The relationship between health literacy and the adoption of COVID-19 preventive behaviors: A cross-sectional study in Iran

Rahman Panahi; Zahra Ghorbanpour; Bagher Moradi; Fereshteh Eidy; Mohiadin Amjadian

doi:10.1371/journal.pone.0299007

. 2024 May 16;19(5):e0299007. doi: 10.1371/journal.pone.0299007

The relationship between health literacy and the adoption of COVID-19 preventive behaviors: A cross-sectional study in Iran

Rahman Panahi ¹, Zahra Ghorbanpour ², Bagher Moradi ², Fereshteh Eidy ³, Mohiadin Amjadian ^4,^*

Editor: Hadi Ghasemi⁵

PMCID: PMC11098504 PMID: 38753850

Abstract

Background and aim

Health literacy (HL) is one of the effective factors in controlling the COVID-19 epidemic. Considering the high prevalence of COVID-19 disease, the present study aimed to determine the relationship between HL and the adoption of COVID-19 preventive behaviors.

Materials and methods

This was a descriptive-cross sectional study conducted on 214 students selected by simple random sampling method in Esfarayen Faculty of Medical Sciences, Iran, in 2022. The data included demographic and background characteristics, health literacy for Iranian Adults (HELIA), and a valid and reliable questionnaire to measure COVID-19 preventive behaviors. The data were analyzed using SPSS 23, descriptive statistics, and ordinal logistic regression tests.

Results

The mean and standard deviation of the scores of adoption of COVID-19 preventive behaviors and HL among students were 18.18) 4.02(out of 25 and 72.14) and 12.75 (out of 100, respectively. The results of the logistic regression test showed that the HL (P = 0.003), gender (P<0.001), mother’s education (P = 0.039), educational level (P = 0.031), smoking (P = 0.032), and physical activity (P = 0.007) were effective factors in adopting preventive behaviors.

Conclusion

Introduction

Today, the coronavirus (SARS-COV-2) is considered a dangerous viral infection for public health [1]. Although most severe complications and mortality were seen in elderly people with background diseases such as liver and kidney diseases, and cancer [2], the risk exists for all people, and the importance of prevention is highlighted because of asymptomatic carriers who can transmit the disease to high-risk people and cause higher rates of mortality [3]. Measures such as education, improving awareness and attitude, and adopting preventive actions to protect against coronavirus disease are important strategies for prevention [4]. The World Health Organization considers washing hands regularly, respiratory hygiene, maintaining proper physical distance, and avoiding shaking hands and hugging as important behaviors to prevent this disease [5].

To identify preventive measures and control viral diseases, factors affecting preventive behaviors against respiratory viral diseases should be identified [6]. One of the effective factors in controlling the epidemic of Coronavirus Disease (COVID-19) is health literacy [7]. Also, health literacy is related to the adoption of preventive behaviors [8]. Health literacy is a cognitive skill and an influential issue in the healthcare system, for which various definitions have been provided so far. Health literacy is defined as a wide range of knowledge and skills for acquiring, processing, and applying health information [9].

Fortunately, low health literacy can be promoted by educating people [10]. Studies show that many diseases are associated with insufficient health literacy, so health literacy has a greater impact on people’s health than other variables such as income, employment status, age, educational level, and race; because people with low health literacy do not understand the written or spoken information of the health team and will not act on it. As a result, they have a poor health status and spend more money to improve their health [9–11].

The university student population in Iran has grown significantly in recent years [12]. Due to the important role they play as managers and future planners in the country [13], students can contribute to having a healthier society by promoting their health literacy [12]. Therefore, it is very important to know the factors that are effective in adopting healthier behaviors among students to reduce their risky behaviors [12]. The results of Sajjadi et al.’s study showed that one-third of the students had insufficient or not very sufficient health literacy [12]. Moreover, the health literacy of students was reported to be in a moderate level in the study of Vozikis et al. [14]. Therefore, Students were chosen to be studied because of their suitable age [13], learnability, as well as being a suitable model for a healthy lifestyle [13,15].

Considering the outbreak of COVID-19 disease [4], the role of health literacy in controlling COVID-19 [7], adopting preventive behaviors [8], and the role of students in promoting a healthier society [13], this study aimed to determine the relationship between health literacy and the adoption of preventive behaviors in the COVID-19 epidemic in university students.

Materials and methods

This was a cross-sectional descriptive-analytical study conducted between January and April 2022. The population included all male and female students at Esfarayen Medical Sciences University in Iran. The names of all students were listed and 214 participants were randomly selected by simple random sampling. The required sample size was estimated to be 175 based on the results of the pilot study among 30 students (considering r = 0.15 for the correlation between health literacy and adoption of preventive behaviors against COVID-19 disease), and also using the sample size table for correlational research [16]. Then, by considering the design effect (DE = 1.2), the sample size was estimated to be 210. Finally, with the possibility of a 5% dropout of samples, 220 students were included in the study.

The inclusion criteria included studying at the Esfarayen Medical Sciences University, willingness to participate in the study, having informed consent to participate in the study, being in the age range of 18 to 65 years, and having Iranian citizenship. Unwillingness to continue the study and incomplete questionnaires were considered exclusion criteria.

The data were gathered by three questionnaires: 1- A demographic and background information questionnaire, 2- Health literacy for Iranian Adults (HELIA), and 3- A questionnaire to measure the adoption of preventive behaviors against COVID-19.

The first part included items about the participants’ gender, years of education, marital status, parents’ occupation, parents’ education, smoking, hookah use, place of residence, level of education, field of study, amount of physical activities per week, method of receiving information, and type of COVID-19 infection.

In the second part, to measure health literacy, a health literacy questionnaire for the Iranian urban population between 18 to 65 years old (HELIA) was used [17]. This questionnaire consisted of 33 items in 5 areas, including access (6 items), reading skill (4 items), comprehension (7 items), evaluation (4 items), and decision-making and use of health information (12 items). The scoring scale was a five-option Likert scale that ranges from 5 (completely easy or always) to 1 (completely difficult or never). The raw score of every participant in each area was obtained from the algebraic sum of scores. To convert this score to a range of 0 to 100, the difference of the raw score obtained from the minimum possible raw score divided by the difference of the maximum possible score from the minimum score was used. Then, to calculate the total score, the scores of all the dimensions (based on the range from zero to 100) were added, and divided by the number of dimensions (number 5). Scores from 0 to 50 were considered inadequate health literacy, 50.1 to 66 as insufficient health literacy, 66.1 to 84 as adequate health literacy, and 84.1 to 100 as excellent health literacy [17]. This questionnaire has been validated by Mantazeri et al., and Panahi et al. in the general population and university students, respectively, and its validity and reliability were confirmed [18,19]. Also, Cronbach’s alpha coefficient was acceptable for the dimensions of reading (α = 0.84), access (α = 0.85), understanding (α = 0.90), evaluation (α = 0.77), decision-making, and use of health information use (α = 0.86), and the entire questionnaire (α = 0.94).

In the third part, the questionnaire designed by Khazaei-Poul et al. [4] was used. This questionnaire contained 5 items and the range of its score was 5 to 25. The options (never-rarely-sometimes-often-always) were given a score of 1 to 5 respectively. All validity (Content validity ratio and content validity index) and reliability steps of this scale have been done and confirmed [4]. Also, in the present study, the questionnaire was pilot-studied among 30 university students, and its Cronbach’s alpha coefficient was calculated to be 0.84. The rate of adoption of preventive behaviors was classified into 3 levels: poor (a score less than 50% of the total score), medium (a score of 50–75% of the total score), and good (a score above 75% of the total score) [20]. However, according to the researcher’s opinion, the rate of adoption of preventive behaviors was classified into 2 levels: poor (scores less than 50% of the total score: less than 12.5) and good (scores more than 50% of the total score: more than 12.5) [21–24] and then it used in the logistic regression.

After receiving the code of ethics from the Deputy of Research and Technology of Esfarayen Medical Sciences University (IR.ESFARAYENUMS.REC.1401.009) explaining the objectives of the study to the participants, and receiving their written informed consent, the questionnaires were given to the participants to fill out. The students were assured that their information would be used confidentially. In addition, the questionnaires were self-reported. Then the data were analyzed using descriptive statistics (Mean, standard deviation, frequency, and percentage) and ordinal logistic regression by SPSS version 23. The variables were entered simultaneously, and by comparing the independent variables classified as indicators, the last class of variables was selected as the reference class. The significance level was considered to be less than 0.05.

Findings

A total of 214 students of the Esfarayen Universit of Medical Sciences were studied (response rate: 97.3%). Among them, 57.5% (123) of the samples were women, 89.3% (191) were single and 79% (169) lived in the dormitory, 54.8% (128) were studying in clinical fields. 74.8% (160) of the students stated that they were infected with COVID-19 (Table 1). Also, the average and standard deviation of the score of adoption of preventive behaviors related to COVID-19 and health literacy among students were 18.18±4.02 out of 25 and 72.14±12.75 out of 100, respectively (Table 2).

Table 1. Demographic and background characteristics of the students.

Variable		N	%
Gender	Female	123	57.5
	Male	91	42.5
Academic years	First Year	79	36.9
	Second Year	56	26.2
	Third Year	41	19.2
	Fourth Year and Above	38	17.8
Marital status	Single	191	89.3
	Married	22	10.3
	Consult a Physician and Phone Call	47	21.9
Ways to receive health content	Internet	123	57.5
Ways to receive health content	TV and Radio	44	20.6
Father’s job	Employed	139	65
	Retired	43	20.1
	Other	32	15
Mother’s job	Employed	37	17.3
	Housewife	177	82.7
Father’s education	Non- University	139	65
	University	75	35
Mother’s education	Non-University	166	77.6
	University	48	22.4
Smoking	Yes	21	9.8
	No	193	90.2
Hookah consumption	Yes	37	17.3
	No	177	82.7
Location	Dormitory	169	79
	Other	45	21
University Degree	Associate Degree	27	12.6
	Bachelor Degree	187	87.4
The amount of physical activity per week	Low	118	55.1
The amount of physical activity per week	Medium	68	31.8
	Much	23	10.7
Major	Clinical	128	54.8
	Not-Clinical	86	40.2
COVID-19 Infection Type	Omicron	54	25.2
	Other	41	19.2
	Don’t Know	65	30.4
	I was not infected	54	25.2

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Table 2. Frequency distribution of the health literacy level and behaviors to prevent COVID-19 among students.

Health Literacy Groups	N	%
Inadequate health literacy	11	5.1
Not enough health literacy	53	24.8
Adequate health literacy	109	50.9
Excellent health literacy	40	18.7
Behaviors to prevent COVID-19	Frequency	Frequency Percentage
Weak	20	9.3
Medium	86	40.2
Good	108	50.5

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The results showed that there was a significant relationship between health literacy, gender, mother’s education, educational level, smoking, and the amount of sports activity of students with the adoption of preventive behaviors against COVID-19.

Participants with inadequate, and not very adequate health literacy adopted less preventive behaviors by 90% and 66%, respectively, compared to the participants with excellent health literacy. (p-value <0.05). Male students adopted preventive behaviors 75% less than the female ones (p-value <0.001). However, students whose mothers had non-university education adopted these behaviors 2.25 times more than the students whose mothers had a university education (p-value <0.039). Associate degree students adopted these behaviors 3.02 times more than undergraduate ones (p-value <0.031). Also, the smoking students adopted preventive behaviors 70% less than the other students (p-value <0.032). Moreover, the students with high and moderate levels of sports activities adopted these behaviors 76% and 57% less than the students with low levels of sports activity respectively (p-value <0.05) (Table 3).

Table 3. Effective factors for adopting preventive behaviors in COVID-19 in the logistic regression model.

Variables		Odds Ratio	CI	P-value
	Insufficient	0.10	(0.02–0.47)	<0.0001
Health literacy	Not quite enough	0.34	(0.13–0.87)	0.02
	Enough	0.53	(0.23–1.22)	0.13
	Excellent	1
Gender	Male	0.25	(0.12–0.53)	<0.0001
	Female	1
Mother’s education	non-university	2.26	(1.04–4.92)	0.03
	University	1
Section	Associate degree	3.02	(1.10–8.29)	0.03
	Bachelor Degree	1
Smoking	Yes	0.30	(0.10–0.90)	0.03
	No	1
Amount of physical activity	High	0.24	(0.08–0.67)	<0.0001
	Moderate	0.43	(0.22–0.84)	0.01
	Low	1
Academic years	Fourth and above	0.81	(0.29–2.27)	0.69
	Third	0.57	(0.21–1.55)	0.27
	Second	0.55	(0.23–1.33)	0.18
	First	1
Marital status	Married	0.81	(0.28–2.26)	0.70
	Single	1
Father’s job	Other	1.06	(0.42–2.68)	0.90
	Retired	1.06	(0.90–2.53)	0.89
	Employed	1
Mother’s job	Employed	0.88	(0.32–2.44)	0.82
	Housewife	1
Father’s education	non-university	0.56	(0.25–1.23)	0.15
	University	1
Location	non-dormitory	0.90	(0.39–2.10)	0.81
	a dormitory	1
Major	non-clinical	1.48	(0.70–3.10)	0.30
	Clinical	1
Hookah Consumption	Yes	0.64	(0.24–1.72)	0.38
	No	1
Ways to receive health content	Ask the doctor and phone	0.95	(0.415–2.16)	0.89
	Radio and television	1.18	(0.52–2.64)	0.70
	Internet	1
Type of COVID-19 Infection	Other	1.97	(0.74–5.23)	0.17
	Omicron	1.08	(0.44–2.65)	0.86
	I do not know	0.81	(0.35–1.89)	0.63
	I did not get infected	1

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Discussion

This study aimed to determine the relationship between health literacy and the adoption of preventive behaviors against COVID-19 among students. The results showed that health literacy level in the students was moderate. Considering the effect of the level of education on the level of health literacy of people [12], and the fact that almost two-thirds of the students in the present study were in the first and second years of study, these results were justifiable to some extent. These results were consistent with the results of Panahi et al. [24], and Panahi et al. [25] which were conducted among university students to determine the relationship between health literacy and the adoption of preventive behaviors. However, they were not consistent with the results of Sajjadi et al. [12] who reported a high level of health literacy in university students. The students’ higher educational levels in their study might be the possible reason for the difference from the present study. It is worth noting that the aforementioned studies were conducted in university students by HELIA questionnaire [12,24,25]. In addition, the results of the present study were not consistent with the results of the study by Vozikis et al. in which the level of health literacy of students was reported to be medium to high [14]. Among the possible reasons for this discrepancy, we could point out the difference in the measurement tool and the higher academic education years of the students in the present study.

The results also showed that the adoption of preventive behaviors against COVID-19 was at a moderate level. Considering the average levels of health literacy in the present study, and the relationship between health literacy and the adoption of preventive behaviors [22–24,26,27], these results were justifiable too. However, in Nasirzadeh et al.s’ study, the adoption of preventive behaviors against COVID-19 was at a high level [5] which could be due to the difference in the scale used for measuring preventive behaviors against COVID-19 and the different participants in the two studies. Also, the findings were consistent with the results of Panahi et al. [23], but it was not consistent with the results of Amjadian et al. [28] and the next study of Panahi et al. [22,24]. One of the reasons for this inconsistency was the difference in the topics and types of preventive behaviors between in these studies and the present one. Also, another possible reason could be that the participants were adolescents in the studies of Amjadian et al. [28] and Panahi et al. [22]. Also, in the current study, among the preventive behaviors against infection with COVID-19, washing hands with soap and water or disinfectants was the most frequent, and the behavior of using masks and gloves when leaving the house was the least frequent. These findings were similar to the results of the study by Khazai Pool et al. [4].

The results also showed that gender was one of the factors affecting the adoption of preventive behaviors. The adoption of preventive behaviors was higher in female students than in male ones because women follow health principles and medical recommendations, and they are more interested in learning health information than men do [17]. In Nakayama et al. [29], Raiserka et al. [30], Panahi et al. [31], and Panahi et al.s’ studies [24] adoption of preventive behaviors against COVID-19 was reported to be more in women which were in line with our results.

Moreover, the results showed that physical activity was one of the factors influencing the adoption of preventive behaviors because doing physical activity in itself was a kind of preventive behavior. Therefore, the homogeneity of these two variables could probably justify the significant relationship between them. In Panahi et al. [23], and Amjadian et al. [28], there was a significant relationship between physical activity and the adoption of preventive behaviors which was consistent with the results here.

The results also showed that the mother’s education level was one of the factors in adopting preventive behaviors. It can be said that possibly with the increase in the education level of the mothers, it is more probable for them to work outside. As a result, they go out more and their possible fear of being infected with COVID-19 is reduced. Therefore, they probably follow preventive behaviors less, and their children also probably follow their parents in adopting preventive behaviors, and as a result, they adopt such behaviors less too.

In the study of Raiserka et al. [30], there was also a significant relationship between the mother’s education level and the adoption of preventive behaviors against COVID-19. The results of Etihad Nejad et al. [32], Manshadi et al. [33], Khani Jihouni et al. [34], and Panahi et al. [35] were also consistent with our results here.

The results also showed that the level of education was one of the factors affecting the adoption of preventive behaviors. There was a significant relationship between the level of education and adopting preventive behavior against COVID-19 in the study of Nguyen et al. [36]. However, the results of Panahi et al. [24,35] indicated that the number of academic years in students did not affect adopting preventive behaviors among them. This could be because of the difference in the preventive behaviors measured between the two studies.

The results also showed that smoking status was one of the factors affecting the adoption of preventive behaviors. The adoption of preventive behaviors was more common among non-smoking students than the smoking ones, because not smoking was itself a kind of preventive behavior and could be a background for adopting other preventive behaviors. These results were also consistent with the results of Panahi et al. [24].

Also, the results showed that health literacy was one of the effective factors in adopting preventive behaviors. This could be because health literacy is a collection of skills, abilities, and capacities in various dimensions. These skills and capacities were sometimes updated in acquiring and obtaining medical and health information, sometimes in reading them, sometimes in understanding them, sometimes in processing and interpreting them, and sometimes in decision-making and applying this information [37]. which could influence adopting the preventive behaviors [38]. Health literacy plays an essential role in promoting peoples’ responsibility to maintain their health; in other words, health literacy- by improving people’s awareness- could be considered one of the basic factors in adopting preventive behaviors [23]. In Nakayama et al.’s study, people with higher health literacy took more precautions to adopt preventive behaviors against COVID-19 [29]. Also, this finding was consistent with the results of Panahi et al. [22–24,26,27], Izadi-Rad et al. [39], and Nguyen et al. [40].

To our knowledge, the present study was the first study that evaluated the relationship between different levels of health literacy and the adoption of preventive behaviors against COVID-19 in Iran. The limitations included; the present study was done in associate and bachelor degree students of medical sciences. Therefore, the results cannot be generalized to students from other parts of the country and other age and student groups. Therefore, it is recommended to conduct it in different populations and groups (with varying ages, education, residential areas, and post-graduate degrees). Also, ignoring other dimensions related to health literacy, such as self-efficacy, communication, and calculation was another limitation of the study. Ignoring cultural contexts and skills such as speaking, listening, and having contextual and cultural knowledge of people was another limitation of this study because these skills should be examined when we measure health literacy. The self-reported data and the small number of the sample were other limitations of the study too.

Conclusion

Adopting preventive behaviors against COVID-19 was lower among students with lower levels of health literacy, male students, students with less physical activity, students with illiterate mothers, undergraduate students, and finally smokers. Therefore, it is necessary to pay more attention to these students in designing educational programs. It is suggested to carry out more extensive studies to clarify the effect of health literacy on the adoption of preventive behaviors against COVID-19. Also, it seems necessary to design a special scale to measure health literacy in COVID-19 in all age groups. In addition, it is recommended to investigate the relationship between different health literacy skills and the adoption of preventive behaviors against COVID-19 in future studies, so that more effective and shorter measures can be taken in this regard.

Supporting information

S1 Data

(RAR)

pone.0299007.s001.rar^{(6.1KB, rar)}

Acknowledgments

This study was carried out with the support of the Research and Technology Vice-Chancellor of Esfarayen Medical Sciences University and the cooperation of the students of this university. The authors would like to express their gratitude to all the students and officials who helped the researchers in this study.

Abbreviations

HL: Health literacy
HELIA: Health Literacy for Iranian Adults
SD: Standard deviation
DE: Design effect
CVI: Content validity index
CVR: Content validity ratio

Data Availability

All relevant data are within the paper and its Supporting Information files.

Funding Statement

he author(s) received no specific funding for this work.

References

1.Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. International Journal of environmental research and public health 2020; 17(5): 1729. doi: 10.3390/ijerph17051729 [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Bahrulolum H, Nooraei S, Entezari M, Hashemi M, Houshmandi K, Raei M. The role of nutrition and nutritional factors in the prevention and treatment of COVID-19: a review study. EBNESINA. 2020; 22(3): 56–66. [Google Scholar]
3.Rothan HA, Byrareddy SN. The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak. Journal of autoimmunity. 2020; 109: 102433. doi: 10.1016/j.jaut.2020.102433 [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Khazaee-Pool M, Shahrvsand S, Naghibi SA. Predicting COVID-19 Preventive Behaviors Based on Health Belief Model: An Internet-Based Study in Mazandaran Province, Iran. Journal of Mazandaran University of Medical Sciences. 2020; 30(190): 56–66. [Google Scholar]
5.Nasirzadeh M, Aligol M. Assessmentof Knowledge, Attitude, and Factors Associated with the Preventive Behaviors of COVID-19 in Qom, Iran, in 2020. Qom University of Medical Sciences Journal. 2020; 14(7): 50–7. [Google Scholar]
6.Xiang Y-T, Yang Y, Li W, Zhang L, Zhang Q, Cheung T, et al. Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. The Lancet Psychiatry. 2020; 7(3): 228–9. doi: 10.1016/S2215-0366(20)30046-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
7.Peyvand M, Kargar S, Hajizade F. The Role of Health Literacy Promotion in Epidemic Control Corona 19. Journal of Health Literacy. 2020; 5(1): 9–11. [Google Scholar]
8.Panahi R, Ramezankhani A, Tavousi M. Health literacy and preventive behaviors. Journal of Research and Health 2018; 8(2): 93–4. [Google Scholar]
9.Delavar F, Pashaeypoor S, Negarandeh R. Health literacy index: A new tool for health literacy assessment. Journal of Hayat. 2018; 24(1): 1–6. [Google Scholar]
10.Panahi R, Samiei Siboni F, Kheiri M, Jahangasht Ghoozlu KH, Shafaei M, Dehghankar L. Promoting the adoption of behaviors to prevent osteoporosis using the Health Belief Model integrated with Health Literacy: a quasi-experimental intervention study. BMC Public Health. 2021; 21: 2221. [DOI] [PMC free article] [PubMed] [Google Scholar]
11.Mousavi H, Bagherian R. Health literacy and breast cancer. QUARTERLY JOURNAL OF HEALTH PSYCHOLOGY. 2019; 8(31): 91–102. [Google Scholar]
12.Sajadi FA, Sajadi HS, Panahi R. Health literacy of university students and its influential factors: A case study at Isfahan University. J Educ Community Health. 2020; 7(1): 23–8. [Google Scholar]
13.Azimi S, Ramezankhani A, Rakhshani F, Ghaffari M, Ghanbari SH. Comparison of health literacy between medical and non-medical students in Shahid Beheshti Universities in the academic year 92–93. Pejouhandeh 2015; 20(2): 78–85. [Persian] [Google Scholar]
14.Vozikis A, Drivas K, Milioris K. Health literacy among university students in Greece: determinants and association with self-perceived health, health behaviors, and health risks. Arch Public Health 2014; 72(1): 15. [DOI] [PMC free article] [PubMed] [Google Scholar]
15.Panahi R, Ramezankhani A,Tavousi M, Osmani F, Karami Jouyani A, Niknami Sh. Effect of Educational Intervention onHealth Literacy and Adoption of Smoking Preventive Behaviors among University Students. J Educ Community Health. 2018; 5(2): 26–35. [Google Scholar]
16.Safari M, Shojaeizadeh D. Theories Models and Methods of Health Education and Promotion. Tehran: Asar-E Sobhan Publishing; (2009). p. 22–24. [Google Scholar]
17.Panahi R, Ramezankhani A, Tavousi M, Osmani F, Ghazanfari E, Niknami Sh. Evaluation of Health Literacy and its Influencing Factors on Dormitory Students of Shahid Beheshti University of Medical Sciences in Tehran. J Educ Community Health 2016; 3(3): 30–6. [Google Scholar]
18.Montazeri A, Tavousi M, Rakhshani F, Azin SA, Jahangiri K, Ebadi M. Health Literacy for Iranian Adults (HELIA): development and psychometric Properties. Payesh. 2014; 13: 589–99. [Google Scholar]
19.Panahi R, Ramezankhani A, Tavousi M, Haeri Mehrizi A, Niknami S. The Psychometric Properties of Health Literacy for Iranian Adults (HELIA) in Medical Sciences Students. J Research Health. 2020; 10(1): 53–8. [Google Scholar]
20.Panahi R, Ramezankhani A, Tavousi M, Osmani F, Niknami S. Predictors of Adoption of Smoking Preventive Behaviors among University Students: Application of Health Belief Model. J Educ Community Health. 2017; 4(1): 35–42. [Google Scholar]
21.Panahi R, Ramezankhani A, Haerimehrizi AA, Tavousi M, Khalilpour Darestani M, Niknami S. Which dimension of health literacy predict the adoption of smoking prevention behaviors? Journal of Health in the Field. 2018; 5(4): 8–17. [Google Scholar]
22.Panahi R, Yekefallah L, Shafaei M, Dehghankar L, Anbari M, Hosseini N, Hasannia E. Effect of health literacy among students on the adoption of osteoporosis-preventive behaviors in Iran. J Edu Health Promot. 2020; 9: 191. doi: 10.4103/jehp.jehp_400_19 [DOI] [PMC free article] [PubMed] [Google Scholar]
23.Panahi R, Namdar P, Siboni FS, Fallah S, Anbari M, Dehghankar L, et al. Association between health literacy and adopting preventive behaviors of breast cancer in Iran. J Edu Health Promot. 2020; 9: 241. doi: 10.4103/jehp.jehp_313_20 [DOI] [PMC free article] [PubMed] [Google Scholar]
24.Panahi R, Osmani F, Javanmardi K, Ramezankhani A, Dehghankar L, Amini RA, et al. The relationship between different levels of Health Literacy and smoking prevention among Medical sciences students. Int J Prev Med. 2021; 12: 124. [DOI] [PMC free article] [PubMed] [Google Scholar]
25.Panahi R, Dehghankar L, Abdollahi F, Anbari M, Hosseini N. Health Literacy and Breast Cancer Preventive Behaviors among Students. Payesh 2019; 18(6): 547–557. [Google Scholar]
26.Panahi R, Ramezankhani A, Tavousi M, Niknami S. Adding Health Literacy to the Health Belief Model: Effectiveness of an Educational Intervention on Smoking Preventive Behaviors Among University Students. Iran Red Crescent Medical Journal (ircmj). 2018; 20(2): e13773. [Google Scholar]
27.Panahi R, Hosseini N, Ramezankhani A, Anbari M, Amjadian M, Dehghankar L, NiknamiS. Measuring the Structures of the Health Belief Model Integrated with Health Literacy in Predicting University Students’ Adoption of Smoking Preventive Behaviors. J Prev Med Hyg 2022; 63: E51–E58. doi: 10.15167/2421-4248/jpmh2022.63.1.2236 [DOI] [PMC free article] [PubMed] [Google Scholar]
28.Amjadian M, Anbari M, Amini R, Khalilipour Darestani M, Dehghankar L, Panahi R. Studying the factors associated with Premenstrual syndrome prevention among pre-university students in Tehran. J Prev Med Hyg 2022; 63: E6–E11. doi: 10.15167/2421-4248/jpmh2022.63.1.2027 [DOI] [PMC free article] [PubMed] [Google Scholar]
29.Nakayama K, Yonekura Y, Danya H, Hagiwara K COVID-19 Preventive Behaviors and Health Literacy, Information Evaluation, and Decision- making Skills in Japanese Adults: Cross-sectional Survey Study JMIR Form Res 2022; 6(1): e34966. doi: 10.2196/34966 [DOI] [PMC free article] [PubMed] [Google Scholar]
30.Riiser K, Helseth S, Haraldstad K, Torbjørnsen A, Richardsen KR. Adolescents’ health literacy, health-protective measures, and health-related quality of life during the COVID-19 pandemic. PloS one. 2020; 15(8): e0238161. doi: 10.1371/journal.pone.0238161 [DOI] [PMC free article] [PubMed] [Google Scholar]
31.Panahi R, Ramezankhani A, Anbari M, Javanmardi K. Adoption of smoking preventive behaviors and its related factors among dormitory students of Shahid Beheshti University of Medical Sciences in Tehran—2016. Journal of Health in the Field. 2020; 8(1): 22–31. [Google Scholar]
32.Etehadnezhad S, Moradi Z, Kashfi SM, Khani‐Jeihooni A, khiyali Z. Predictors of osteoporosis preventive behaviors among women: an application of the transtheoretical model. J Educ Community Health 2018; 5(3): 48‐56. [Persian [ [Google Scholar]
33.Menshadi F, Azari A, Kouhpayehzadeh J, Ghasemi M. Knowledge, attitude and practice of osteoporosis among a group of Iranian adolescent females (2007). J Mod Rehibilit. 2009; 2 (3 and 4): 47‐54. [Persian] [Google Scholar]
34.Khani Jeihooni A, Heidarnia AR, Kaveh MH, Hajizadeh E, Gholami T. Survey of osteoporosis preventive behaviors among women in Fasa: The application of the health belief model and social cognitive theory. Iran South Med J. 2016; 19(1): 48‐62. [Persian] [Google Scholar]
35.Panahi R, Dehghankar L, Hosseini N, Hasannia E. Factors Related to Adoption of Osteoporosis Preventive Behaviors among Females’ High School Students; a Case Study of Qazvin City. Journal of Education and Community Health. 2020; 7(2): 105–12. [Google Scholar]
36.Nguyen TT, Le NT, Nguyen MH, Pham LV, Do BN, Nguyen HC, et al. Health Literacy and Preventive Behaviors Modify the Association between Pre-Existing Health Conditions and Suspected COVID-19 Symptoms: A Multi-Institutional Survey. International Journal of environmental research and public health 2020; 17(22): 8598. [DOI] [PMC free article] [PubMed] [Google Scholar]
37.Tavousi M, Ebadi M, Azin A, Shakerinejad GH, Hashemi A, Fattahi E, et al. Definitions of health literacy: a review of the literature. Payesh 2014; 13: 119–24 (In Persian). [Google Scholar]
38.Mahdavi ZH, Ramezankhani A, Ghanbari SH, Khodakarim L. Relationship between health literacy and female cancers preventive behaviors. Payesh 2017; 5: 613–25 (Persian). [Google Scholar]
39.Izadirad H, Zareban I. The Relationship of Health Literacy with Health Status, Preventive Behaviors, and Health Services Utilization in Baluchistan, Iran. Journal of Education and Community Health. 2015; 2(3): 43–50. [Google Scholar]
40.Nguyen LHT, Vo MTH, Tran LTM, Dadaczynski K, Okan O, Murray L et al. Digital Health Literacy About COVID-19 as a Factor Mediating the Association Between the Importance of Online Information Search and Subjective Well-Being Among University Students in Vietnam. Digit. Health 2021; 3)739476(. doi: 10.3389/fdgth.2021.739476 [DOI] [PMC free article] [PubMed] [Google Scholar]

PLoS One. doi: 10.1371/journal.pone.0299007.r001

Decision Letter 0

Lucinda Shen

3 Apr 2023

PONE-D-22-35718The relationship between health literacy and the adoption of covid-19 preventive behaviors: a cross-sectional study in IranPLOS ONE

Dear Dr. Amjadian,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Two reviewers have evaluated the manuscript and their comments are presented below. The reviewers suggest that the English language used in the manuscript could be improved to enhance the clarity of the scientific content. Additionally, they have requested clarification on whether the questionnaire used in the study was previously validated, and have recommended a thorough check of the accuracy and consistency of numerical values in the tables.

Could you please carefully revise the manuscript to address all comments raised?

Please submit your revised manuscript by May 15 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

Kind regards,

Lucinda Shen, MSc

Staff Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Well-written paper. However, some sections need to be revised. The methods section should be more concise, and the results should reflect stated ways of reporting logistic regressions. The rationale behind health literacy for COVID-19 prevention behaviors should be well outlined in the discussion, especially if medical students have average health literacy. How does this impact health communication with patients or the general population? This manuscript has the potential to impact public health programming. Also, cross check grammar for errors. See comments below. Good job!

Reviewer #2: English language text should be checked and improved.

The introduction is inadequate, it just repeats the same thoughts without explaining the terms and without providing some background literature.

In the Method section they present the content of the ‘Demographic and background information’ of which the final element is “the type of Covid-19”. What does it mean here? Who’s type, what types exist at all, etc. This should be clarified!

In Table 1, the last column contains percentage of the participants answering to the particular question; however, the sum of the percentages regularly is 98 and not 100. Why?

The format applied in these tables are curious and unusual (e.g. 0/10, 0/34, 0/54). What this format means?

The performance percentages (%) at the Findings chapter (in most of the journals usually entitled as Results) are very confusing. These behaviors (what behaviors?) are mentioned as done less, in other sentences more, but it is not clear less of what?

In general, this paper should be significantly improved, regarding terms, data presentation, format and language.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

**********

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While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Attachment

Submitted filename: Health literacy and the adoption of covid-19 preventive behaviors_review.docx

pone.0299007.s002.docx^{(17.1KB, docx)}

PLoS One. 2024 May 16;19(5):e0299007. doi: 10.1371/journal.pone.0299007.r002

Author response to Decision Letter 0

19 May 2023

Reviewer Response to the comments of the dear Reviewers

1. There are many types of coronavirus diseases, so it is important to state the specific disease. Done

( Highlighted in Yellow in the manuscript)

2. Write COVID-19 in full first Done

( Highlighted in Yellow in the manuscript)

3. It may be helpful to indicate the country. (Consider using the third person). Done

( Highlighted in Yellow in the manuscript)

4. Was it a “sudden outbreak” worldwide? Consider revising this to more accurate information. Done

( Highlighted in Yellow in the manuscript)

5. Who were the participants in Mazandaran? Are these different from the 30 university students? Were these two different pilot studies? Were these studies separate from the current study?

The participants in the previous study, conducted in Mazandaran, were people living in Mazandaran- a province in Iran. The designers of this instrument approved its reliability through a pilot study among 30 participants from Mazandaran.

Considering that students were studied instead of ordinary people in the current study, the current research team approved the reliability of this instrument for students by conducting a pilot study among 30 students. Therefore, these two pilot studies are different and separate from each other.

6. Revise this sentence. Who received the code of ethics?

The code of ethics was obtained from the Research and Technology Vice-Chancellor of Esfrain Medical Sciences University by the main researcher ( The Corresponding Author).

7. What was the nature of informed consent? Written or verbal? Written informed consent was obtained from the students

8. Enter? Dear Reviewer; As we have mentioned in the manuscript, the variables were entered simultaneously.

9. While some information in the methods section is helpful, the authors should consider being concise but comprehensive. As it is, it is difficult to follow the methodology logic/flow It was done and some information that seemed to be extra was deleted.

10. Consider writing the frequency as percentages. E.g. 57.5% rather than 57/5 Done

( Highlighted in Yellow in the manuscript)

11. It is unclear what chance ratio means. Done

( Highlighted in Yellow in the manuscript)

12. Highlight in Table 3 any significant associations. Done

( Highlighted in Yellow in the manuscript)

13. Use standardized ways of reporting logistic regression results. E.g. Odds ratio, 95%CI, Done

( Highlighted in Yellow in the manuscript)

14. The means and standard deviations are not reflected in the tables. Ensure that what is presented in text and table match. Qualitative results were reported in the tables, while quantitative results were reported in the text.

15. n general, the tables are not synchronized. For example, Table 1 has University degree (Bachelor’s / Associate's) _ yet table 3 talks about section as (Associate and master's). Need to be consistent throughout. Done

( Highlighted in Yellow in the manuscript)

16. Average literacy levels are based on what measure? What is considered high vs. low?

As mentioned in the article, according to the designers of the questionnaire, scores from 0 to 50 are insufficient, 50.1 to 66 not very sufficient, 66.1 to 84 sufficient, and 84.1 to 100 are excellent health literacies.

The average health literacy in the present study was 72, which, according to the research team, was at an average level. In other words, we believed that 72 was at a sufficient level and belonged to the average category. If the average health literacy was between 84.1 and 100, it would be in a good category. Also, if the average health literacy were between 0 and 66, then it would be placed in the weak category.

17. Why is it justifiable that medical students have average health literacy levels, yet they are expected to have higher levels generally?

It was modified in the manuscript:

Considering the effect of the level of education on the level of health literacy of people, and the fact that almost two-thirds of the students in this study were in the first and second years of education, these results could be justified to some extent.

Attachment

Submitted filename: Response to the comments(Plos one J.).docx

pone.0299007.s003.docx^{(16.9KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0299007.r003

Decision Letter 1

Sylvia Ayieko

28 Jun 2023

PONE-D-22-35718R1The relationship between health literacy and the adoption of covid-19 preventive behaviors: a cross-sectional study in IranPLOS ONE

Dear Dr. Mohiadin Amjadian

There was some improvement from the previous submission. However, we invite you to make minor revisions , double check your work and ensure that all comments are addressed and that there are no errors. While some reviewers had differing comments, we believe that the title is appropriate and that your article is still valid for this journal. We apologize for taking long to respond. This was due to a lack of reviewers.

Please submit your revised manuscript by Aug 12 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Sylvia Ayieko,

Guest Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

Dear Author,

Congratulations. The paper is quite good but needs a few revisions. See below.

Introduction

1. Recommend writing COVID-19 in all caps throughout the text.

2. Be consistent. Will you be using SARS-COV-2 or COVID-19, or both? If using COVID-19, write it in full in the first instance, then put COVID-19 in parenthesis.

3. Move line 87: The definition of Health literacy should be before explaining its effectiveness etc.

4. Lines 91-94: Does low health literacy cause diseases? Was there a causal effect? Consider changing the wording to an association or a relationship.

5. Line 90/95: Since you mention studies… provide multiple citations to support the claim.

6. Lines 105-107: need to have more substance. What does average mean?

7. Revise lines 112- 116. This paragraph can be comprehensive by not repeating health literacy in one sentence.

Methods

1. Line 116- Provide more information about Esfrain Faculty of Medical Sciences. What City and country?

2. Line 128: Revise this section. Briefly mention the three instruments at the beginning, then proceed to describe the instruments.

3. Line 133-158: The health literacy questionnaire's description is lengthy but can be made clearer. For example, rather than writing out each study that indicates the validity of the scale, simply just state that the questionnaire has been validated by (X, Y, and Z). Also, you could just note that the Likert scale ranges from 5 (completely easy )to 1 (completely difficult). You could also insert Cronbach's alpha coefficient at the beginning next to each item, e.g., Access (α=0.85), instead of repeating the items at the end of the paragraph.

4. 159-175- Condense this information as suggested above. Too long. You don’t have to mention that reliability was measured using a pilot study; simply cite them if describing reliability and validity.

Findings

1. Line 188: Suggest revision- Start with a word rather than a numeral. Also, consider stating that the participants completed the survey. “Studied” is a bit vague. What does it mean?

2. Table 2: Bold the “ Behaviors to prevent corona”. Be consistent in the description of COVID-19. Replace “corona”

3. Table 3: What do the figures in bold mean? Include more information as a description at the end of the table. Stick to two or three decimal points throughout.

4. Table 3: Under health literacy is “Enough“ significant? Is there a reason it is bolded?

5. The results section should be the core of the paper. You need to include additional information based on the analysis. What do the odds ratios mean based on the variables?

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: All comments have been addressed

Reviewer #4: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #3: No

Reviewer #4: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: No

Reviewer #4: I Don't Know

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #3: (No Response)

Reviewer #4: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #3: No

Reviewer #4: Yes

**********

6. Review Comments to the Author

Reviewer #3: hi

Descriptive title is not suitable for this journal

The article is poorly written

A proper analysis has not been done

Reviewer #4: Congratulations on your valuable work. Comments are included to improve your article.

Abstract

Also report health literacy results in the results section.

Introduction

In the introduction section, line number 85, first include the definition of health literacy, then include previous studies related to health literacy and healthy behaviors.

Having or not having the disease of Covid-19 and having or not having the previous experience of suffering from the disease of Covid-19 are not among the entry criteria?

Method

In the method section, Cronbach's alpha include the different dimensions of the health literacy questionnaire.

In the method section of line number 180, specify which score is less than 50% and which score is more than 50%. The cut off point is not known.

Discussion

Information about study 12, 24, and 25 has not been included that these studies were conducted on whom and at what setting and with what tools.

Clarify the differences between 2 studies 5 and 28 with the current study.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: No

Reviewer #4: No

**********

PLoS One. 2024 May 16;19(5):e0299007. doi: 10.1371/journal.pone.0299007.r004

Author response to Decision Letter 1

19 Jul 2023

Additional Editor Comments Point by point Responses to the comments

Recommend writing COVID-19 in all caps throughout the text. OK

Be consistent. Will you be using SARS-COV-2 or COVID-19, or both? If using COVID-19, write it in full in the first instance, then put COVID-19 in parenthesis. OK

Move line 87: The definition of Health literacy should be before explaining its effectiveness etc. Dear Reviewers: In response to your opinion regarding the weakness and inadequacy of the introduction, the research team believes that the introduction should be written according to the keywords in the title of the article. Therefore, in the first paragraphs, we talked about the corona virus and its complications and risk of infection and death. Then it was briefly talked about how to prevent it. Then, we went to health literacy, which is one of the effective factors in preventing Covid-19, and it is related to the adoption of preventive behaviors. Then, the definition of health literacy and the scope of its effects on people's health have been presented. In the following, we have addressed our other key word, students, and we have brought why students were chosen, and also their level of health literacy. Finally, the reason why the present study was done has been summarized.

Lines 91-94: Does low health literacy cause diseases? Was there a causal effect? Consider changing the wording to an association or a relationship. OK

Line 90/95: Since you mention studies… provide multiple citations to support the claim. OK

Lines 105-107: need to have more substance. What does average mean? OK

Revise lines 112- 116. This paragraph can be comprehensive by not repeating health literacy in one sentence. OK

Line 116- Provide more information about Esfrain Faculty of Medical Sciences. What City and country? OK

Line 128: Revise this section. Briefly mention the three instruments at the beginning, then proceed to describe the instruments. OK

Line 133-158: The health literacy questionnaire's description is lengthy but can be made clearer. For example, rather than writing out each study that indicates the validity of the scale, simply just state that the questionnaire has been validated by (X, Y, and Z). Also, you could just note that the Likert scale ranges from 5 (completely easy) to 1 (completely difficult). You could also insert Cronbach's alpha coefficient at the beginning next to each item, e.g., Access (α=0.85), instead of repeating the items at the end of the paragraph. OK

159-175- Condense this information as suggested above. Too long. You don’t have to mention that reliability was measured using a pilot study; simply cite them if describing reliability and validity. OK

Line 188: Suggest revision- Start with a word rather than a numeral. Also, consider stating that the participants completed the survey. “Studied” is a bit vague. What does it mean? OK

Table 2: Bold the “ Behaviors to prevent corona”. Be consistent in the description of COVID-19. Replace “corona” OK

Table 3: What do the figures in bold mean? Include more information as a description at the end of the table. Stick to two or three decimal points throughout. OK

Table 3: Under health literacy is “Enough“ significant? Is there a reason it is bolded? OK

The results section should be the core of the paper. You need to include additional information based on the analysis. What do the odds ratios mean based on the variables? OK

Reviewer #3:

Descriptive title is not suitable for this journal

The article is poorly written

A proper analysis has not been done Dear Reviewer; We sought to determine factors influencing the adoption of preventive behaviors against Covid-19. Therefore, to achieve this goal, we used logistic regression, which is a cumulative statistical test that measures the effects of all variables simultaneously. In addition, we believe that if only health literacy was included in the regression model, then our study would be of the correlation type, while it is practically impossible to investigate this relationship without considering other variables. Therefore, in our opinion, a descriptive title is more appropriate. At the same time, we re-examined our analysis. We have strengthened the article as much as possible.

Reviewer #4:

Congratulations on your valuable work. Comments are included to improve your article. Also report health literacy results in the results section. Dear Reviewer: Health literacy results have already been reported in the results section.

In the introduction section, line number 85, first include the definition of health literacy, then include previous studies related to health literacy and healthy behaviors. Dear Reviewers: In response to your opinion regarding the weakness and inadequacy of the introduction, the research team believes that the introduction should be written according to the keywords in the title of the article. Therefore, in the first paragraphs, we talked about the corona virus and its complications and risk of infection and death. Then it was briefly talked about how to prevent it. Then, we went to health literacy, which is one of the effective factors in preventing Covid-19, and it is related to the adoption of preventive behaviors. Then, the definition of health literacy and the scope of its effects on people's health have been presented. In the following, we have addressed our other key word, students, and we have brought why students were chosen, and also their level of health literacy. Finally, the reason why the present study was done has been summarized.

Having or not having the disease of Covid-19 and having or not having the previous experience of suffering from the disease of Covid-19 are not among the entry criteria? NO

In the method section, Cronbach's alpha includes the different dimensions of the health literacy questionnaire. OK

In the method section of line number 180, specify which score is less than 50% and which score is more than 50%. The cut off point is not known. It was Corrected and strengthened.

Information about study 12, 24, and 25 has not been included that these studies were conducted on whom and at what setting and with what tools.

Clarify the differences between 2 studies 5 and 28 with the current study. It was Corrected and strengthened.

Attachment

Submitted filename: Responses to Reviewers.docx

pone.0299007.s004.docx^{(21.7KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0299007.r005

Decision Letter 2

Hadi Ghasemi

15 Sep 2023

PONE-D-22-35718R2The relationship between health literacy and the adoption of COVID-19 preventive behaviors: a cross-sectional study in Iran.PLOS ONE

Dear Dr. Mohiadin Amjadian,

Please submit your revised manuscript by 30 September, 2023. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Hadi Ghasemi

Academic Editor

PLOS ONE

Journal Requirements:

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #4: (No Response)

Reviewer #5: All comments have been addressed

Reviewer #6: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #4: (No Response)

Reviewer #5: (No Response)

Reviewer #6: (No Response)

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #4: (No Response)

Reviewer #5: (No Response)

Reviewer #6: (No Response)

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #4: (No Response)

Reviewer #5: Yes

Reviewer #6: (No Response)

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #4: (No Response)

Reviewer #5: Yes

Reviewer #6: (No Response)

**********

6. Review Comments to the Author

Reviewer #4: Congratulations on your valuable research. Comments are included to improve your article.

Abstract

“Health literacy is one of the effective factors in controlling the 45 COVID-19 epidemic and is related to the adoption of preventive behaviors” When you bring this up in the background, it's like the issue is clear and no further research is needed. Revise the sentence.

Introduction

Line number 86 in the introduction section, define health literacy and describe its dimensions.

Of course, it is necessary to mention the dimensions of health literacy and its relationship with behaviors to prevent covid 19.

Include related and similar previous studies in this field in the background of the article and explain the necessity of your study.

Methods

Write the time frame of the research.

Explain what tests you used to analyze which variables

Discussion

Write the discussion more coherently. Write each finding of your study in a paragraph and after you compare it with previous studies, then write your conclusion.

Reviewer #5: Abstract

The mean and standard deviation (SD) of the scores of adoption of COVID-19 preventive behaviors and HL among students were 18.18±4.02 out of 25 and 72.14±12.75 out of 100, respectively.

What are the inclusion and exclusion criteria?

Please harmonize the statements. Make confused.

Adoption of COVID-19 preventive behaviors was less among students with lower levels of HL, male students, students with less physical activity, students with

educated mothers, undergraduate students, and smokers.

Please harmonize the statements.

Introduction

Sajjadi et al.'s

Azimi et al.'s

Need to explain what is Health literacy.

Correct this.( Sajjadi et al)

among whom 214 were selected by simple random so that the names of 115 all the students were listed and the participants were randomly selected.

Please harmonize this statement.

Health literacy for Iranian Adults (HELIA)

This questionnaire was adapted or adopted from where?

Results

Table 1& 2(Findings)

For the tables, write the symbol

% -percent

n-frequency

74.8 percent

Change to 74.8%

Discussion

The discussion is too descriptive.

How do the findings add to the body of scientific knowledge on the issue?

Recommendation:

Make the discussion based on subheadings, more clear to the reader.

E.g:

The relationship between the mother's education level and the adoption

of preventive behaviors.

Conclusion

Adoption of preventive behaviors against COVID-19 was lower among students with lower levels of health literacy, male students, students with less physical activity, students with

educated mothers, undergraduate students, and smokers.

Please harmonize this statement.

References

Most of the citations are above 5 years.

Very good.

Reviewer #6: Thank you for your effort and the fluent article. Here I provide some suggestion that may enhance the manuscript:

Line 55: you do not need to mention standard deviation. Just insert the mean score and insert SD in parentheses: 18.18 (±4.02)

Line 95: This seems more correct: University student population in Iran

Line 96: "Due to the important role, they play as managers and future planners in the country" omit the comma

Line 100: "Sajjadi et al.'s study showed that one-third of the students had insufficient or not very please for this and other studies mention the sample groups more specific.

Line 102: " The critical situation of the prevalence of COVID-19 disease can cause negative and positive psycho-social effects in society including the university students [14]" this sentence seems unnecessary. what is the relevance of this to your study? Did you consider these effects in your work?

Line 107-110: Was your sample group medical students or from other majors in health sciences? You may mention it here and it seems more reasonable when the participants are from health sciences.

The method section was described thoroughly and in details. Some comments:

How did you chose the background variables?

Line 113-116: "The statistical population was all the male and female students of Esfarayen Faculty of Medical Sciences, North Khorasan, Iran, among whom 214 were selected by simple random so that the names of all the students were listed and the participants were randomly selected." Please re-write this art in proper English writing.

Line 131: parents'

Line 133: what do you mean by "type of COVID-19"

LINE 179: please insert numbers alphabetically in the beginning of a sentence.

Table 1: what do you mean by "How to get content"- what content?

Table 1: it would be much better if you asked participants the weekly amount of their exercise and in some ranges ( e.g more than 2 hours, less than 2 hours …) this way it would be more objective.

Table 1: what is the importance of their Covid-19 type? What difference does it make?

Results: would you please a chart or graph ( as supplementary items) that shows the questionnaires items and the frequency of each answers in specific?

Discussion:

" These results were consistent with the results of Panahi et al. [24] and Panahi et al. [25]" please mention more details on these studies. Their sample. Their aim?

"In addition, the results of the present study were not consistent with the results of the study by Vozikis et al. [15] " what was this study results and what is the controversy?

"The results also showed that gender was one of the factors affecting the adoption of preventive behaviors so the adoption of preventive behaviors was higher in female students than in male

ones because following health principles, and medical recommendations, and more interest in learning and obtaining health information are more in women than in men." Reference please.

" Mothers with higher education worked outside more and they go out more, thus their fear of COVID-19 was reduced. Therefore, they had probably fewer preventive behaviors and their children also followed their parents in adopting preventive behaviors." These statements are your opinion and your suggested reasons. But you have mentioned them like some facts. Please re-write this part or if they are proven in other studies please provide references.

Please provide a part on your suggestions or your studies implications.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #4: No

Reviewer #5: Yes: DR RUSNANI AB LATIF

Reviewer #6: No

**********

Attachment

Submitted filename: Comment Reviewer The relationship between health literacy and the adoption of COVID-19 preventive.pdf

pone.0299007.s005.pdf^{(46.9KB, pdf)}

PLoS One. 2024 May 16;19(5):e0299007. doi: 10.1371/journal.pone.0299007.r006

Author response to Decision Letter 2

8 Dec 2023

Comments Responses

Reviewer #4: The revised parts were highlighted in yellow inside the manuscript.

Line number 86 in the introduction section, define health literacy and describe its dimensions.

Of course, it is necessary to mention the dimensions of health literacy and its relationship with behaviors to prevent covid 19.

Include related and similar previous studies in this field in the background of the article and explain the necessity of your study.

Dear Reviewers: the research team believes that the introduction should be written according to the keywords in the title of the article. Therefore, in the first paragraphs, we talked about the coronavirus and its complications and risk of infection and death. Then it was briefly talked about how to prevent it. Then, we went to health literacy, which is one of the effective factors in preventing COVID-19, and it is related to the adoption of preventive behaviors. Then, the definition of health literacy and the scope of its effects on people's health have been presented. In the following, we have addressed our other keyword, students, and we have explained why students were studied, and also their level of health literacy. Finally, the reason why the present study was done has been summarized.

Write the time frame of the research. Ok

Explain what tests you used to analyze which variables Ok

Write the discussion more coherently. Write each finding of your study in a paragraph and after you compare it with previous studies, then write your conclusion.

Dear reviewer; First, we started our discussion with the levels of health literacy and the adoption of preventive behavior, and then we analyzed each significant result completely. Please check again. Thanks.

Reviewer #5:

The mean and standard deviation (SD) of the scores of adoption of COVID-19 preventive behaviors and HL among students were 18.18±4.02 out of 25 and 72.14±12.75 out of 100, respectively. Please harmonize the statements. Make confused. Thanks a lot. It was revised.

Adoption of COVID-19 preventive behaviors was less among students with lower levels of HL, male students, students with less physical activity, students with

educated mothers, undergraduate students, and smokers. Please harmonize the statements.

Introduction

Sajjadi et al.'s

Azimi et al.'s

Need to explain what is Health literacy.

Correct this.( Sajjadi et al) It was revised.

In addition, health literacy was explained in the above lines inside the manuscript.

among whom 214 were selected by simple random so that the names of 115 all the students were listed and the participants were randomly selected.

Please harmonize this statement. The population included all male and female students at Esfarayen Medical Sciences University in Iran. The names of all students were listed and 214 participants were randomly selected by simple random sampling.

Health literacy for Iranian Adults (HELIA)

This questionnaire was adapted or adopted from where?

This questionnaire was designed and psychometrically evaluated by Dr. Montazeri and colleagues in Iran and has the following specifications:

It consists of 33 items in 5 areas including access (6 items), reading skill (4 items), comprehension (7 items), evaluation (4 items), decision making, and use of health information (12 items). Was used. The scoring scale is Likert with 5 choices. In the items related to reading skills; 5 scores were assigned to the completely easy choice, 4 to the easy choice, 3 to neither the easy nor difficult choice, 2 to the difficult choices, and 1 to the completely difficult choice. Also, 5 scores were assigned to always, 4 to most of the time, 3 to sometimes, 2 to rarely, and 1 to never. The scoring method was such that the raw score of each participant in each area was obtained from the algebraic sum of the scores. To convert this score into a range of 0 to 100, the formula of the raw score difference is obtained from the minimum possible raw score divided by the difference between the maximum possible score and the minimum score. Then, to calculate the total score, the scores of all the dimensions (based on the range from zero to 100) are added and divided by the number of dimensions (5 dimensions). Scores from 0 to 50 are considered inadequate health literacy, 50.1 to 66 as insufficient health literacy, 66.1 to 84 as adequate health literacy, and 84.1 to 100 as excellent health literacy (18). This questionnaire has been designed and psychometrically evaluated by Montazeri and colleagues in Iran, and its validity and reliability have been confirmed. The construct validity in the 5 areas was 53.2%, and the reliability of the questionnaire items was determined to be 0.72 to 0.89 by Cronbach's Alpha Coefficient.

Table 1& 2(Findings)

For the tables, write the symbol

% -percent

n-frequency

74.8 percent

Change to 74.8% It was revised.

The discussion is too descriptive. How do the findings add to the body of scientific knowledge on the issue?

Dear reviewer, we believe that we have done a complete analysis, and all results have been analyzed, compared, and criticized with the existing studies in the discussion part.

To our knowledge, the present study is the first study that evaluated the relationship between different levels of health literacy and the adoption of preventive behaviors against COVID-19 in Iran. Therefore, it can add new findings to the existing scientific knowledge in this field.

Recommendation:

Make the discussion based on subheadings, more clear to the reader.

E.g:

The relationship between the mother's education level and the adoption

of preventive behaviors. All these things have been done and each significant relationship has been analyzed and compared.

Adoption of preventive behaviors against COVID-19 was lower among students with lower levels of health literacy, male students, students with less physical activity, students with educated mothers, undergraduate students, and smokers. Please harmonize this statement.

References

Most of the citations are above 5 years.

Very good. Thanks so much.

Reviewer #6:

Line 55: you do not need to mention standard deviation. Just insert the mean score and insert SD in parentheses: 18.18 (4.02) Thanks a lot, it was revised.

Line 95: This seems more correct: University student population in Iran Thanks a lot, it was revised.

Line 96: "Due to the important role, they play as managers and future planners in the country" omit the comma Thanks a lot, it was revised.

Line 100: "Sajjadi et al.'s study showed that one-third of the students had insufficient or not very please for this and other studies mention the sample groups more specific. Thanks a lot, it was revised.

We wanted to say that COVID-19 can even affect students.

Line 107-110: Was your sample group medical students or from other majors in health sciences? You may mention it here and it seems more reasonable when the participants are from health sciences. Esfrain Medical Sciences University has only 7 different fields of study including nursing, public health, intelligence, operating room technician, etc.

The method section was described thoroughly and in details. Some comments:

How did you chose the background variables?

We chose the background variables by studying various studies in the field of health literacy and COVID-19.

The population included all male and female students at Esfarayen Medical Sciences University in Iran. The names of all students were listed and 214 participants were randomly selected by simple random sampling.

Line 131: parents' Thanks, it was revised.

Line 133: what do you mean by "type of COVID-19" We meant the type of infection, such as O’micron, Gamma, Beta, etc.

LINE 179: please insert numbers alphabetically in the beginning of a sentence. Ok

Table 1: what do you mean by "How to get content"- what content? It was revised.

Table 1: it would be much better if you asked participants the weekly amount of their exercise and in some ranges (e.g more than 2 hours, less than 2 hours …) this way it would be more objective.

Thanks a lot, your suggestion is very good, but the study has been completed and it can no longer be done.

Table 1: what is the importance of their Covid-19 type? What difference does it make? We wanted to see whether COVID-19 infection can be effective in preventing re-infection or initial infection.

Results: would you please a chart or graph (as supplementary items) that shows the questionnaires items and the frequency of each answers in specific?

Thanks so much, but the results should be mentioned based on the most important goals of the study.

Discussion:

" These results were consistent with the results of Panahi et al. [24] and Panahi et al. [25]" please mention more details on these studies. Their sample. Their aim?

"In addition, the results of the present study were not consistent with the results of the study by Vozikis et al. [15] " what was this study results and what is the controversy?

Both were done among students and we added to the relevant part.

Also, it is not appropriate to bring the goals in the discussion section.

In the discussion you could have compare the preventive behaviors in more detail with other studies. What type of behaviors were adapted the most? Which behaviors were neglected the most? It would be beneficial for future guidelines and educational purposes. Thanks, but this case is not a part of the objectives of this study.

"The results also showed that gender was one of the factors affecting the adoption of preventive behaviors so the adoption of preventive behaviors was higher in female students than in male

ones because following health principles, and medical recommendations, and more interest in learning and obtaining health information are more in women than in men." Reference please.

The reference was given.

Please provide a part on your suggestions or your studies implications. Dear reviewer, we have mentioned these things at the end of the results section:

It is suggested to carry out more extensive studies to clarify the effect of health literacy on the adoption of preventive behaviors against COVID-19. Also, it seems necessary to design a special tool to measure health literacy related to COVID-19 in all age groups.

Attachment

Submitted filename: plos one responses to reiewers-third.docx

pone.0299007.s006.docx^{(22.3KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0299007.r007

Decision Letter 3

Hadi Ghasemi

2 Jan 2024

PONE-D-22-35718R3The relationship between health literacy and the adoption of COVID-19 preventive behaviors: a cross-sectional study in Iran.PLOS ONE

Dear Dr. Amjadian,

Please submit your revised manuscript by Feb 16 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Hadi Ghasemi

Academic Editor

PLOS ONE

Journal Requirements:

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #4: All comments have been addressed

Reviewer #5: All comments have been addressed

Reviewer #6: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #4: I Don't Know

Reviewer #5: Yes

Reviewer #6: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: Yes

**********

6. Review Comments to the Author

Reviewer #4: (No Response)

Reviewer #5: Dear authors

Congratulation on the submitted manuscript. The topic is timely and will be of interest to the readers of the journal.

Thanks for the authors' effort on the paper. I have read and reviewed the manuscript, corrections from reviewers have been made.

Reviewer #6: Thank you for your efforts but some of my main comments were not answered properly. The suggestions were made to improve the final work but the authors neither made the changes nor provided reasonable justifications.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #4: No

Reviewer #5: No

Reviewer #6: No

**********

Attachment

Submitted filename: revision.docx

pone.0299007.s007.docx^{(14KB, docx)}

PLoS One. 2024 May 16;19(5):e0299007. doi: 10.1371/journal.pone.0299007.r008

Author response to Decision Letter 3

19 Jan 2024

Comments Responses (The revised parts were highlighted in yellow inside the manuscript)

Line 102: "The critical situation of the prevalence of COVID-19 disease can cause negative and positive psycho-social effects in society including the university students [14]" this sentence seems unnecessary. what is the relevance of this to your study? Did you consider these effects in your work? Thanks a lot. It was revised and answered. (Fourth paragraph in the introduction part)

Results: would you please a chart or graph (as supplementary items) that shows the questionnaires items and the frequency of each answers in specific? Dear reviewer; Within the methodology, we have determined that the Helia questionnaire had 33 items, the behavior questionnaire included 5 items, and 15 items belonged to the background demographic variables. As we have already answered, the results should be mentioned based on the most important objectives of the study. The case considered by the respected reviewer is not within the scope of our goals, because we believe that we have mentioned the most important findings based on the study goals.

Discussion:" These results were consistent with the results of Panahi et al. [24] and Panahi et al. [25]" please mention more details on these studies. Their sample. Their aim?

…….

"In addition, the results of the present study were not consistent with the results of the study by Vozikis et al. [15]" what was this study results and what is the controversy? Both were done among students and we added to the relevant part. Also, it is not appropriate to bring the goals in the discussion section.

……………

Thanks so much. They were revised inside the manuscript.

"Mothers with higher education worked outside more and they go out more, thus their fear of COVID-19 was reduced. Therefore, they had probably fewer preventive behaviors and their children also followed their parents in adopting preventive behaviors."These statements are your opinion and your suggested reasons. But you have mentioned them like some facts. Please re-write this part or if they are proven in other studies please provide references. Thanks so much. They were revised in the manuscript.

Please provide a part on your suggestions or your studies implications. Dear reviewer:

we have mentioned these things at the end of the conclusion:

It is suggested to conduct more extensive studies to clarify the effect of health literacy on the adoption of preventive behaviors against COVID-19 In addition, it is recommended to investigate the relationship between different health literacy skills and the adoption of preventive behaviors against COVID-19 in future studies, so that more effective and shorter measures can be taken in this regard. Also, it seems necessary to design a special tool to measure health literacy related to COVID-19 among all age groups.

Attachment

Submitted filename: Responses to the Reviewers(4th revised).docx

pone.0299007.s008.docx^{(16.4KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0299007.r009

Decision Letter 4

Hadi Ghasemi

5 Feb 2024

The relationship between health literacy and the adoption of COVID-19 preventive behaviors: a cross-sectional study in Iran.

PONE-D-22-35718R4

Dear Dr. Mohiadin Amjadian,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Hadi Ghasemi

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #6: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #6: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #6: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #6: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #6: Yes

**********

6. Review Comments to the Author

Reviewer #6: Thank you, the revised version is sound and well-written and all the comments were properly answered.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #6: No

**********

PLoS One. doi: 10.1371/journal.pone.0299007.r010

Acceptance letter

Hadi Ghasemi

7 May 2024

PONE-D-22-35718R4

PLOS ONE

Dear Dr. Amjadian,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team.

At this stage, our production department will prepare your paper for publication. This includes ensuring the following:

* All references, tables, and figures are properly cited

* All relevant supporting information is included in the manuscript submission,

* There are no issues that prevent the paper from being properly typeset

If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps.

Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

If we can help with anything else, please email us at customercare@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Hadi Ghasemi

Academic Editor

PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Data

(RAR)

pone.0299007.s001.rar^{(6.1KB, rar)}

Attachment

Submitted filename: Health literacy and the adoption of covid-19 preventive behaviors_review.docx

pone.0299007.s002.docx^{(17.1KB, docx)}

Attachment

Submitted filename: Response to the comments(Plos one J.).docx

pone.0299007.s003.docx^{(16.9KB, docx)}

Attachment

Submitted filename: Responses to Reviewers.docx

pone.0299007.s004.docx^{(21.7KB, docx)}

Attachment

Submitted filename: Comment Reviewer The relationship between health literacy and the adoption of COVID-19 preventive.pdf

pone.0299007.s005.pdf^{(46.9KB, pdf)}

Attachment

Submitted filename: plos one responses to reiewers-third.docx

pone.0299007.s006.docx^{(22.3KB, docx)}

Attachment

Submitted filename: revision.docx

pone.0299007.s007.docx^{(14KB, docx)}

Attachment

Submitted filename: Responses to the Reviewers(4th revised).docx

pone.0299007.s008.docx^{(16.4KB, docx)}

Data Availability Statement

All relevant data are within the paper and its Supporting Information files.

[pone.0299007.ref001] 1.Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. International Journal of environmental research and public health 2020; 17(5): 1729. doi: 10.3390/ijerph17051729 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0299007.ref002] 2.Bahrulolum H, Nooraei S, Entezari M, Hashemi M, Houshmandi K, Raei M. The role of nutrition and nutritional factors in the prevention and treatment of COVID-19: a review study. EBNESINA. 2020; 22(3): 56–66. [Google Scholar]

[pone.0299007.ref003] 3.Rothan HA, Byrareddy SN. The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak. Journal of autoimmunity. 2020; 109: 102433. doi: 10.1016/j.jaut.2020.102433 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0299007.ref004] 4.Khazaee-Pool M, Shahrvsand S, Naghibi SA. Predicting COVID-19 Preventive Behaviors Based on Health Belief Model: An Internet-Based Study in Mazandaran Province, Iran. Journal of Mazandaran University of Medical Sciences. 2020; 30(190): 56–66. [Google Scholar]

[pone.0299007.ref005] 5.Nasirzadeh M, Aligol M. Assessmentof Knowledge, Attitude, and Factors Associated with the Preventive Behaviors of COVID-19 in Qom, Iran, in 2020. Qom University of Medical Sciences Journal. 2020; 14(7): 50–7. [Google Scholar]

[pone.0299007.ref006] 6.Xiang Y-T, Yang Y, Li W, Zhang L, Zhang Q, Cheung T, et al. Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. The Lancet Psychiatry. 2020; 7(3): 228–9. doi: 10.1016/S2215-0366(20)30046-8 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0299007.ref007] 7.Peyvand M, Kargar S, Hajizade F. The Role of Health Literacy Promotion in Epidemic Control Corona 19. Journal of Health Literacy. 2020; 5(1): 9–11. [Google Scholar]

[pone.0299007.ref008] 8.Panahi R, Ramezankhani A, Tavousi M. Health literacy and preventive behaviors. Journal of Research and Health 2018; 8(2): 93–4. [Google Scholar]

[pone.0299007.ref009] 9.Delavar F, Pashaeypoor S, Negarandeh R. Health literacy index: A new tool for health literacy assessment. Journal of Hayat. 2018; 24(1): 1–6. [Google Scholar]

[pone.0299007.ref010] 10.Panahi R, Samiei Siboni F, Kheiri M, Jahangasht Ghoozlu KH, Shafaei M, Dehghankar L. Promoting the adoption of behaviors to prevent osteoporosis using the Health Belief Model integrated with Health Literacy: a quasi-experimental intervention study. BMC Public Health. 2021; 21: 2221. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0299007.ref011] 11.Mousavi H, Bagherian R. Health literacy and breast cancer. QUARTERLY JOURNAL OF HEALTH PSYCHOLOGY. 2019; 8(31): 91–102. [Google Scholar]

[pone.0299007.ref012] 12.Sajadi FA, Sajadi HS, Panahi R. Health literacy of university students and its influential factors: A case study at Isfahan University. J Educ Community Health. 2020; 7(1): 23–8. [Google Scholar]

[pone.0299007.ref013] 13.Azimi S, Ramezankhani A, Rakhshani F, Ghaffari M, Ghanbari SH. Comparison of health literacy between medical and non-medical students in Shahid Beheshti Universities in the academic year 92–93. Pejouhandeh 2015; 20(2): 78–85. [Persian] [Google Scholar]

[pone.0299007.ref014] 14.Vozikis A, Drivas K, Milioris K. Health literacy among university students in Greece: determinants and association with self-perceived health, health behaviors, and health risks. Arch Public Health 2014; 72(1): 15. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0299007.ref015] 15.Panahi R, Ramezankhani A,Tavousi M, Osmani F, Karami Jouyani A, Niknami Sh. Effect of Educational Intervention onHealth Literacy and Adoption of Smoking Preventive Behaviors among University Students. J Educ Community Health. 2018; 5(2): 26–35. [Google Scholar]

[pone.0299007.ref016] 16.Safari M, Shojaeizadeh D. Theories Models and Methods of Health Education and Promotion. Tehran: Asar-E Sobhan Publishing; (2009). p. 22–24. [Google Scholar]

[pone.0299007.ref017] 17.Panahi R, Ramezankhani A, Tavousi M, Osmani F, Ghazanfari E, Niknami Sh. Evaluation of Health Literacy and its Influencing Factors on Dormitory Students of Shahid Beheshti University of Medical Sciences in Tehran. J Educ Community Health 2016; 3(3): 30–6. [Google Scholar]

[pone.0299007.ref018] 18.Montazeri A, Tavousi M, Rakhshani F, Azin SA, Jahangiri K, Ebadi M. Health Literacy for Iranian Adults (HELIA): development and psychometric Properties. Payesh. 2014; 13: 589–99. [Google Scholar]

[pone.0299007.ref019] 19.Panahi R, Ramezankhani A, Tavousi M, Haeri Mehrizi A, Niknami S. The Psychometric Properties of Health Literacy for Iranian Adults (HELIA) in Medical Sciences Students. J Research Health. 2020; 10(1): 53–8. [Google Scholar]

[pone.0299007.ref020] 20.Panahi R, Ramezankhani A, Tavousi M, Osmani F, Niknami S. Predictors of Adoption of Smoking Preventive Behaviors among University Students: Application of Health Belief Model. J Educ Community Health. 2017; 4(1): 35–42. [Google Scholar]

[pone.0299007.ref021] 21.Panahi R, Ramezankhani A, Haerimehrizi AA, Tavousi M, Khalilpour Darestani M, Niknami S. Which dimension of health literacy predict the adoption of smoking prevention behaviors? Journal of Health in the Field. 2018; 5(4): 8–17. [Google Scholar]

[pone.0299007.ref022] 22.Panahi R, Yekefallah L, Shafaei M, Dehghankar L, Anbari M, Hosseini N, Hasannia E. Effect of health literacy among students on the adoption of osteoporosis-preventive behaviors in Iran. J Edu Health Promot. 2020; 9: 191. doi: 10.4103/jehp.jehp_400_19 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0299007.ref023] 23.Panahi R, Namdar P, Siboni FS, Fallah S, Anbari M, Dehghankar L, et al. Association between health literacy and adopting preventive behaviors of breast cancer in Iran. J Edu Health Promot. 2020; 9: 241. doi: 10.4103/jehp.jehp_313_20 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0299007.ref024] 24.Panahi R, Osmani F, Javanmardi K, Ramezankhani A, Dehghankar L, Amini RA, et al. The relationship between different levels of Health Literacy and smoking prevention among Medical sciences students. Int J Prev Med. 2021; 12: 124. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0299007.ref025] 25.Panahi R, Dehghankar L, Abdollahi F, Anbari M, Hosseini N. Health Literacy and Breast Cancer Preventive Behaviors among Students. Payesh 2019; 18(6): 547–557. [Google Scholar]

[pone.0299007.ref026] 26.Panahi R, Ramezankhani A, Tavousi M, Niknami S. Adding Health Literacy to the Health Belief Model: Effectiveness of an Educational Intervention on Smoking Preventive Behaviors Among University Students. Iran Red Crescent Medical Journal (ircmj). 2018; 20(2): e13773. [Google Scholar]

[pone.0299007.ref027] 27.Panahi R, Hosseini N, Ramezankhani A, Anbari M, Amjadian M, Dehghankar L, NiknamiS. Measuring the Structures of the Health Belief Model Integrated with Health Literacy in Predicting University Students’ Adoption of Smoking Preventive Behaviors. J Prev Med Hyg 2022; 63: E51–E58. doi: 10.15167/2421-4248/jpmh2022.63.1.2236 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0299007.ref028] 28.Amjadian M, Anbari M, Amini R, Khalilipour Darestani M, Dehghankar L, Panahi R. Studying the factors associated with Premenstrual syndrome prevention among pre-university students in Tehran. J Prev Med Hyg 2022; 63: E6–E11. doi: 10.15167/2421-4248/jpmh2022.63.1.2027 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0299007.ref029] 29.Nakayama K, Yonekura Y, Danya H, Hagiwara K COVID-19 Preventive Behaviors and Health Literacy, Information Evaluation, and Decision- making Skills in Japanese Adults: Cross-sectional Survey Study JMIR Form Res 2022; 6(1): e34966. doi: 10.2196/34966 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0299007.ref030] 30.Riiser K, Helseth S, Haraldstad K, Torbjørnsen A, Richardsen KR. Adolescents’ health literacy, health-protective measures, and health-related quality of life during the COVID-19 pandemic. PloS one. 2020; 15(8): e0238161. doi: 10.1371/journal.pone.0238161 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0299007.ref031] 31.Panahi R, Ramezankhani A, Anbari M, Javanmardi K. Adoption of smoking preventive behaviors and its related factors among dormitory students of Shahid Beheshti University of Medical Sciences in Tehran—2016. Journal of Health in the Field. 2020; 8(1): 22–31. [Google Scholar]

[pone.0299007.ref032] 32.Etehadnezhad S, Moradi Z, Kashfi SM, Khani‐Jeihooni A, khiyali Z. Predictors of osteoporosis preventive behaviors among women: an application of the transtheoretical model. J Educ Community Health 2018; 5(3): 48‐56. [Persian [ [Google Scholar]

[pone.0299007.ref033] 33.Menshadi F, Azari A, Kouhpayehzadeh J, Ghasemi M. Knowledge, attitude and practice of osteoporosis among a group of Iranian adolescent females (2007). J Mod Rehibilit. 2009; 2 (3 and 4): 47‐54. [Persian] [Google Scholar]

[pone.0299007.ref034] 34.Khani Jeihooni A, Heidarnia AR, Kaveh MH, Hajizadeh E, Gholami T. Survey of osteoporosis preventive behaviors among women in Fasa: The application of the health belief model and social cognitive theory. Iran South Med J. 2016; 19(1): 48‐62. [Persian] [Google Scholar]

[pone.0299007.ref035] 35.Panahi R, Dehghankar L, Hosseini N, Hasannia E. Factors Related to Adoption of Osteoporosis Preventive Behaviors among Females’ High School Students; a Case Study of Qazvin City. Journal of Education and Community Health. 2020; 7(2): 105–12. [Google Scholar]

[pone.0299007.ref036] 36.Nguyen TT, Le NT, Nguyen MH, Pham LV, Do BN, Nguyen HC, et al. Health Literacy and Preventive Behaviors Modify the Association between Pre-Existing Health Conditions and Suspected COVID-19 Symptoms: A Multi-Institutional Survey. International Journal of environmental research and public health 2020; 17(22): 8598. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0299007.ref037] 37.Tavousi M, Ebadi M, Azin A, Shakerinejad GH, Hashemi A, Fattahi E, et al. Definitions of health literacy: a review of the literature. Payesh 2014; 13: 119–24 (In Persian). [Google Scholar]

[pone.0299007.ref038] 38.Mahdavi ZH, Ramezankhani A, Ghanbari SH, Khodakarim L. Relationship between health literacy and female cancers preventive behaviors. Payesh 2017; 5: 613–25 (Persian). [Google Scholar]

[pone.0299007.ref039] 39.Izadirad H, Zareban I. The Relationship of Health Literacy with Health Status, Preventive Behaviors, and Health Services Utilization in Baluchistan, Iran. Journal of Education and Community Health. 2015; 2(3): 43–50. [Google Scholar]

[pone.0299007.ref040] 40.Nguyen LHT, Vo MTH, Tran LTM, Dadaczynski K, Okan O, Murray L et al. Digital Health Literacy About COVID-19 as a Factor Mediating the Association Between the Importance of Online Information Search and Subjective Well-Being Among University Students in Vietnam. Digit. Health 2021; 3)739476(. doi: 10.3389/fdgth.2021.739476 [DOI] [PMC free article] [PubMed] [Google Scholar]

PERMALINK

The relationship between health literacy and the adoption of COVID-19 preventive behaviors: A cross-sectional study in Iran

Rahman Panahi

Zahra Ghorbanpour

Bagher Moradi

Fereshteh Eidy

Mohiadin Amjadian

Roles

Abstract

Background and aim

Materials and methods

Results

Conclusion

Introduction

Materials and methods

Findings

Table 1. Demographic and background characteristics of the students.

Table 2. Frequency distribution of the health literacy level and behaviors to prevent COVID-19 among students.

Table 3. Effective factors for adopting preventive behaviors in COVID-19 in the logistic regression model.

Discussion

Conclusion

Supporting information

Acknowledgments

Abbreviations

Data Availability

Funding Statement

References

Decision Letter 0

Lucinda Shen

Roles

Author response to Decision Letter 0

Decision Letter 1

Sylvia Ayieko

Roles

Author response to Decision Letter 1

Decision Letter 2

Hadi Ghasemi

Roles

Author response to Decision Letter 2

Decision Letter 3

Hadi Ghasemi

Roles

Author response to Decision Letter 3

Decision Letter 4

Hadi Ghasemi

Roles

Acceptance letter

Hadi Ghasemi

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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