This study explored the HL of Brazilian undergraduate health students based on applying the multidimensional HL measurement instrument and identifying, through cluster analysis, the strengths and limitations of HL in subgroups of participants. First Brazilian study to measure HL in this profile and to describe this relationship, offering a comprehensive view of the potential vulnerabilities of this group at a national level, which could serve as a basis for educational interventions aimed at this population.
Descriptive analysis
About sociodemographic, clinical, and health perception variables, in general, the results are equivalent to the findings of international studies that have explored this construct in this profile of participants, which reinforce that HL is a phenomenon that can be influenced by various factors, including age, semester of study, gender, undergraduate course, parents' level of education, socioeconomic level, and financial situation, access to information, health-related experiences, among others.25–28
In the present study, the average scores of the nine HQL-Br scales indicated various challenges regarding HL in this sample, a fact that can be seen from the position of these scores, which are between the maximum score and the possible averages of the scales (possible averages - scale 1 to 5 = 2.0; scale 6 to 9 = 2.5).
On scale 1 (Feeling understood and supported by healthcare providers), which aims to measure a person's ability to establish a trusting relationship with a healthcare provider that helps them understand information and make decisions about their health, the average score was 2.74. This result shows that the students in this sample had a certain degree of difficulty but could establish a relationship with at least one health professional who knows them well, whom they trust to provide advice and valuable information and help them understand information and make decisions about their health.19,29
On scale 2 (Having sufficient information to manage my health), which assesses whether the participant has all the information they need to manage their health condition and make decisions, the average score was 2.78. This result indicates that the participants felt they needed more confidence about having all the information they needed to manage their condition and make decisions.19,29
For scale 3 (Actively managing my health), which assesses the participant's ability to take responsibility for their health, become proactively involved in their care, and make their own decisions about their health, the average score was 2.81. This result shows that the students thought they had some limitations but felt capable of taking responsibility for their health, being proactively involved in their care, and making their own decisions about their health. 19,29
As for scale 4 (Social health support), which is linked to the person's perception of the social system and whether it provides them with all the support they need to manage their health, the average score of 2.79 indicates that the students identified that they did not receive full support from the social system concerning their health needs. 19,29
On a scale 5 (Appraisal of health information), which measures the participant's ability to identify reliable sources of information and to resolve conflicts of information on their own or with third parties, the result achieved was 2.79. This result indicates that the students did not consider themselves fully capable of identifying good information and reliable sources, with difficulty discerning conflicting information on their own or with the help of others. 19,29
As for scale 6 (Ability to actively engage with healthcare providers), which seeks to reflect seeking advice from healthcare providers when necessary and asking questions to obtain the information they need, the average score (3.49) shows that students thought they were proactive about their health and that most of the time they felt in control of their relationship with health professionals. 19,29
To scale 7 (Navigating the healthcare system), which assesses the ability to know about services and support so that all their needs are met, the average score obtained (3.54) indicates that the students identified as having a reasonable degree of knowledge about health services and support so that all their needs are met. 19,29
On scale 8 (Ability to find good health information), which measures the ability to actively use a vast network of sources to find up-to-date information, the result achieved (3.54) shows that the participants considered themselves to have an excellent ability to explore information, with active use of a wide range of up-to-date information sources. 19,29
Finally, for scale 9 (Understand health information well enough to know what to do), which aims to analyze the ability to understand written/numerical health information and to write appropriately on forms, the average score (3.78) shows that the students thought they had an excellent ability to understand all the written information, when necessary. 19,29
In general, the average scores obtained for the nine scales were lower than those found in surveys of health students carried out in Australia29 and Denmark27. This result mainly reflects the socio-economic, cultural, and quality of life differences between these countries and Brazil, as measured by the Human Development Index (HDI)30. For example, Australia and Denmark rank second (2a) and nineteenth (19a), respectively, while Brazil ranks eighty-seventh out of 191 countries30. Therefore, it is understood that the higher a country's HDI, the better its gross per capita income, the better its access to and conditions of health and longevity, and the better the quality and guarantee of education, conditions recognized in the literature as intrinsic to HL results.25,26,31
Corroborating this analysis, we can also observe that when we compare the results of this study with those carried out in countries with an equivalent HDI classification and socio-economic characteristics similar to the Brazilian scenario, such as China26, Jordan32, Nepal33, and Palestine34, we see, within their particularities, similar levels of HL in the nine scales.
In a general analysis of these results, the lowest scores were obtained on scales 1 and 6, which reflects that this group's main limitation is associated with health professionals' ability to understand, interact with, and support them. However, the group found it easier to carry out active care, understand health information, and know how to apply it, as indicated by the higher scores on scales 3 and 9. 19,29
Therefore, in summary, it is understood that the participants felt that they did not have an established relationship of trust with a healthcare provider of reference who could help them understand information and make decisions about their health, accompanied by a feeling of inability to seek advice from healthcare providers, to ask questions and obtain the information they need.19,29
This result may be because the majority of the sample was made up of young adults (average age = 25.2 years), who find it very easy to access and acquire health information from websites, often not identifying the need and importance of consulting a health professional to answer their questions or even to confirm this information.35
Another point may be related to the difficulties encountered by many patients in establishing good interaction and communication with the health professionals who attend to them, a skill recognized in the literature as one of the main pillars of HL, which directly influences this relationship and the patient's loyalty to the health professional.36
The ability to take responsibility for one's health, to be proactively involved in one's care, and to make one's own decisions about one's health, along with the ability to understand written/numerical information about one's health and to write appropriately on forms when necessary, were skills that stood out positively in this sample.29
Similar results were found in international studies, such as the one carried out in Victoria, Australia, with health and art students, in which the lowest scores were given to scales 1 and 7 and the highest to scales 3 and 9. 29 In the study carried out in Chongqing, China, with health students, scale 1 was the lowest and scale 9 the highest.26 Research carried out in Jordan32 and Nepal33, with the same profile of students, similarly identified lower scores for scales 1 and 6, respectively.
Cluster Analysis
Cluster analysis examined the patterns of HL among the participants in this study and related them to sociodemographic data, which resulted in eight distinct groups. Although the descriptive analysis demonstrated the challenges of this sample in achieving adequate HL, the cluster analysis revealed subgroups of participants with similar socio-demographic data, which exhibit characteristic patterns of strengths and limitations.37
This statistical method has the potential to signal the specific needs of strategically delimited population subgroups, especially groups facing social disadvantage or marginalization, which can be masked by using descriptive data analysis alone to explain the characteristics of a population.37
The cluster analysis applied to this study showed that all the groups were made up mostly of female participants, thus representing the general characteristic of this sample (84.3% female participants), which corroborates the scenario of health professions nationwide.38
In Brazil, women represent 65% of the total workforce in the health sector, and this share is even higher in some professions, such as nutrition (90%), nursing (85.1%) and psychology (80%).38
Within a historical and sociocultural context, professions related to care practices, such as health care, have long been associated with the female sex as a place socially linked to an innate condition of women, represented by the direct relationship with the natural capacity for biological reproduction and the culturally imposed and historically taught responsibilities of women with domestic and family care.39
Group A showed the best results among the clusters in all nine HLQ-Br scales. This group comprised women with the highest average age in the sample (29.5), who were studying nursing, were self-declared white, and had parents with complete or incomplete higher education.
Different from the overall average score, group A had a high score on a scale 1, which indicates that this group, in particular, did not struggle to understand and receive support from health professionals like the other students.
About average age, the literature mentions the direct relationship between this variable and the level of HL, so the older the participant, the higher their level of HL.25,32,40 This may be justified by the more significant number of opportunities and experiences in the health system. With increasing age and experience, older students can better navigate the health system and relate to health professionals. This results in greater awareness of health promotion resources and self-confidence when interacting with health professionals.25,40
Another critical point is the level of education of the parents. Research has shown that the highest levels of HL are observed in students with parents with complete or incomplete higher education. This result may be directly related to parents' greater awareness of the importance of health due to their level of education, which allows them to properly guide their children in using the health system.25–27,31,32,40
Regarding the skin color variable, the results of this study show that the groups in which students who identified themselves as white predominated had better HL levels than the other groups.
In two North American studies, one with patients with cardiovascular diseases and the other with patients undergoing dialysis, the authors concluded that black patients had lower HL rates compared to white patients.41,42 However, we did not find this analysis for students or health professionals.
According to the literature, HL is directly related to the construct of literacy because when accessing health services, individuals with low literacy are more likely to show restrictions with the type of reading required for this environment, such as reading treatment guidelines and drug prescriptions, scheduling appointments and reading health education materials.43
Throughout history, the black and indigenous populations have faced significant challenges in accessing formal education, representing a complex relationship that is subject to socio-economic, cultural, and historical influence. However, despite recent progress in Brazil, these populations still struggle to access and remain in education, whether in primary or higher education.44
Group B showed similar characteristics to Group A but with a lower average age (25.4 years) and parents with up to high school education (complete or incomplete). These circumstances may have interfered with the average scores of the nine scales in this group, which were lower than in group A. The participants in this group thought they had a good understanding and evaluation of the health information they received but needed more information and social support to care for their health.
Concerning the difference in scores between undergraduate programs, studies have shown different levels of HL in comparison between health programs. They also highlight the importance of interpreting these results with caution due to the specific nature of the curricula of each course.13,27,32,40
However, no studies in the literature compare students' HL levels between the undergraduate courses discussed here. However, in a study consecutively in Spain and France with nursing and social work students, nursing students stood out with the best HL results.45 In a second study in Nepal with medical, dental, nursing, and public health students, medical students showed the highest levels of HL, and nursing students showed the lowest.40
In the present study, the undergraduate nursing students with the best levels of HL were in groups A and B. From a care point of view, nursing professionals are the ones who spend most of their working time on direct care, which makes them more accessible to patients than other health professionals. Nursing professionals, therefore, play a fundamental role in understanding, guiding, and clarifying health information.14 This highlights the importance of developing themes around the HL construct in the curricula of undergraduate health courses, especially nursing courses.14
Group C had similar characteristics to the previous groups but with more physiotherapy students. This student profile considered that they had sufficient information and social support to care for their health but needed help interacting with health professionals and navigating the health system to obtain good information.
Group D, on the other hand, was made up mostly of students studying psychology with characteristics similar to those described above. The members of this group had a good understanding of health information. They knew how to apply it but needed more social and health professional support to find good health information.
Group E had characteristics similar to those of Group D but differed in average age, which was lower in Group E (23.7 years) and the parent's level of education (complete or incomplete higher education). The participants in this group thought they could navigate the health system and understand and apply the health information they found. Nevertheless, they needed more social support and support from health professionals to obtain sufficient information to look after their health.
Group F was the second largest group, with similar characteristics to Group D, but mostly composed of participants who declared themselves non-white (50.6%). The students in this group considered that they had some capacity for active health care and understanding health information. However, they identified barriers to accessing information and interacting with health professionals.
Group G was made up mostly of psychology students, with the second lowest average age (23.3 years), who declared themselves to be non-white (52.7%) and had parents with up to elementary school education (complete or incomplete) (38.8%). The students in this group considered that they had a certain degree of limitation in understanding and applying health information, accompanied by low interaction, support, and understanding by health professionals.
Group H had the smallest number of students: pharmacy students with the lowest average age (21.1 years), half of whom declared themselves white and the other half non-white, with parents who had attended high school (complete or incomplete). In a broader context, this group thought they had significant limitations when carrying out active health care, interacting with health professionals, navigating the health system, finding good health information, understanding health information, and knowing what to do.
Limitations
Firstly, using a self-reported measure of HL has the disadvantage of social desirability that may have interfered with the result. Secondly, more studies using cluster analysis to assess the same population profile are needed, limiting the comparison of results with similar studies. Thirdly, there was a need for national studies with undergraduate health students, which made it difficult to compare the data directly. Fourthly, as this was a cross-sectional study, it was impossible to verify cause-and-effect relationships.