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The Association Between Health Literacy and Breast and Cervical Cancer Screening Behaviors

Findings From the Behavioral Risk Factor Surveillance System

Kim, Kyounghae; Han, Hae-Ra

doi: 10.1097/NNR.0000000000000346

Background Health literacy has been linked to breast and cervical cancer screening, with inconsistent findings, which may result from the use of nonprobability sampling and a health literacy instrument that measures a subset of health literacy.

Objective The aim of this study was to examine the association between health literacy and breast and cervical cancer screening using data from the Behavioral Risk Factor Surveillance System (BRFSS) that uses a nationally representative U.S. probability sample.

Methods This cross-sectional, correlational study used national-level data from the 2016 BRFSS for women eligible for breast (N = 44,241) and cervical (N = 38,956) cancer screening per the American Cancer Society guidelines. A health literacy survey consisted of three items: oral (asking for medical advice), listening (understanding information that providers offer), and written (understanding printed health information) literacy. We extracted data regarding age, race/ethnicity, income, marital status, education, employment, insurance, and access to providers. Analyses were weighted using the complex survey design and multiple logistic regressions were used to test for the associations between health literacy and cancer screening after controlling for sociodemographic and healthcare system factors.

Results Oral and listening literacies were contributing factors to up-to-date breast cancer screening (p = .002, p < .001, respectively). The association ceased to be significant in the presence of all three literacy items in one model. Oral and listening literacies were also associated with cervical cancer screening (p < .001, p = .005, respectively), but only oral literacy maintained significance in the presence of listening and written literacy items.

Discussion Oral and listening literacies are contributing factors to lifetime breast cancer screening and up-to-date cervical cancer screening. Providers should create an atmosphere of effective patient–provider communication and informed decision-making by reducing health literacy demands in the medical encounter.

Kyounghae Kim, PhD, RN, is Assistant Professor, School of Nursing, University of Connecticut, Storrs.

Hae-Ra Han, PhD, RN, FAAN, is Professor, School of Nursing, and Codirector, Center for Cardiovascular and Chronic Care, Johns Hopkins University, Baltimore, Maryland.

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Accepted for publication September 17, 2018.

This study was exempt because the BRFSS is a public data file prepared for public use.

The authors have no funding or conflicts of interests to report.

Corresponding author: Kyounghae Kim, PhD, RN, University of Connecticut School of Nursing, 231 Glenbrook Road, Storrs, CT 06269 (e-mail:

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