Relationship between Health Literacy and Health Information Avoidance in University Students

Authors
F. Baji
M. Rahimizadeh
Z. Sabaghinejad
Department of Medical Library and Information Sciences, School of Allied Medical Sciences, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
10.58209/hehp.13.2.375
Abstract
Aims: Health literacy is a crucial component in enabling individuals to make informed decisions, recognize health risks, and prevent diseases at both personal and community levels. Despite its importance, some individuals consciously avoid seeking health-related information. This study aimed to explore the relationship between health literacy and health information avoidance among university students.

Instrument & Methods: This cross-sectional study was conducted in 2024 involving 369 students from Ahvaz Jundishapur University of Medical Sciences. Participants were selected using a random stratified proportional sampling technique. Data collection was carried out through two questionnaires on health literacy and health information avoidance. Data analysis was performed using descriptive statistics and correlation analysis.

Findings: Nearly 50% of the students demonstrated a satisfactory level of health literacy, with 7.25% exhibiting a high degree, while less than 25% revealed a somewhat insufficient or inadequate level of health literacy. Despite students displaying a robust comprehension of health information, their proficiency in applying this knowledge for decision-making purposes was notably deficient. Regarding health information avoidance, a substantial majority of participants (93.2%) exhibited a moderate degree of avoidance. A significant inverse correlation was established between health literacy and health information avoidance. Furthermore, a notable association was identified between gender and academic year in relation to health literacy.

Conclusion: Health literacy is essential for improving health outcomes and minimizing disparities, particularly among students, where lower health literacy correlates with higher health information avoidance.

Keywords

Subjects

Introduction
Health literacy (HL) refers to an individual’s capacity, motivation, knowledge, and competencies necessary for effectively accessing, comprehending, evaluating, and utilizing health information. It constitutes a fundamental component in facilitating informed decision-making regarding health matters [1]. According to the World Health Organization (WHO), HL encompasses both cognitive and social proficiencies that signify an individual’s motivation and ability to obtain, interpret, and implement health information to improve and maintain their well-being [2]. This construct empowers individuals to actively engage in altering their environments to positively influence their health, serving as an essential component in gaining control over social determinants of health and promoting community welfare. Moreover, HL plays a critical role in influencing health disparities prevalent in both affluent and economically disadvantaged nations. Demographics characterized by low HL frequently encounter adverse health outcomes and demonstrate insufficient self-care behaviors. Individuals with limited HL commonly experience deteriorating health status, utilize preventive and screening services less regularly, and incur elevated healthcare costs. The consequences of inadequate HL are significant, impacting patient behavior, increasing mortality rates, and posing a considerable public health challenge [3].
HL and health information avoidance (HIA) are interrelated constructs that pertain to the field of information studies. The acquisition and application of information are crucial for the sustenance of both individuals and organizations [4]. Thus, the interplay between humans and information constitutes a significant area of inquiry within the domains of information science and knowledge studies [5]. Information avoidance signifies a mode of human interaction with information, characterized by behaviors that inadvertently obstruct the acquisition or delay the reception of accessible information. Such avoidance may be exemplified by the intentional sidestepping of particular subjects or contexts [5]. A salient illustration of this phenomenon is HIA, wherein individuals may refrain from seeking or utilizing health-related data for various reasons [6]. Individuals who exhibit a propensity for avoiding health information frequently demonstrate diminished engagement in preventive health behaviors. Moreover, those with lower levels of HL are more susceptible to evading information concerning illnesses. A significant correlation exists between knowledge and the tendency for avoidance; as an individual’s comprehension in a specific domain increases, the inclination to avoid information diminishes [7, 8]. Numerous scholarly inquiries have investigated the dimensions of HL alongside the phenomenon of information avoidance. Hironen’s empirical investigation revealed a significant correlation between daily HL and the tendency to circumvent information related to physical activity [9]. The research conducted by Jean et al. elucidated that information avoidance, limited HL, and the lack of health equity are intrinsically linked [10]. Chen et al. determined that individuals exhibiting lower levels of HL are more predisposed to eschew information regarding COVID-19 [8]. Orom et al. illustrated that a notable association exists between inadequate HL and HIA, particularly in understanding the risks associated with diabetes and colorectal cancer [11].
The principal objective of this study was to investigate the relationship between HL and HIA among students. This research aimed to evaluate the degree of HL, considering factors, such as the reading capability of health information, accessibility to health information, comprehension and interpretation of health information, assessment of health information, and the decision-making process and application of health information. Additionally, it sought to gauge the extent of HIA, based on attitudes toward health information, the pursuit and reception of health information, and the acquisition of health information. Furthermore, the study aimed to clarify the relationship between varying levels of HL and HIA within the student population. The results of this study could potentially benefit professionals in information science, researchers, and policymakers in the fields of health and wellness by expanding the knowledge base and elucidating the dynamics between HL and HIA.

Instrument and Methods
Design and Sample
This descriptive research is quantitative and cross-sectional. A correlational research design was adopted, employing a survey-based methodology conducted in 2024.
The participant cohort consisted of 7,500 students enrolled at Ahvaz Jundishapur University of Medical Sciences (AJUMS) during that year. A proportional stratified sampling method was utilized to collect data from a diverse array of academic levels, encompassing undergraduate (BA), master’s (MA), professional doctorate (MD), and PhD programs. Using the Krejcie and Morgan formula, the determined sample size was 369. Within the participant group, 68.8% (253 individuals) were classified as female, while 31.4% (116 individuals) were classified as male. The distribution of students across various academic levels showed that 46% of the participants were MD students, and 38% were BA students. MA students (13%) and PhD students (3%) had the lowest representation.
The eligibility criteria for participation mandated that individuals be currently enrolled at the university and demonstrate a willingness to partake in the research study. Students who were on academic leave left the research community.
Instrument
Data were collected using two questionnaires; a validated Iranian Health Literacy (HL) Questionnaire (Helia) assessing access, understanding, utilization, reading, and evaluation of health information [12] (Cronbach’s alpha=0.91 in this study) and a researcher-developed Health Information Avoidance Questionnaire [13] with three subscales (attitude, seeking avoidance, and acquiring avoidance), which was validated with a Cronbach’s alpha of 0.88. To determine the total score, the sum of the subscale scores was divided by the number of subscales. The HL levels were categorized as insufficient (0-50), not quite sufficient (50.1-66.0), sufficient (66.1-84.0), and excellent (84.1-100). HIA was classified as low, moderate, or high avoidance based on quartile scores, with the scoring range spanning from 13 to 65. To classify scores into quartiles, three distinct categories (low, moderate, and high avoidance) were established. The delineation of score ranges was set as low avoidance level (scores from 1 to 21.6), moderate avoidance level (scores between 21.7 and 43.3), and high avoidance level (scores ranging from 43.4 to 65). Self-administered printed questionnaires were enclosed in sealed envelopes and distributed to participants.
Data collection
Respondents were instructed to complete the questionnaires, reseal them in the original envelopes, and submit them to their respective faculty libraries. Upon collection, the questionnaires were examined for completeness and subsequently entered into statistical analysis software for data processing.
Data analysis
Data analysis was conducted using SPSS version 21 employing correlation tests, independent t-tests, one-way ANOVA, and LSD post-hoc tests, with all analyses performed at a 95% confidence level.

Findings
The findings reveal a nuanced picture, highlighting both strengths and areas for improvement in students’ ability to access, understand, and utilize health information (Table 1). Total HL levels included excellent (95, 25.7%), sufficient (186, 50.4%), not quite sufficient (79, 21.4%), and insufficient (9, 2.4%), with a standard error of 0.75 for all categories.

Table 1. Health literacy standardized scores


Considering the standard score cutoff, the component “understanding health information" was classified in the “excellent” category, whereas the component related to “decision-making and health information utilization” was positioned in the “not quite sufficient” category. A significant portion of the student population (50%) demonstrated a sufficient level of HL, with 25.7% exhibiting an excellent level, while 23.8% of students were categorized as “not quite sufficient” or “insufficient” in terms of HL. To investigate HL in relation to gender, an independent samples t-test was employed, while a one-way ANOVA was utilized for the analysis based on academic level. The mean HL scores of females exhibited a statistically significant increase compared to those of males. Furthermore, a significant disparity existed in the mean HL scores among students enrolled at different educational levels. The results derived from the LSD post-hoc analysis indicated that the mean HL scores of undergraduate students were considerably lower than those of other academic levels (p<0.0001), with the most pronounced difference identified in relation to PhD students (mean difference: -18.16). The mean HL scores of master’s degree students were significantly higher than those of undergraduate students (mean difference: 6.08, p<0.002) but lower than the scores of PhD students (mean difference: -12.07, p<0.002). Additionally, the mean HL scores of MD students were significantly greater than those of undergraduate students (mean difference: 4.02, p<0.003) while remaining lower than those of PhD candidates (mean difference: -14.13, p<0.0001; Table 2).

Table 2. Comparison of health literacy mean scores by gender and educational level


The highest mean was related to “attitude toward HIA,” with a substantial proportion of participants (93.2%) exhibiting a moderate level of HIA (Table 3). The frequency of HIA was 1(0.3), 344(93.2), and 24(6.5) for low, moderate, and high levels, with a standard error of 0.25 for all categories.

Table 3. The status of health information avoidance


To analyze the patterns of HIA in relation to gender, an independent samples t-test was employed, while a one-way ANOVA was utilized to assess the differences based on educational attainment. Males demonstrated elevated mean scores in HIA compared to their female counterparts; however, this difference was not significant. Moreover, there was an absence of significant variation in the mean scores of HIA among students across different academic tiers (Table 4).

Table 4. Comparison of health information avoidance mean scores by gender and educational level


A correlation analysis using Spearman’s coefficient was conducted to examine the relationship between HL and HIA. There was a significant inverse correlation between HL and HIA, indicating that enhanced HL results in a reduction of HIA. Among the 15 relationships identified between the components, seven demonstrated statistical significance. The relationship between gender and educational attainment with HL and HIA was assessed using Spearman’s correlation. There was a significant correlation between HL and gender (0.103, p-value=0.048), as well as educational attainment (0.022, p-value=0.0001). Conversely, no significant correlation was identified between HIA and gender (0.028, p-value=0.58) or educational attainment (0.027, p-value=0.68; Table 5).

Table 5. Relationship between health literacy and health information avoidance


Discussion
This study investigated students’ comprehension and application of health information, revealing a strong understanding of concepts but a deficiency in decision-making and practical application. While students demonstrated the ability to interpret information, access resources, and assess validity, they struggled to translate knowledge into action, such as engaging in routine medical examinations [14]. These findings contrast with some studies that show challenges in health information acquisition [15] but align with others indicating strong HL among clinical program students [16, 17]. Furthermore, individuals engaged in medical emergencies demonstrated remarkable proficiency in comprehension, whereas participants in radiology technology exhibited superior capabilities in evaluation. Students specializing in laboratory science revealed commendable competencies in decision-making and behavior, thereby substantiating the findings of this study.
The research highlighted that students could generally evaluate health information and assess the accuracy of recommendations, contradicting findings that suggest students struggle to distinguish between reliable and unreliable online sources [18]. Support for this finding comes from studies that reported above-average HL and the ability to discern fraudulent health information [19]. Students often demonstrated the capacity to assess the reliability of health advice from their social circles, showing promise in navigating health-related information.
Despite their understanding, many students did not routinely engage in preventive health measures, citing “time limitations” as a factor [14]. We found varying levels of HL, with 50% demonstrating adequate proficiency and 28% exhibiting excellent proficiency. This contrasts with research indicating lower HL levels among university students [20] and highlights the need for tailored health communication strategies. Gender differences were also observed, with women demonstrating higher HL than men [21], a finding that diverges from studies showing lower HL among women and older adults [22], emphasizing the necessity for targeted approaches.
HL scores varied significantly across educational levels. Students in graduate programs and basic sciences exhibited higher HL [1]. Education level significantly influences HL [20], with final-year students showing higher levels than first-year students [23]. Factors, such as education, field of study, parental education, age, and region, are key determinants of HL [24]. Prioritizing education level is a viable strategy for health policymakers due to this correlation.
A majority of students were inclined to engage with health information, even if it caused psychological distress. This contrasts with research showing that high information distress leads to information avoidance and reduced compliance with preventive measures [6, 25, 26]. However, the current findings align with studies indicating that concern and perceived risk can drive information-seeking behavior [8].
Students actively seek information during pandemics, demonstrating a desire for diverse health data [27]. Deliberate evasion of health information may be influenced by concerns about influential entities exploiting the data [28]. Students expressed eagerness to learn about severe medical conditions affecting relatives, even if it caused emotional instability. This contrasts with studies indicating that people often avoid information that may cause discomfort or psychological distress [29]. Gender did not play a significant role in HIA, contradicting findings that suggest males are more likely to avoid health information than females [30].
This study assessed students’ HL, HIA, and their capacity to make informed health decisions. Students possessed a strong understanding of health information and could evaluate its reliability, contrary to some past studies. However, they struggle to apply this knowledge and make proactive health decisions, such as engaging in routine check-ups. HL levels varied, with women generally scoring higher than men, although some research contradicts this. Factors, such as education level, significantly influenced HL. While many students actively sought health information during crises, a moderate number exhibited HIA, though not necessarily due to anxiety or distress as previously suggested. Additionally, no significant gender differences were found in HIA, contradicting other research.
Enhancing HL through educational initiatives, accessible resources, and policy-driven strategies (especially for vulnerable populations) can empower individuals to make informed decisions, strengthen preventive health behaviors, and reduce HIA.

Conclusion
HL is essential for improving health outcomes and minimizing disparities, particularly among students, where lower HL correlates with higher HIA.

Acknowledgments: This article is taken from the Master's thesis in Medical Library and Information Sciences (Marzieh Rahimizadeh). We would like to thank the participants in the research and Ahvaz Jundishapour University of Medical Sciences for funding it.
Ethical Permissions: The ethical code for this study is IR.AJUMS.REC.1402.389.
Conflicts of Interests: The authors declared no conflicts of interests.
Authors' Contribution: Baji F (First Author), Introduction Writer/Discussion Writer (25%); Rahimizadeh M (Second Author), Introduction Writer/Discussion Writer (20%); Sabaghinejad Z (Third Author), Introduction Writer/Methodologist/Main Researcher/Discussion Writer/Statistical Analyst (55%)
Funding/Support: This study was funded by the Ahvaz Jundishapur University of Medical Sciences.
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Health Education and Health Promotion
Volume 13, Issue 2
Spring 2025
Pages 375-380