevalence of Public HL in Saudi Arabia

The total number of responses was 903; of which, 529 had limited HL (58.58%) and 374 had adequate HL (41.42%).

In this study, we were able to collect data from 903 participants. The mean age was 31 (SD ± 13.5). Moreover, 80% of the participants were women, and majority (97.4%) were Saudis. Furthermore, approximately more than half (56%) of the participants were single and less than half (37.6%) were married. Approximately 96% reported having at least high school education (Table 1). However, almost half (46.2%) of the respondents were full-time students, 28.5% had no healthcare provider (non-HCPs), 21.6% were non-employed, retired, or housewives, and only 3.6% had HCP.

Table 1 Socio-Demographic Distribution of the Study Participants

Finally, approximately half (46.7%) of the participants had family income from 10 to 30 thousand riyals per month while approximately a quarter (24%) reported less than 10 thousand riyals, as family income.

The average of the health knowledge score observed was 60.79 ± 21.03; this was considered a weak average according to HELIA evaluation system for HL. This indicated a low level of health knowledge. The average score of health understanding was 68.51 ± 25.44, the overall highest average, and the lowest average for the evaluation was 52.76 ± 26.85, and the rest of the subscales are as shown in Table 2. In general, the averages of all aspects were weak, indicating a low level of health knowledge in reading, access, comprehension, evaluation, and decision-making.

Table 2 Mean Scores of Health Literacy Total and Sub-Total Scores

We noted that 14% of the participants suffered from chronic diseases, whereas 69.9% had first-degree relatives with chronic diseases (Figure 1). Participants who had visited ED before were 46.6%, and the largest percentage of the participants (53.6%) had been infected with SARS-CoV-2, while the majority took vaccine doses against COVID-19 (90.5%).

Figure 1 Frequency distribution of selected variables.

Certain categories had significant observations among participants with limited HL. Out of these, the age range 35 to 45 years exhibited the largest proportion (61.7%) of participants with limited HL. Regarding sex, compared to women, men were more likely to have limited HL (68.9%; p < 0.05). Furthermore, the highest percentage of people with limited HL by marital status was the divorced group (65.9%). By nationality, non-Saudi participants more commonly had limited HL (69.6%). Regarding level of education, those with elementary level had the highest percentage (66.7%) of participants with limited HL. Furthermore, not being a healthcare student or graduate was significantly more common (64.0%, p < 0.05) among participants with limited HL. Participants who were retired seemed to make up the highest percentage of participants with limited HL by employment status (69.6%). Additionally, there was a substantial difference in family income, with most families who had limited HL (67.3%, p < 0.05) earning below 10 thousand riyals. Moreover, more than half of the participants without chronic diseases or first-degree relatives with chronic diseases had limited HL. Furthermore, regarding whether individuals had attended ED in the preceding year, nearly two-thirds of those who attended had limited HL. Moreover, in terms of whether the participants were infected with COVID-19, the study found that those who were infected three times were more likely to have limited HL.

Among participants with adequate HL, some observations stood out. The under-35 age group made up the highest percentage (43.1%), despite having a non-significant p-value of 0.452. Single participants were slightly more common (43.2%). Moreover, compared with other education levels, master’s and PhD holders comprised a marginally higher proportion (48.1%) among those with adequate HL. Notably, by work status, health care providers made up the highest group (54.5%) among those with adequate HL. In terms of family income, individuals earning >30 thousand riyals had the highest representation among the participants with adequate HL (55.6%, p < .05). Finally, among those infected with COVID-19, participants who were infected once with covid (43%) had adequate HL (Table 3).

Table 3 Relation Between Health Literacy and the Associated Factors: Between Health Literacy and the Associated Factors

Discussion

This study demonstrated a low rate of adequate HL, with more than half of the participants having difficulty reading, understanding, and interpreting healthcare information. In terms of work status, we found that students constituted a larger proportion of participants who had inadequate HL. In the descriptive analysis, Saudis, non-healthcare students or graduates, those with lower incomes, and those who did not complete their COVID-19 vaccinations were over-represented among those with limited HL. In general, our representative sample displayed a weak average HL according to the HELIA scoring. More than half of our sample showed limited HL, which is consistent with the results of a study conducted in Iran (2016) using the same evaluation tool. Moreover, another study in the KSA suggested that almost half of the residents had low HL.^5,9

Our analysis showed that male participants were significantly less likely than female participants to have adequate HL; however, another study reported no difference in HL scores between the two sexes.⁸ In addition, older age groups had a lower HL score than younger groups, which aligns with the finding in another study that justifies the reasons for the decline in comprehension, memory, and word recognition abilities that occur in older age groups.⁸

Participants with higher education levels reported adequate HL scores. This result is consistent with the literature, as another study in the KSA showed that participants with low education levels are nearly three times more likely to have low HL than those with good education.¹⁰ Not surprisingly, healthcare students and graduates reported higher levels of HL. Moreover, our findings indicated a higher percentage of limited HL with lower family income. This is consistent with the findings of a study that reported that patients with no income or annual income below $20,000 had inadequate or low HL compared with 25% of patients with a yearly income of $75,000 or greater.⁸ Moreover, the findings of this study were similar to those of another study by Abdel-Latif and Saad,²¹ who stated that age, sex, and educational status were strong factors affecting the level of HL.¹¹

Our study reported no statistical differences between having a chronic condition and having a first-degree relative with a chronic condition, based on the HL score. However, a study in Iran using the HELIA score of patients with hypertension reported that the majority of patients with hypertension had inadequate HL and that there was a significant correlation between blood pressure knowledge and the mean HL score.¹² Another study examining the relationship between HL and patients’ knowledge of chronic diseases and found a relationship between HL and knowledge of chronic diseases. HL has been shown to be an independent predictor of patients’ knowledge of chronic illnesses.¹³

There was no significant difference between those who visited ED in the past year and those who did not in terms of HL score; however, another study reported that patients with inadequate HL were more likely to revisit ED than those with adequate HL.⁸ HL was inversely associated with healthcare utilization and expenditure. Individuals with below-basic or basic HL level (HLL) have greater healthcare utilization and expenditures, spending more on prescriptions than individuals with above-basic HLL.⁵ The results of this study established a link between lower HL status and higher healthcare spending. To make the most of the expanding healthcare system in the KSA, the general public will need to be able to locate appropriate healthcare services and information, comprehend it, and use it successfully to improve their health. It is estimated that approximately half of the population did not have sufficient HL levels to fully benefit from healthcare.⁵ It has been noticed that those who have low HL may struggle to understand the medical information read or the medical instructions they were given; thus, they lack proper understanding of their own diseases and treatments, which can result in the development of chronic diseases that will require much more expenditure.¹⁴

The inappropriate use of EDs places an enormous strain on the healthcare system.¹⁵ Enhancing patient knowledge may alleviate this strain. Some studies have proposed that ED may serve as ideal settings for educating patients regarding ED usage, thereby enhancing HL.^16–18

The limitations of the present study include the unbalanced representation of sex; females constituting approximately 80.1% of the participants, and the student representations being 46.2% of the sample. Owing to the cross-sectional nature of our study, we could not confirm the relationship between the number of ED visits and COVID-19 or adequate HL. Nevertheless, these results provide valuable information on the prevalence of public HL.

Furthermore, these data will be useful for healthcare providers planning community education.

Conclusion

This study analyses the prevalence, factors, ED service utilisation, and outcomes of low HL status in Saudi Arabia, considering different factors. Most participants who had limited HL were more associated with low-income, non-healthcare students and graduates, and participants who did not complete their COVID-19 vaccination.

Low HL makes people unable to understand medical knowledge and instructions. The study lacks explanations for the relationship between having COVID-19 and the number of visits to the ER and the association between low HL and ER visits. Inappropriate gender representation and the lack of explanation between HL and ER visits are the primary limitations; specifically, four-fifths of the participants are women. Further research on the HL and its association with the number of ER visits in Saudi Arabia and with more diverse representatives can help better understand the adequacy of health literacy in the country.