Caspian Journal of

Introduction
Cancer remains a pressing global health concern, driven by an alarming rise in incidence rates worldwide [1]. Although the precise causes of many cancers are not fully understood, a range of factors, including individual behaviors, social characteristics, medical history, and lifestyle choices, are known to elevate cancer risk [2]. Focusing on factors that impact individuals’ lives, especially environmental factors affecting health, has become an essential preventive strategy. The World Health Organization (WHO) recognized the importance of social factors and their effects on health as early as 1948, highlighting their significance in health promotion [3].
The social determinants of health—including socioeconomic status, marginalization, stress, early childhood experiences, employment status, working conditions, insurance coverage, social support, and other factors such as diet, transportation, urbanization, and globalization are now widely acknowledged to have a profound impact on health outcomes [4]. As a result, empowering individuals to actively manage their health through health-promoting behaviors has become a core principle in contemporary health policy [5]. This approach aligns with the principles of the Alma-Ata Declaration, which advocates for health promotion through individual awareness, education, and proactive engagement in behaviors that protect and enhance health [6]. 
One of the critical factors influencing engagement in health-promoting behaviors is health literacy. Health literacy is an individual’s ability to effectively use their reading, writing, verbal, and numerical skills to participate positively in their personal health care [7]. A person’s health literacy skills are crucial for making health-related decisions. Health literacy is described as “the personal knowledge and competencies that enable individuals to access, understand, evaluate, and use information and services in ways that promote and maintain good health and well-being for themselves and those around them” [8]. General literacy does not provide all the skills necessary to manage and communicate critical health information and concerns [9]. Health literacy, a topic of increasing global relevance, encompasses the cognitive and social skills needed to access, understand, and utilize health information effectively to maintain and improve health [10]. Evidence suggests that low health literacy is associated with poorer health outcomes, adverse health behaviors, lower patient satisfaction, and, in some cases, increased mortality rates. Health literacy disparities contribute to health inequities, as individuals with limited health literacy face challenges in understanding medical information, adhering to treatment, participating in preventive measures, and managing chronic conditions effectively [5]. 
Studies indicate that individuals with low health literacy tend to rely more on emergency services, experience higher rates of hospital admission, and engage less frequently in preventive healthcare behaviors, all of which contribute to elevated healthcare costs and strain on health systems [11]. Additionally, limited health literacy is linked to reduced participation in cancer screening programs and a diminished capacity to make informed health decisions, potentially impacting cancer outcomes [5, 12], For example, a study in Isfahan reported that approximately 80% of individuals had low health literacy, leading to increased hospitalization rates and more frequent doctor visits [12]. The implications of these findings are critical for policymakers and healthcare planners worldwide, underscoring the need for targeted interventions to improve health literacy and reduce associated costs [13]. Investigating the relationship between health literacy and social determinants of health in cancer patients may offer valuable insights for enhancing patient care and reducing disparities. Health literacy enables cancer patients to better understand their condition and use healthcare information effectively, potentially improving their overall well-being. This study, as part of the PERSIAN Guilan cohort, aims to examine the link between social determinants of health and health literacy in cancer patients in Guilan province to identifying strategies to enhance health literacy and support cancer prevention efforts.

Methods
Study design and participants
This cross-sectional descriptive study was conducted in 2019 as part of the PERSIAN Guilan cohort, using data from all known cancer patients within this cohort. The Guilan cohort study was conducted on 10520 men and women between 35-70 years of age in Guilan province and Some’e Sara county, northern Iran, from October 8, 2014 to January 20, 2017 as part of the prospective epidemiological research studies in Iran (PERSIAN) [14].
Eligibility criteria included patients who diagnosed with any type of cancer who provided informed consent, had a medical record in the PERSIAN Guilan cohort, and were able to complete the questionnaire. Patients who declined to participate in the study, were unwilling or unable to respond were excluded from the study.
From 102 identified cancer patients in the cohort, data were gathered on all available individuals. During follow-up calls, 10 patients were found to be deceased, and 21 individuals either could not be reached or declined participation. A total of 69 patients consented to participate via telephone interviews, conducted with confidentiality assurances. For two additional patients with speech difficulties due to laryngeal cancer, interviews were completed with assistance from their spouses. Before the telephone interview began, the study objectives were explained to the individuals, the text of the approved informed consent form was read to them, and their verbal consent was obtained. Data collection spanned 35 days, from December 11, 2020, following approval from the Guilan University of Medical Sciences’ Research and Technology Deputy and Ethics Committee.

Data collection instruments
Data were collected through a structured questionnaire comprising two parts.

Social determinants of health
This section included 15 items on demographic and socioeconomic factors: Age, sex, height, weight, marital status, employment, education level, monthly income, number of children and household members, housing status, socioeconomic status, insurance, supplementary insurance, and primary health information sources. These data were obtained from participants’ cohort records. The economic status was assessed using the wealth index, a reliable measure for household welfare in low- to middle-income settings. PCA was employed to create an index based on household access to assets including having television, computer, washing machine, dishwasher, microwave, smart phone, internet and car with higher scores indicating greater wealth.

Health literacy assessment  
Health literacy was measured using the health literacy for iranian adults (HELIA) tool, validated by Montazeri et al. [15] for use in Iranian populations with Cronbach’s α coefficients ranging from 0.72 to 0.89. This self-administered questionnaire includes demographic data and 33 items assessing health literacy across five domains: reading comprehension (4 items), information access (6 items), understanding (7 items), appraisal (4 items), and decision-making/behavior (12 items). Responses were scored on a 5-point Likert scale: For reading items, scores ranged from 1 (very difficult) to 5 (very easy), while for other items, scores ranged from 1 (never) to 5 (always). Each domain’s score was calculated by summing item scores and rescaling to a 0–100 range. A total health literacy score was obtained by averaging across the five domains, categorized as follows: insufficient (0–50), marginal (51–66), sufficient (67–84), and excellent (85–100) [15].

Data analysis
Data described using frequency and percent or Mean±SD. PCA of the households’ assets was used to define wealth index as socioeconomic status. To determine the predictors of health literacy, ordinary least squares regression model  was used with health literacy as the dependent variable and social determinants of health as independent variables. The collinearity between the explanatory variables was assessed using variance inflation factor (VIF). Variables associated with high VIF scores were eliminated from the regression model. χ2 Breusch-Pagan test was used for assessing heteroscedasticity. The model coefficients and statistical significance were evaluated at a 95% confidence level (P<0.05), using STATA software, version 13.1.

Results
Out of the 71 participants, 73.2% were women, with a Mean±SD age of 54.45±9.13. Approximately 36.6% resided in urban areas, and 95.8% were married. The majority (59.2%) were housewives, with the most common comorbidities being hypertension and diabetes, affecting 50.7% of the sample (Table 1).


Breast cancer was the most prevalent type, affecting 38% of participants. Totally, 77.4% having at least one chronic disease. 

Sources of health information
When asked about preferred sources for information about health and illness, 61.97% of participants reported obtaining information from physicians and healthcare staff, followed by other patients, friends, and acquaintances (19.72%). Internet sources were used by 16.90% of participants, while only one respondent (1.4%) indicated uncertainty about where to obtain health-related information.

Health literacy scores
The Mean±SD total health literacy score among participants was 81.6±2.26. Scores were highest in the decision-making and behavior domain, averaging 24.95±1.12, and lowest in reading skills, with a Mean±SD of 57.65±5.00. Regarding health literacy levels, 49.3% of participants demonstrated excellent health literacy, while 19.72% had sufficient literacy. Meanwhile, 30.99% of patients exhibited inadequate or marginal health literacy (Table 2).


Table 3 shows the results of principal component analysis (PCA) and its eigenvalues.


In the table, each of the variables added for the PCA and their proportion for the total wealth score is shown.  

Regression analysis
Table 4 shows the results of ordinary least square regression analysis to show the relationship between different variables and scores of health literacy.


The results of regression analysis showed a significant relationship between health literacy score and wealth index (β=7.827, P<0.001), not having diabetes (β=-3.85, P=0.022), not having hypertension (β=-10.05, P=0.045), and years of schooling (β=0.87, P<0.001). 

Discussion
This study explored the relationship between social determinants of health and health literacy among cancer patients participating in the PERSIAN Guilan Cohort Study in 2020. We found that most patients obtained health information primarily through healthcare professionals, consistent with findings from similar studies using the HELIA questionnaire [16-19]. Improving health literacy is likely to lead to improved use of preventive services, adherence to treatment, and participation in health decision-making [20]; therefore, policymakers’ interventions in promoting the provision of health information through experts can improve healthcare performance [21].

Health literacy domains
Our results indicated that patients scored highest in the decision-making and behavior domain, followed by access, evaluation, comprehension, and reading skills. These findings are consistent with studies conducted in Iran [22-24] and internationally, such as those by Dai Minh in Vietnam [25] and Hosking et al. in Australia [26], which similarly reported higher scores in decision-making and behavior. This domain, which involves using health information for self-care and daily health-related decisions, is crucial for chronic disease management, as also suggested in qualitative research by Karim Saberi et al. [27].

Health literacy levels
Approximately 70% of participants demonstrated adequate health literacy, with nearly half scoring in the excellent range. These results align with studies by Mirsamiyazdi [28], Javadzade [29], Bánfai-Csonka [30], Liu [31], and Moon [32]. However, Tehrani et al. found that only 21% of women in their study exhibited excellent health literacy [16]. Meta-analyses, such as one summarizing 19 studies in the U.S., indicated that 23% of adults had insufficient or borderline health literacy [33]. In contrast, studies from Hormuz Island and Kerman reported high levels of inadequate or marginal health literacy among adults, suggesting regional disparities in health literacy in Iran [28]. Intervention programs associated with the PERSIAN Guilan Cohort may have contributed to higher health literacy levels in this population, highlighting the potential impact of structured health interventions.

Health literacy levels
Approximately 70% of participants in the PGCS demonstrated adequate health literacy, with nearly half scoring in the excellent range. These findings are consistent with those of Mirsamiyazdi et al. [28], who evaluated health literacy among patients with chronic diseases in urban health centers and found generally adequate literacy levels. Similarly, Javadzade et al. [29] assessed adult patients with type 2 diabetes and reported moderate to high health literacy among the majority of participants.
In a hospital-based study in Hungary, Bánfai-Csonka et al. [30] investigated health literacy in cancer patients and found that a substantial proportion had sufficient literacy, supporting our findings in a cancer population. Liu et al. [31], studying health literacy among Chinese patients undergoing chemotherapy, also reported moderate to high levels of literacy, suggesting that patients actively engaged in care may achieve higher literacy. Moon et al. [32] examined Korean cancer patients and similarly found acceptable levels of health literacy, reinforcing the relevance of these results in oncology settings.
However, Tehrani et al. [16], in a study of women attending public health clinics in Iran, found that only 21% exhibited excellent health literacy, suggesting disparities across gender or healthcare settings. Additionally, a U.S. meta-analysis summarizing data from 19 general population studies indicated that 23% of adults had insufficient or borderline health literacy [33], pointing to a wider global challenge.
In contrast, studies from Hormuz Island and Kerman, which assessed health literacy among general adult populations, reported high levels of inadequate or marginal health literacy [34]. These regional differences highlight variability across geographic and sociodemographic contexts in Iran.
The relatively high health literacy levels observed in the PGCS sample may be partially attributable to structured educational and health promotion programs associated with the PERSIAN Cohort infrastructure. These results underscore the potential benefits of targeted, long-term health interventions in improving literacy outcomes among patients with cancer.

Associations with social determinants
Our findings showed that education level was positively associated with health literacy, consistent with the results of Barikani et al. [23] and Cabellos-García et al. [35]. Wealth index also correlated positively with health literacy, aligning with Saatchi et al. [34], Saberipour et al. [36], findings, which found socioeconomic status to be an important predictor of health literacy. The study also found that higher health literacy was associated with lower rates of chronic diseases such as hypertension and diabetes. This observation is consistent with the results of various studies that show that adequate health literacy is associated with better quality of life and is a protective factor against chronic diseases [37-40]. In fact, individuals with higher health literacy tend to engage in healthier behaviors, manage chronic diseases more effectively, and navigate the health care system successfully, which leads to improved quality of life. Adequate health literacy helps individuals understand the risk factors and preventive measures associated with chronic diseases, which can reduce their incidence and severity.
These results indicate that individuals with higher education and socioeconomic status tend to have better health literacy, potentially enhancing their ability to engage in informed decision-making about health.

Conclusions
Our findings underscore the significant relationship between health literacy and social determinants such as education level. Recognizing and addressing these determinants is essential for policymakers and healthcare providers to design effective interventions that improve health literacy, particularly in chronic disease contexts where health literacy can impact patient outcomes. As chronic disease prevalence increases, so does the need for strategies that address the underlying social factors influencing health literacy. Enhancing health literacy through tailored interventions can help mitigate the social and economic burden of chronic disease on individuals and society, supporting a more health-literate and resilient population.

Limitations and future directions  
This study has several limitations. First, reliance on self-reported data may introduce response and recall biases, potentially affecting the accuracy of reported health literacy levels. Second, the study population consisted of participants enrolled in the PERSIAN Guilan Cohort Study—a structured, long-term health initiative—which may not fully represent the general population or other patient groups outside this cohort. Therefore, the findings may not be generalizable to broader or less-engaged populations. Additionally, some participants were excluded based on study-specific criteria, which may limit the diversity of the sample and the applicability of findings to populations not meeting those criteria.
Future research should aim to include more heterogeneous samples, encompassing diverse geographic regions, socioeconomic backgrounds, and patient populations beyond cancer cohorts. It is also important to examine a broader range of social determinants of health, such as digital access, social capital, and healthcare system navigation, to better understand cultural and contextual variations in health literacy. Longitudinal studies that assess the impact of targeted interventions on health literacy outcomes across different patient populations would further enhance the field.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Guilan University of Medical Sciences, Rasht, Iran (Code: IR.GUMS.REC.1399.404).

Funding
This study is the result of a research project of Guilan University of Medical Sciences, Rasht, Iran (Code:2495-583).

Authors' contributions
Conceptualization and supervision: Fataneh Bakhshi and Enayatollah Homaei Rad; Methodology: Farahnaz Joukar and Mohammadreza Naghipour; Data collection: Amirhossein Javadi; Data analysis: Amirhossein Javadi and Enayatollah Homaei Rad; Funding acquisition and resources: Fataneh Bakhshi and Fariborz Mansour Ghanaei; Investigation, Writing the original draft, review & editing: All authors.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgements
The authors of this article express their gratitude and thank all the loved ones as well as the PERSIAN Guilan cohort team of the Guilan University of Medical Sciences who helped them in this study. They also appreciate the Research Vice-Chancellor of Guilan University of Medical Sciences for approving this project.

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