Health literacy and its relationship with mental health and quality of life in freshmen students
Health literacy (HL) refers to the capacity of individuals to obtain, interpret, comprehend, and apply healthcare information and treatment protocols to make informed health choices . Insufficient health literacy is regarded as a pervasive health crisis . Health literacy enables individuals to make informed decisions about their health or that of their family members. Evidence suggests that limited health literacy is associated with adverse health outcomes, destructive health behaviors, lower patient satisfaction, impaired decision-making in healthy habits, misinterpretation and poor adherence to prescribed medications, and frequent hospital admissions . Additionally, the need for costly healthcare services, including specific and emergency services, and an elevated risk of various health issues, including mental health disorders increases with low health literacy . The World Health Organization (WHO) characterizes mental health as a psychological well-being condition that empowers individuals to manage life’s challenges, recognize their potential, engage in effective learning and work, and contribute to their communities . In 2019, WHO estimated that approximately one in eight individuals, equating to 970 million people globally, experienced a mental disorder . Notably, 80% of those affected live in low- and middle-income nations . The incidence of mental disorders in Asia rose significantly from 377.9 million cases in 1990 to 555.4 million cases by 2019 . In Iran, the prevalence of mental disorders within the general population was reported to be almost 30% in 2020 . Numerous studies have demonstrated a correlation between low health literacy and adverse health outcomes . However, when examining the connection between health literacy and mental health, the majority of research has concentrated on mental health and mental health literacy . Consequently, only a limited number of studies have established a relationship between health literacy and mental disorders, indicating a distinct association between inadequate health literacy and mental health issues. One of the factors that is affected by low health literacy is, the mental health of people . Nowadays, one of the most obvious issues that every person’s mind is engaged with is mental health issues . it is a general concept of different aspects of health that can include the psychological dimension and have a social impact . Furthermore, the challenge of the new century is superior quality of life . On the other hand, good physical and mental health are important consequences of the quality of life . According to the WHO definition, quality of life refers to individuals’ evaluation and understanding of their life situation, influenced by their cultural and value system and the environment in which they live. People’s aims, beliefs, values, and desires knowingly affect their physical and mental condition, level of independence, social relations, and principles. Various studies exhibited that health literacy impacts both the overall health status of individuals  and health-related quality of life . Healthy populations, such as students, generally have a better quality of life than patients . However, studies have shown that in Iran, the quality of life and life satisfaction of students is lower compared to their peers in developed countries . Therefore, the low quality of life among Iranian students remains a subject of debate. Numerous studies found the relationship between quality of life and health literacy, yielding conflicting results . However, these studies have not examined the influence of health literacy on both mental health and quality of life, simultaneously. Given the societal significance of health literacy, particularly among the younger generation, and its potential implications for mental well-being and quality of life, this study aimed to investigate the status of health literacy in students of medical sciences and its relationship with their mental health and overall quality of life. One of the reasons for choosing students as the research community is that they make up a large amount of the country’s young population . Moreover, selecting the freshmen students allow us to assess the youngsters’ health literacy. Also, their health level and quality of life have a significant impact on learning and academic performance . 

This cross-sectional descriptive-analytical study was conducted from November 2022 to April 2023. The study population comprised Babol University of Medical Sciences freshmen students. 311 students were selected using a multi-stage sampling method. Initially, a list of university majors and the number of students enrolled in the academic year 2022 was compiled. Subsequently, the total number of students within each faculty was calculated, and participants were selected based on the proportional representation of each faculty’s student population overall. Following the selection process, written informed consent was obtained from all participating students, and then they were asked to complete the research questionnaires. Sample size calculation and inclusion/exclusion criteria The sample size for this study was determined using Cochran’s formula, with an error margin of 0.05 and a power of 80% while considering a correlation coefficient of 0.21 . This calculation indicated a minimum sample size of 200 individuals. However, to ensure greater accuracy and a more comprehensive investigation, the sample size was increased to 311 participants. [12pt]{minimal}
				
				 
				 
				 
				
				
				
				
				$$\:n\:{(_{1-{\:}/{2}}+{Z}_{1-\:}}{}_{e}})}^{2}+3$$ Inclusion criteria for participation in the study included enrollment in a continuous bachelor’s degree or professional doctorate program, being over 18 years old, being a first-year student, holding Iranian citizenship, and providing written consent. Exclusion criteria include having known mental disorders or being under treatment for mental disorders. Data collection tool The data collection instruments included four questionnaires: Demographic Characteristics Questionnaire: This questionnaire comprised 13 questions aimed at gathering information regarding participants’ demographic details, including gender, Educational program, marital status, economic status, employment status during studies, and the employment and educational status of their families. Health Literacy Questionnaire: The Health Literacy Measurement Tool for Adults (HELIA) was employed in this study. This questionnaire consists of 33 questions designed to assess five main dimensions of health literacy: reading, access, comprehension, evaluation, and decision-making. access (4 items), reading (4 items), comprehension (7 items), evaluation (4 items), and decision-making and behavior (12 items). Responses were recorded using a five-choice Likert scale. The total score range for this questionnaire is between 33 and 165. Raw scores were converted to a range of 0 to 100 using a formula based on the difference between the minimum and maximum possible scores. Health literacy scores were categorized as follows: 0 to 50 (insufficient), 50.1 to 66 (Not quite enough), 66.1 to 84 (Enough), and 84.1 to 100 (excellent). The reliability and validity of the health literacy questionnaire were established in several studies indicating overall good reliability . (Supplementary file ). General Health Questionnaire Short-Form (GHQ-12): The GHQ-12, developed by Goldberg and Hillier in 1979, serves as a measure of general health. Its validity and reliability in the Iranian population were confirmed by Montazeri et al. . This questionnaire consists of 12 questions and two subscales: positive mental health symptoms and symptoms of mental disorder. Responses are usually scored as ‘not at all,’ ‘normally,’ ‘more than usual,’ and ‘much more than usual.’ There are different scoring methods for this test: The Likert method (3-2-1-0) and the traditional method (0-0-1-1). In this study, the bimodal GHQ scoring method (0-0-1-1) was used. The maximum score on the general health questionnaire (12 questions) is 12 . (supplementary file ). Quality of Life Questionnaire (SF-12): The Quality of Life questionnaire, designed by Ware et al. in 1996, measures eight health domains to assess physical and mental health. Physical health domains include general health, physical function, physical role, and bodily pain, while mental health domains encompass vitality, social function, emotional role, and mental health. This questionnaire comprises 12 questions, with scores ranging from 12 to 48. Scores between 12 and 24 indicate poor quality of life, 24 to 36 indicate average quality of life, and 36 to 48 indicate good quality of life. Montazeri et al. (2008) confirmed the reliability and validity of the questionnaire, with reported reliability coefficients of 0.73 for physical components and 0.72 for mental components . (supplementary file ). Ethics approval and consent to participate The study design was approved by Ethics Committee of Babol University of Medical Sciences, Babol, Iran (IR.MUBABOL.HRI.REC.1400.270). Written informed consent was taken from all the participants. All methods were carried out per relevant guidelines and regulations. Data analysis The data were entered into SPSS version 22 and analyzed using descriptive statistics and for analytical analysis, independent t-tests and chi-square tests, ANOVA were employed. Multiple linear regression analyses were conducted to predict mental health and quality of life through health literacy. A significance level of 0.05 was utilized in this study to determine statistical significance. 

The sample size for this study was determined using Cochran’s formula, with an error margin of 0.05 and a power of 80% while considering a correlation coefficient of 0.21 . This calculation indicated a minimum sample size of 200 individuals. However, to ensure greater accuracy and a more comprehensive investigation, the sample size was increased to 311 participants. [12pt]{minimal}
				
				 
				 
				 
				
				
				
				
				$$\:n\:{(_{1-{\:}/{2}}+{Z}_{1-\:}}{}_{e}})}^{2}+3$$ Inclusion criteria for participation in the study included enrollment in a continuous bachelor’s degree or professional doctorate program, being over 18 years old, being a first-year student, holding Iranian citizenship, and providing written consent. Exclusion criteria include having known mental disorders or being under treatment for mental disorders. 

The data collection instruments included four questionnaires: Demographic Characteristics Questionnaire: This questionnaire comprised 13 questions aimed at gathering information regarding participants’ demographic details, including gender, Educational program, marital status, economic status, employment status during studies, and the employment and educational status of their families. Health Literacy Questionnaire: The Health Literacy Measurement Tool for Adults (HELIA) was employed in this study. This questionnaire consists of 33 questions designed to assess five main dimensions of health literacy: reading, access, comprehension, evaluation, and decision-making. access (4 items), reading (4 items), comprehension (7 items), evaluation (4 items), and decision-making and behavior (12 items). Responses were recorded using a five-choice Likert scale. The total score range for this questionnaire is between 33 and 165. Raw scores were converted to a range of 0 to 100 using a formula based on the difference between the minimum and maximum possible scores. Health literacy scores were categorized as follows: 0 to 50 (insufficient), 50.1 to 66 (Not quite enough), 66.1 to 84 (Enough), and 84.1 to 100 (excellent). The reliability and validity of the health literacy questionnaire were established in several studies indicating overall good reliability . (Supplementary file ). General Health Questionnaire Short-Form (GHQ-12): The GHQ-12, developed by Goldberg and Hillier in 1979, serves as a measure of general health. Its validity and reliability in the Iranian population were confirmed by Montazeri et al. . This questionnaire consists of 12 questions and two subscales: positive mental health symptoms and symptoms of mental disorder. Responses are usually scored as ‘not at all,’ ‘normally,’ ‘more than usual,’ and ‘much more than usual.’ There are different scoring methods for this test: The Likert method (3-2-1-0) and the traditional method (0-0-1-1). In this study, the bimodal GHQ scoring method (0-0-1-1) was used. The maximum score on the general health questionnaire (12 questions) is 12 . (supplementary file ). Quality of Life Questionnaire (SF-12): The Quality of Life questionnaire, designed by Ware et al. in 1996, measures eight health domains to assess physical and mental health. Physical health domains include general health, physical function, physical role, and bodily pain, while mental health domains encompass vitality, social function, emotional role, and mental health. This questionnaire comprises 12 questions, with scores ranging from 12 to 48. Scores between 12 and 24 indicate poor quality of life, 24 to 36 indicate average quality of life, and 36 to 48 indicate good quality of life. Montazeri et al. (2008) confirmed the reliability and validity of the questionnaire, with reported reliability coefficients of 0.73 for physical components and 0.72 for mental components . (supplementary file ). Ethics approval and consent to participate The study design was approved by Ethics Committee of Babol University of Medical Sciences, Babol, Iran (IR.MUBABOL.HRI.REC.1400.270). Written informed consent was taken from all the participants. All methods were carried out per relevant guidelines and regulations. 

The study design was approved by Ethics Committee of Babol University of Medical Sciences, Babol, Iran (IR.MUBABOL.HRI.REC.1400.270). Written informed consent was taken from all the participants. All methods were carried out per relevant guidelines and regulations. 

The data were entered into SPSS version 22 and analyzed using descriptive statistics and for analytical analysis, independent t-tests and chi-square tests, ANOVA were employed. Multiple linear regression analyses were conducted to predict mental health and quality of life through health literacy. A significance level of 0.05 was utilized in this study to determine statistical significance. 

The mean age of the 311 participating students in this study was 19.8 ± 1.74 years. The gender distribution was 45.5% female and 54.5% male. The findings showed a significant relationship between health literacy and the variables of gender and residential place ( P < 0.05) Table . The mean score of health literacy was 76.49 ± 10.9. The distribution of health literacy levels among students showed that 8% had insufficient, 32.2% had not quite enough, 42.1% had adequate, and 17.7% had excellent health literacy. The highest level of awareness among students was in the dimension of comprehension, while the lowest score among the dimensions was associated to decision-making and behavior (Table ). The assessment of each dimension considers the total score of 100 points, which includes the quantity of items and their impact. The mental health mean score obtained in the study was 2.62 ± 0.149. The mean score was 1.06 ± 0.089 in the subscale of positive mental health symptoms and 1.56 ± 0.076 in the subscale of mental disorder symptoms. The regression test results indicated that the variables of health literacy, age, educational program, and residential place were predictors of students’ mental health (Table ). The mean score of quality of life in the students was 68.81 ± 16.56. The mean scores for the physical and mental dimensions of quality of life were 77.16 ± 44.53 and 63.3 ± 19.13, respectively. Among these students had, 3.2% poor, 44.1% average, and 52.7% good quality of life, respectively. The regression test indicated that health literacy, educational program, and residential place were significant predictors of students’ quality of life (Table ). Health literacy was correlated with mental health, positive mental health symptoms, and quality of life (physical and mental dimensions) (Table ). 

In the present study, the range of health literacy mean score was sufficient. Comparing the students’ health literacy scores with the existing literature, it is clear that the mean score is consistent with findings from several studies inside  and outside of the country . However, other studies have reported higher health literacy among students  while others have reported lower levels . The variation in these findings can be attributed to differences in participant characteristics, such as educational program, age, gender, year of study, and differences in scales, cultural backgrounds, and educational systems. Roe and colleagues (2023) reviewed educational approaches in their study on health literacy in higher education. The review revealed that the majority of studies examined concentrated mainly on individual aspects of health literacy . Similarly, our study found that health literacy, age, education, and residential place predict students’ mental health. This aligns with findings from various studies, including those by Beasley et al. (2023) in the United States, Rababah et al. in Jordan, and Rahimi et al. in Iran . The present study exhibited health literacy is a predictors of mental health. However, there are studies with conflicting results  this difference may be due to the difference in the study population. Our population was the first year students of University, while Mashayekhi et al. evaluated health literacy among parents of the children. Health literacy enhances mental health and resilience by reducing negative emotions, improving physical condition, enhancing control over mental health issues, and reducing physical limitations. Individuals with higher health literacy are better equipped to make informed decisions regarding their and others’ health. Perceived stress adversely affects academic performance, physical and mental health . Consequently, comprehending the influence of health literacy on psychological well-being and overall quality of life holds significant importance for university counseling services. It is imperative to offer training to counseling personnel regarding health literacy and its implications for mental health and life quality. Highlighting the importance of delivering precise information is vital, as it can positively impact students’ psychological well-being and enhance their quality of life. Existing studies on the effect of health literacy on quality of life yield contradictory results. Several studies indicate a positive relationship between health literacy and quality of life, while others suggest a negative association . These discrepancies may arise from variations in the dimensions of health literacy and quality of life surveyed, as well as differences in the questionnaires used, potentially leading to conflicting results. However, a systematic review and meta-analysis spanning from 1970 to 2018 on the relationship between health literacy and quality of life showed a moderate correlation with students’ quality of life . This suggests that individuals who possess low health literacy may neglect their health status, leading to detrimental behaviors that adversely affect their quality of life. The ability to convert health knowledge into practical health behaviors, known as health skills, is essential for enhancing both health status and overall quality of life. Furthermore, mental health conditions, which are intricately linked to an individual’s quality of life, also improvements through the development of health skills . In a subgroup analysis, Zheng and colleagues examined factors such as population demographics, study duration, design, quality, geographic region, and types of health literacy tools . They found a lower correlation between health literacy and quality of life among student populations. This indicates that while students may have similar levels of general health literacy, differences in quality of life scores are more closely linked to psychological states such as anxiety and depression. The underlying mechanism of the relationship between health literacy, mental health, and quality of life involves a complex interaction of understanding, decision-making, and the application of health information. Authors have emphasized how health literacy enables individuals to navigate health systems and make informed decisions, in that way positively impacting mental health and overall well-being. The practical implications of our study underscore the importance of appropriate interventions to enhance health literacy among young people, ultimately improving their mental health and quality of life during their schooling. Further studies on the integration of other health domains, such as physical health and health promotion, are necessary to provide deeper insight into the potential impact of health literacy on students’ overall health. Future studies should also consider conducting multi-site research with students from diverse cultural and demographic circumstances. The importance of university entrance examinations in Iran has led to a concentration of various school counseling initiatives on this subject . Consequently, school counselors should prioritize the enhancement of adolescents’ health literacy instead of solely offering academic guidance. Although this study provides valuable insights, it is not without limitations. These include potential biases inherent in self-report data, the cross-sectional design limiting causal inferences, and the exclusive focus on first-year students at a single university. Future research could benefit from using longitudinal designs, incorporating diverse student populations, and employing qualitative methods to gain deeper visions into the complexities of health literacy, mental health, and quality of life among college students. 

This research highlights the pivotal importance of health literacy in influencing the mental health and overall quality of life among first-year students. By identifying and addressing deficiencies in health literacy, and by customizing interventions to meet the unique requirements of these students, educational institutions can foster a nurturing environment that enhances overall well-being. 

Below is the link to the electronic supplementary material. Supplementary Material 1 Supplementary Material 2 Supplementary Material 3 

