INTRODUCTION

Health literacy (HL) is defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” [1]. It involves the ability to comprehend medical instructions, evaluate health information, and make informed choices regarding personal health [2]. Adequate HL is therefore a fundamental component of health promotion and disease prevention [3].

In Turkey, approximately 74% of the population demonstrates inadequate or limited HL, which is associated with reduced use of preventive health services and unnecessary hospital visits, thereby increasing healthcare costs and morbidity [4]. Low HL has been shown to impair individuals’ ability to understand health information and act upon it, particularly in chronic conditions such as kidney disease, asthma, COPD, type 2 diabetes, rheumatoid arthritis, and depression [5, 6]. Individuals with low HL are hospitalized more often and for longer periods, contributing to higher healthcare expenditure and poorer quality of care [7].

HL extends beyond individual behaviors and communication skills; it is also shaped by social, organizational, and environmental determinants. Therefore improving HL requires building trust between patients and healthcare providers and ensuring equitable access to reliable health information [3].

Nutbeam categorizes HL into three progressive levels: (1) functional (basic reading and writing skills for everyday health contexts), (2) interactive (advanced cognitive and communication abilities enabling active participation in health care), and (3) critical (analytical skills that allow evaluation and influence of health-related information and systems).

Health anxiety (HA) refers to excessive worry or fear of having a serious illness, often triggered by normal bodily sensations or misinterpretation of health information [8]. Diagnostic criteria for HA were first established in 1995 under the Diagnostic Criteria for Psychosomatic Research [9]. According to these, HA is characterized by (1) persistent concern about illness and bodily sensations lasting less than six months, (2) relief with appropriate medical reassurance or treatment, and (3) absence of another primary anxiety or mood disorder.

Studies report that 20-84% of hospital visits are by individuals without a physical illness [10]. Early recognition and management of HA may therefore improve quality of life and reduce unnecessary healthcare use. Management of HA focuses on reducing excessive concern and promoting adaptive coping. The main treatment options are cognitive-behavioral therapy (CBT) and pharmacotherapy [11]. CBT helps individuals modify maladaptive thoughts and behaviors related to health concerns and is the most evidence-based psychotherapeutic approach to HA [12]. When HA coexists with other psychiatric conditions, pharmacological treatment – particularly selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (40-80 mg/day) or paroxetine (40 mg/day) – may be indicated. Combined therapy with CBT enhances treatment efficacy [13, 14].

Methods

Women between the ages of 18 and 45 who satisfied the inclusion criteria and consented to participate in the study were asked to complete a face-to-face survey over the course of two months at the Şişli Training Family Health Center of Istanbul Prof. Dr. Cemil Taşcıoğlu City Hospital. A cross-sectional observational survey was the study’s design. At the Şişli Training Family Health Center, there were 721 registered female patients between the ages of 18 and 45. 231 participants were determined to be the minimum necessary sample size based on a 95% confidence interval and a 5% margin of error.

A convenience sampling method was employed, including all eligible women who visited the Şişli Training Family Health Center during the data collection period and consented to participate.

The inclusion criteria were as follows: women aged 18-45 who were registered at Istanbul Prof. Dr. Cemil Taşcıoğlu City Hospital Şişli Training Family Health Center and agreed to participate in the study. The exclusion criteria included individuals who did not consent to participate, were outside of the specified age range and were not registered at the health center. Also healthcare professionals, such as doctors, nurses, midwives, technicians, laboratory staff, dietitians, and hospital cleaning staff were excluded along with individuals with a known history of psychiatric disorders.

After obtaining ethical approval, data collection was carried out between 01.12.2023 and 31.01.2024. Participants who met the inclusion criteria were enrolled after providing the informed consent. The survey, which included questions on sociodemographic characteristics, the Health Literacy Scale (HLS), and the Health Anxiety Inventory (HAI), was conducted through face-to-face interviews.

The sociodemographic and health behavior items (including information on chronic diseases, medication use, smoking and alcohol consumption, multivitamin use, and the number of annual doctor visits) were developed based on a comprehensive literature review and adapted from previously validated national and international po-pulation surveys to ensure content validity. The questionnaire was reviewed by three family medicine specialists for clarity and relevance, and a pilot test was conducted with 10 participants to confirm comprehensibility; minor wording adjustments were made accordingly.

The HLS was developed by Suka et al. [15] in Japan in 2010 to assess the HL levels in adults. The Turkish validity and reliability study was conducted by Nihan Türkoğlu and Dilek Kılıç in 2021 [16]. The scale consists of three sub-dimensions: Functional Health Literacy (5 items), Interactive Health Literacy (5 items), and Critical Health Literacy (4 items). Each item in the ori-ginal scale is rated on a 5-point Likert scale ranging from “strongly disagree” (1 point) to “strongly agree” (5 points), with total scores ranging from 14 to 70. Higher total scores indicate higher levels of HL.

To assess HA, the HAI was developed by Salkovskis et al. [17]. The Turkish validity and reliability study was conducted by Aydemir et al. [18]. This self-report scale consists of 18 items, 14 of which include four-level response options assessing the patient’s mental state. The remaining four questions require participants to consider their psychological responses under the assumption of having a serious illness. Each item is scored between 0 and 3, with higher scores indicating higher levels of HA.

Results

A total of 245 women aged 18-45 years participated in the study. The median total HLS score was 52 (IQR: 43-59), and the mean was 50.79 ± 9.60. Among the subdimensions, the mean scores were 17.02 ± 4.64 for Functional Health Literacy (FHL), 18.54 ± 4.23 for Interactive Health Literacy (IHL), and 15.22 ± 3.51 for Critical Health Literacy (CHL). The median HAI score was 17 (IQR: 11-23), with mean subscale scores of 13.8 ± 6.36 for Hypersensitivity to Physical Symptoms and Anxiety (HPSA) and 3.58 ± 2.52 for Negative Consequences of Illness (NCI).

As presented in Table 1, HL levels varied significantly by marital status, education, parental status, and health-related variables. Single participants had significantly higher FHL and IHL scores compared to married or widowed women (p < 0.01). Women without children also exhibited higher literacy scores across all subdimensions (p < 0.05).

Education emerged as one of the strongest determinants of HL. Participants with only a primary school education had markedly lower scores in FHL, IHL, CHL, and overall HLS compared to those with higher education levels (p < 0.01). The difference was particularly notable between primary and undergraduate/postgraduate groups. Similarly, white-collar workers showed higher critical and total HL compared to unemployed participants (p < 0.05).

The presence of chronic disease, regular medication use, and obesity were all associated with significantly lower HL scores (p < 0.05). Specifically, women with chronic illnesses had reduced FHL and CHL scores, while obesity correlated negatively with both FHL and overall HL. These findings indicate that individuals managing chronic health conditions may face additional barriers in processing and utilizing health information effectively.

As shown in Table 2, participants with chronic diseases and those taking medication regularly had significantly higher scores in both HPSA and NCI subscales, as well as in the total HAI (p < 0.05). This trend highlights the psychological burden of ongoing illness management.

Education again played a decisive role: primary school graduates scored higher on both anxiety subscales and total HAI compared with high school and university graduates (p < 0.05). In contrast, participants with higher education displayed lower levels of anxiety, consistent with their higher literacy levels. Smoking status showed a weak inverse relationship, with non-smokers reporting higher anxiety levels (p < 0.05), possibly reflecting heightened health awareness or concern among those who avoid tobacco use.

Correlation analyses (Table 3) demonstrated a clear inverse relationship between HL and HA. The FHL subscale correlated negatively with both the HPSA (r = –0.26, p < 0.001) and NCI (r = –0.21, p < 0.01) subscales, as well as with total HAI (r = –0.34, p < 0.001). Similarly, CHL correlated negatively with both NCI (r = –0.27, p < 0.001) and total HAI (r = –0.29, p < 0.001).

Overall, total HLS scores were negatively correlated with total HAI (r = –0.31, p < 0.001), indicating that as literacy increased, health-related anxiety decreased. The relationship remained significant even when controlled for education and chronic disease status. These findings suggest that improved literacy skills may reduce anxiety through better understanding and interpretation of health information.

A low-to-moderate negative correlation was also found between HL (particularly FHL and CHL subscales) and both body weight and BMI (r ≈ –0.28 to –0.33, p < 0.01). This indicates that women with higher literacy were less likely to be overweight or obese, aligning with prior evidence linking literacy with health-promoting behaviors.

Conversely, a weak but significant positive correlation was observed between HA (especially the HPSA subscale) and the number of doctor visits per year (r = 0.22, p < 0.05). Participants with greater anxiety tended to seek medical consultations more frequently, potentially reflecting reassurance-seeking behavior typical of health- anxious individuals.

Discussion

Participants’ mean score for the functional HL subscale was 17.02 ± 4.64, with a median score of 18; the interactive HL subscale mean score was 18.54 ± 4.23, with a median score of 19; the critical HL subscale mean score was 15.22 ± 3.51, with a median score of 16; and the overall HL scale mean score was 50.79 ± 9.60, with a median score of 52.

Participants who were single and childless had higher FHL, IHL, and total HL scores. In the study conducted by Yücel et al. [19], married individuals had higher FHL, whereas, in the study by Üstünbaş et al. [20], single individuals had higher FHL scores. In our study, single and childless women had higher HL scores, possibly because they were relatively younger or had more time and energy to engage in health-related research and play a more active role in healthcare.

Participants with only primary school education had lower functional, interactive, and critical HL subscale scores, as well as lower overall HL scores. A positive correlation was observed between education level and HL. However, Yücel et al. [19], reported higher general HL among individuals with primary school education. Van der Heide et al. [21] demonstrated that as education levels increased, HL scores also increased. Similarly, Sun et al. [22] found higher education levels associated with greater HL. Froze et al. [23] also concluded that education positively affects HL levels.

Higher HL observed among individuals with higher education levels in our study can be attributed to their superior reading and comprehension skills, greater capacity for active engagement in health-related matters and enhanced cognitive and social skills.

Participants with chronic diseases and those who used medication regularly had significantly lower FHL subscale scores. This trend was also reflected in their total HL scale scores. In contrast, Uslu and İpek [24] found no significant association between chronic diseases and HL, while Güzel et al. [25] reported lower HL in individuals with chronic diseases compared to those without.

Participants with obesity had significantly lower functional and critical HL subscales scores as well lower overall HL score. A European HL survey found that indivi-duals with high HL were more likely to engage in physical exercise or sports, and that obesity was associated with lower HL [26].

The mean score for the excessive sensitivity to bodily symptoms and anxiety subscale was 13.8 ± 6.36, with a median score of 13; the mean score for the negative consequences of illness subscale was 3.58 ± 2.52, with a median score of 3; and the mean score for the HAI was 17.38 ± 7.83, with a median score of 17. Özlü et al. [27] reported mean scores of 19.19 ± 8.64 for the total HAI, 15.09 ± 7.02 for the bodily symptoms and anxiety subscale, and 4.09 ± 2.72 for the negative consequences of illness subscale. Similarly, Uslu-Şahan and Purtul [28] reported a mean HA score of 18.93 ± 10.78. A literature review indicates that most findings align with the results of our study.

Participants with chronic diseases and regular medication use had significantly higher HAI scores for bodily symptoms and anxiety subscale, and overall HAI score. In a 2016 study Bobevski et al. [29] found higher HA in individuals with chronic diseases. Similarly, in the study by Şarlak and Aslantaş [30] adults with chronic diseases had higher HA scores. In a study conducted by Göde and Kuşcu [31] university students with chronic conditions and those who regularly used medication showed higher levels of HA. These long-term conditions involving years of treatment and frequent hospital visits, can negatively impact individuals’ quality of life, disrupt biological systems, and potentially trigger anxiety.

Participants with only primary school education had significantly higher HAI scores for bodily symptoms and anxiety subscale, and negative consequences of illness subscale, as well as total HAI scores compared to those with high school or university education. Doğanyiğit and Keçeligil [32] who investigated the impact of HA on cyber-chondria during the pandemic found that individuals with primary school education had higher HA levels compared to university graduates. This suggests that lower education levels may result in the lack of knowledge about health, leading to increased anxiety, whereas higher education equips individuals with better knowledge, perception, and experience related to health, thereby reducing anxiety.

According to our research, HA declined as HL increased. Low HL and high anxiety levels were found to be significantly correlated in a Smith et al. study [33]. However, there was no discernible link between anxiety and e-health literacy levels in a 2024 study that looked at patients slated for thoracic surgery [34]. On the other hand, a study of pregnant women in Japan by Haruyama et al. [35] found that anxiety was positively correlated with HL. People with high HL are able to comprehend and assess health-related information better. They can access information about the disease symptoms, treatments available, and use of medical services as a result. They also have greater control over their health, make better judgments regarding their health, and are capable of avoiding inaccurate or misleading health information – all contributing to reduced HA.

This cross-sectional design precludes causal inference. Self-reported data may involve recall or social- desirability bias. The sample was limited to a single urban center, restricting generalizability. Future multi-center, longitudinal studies are recommended to explore causal links between HL and HA.

Conclusions

Primary healthcare services play a crucial role in improving HL and reducing HA. They equip individuals to better understand health information and manage their health-related decisions more effectively. By providing education and programs that enhance HL, primary healthcare enables individuals to use health information more efficiently. Additionally, HA often stems from the lack of knowledge; therefore, healthcare services can help alleviate anxiety by providing accurate information and regular check-ups.

The association between HL and HA can be positively impacted by the availability of basic healthcare services as well as educational and counseling options. In order to improve general health and reduce HA, it is crucial to expand access to basic healthcare, spread knowledge about health, and facilitate access to trustworthy health resources.

In conclusion, primary healthcare services play a key role in enhancing HL and managing HA. The quality, accessibility, and scope of these services can help alle-viate a variety of health-related concerns and make health management more effective. Therefore, strengthen-ing and expanding these services will positively impact public health and contribute to better health mana-gement for individuals.