Associations among Health Literacy, Psychosocial Factors, and Cancer-related Health Actions: A Systematic Literature Review

Eun Jin Kim; Su Hyun Kim

doi:10.7475/kjan.2018.30.6.565

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Kim and Kim: Associations among Health Literacy, Psychosocial Factors, and Cancer-related Health Actions: A Systematic Literature Review

Review Article

Korean J Adult Nurs 2018;30(6):565-576.

Published online: 21 December 2018

DOI: https://doi.org/10.7475/kjan.2018.30.6.565

Associations among Health Literacy, Psychosocial Factors, and Cancer-related Health Actions: A Systematic Literature Review

Eun Jin Kim¹, Su Hyun Kim^2,

¹Doctoral Student, Graduate School, College of Nursing, Kyungpook National University, Daegu, Korea

²Professor, College of Nursing ․ Research Institute of Nursing Science, Kyungpook National University, Daegu, Korea

Corresponding author: Kim, Su Hyun https://orcid.org/0000-0003-4268-6437 College of Nursing, Kyungpook National University, 680 Gukchaebosang-ro, Jung-gu, Daegu 41944, Korea. Tel: +82-53-420-4928, Fax: +82-53-421-2758, E-mail: suhyun_kim@knu.ac.kr

Received 6 September 201830 October 2018 Accepted 19 November 2018

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

The purpose of the study was to systematically review the associations among health literacy, psychosocial factors, and cancer-related health actions.

Methods

PubMed, CINAHL, PsycARTICLES, KISS, RISS, and KoreaMed were searched for articles published between January 2000 and March 2018. Fourteen studies were identified and reviewed for the associations among the variables based on Von Wagner's framework on health literacy and health actions. Two researchers reviewed the articles independently using the Mixed Methods Appraisal Tool.

Results

Of the 14 relevant studies, five studies analyzed all of the associations among health literacy, motivational or volitional factors, and cancer-related health actions. Eleven studies investigated the association between health literacy and motivational factors, including knowledge (n=11) and attitudes (n=6). Four studies investigated the association between health literacy and volitional factors, including self-efficacy (n=4) and efforts to search cancer-related information (n=1).

Conclusion

The possible paths between health literacy and cancer-related health actions mediated through the psychosocial variables were identified. Further research is warranted to substantiate the mediating pathways of the associations between health literacy and cancer-related health actions.

Keywords: Health literacy, Health behavior, Knowledge, Self-efficacy, Systematic review

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Appendix 1. Studies Included in Systematic Review

A1. Arnold CL, Rademaker A, Bailey SC, Esparza JM, Reynolds C, Liu D, et al. Literacy barriers to colorectal cancer screening in community clinics. Journal of Health Communication. 2012; 17(sup3):252–64. https://doi.org/10.1080/10810730.2012.713441.

A2. Dolan NC, Ferreira MR, Davis TC, Fitzgibbon ML, Rademaker A, Liu D, et al. Colorectal cancer screening knowledge, attitudes, and beliefs among veterans: does literacy make a difference? Journal of Clinical Oncology. 2004; 22(13):2617–22. https://doi.org/10.1200/jco.2004.10.149.

A3. Guerra CE, Krumholz M, Shea JA. Literacy and knowledge, attitudes and behavior about mammography in Latinas. Journal of Health Care for the Poor and Underserved. 2005; 16(1):152–66. https://doi.org/10.1353/hpu.2005.0012005.0012.

A4. Hwang H. Health literacy, cancer knowledge, and cancer preventive behaviors among rural older adults. Asian Oncology Nursing. 2016; 16(4):234–41. https://doi.org/10.5388/aon.2016.16.4.23.

A5. Hwang H. Impacts of colorectal cancer knowledge and health literacy on self-management behaviors among elderly women in rural areas. Korean Journal of Adult Nursing. 2017; 29(5):527–35. https://doi.org/10.7475/kjan.2017.29.5.527.

A6. Kim NS, Lee KE. Factors affecting cancer preventive behavior in middle-aged people. Korean Academy of Fundamen-tals of Nursing. 2014; 21(1):29–38. https://doi.org/10.7739/jkafn.2014.21.1.29.

A7. Lee SYD, Tsai TI, Tsai YW, Kuo KN. Health literacy and women's health-related behaviors in Taiwan. Health Education & Behavior. 2012; 39(2):210–8. https://doi.org/10.1177/1090198111413126.

A8. Morris NS, Field TS, Wagner JL, Cutrona SL, Robin DW, Gaglio B, et al. The association between health literacy and cancer-related attitudes, behaviors, and knowledge. Journal of Health Communication. 2013; 18(sup1):223–41. https://doi.org/10.1080/10810730.2013.825667.

A9. Peterson NB, Dwyer KA, Mulvaney SA, Dietrich MS, Roth-man RL. The influence of health literacy on colorectal cancer screening knowledge, beliefs and behavior. Journal of the National Medical Association. 2007; 99(10):1105–12.

A10. Rust CF, Davis C, Moore MR. Medication adherence skills training for African-American breast cancer survivors: the effects on health literacy, medication adherence, and self-efficacy. Social Work in Health Care. 2015; 54(1):33–46. https://doi.org/10.1080/10810730.2012.713441.

A11. Schapira MM, Neuner J, Fletcher KE, Gilligan MA, Hayes E, Laud P. The relationship of health numeracy to cancer screening. Journal of Cancer Education. 2011; 26(1):103–10. https://doi.org/10.1007/s13187-010-0133-7.

A12. Shelton RC, Jandorf L, Ellison J, Villagra C, DuHamel KN. The influence of sociocultural factors on colonoscopy and FOBT screening adherence among low-income Hispanics. Journal of Health Care for the Poor and Underserved. 2011; 22(3):925. https://doi.org/10.1353/hpu.2011.0074.

A13. Todd L, Harvey E, Hoffman-Goetz L. Predicting breast and colon cancer screening among English-as-a-second-language older Chinese immigrant women to Canada. Journal of Cancer Education. 2011; 26(1):161–9. https://doi.org/10.1007/s13187-010-0141-7.

A14. Von Wagner C, Semmler C, Good A, Wardle J. Health literacy and self-efficacy for participating in colorectal cancer screening: the role of information processing. Patient Education & Counseling. 2009; 75(3):352–7. https://doi.org/10.1016/j.pec.2009.03.015.

Figure 1.

Findings of the literature based on the framework of the Von Wagner's health literacy and health action.

Figure 2.

PRISMA flow diagram.

Table 1.

Overview of Studies on the Associations of Health Literacy, Social Cognitive and Psychological Variables, and Cancer- related Health Behaviors

Author, year	Aim	Design	Country	Population & setting	HL and outcomes (measurements)	Results
Association between health literacy and motivational factors
Dolan et al. 2004 [A2]	To identify the association between knowledge, attitude, and beliefs toward CRC screening.	Cross-sectional survey	U.S.A	Male veterans in general medicine clinic (n=377)	- HL (REALM)	Men with lower HL had less knowledge about colorectal cancer screening tests and had negative attitudes about FOBT.
Dolan et al. 2004 [A2]		Cross-sectional survey	U.S.A	Male veterans in general medicine clinic (n=377)	- CRC screening knowledge, attitudes, and beliefs (Colorectal cancer screening knowledge, attitudes, and beliefs questionnaire)
Guerra et al. 2005 [A3]	To examine the association between HL and knowledge, beliefs and attitudes, and CRC screening.	Cross-sectional survey	U.S.A	Patients in community clinics (n=136)	- HL (S-TOFHLA)	In bivariate analyses, HL was significantly associated with knowledge and screening of FOBT, sigmoidoscopy, or colonoscopy. After adjusting for covariates, HL was not associated with knowledge, beliefs, attitudes, and CRC screening.
Guerra et al. 2005 [A3]		Cross-sectional survey	U.S.A	Patients in community clinics (n=136)	- Knowledge, attitudes, and behavior about CRC screening (Adapted from the instrument about knowledge, attitudes, beliefs, and influences about screening mammography)
Hwang, 2016 [A4]	To explore the impact of health literacy and cancer knowledge on cancer preventive behaviors among older rural adults.	Cross-sectional survey	Korea	Older adults in community (n=95)	- HL (Brief question measure for health literacy)	HL was significantly associated with knowledge. HL and cancer knowledge were significant predictors of cancer preventive behaviors.
Hwang, 2016 [A4]		Cross-sectional survey	Korea	Older adults in community (n=95)	- Cancer preventive behavior (Cancer preventive behavior scale)
Hwang, 2017 [A5]	To identify the influences of CRC knowledge and health literacy on self-management behaviors among elderly women in rural area.	Cross-sectional survey	Korea	Older women in community (n=121)	- HL (Brief question measure for health literacy)	Health literacy and CRC knowledge was significantly associated with cancer preventive behaviors. HL was not significantly associated with cancer knowledge.
Hwang, 2017 [A5]		Cross-sectional survey	Korea	Older women in community (n=121)	- Cancer preventive behavior (Cancer preventive behavior scale, question about CRC screening completion)
Kim et al. 2014 [A6]	To identify the influences of knowledge and health literacy on cancer preventive behavior.	Cross-sectional survey	Korea	Middle-aged people in community (n=203)	- HL (Korea health literacy assessment test)	Cancer knowledge, but not HL, was a significant predictor of cancer preventive behavior. Cancer knowledge was significantly associated with health literacy.
Kim et al. 2014 [A6]		Cross-sectional survey	Korea	Middle-aged people in community (n=203)	- Cancer preventive behavior (Cancer preventive behavior scale)
Morris et al. 2013 [A8]	To examine the association between low HL, and selected health attitudes, beliefs, and health behaviors.	Cross-sectional survey	U.S.A	A stratified random sample of adult health plan members in community (n=1,013)	- HL (Cancer Message Literacy Test-Listening, Lipkus Numeracy Scale)	Low HL was significantly associated with less knowledge and fatalistic attitudes on cancer but not significantly associated with being up to date with CRC screening.
Morris et al. 2013 [A8]		Cross-sectional survey	U.S.A		- Cancer screening (assessment with administrative data)
Shelton et al. 2011 [A12]	To identify the influence of sociocultural factors on adherence to FOBT and colonoscopy.	Cross-sectional survey	U.S.A	Hispanic patients over 50 years in health clinics (n=400)	- HL (The Short Assessment of Health Literacy for Spanish speaking populations)	Fatalism and HL were associated with adherence to colonoscopy or FOBT in bivariate models. Only fatalism remained significant in multivariate models.
Shelton et al. 2011 [A12]		Cross-sectional survey	U.S.A	Hispanic patients over 50 years in health clinics (n=400)	- CRC screening adherence (Brief question on cancer screening)
Association between health literacy and volitional factors
Rust et al. 2015 [A10]	To examine the association between HL and medication adherence, self- efficacy toward breast cancer screening.	Cross-sectional survey (part of randomized controlled study)	U.S.A	African American breast cancer survivors in community (n=48)	- HL (Brief question measure for health literacy)	HL was significantly associated with medication adherence and self-efficacy for appropriate medication use.
Rust et al. 2015 [A10]			U.S.A		- Medication adherence (Adherence to Refills and Medications Scale)
Todd et al. 2010 [A13]	To examine the breast and colon cancer screening rates, predictors of self- reported breast and colon cancer screening.	Cross-sectional survey	Canada	Women over 50 years of age in community organizatio ns (n=103)	-HL (S-TOFHLA)	Women who were current screeners had higher health literacy scores and reported greater self-efficacy to perform a colon cancer screening test.
Todd et al. 2010 [A13]		Cross-sectional survey	Canada		-Cancer Screening Behaviors (Self-report on breast and colon cancer screening)
Associations of health literacy and motivational and volitional factors
Arnold et al. 2012[A1]	To examine the relationship between literacy and CRC screening knowledge, awareness, and experiences.	Cross-sectional survey (A part of randomized controlled study)	U.S.A	Patients in community health centers (n=975)	- HL (REALM)	In bivariate analysis, low HL was significantly associated with knowledge, and negative beliefs about CRC less screening. In multivariate analysis, HL were not significantly associated with knowledge and belief about colorectal cancer screening but was significantly for the completion of the FOBT.
Arnold et al. 2012[A1]			U.S.A	Patients in community health centers (n=975)	- Cancer knowledge, attitudes, screening, behaviors (Colorectal Cancer screening Knowledge, Attitudes, and Beliefs questionnaire)
Lee et al. 2012 [A7]	To examine the association between health literacy and Pap smear screening and to test if the association was mediated by health knowledge.	Cross-sectional survey	Taiwan	Taiwanese women, aged 18+ in community (n=1,754)	- HL (REALM)	HL was significantly associated with knowledge and Pap smear screening. Knowledge was significantly associated with Pap smear screening. In binomial logistic regression analysis, the addition of health knowledge did not change those significant associations of health literacy with Pap smear screening.
Lee et al. 2012 [A7]		Cross-sectional survey	Taiwan	Taiwanese women, aged 18+ in community (n=1,754)	- Pap smear screening (self- report)
Peterson et al. 2007 [A9]	To examine the association between HL and knowledge, beliefs and barriers, self-efficacy, and CRC screening.	Cross-sectional survey	U.S.A	People aged 50+ at community health clinic (n=99)	- HL (REALM)	Low HL was significantly associated with less knowledge about CRC but not perceived benefits or self-efficacy for completing CRC.
Peterson et al. 2007 [A9]		Cross-sectional survey	U.S.A	People aged 50+ at community health clinic (n=99)	- CRC screening knowledge, benefits, barriers, and self efficacy (Developed for the study)
Schapira et al.2010 [A11]	To examine the relationship between health numeracy and cancer screening in using a framework of the HBM.	Cross-sectional survey	U.S.A	Patients aged 40~74 in primary care clinics (n=359)	- HL (REALM)	Health numeracy was significantly associated with knowledge and cancer screening but not significantly associated with beliefs. In multivariate analysis, knowledge and perceived barriers to screening were associated with cancer screening.
Schapira et al.2010 [A11]		Cross-sectional survey	U.S.A	Patients aged 40~74 in primary care clinics (n=359)	- Cancer screening (developed for the study)
Wagner et al. 2009 [A14]	To examine the association between HL and willingness and ability to seek information about the new CRC screening program.	Cross-sectional survey	UK	Participant aged 50~69 at health behavior research center (n=144)	- HL (TOFHLA)	Low HL was significantly associated with less self-efficacy for CRC and less information- seeking but not with CRC screening knowledge.
Wagner et al. 2009 [A14]		Cross-sectional survey	UK		- CRC screening knowledge (developed for the study)

CRC=colorectal cancer; FOBT=fecal occult blood testing; HL=health literacy; REALM=the rapid estimate of adult literacy in medicine; S-TOFHLA=the short test of functional health literacy in adults; TOFHLA=the test of functional health literacy in adults.

Table 2.

Study Quality Assessment

Author, year	Representativeness of the sample	Appropriate measurement	Controlling for group difference or factors	Response rate	MMAT-Score (%)
Arnold et al. 2012 [A1]	N	Y	Y	Y	75.0
Dolan et al. 2004 [A2]	N	N	Y	Y	50.0
Guerra et al. 2005 [A3]	N	Y	Y	N	50.0
Hwang, 2016 [A4]	N	Y	Y	Y	75.0
Hwang, 2017 [A5]	N	Y	Y	Y	75.0
Kim et al. 2015 [A6]	N	Y	Y	Y	75.0
Lee et al. 2012 [A7]	Y	Y	Y	Y	100.0
Morris et al. 2013 [A8]	Y	N	N	Y	50.0
Peterson et al. 2007 [A9]	N	Y	Y	Y	75.0
Rust et al. 2015 [A10]	N	Y	Y	N	50.0
Schapira et al. 2010 [A11]	Y	N	Y	N	50.0
Shelton et al. 2011 [A12]	N	Y	Y	Y	75.0
Todd et al. 2010 [A13]	N	Y	Y	N	50.0
Wagner et al. 2009 [A14]	N	Y	Y	Y	75.0

MMAT=the mixed methods appraisal tool; N=no; Y=yes.

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