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. 2023 Jan 26;50(2):161–171. doi: 10.1177/10901981221148960

A Psychometric and Relative Importance Evaluation of Health Literacy and Health Consciousness on COVID-19 Preventive Behaviors Among Hispanic Adults

Adriana Espinosa 1,✉
PMCID: PMC9892813  PMID: 36703489

Abstract

Given the COVID-19 pandemic’s disproportionate impact on Hispanic individuals in the United States, research examining modifiable psychosocial correlates of COVID-19 preventive behaviors in this population is warranted. Prior research highlights health literacy and health consciousness as integral for the establishment of health-promoting behaviors. Notwithstanding, very little research has validated theory-based measures for health literacy and health consciousness and no research has investigated their relative importance in explaining behaviors that prevent COVID-19 illness among Hispanic individuals. This information is necessary for informing behavioral interventions seeking to promote the well-being of Hispanic people during the current pandemic and in future ones. This study provides a psychometric evaluation of the General Health Literacy Scale (GHLS) and the Health Consciousness Scale (HCS) and further examines their association with conventional COVID-19 preventive behaviors. Confirmatory factor analyses evaluated the psychometric properties of GHLS and HCS. Four separate hierarchical linear regressions, followed by dominance analyses, estimated the relative importance of health literacy and health consciousness on COVID-19 preventive behaviors, adjusting for sociodemographic characteristics. Both GHLS and HCS achieved adequate psychometric criteria, and holding constant sociodemographic characteristics, positively related to COVID-19 preventive behaviors. Although both health literacy and health consciousness were more important than sociodemographic characteristics in explaining COVID-19 preventive behaviors, health consciousness was most important, exceeding the explanatory power of health literacy in all regressions. COVID-19 public health campaigns that seek to raise health awareness among Hispanic people might prove more effective than campaigns that only seek to improve their health literacy.

Keywords: COVID-19 preventive behaviors, health literacy, health consciousness, dominance analysis

The COVID-19 pandemic has generated many negative health consequences that have been disproportionately experienced by racial/ethnic minoritized individuals in relation to White counterparts (Acosta et al., 2021; Artiga et al., 2021; Cucinotta & Vanelli, 2020). Among the groups disproportionately affected, Hispanic individuals shoulder the highest disease burden. As of February 2022, Hispanic people constituted a larger share of COVID-19 cases (24.8%) than their share of the U.S. population (18.5%; Centers for Disease Control and Prevention [CDC], 2022). In contrast, the share of COVID-19 cases for non-Hispanic (NH) Black individuals was comparable to their share of the U.S. population (12.3% vs. 12.5%). For Asian individuals, the share of COVID-19 cases was lower than their share of the U.S. population (3.8% vs 5.8%) (CDC, 2022).

The disproportionate incidence of COVID-19 cases among Hispanic communities presents a substantial long-lasting public health threat for three major reasons. First, Hispanic individuals of any race constitute the second largest ethnic group in the United States (CDC, 2022; United States Census, 2021). Second, before the World Health Organization officially declared the COVID-19 outbreak a pandemic, Hispanic individuals faced higher risks of chronic morbidity than NH White counterparts (Miller et al., 2018; Odlum et al., 2020; Velasco-Mondragon et al., 2016). Third, the disproportionate negative health consequences of COVID-19 on Hispanic individuals are lingering (Kearney et al., 2021) and if they persist, can have serious demographic and public health consequences, such as a steeper decline in the life expectancy of Hispanic people (Andrasfay & Goldman, 2021).

Given high opposition to COVID-19 vaccines among Hispanic adults (Khubchandani et al., 2021; Webb Hooper et al., 2021), there is a growing urgency for research to understand modifiable psychosocial factors that inform behaviors which prevent the transmission of the SARS-CoV-2 virus, such as wearing masks, practicing social distance, and others. This information can be used to create public health campaigns that promote COVID-19 preventive practices among Hispanic people, regardless of their COVID-19 vaccination status. This information also can inform pandemic preparedness initiatives that effectively address health-promoting practices among Hispanic people in future pandemics.

The Information-Motivation Behavioral Skills model (IMB; Fisher et al., 1996; Fisher & Fisher, 1992), a commonly used model for understanding and addressing health risk behaviors (e.g., Kamb et al., 1998; Rongkavilit et al., 2010; Tsamlag et al., 2020; Walsh, 2019), highlights two individual-level interrelated factors as primary requirements for encouraging behavioral skills and behavioral change. The first factor pertains to the ability to search, understand, and use health-related information (Fisher et al., 1996; Fisher & Fisher, 1992; Misovich et al., 2003). The second factor corresponds to an individual’s health awareness and motivation to change their behavior to improve their health (Fisher et al., 1996; Fisher & Fisher, 1992; Misovich et al., 2003). Together, these factors, also known as health literacy and health consciousness respectively, predict the behavioral skills needed to change one’s behaviors for the sake of promoting one’s health (Fisher & Fisher, 1992; John et al., 2017).

Health Literacy

Health literacy corresponds to the degree to which individuals obtain, process, and understand health information in so much as to make health-related decisions, including the adoption of new health-promoting practices (Berkman et al., 2011; Soto Mas & Jacobson, 2019). Numerous studies document a connection between low health literacy and health risk behaviors such as having a poor diet, low physical activity, and the use of alcohol and tobacco (Aaby et al., 2017; Osborn et al., 2011; Park et al., 2017).

In the context of the current COVID-19 pandemic, a large study conducted in Mexico indicated that higher health literacy was related to higher participation in behaviors that prevent the infection and transmission of COVID-19 (Sánchez-Arenas et al., 2021). In agreement, studies conducted among Hispanic people in the United States document a positive association between health literacy and health-promoting behaviors, including behaviors that protect against COVID-19 infection or illness severity (Cuellar et al., 2021; Velasco-Mondragon et al., 2016). Accordingly, health literacy is an important factor recommended for public health interventions, including those related to the current COVID-19 pandemic (Garcia et al., 2021; Paakkari & Okan, 2020). Within existing health literacy measures, the General Health Literacy Scale (GHLS) is among the most rigorously tied to theory and was specifically designed to assess changes in health literacy resulting from public health interventions (Pleasant et al., 2018).

Health Consciousness

Health consciousness corresponds to an individual’s awareness of their health status, attitudes about their health, and their motivation to alter behaviors for the sake of achieving good health (Chen & Lin, 2018; Gould, 1988, 1990). Individuals high in health consciousness are highly motivated to improve their health and seek to learn methods to use health-related information effectively for the purpose of avoiding disease and promote their overall well-being (Basu & Dutta, 2008; Dutta & Feng, 2007; Lucas et al., 2017). The Health Consciousness Scale (HCS), which conceptualizes health consciousness as a mindset regarding one’s health that in turn influences one’s behaviors (Gould, 1988, 1990), is among the most celebrated measures of health consciousness.

Empirical studies have shown a positive association between health consciousness and having a healthy lifestyle and adhering to medical recommendations, including cancer screening, medication adherence, and the prevention of gum disease (Espinosa & Kadić-Maglajlić, 2018, 2019; Chen, 2009; Chen & Lin, 2018). In agreement, a recent investigation indicated that positive health attitudes and high motivation to safeguard or improve one’s health (i.e., health consciousness) are strongly associated with behaviors that prevent the infection and transmission of COVID-19 (e.g., wearing masks, washing hands; Duan et al., 2022).

Notwithstanding, the literature identifying the role of health consciousness for informing COVID-19 preventive behaviors among Hispanic people in the United States is small. Given the connection between health consciousness and behaviors that prevent chronic illness among Hispanic individuals (Espinosa, 2021), research in this direction is warranted.

The Current Study

As discussed, health literacy and health consciousness are two important factors that aid in the understanding of health preventive behaviors. Nonetheless, no study has assessed which of these two factors is most important in the context of the COVID-19 pandemic among Hispanic individuals. Moreover, studies have seldom examined the psychometric properties of the GHLS and HCS in Hispanic samples, which is necessary to determine the utility of these constructs for informing health among this fast emerging minoritized group. The goals of the current study are (1) to present a psychometric evaluation of GHLS and HCS in a sample of Hispanic adults and (2) to assess the relative importance of these scales for informing COVID-19 preventive behaviors. It is hypothesized that both scales will positively relate to COVID-19 preventive behaviors. Given the lack of literature informing their relative importance, no hypotheses about which of them is most important were generated. It is expected that this exploratory assessment will inform future studies and intervention approaches during the current COVID-19 pandemic as well as in future ones.

Method

Participants and Procedure

Participants for the current study responded to an online survey seeking to identify correlates of COVID-19-related behaviors. The survey ran between July 20 and August 24, 2020, time at which COVID-19 vaccines were not available. Participants were recruited by a large market research organization through loyalty programs, mass-market digital advertising, affiliate networks, and mobile apps. The inclusion criteria corresponded to Hispanic adults (18+ years) of any race who resided in the New York City (NYC) metropolitan area at the time of the study. A total of 272 individuals answered the survey. Validation techniques identified 36 invalid responses as follows: duplicate cases (n = 4), early drop out (n = 4), no variance (n = 12), and questionable response time (n = 16). Invalid cases were removed, yielding an analytical sample of 236 responses. The analytical sample was comparable to the Hispanic population of NYC in terms of age group, sex, and Hispanic nationality (United States Census, 2019).

Participants were between 18 and 85 years old (M = 35, SD = 15.19) and from different Hispanic nationalities, including Mexican (14.0%), Puerto Rican (26.3%), Cuban (2.0%), Dominican (21.5%), Other Central American (3.5%), Other South American (27.8%), and Other (4.9%). Slightly more than half were female (52%) and employed at least part time (52.3%). Less than 20% were college students (19.3%) and for the majority (62.4%), household income was below $60,000, which is lower than the median household income of NYC (United States Census, 2021). This study and all associated procedures were reviewed and approved by the Institutional Review Board of The City University of New York. All participants provided informed consent.

Measures

COVID-19 Preventive Behaviors

Questions assessing participants’ adherence to behaviors that prevent the transmission of the SARS-CoV-2 virus were generated in accordance with CDC recommendations (CDC, 2021). Instructions and response patterns for these questions were modeled after existing health behavior scales (Frank et al., 2007). Specifically, participants were presented with a list of four COVID-19 preventive behaviors and were asked to state on a scale from 1 (not at all) to 7 (very) the degree with which they were successful adhering to them in the past 6 months. The behaviors included wearing masks, washing hands regularly, practicing social distance or abiding by stay-at-home orders, and disinfecting common surfaces. We selected these specific behaviors because these corresponded to CDC recommendations at the time the study took place (CDC, 2021). In this sample, the four items yielded a Cronbach’s alpha estimate of .89.

Health Literacy

Participants answered questions from the GHLS, which is a theory-based scale developed to rigorously assess changes in health literacy during a community-based integrative health intervention in the United States (Pleasant et al., 2018). The measure has five self-reported items assessing the extent to which individuals search for, understand, evaluate, communicate, and act on information about their health. Items are presented in Likert-type scale format ranging from 1 (never) to 4 (always). Sample items include “I understand information about my health” or “I find or look for health information.” Items are averaged to produce a total score ranging from 1 to 4, with higher values indicating more health literacy. Evaluations of the scale’s validity and reliability among 633 intervention participants (92 Hispanic) yielded a Cronbach’s alpha estimate of .80, and significant correlations with health-related attitudes and behaviors (Pleasant et al., 2018). As the psychometric properties of the scale have not been investigated outside of the context in which it was developed, herein we provide a psychometric evaluation of the scale in a community sample of Hispanic adults. In this sample, the items yielded a Cronbach’s alpha estimate of .83.

Health Consciousness

Participants answered questions from the HCS (Gould, 1990), which is a nine-item measure developed from the Self-Consciousness scale (Gould, 1990). The HCS assesses one’s health awareness and willingness to engage in behaviors that improve one’s health. Sample items include “I am very involved with my health” and “I am constantly examining my health.” Items, presented in Likert-type scale format ranging between 1 (strongly disagree) and 7 (strongly agree), are added to create a total score. Higher values imply more health consciousness. The psychometric properties of the scale have been verified in studies, which also have presented a correlation between HCS scores and multiple health behaviors and practices (Gould, 1988, 1990; Marsall et al., 2021). Additional studies have validated the psychometric properties of the scale among racial/ethnic minoritized samples (Espinosa & Kadić-Maglajlić, 2018, 2019). Notwithstanding, no study has validated the HCS in samples of Hispanic participants. In this article, we present a psychometric evaluation of the scale in a sample of Hispanic adults. In this sample, the items yielded a Cronbach’s alpha estimate of .95.

Sociodemographic Characteristics

Participants reported their biological sex (0 = male; 1 = female), age (years), annual household income (1 = less than $10,000; 12 = $150,000+), highest level of education completed (1 = never attended school; 11 = doctoral degree), and employment status (0 = not currently employed; 1 = employed at least part time).

Analytical Approach

Confirmatory factor analyses (CFAs) verified the psychometric properties of GHLS and HCS. The chi-square statistic, root mean square error of approximation (RMSEA), comparative fit index (CFI), Tucker–Lewis index (TLI), and the standardized root mean squared residual (SRMR) established goodness of fit. A good fitting model meets the following criteria: p value for chi-square statistic >.05, RMSEA < 0.06, CFI > 0.95, TLI > .95, and SRMR ≤ 0.08 (Hu & Bentler, 1999; Kim & Bentler, 2006). As recommended, we retained standardized factor loadings of 0.60 or higher (Comrey & Lee, 1992). Convergent validity was assessed by comparing each construct’s reliability (CR) and average variance extracted (AVE) against the benchmarks of 0.70 and 0.50, respectively (Bagozzi & Yi, 1988; Fornell & Larcker, 1981). Finally, discriminant validity was assessed by verifying whether each construct’s AVE was larger than the squared correlation between constructs (Fornell & Larcker, 1981).

After verifying the psychometric properties of GHLS and HCS, three-step hierarchical regressions assessed their associations with each of the four COVID-19 preventive behaviors. The regressions added sex, age, household income, education, and employment to the first step given their relation to health behaviors, including those that prevent COVID-19-related illness severity (Gast et al., 2017; Kearney et al., 2021; Stringhini et al., 2010). The second and third steps added GHLS and HCS, respectively. Changes in the model’s R2 between steps assessed the additional contribution from each step to the model’s fit.

Finally, dominance analysis (DA; Budescu, 1993) ranked GHLS and HCS in terms of their relative association with COVID-19 preventive behaviors, holding constant sociodemographic variables. DA is a statistical approach that estimates the relative strength of correlated predictors in a regression model. There are three steps to DA: (1) subgroups of regressions and corresponding R2 values are estimated for all possible combinations of predictors from the full regression model; (2) pairwise comparisons of all R2 values are performed; and (3) predictor variables are ranked according to the amount of variance each one explains in relation to all others. This process yields three types of dominance: conditional, general, and complete (Azen & Budescu, 2003). Among these, the most rigorous is complete dominance. A variable completely dominates another if it yields an additional R2 that is larger than that of the other variable in all possible regression subgroups. The second and less rigorous form of dominance is conditional dominance. A variable conditionally dominates another if its additional R2, averaged across all regression subgroups that have the same number of predictor variables, is greater than that of the other variable. The least rigorous form of dominance is general dominance. A variable generally dominates another if its overall R2 (averaged across all regression subgroups) is greater than that of the other variable. A major benefit of DA is that it yields robust results among correlated predictors even in the presence of common sources of bias with self-report data such as sampling error and measurement error variance (Braun et al., 2019).

We ensured that the data did not have outliers, or excess skewness and kurtosis. No single item had more than 5.2% missing, and missing cases were missing completely at random (MCAR; χ2 = 2,556.67, df = 3669, p = .99). Missing cases were imputed using the expectation maximization algorithm, which is an unbiased imputation approach if missing cases are MCAR (Lou et al., 2017). Variance inflation factors were no greater than 3.09 (M = 1.80, SD = 0.82), ruling out multicollinearity as a significant source of bias. Finally, probability sampling weights generated from U.S. Census data were used in the analyses, thus reducing sampling error bias.

Results

Psychometric Properties of Health Consciousness and Health Literacy

The CFAs (Table 1) identified one factor for each construct with adequate fit criteria, HCS: χ2(16) = 24.87, p = .07, RMSEA = .048, p = .49, CFI = .99, TLI = .99, SRMR = .02 and GHLS: χ2(2) = 3.26, p = .17, RMSEA = .058, p = .34, CFI = .99, SRMR = .02. The standardized factor loading for the first item of the GHLS measure was lower than .60 so we excluded this item (Comrey & Lee, 1992). All retained items’ factor loadings were statistically significant. The AVE and CR values for each construct exceeded the recommended benchmarks, yielding adequate convergent validity and construct reliability. We created scores for each construct as the average of all corresponding items. The correlation between the scored HCS and GHLS variables was positive and strong (r = .70, p < .001). The square correlation (.49) was lower than each construct’s AVE (.69 and .54), thus confirming discriminant validity.

Table 1.

Confirmatory Factor Analyses of Health Literacy and Health Consciousness Measures.

Health literacy scale (GHLS) β SE
Understand information about your health .65*** 0.04
Evaluate how health information relates to your life .86*** 0.03
Communicate about your health to others .63*** 0.05
Act on information about your health .78*** 0.04
χ2(3) 3.56
RMSEA (p RMSEA < .05) 0.058 (0.34)
CFI 0.99
TLI 0.98
SRMR 0.02
AVE 0.54
CR 0.82
M (SD) 2.95 (0.69)
Health Consciousness Scale (HCS)a β SE
I reflect about my health a lot .77*** 0.03
I’m very self conscious about my health .80*** 0.02
I am generally attentive to my inner feelings about my health .85*** 0.02
I am constantly examining my health .83*** 0.03
I’m alert to changes in my health .86*** 0.02
I’m usually aware of my health .82*** 0.02
I’m aware of the state of my health as I go through the day .82*** 0.02
I notice how I feel physically as I go through day .87*** 0.02
I am very involved with my health .87*** 0.02
χ2(16) 27.87
RMSEA (p RMSEA < .05) 0.048 (.49)
CFI 0.99
TLI 0.99
SRMR 0.02
AVE 0.69
CR 0.95
M (SD) 5.05 (1.47)
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Note. The one-factor model incorporating all items from both constructs yielded a worse fit than the CFAs for each construct separately: χ2(77) = 482.40, p < .001, RMSEA = 0.15, CFI = 0.85, and SRMR = 0.07. CFA = confirmatory factor analysis; GHLS = General Health Literacy Scale; RMSEA = root mean square error of approximation; CFI = comparative fit index; TLI = Tucker–Lewis index; SRMR = standardized root mean squared residual; AVE = average variance extracted; CR = construct reliability; M = mean of scored construct; SD = standard deviation of scored construct; χ2 = chi-square statistic comparing model with saturated presented.

a

Standardized factor loading for first item of scale was below 0.60 and not retained.

***

p < .001.

Bivariate Associations

Pearson correlations appear in Table 2. All COVID-19 preventive behaviors positively and strongly correlated with each other. These preventive behaviors also positively correlated with GHLS and HCS. The latter were positively related to household income. GHLS was also positively related to education level. Finally, practicing social distance positively correlated with household income.

Table 2.

Pearson Correlations Between COVID-19 Preventive Behaviors, Health Literacy, Health Consciousness, and Sociodemographic Characteristics Among Hispanic Individuals (N = 236).

Model variables 1 2 3 4 5 6 7 8 9
1. Washing hands — .75*** .77*** .59*** .30*** .43*** −.06 .07 −.03
2. Avoiding contact/stay at home — .76*** .59*** .34*** .48*** .10 .09 .15*
3. Wearing a mask — .62*** .30*** .37*** .02 .05 .07
4. Disinfect common surfaces — .41*** .47*** .09 .06 −.00
5. Health literacy (GHLS) — .70*** −.00 .27*** .14*
6. Health consciousness (HCS) — .04 .20** .08
7. Age — −.01 .08
8. Household income — .42***
9. Education —
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Note. GHLS = General Health Literacy Scale; HCS = Health Consciousness Scale.

*

p < .05. **p < .01. ***p < .001.

Hierarchical Regressions

The first step of the hierarchical regressions (Table 3) yielded several significant associations between sociodemographic characteristics and COVID-19 preventive behaviors. Age was positively related to avoiding close contact/following stay-at-home orders and disinfecting common surfaces. Higher household income was associated with washing hands regularly and disinfecting common surfaces. Finally, higher education was related to avoiding close contact or following stay-at-home orders and to disinfecting common surfaces. These variables explained between 4% and 13% of the variance in the outcomes.

Table 3.

Hierarchical Regressions of COVID-19 Preventive Behaviors, Sociodemographic Characteristics, Health Literacy, and Health Consciousness Among Hispanic Individuals (N = 236).

Washing hands regularly Avoiding close contact/following stay-at-home orders Wearing a face mask in public Disinfecting common surfaces
Variables b β b β b β b β
Step 1
 Female −0.07 −0.02 −0.11 −0.04 0.13 0.05 0.41 0.13
 Age −0.01 −0.05 0.01* 0.14 0.01 0.12 0.02** 0.17
 Household income 0.10* 0.19 0.05 0.11 0.02 0.04 0.09* 0.19
 Education 0.00 −0.01 0.19** 0.25 0.12** 0.21 −0.00 −0.00
 Employed −0.02 −0.01 0.06 0.02 0.04 0.01 0.42 0.13
 F(5, 228) 1.97 6.85*** 2.89* 3.78**
 R2 .04 .13 .06 .08
Step 2
 Health literacy (GHLS) 1.15*** 0.51 1.18*** 0.54 0.73*** 0.41 1.28*** 0.60
 F(6, 227) 13.12*** 22.55*** 9.63*** 22.49***
 ΔR2 .21*** .24*** .14*** .30***
Step 3
 Health consciousness (HCS) 0.34* 0.32 0.51*** 0.50 0.23** 0.28 0.37*** 0.37
 F(7, 226) 15.90*** 28.27*** 9.83*** 23.79***
 ΔR2 0.06** 0.09*** 0.03** 0.05***
 Final R2 .31 .46 .23 .42
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Note. Unstandardized (b) and standardized (β) coefficients reported. Δ = change; GHLS = General Health Literacy Scale; HCS = Health Consciousness Scale.

*

p < .05. **p < .01. ***p < .001.

In the second step, GHLS positively related to all preventive behaviors, yielded significant increments in R2 in every regression, and captured 14% to 22% of the variance in COVID-19 preventive behaviors beyond that which was captured by step 1. In the final step, HCS also positively related to all COVID-19 preventive behaviors and yielded significant increments in R2. HCS captured 3% to 9% of additional variance for COVID-19 preventive behaviors. All variables combined explained between 23% and 46% of the variance of COVID-19 preventive behaviors.

Dominance Analysis

Table 4 provides dominance statistics, percent contribution to the model’s R2, and rankings for GHLS and HCS in the regression models. The analyses ranked HCS and GHLS as the most influential variables. The percent contribution of HCS was greater than that of GHLS, with HCS contributing between 6 and 21.2 percentage points more than GHLS. Furthermore, the standardized average R2 corresponding to HCS across all regression subgroups was greater than that of GHLS for all COVID-19 behaviors, highlighting HCS as generally dominant over GHLS. In addition, the R2 values averaged across all regression subgroups with the same number of predictors were higher for HCS than for GHLS, indicating that HCS conditionally dominated GHLS. Finally, the marginal contribution of HCS in all regression subsets was larger than that of GHLS, designating HCS as completely dominant over GHLS.

Table 4.

Dominance Analysis Identifying the Relative Importance of Health Literacy and Health Consciousness on COVID-19 Preventive Behaviors (N = 236).

Dominance analysis statistics Washing hands regularly Avoiding contact/following stay-at-home orders Wearing a face mask in public Disinfecting common surfaces
Health literacy Health consciousnessa Health literacy Health consciousnessa Health literacy Health consciousnessa Health literacy Health consciousnessa
General dominance statistic 0.12 0.17 0.13 0.23 0.08 0.10 0.18 0.20
% Contribution to model’s R2 37.0% 53.2% 27.5% 48.7% 33.5% 44.2% 41.9% 47.8%
Conditional dominance statistic
 1 predictor 0.23 0.29 0.27 0.38 0.15 0.18 0.34 0.37
 2 predictors 0.19 0.24 0.21 0.32 0.12 0.15 0.28 0.31
 3 predictors 0.15 0.20 0.16 0.26 0.10 0.12 0.22 0.25
 4 predictors 0.11 0.16 0.12 0.22 0.07 0.10 0.17 0.20
 5 predictors 0.08 0.13 0.08 0.18 0.05 0.08 0.12 0.14
 6 predictors 0.05 0.09 0.05 0.14 0.03 0.05 0.08 0.10
 7 predictors 0.01 0.06 0.01 0.09 0.01 0.03 0.03 0.05
Rank among all regression variables in full model 2 1 2 1 2 1 2 1
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Note. Table reports results from the dominance analysis of the regression model from Table 3. GHLS = General Health Literacy Scale; HCS = Health Consciousness Scale.

a

Health consciousness (HCS) completely dominated health literacy (GHLS) in all regression models.

Discussion

Hispanic communities have disproportionately faced high disease-related burdens due to the COVID-19 pandemic (CDC, 2022). In tandem, COVID-19 vaccine hesitancy is high among Hispanic people (Kearney et al., 2021). Thus, research that explores key factors that promote the adoption of COVID-19 preventive behaviors among Hispanic individuals, regardless of their COVID-19 vaccine acceptance, is necessary for the creation of public health campaigns tailored for this population. Theoretical health frameworks highlight health literacy and health consciousness as two key and interrelated factors that promote behaviors that prevent chronic illness (Fisher et al., 1996; Fisher & Fisher, 1992; Misovich et al., 2003). In agreement, the emerging empirical research indicates that these constructs, particularly health literacy, are important for informing health practices among Hispanic and other minoritized individuals in multiple contexts (Calvo, 2016; Espinosa & Kadić-Maglajlić, 2018, 2019; Key, 2019; White et al., 2013). Yet, the empirical evidence in the context of the current COVID-19 pandemic is small, including research evaluating the psychometric properties of commonly used measures and identifying which of these two factors is most important for understanding COVID-19 preventive behaviors among Hispanic people. Using a community sample of Hispanic adults in New York City, the current study examined the psychometric properties of the GHLS (Pleasant et al., 2018) and the HCS (Gould, 1990) and assessed their relative association with COVID-19 preventive behaviors.

CFAs indicated that both constructs were valid and reliable in the sample. As hypothesized, hierarchical regressions indicated that both health literacy and health consciousness were strongly related to higher hand washing, use of face masks, social distancing/following stay-at-home orders, and the disinfecting of common surfaces. Furthermore, both factors explained a significant amount of variance in COVID-19 preventive behaviors above and beyond sociodemographic characteristics. These findings are in accordance with emerging research highlighting both health literacy and health consciousness as important correlates of COVID-19 preventive behaviors (Cuellar et al., 2021; Duan et al., 2022; Sánchez-Arenas et al., 2021; Velasco-Mondragon et al., 2016). Moreover, this study presents additional evidence regarding the association between these factors and COVID-19 preventive behaviors among Hispanic people. Thus, the findings highlight the applicability of factors theorized within the IMB framework (Fisher & Fisher, 1992) for explaining illness prevention among Hispanic individuals in the context of the current pandemic.

Notwithstanding, the findings show that health consciousness explained the variance of COVID-19 preventive behaviors above and beyond that which was explained by sociodemographic characteristics and health literacy combined. More importantly, dominance analyses indicated that health consciousness overpowered the explanatory role of health literacy. These findings add to our understanding of correlates of COVID-19 preventive behaviors among Hispanic adults and highlight the robust role of psychosocial factors as important individual-level determinants of health behaviors that future research should explore in addition to other well-recognized social determinants (Mills et al., 2020; Nutbeam & Lloyd, 2020; Ramírez García, 2019; Schillinger, 2020).

Since the outbreak of SARS-CoV-2, which led to the COVID-19 pandemic, public health officials and researchers alike have developed multiple communication campaigns aiming to mitigate the spread of COVID-19 worldwide. Campaigns tailored for Hispanic populations in the United States predominantly center on improving COVID-19-related literacy and behavioral skills, while raising awareness about the Hispanic population’s vulnerability to the virus (Calo et al., 2020; Ramirez, 2020; Sukumaran, 2021). Our study’s findings indicate that campaigns, which also address psychological influences such as health consciousness, may prove more successful than campaigns focusing on health literacy alone at encouraging behaviors that prevent the illness and transmission of COVID-19 among Hispanic people.

In the context of sociodemographic variables, regressions indicated that age, income, and education were correlates of COVID-19 preventive behaviors. The findings indicated that older individuals were more likely than younger counterparts to engage in behaviors that prevent the transmission of COVID-19. These findings agree with evidence highlighting Hispanic young adults as a group that, due to poor health prevention practices, face the highest risks of chronic morbidity in the long run (Gast et al., 2017; Kearney et al., 2021; Thomas et al., 2016). Similarly, and in accordance with the literature on social determinants of health (Schillinger, 2020; Stringhini et al., 2010), higher income and education were related to higher COVID-19 preventive behaviors. As the Hispanic population is heterogeneous in sociodemographic characteristics (Zambrana et al., 2021), the results from this study underscore the importance of incorporating the role of sociodemographic influences in public health campaigns tailored for Hispanic communities.

Limitations, Strengths, and Implications

A few limitations are important to highlight. First, the cross-sectional design of the study does not allow for causal interpretations of the results. Second, the results rely on self-reported data, which is subject to recollection and social desirability biases. Third, because this study took place before any COVID-19 vaccines were available, the findings may not inform COVID-19 vaccine acceptance. Despite these limitations, this study is the first to present evidence corresponding to salient modifiable factors that are most influential for informing recommended COVID-19 preventive practices among Hispanic adults. Findings can inform the creation of public health campaigns aiming to improve COVID-19 prevention in Hispanic communities. Moreover, findings from this study can provide new information for the development of pandemic preparation guidelines for Hispanic people during future public health crises.

Footnotes

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by a PSC-CUNY grant (#63494-00 51, PI: Espinosa).

Ethical Standards: The author asserts that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. All associated procedures were approved by the Institutional Review Board of The City College of New York.

ORCID iD: Adriana Espinosa Inline graphichttps://orcid.org/0000-0003-1117-8595

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