Although educational and health disparities in the Delta region are well documented, no other published studies have directly examined the health or nutrition literacy status of residents (5
). The finding that most (52%) participants had a high likelihood or a possibility of limited literacy skills helps establish the scope of health literacy among adults in the Delta region. The proportional sampling of educational achievement and adequate distribution of ages provides reasonable assurance that these nutrition literacy findings are generalizable to the greater Delta region. Although Healthy People 2010
established the objective to improve the health literacy of people with inadequate or marginal literacy skills, this is a developmental objective; therefore, baseline data and targets have not been established (17
The National Assessment of Adult Literacy (NAAL) recently released the first large-scale study of health literacy among approximately 19,000 US adults (18
). The comprehensive assessment examined prose, document, and quantitative health literacy for 3 domains of health and health care information and services: clinical, prevention, and navigation of the health system. Analyses were weighted to represent the total US population. Results indicate that 12% of US adults have proficient health literacy, 53% have intermediate health literacy, 22% have basic health literacy, and 14% have below-basic health literacy. Because of methodologic differences in assessing and scoring health literacy, a precise comparison between the NAAL health literacy findings and our findings is difficult (16
). However, crude comparisons of these national data to our data from the rural Mississippi Delta suggest that health literacy rates in the Delta may differ from those of the general US population. These suggested differences call for further exploration. The NAAL study revealed that health literacy increases with each higher level of educational attainment and that people living below the poverty level have lower average health literacy than do those above it. Our findings, which identify significant relationships between educational achievement and nutrition literacy scores and between income level and nutrition literacy scores, support the NAAL findings. Although our study did not identify race, age, or sex differences between nutrition literacy categories, the NAAL study indicated that blacks have lower average health literacy than whites, adults aged 65 or older have lower average health literacy than younger age groups, and the average health literacy scores for men are lower than those for women (18
In our study, we assessed nutrition information-seeking behaviors and defined seeking as an active and purposeful effort to obtain nutrition information. Our results suggest a clear association between nutrition-seeking behaviors and nutrition literacy. The significant linear-by-linear association with nutrition literacy category and each media source we queried, including television, newspapers/magazines, and the Internet, indicates that nutrition information-seeking increases as nutrition literacy skills increase. Other researchers have studied cancer-related information-seeking behaviors and distinguish seeking behaviors from scanning behaviors, where scanning is defined as passive or casual exposure to information (19
). Scanning for and seeking cancer-related information are unmistakably separate behaviors that have clear associations with sociodemographic characteristics, lifestyle behaviors, cancer knowledge, and several health-relevant outcomes such as fruit and vegetable intake (21
). However, a limitation of our study is that we were unable to specifically distinguish between nutrition information-scanning and information-seeking behaviors. The differences between nutrition information-scanning and information-seeking behaviors and their relationships to nutrition literacy and dietary behaviors warrant further investigation.
The low use of the Internet for general purposes and for seeking information related to nutrition, food, or diet was a finding of this study. The Internet was also the least trusted source of nutrition information. With launch of the www.MyPyramid.gov
Web site, the Internet appears to be the major communication channel used to promote the 2005 Dietary Guidelines and MyPyramid key messages. During the past decade, the Internet has caused a nationwide revolution in health information access, and in national surveys the Internet is consistently ranked among the most popular sources of health information (10
). However, our findings suggest that the Internet is not a frequently used or trusted source of nutrition information among adults in the Delta region. Not only is television viewing more than 4 times higher than Internet use, television is also a more trusted source of nutrition information. These findings suggest that television is a more appropriate media channel for disseminating health and nutrition information for this population and imply a need to increase the number of scientifically based messages related to dietary recommendations provided during television programming. Although trust of nonprint sources (including doctors or other health care providers, television, and family or friends) did not vary among literacy categories, people with lower literacy rated their trust in print sources (including magazines and newspapers) lower than did those in higher nutrition literacy categories. We also noted that people with lower nutrition literacy reported less confidence in getting advice or information about nutrition and rated barriers to seeking nutrition information as higher than did those with adequate literacy. However, the trend was not significant after accounting for covariates. These results identify associations between seeking nutrition information and nutrition literacy. Although the NAAL study did not assess trust, barriers, or confidence in seeking health information, the results indicated that, compared with adults who had higher health literacy, those with lower health literacy receive less information about health from written sources, including the Internet (18
This research was conducted between November 2006 and April 2007, approximately 2 years after release of the Dietary Guidelines in January of 2005 and MyPyramid in April of 2005. Only 12% of the Delta residents surveyed could correctly identify the MyPyramid graphic, and most respondents were not aware of the new 2005 Dietary Guidelines and rated their knowledge as poor. These findings may not be comparable to those for other populations; no other published research has examined the degree to which these new recommendations have reached other populations. Nevertheless, this finding illustrates poor dissemination of nutrition recommendations to this rural region of the Delta, where health disparities are common.
The fact that 82% of participants in this study were classified as overweight or obese, compared with a national average of 66%, illustrates the nutrition- and obesity-related health disparities experienced by this Delta population (21
). Furthermore, considering that people tend to underreport weight, the documented rates of overweight and obesity based on self-reported measures in this study may be understated (22
This study is not without limitations. The primary limitation is that temporality cannot be determined in this cross-sectional design. Furthermore, potential limitations are also imposed by the survey instruments. Validation of the NVS was conducted in a primary care setting where only 5% of the participants were African American (16
). Therefore, use of NVS to assess literacy levels in a community-based setting with mostly African Americans should be accounted for in the interpretation of this study. Although appropriate efforts were taken to establish content and face validity of the modified HINTS instrument, this is the lowest level of validity and also imposes study limitations. Finally, no questions were targeted at exploring access to the Internet. The proportion of participants who had access to the Internet should be assessed and accounted for in future research.
Notwithstanding these limitations, our findings have several implications for practice and policy. First, if awareness of and access to trusted nutrition information is problematic, the likelihood of adopting healthy nutrition recommendations is greatly diminished. If health and nutrition professionals expect to compete with nutrition claims made through television and other types of advertising, they must understand and use appropriate communication channels and overcome barriers to nutrition information use. Second, interpretations of our findings suggest it may be unrealistic to expect people with low nutrition literacy to seek information, regardless of the source. The problem of low nutrition literacy is then partially shifted to nutrition educators to develop and deliver targeted nutrition outreach interventions that deemphasize the use of printed materials and remove the burden on people to seek nutrition information on their own. The complexity of health literacy is affected not only by individual skills but also by the organizations responsible for the delivery of health information and services. Finally, the link between health literacy and disease prevention and health promotion has not been fully explored because most research on health literacy has focused on the health care setting (23
). Because health literacy in the context of primary prevention can affect public health, our study emphasizes the need to understand limited health and nutrition literacy in nonprimary care settings.
These results suggest that the use of technology for health communication is problematic for impoverished rural areas. Understanding the causes and consequences of limited nutrition literacy may help effectively communicate science-based nutrition information and reduce the burden of nutrition-related chronic diseases among members of disadvantaged rural communities. Future studies are needed to 1) evaluate the validity of health and nutrition literacy screening instruments for African American populations in nonprimary care settings, 2) explore the effect of relying on the Internet as a central mode of health communication in impoverished rural regions, and 3) determine if focused attention on nutrition literacy is an effective intervention strategy for reducing the burden of obesity and other nutrition-related chronic diseases among disadvantaged populations with health disparities.