The Association among Literacy, Numeracy, HIV Knowledge and Health-Seeking Behavior: A Population-Based Survey of Women in Rural Mozambique

In 2009, an estimated 22.5 million individuals were living with HIV infection in sub-Saharan Africa, with only 37% of those eligible for treatment receiving antiretroviral therapy. Factors contributing to these disparities have not been well-described, and developing a better understanding of these contributing factors may help to generate new strategies to improve HIV care across resource-limited settings. Literacy skills include an individual's ability to read, write, and comprehend written language, speak and understand spoken language, and understand and use numbers in daily life. Limited literacy, defined as an ability to complete only basic, concrete, and everyday literacy-related tasks, is common in developed nations such as the United States, affecting over 100 million people. Research has shown that literacy is an important independent factor in explaining disparities in many health-related behaviors and outcomes. Among individuals with HIV infection who live in the US, poor literacy skills have been associated with worse HIV knowledge, lower adherence to antiretroviral treatment, and lower likelihood of achieving undetectable viral loads. A study conducted in rural Mozambique aimed to adapt a measure of general literacy and numeracy, the Wide-Range Achievement Test, version 3 (WRAT-3), for use in a Portuguese-speaking country. The study used a provincially representative sample of 3,557 female heads-of-household, who were interviewed from August 8 to September 25, 2010. The survey was translated into Portuguese and the five languages most commonly spoken in the province, and all language versions were piloted prior to the start of the survey. The WRAT-3 was adapted to include word reading and arithmetic subscales, which were administered to the respondents. The study found that illiteracy was common among the respondents, with 50.4% of Portuguese speakers and 93.7% of non-Portuguese speakers unable to read or write. The mean numeracy score corresponded to US kindergarten-level skills, indicating a significant gap in literacy and numeracy skills among the respondents. The study also found that literacy and numeracy skills were associated with education, income, age, and other markers of socioeconomic status. Furthermore, the study found that literacy and numeracy skills were associated with HIV knowledge, but not with HIV testing or receipt of clinic-based prenatal care. The study's findings suggest that limited literacy and numeracy skills are common among women in rural Mozambique and are associated with lower HIV knowledge. The study's results also highlight the need for interventions to improve literacy and numeracy skills among women in this population, in order to improve health outcomes and reduce disparities in HIV care. The adapted WRAT-3 measure used in this study provides a valid and reliable tool for assessing literacy and numeracy skills in non-English speaking populations in sub-Saharan Africa.