Skip to main content
Download PDF
  • Systematic Review
  • Open access
  • Published:

The low health literacy in Latin America and the Caribbean: a systematic review and meta-analysis

BMC Public Health volume 24, Article number: 1478 (2024) Cite this article

Abstract

Background

Health literacy (HL) impacts people’s health and well-being. In Latin America and the Caribbean (LAC), there are no general estimates of the prevalence of low HL. This study aimed to estimate the prevalence of low HL among citizens of LAC and identify the tools used to measure it.

Methods

We included observational studies quantifying the prevalence of low HL in people living in LAC. We searched PubMed, CINAHL, EMBASE, ERIC, LILACS, PsycINFO, Redalyc, SciELO, Web of Science, PQDT, and the reference lists of the included studies in June 2023. Two reviewers independently conducted the selection, extraction, and risk of bias assessment using the JBI Critical Appraisal Tools. Meta-analysis of proportions using random effects models was used to summarize the prevalence of low HL estimated. This prevalence was measured in each study using different classification methods: word recognition items, reading and numeracy comprehension items, and self-reported comprehension items.

Results

Eighty four studies involving 23,914 participants from 15 countries were included. We identified 23 tools to assess HL, and most of the studies were carried out in health services. The pooled prevalence of low HL were 44.02% (95%CI: 36.12–52.24) for reading and numeracy comprehension items, 50.62% (95%CI: 41.82–59.39) for word recognition items, and 41.73% (95%CI: 31.76–52.43) for self-reported comprehension items.

Conclusion

Despite the variability in the prevalence of low HL and a diversity of tools, the average of low HL is of concern. Almost half of the participants in the included studies have low HL. Most of the studies targeted users of healthcare services. Further research investigating the prevalence of low HL in the general population and actions focused on health education, communication, and information are necessary.

Trial registration

PROSPERO (CRD42021250286).

Peer Review reports

Background

Health literacy (HL) is the degree to which individuals can find, understand, and use information and services to inform health-related decisions and actions for themselves and others [1]. Many governments recognize its importance, and nations like China and the United States (U.S.) encompass HL in their public health strategies. Healthy China 2030 includes an increase in people’s HL as one of the targets for health promotion [2]. In the U.S., Healthy People 2030 included HL as part of its framework [1] and also signalized that organizations must take action to reduce the complexity of health systems [3].

In Latin America and the Caribbean (LAC), health systems are often uncoordinated and segmented [4], causing difficulties for users in navigating the healthcare system. With an ethnically and culturally diverse population, increasing political instability, and marked levels of inequality [5], exploring this region’s social and health scenario is a great challenge. Socially disadvantaged populations are likelier to have low HL, and several studies suggest that HL may be an explanatory factor in the pathways that generate health disparities [6].

Thus, studies that evaluate the prevalence of low HL and identify the population’s difficulties in finding, understanding, and using health information and navigating healthcare systems are necessary for planning actions to promote health literacy. So far, no systematic reviews have investigated the prevalence of low HL in LAC scenario and its associated factors. Therefore, this systematic review and meta-analysis aimed to estimate the prevalence of low HL in LAC and identify the tools used to measure it.

Methods

This systematic review was conducted according to the protocol registered in the International Prospective Register of Systematic Reviews (PROSPERO) under CRD42021250286. The reporting follows the Cochrane Handbook recommendations [7] and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement [8].

Eligibility criteria

We included: (1) observational studies (i.e., cohort and cross-sectional studies) quantifying the prevalence of low HL in general or specific populations in LAC countries; (2) published and unpublished manuscripts in any language and year of publication. We excluded: (1) studies assessing specific HL (i.e., oral and nutritional HL) (2) studies assessing HL of health professionals and university students, knowledge assessment of health conditions or disease; (3) abstracts, reviews, and protocols; (4) studies that did not report HL prevalence, reporting only the mean scores.

Information sources and search strategy

We searched PubMed, CINAHL, EMBASE, ERIC, LILACS, PsycINFO, Redalyc, SciELO, and Web of Science databases from inception to June 2023. The grey literature was searched by ProQuest Dissertations and Theses Global (PQDT). References of the included studies were manually screened.

The search strategy was adapted and performed at each database and sources using terms such as “health literacy”, “Latin America”, “Caribbean”, and countries’ names (Additional file 1).

Selection process

Citations were exported from databases into Rayyan [9] web app to remove duplicates and perform the selection process. Two review authors (PRJ, BVB) independently screened the titles and abstracts and selected the articles for full-text review. A third researcher (TSP) resolved any discrepancies between reviewers. Following a full-text review, the two reviewers (PRJ, BVB) independently determined the final list of included studies, with any discrepancies to be resolved by the third reviewer (TSP).

Data collection process and data items

Two reviewers (PRJ, BVB) extracted the following data independently: author, title, publication date, country, language, study design, setting, target population, sample size, age, sex, formal education, tools used to assess HL and their validity, and the prevalence of low HL (i.e., the total number of people with low HL among the total number of participants who had their HL level assessed). Disagreements were resolved by consensus, and, if necessary, a third researcher (TSP) was consulted.

The tools were classified based on the assessment method used by Baccolini et al. 2021 [10]: word recognition items, reading or numeracy comprehension items, self-reported comprehension items, or mixed method. We adapted the classification for reading and numeracy comprehension items and did not use the mixed methods classification (involving more than one type of method). This decision was made because the studies included in our review did not align with those categories. Therefore, our studies were categorized as reading and numeracy comprehension items, word recognition items and self-reported comprehension items. Results of the prevalence classified as inadequate, low, and insufficient were considered low HL. Results in intermediate categories such as moderate, marginal, and problematic were not considered low HL. When more than one tool was used to assess the HL, we collected the data from the tool assessing general HL or more than one domain. Study authors were contacted for further information in case of missing or unclear information.

Study risk of bias assessment

Two reviewers (PRJ, BVB) independently assessed the risk of bias using the Joanna Briggs Institute (JBI) Critical Appraisal Tools - Checklist for studies reporting prevalence data [11]. The tool assesses the risk of bias in the studies’ design, conduct, and analyses. The answer options for all items are Yes, No, Unclear, or Not/Applicable. It consists of 9 items (in parentheses are the necessary information to consider “yes”): 1.sample frame (studies reporting basics information such as sex, age, and education); 2.recruitment of participants (studies using probabilistic sampling); 3.sample size calculation; 4.detail of subjects and setting (enough details to be reproduced by another researcher); 5.sufficient coverage of the sample (few missings); 6.valid methods (studies using validated tools, which means when there is a report assessing their psychometric properties);7. condition measured (researchers/interviewers trained in tool application);8. statistical analysis (effect measure presenting at least confidence interval and p-value); 9.response rate (low rate of refusals). Disagreements between reviewers were resolved by consensus or by a third researcher (TSP).

Synthesis methods

The pooled prevalence of low HL was calculated by meta-analysis of proportions. First, we pooled all studies according to their countries and the results were shown using the LAC map. Afterward, the prevalence was estimated according to the classification of the assessment method: word recognition items, reading and numeracy comprehension items, and self-reported comprehension items [10].

The meta-analysis were performed using random effects with logit transformation models with 95% confidence interval (CI). The inverse of variance was employed to calculate pooled prevalence. Heterogeneity across studies was estimated using the restricted maximum-likelihood method, with the Q-profile method used for calculating CI. Additionally, a continuity correction of 0.5 was applied in studies with zero cells. Heterogeneity was evaluated by Cochran’s Q test, and the I2 statistic was calculated to estimate the percentage of the variation across studies not attributed to sampling error.

Prediction intervals (PI), funnel plots and Begg’s tests for publication bias assessment were calculated whenever possible (i.e., at least three studies for prediction and at least ten studies for funnel plot). All the meta-analyses and the map of the prevalence of low HL were performed using RStudio® version 2023.09.1 with the ‘meta’ and ‘rworldmap’ packages, respectively.

Secondary analyses

Subgroup meta-analyses were performed considering the target population, tools used to assess HL, tools validation status, country, and setting as potential factors for heterogeneity. The sensitivity analyses was performed by excluding groups that could influence the prevalence estimates of low HL.The subgroups included in the sensitivity analysis were: grey literature, children and adolescents, older people, healthcare service users, and studies from Brazil. Also, the studies with non-validated tools and validation studies were performed in the sensitivity analyses to evaluate the influence of non-validated tools on the prevalence of HL.

Results

Study selection

After removing duplicates, our search resulted in 9,227 potentially relevant articles (Fig. 1). Following title/abstract screening, 221 full-text articles via databases and 17 via other methods were retrieved and assessed for eligibility, totaling 238 full-text articles. Finally, 74 studies [12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85] from databases and 10 studies [86,87,88,89,90,91,92,93,94,95] were identified via other methods, totaling 84 studies. The list of excluded studies and reasons for exclusion are in the supplementary material (Additional file 2).

Fig. 1
figure 1

PRISMA flow diagram

Full size image

Study characteristics

A total of 23,914 people were included in this systematic review (Table 1). Studies were published between 2009 and 2023 and most of them were conducted in Brazil (57 studies; n = 11,445; 47.9%) [14,15,16,17,18,19, 22, 23, 25,26,27,28,29,30,31,32,33,34, 41, 42, 45, 49, 50, 52,53,54,55, 58,59,60,61,62, 64,65,66, 68,69,70,71, 74,75,76,77,78,79,80,81, 83, 86,87,88,89,90,91,92,93,94], with a cross-sectional design (82 studies; n = 23,660; 98.9%). Most people were interviewed in health services (70 studies; n = 14,570; 60.9%) [12,13,14,15,16,17, 19, 21,22,23, 25,26,27,28,29,30,31,32,33,34,35,36,37,38, 40, 41, 43,44,45, 47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67, 69, 71, 73,74,75,76,77,78, 81,82,83,84,85,86, 89, 91,92,93,94,95]. The predominant population was general population (15 studies; n = 9,112; 38.1%) [18, 20, 22, 24, 26, 35, 41, 44, 52, 63, 64, 71, 72, 80, 85].

Table 1 Characteristics of included studies (n = 84)
Full size table

Due to the different age and formal education presentation formats, the results were shown narratively for studies that reported mean or median. Four studies (n = 729; 3.0%) [41, 46, 68, 85] evaluated a population under 30 years of age, and 35 studies (n = 8,315; 34.8%) [12, 14, 16, 25, 26, 29, 31, 32, 35, 40, 44, 45, 48, 50, 51, 53, 54, 56, 57, 60, 62,63,64, 66, 67, 69, 71, 79, 82, 86, 89, 90, 92, 93, 95] assessed HL in adults with an average age between 30 and 60 years of age. 25 studies had a population with an average age above 60 years (n = 5,870; 24.5%) [13, 15, 17, 21, 24, 28, 33, 37,38,39, 42, 49, 55, 59, 61, 65, 70, 75,76,77, 81, 83, 84, 88, 91]. In the mean years of formal education, 1,849 (7.7%) [13, 16, 26, 29, 40, 54, 69, 85] participants had eight years or more of schooling, and 1,247 (5.2%) [15, 55, 65, 81] had less than eight years of schooling. The table with the individual characteristics of the included studies is in Additional file 3.

We identified 22 tools used to assess HL (Table 2). The most used tool was the the Brazilian portuguese version of Short Test of Functional Health Literacy in Adults (S-TOFHLA) (29 studies; n = 5,558; 23.2%) [14, 16, 19, 22, 23, 26, 27, 29, 31, 32, 34, 49, 50, 52, 58, 59, 61, 69, 70, 74,75,76, 78, 79, 87, 88, 93, 94] followed by Newest Vital Sign (NVS) (7 studies; n = 5,632; 23.6%) [20, 43, 44, 46, 64, 71, 91]. Several studies used the term Brief Test of Functional Health Literacy in Adults (B-TOFHLA) [19, 26, 32, 49, 52, 58, 75, 78, 87, 88, 93] referring to the Brazilian version of Short Test of Functional Health Literacy in Adults (S-TOFHLA) [29] that evaluates numeracy and reading comprehension. For standardization, we used the S-TOFHLA nomenclature. Regarding the tools’ validation, most were validated in the country of origin (47 studies; n = 9,483; 39.7%) [13, 14, 16, 17, 19, 22, 23, 26,27,28, 31,32,33,34, 38, 39, 41, 46, 49, 50, 54, 55, 58,59,60, 62, 65,66,67,68, 70, 74,75,76,77,78,79,80,81, 83, 84, 86, 88, 91,92,93,94]. The predominant language was Portuguese (57 studies; n = 11,445; 47.9%) [14,15,16,17,18,19, 22, 23, 25,26,27,28,29,30,31,32,33,34, 41, 42, 45, 49, 50, 52,53,54,55, 58,59,60,61,62, 64,65,66, 68,69,70,71, 74,75,76,77,78,79,80,81, 83, 86,87,88,89,90,91,92,93,94] and Spanish (22 studies; n = 11,593; 48.5%) [12, 13, 20, 21, 36,37,38,39, 44, 46,47,48, 51, 57, 63, 67, 72, 73, 82, 84, 85, 95].

Table 2 Characteristics of tools in included studies (n = 84)
Full size table

Risk of bias in studies

Table 3 shows the risk of bias assessment. Only 16 studies (n = 3,597) used appropriated sampling [14, 18, 21, 22, 24, 40, 43, 47, 51, 54, 63, 68, 80, 83, 86, 89], and 33 studies (n = 11,925) had an adequate sample size [13, 14, 18, 20, 22, 23, 28, 30, 31, 35, 38, 43, 47, 48, 50, 54, 62, 68, 69, 73, 74, 79, 80, 83, 84, 86,87,88,89,90, 92,93,94] (Additional file 6). Half of the participants (n = 11.892) were not assessed by a validated tool [20, 21, 30, 35,36,37, 40, 42,43,44,45, 47, 48, 52, 57, 63, 69, 72,73,74, 82, 85, 87, 89, 95], and the measurement was not measured in a standardized and reliable way for 57.6% of the participants (54 studies; n = 13,790) [12, 14, 18,19,20,21, 24, 25, 28, 29, 32,33,34, 36, 39, 40, 42, 43, 45, 47,48,49,50,51,52,53, 55, 57,58,59,60,61, 64,65,66, 68, 69, 73,74,75,76,77,78, 80,81,82, 84, 86, 87, 90,91,92,93, 95].

Table 3 Risk of bias in the included studies
Full size table

Results of syntheses

In total, there are 42 countries in the LAC region [96]. The map shows the estimated prevalence of low HL in 15 countries of this region (Fig. 2). The estimated prevalence of low HL by country were: Argentina varied from 30.13 to 60.26% (44.65%; 95%CI: 19.05–73.44) [21, 47], Brazil varied from 0 to 100% (50.91%; 95%CI: 45.06–56.74; 95%PI: 15.15–85.76) [14,15,16,17,18,19, 22, 23, 25,26,27,28,29,30,31,32,33,34, 41, 42, 45, 49, 50, 52,53,54,55, 58,59,60,61,62, 64,65,66, 68,69,70,71, 74,75,76,77,78,79,80,81, 83, 86,87,88,89,90,91,92,93,94], Chile varied from 20 to 23.53% (19.20%; 95%CI: 16.33–22.44; 95%PI: 10.72–31.98) [13, 38, 39, 84], Jamaica varied from 27.27 to 48.17% (37.71%; 95%CI: 19.95–59.54) [24, 43], Mexico varied from 23.01 to 45.56% (31.79%; 95%CI: 20.99–44.98; 95%PI: 0.04–99.85) [20, 37, 48], Peru varied from 29.04 to 43.00% (36.07%; 95%CI: 31.20-41.25; 95%PI: 21.53–53.71) [51, 63, 73, 85, 95], and Puerto Rico varied from 5.18 to 59.65% (23.27%; 95%CI: 4.45–66.40; 95%PI: 0.00-100.00) [44, 67, 72]. Barbados (19.81%; 95%CI: 12.70-28.68) [40], Bolivia (57.85%; 95%CI: 53.93–61.70) [12]), Costa Rica (100%; 95%CI: 93.02–100) [57], Dominican Republic (69.16%; 95%CI: 59.50-77.73) [82], Guatemala (16.67%; 95%CI: 11.89–22.41) [46], Guyana (45.18%; 95%CI: 38.60-51.88) [56], Honduras (86.36%; 95%CI: 65.09–97.09) [36], and Suriname (34.34%; 95%CI: 25.09–44.56) [35] presented only one study each.

Fig. 2
figure 2

Map with the estimated prevalence of low health literacy in Latin America and the Caribbean according to the country

Full size image

Low HL according to reading and numeracy comprehension items

The overall prevalence of low HL varied considerably from 0 to 100%, with a pooled of 44.02% (95%CI 36.12–52.24; 95%PI: 9.15–85.99; I2 = 97%) [14, 16, 19, 20, 22, 23, 26, 27, 29, 31, 32, 34, 43, 44, 46, 49, 50, 52, 53, 58, 59, 61, 64, 67, 69,70,71, 74,75,76, 78, 79, 87,88,89, 91, 93, 94] (Fig. 3). Considering only the studies using the TOFHLA versions, the low HL prevalence (45.40%; 95%CI: 36.09–55.05; 95%PI: 8.46–88.21; I2 = 96%) [14, 16, 19, 22, 23, 26, 27, 29, 31, 32, 34, 49, 50, 52, 53, 58, 59, 61, 67, 69, 70, 74,75,76, 78, 79, 87,88,89, 93, 94] was higher than those studies that used NVS (38.35%; 95%CI: 24.74–54.06; 95%PI: 5.71–86.46; I2 = 98%) [20, 43, 44, 46, 64, 71, 91] there was no statistically significant difference (p = 0.45).

In the tools that are not validated in the country of application, (51.28%; 95%CI: 39.69–62.77) [69] higher low HL prevalence was found when compared to the other tools, but without a statistically significant difference (p = 0.18). Studies from Brazil (46.28%; 95%CI: 37.46–55.34; 95%PI: 9.36–87.79; I2 = 96%) [14, 16, 19, 22, 23, 26, 27, 29, 31, 32, 34, 49, 50, 52, 53, 58, 59, 61, 64, 69,70,71, 74,75,76, 78, 79, 87,88,89, 91, 93, 94] and with patients with nephropathies (86.49%; 95%CI: 40.14–98.39; 95%PI: 0-100; I2 = 83%) [19, 58, 78] had a higher prevalence compared to the other subgroups (p < 0.01). The results of the subgroup analyses are in Additional file 4.

Fig. 3
figure 3

Meta-analysis of low health literacy prevalence in reading and numeracy comprehension items

Full size image

Low HL according to word recognition items

The overall prevalence of low HL varied considerably from 16.64 to 100%, with a pooled of 50.62% (95%CI:41.82–59.39; 95%PI:12.45–88.08; I2 = 97%) [13, 15, 17, 21, 28, 30, 33, 35, 38,39,40,41, 47, 51, 54, 55, 57, 63, 65, 66, 73, 77, 81, 82, 84,85,86, 92, 95] (Fig. 4). Subgroup analyses indicated that the tool with higher prevalence of low HL was SAHL-S&E (77.59%; 95%CI: 15.37–98.51; 95%PI: 0-100; I2 = 97%) [57, 63, 82] when compared to the other tools (p < 0.01).

The tools not validated in the country of application (54.90%; 95%CI: 48.93–60.76) [30] presented higher prevalence of low HL when compared to the other tools, but without a statistically significant difference (p = 0.41). Costa Rica (100%; 95%CI: 93.02–100) [57] had the highest prevalence of low HL among the subgroups (p < 0.01). Heart disease patients (73.34%; 95%CI: 48.68–88.86) [17, 33, 77] had the highest prevalence compared to the other subgroups but without a statistically significant difference (p = 0.13). The results of the subgroup analyses are in Additional file 4.

Fig. 4
figure 4

Meta-analysis of low health literacy prevalence in word recognition items

Full size image

Low HL according to self-reported comprehension items

The overall prevalence of low HL varied considerably from 5.18 to 86.36%, with a pooled of 41.73% (95%CI: 31.76–52.43; 95%PI: 9.35–83.26; I2 = 98%) [12, 18, 24, 25, 36, 37, 42, 45, 48, 56, 60, 62, 68, 72, 80, 83, 90] (Fig. 5). Subgroup analyses indicated that the tool that detected a higher prevalence of low HL was the Brief Health Literacy Screening Tool (71.27%; 95%CI: 33.17–92.54; I2 = 85%) [36, 42] when compared to the other tools (p < 0.01).

Tools that are not validated (48.17%; 95%CI 42.86–53.50) [24] also showed higher prevalence without a statistically significant difference (p = 0.42). Honduras (86.36%; 95%CI: 65.09–97.09) [36] had the highest prevalence of low HL among the subgroups (p < 0.01). The caregivers and parents (86.36%; 95%CI: 65.09–97.09) [36] had the highest prevalence among the subgroups (p < 0.01). The results of the subgroup analyses are in Additional file 4.

Fig. 5
figure 5

Meta-analysis of low health literacy prevalence in self-reported comprehension items

Full size image

Sensitivity analyses and publication bias

Sensitivity analyses excluding subgroups (grey literature, children and adolescents, older people, healthcare service users, and studies from Brazil) were performed. The results remained similar across all subgroups, except when studies from Brazil were excluded, resulting in a decrease in the prevalence of low HL in reading and numeracy comprehension items, as well as word recognition items. (Additional file 5). The prevalence without tools not validated and validation studies remained similar (reading and numeracy comprehension items, 46.55% [95%CI: 37.17–56.17; PI: 9.41–87.96]; word recognition items, 50.71% [95%CI:41.36–60.01; PI:11.84–88.74]; self-reported comprehension items, 40.79% [95%CI:28.85–53.92; PI:6.91–86.47] (Additional file 7). In the meta-analyses by tools, Begg’s test p-value was not significant (reading and numeracy comprehension items, p = 0.9099; word recognition items, p = 0.9701; self-reported comprehension items, p = 0.3228), with no asymmetry in the funnel plots (Additional file 8).

Discussion

To our knowledge, this systematic review and meta-analysis summarise, for the first time, the prevalence of low HL in LAC countries. We showed that nearly half of the participants included in the studies presented low HL. Among the three categories of analyzed methods, the estimates found were similar, showing that low HL is an urgent concern for public health in LAC. It was possible to have an overview of which countries are evaluating HL and which tools are being used.

Due to the diversity of tools used in the studies and the lack of a gold standard for HL measuring, we categorized the tools by the assessment method. Word recognition studies evaluated the ability to read and understand commonly used medical terms. The tools using reading and numeracy comprehension items assess the functional ability of the individual to understand texts and use numerical information in everyday situations that occur in healthcare services. Self-reported comprehension items assess other HL domains based on the individual’s self-perception.

Regardless of the assessment method, we found high variability in the prevalence of low LS. Other reviews conducted in the European Union Member States [10], and Southeast Asian [97] have also found high variability in their analyses.

We explored the status validation of the tools and identified that less than half of the studies used tools validated in the language and country of application (39,7%). Some used tools were validated only in the language (14,6%) or not validated in the country of application (13,8%). According to our sensitivity analyses, the use of tools that were not validated did not change the prevalence of low HL.

The process of evaluating psychometric properties influences the accuracy of the measurement, especially in multidimensional constructs such as HL. This aspect is a critical factor, especially in the LAC, since the tools used come from regions with different sociocultural aspects from those of LAC countries. Therefore, translation and cultural adaptation to the local context is fundamental. At this point, we emphasize that although the HL topic is indirectly present in the literature in LAC through other approaches, such as health and patient education, the studies found in this review were published since 2009. Thus, the insertion of HL is a recent movement in LAC countries compared to European and North American countries.

There was a marked disparity in the countries of origin of the studies. Many countries had few studies and most were conducted in Brazil. This discrepancy can be due to the size of the country, which influences the greater number of research centers, universities, researchers, and publications. Based on sensitivity analyses, we can demonstrate that studies originating from Brazil influenced prevalence estimates. These studies increased the prevalence of low HL in reading and numeracy comprehension items, as well as in word recognition items. Furthermore, we must consider that due to the limited number of countries representing the LAC region, there may be insufficient evidence to support the prevalence data. With the map of subgroup analyses of countries, it was possible to show the prevalences of low HL found in the databases. Among the countries with the lowest prevalence of low HL, Guatemala and Barbados had only one study each. We can highlight Chile and Puerto Rico, which had four and three studies respectively, and also showed a low prevalence of low HL. On the other hand, Costa Rica and Honduras, with a high prevalence of low HL, also had only one study found. Hence, we must be cautious when comparing these data, as most countries are underrepresented, and it was not possible to find HL studies from all countries in LAC.

Most studies have evaluated specific populations, focusing mainly on users of health services and populations with some chronic diseases. We observed a decrease in the prevalence of low HL, independent of the evaluation method, in diabetic patients compared to patients with other diseases. We also noticed an increase in low HL in the elderly in the reading and numeracy comprehension items, corroborating with another review [98].

Another point is regarding the setting. Most studies were set in health services, probably due to the financial difficulty of carrying out population-based studies, mainly in LAC.

In general, the quality of the studies was inappropriate. It is essential to perform sample size calculation and random probabilistic sampling to ensure good precision of the summary estimative and population representativeness in prevalence studies [11]. Many studies did not meet these criteria, using convenience samples and not performing sample size calculation. In the question concerning valid methods, we consider valid the tools with some reports demonstrating psychometric properties. Thus, this criterion was met by tools validated in the country and in the validation process. We identified that most tools have flaws in their psychometric properties. Studies evaluating the psychometric properties of tools used to measure HL are necessary to understand these weaknesses [99, 100]. Further research is needed to evaluate the tools used in the LAC scenario.

Overall, most studies used small samples, mainly ones that evaluated specific health conditions or age groups. These findings highlight the lack of research on multicentric studies, such as the European comparative survey [101] and population-based studies in other countries [102,103,104]. Furthermore, most studies focused on functional HL, assessing reading, numeracy, and comprehension of medical terms. Tools assessing the communicative/interactive HL, which refers to the development of personal skills, and critical HL, which considers more advanced cognitive skills such as individual and community empowerment [105], were few approached.

Strengths and limitations

This systematic review and meta-analysis brought unprecedented results from a comprehensive search strategy in several databases, including the grey literature, without limitations regarding language, year, and publication status. The methodology was carried out transparently and strictly followed the recommended guidelines for systematic reviews. On the other hand, our review has some limitations that should be considered when interpreting the results. First, studies reporting the mean HL were not included in the review. Second, there was a high heterogeneity and wide prediction intervals in the meta-analysis attributed to methodological differences from observational studies. Third, the low HL used to estimate the prevalence was considered according to the classification of study authors. The high, medium, and low HL estimates are not standardized and vary by study or tool. Intermediate estimates were not considered low HL so that the prevalence may be underestimated.

Conclusion

This systematic review and meta-analysis showed that almost half of the participants of the studies conducted in LAC countries had low HL. We found several tools assessing HL and a growing interest in the field. Thus far, the studies found had a small sample size and focused on specific populations. National and multicentric studies applying validated tools are needed to identify the profile and needs of this population. Furthermore, the presented estimates are relevant to alert public governance about this critical concern and demand interventions and public policies to improve the people’s HL. Therefore, it is essential to expand the debate on HL in LAC, strengthening health education, information, and communication actions. Multisectoral efforts and actions are needed to empower and increase the HL of LAC citizens.

Data availability

Data is provided within the manuscript or supplementary information files.

Abbreviations

CI:

Confidence Interval

HLS-14:

14-item Health Literacy Scale

HLS-EU-BR:

European Health Literacy Survey

HLS-EU-Q47:

Spanish version of the European Health Literacy Questionnaire

HLS-EU-Q6:

Brazilian version of European Health Literacy Survey Questionnaire short-Short Form

HLSQ:

Health Literacy Screening Questions

HL:

Health Literacy

JBI:

Joanna Briggs Institute

LAC:

Latin America and the Caribbean

NVS:

Newest Vital Sign

PI:

Prediction Interval

PRISMA:

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

PROSPERO:

Prospective Register of Systematic Reviews

PQDT:

ProQuest Dissertations and Theses Global

REALM:

Rapid Estimate of Adult Literacy in Medicine

REALM-D:

Rapid Estimate of Adult Literacy in Medicine Adapted for the Dutch language

REALM-SF:

Rapid Estimate of Adult Literacy in Medicine–Short Form

SAHLPA-18:

Short Assessment of Health Literacy for Portuguese-speaking Adults

SAHLPA-50:

Short Assessment of Health Literacy for Portuguese-speaking Adults

SAHLSA-50:

Short Assessment of Health Literacy for Spanish-speaking Adults

SAHL-S&E:

18-item Short Assessment of Health Literacy Spanish and English

SHLS:

Single-item variant of the Subjective Health Literacy Screener

S-TOFHLA:

Brazilian version of Short Test of Functional Health Literacy in Adults

TOFHLA:

Test of Functional Health Literacy in Adults

TOFHLA-SPR:

Test of Functional Health Literacy in Adults-Spanish – Puerto Rico version

US:

United States

SILS:

Single Item Literacy Screener

References

  1. Office of Disease Prevention and Health Promotion. 2020 (2020) Health Literacy in Healthy People 2030. https://health.gov/healthypeople/priority-areas/health-literacy-healthy-people-2030.

  2. Tan X, Liu X, Shao H. Healthy China 2030: a vision for Health Care. Value Health Reg Issues. 2017;12:112–4.

    Article  PubMed  Google Scholar 

  3. Santana S, Brach C, Harris L, Ochiai E, Blakey C, Bevington F, Kleinman D, Pronk N. Updating health literacy for healthy people 2030: defining its importance for a New Decade in Public Health. J Public Health Manag Pract. 2021;27:S258–64.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Arrighi E, Ruiz de Castilla EM, Peres F, et al. Scoping health literacy in Latin America. Glob Health Promot. 2022;29:78–87.

    Article  CAS  PubMed  Google Scholar 

  5. Ruano AL, Rodríguez D, Rossi PG, Maceira D. Understanding inequities in health and health systems in Latin America and the Caribbean: a thematic series. Int J Equity Health. 2021;20:94.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Schillinger D. Social determinants, Health Literacy, and disparities: intersections and controversies. Health Lit Res Pract. 2021;5:e234–43.

    PubMed  PubMed Central  Google Scholar 

  7. Higgins J, Thomas J, Chandler J, Cumpston M, Li T, Page M, Welch V, editors. (2022)Cochrane Handbook for Systematic Reviews of Interventions version 6.3 (updated February 2022).

  8. Page MJ, Moher D, Bossuyt PM, et al. PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews. BMJ. 2021. https://doi.org/10.1136/bmj.n160.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan—a web and mobile app for systematic reviews. Syst Rev. 2016;5:210.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Baccolini V, Rosso A, Di Paolo C, et al. What is the prevalence of Low Health Literacy in European Union Member States? A systematic review and Meta-analysis. J Gen Intern Med. 2021;36:753–61.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Munn Z, Moola S, Lisy K, Riitano D, Tufanaru C. Methodological guidance for systematic reviews of observational epidemiological studies reporting prevalence and cumulative incidence data. Int J Evid Based Healthc. 2015;13:147–53.

    Article  PubMed  Google Scholar 

  12. Abbott P, Banerjee T, Aruquipa Yujra AC, Xie B, Piette J. Exploring chronic disease in Bolivia: a cross-sectional study in La Paz. PLoS ONE. 2018;13:e0189218.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Aguayo-Verdugo N, Valenzuela-Suazo S, Luengo-Machuca L. (2019) Autocuidado, alfabetización en salud y control glicémico en personas con diabetes mellitus tipo 2. Cienc enferm (En línea) 25.

  14. de Almeida KMV, Toye C, Silveira LV, de Slatyer A, Hill S, Jacinto K AF. Assessment of functional health literacy in Brazilian carers of older people. Dement Neuropsychol. 2019;13:180–6.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Apolinario D, Braga R, de Magaldi COP, Busse RM, Campora AL, Brucki F, Lee S S-YD. Short Assessment of Health Literacy for portuguese-speaking adults. Rev Saúde Pública. 2012;46:702–11.

    Article  PubMed  Google Scholar 

  16. Apolinario D, Mansur LL, Carthery-Goulart MT, Brucki SM, Nitrini R. Cognitive predictors of limited health literacy in adults with heterogeneous socioeconomic backgrounds. J Health Psychol. 2015;20:1613–25.

    Article  PubMed  Google Scholar 

  17. Bartolazzi F, Ribeiro ALP, de Sousa WJFN, Vianna MS, da Silva JLP, Martins MAP. Relationship of health literacy and adherence to oral anticoagulation therapy in patients with atrial fibrillation: a cross-sectional study. J Thromb Thrombolysis. 2021;52:1074–80.

    Article  PubMed  Google Scholar 

  18. Batista MJ, Marques AC, de Silva Junior P, Alencar MF, Sousa GP. M da LR de (2020) Tradução, adaptação transcultural e avaliação psicométrica da versão em português (brasileiro) do 14-item Health Literacy Scale. Ciênc saúde coletiva 25:2847–2857.

  19. Bezerra JN, de Lessa M, de O SR, Ó MF do, Luz GO, de Borba A. OT (2019) Letramento em saúde dos indivíduos submetidos à terapia dialítica. Texto contexto - enferm 28:e20170418.

  20. Bhawra J, Kirkpatrick SI, Hall MG, Vanderlee L, White CM, Hammond D. Patterns and correlates of nutrition knowledge across five countries in the 2018 international food policy study. Nutr J. 2023;22:19.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Bolivar AA, Lanteri ME, Cícero CY, Pérez A, Puchulu FM, Mejía R. Alfabetización en salud y control de la diabetes en pacientes de un hospital universitario de Argentina. Med (BAires). 2017;77:167–72.

    Google Scholar 

  22. Borges FM, Silva ARV da, Lima LH, de O, Almeida PC, Vieira NFC, Machado ALG. (2019) Health literacy of adults with and without arterial hypertension. Rev Bras Enferm 72:646–653.

  23. Moura Borges F, Wellington Costa Lima E, Nunes Carvalho GC, De Oliveira Lima LH, Gomes Machado AL, Vilarouca, Da Silva AR, Relação entre letramento em saúde e qualidade de vida em indivíduos com hipertensão arterial. (2022). Ciencia y enfermería. https://doi.org/10.29393/CE28-6REFA60006.

  24. Bourne P, Morris C, Charles CA, Eldemire-Shearer D, Kerr-Campbell MD, Crawford TV. (2010) Health literacy and health seeking behavior among older men in a middle-income nation. Patient Relat Outcome Meas 39–49.

  25. Cajita MI, Denhaerynck K, Dobbels F, et al. Health literacy in heart transplantation: prevalence, correlates and associations with health behaviors—findings from the international BRIGHT study. J Heart Lung Transpl. 2017;36:272–9.

    Article  Google Scholar 

  26. Campos AAL, Neves FS, Saldanha R, de Duque F, de CD K, Guerra MR, Leite ICG, Teixeira MTB. Fatores associados ao letramento funcional em saúde de mulheres atendidas pela Estratégia de Saúde da Família. Cad saúde Colet. 2020;28:66–76.

    Article  Google Scholar 

  27. Cangussú LR, Alho EAS, Cardoso FEL, Tenório AP, de O, Barbosa RH, de Lopes A, Lopes JM MR. Concordância entre dois instrumentos para avaliação do letramento em saúde. Epidemiol serv saúde. 2021;30:e2020490–2020490.

    Article  PubMed  Google Scholar 

  28. Carrilho LE, Leite ICG, Dal Col AG, Vita ARP, Travenzoli AEA, Oliveira EC, Fernandes EG, Franco LD, Fonseca LAB, Santiago MHD. Rastreamento Da síndrome Da apneia e hipopneia obstrutiva do sono em hipertensos na Atenção Primária à Saúde. Rev APS. 2022. https://doi.org/10.34019/1809-8363.2022.v25.35054.

    Article  Google Scholar 

  29. Carthery-Goulart MT, Anghinah R, Areza-Fegyveres R, et al. Performance of a Brazilian population on the test of functional health literacy in adults. Rev Saúde Pública. 2009;43:631–8.

    Article  PubMed  Google Scholar 

  30. Cavalcante LR, Brito LL, Fraga-Maia H. Functional health literacy: protective role in adherence to treatment for hypertensive patients. Rev bras promoç saúde (Impr). 2020;33:1–12.

    Article  Google Scholar 

  31. Chehuen Neto JA, Costa LA, Estevanin GM, Bignoto TC, Vieira CIR, Pinto FAR, Ferreira RE. Letramento funcional em saúde nos portadores de doenças cardiovasculares crônicas. Ciênc saúde Coletiva. 2019;24:1121–32.

    Article  Google Scholar 

  32. Coelho MAM, Sampaio HA, Passamai de C, M da PB, Cabral LA, Passos TU, Lima GP. Functional health literacy and healthy eating: understanding the Brazilian food guide recommendations. Rev Nutr. 2014;27:715–23.

    Article  Google Scholar 

  33. da Costa FAS, Pessoa VLM, de Salles P, Frota DL, Sobral KC, de Souza MGV. (2021) Letramento Funcional em Saúde de pacientes portadores de síndrome coronariana aguda - Functional Health Literacy in patients with acute coronary syndrome. Cogitare Enfermagem 26:e75415–e75415.

  34. de Castro SH, Brito GNO, Gomes MB. Health literacy skills in type 2 diabetes mellitus outpatients from an university-affiliated hospital in Rio De Janeiro, Brazil. Diabetol Metab Syndr. 2014;6:126.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Diemer FS, Haan YC, Nannan Panday RV, van Montfrans GA, Oehlers GP, Brewster LM. Health literacy in Suriname. Soc Work Health Care. 2017;56:283–93.

    Article  PubMed  Google Scholar 

  36. Dingemans AJM, Krois W, Rios JC, Wood RJ, Levitt MA, Reck-Burneo CA. Health literacy and health-related quality of life in patients with anorectal malformations: a comparison between a charity hospital in Honduras and a tertiary care center in the United States. J Pediatr Surg. 2018;53:1951–4.

    Article  PubMed  Google Scholar 

  37. Doubova SV, Infante C, Villagrana-Gutiérrez GL, Martínez-Vega IP, Pérez-Cuevas R. Adequate health literacy is associated with better health outcomes in people with type 2 diabetes in Mexico. Psychol Health Med. 2019;24:853–65.

    Article  PubMed  Google Scholar 

  38. Durán D, Retamal I, Ochoa T, Monsalves MJ. Health literacy and adherence to treatment in different districts in Chile. Health Promot Int. 2021;36:1000–6.

    Article  PubMed  Google Scholar 

  39. Figueroa Saavedra CS, Otzen Hernández TF, Figueroa Delgado V, Sanhueza P, Candia J. Alfabetización en salud y adherencia farmacológica en adultos mayores con enfermedades crónicas, de la ciudad de Temuco. Rev méd Chile. 2020;148:653–6.

    Article  PubMed  Google Scholar 

  40. Flower C, Hambleton I, Campbell M. The Effect of Psychosocial and neuropsychiatric factors on Medication Adherence in a cohort of women with systemic Lupus Erythematosus. J Clin Rheumatol. 2016;22:411–7.

    Article  PubMed  Google Scholar 

  41. França AS, Pirkle CM, Sentell T, Velez MP, Domingues MR, Bassani DG, Câmara SMA. Evaluating Health literacy among adolescent and young adult pregnant women from a low-income area of Northeast Brazil. Int J Environ Res Public Health. 2020;17:8806.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Ghisi GLM, Santos RZ, Korbes AS, de Souza CA, Karsten M, Oh P, Benetti M. Percepções dos Participantes De Reabilitação Cardíaca sobre seus comportamentos em Saúde E Necessidades De Informação durante a pandemia COVID-19 no Brasil. Arq bras Cardiol. 2022;118:949–60.

    CAS  PubMed  PubMed Central  Google Scholar 

  43. Gordon Singh S, Aiken J. The effect of health literacy level on health outcomes in patients with diabetes at a type v health centre in western Jamaica. Int J Nurs Sci. 2017;4:266–70.

    PubMed  PubMed Central  Google Scholar 

  44. Hadden KB, Puglisi L, Prince L, Aminawung JA, Shavit S, Pflaum D, Calderon J, Wang EA, Zaller N. Health literacy among a formerly incarcerated Population using data from the transitions Clinic Network. J Urban Health. 2018;95:547–55.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Hagger MS, Hardcastle SJ, Hu M, et al. Health literacy in familial hypercholesterolemia: a cross-national study. Eur J Prev Cardiolog. 2018;25:936–43.

    Article  Google Scholar 

  46. Hoffman S, Marsiglia FF, Nevarez L, Porta M. Health Literacy among Youth in Guatemala City. Soc Work Public Health. 2017;32:30–7.

    Article  PubMed  Google Scholar 

  47. Konfino J, Mejia R, Majdalani MP, Perez EJ. Alfabetizacion en salud en pacientes que asisten a un hospital universitario. Med (B Aires). 2009;69:631–4.

    Google Scholar 

  48. León-Landa EH, Orozco-Castillo L, Argüelles-Nava VG, Hernández-Barrera L, Luzanía-Valerio MS, Campos-Uscanga Y. La alfabetización en salud como factor clave en El Autocuidado De La Dieta en personas con diabetes mellitus tipo 2. Univ Salud. 2019;21:132–40.

    Article  Google Scholar 

  49. Lima M, de FG, Vasconcelos EMR, Borba AK, de OT, Santos CR dos, Carvalho JC, Zimmermann RD. (2020) Fatores associados ao letramento funcional em saúde da pessoa idosa em tratamento pré-dialítico. Rev bras geriatr gerontol 23:e200114.

  50. Lima RIM, Parente MA, Ferreira TISP, Coelho AAS, de Loureiro EVS, Barbosa TM, Lustosa SB, Damasceno OC, Teixeira FB. Letramento funcional em saúde de usuários da atenção primária de Altamira, Pará. Rev bras med fam Comunidade. 2022;17:2763–2763.

    Article  Google Scholar 

  51. Macha Quillama LF, Samanamu Leandro AE, Rodriguez Hurtado D. Alfabetización sanitaria y factores relacionados en pacientes que acuden a consulta externa de Medicina Interna En Un Hospital Nacional en Lima,Perú. Rev Salud pública. 2017;19:679–85.

    Article  PubMed  Google Scholar 

  52. Manola CCV, de Melo EBM, Lau YKC, Bedin LP, de Oliveira MV, de Almeida MAI, de Castro MR, Machado PS. Letramento funcional em saúde: sífilis em gestantes. Nurs (Säo Paulo). 2020;23:4193–8.

    Google Scholar 

  53. Maragno CAD, Mengue SS, Moraes CG, Rebelo MVD, Guimarães AM, de Pizzol M. T da SD (2019) Teste de letramento em saúde em português para adultos. Rev bras epidemiol 22:e190025.

  54. Marques SRL, Lemos SMA. Letramento em saúde e fatores associados em adultos usuários da atenção primária. Trab educ saúde. 2018;16:535–59.

    Article  Google Scholar 

  55. Martins MAP, Costa JM, Mambrini JV, de Ribeiro M, Benjamin ALP, Brant EJ, Paasche-Orlow LCC, Magnani MK JW. Health literacy and warfarin therapy at two anticoagulation clinics in Brazil. Heart. 2017;103:1089–95.

    Article  PubMed  Google Scholar 

  56. McNaughton CD, Korman RR, Kabagambe EK, Wright SW. Health literacy and blood glucose among Guyanese emergency department patients without diagnosed diabetes: a cross-sectional study. Diabetol Metab Syndr. 2015;7:31.

    Article  PubMed  PubMed Central  Google Scholar 

  57. Mora Vicarioli R, Leon-Salas A, Castro Granados A, Lizano-Barrantes C. (2021) Alfabetización en salud y necesidades para El etiquetado de medicamentos identificadas en población indígena de Alto telire del Área De Salud Talamanca, Costa Rica. Poblac Salud Mesoam 18.

  58. Moraes KL, Brasil VV, de Oliveira GF, Cordeiro JABL, Silva AMTC, Boaventura RP, Munari DB, Ribeiro Canhestro M. Letramento funcional em saúde e conhecimento de doentes renais em tratamento pré-dialítico. Rev Bras Enferm. 2017;70:155–62.

    Article  PubMed  Google Scholar 

  59. Oliveira MO, Nitrini R, Brucki SMD. The S-TOFHLA as a measure of functional literacy in patients with mild Alzheimer’s disease or mild cognitive impairment. Arch Clin Neuropsychol. 2014;29:269–77.

    Article  PubMed  Google Scholar 

  60. Paes RG, Mantovani M, de Silva F, Boller ÂTM, Nazário C, de Cruz S. A (2022) Health literacy, knowledge of disease and risk for diabetic foot in adults: cross-sectional study. Rev baiana enferm 36:e45868–e45868.

  61. Pasklan ANP, Pereira JF, Mesquita MJT, Portela YMC, Lima SF. (2021) Letramento em saúde e características socioeconômicas das pessoas idosas: uma abordagem da comunicação no sistema único de saúde. Rev Enferm Atenção Saúde. https://doi.org/10.18554/reas.v10i2.4487.

  62. Pavao A, Werneck G, Saboga-Nunes L, de Sousa R. Assessment of health literacy in diabetic patients followed at a public outpatient clinic. Cad Saude Publica. 2021. https://doi.org/10.1590/0102-311X00084819.

    Article  PubMed  Google Scholar 

  63. Penaloza R, Navarro JI, Jolly PE, Junkins A, Seas C, Otero L. Health literacy and knowledge related to tuberculosis among outpatients at a referral hospital in Lima, Peru. Res Rep Trop Med. 2019;10:1–10.

    PubMed  PubMed Central  Google Scholar 

  64. Pereira Cruvinel AF, Cusicanqui Méndez DA, Campos Chaves G, Gutierres E, Lotto M, Marchini Oliveira T, Cruvinel T. The Brazilian validation of a health literacy instrument: the newest vital sign. Acta Odontol Scand. 2018;76:587–94.

    Article  PubMed  Google Scholar 

  65. Pinhati RR, Tavares PL, Marsicano E, de O, Fernandes NdaS, Colugnati FAB, Bastos MG, De Paula RB, Pinheiro HS. Low health literacy in older patients with uncontrolled blood pressure at secondary care. HU Rev. 2019;45:13–21.

    Article  Google Scholar 

  66. Ribeiro UASL, Vicente LCC, Lemos SMA. (2021) Letramento funcional em saúde em adultos e idosos com disfagia. Audiol - Communication Res 26.

  67. Rivero-Méndez M, Suárez-Pérez EL, Solís-Báez SS. Measuring Health Literacy among people living with HIV who attend a community-based ambulatory clinic in Puerto Rico. P R Health Sci J. 2015;34:31–7.

    PubMed  PubMed Central  Google Scholar 

  68. Rocha PC, Rocha DC, Lemos SMA. (2017) Letramento funcional em saúde na adolescência: associação com determinantes sociais e percepção de contextos de violência. CoDAS 29.

  69. da Rocha MR, Santos SD dos, de Moura KR, Carvalho L, de Moura S, de Silva IH. ARV da (2019) Health literacy and adherence to drug treatment of type 2 diabetes mellitus. Esc Anna Nery 23:e20180325.

  70. Romero SS, Scortegagna H, de Doring M M. Nível De Letramento funcional em saúde e comportamento em saúde de idosos. Texto contexto - enferm. 2018;27:e5230017.

    Article  Google Scholar 

  71. Rodrigues R, de Andrade SM, González AD, Birolim MM, Mesas AE. Cross-cultural adaptation and validation of the Newest Vital sign (NVS) health literacy instrument in general population and highly educated samples of Brazilian adults. Public Health Nutr. 2017;20:1907–13.

    Article  PubMed  PubMed Central  Google Scholar 

  72. Rodriguez M, López-Cepero A, Ortiz-Martínez AP, Fernández-Repollet E, Pérez CM. Influence of Health beliefs on COVID-19 vaccination among individuals with Cancer and other comorbidities in Puerto Rico. Vaccines (Basel). 2021. https://doi.org/10.3390/vaccines9090994.

    Article  PubMed  PubMed Central  Google Scholar 

  73. Rosas-Chavez G, Romero-Visurraga CA, Ramirez-Guardia E, Málaga G. El Grado De alfabetización en salud y adherencia al tratamiento en pacientes con hipertensión arterial en un hospital nacional de Lima, Perú. Rev Peru Med Exp Salud Publica. 2019;36:214.

    Article  PubMed  Google Scholar 

  74. de Sá AM, Casagrande V, Chagas EFB, Pinheiro OL. (2022) Influence of functional health literacy on adherence to antidepressant treatment. Revista Gaúcha De Enfermagem 43.

  75. Santos Júnior J, Camilo M, Santos I, Rosas M, Silva J, Medeiros L. Relação do letramento funcional em saúde com a insuficiência renal em pessoas com diabetes mellitus. Enferm Foco. 2021. https://doi.org/10.21675/2357-707X.2021.v12.n2.3938.

    Article  Google Scholar 

  76. Santos MIP, de Portella O MR. Condições do letramento funcional em saúde de um grupo de idosos diabéticos. Rev Bras Enferm. 2016;69:156–64.

    Article  Google Scholar 

  77. dos Santos JEM, Brasil VV, Moraes KL, et al. Comprehension of the education handout and health literacy of pacemaker users. Rev Bras Enferm. 2017;70:633–9.

    Article  PubMed  Google Scholar 

  78. Silva JRR da, Luz GO, de Silva A, Medeiros SMB, de Santos Júnior LKA, Santos JL. ICRV (2019) Letramento funcional em saúde e o conhecimento dos doentes renais crônicos em tratamento conservador. Rev bras promoç saúde (Impr) 32:1–11.

  79. da Silva IC, Nogueira MR do, Cavalcante N, Felipe TF, Morais GF, Moreira HCC, de Oliveira RP. (2022) Health literacy and adherence to the pharmacological treatment by people with arterial hypertension. Rev Bras Enferm 75:e20220008.

  80. Silva-Junior MF, Rosário de Sousa M da, Batista L. MJ (2021) Health literacy on oral health practice and condition in an adult and elderly population. Health Promot Int 36:933–942.

  81. Souza JG, Apolinario D, Magaldi RM, Busse AL, Campora F, Jacob-Filho W. Functional health literacy and glycaemic control in older adults with type 2 diabetes: a cross-sectional study. BMJ Open. 2014;4:e004180.

    Article  PubMed  PubMed Central  Google Scholar 

  82. Stonbraker S, Smaldone A, Luft H, Cushman LF, Lerebours Nadal L, Halpern M, Larson E. Associations between health literacy, HIV-related knowledge, and information behavior among persons living with HIV in the Dominican Republic. Public Health Nurs. 2018;35:166–75.

    Article  PubMed  Google Scholar 

  83. Tenani CF, Silva Junior MF, Lino CM, Sousa M da, de Batista LR. MJ (2021) The role of health literacy as a factor associated with tooth loss. Rev Saude Publica 55:116.

  84. Torrejón-Peces D, Durán-Agüero S, Pizarro-Mena R, Vásquez-Vergara R. Nivel De Alfabetización en salud entre Adultos Mayores Atendidos en Dos Centros Comunitarios De Rehabilitación X1 - Level of Health Literacy among older adults served in two Community Rehabilitation centers. J Negat No Posit Results. 2021;6:1327–40.

    Google Scholar 

  85. Vílchez-Román C, Quiliano-Terreros R, Canales-Negrón R, Chiroque-Solano R. Demographic factors associated with health literacy in a sample of females residing in Lima, Peru in 2008: results from the SAHLSA-50 test. Rev Colomb Obstet Ginecol. 2009;60:223–9.

    Article  Google Scholar 

  86. Cardoso T, de Ribeiro A, Roncada MC, Pitrez C PMC. Avaliação Dos níveis De alfabetismo em saúde, conhecimento em asma e qualidade de vida de pais associados ao controle da doença em crianças e adolescentes com diagnóstico de asma de centros especializados. Sci Med. 2021;31:e38767.

    Article  Google Scholar 

  87. Carvalho TR, Ribeiro LC. Associação entre letramento funcional em saúde e adesão ao tratamento medicamentoso da Hipertensão arterial Sistêmica na atenção primária à saúde. Rev APS. 2020;23:734–49.

    Google Scholar 

  88. de Lima JP, Abreu DPG, Bandeira EDO, Brum AN, de Mello MCVA, Varela VDS, Martins NFF. (2019) Letramento funcional em saúde e fatores associados em pessoas idosas. Cogit Enferm 24.

  89. Medina LAC, Silva RA, de Sousa Lima MM, Barros LM, Lopes ROP, Melo GAA, Garcia Lira Neto JC, Caetano JÁ. Correlation between Functional Health Literacy and self-efficacy in people with type 2 diabetes Mellitus: cross-sectional study. Clin Nurs Res. 2022;31:20–8.

    Article  PubMed  Google Scholar 

  90. Mialhe FL, Moraes KL, Bado FMR, Brasil VV, Sampaio HADC, Rebustini F. Psychometric properties of the adapted instrument European Health Literacy Survey Questionnaire short-short form. Rev Latino-Am Enfermagem. 2021;29:e3436.

    Article  Google Scholar 

  91. Oscalices MIL, Okuno MFP, Lopes MCBT, Batista REA, Campanharo CRV. Health literacy and adherence to treatment of patients with heart failure. Rev Esc Enferm USP. 2019;53:e03447.

    Article  PubMed  Google Scholar 

  92. Rocha KT, Figueiredo AE. Letramento em saúde: avaliação de pacientes em terapia renal substitutiva. Enferm Nefrol. 2019;22:388–97.

    Article  Google Scholar 

  93. Sampaio HA, de Carioca C, Sabry AAF, Santos MOD, Coelho PM, Passamai MAM, M da PB. (2015) Letramento em saúde de diabéticos tipo 2: fatores associados e controle glicêmico. Ciênc saúde coletiva 20:865–874.

  94. Scortegagna H, de Santos M, Santos PCS, de O MIP, Portella MR. (2021) Letramento funcional em saúde de idosos hipertensos e diabéticos atendidos na Estratégia Saúde da Família. Esc Anna Nery 25:e20200199.

  95. Inés HCJ, Rosa VDV. (2018) Alfabetización sanitaria evaluada mediante un instrumento validado y factores relacionados en pacientes hospitalizados en los servicios de Medicina Interna en un Hospital Nacional en Lima-Perú 2018. Bachelor’s thesis, Universidad Peruana Cayetano Heredia.

  96. World Bank Country and Lending Groups. In: The World Bank. https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups.

  97. Rajah R, Hassali MAA, Murugiah MK. A systematic review of the prevalence of limited health literacy in southeast Asian countries. Public Health. 2019;167:8–15.

    Article  CAS  PubMed  Google Scholar 

  98. Kobayashi LC, Wardle J, Wolf MS, von Wagner C. Aging and Functional Health Literacy: a systematic review and Meta-analysis. J Gerontol B Psychol Sci Soc Sci. 2016;71:445–57.

    Article  PubMed  Google Scholar 

  99. Jordan JE, Osborne RH, Buchbinder R. Critical appraisal of health literacy indices revealed variable underlying constructs, narrow content and psychometric weaknesses. J Clin Epidemiol. 2011;64:366–79.

    Article  PubMed  Google Scholar 

  100. Tavousi M, Mohammadi S, Sadighi J, Zarei F, Kermani RM, Rostami R, Montazeri A. Measuring health literacy: a systematic review and bibliometric analysis of instruments from 1993 to 2021. PLoS ONE. 2022;17:e0271524.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  101. Sørensen K, Pelikan JM, Röthlin F, et al. Health literacy in Europe: comparative results of the European health literacy survey (HLS-EU). Eur J Public Health. 2015;25:1053–8.

    Article  PubMed  PubMed Central  Google Scholar 

  102. Tolabing MCC, Co KCD, Mendoza OM, Mira NRC, Quizon RR, Tempongko MSB, Mamangon MAM, Salido ITO, Chang PWS. (2022) Prevalence of Limited Health Literacy in the Philippines: First National Survey. Health Lit Res Pract 6.

  103. Haghdoost AA, Karamouzian M, Jamshidi E, et al. Health literacy among Iranian adults: findings from a nationwide population-based survey in 2015. East Mediterr Health J. 2019;25:828–36.

    Article  PubMed  Google Scholar 

  104. Jaafar N, Perialathan K, Krishnan M et al. (2021) Malaysian health literacy: Scorecard Performance from a National Survey. Int J Environ Res Public Health 18.

  105. Nutbeam D. Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century. Health Promot Int. 2000;15:259–67.

    Article  Google Scholar 

Download references

Acknowledgements

We thank the librarian Raquel Schmitt Domingos, from the Faculty of Medicine of UFRGS, for her excellent support in developing the search strategy. We thank all included study authors who kindly provided additional information for this review.

Funding

This study was financed by the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)-Chamada CNPq/MCTI/FNDCT Nº 18/2021. The Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) finance the scholarship of the first author - Finance Code 001.

Author information

Authors and Affiliations

  1. Postgraduate Program in Epidemiology, Faculty of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, Brazil

    Patricia Romualdo de Jesus, Bianca Vendruscolo Bianchini, Patrícia Klarmann Ziegelmann & Tatiane da Silva Dal Pizzol

Authors
  1. Patricia Romualdo de Jesus
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Bianca Vendruscolo Bianchini
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Patrícia Klarmann Ziegelmann
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Tatiane da Silva Dal Pizzol
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

PRJ and TSP conceptualized the idea. PRJ and BVB carried out the data extraction. PRJ and PKZ conducted the meta-analysis. PRJ, BVB, TSP, and PKZ developed the methodology. TSP supervised the study. PRJ drafted the initial manuscript. PRJ, BVB, TSP, and PKZ edited and revised the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Patricia Romualdo de Jesus.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

de Jesus, P., Bianchini, B., Ziegelmann, P. et al. The low health literacy in Latin America and the Caribbean: a systematic review and meta-analysis. BMC Public Health 24, 1478 (2024). https://doi.org/10.1186/s12889-024-18972-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12889-024-18972-2

Keywords

BMC Public Health

ISSN: 1471-2458

Contact us