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. Author manuscript; available in PMC: 2025 Oct 30.
Published in final edited form as: Rural Remote Health. 2024 Oct 30;24(4):9147. doi: 10.22605/RRH9147

Health Literacy and COVID-19 Pandemic Impacts among Adults in Rural Northern Arizona

Olivia J Lindly 1, Taylor A Wahl 1, Noa M Stotts 2, Brianna R Kirby 1, Sarah M Asantewaa 1, Amy M Shui 3
PMCID: PMC11952201  NIHMSID: NIHMS2059328  PMID: 39477211

Abstract

Introduction:

Limited health literacy – the ability to access, process, and use health information and services – contributes to persistent health inequities. Yet little is known about associations of limited health literacy with impacts from the COVID-19 pandemic particularly for U.S. adults in rural areas. This study sought to determine associations of limited health literacy with impacts from the COVID-19 pandemic among a diverse sample of adults in rural Northern Arizona.

Methods:

A cross-sectional, interviewer-administered survey was conducted with 119 adults from June 2020 to August 2021. Participants were recruited from two federally qualified health centers and by word of mouth. The Newest Vital Sign was used to measure health literacy, and the Epidemic-Pandemic Impacts Inventory was used to measure the effects of the COVID-19 pandemic on various aspects of personal and family life (e.g., spent more time on screens and devices, had family celebrations canceled or restricted). Descriptive, bivariate, and multivariable linear regression statistics were computed.

Results:

Nineteen percent of participants had limited health literacy, and participants had an average of 22 individual impacts and 2 household impacts of the 92 COVID-19 impacts assessed. Multivariable regression model results showed that being male versus female or having public only versus any private insurance was significantly associated with fewer individual COVID-19 impacts on average. Being black, indigenous, people of color (BIPOC) versus white or being Hispanic, Latino, or Spanish versus not were each associated with significantly more individual COVID-19 impacts on average. Limited versus adequate health literacy was significantly associated with more household COVID-19 impacts on average. Sensitivity analysis results further showed that limited versus adequate health literacy was associated with significantly higher adjusted rates of household social, emotional, and infection COVID-19 impacts.

Conclusion:

This study’s findings highlight the importance of assessing and accounting for health literacy in clinical practice and health services research addressing the impacts of the COVID-19 pandemic and future emergency events.

Keywords: Health literacy, COVID-19 pandemic, health center, adults, rural, North America

Introduction

The COVID-19 pandemic began in March 2020 causing major disruptions to social activities, education, employment, and healthcare delivery (1–3). Misinformation–unintentionally false information—and disinformation—deliberately misleading information—about COVID-19 were widespread (4–6). For example, misinformation about hydroxychloroquine, an antimalarial drug, effectively treating COVID-19 contributed to public uncertainty about the pandemic and highlighted the importance of health literacy (7). The influx of both inaccurate and accurate COVID-19 information was labeled as an “infodemic” (8).

To be prepared for future infodemics, the role of health literacy with impacts brought about through the COVID-19 pandemic must be better understood (9). Health literacy is the ability to access, understand, and use health information and services (10). An individual’s health literacy level is often determined from their performance on health literacy assessments, where lower scores are indicative of limited health literacy and higher scores are indicative of adequate health literacy (10). Limited health literacy is associated with poor overall health, while adequate health literacy is correlated with health and well-being (11). It is estimated that approximately 80 million adults (36%) in the United States have limited health literacy, and limited health literacy is overrepresented in individuals who have lower socioeconomic status and/or are Black, Indigenous, and people of color (BIPOC) (11,12).

Associations of health literacy with COVID-19 knowledge (13), beliefs (14), and behaviors such as vaccine hesitancy (15) or refusal (16) have recently been explored. Overall, these studies show that adequate health literacy is associated with greater knowledge of COVID-19 and engagement in preventive health behaviors (e.g., COVID-19 vaccination). Other factors, such as health consciousness (17) and political ideology, may also play a role in COVID-19 beliefs and related behaviors (14). This prior work contributed to this study’s conceptual framework linking health literacy to COVID-19 pandemic impacts at both the individual and household levels. We inferred that COVID-19 pandemic impacts would be experienced on both individual and household levels, but that these impacts would be most frequently identified at the individual level. According to past research, COVID-19 awareness and beliefs contributing to COVID-19 pandemic behaviors including immunization were thought to be more strongly associated with adequate versus limited health literacy. In turn, adequate versus limited health literacy, by way of COVID-19 awareness, beliefs, and behaviors, was thought to be associated with fewer individual and household adverse COVID-19 pandemic impacts and more positive COVID-19 pandemic impacts.

Still, a dearth of published work has examined associations of health literacy with negative and positive impacts resulting from the COVID-19 pandemic. Particularly in more rural areas with culturally diverse individuals, including Indigenous communities, little research has been conducted to better understand the relationship of health literacy with various impacts from the COVID-19 pandemic. Northern Arizona is home to Coconino County, the second-largest county in the contiguous United States. Within the county, tribal lands (39.1%) and forest service (27.2%) make up much of its unique geography. Due to the rural nature of many of these inhabited areas, limited access to health facilities, grocery stores, and reliable internet, further exacerbated adverse COVID-19 pandemic impacts for Northern Arizona residents (18).

Because health literacy is a modifiable determinant of health, it is essential for future preparedness and response efforts to better understand how health literacy was related to COVID-19 pandemic impacts. This study sought to examine associations of health literacy with impacts from the COVID-19 pandemic among a diverse sample of adults in Northern Arizona. Based on past research and our conceptual framework (12–17), we hypothesized that individuals with limited rather than adequate health literacy would experience more significant adverse impacts from the COVID-19 pandemic, with a greater likelihood of individual rather than household impacts.

Methods

Design

This cross-sectional survey was part of a larger randomized crossover trial (19). Data were collected from June 2020 to August 2021. The first author’s Institutional Review Board approved this study.

Instruments

The survey’s questionnaire included measures of participant demographic and health characteristics, health literacy, and COVID-19 pandemic impacts.

Measures of Participant Demographic Characteristics

To assess participant demographic characteristics, items were adapted from the 2020 National Health Interview Survey on age, biological sex, Hispanic ethnicity, race, health insurance coverage, marital status, and employment (20). Additional questionnaire items on health status and quality of life from the 36-item Short Form Health Survey were included (21).

Health Literacy Assessment

The Newest Vital Sign (NVS) is a validated six-question tool that utilizes an ice cream nutrition label, and it is read aloud by an interviewer to assess a participant’s health literacy and numeracy skills (21, 22). Correct responses are scored with one point, and incorrect responses score a zero. Adequate health literacy is determined by a total score of four to six, while anything below indicates limited health literacy. A total score of zero or one indicates likely limited health literacy, and a total score of two or three indicates possible limited health literacy (23).

COVID-19 Pandemic Impacts Measure

The Epidemic–Pandemic Impacts Inventory (EPII) was developed to learn more about the impact of the COVID-19 pandemic and future epidemics and pandemics on an array of personal and family life domains (24). A total of 92 items are included in the EPII. There are nine categories of negative impacts within the EPII including: work and employment (11 items), education and training (2 items), home life (13 items), social activities (10 items), economic (5 items), emotional health and well-being (8 items), physical health problems (8 items), physical distancing and quarantine (8 items), infection history (8 items). There are also 19 positive change items within the EPII. The following question stem preceded all the EPII items: “Since the coronavirus disease pandemic began, what has changed for you or your family?” Each question within these categories allowed participants to answer yes for themselves and/or someone else in their home (i.e., another person or people), no, or does not apply to them or another person in the home. No psychometric properties or optimal scoring procedures were available for the EPII when this study occurred. Because the EPII does include one domain on positive change impacts, we separated this subdomain with 19 items in determining and analyzing the total number of other, adverse COVID-19 pandemic impacts. For descriptive purposes, we did however examine the 19 positive change subdomain items. Individual items are shown in Figures 1a–1d.

Figure 1a.

Figure 1a.

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Frequency of Economic, Education and Training, and Work and Employment COVID-19 Impacts

Figure 1d.

Figure 1d.

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Frequency of Positive Change COVID-19 Impacts

Sample

Recruitment

Patients were randomly sampled based on the following criteria: (1) 18 years or older, and (2) had 1+ visit(s) at either the Native Americans for Community Action Family Health & Behavioral Health Center or the North Country HealthCare Flagstaff (4th Street) clinic in Northern Arizona within the past 12 months of when the sample was drawn. Recruitment initially occurred by mail with an invitation letter containing study information. Patients at one of the federally qualified health centers were also contacted by telephone one to four weeks after the recruitment letters were sent if they had not already contacted the study team about participating. Some individuals were also recruited through word of mouth. Eligibility based on inclusion criteria was confirmed by the research team prior to individuals participation. All individuals enrolled provided verbal informed consent.

Participants

There were 119 participants in this study: 19.3 percent had limited health literacy, and 80.7 percent had adequate health literacy. The average age of participants was approximately 54 years, and 56 percent were female. Nearly 23 percent of participants identified as American Indian or Alaska Native, and 73 percent identified as white. About eight percent of participants identified as Hispanic, Latino, or Spanish. Slightly more than half of the participants (51.3%) were not employed, and 52 percent had public health insurance or no health insurance. Only two participants reported not having health insurance. Approximately 47 percent of participants were married, and 31 percent had children less than 18 years old. Most participants (63%) rated their overall health as excellent or very good, and most participants (84%) were recruited from one of the two federally qualified health centers involved with this study. Table 1 displays all participant characteristics.

Table 1.

Participant Demographics (N = 119)

Overall Limited Health Literacy (n = 23) Adequate Health Literacy (n = 96) p
Mean (SD)
Age, years 53.8 (18.1) 52.7 (21.6) 54.1 (17.3) 0.75
Sex n (%)
 Female 67 (56.3) 10 (14.9) 57 (85.1) 0.17
 Male 52 (43.7) 13 (25.0) 39 (75.0)
Race n (%)
 American Indian or Alaska Native 27 (22.7) 9 (33.3) 18 (66.7) 0.036
 Black or African American 1 (0.8) 0 1 (100) 0.99
 Native Hawaiian or other Pacific Islander 2 (1.7) 1 (50.0) 1 (50.0) 0.35
 Other Race 2 (1.7) 2 (100) 0 0.036
 White (Only) 87 (73.1) 11 (12.6) 76 (87.4) 0.002
Ethnicity n (%)
 Hispanic, Latino, or Spanish 9 (7.6) 5 (55.6) 4 (44.4) 0.013
 Not Hispanic, Latino, or Spanish 110 (92.4) 18 (16.4) 92 (83.6)
Employed n (%)
 Yes 58 (48.7) 14 (24.1) 44 (75.9) 0.2
 No 61 (51.3) 9 (14.8) 52 (85.3)
Health Insurance Coverage n (%)
 Public or No Insurance 57 (52.10) 8 (12.9) 54 (87.10) 0.1
 Any Private Insurance 62 (47.90) 15 (26.3) 42 (73.7)
Marital Status n (%)
 Married 56 (47.1) 8 (14.3) 48 (85.7) 0.19
 Divorced 14 (11.8) 3 (21.4) 11 (78.6) 0.73
 Widowed 5 (4.2) 2 (40.0) 3 (60.0) 0.25
 Single 44 (37.0) 10 (22.7) 34 (77.3) 0.48
Have Children < 18 years n (%)
 Yes 23 (31.1) 18 (78.3) 5 (21.7) 0.83
 No 51 (68.9) 41 (80.4) 10 (19.6)
Overall Health Status
 Excellent or Very Good 75 (63.0) 12 (16.0) 63 (84.0) 0.23
 Good, Fair, or Poor 44 (37.0) 11 (25.0) 33 (75.0)
Recruited From n (%)
 Health Center 100 (84.0) 20 (20.0) 80 (80.0) 0.99
 Word of Mouth 19 (16.0) 3 (15.8) 16 (84.2)
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Note. A Fisher’s exact test used when cell sizes were < 5, otherwise chi-square tests were used to compute p-values. The race and marital status variables were sets of binary variables in which each racial category was compared to all other racial categories and each marital status category was compared to all other marital status categories. There were only two participants who reported having no health insurance. Not all percentages may sum to one hundred due to rounding.

Procedure

The interviewer-administered survey was conducted via telephone or videoconference, depending on participant preference. Data were collected and managed using REDCap (Research Computerized Data Capture) tools hosted at the first author’s institution (25). All research team members underwent training in administering the survey and collecting data in REDCap. Each participant received a $20 payment.

Analysis

Exploratory data analyses were initially performed by computing descriptive statistics such as means, standard deviations, frequencies, and relative frequencies to determine the distributional properties for all variables of interest and to characterize the sample. We created charts to visualize the frequency of the 73 adverse and 19 positive change COVID-19 impacts for participants individually and their households. Bivariate statistics including cross-tabulated proportions and means were computed to determine differences in participant demographic characteristics by health literacy level (i.e., limited versus adequate health literacy). Chi-square or Fisher’s exact tests were used, as appropriate, for categorical variables. The total mean number of individual and household COVID-19 impacts reported were compared according to health literacy level using a Wilcoxon rank sum, given the skewness and kurtosis of the individual and household impact variables’ distributions (26). We further examined differences in each of the ten COVID-19 pandemic impacts areas (e.g., work and employment, home life) for individuals and households by health literacy level using the same approach insofar as a Wilcoxon rank sum test was used to determine statistical significance when skewness was greater than 3 or less than −3 and Kurtosis was greater than 7 or less than −7. Because the individual and household impacts variables were count variables and their conditional variances exceeded their means, two negative binomial regression models were fit. The independent variable of interest in these models was health literacy level (adequate versus limited); however, we additionally included several covariates that had statistically significant or marginally significant associations (p < .20) with health literacy level including biological sex, health insurance status, and race and ethnicity (due to small cell sizes, categories were combined as follows: white and non-Hispanic; Hispanic, Latino, or Spanish; or American Indian/Alaska Native, Black/African American, Native Hawaiian/Pacific Islander, or other race). We conducted sensitivity analysis based on our bivariate analysis results to further examine the multivariable associations of limited versus adequate health literacy with each of the three household COVID-19 impact domains (social, emotional, infection) adjusting for demographic factors using negative binomial regression models. All statistical tests were two-tailed, and an alpha level of 0.05 was used to determine statistical significance. Data were analyzed in Stata 17 (27).

Results

Participant Demographic Characteristics and Health Literacy Level

Participants who identified as American Indian or Alaska Native were significantly less likely to have adequate health literacy than those who identified as white only (66.7% versus 87.4%, p = 0.036). Participants who identified as Hispanic, Latino, or Spanish were also less likely than non-Hispanic participants to have adequate health literacy (44.4% versus 83.6%, p = 0.013). No other demographic characteristics were found to have statistically significant associations with health literacy (Table 1).

Frequency of COVID-19 Pandemic Impacts

On average, participants experienced an average of 14 impacts themselves (standard deviation = 6.8; median = 14; range = 1–39; interquartile range = 9–18), and their household experienced an average of one impact (standard deviation = 3.8; median = 0, range = 0–25; interquartile range = 0–23) of the 73 impacts measured (Table 2). The most frequently experienced COVID-19 impacts for individuals were in the domains of emotional health and well-being, social activities, and physical health problems. Participants reported the following individual impacts most frequently: spending more time on screens and devices (emotional health and well-being domain, 76%); having family celebrations canceled or restricted (social activities domain, 74%); having travel plans or vacations canceled (social activities domain, 71%); being separated from family or close friends (social activities domain, 68%); being unable to participate in social clubs, sports teams, or volunteer activities (social activities domain, 68%); being unable to do enjoyable activities or hobbies (social activities domain, 68%); and spending more time sitting down or being sedentary (physical health problems domain, 67%). The following COVID-19 impacts were not reported by any participants: becoming homeless, having an increase in physical conflict with a spouse, having an increase in physical conflict with other adults in the household, and having someone in the home who died of COVID-19. Impacts for the household generally followed a similar pattern but were reported far less frequently than the individual impacts experienced by participants. Figures 1a–1d display the frequencies of COVID-19 impacts on individuals and their households. In the positive change domain (Figure 1e), participants reported the following individual impacts most frequently: being more appreciative of things usually taken for granted (84%) and paid more attention to personal health (84%).

Table 2.

COVID-19 Impacts at the Individual and/or Household Levels by Participant Health Literacy Level

Individual Impacts (range = 1– 39) Household Impacts (range = 0 – 25)
Overall, M (SD) 13.91 (6.84) 1.34 (3.81)
 Median (Q1-Q3) 14 (9–18) 0 (0–23)
Limited Health Literacy, M (SD) 13.35 (7.17) 3.43 (6.73)
 Median (Q1-Q3) 13.5 (0–39) 0 (0–23)
Adequate Health Literacy, M (SD) 14.04 (6.79) 0.84 (2.50)
 Median (Q1-Q3) 14 (1–29) 0 (0–15)
p 0.88 0.022
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Note. M, mean, SD, standard deviation, Q, quartile.

Bivariate Results on Health Literacy and COVID-19 Impacts

As shown in Table 2, health literacy level was not significantly associated with individual COVID-19 impacts. Participants with limited versus adequate health literacy did, however, report more household impacts on average (3.43 versus 0.84, p = 0.022). Results for each COVID-19 pandemic impact domain showed that participants with adequate versus limited health literacy reported significantly more individual social impacts on average (4.97 versus 3.78, p = 0.034). The opposite was found for household social impacts: participants with limited versus adequate health literacy reported more household social impacts on average (1.26 versus 0.32, p = 0.024). Participants with limited versus adequate health literacy also reported more household emotional health and well-being impacts (0.30 versus 0.07, p = 0.026), as well as more household infection history impacts (0.13 versus 0.01, p = 0.045) on average.

Multivariable Results on Health Literacy and COVID-19 Impacts

As shown in Table 3, health literacy level was not significantly associated with the rate of individual COVID-19 impacts controlling for covariates (Incidence Rate Ratio [IRR]: 0.84, 95% CI: 0.67–1.06, p = 0.14). The biological sex of participants (male versus female) and health insurance type (having public insurance versus any private insurance) were each associated with a lower rate of individual-level COVID-19 impacts. Conversely, participants who did not identify as white and non-Hispanic had a significantly higher rate of individual COVID-19 impacts. In terms of household COVID-19 impacts, health literacy level was the only factor with a statistically significant association. That is, participants with limited versus adequate health literacy had a higher rate of household COVID-19 impacts (IRR: 5.89, 95% CI: 1.82–19.1, p = 0.003), after adjusting for covariates.

Table 3.

Multiple Negative Binomial Regression Model Results for Covid Impacts

Model 1. Individual Impacts p Model 2. Household Impacts p
Health Literacy Level
 Adequate Health Literacy Referent Referent
 Possible or Likely Limited Health Literacy 0.84 (0.67, 1.06) 0.14 5.88 (1.82, 19.09) 0.003
Sex
 Female Referent Referent
 Male 0.80 (0.67, 0.95) 0.013 2.21 (0.85, 5.73) 0.11
Race
 White and non-Hispanic Referent Referent
 Hispanic, Latino, or Spanish 1.87 (1.43, 2.47) < .001 1.12 (0.10, 12.88) 0.93
 American Indian, Alaskan Native, or Other Race 1.39 (1.14,1.71) .001 0.48 (0.12, 1.88) 0.29
Health Insurance
 Any Private Insurance Referent 0.016 Referent
 Public Insurance Only or Uninsured 0.82 (0.69, 0.96) 0.53 (0.16, 1.74) 0.29
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Results from the sensitivity analysis of the three household COVID-19 impact domains (social, emotional, infection) showed that for each domain, limited health literacy was associated with a higher adjusted rate of household impact in each domain (social COVID-19 impact domain IRR = 7.21, 95% CI: 2.11–24.66, p = 0.002; emotional COVID-19 impact domain IRR = 5.17, 95% CI: 1.42–18.77, p = 0.013; infection COVID-19 impact domain IRR = 14.78, 95% CI: 1.79–121.79, p = 0.012). Model results for the household social COVID-19 impacts additionally revealed a statistically significant association with being male versus female (IRR: 3.34, 95% CI: 1.21–9.24). Having public insurance or being uninsured was associated with a lower rate of household infection impact (IRR: 0.17, 95% CI: 0.03–0.90, p = 0.037).

Discussion

This study is one of the first to examine associations of health literacy with COVID-19 pandemic impacts on various aspects of personal and family life in a diverse sample of adults living in a rural region of the Southwestern United States. Adults in this study’s sample were found to have had approximately 22 individual impacts and two household impacts of the total 92 COVID-19 pandemic impacts that were assessed. COVID-19 pandemic impacts related to positive change, emotional health and well-being, social activities, and physical health problems were commonplace. Although both bivariate and multivariable analysis showed that participant health literacy level was not significantly associated with individual COVID-19 pandemic impacts, health literacy level was significantly associated with household COVID-19 pandemic impacts. Specifically, limited versus adequate health literacy was associated with more household COVID-19 pandemic impacts on average. Sensitivity analysis results additionally suggest that limited health literacy may be most strongly associated with household social, emotional, and infection impacts. Because household COVID-19 pandemic impacts were reported less frequently than individual impacts overall, household impacts may be indicative of a greater burden or hardship brought about through the pandemic.

Our study’s findings showed that a higher percentage of participants who identified as being BIPOC had limited health literacy and that being BIPOC versus white and non-Hispanic was associated with having more individual COVID-19 pandemic impacts on average, which is similar to a recently published research on associations of race and ethnicity with health literacy and COVID-19 vaccine confidence (12). Although several recent studies show that adequate health literacy is protective in terms of COVID-19-related beliefs (14,28), knowledge (13), and behaviors (16,17,29), this study’s findings did not show adequate health literacy was significantly associated with individual COVID-19 pandemic impacts. Our study’s results also suggest that identifying as male versus female and having public versus private health insurance is related to fewer individual COVID-19 pandemic impacts. This study’s results related to men possibly faring better in terms of individual-level COVID-19 pandemic impacts may be explained, in part, by prior research showing females were more likely than males to have mental distress and greater social, financial, and medical impacts during the pandemic (30). It is additionally possible that some information bias may have been at play as far as men may have felt more societal pressure to report fewer individual impacts than women during a crisis such as the COVID-19 pandemic. Furthermore, being male versus female was associated with a higher rate of household social COVID-19 impact suggesting that males may have experienced greater impacts in certain domains and plausibly felt more comfortable reporting this type of impact at a household versus an individual level. Future research is also needed to tease apart how other household and individual characteristics such as the number of household members and marital status may contribute to the gender effects found in this study (e.g., marital status and number of household members may modify associations of health literacy with individual and/or household impacts). The health insurance findings may be partly due to more than one-third of our study’s sample being 65 years or older and therefore eligible for Medicare, as their public insurance. That is, public insurance in this study was not necessarily a marker of poverty but rather age.

This study’s findings suggest that the use of health literacy screening with the NVS or other time-efficient tools in clinical settings could help to identify individuals who are at the highest risk for adverse impacts brought about through epidemics, pandemics, and other emergency events such as natural disasters (e.g., hurricanes, wildfires). Greater risk mitigation potentially involving emergency preparedness education and other related measures may be undertaken to help individuals with limited health literacy better optimize their health in the face of adversity. Maintaining a universal precautions approach in tailoring and delivering such health education and promotion initiatives (i.e., approaching everyone as though they may have limited health literacy) will remain essential (31). Adopting innovative approaches to deliver health education such as mobile health (mHealth) options, including gaming through phone apps, may also be a promising approach to building electronic health (eHealth) literacy and reducing risk related to limited health literacy in crises (32). Intervention models to enhance health literacy and health consciousness in crises may also help to reduce adverse impacts and address infodemics. Some recent research additionally indicates that interventions incorporating peer-to-peer learning and other trusted sources to deliver health education may be especially helpful in increasing health literacy related to the COVID-19 pandemic (33,34).

It is also important to address the current shortage of healthcare professionals across the country, especially in Northern Arizona. Healthcare professionals (e.g. primary care, dental health, & mental health) play an important role in counseling individuals regarding their health as well as the impact of pervasive health-related problems such as COVID-19 (35). Areas where these shortages are most concentrated are Health Professional Shortage Areas (HPSAs). The Health Resources and Service Administration reports that there are around 74 million people living in 7,456 HPSAs nationwide with 613 of those areas belonging to Arizona alone (36). Health literacy-boosting interventions targeting clinicians and trainees may also be important during epidemics and pandemics to reduce the spread of misinformation (37) and to help ensure healthcare workers take recommended infection control precautions themselves (38).

Limitations

Despite drawing random samples of adult patients from two federally qualified health centers in Northern Arizona, this study’s sample self-selected (opted in) to participate. This may, in part, explain the older age and the lower percentage of adults (19.3%) in our sample with limited health literacy than found in the general U.S. population (10,39,40). Nevertheless, our sample had considerable racial and socioeconomic diversity with approximately 23% of participants identifying as American Indian or Alaska Native, and 52% having public health insurance. Of note, 37% of participants were 65 years or older, which may be important to consider regarding their likely enrollment in Medicare (public insurance regardless of income level). Another limitation of our study is that we did not measure all factors potentially contributing to health literacy and individual and household COVID-19 pandemic impacts (e.g., household income, participant education, political ideology). We also did not measure COVID-19 or epidemic/pandemic health literacy more specifically, which may have contributed to the nonsignificant association between the general health literacy level measured by the NVS and individual COVID-19 pandemic impacts. Adapting health literacy measures relevant to epidemic/pandemic contexts is an area in which future work is needed (41). Along these lines, we did not examine certain COVID-19 pandemic-related outcomes such as COVID-19 beliefs, knowledge, and behaviors such as vaccine hesitancy or refusal. This may also be a strength of our study as far as we examined many other pandemic impacts.

Conclusion

This study was one of the first to examine associations of health literacy with individual and household COVID-19 pandemic impacts among adults in a rural area of the United States. Biological sex, race and ethnicity, and health insurance type were each significantly associated with individual COVID-19 pandemic impacts. Limited health literacy was significantly associated with higher household COVID-19 pandemic impacts on average. Findings reinforce that health literacy is important to address in preparing for and mitigating impacts from emergency events.

Figure 1b.

Figure 1b.

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Frequency of Social Activities and Home Life COVID-19 Impacts

Figure 1c.

Figure 1c.

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Frequency of Infection History, Physical Distancing and Quarantine, Physical Health Problems, and Emotional Health and Well-Being COVID-19 Impacts

Acknowledgments:

We acknowledge the assistance of Ivonne Garber and Levi Stidham with recruitment and data collection for this study.

Sources of Support:

We also acknowledge the funding support for this project that was provided by the Southwest Health Equity Research Collaborative at Northern Arizona University (U54MD012388), which is sponsored by the National Institute on Minority Health and Health Disparities (NIMHD).

Footnotes

We have no conflicts of interest to declare.

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