Health Literacy in Ethiopia: Evidence Synthesis and Implications

Figures & data

Figure 1 Flow diagram of eligible studies selection process and results.

Notes: PRISMA figure adapted from Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;338(7716):332.²⁸

Table 1 A Map of the Studies Included in the Review

Author, year	Region	Objective of the Study	Design/Method		Study Setting	Study population (Sample Size, Sex and Age in Analysis)	Sampling Technique	Aspect of Health Literacy	Measure of Health Literacy	Main Findings
Mengiste, Ahmed, Bogale, Yilma;^Citation29 2021	Amhara	To assess the information-seeking behavior about diabetes and associated factors among diabetes patients	Cross-sectional (Mixed methods)		Hospital	Patients with diabetes attending healthcare at hospital (423; Sex: M= 51.8%, F= 48.2%; age ranges 18 to > 60 years)	Systematic random sampling and purposive sampling	Disease- specific health literacy	Questionnaire adapted from the Newest Vital Sign and In- depth interview	About 53% of the participants had limited HL, and only 41.6% were diabetes information seekers. Their sources of information were health professionals, mass media, internet, brochures, family, friends, and magazines/newspapers. Educational status, place of residence, comorbidity, and HL were associated with diabetes information seeking.
Gedefaw, Yilma, Endehabtu;^Citation30 2020	Amhara	To assess information seeking behavior about cancer and associated factors among students	Cross-sectional/Quantitative		University	University students (844; Sex: M=52. 4% and F=47. 6%; age range 18 to 38 years)	Stratified multi-stage sampling	Disease-specific health literacy	European health literacy survey questionnaire	Of the total study participants, only 37.2% had adequate HL level. Their most preferred cancer information sources were health-care providers (48%) and internet (27.6%). The factors associated with information seeking were year of study, internet access, HL level, self-reported health condition, perceived susceptibility and severity.
Tefera, Gebresillassie, Emiru, Yilma, Hafiz, Akalu, Ayele;^Citation31 2020	Amhara	To assess the diabetic health literacy and the association with glycemic control in type 2 diabetes mellitus adult patients	Cross-sectional/Quantitative		Hospital	Adult outpatients with type 2 diabetes mellitus (400; Sex: M=47.3%; F=52.8%; age range < 40 to > 60 years)	Simple random sampling technique	Disease-specific health literacy	The comprehensive 15-items diabetic health literacy questions with a 5-point Likert scale	Of the total participants, 17.3%, 26.3%, and 56.5% had low, medium and high diabetic-related HL, respectively. Younger age, high diabetic HL and good adherence were associated with achieving the targeted glycemic control, and adequate diabetic HL and better glycemic control were highly correlated. Patients who had high diabetes literacy were 1.85 times more likely to achieve target glycemic control than those who had lower diabetic literacy with 95% CI AOR. 1.85(1.09–3.40).
Tilahun, Gezahegn, Tegenu, Fenta;^Citation32 2021	Oromiya	To assess functional health literacy (FHL) and associated factors in cardiovascular diseases (CVDs) patients	Cross-sectional/Quantitative		Hospital	Adult patients with CVDs (410; Sex: M=51.7%; F=48.3% age range 18 to 88 years)	Simple random sampling technique	Functional health literacy	A functional health literacy questionnaire	Of the total participants, 53.9% and 50.5% had low FHL in finding health information and for having sufficient information to manage their health respectively, but 55.4% of the participants had adequate FHL in understanding health information. Education, income, gender, access to information, and the disease situation were associated with FHL.
Tilahun, Abera, Nemera;^Citation33 2021	Oromia	To assess communicative health literacy (CHLL) and associated factors among patients with NCDs	Cross-sectional/Quantitative		Hospital	Patients with NCDs (408; Sex: not clearly specified; age range18 to over 65)	Simple random sampling	Communicative health literacy	Health Literacy Questionnaire	More than half of the respondents had high CHLL levels in four of the six HL domains (healthcare provider support (56.1%), social support for health (53.7%), active engagement with healthcare providers (56.1%), and navigating the healthcare system (53.4%)). However, they had low CHL levels in the remaining two domains (actively managing health (49.5%) and ability to find good health information (45.8%)). HL levels vary based on socio-demographic and disease characteristics of the patients.
Gurmu Dugasa;^Citation34 2022	Oromia	To assess health literacy levels and associated factors among admitted adult patients	Cross-sectional/Quantitative		Hospital	Patients (403; Sex: M=58.3%; F=41.7; age range 20 to over 60)	Stratified sampling	General health literacy	Health Literacy Questionnaire (HLQ)	About 40% of the participants had low HL. Patients who had tertiary education level were 2.45 times more likely to have high HL (AOR = 2.45, 95% CI: 1.21, 4.98) compared to those who were unable to read and write, and patients who had age greater or equal to 60 were 65% less likely to have high HL (AOR: 0.35, 95% CI: 0.18, 0.70).
Shiferaw, Tilahun, Endehabtu, Gullslett, Mengiste;^Citation35 2020	Amhara	To assess eHealth literacy status and associated factors in chronic patients using internet	Cross-sectional/Quantitative		Hospital	Chronic patients (423; Sex: M= 66.3%; mean age was 35.58 ± 14.8 years)	Stratified sampling technique	Domain-specific health literacy	The eHealth literacy scale (eHEALS)	Only 46.5% of the patients had high eHealth literacy level. Their major sources of information were health professionals (83.4%) and television broadcasts (30.0%). Educational status, occupation type, residence, self-reported health status, monthly salary, internet use frequency, knowledge about the importance and availability of online resources, attitude toward using online it, and computer literacy status were associated with eHealth literacy status.
Shiferaw, Mehari, Eshete;^Citation36 2020	Amhara	To assess Internet use and eHealth literacy status among nursing students	Cross-sectional/Quantitative		University	Undergraduate nursing students (229; Sex: M= 48.5; F= 51.5; mean age 20.66 ± 1.45 years)	Stratified random sampling	Domain-specific health literacy	eHealth literacy scale (eHEALS)	About 89.1% of the students reported that they had access to the Internet, and 60.7% of them reported using it daily. Majority of them (52.8%) reported using Internet for social media and chats, and only 22.7% of them reported using it for educational purposes. Their mean eHealth literacy status was 25.23 with a 7.29 SD. Factors associated with eHealth literacy were gender, enrolment year, and residence place (p < 0.01).
Mengestie, Yilma, Beshir, Paulos;^Citation37 2021	Amhara	To assess eHealth literacy level and associated factors among students		Cross-sectional/Quantitative	University	Medical and health science students (801; Sex: M= 60%; age range ≤ 21 to > 21)	Stratified multistage sampling	Domain-specific health literacy	eHealth literacy scale	About 60% of the respondents had high eHealth literacy. Using health-specific web sites, having higher Internet efficacy, Internet perceived usefulness, using medical app, female sex, and being student of health informatics were the factors associated with a high eHealth literacy level.
Chereka, Demsash, Ngusie, Kassie;^Citation38 2022	Amhara	To assess digital health literacy (DHL) to share COVID-19 related information and associated factors among healthcare providers		Cross-sectional/Quantitative	Health facility centres	Healthcare providers (456; Sex: M= 74.1%; age range 21–50 years)	Availability sampling	Domain-specific health literacy	A pretested questionnaire; The tool was adapted and modified from different literature	About half of the respondents (50.4%) had digital HL to share COVID-19 related information, and that was inadequate. Educational status [AOR = 4.37, 95% CI 2.08–9.17], training [AOR = 3.00, 95% CI 1.80–5.00], attitude [AOR = 1.99, 95% CI 1.18–3.36], perceived usefulness [AOR = 2.01, 95% CI 1.22–3.32], perceived ease of use [AOR = 2.00, 95% CI 1.25–3.21] and smartphone access [AOR = 5.21, 95% CI 2.34–9.62] as predicting it at P-value less than 0.05.
Bejiga;^Citation39 2021	Oromia	To assess reproductive health literacy status (RHL) and associated factors among high schools adolescents		Cross-sectional/Quantitative	School	Adolescents (391; Sex: M= 62.9% F= 37.1%; age range 15 to 19 years)	Systematic random sampling	Domain-specific health literacy	Health Literacy Measure for Adolescents (HELMA)	Most (81.6%) of the adolescents had limited RHL levels. Females were about 52% times (AOR = 0.48, 95% CI: 0.257, 0.881) less likely to have adequate RHL status. School adolescents never attending RH topic in class were about 56% times (AOR = 0.44, 95% CI: 0.233, 0.843) less likely to have adequate RHL status. School adolescents never used of RH service ever was also about 60% times (AOR = 0.40, 95% CI: 0.231, 0.704) less likely to have adequate RHL status.
Hassen;^Citation40 2022	Oromia/Eastern Ethiopia	To assess mental health literacy (MHL) level and effects among adolescent students		Cross-sectional/Quantitative	Public and private schools	Adolescent students (751; Sex: M= 50.1%; F= 49.9%; age range 11 to19 years)	Multistage random sampling	Domain-specific health literacy	Mental health literacy questionnaire (MHLq)	The MHL score was normally distributed with mean of 135.98 ± 15.50. MHL was higher among females (138.12) than males (133.84) with p<0.01. Ethnicity/culture, school class/grade, and parental education level accounted for 10.7% of the variability in MHL of female and 8.9% of the variability in MHL of male participants.
Negesa Bulto;^Citation41 2021	Eastern Ethiopia/Oromia	To assess risk behaviours for CVD and related health literacy in patients with CVD conditions		Cross-sectional (Mixed methods)	Hospital	Patients with a confirmed diagnosis of CVD (287; Sex: F=56.4%; age range 18 to 64 years)	Convenience sampling	Disease-specific health knowledge	A heart disease fact questionnaire and in-depth interview	About half of CVD patients had suboptimal knowledge about CVD risk factors, and majority (70%) had multiple risky behaviours although they attended chronic follow up care clinics. Lower educational level, rural residence and single marital status were associated with lower CVD knowledge risk factors. However, there was no significant relationship between knowledge of cardiovascular risk factors and actual cumulative risk behaviour (p > 0.05).
Paul;^Citation42 2014	Southern province	To explore the knowledge and attitudes of HIV/AIDS among students		Cross-sectional/Quantitative	College and university	College and university students (227; Sex: M=101, F=126; age range 18 to 30 years)	Non-probabilistic sampling	Disease-specific health knowledge and attitude	The HIV Knowledge Questionnaire and AIDS Attitude Scale (HIV-KQ-18 and AAS scales)	The mean HIV-KQ-18 score among the male group was 12.4 (SD=2.3), and among females it was slightly lower 12.3 (SD=2.5). However, the t-test demonstrated no difference between males and females HIV knowledge scores (t=0.6, df =225, p=0.4). In addition, the mean total AAS scores among male students was 1.6 (SD= 1.1), while females scored slightly lower with a mean score of 1.5 (SD=1.3) on the AAS, but there was no significant difference among males and females mean scores (p=0.1). The mean AAS avoidant scores demonstrated a higher mean score among the females (mean=3.4, SD=0.7) in contrast to the males (mean=3.2, SD=0.8). The Pearson’s test demonstrate a significant negative association between AAS avoidant scores and HIV knowledge scores (r=−0.2 p<0.01).
Hassen, Behera, Jena, Satpathy;^Citation43 2020	Dire Dawa,/ Oromia	To test the validity and reliability of the Amharic version of the HLS-EU-Q47 among students		Cross-sectional/Quantitative	Public schools and University	School adolescents and university students (677; Sex: M=54.36%; F= 45.64%; age range 10 to 25 years)	Multistage random sampling	General health literacy	Amharic version of HLS- EU-Q47 (HLS-Amh)	For most domains, the RMSEA index was < 0.10, and other goodness-of-fit indices (GFI, AGFI, CFI and IFI) were within range of 0.90 to 0.80. The NFI score for all were < 0.80. The item-total correlations were ranged from 0.287 to 0.542. However, it showed high levels of internal consistency of reliability with Cronbach’s alpha coefficient, α=0.910. The Amharic version of HLS- EU-Q47 was reliable but weak for its validity to measure health literacy among the students.
Shiferaw;^Citation44 2020	Amhara	To assess the validity and reliability of the Amharic version of eHEALS among patients with chronic disease		Cross-sectional/Quantitative	Hospital	Patients with chronic disease (187; Sex: M= 63.1%; F= 36.9%; age range < 18 to > 35)	Convenient sampling	Domain-specific health literacy	eHEALS	The Cronbach’s alpha coefficient for the translated eHEALS total score was 0.94, and the test–retest reliability of eHEALS total score was acceptable with interclass correlation coefficient of 0.92. The KMO ratio of sampling appropriateness was satisfactory (0.91), and Bartlett’s test of sphericity was significant with p < 0.001. The EFA extracted two factors, and the extracted factor explained 80.2% of the common variance with 51.8% for factor 1 and 28.4% for factor 2. Except for item 8, item fit for both infit and outfit mean squares were within the adequate range (0.5–1.5). The translated eHEALS is a consistent and valid instrument to evaluate Amharic-speaking chronic patients’ eHealth literacy level.

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Gedefaw A, Yilma TM, Endehabtu BF. Information seeking behavior about cancer and associated factors among university students, Ethiopia: a cross-Sectional study. Cancer Manag Res. 2020;12:4829. doi:10.2147/CMAR.S259849

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Tefera YG, Gebresillassie BM, Emiru YK, et al. Diabetic health literacy and its association with glycemic control among adult patients with type 2 diabetes mellitus attending the outpatient clinic of a university hospital in Ethiopia. PLoS One. 2020;15(4):e0231291. doi:10.1371/journal.pone.0231291

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