Health Literacy in Lower Limb Orthopedic Trauma Patients in Riyadh Saudi Arabia

Turki Abdullah Alajmi1, Hussain Mohammed Alyassein2, Bashah Mohammed Almustanir2, Abdullah Mohammed Altheyab3, Fahad Othman Almehrej4, Faisal Hamad Alnaqa5

1 Prince Mohammed Bin Abdulaziz Hospital & Trauma Center
2 King Saud Medical City & Trauma Center
3 King Faisal Specialist Hospital & Research Center
4 Security Forces Hospital
5 King Saud bin Abdulaziz University of Health Sciences

Conflict-of-interest statement: The author(s) declare(s) that there is no conflict of interest regarding the publication of this paper.

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http: //creativecommons.org/licenses/by-nc/4.0/

Correspondence to: Turki Abdullah Alajmi, Prince Mohammed Bin Abdulaziz Hospital & Trauma Center
Email: Turki--aj@hotmail.com
Telephone: +966 555 404 237

Received: March 1, 2019
Revised: April 6, 2019
Accepted: April 10 2019
Published online: August 28, 2019


Background: Health literacy and knowledge is the persons’ capabilities which allow them to understand basic health information to make their health decisions. Low understanding about the patients own condition is more associated with low medical knowledge and bad disease outcomes. Instructions should be given to patients for recovery to avoid complications.

Aim: To evaluate health knowledge of orthopedic trauma patients regarding their own condition in two level 1 Trauma centers in Riyadh, KSA and the association between health knowledge and patients demographics.

Methods: This cross-sectional study included 102 participants from 2 level 1 Trauma centers in Riyadh, in the period from the 1st of July 2018 to the 30th of September 2018. A survey was given to participants upon discharge after receiving discharge instruction.

Results: 60.8% of the individuals had good knowledge. The mean rank score of males was 53.88, while for females it was 48.71, the highest mean rank was found in the age group 25-30 years old and it was 57.9, the highest mean rank regarding level of education was 56.93 for those with intermediate education and those with monthly income 5000 to 10000 SR had the highest score (64.2).

Conclusion: There was a high prevalence of health knowledge between orthopedic trauma patients regarding their own condition in Riyadh, KSA. Further multi center studies with a larger population should be conducted in order to asses and improve the health knowledge regarding the patients own condition among orthopedic patients and other specialties.

Key words: Health Literacy, Orthopedics, Trauma, Saudi Arabia

© 2019 The Author(s). Published by ACT Publishing Group Ltd. All rights reserved.

Alajmi TA, Alyassein HM, Almustanir BM, Altheyab AM, Almehrej FO, Alnaqa FH. Health Literacy in Lower Limb Orthopedic Trauma Patients in Riyadh Saudi Arabia. International Journal of Orthopaedics 2019; 6(4): 1146-1150 Available from: URL: http://www.ghrnet.org/index.php/ijo/article/view/2672


Health literacy and knowledge became an area of research over the last decade[1]. Health literacy refers to the persons’ abilities which allow the person to process, obtain and understand basic health information to make their health decisions[2], these abilities can be improved by educational programs, however, it can be decreased with increasing age[3].

General health understanding is a poorly targeted factor that affecting public health[4]. Those with very limited health understanding are more associated with low medical knowledge, increased hospitalization, bad control of chronic diseases, infrequent use of preventative services and bad disease outcomes[5-7]. On the contrary, those with adequate health literacy have more effective interactions with their physicians and they can make their appropriate treatment decisions[8,9].

Health literacy of surgical procedures includes the awareness of patients about their conditions, interventions and post-operative treatment plans[1]. The American College of Physicians Foundation has advertised informational cards that can be given to the patients to increase the health literacy level of patients[10]. Patients should be informed about their conditions and the available treatment options, and after surgery, patients should be given instructions for recovery which are essential to avoid complications and to manage their own care[4].

It was found in the US that 33% to 48% of individuals had inadequate health literacy[11-14]. In the United Kingdom, it was found that one in five persons required to understand simple health information[15], while in Canada 60% of adults were found to lack the capacity to understand, obtain health information and lack the ability to make appropriate health decisions[16]. There were several studies reported that many patients had difficulties in comprehending their mediations[17-19], discharge instructions[17-23], and diagnosis[20-23].

It was reported that post-operative adverse events that result from a lack of information transfer was high as 30%[24] and the lack in comprehension leads to low patient satisfaction and compliance[25-27]. Physicians may increase the problem by overestimating patients’ understanding of postsurgical treatment plans and discharge instructions[17]. Calkins et al[28] found that physicians thought that 95% of patients understood when to resume their normal activities, while only 58% of them said that they already understood that.

It was reported that in the orthopedic trauma clinic, the patients who received the text and pictorial intervention had higher mean score in the survey used increasing the patient comprehension can be obtained by using additional education modalities[4]. Berkman et al[29] reported that comprehension of the print material and health literacy was directly associated with health outcomes, where they found that patients who had low health literacy, identified less of their medications. There are few studies that reported about health literacy of patients, so this study aims to evaluate health literacy of orthopedic trauma patients after receiving a printed informational document at the time of discharge.

Materials and methods


This cross-sectional study included 102 participants from two level 1 Trauma centers in Riyadh, the study was conducted in the period from the 1st of July 2018 to the 30th of September 2018. The participants included in this study were admitted with single isolated lower limb traumatic fractures and the patient’s age selected to be 15 years and above. Patients with clinical dementia, psychiatric patients, and patients who were had an impaired judgment were excluded. The survey was given to participants upon discharge after receiving discharge instructions and an appointment included. The survey included 10 questions, 4 demographic questions and 6 questions regarding the patient’s knowledge of his/her own condition.

Statistical analysis

Data were analyzed by using Statistical Package for Social Studies (SPSS 22; IBM Corp., New York, NY, USA). Chi-square test was used for categorical variables. The Mann-Whitney U test was used for the mean rank scoring. P-value <0.05 was considered statistically significant.


The survey was distributed to 130 patients, 9 patients denied to take the survey and 19 patients returned and incomplete questionnaire. The present study included 102 individuals with a response rate of 78.46%, 55 (53.9%) of them were males, while 47 (46.1%) were females. The most common age group was those with age range 18-25 representing 43.1%, followed by those with more than 40years old (17.6%), then those with age range 26-30 years and 31-35 years representing 14.7% and 10.8% respectively and finally those with age less than 18 years and age of 36-40 years which represented 8.8% and 4.9% respectively as shown in figure 1. Most of participants 46 (45.1%) had university level of education, followed by those with secondary level 40(39.2%), while few percents 6.9%, 3.9% and 4.9% were with intermediate or less education level, postgraduate and others respectively as shown in figure 2. The percent of participants who receive monthly income ≤ 5000 SR was 50%, those who receive 5000-10000 SR was 20.6%, while individual with monthly income 10000 to 15000 SR, 15000 to 20000 SR and ≥ 20000 SR represented 9.8%, 11.8%, and 7.8% respectively as shown in figure 3. There were 6 questions in the survey to evaluate the knowledge of the patient’s condition and treatment, the answers of participants about each question are shown in table 1 and figure 1.

Table 1 Answers of participants about health knowledge and understanding questions regarding their own condition.
Question number N (%)
Can you name what bone you broke?
Yes75 (73.5%)
NO27 (26.5%)
Do you know how it was fxed?
Do you know how much weight you can bear on your extremity?
Do you know how long your bone will take to heal?
Are you supposed to be on a medicine to prevent blood clots?
Do you think that Your Doctor gave you enough information about your status?

Figure 1 Age group of the involved participants.

Figure 2 Level of Education of the involved Participants.

Figure 3 Monthly Income of the involved participants.

Figure 4 Participants Answers ( It should show that BLUE IS YES and RED IS NO ) I think it might be a technical error.

Each question the patient answered with yes was equal to 16.66% of the total score, and each question answered with no was given 0% of the total score. Patients who answered 4 or more questions with YES which is were considered to have adequate health knowledge. The overall health knowledge and understanding of patients was evaluated and there were 62 (60.8%) of patients had adequate health knowledge, while 40 (39.2%) had and inadequate understanding regarding their condition. Scoring of questions showed that males had higher mean rank score (53.88) than female (48.71), those in the age range 25-30 years old had the highest mean rank score (57.9) between other age groups, Patients with intermediate education had the highest mean rank score (56.93) and the highest mean rank score was found for those with monthly income5000-1000 SR (64.2), table2.

Regarding presence and absence of health literacy, correlations were investigated with socio-demographics, table3.

Table 2 Mean patient rank score of health knowledge and understanding of their condition
Socio-demographicsMean RankP-value
Age group
< 1837.5 
˃ 4051.67 
Level of education
Intermediate or less56.93 
Monthly income
Less than or = 500046.5 
˃ 2000052.38 

Table 3 Correlation of socio-demographics with presence and absence of health knowledge and understanding.
Socio-demographicsHealth literacy presenceP-value
N (%)  N (%) 
Age group
< 183-4.86-15 
> 4011-17.77-17.5 
Level of education
Intermediate or less2-3.25-12.5 
Monthly income
Less than or =500026-41.925-62.5 
> 200005-8.13-7.5 


The survey of the present study involved 6 questions to investigate the health knowledge and understanding of the patient’s own fracture, in question one the large majority of participants (73.5%) could name the broken bone, while in a previous study 48% only could correctly name their broken bones[17].

In this study, a high percent of patients (64.7%) knew how it was fixed. In the third question, only 27.5% knew how much weight they could bear on their extremity, higher percent 54.8% in another study[17] did not know their weight-bearing status after surgery. In question 4 most of the participants (74.5%) knew the time required for the bone to heal, this percent was very high when compared with the percent obtained from a previous study[17], where 81% of patients didn’t know the time needed for healing. In the fifth question low percent (32.4%) answered correctly regarding prevention of blood clot, while in the last questions, close percents for correct and wrong answers of the patients were obtained.

Our study concluded that a high percentage (60.8%) had an overall adequate health knowledge and understanding, while 39.2% of them didn’t. In a Saudi study, it was found that one-half of Saudi population had a poor knowledge of health literacy[30]. In the US, studies to estimate health understanding were established and it was reported that between 33% to 48% of Americans had inadequate health knowledge[11-14].

In a study on the prevalence of musculoskeletal literacy, it was demonstrated that the prevalence of inadequate musculoskeletal literacy was 34%[2]. It was demonstrated that one-third of patients at two urban public hospitals had inadequate health literacy[31]. It was demonstrated that low understanding of a patient’s general condition was correlated to older adults, low educational level, and people with low-income levels[32]. In the present study, the mean of the score for males were higher (53.88) than that of females (48.71), the opposite was found in a previous Saudi study[30], where it was found that females scored higher than males. Regarding age, the highest score in this study was found for those in the age range 26-30 years old (57.9) than those older than 40 years old (51.67), however, no significances were found, this was in agreement with a Saudi study[30].

Regarding educational level the highest score was found for those with intermediate education (56.93), and no significant difference was found between different education levels and health knowledge scores, this means that education level didn’t influence the comprehension of patients, this was in agreement with a previous study[17], where it was reported that higher education was not significantly correlated to better performance on the questions. In our study, although there was a significant difference in health understanding regarding different monthly income, the low-income wasn’t associated with low scores as it was previously stated[32].

On the contrary to our findings, a Saudi study[30] showed that there was a relationship between health literacy level and gender, age, and educational attainment. In the present study, by scoring and evaluating health literacy between patients, the only significance was found regarding monthly income of patients (P-value=0.03), while no significances were found regarding gender, age groups or level of education.


There was a high prevalence of health knowledge and understanding of ones general condition between patients, this, in turn, will affect positively on their health and making the correct decision for their treatment. Although there was no significant difference regarding health knowledge between different age groups, better health understanding was associated with younger age. The monthly income had an influence on the health literacy. Other studies with a larger population and a multi-center approach are recommended because there are few studies studied health literacy.


The author would like to thank Dr.Marwa Adel for her assistance in process of the biostatistics and statistical analysis.


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