There are several limitations in the current study. First, the convenience sample consists of only ED patients. The results may not be representative of the general population who do not seek ED care. A second concern is that despite the pertinence and accuracy of BHLS, further research using other measurements of health literacy is warranted. Third, this is a pilot study based on a relatively small sample size, although the sample size was larger than the minimum obtained from the power analysis. Certain trends, like the relationship between the primary language spoken at home, or race with COVID-19 knowledge, could have shown to be statistically significant if a larger sample had been obtained. Lastly, the data collected were from a single urban tertiary hospital in a city with about 1/3 of the population being Hispanic. The generalizability of the conclusions to other areas of the US could be limited.
This study found that even after controlling for patients’ characteristics, patients with better general health literacy had better knowledge of basic epidemiology, prevention, diagnosis, treatment, and prognosis of COVID-19. This is in line with findings from studies of other infectious diseases that patients with lower health literacy had worse knowledge of antibiotics, decreased immunization rate and health screenings.4, 6, 14 Reading comprehension, education level, English proficiency, and cultural differences were identified to be common additional contributing factor to health literacy.15
Despite these similarities, the ways the public acquire the knowledge of COVID-19 are distinctly different from those for other infectious diseases in the past, as COVID-19 is presented in a completely different epidemiological, cultural, technological, and even political context. The public have been exposed to some aspects of COVID-19 daily, as information and misinformation about COVID-19 permeate all media sources. Additionally, the drastic change in society with a near-nationwide shutdown and all individual lives being disrupted to some level created a unified front combating the transmission of COVID-19, making the efforts more focused than those for other infectious diseases in recent US history. Consequently, it is not surprising to find that overall, the participants of the current study had a good knowledge of COVID-19.
Furthermore, even after controlling for confounding variables, this study found that ED patients with low income and those with lower education had a lower level of COVID-19 knowledge. Similar findings were demonstrated in an outpatient setting. In a recent study of adult outpatient clinic patients with at least 1 chronic condition, researchers found that blacks, the poor and those with low health literacy were less worried about COVID-19, less likely to believe that they would become infected and felt less prepared for an outbreak.16 It is very concerning that recent studies, however limited in number, identified that the same subpopulations had higher mortality and hospitalization rates of COVID-19.17, 18 This is consistent with prior studies that demonstrated lower education and income resulted in poor outcomes in other diseases.15, 19-21 It is likely that the worse health outcomes of these disadvantaged subpopulations are the result of the lack of effective COVID-19 prevention and coping strategies stemming from the inadequate COVID-19 knowledge. This is further complicated by the already existing barriers to medical care for these patients. Therefore, identifying ways to improve the COVID-19 knowledge within these subpopulations should become an integral part of any community-based interventions to better prepare the public for the pandemic and decrease the health disparities.
Various interventions have been shown to be effective for other diseases in the past, such as simplified wording during media presentations, numerical charts, addition of images and increased funding to media sources.22-24 Applying similar strategies to COVID-19 education should yield similar favorable results. For examples, one study demonstrated the effective use of infographics of COVID-19 on websites and social media.25 In addition to improving the format of the information, targeting the social media platforms that are mostly frequently used by the disadvantaged subpopulations to disseminate the information of COVID-19 can be highly effective. However, as the World Health Organization (WHO) noted, “infodemic” of COVID-19 presented a significant challenge to the local, national and global public health management as there was over-abundance of information and misinformation.26