Text box 1. Contributions to the literature

• Nutrition literacy is closely related to dietary habits and many chronic NCDs, but few people are concerned about their nutrition literacy levels, and this study will help to evaluate the nutrition literacy levels of healthcare workers, an important group in society.

• NL-SF12 appears to be a valid and reliable instrument for assessing the nutrition literacy of medical personnel.

• There is an urgent need for decision-making on nutrition literacy among male health workers.

Introduction

In the current healthcare environment, the nutrition literacy (NL) of medical personnel has become a significant topic. Particularly in tertiary hospitals, which are high-level centers of medical service, medical personnel not only bear a heavy workload but also play a crucial role in disseminating public health education. The NL of medical personnel in tertiary hospitals directly impacts their work efficiency and service quality and subsequently affects patient recovery outcomes and the implementation of health promotion activities.

In recent years, with changes in lifestyle and an increase in the incidence of chronic diseases, nutrition issues have gained increasing attention from the public and medical community. Unhealthy diet is one of the major risk factors for Noncommunicable diseases (NCDs), such as diabetes, hypertension, heart disease, cancer, and other conditions linked to obesity, which accounts for 71% of all deaths worldwide [1]. The 2030 Agenda for Sustainable Development regards NCDs as a major challenge for sustainable development [2]. World Health Organization (WHO) recommends that we have a healthy diet like reducing the intake of saturated and trans fats to help preventing a range of diet-related NCDs [3,4,5,6]. Nutrition literacy is closely related to healthier dietary habits. Hence, those with high NL levels may make better nutrition-related decisions [7,8,9,10].

NL is an important aspect of health literacy, NL is mainly about the understanding, acquisition, and correct application of nutrition knowledge [11]. NL is affected by many factors including internal factors and external factors. Among college students, NL is related to their gender [12], birthplace, and nutrition education [13]. The change in health behavior is often affected by the surrounding environment. To effectively modify behavior, it’s crucial to first identify the factors influencing it. This understanding can enhance the application of ecosystem theory within the health sector [14]. Additionally, methods for assessing NL are crucial in public health and clinical practice. Considering the burden of surveys, NF-SF12 offers an efficient and practical solution [15]. This scale includes only 12 items, covering key areas such as cognition and skills. Although simplified, these scales require rigorous testing to ensure they effectively measure NL.

In recent years, researchers have concentrated studies on NL among college students, pregnant women, and the elderly [16,17,18,19]. Medical personnel are the indispensable group in society, especially in the last three years of the COVID-19 pandemic. Good nutritional status is essential not only for individual health but also a key factor in improving the quality and efficiency of medical services [20]. Therefore, enhancing the NL of medical personnel, especially those on the front lines of medical service provision, is particularly important. However, existing research shows that despite their expertise in medical knowledge, medical staff often lack sufficient nutrition literacy, which could affect their professional performance and their nutritional guidance to patients [21].

This study aims to explore the level of NL among medical personnel in tertiary hospitals, analyze its influencing factors, and propose strategies and recommendations to improve their nutrition literacy, thereby enhancing the overall quality and efficiency of medical services. By conducting a comprehensive assessment of the nutritional knowledge, attitudes, and behaviors of medical personnel in tertiary hospitals, this research hopes to provide data support and empirical suggestions for hospital management and policymakers, offering a basis for optimizing the healthcare service system and advancing the formulation and implementation of public health policies.

Materials and methods

Study design and setting

This cross-sectional study was implemented from May to July 2022 in Bengbu, China. Firstly, we selected all tertiary hospitals in Bengbu City using whole cluster sampling, and then 4–5 departments were randomly selected from the seven tertiary hospitals.

Participants and procedure

All medical personnel in 4–5 randomly selected departments were surveyed. Inclusion criteria for the study population: (1) being active hospital employees; (2) voluntary participation in the survey. This study was approved by the Ethics Committee of Bengbu Science & Technology Bureau (20220139). Informed consent was obtained from all participants.

Sample size

Take the sample size calculation method to calculate the minimum sample size required:

$$\:N=\frac{{\mu\:}_{\alpha\:}^{2}P(1-P)}{{\delta\:}^{2}}\times\:deff$$

N is the sample size, when α = 0.05, µ = 1.96, P is 30% of the pre-survey NL rate for medical personnel, δ = 0.15*P, as calculated, N = 799. Considering the presence of incomplete questionnaires, a minimum sample size of 879 individuals is necessary, assuming a 10% non-response rate.

Nutrition literacy assessment

The 12-item Short-Form Nutrition Literacy Assessment Scale (NL-SF12) [15] was performed to assess the level of NL. The scale was simplified from the Nutrition Literacy Assessment Scale for adults [22] developed by our research group in the previous period, including cognitive domains and skill domains, three dimensions of functional, interactive and critical NL, and six dimensions of knowledge, understanding, obtaining, applying, interactive skill, and critical skill, with each dimension containing two items. Each item was rated on a 5-point Likert-type scale i.e.1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree. For example, item 1: balanced diet and reasonable nutrition are important measures to prevent and control chronic diseases such as diabetes and hypertension; item 2: steaming and boiling are healthier ways of cooking than frying and grilling. A high score on these two items indicates a given level of nutrition knowledge. The level of total NL was judged by adding up the sum of the scores for each item, high scores indicated a high level of NL, in addition, according to the median of the NL score, the scores will be divided into two groups, i.e., high-level NL group and low-level NL group. The reliability of the scale in this study showed that Cronbach’s α was 0.907.

Demographic characteristics

General demographic characteristics were also included in the questionnaire, such as gender, marital status (married, unmarried, and others), the status of children born (one child, two children, and infertile or others), education level (associate degree or below, bachelor’s degree, and master’s degree or above, career (doctor, nurse, other technical personnel such as pharmacists and inspector, and administrative personnel), professional and technical title (primary and below, middle level, and high-level professional title), number of years working (below 5 years, 5–10 years, 10–15 years, and above 15 years), average monthly income (below 5,000 CNY, 5,000–8,000 CNY, 8,000–10,000 CNY, and above 10,000 CNY).

Statistical analysis

All data was entered into Epidata version 3.1. Measurement data were summarized as mean ± standard deviation. Categorical variables were expressed as frequency and percentage. Descriptive statistics were performed to determine the distributions of total nutrition literacy and the two domains and three levels. Confirmatory factor analysis (CFA) was carried out to evaluate the construct validity of NL-SF12. Several fit indexes were calculated, including adjusted goodness-of-fit index (AGFI), comparative fit index (CFI), incremental fit index (IFI), Tucker-Lewis index (TLI), normal fit index (NFI), and goodness-of-fit index (GFI), with their values above 0.9 considering satisfactory [23]. Internal consistency was assessed by 0.70 of Cronbach’s α value for satisfactory reliability [24]. The chi-square test was applied to test for differences in the groups. Logistic regression analysis was conducted to evaluate influencing factors of total NL and two domains and three levels. All statistical analyses were performed by using SPSS (Version 26.0) and AMOS (Version 24.0). A P value of < 0.05 was considered to be statistically significant.

Results

Participant characteristics

A total of 1,185 medical personnel completed the survey. Invalid questionnaires provided by 25(2.1%) medical personnel were excluded. As Table 1 showed, a total of 1,160 medical personnel were included in the study, the average age of participants was 36.37 (SD = 8.79) years. Of these participants, 34.22% were male and 65.78% were female, 41.03% were doctors, 42.16% were nurses, 18.36% had received an associate degree or below, 68.71% had received bachelor’s degree, 12.93% had received master’s degree or above, 19.74% had average monthly income of < 5,000 CNY

Table 1 General demographic characteristics of medical personnel (N = 1160)
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Validation of the NL-SF12 scale for the medical personnel

A CFA was conducted to examine the structural validity of the NL-SF12, Table 2 showed good model-data-fit and the values of AGFI, CFI, IFI, TLI, NFI, and GFI ranged from 0.91 to 0.97. The result of convergent validity was reported in Table 3, the values of average variance extracted (AVE) and composite reliability (CR) were greater than 0.5 and 0.6, indicating that NL-SF12 has good convergence validity. Cronbach’s α was 0.907 for the NL-SF12 among medical personnel, suggesting a good internal consistency reliability.

Table 2 Construct validity of the NL-SF12 with goodness-of-fit indices
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Table 3 The results of AVE and CR in NL-SF12
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NL level of medical personnel

In our study, 45.68% of medical personnel have a high overall level of NL. In the cognitive domain and skill domain, 47.84% and 43.97% of medical personnel are of a high level. Comparing the three levels, it was found that 46.03% of medical personnel are of a high level at the functional level, and only 24.22% and 17.93% of the medical personnel had high levels at the functional interactive and critical levels.

NL levels of medical personnel with different characteristics

Table 4 illustrated the frequency and proportion of medical personnel with different characteristics who are at a high level of NL, as well as their distribution by gender, marital status, status of children born, education level, career, etc. The results of the study presented that females had higher levels of NL than males in the cognitive domain and skill domain, and the difference was statistically significant. Medical personnel with a master’s degree or higher had a higher level of NL in the cognitive domain than other participants (χ2 = 24.68, P<0.001).

Table 4 Nutrition literacy levels of medical personnel with different characteristics
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Factors affecting the NL of medical personnel

Multiple logistic regression analysis was performed with the level of NL as the dependent variable and general demographic characteristics such as gender, marital status, status of children born, career, professional and technical title, years of working experience, and average monthly income as independent variables (Table 5). The results showed that females reported higher levels of total NL (OR = 1.47, 95% CI: 1.08–1.98), cognition domain (OR = 1.66, 95% CI: 1.22–2.24), skill domain (OR = 1.48, 95% CI: 1.09-2.00) and interactive NL (OR = 2.21, 95% CI: 1.53–3.19) than male. In addition, medical personnel who possessed a master’s degree or above reported higher levels of total NL (OR = 2.20, 95% CI: 1.33–3.65) and cognition domain (OR = 3.23, 95% CI: 1.94–5.37) than associate degree or below. It was worth mentioning that pharmacist and inspector technical personnel reported higher levels of total NL (OR = 1.55, 95% CI: 1.06–2.26), functional NL (OR = 1.49, 95% CI: 1.02–2.17), and interactive NL (OR = 1.54, 95% CI: 1.00-2.36) than doctor. We also found that medical personnel with between 10 and 15 years of working experience had lower levels of total NL (OR = 0.55, 95% CI: 0.33–0.93) and functional NL (OR = 0.58, 95% CI: 0.34–0.96) than those with less than 5 years of working experience.

Table 5 Multivariate analysis for variables associated with total NL and two domains and three levels among medical personnel
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Discussion

Validation of the NL-SF12 scale for the medical personnel

The NL-SF12 scale was administered for the first time to medical personnel, which is one of the innovations of this study. CFA has been recognized as a common method for validating the validity of scale constructs [25,26,27]. As we have seen, the NL-SF12 scale has good reliability and validity among medical personnel. Specifically speaking, the model fit indices for this scale were all greater than 0.9, indicating the scale is well structured [23]. The values of AVE were greater than 0.5, indicating that NL-SF12 has a good fit [28, 29]. This is also a good basis for rationalizing the use of measurement tools in the research.

NL level of medical personnel

This study shows that nearly half of the medical personnel (45.68%) possess a high overall level of NL. This result indicates that most medical personnel have a good grasp of nutritional knowledge, which they can apply in their practical work. High levels of NL are crucial for improving the quality of patient care and promoting health management. This is also consistent with previous studies [30,31,32,33]. In the cognitive (47.84%) and skill domains (43.97%), nearly half of the medical personnel exhibited high levels. This may reflect the effectiveness of medical education and continuous training in enhancing the understanding and application skills of nutritional knowledge among medical personnel. However, the proportion of medical personnel exhibiting high levels in the interactive (24.22%) and critical (17.93%) domains is relatively low. This indicates potential deficiencies among medical personnel in using nutritional knowledge for deeper communication and critical thinking. The interactive domain requires medical personnel to effectively communicate nutritional information with patients or colleagues; the critical domain requires them to evaluate and integrate complex nutritional information and make scientific judgments [34,35,36].

Evaluation of NL levels of medical personnel with different characteristics

NL is closely related to social factors [37]. Both internal and external factors may affect the acquisition and utilization of nutritional knowledge. Overall, 34.22% of the medical personnel recruited in our study were male and 65.78% were female. Within the healthcare industry, females are likely to be in the majority in nursing fields, which are often more closely associated with the dietary and nutritional management of patients. However, this is not uncommon, and it has been shown in many studies of medical personnel [38,39,40,41].

In previous studies [42,43,44,45], it is not difficult to find that females show an advantage in NL. In our study, it was found that the NL level of females in cognitive and skill domains was significantly higher than that of males, because females are more likely to choose a healthy and balanced diet [46]. In another word, females are largely influenced by socio-cultural factors and pay more attention to appearance and health, so they pay more attention to diet and nutrition [47]. This further reveals gender disparities in nutritional education and health awareness. But there is no difference between females and males in the critical NL. Critical NL is a capability that involves an individual’s critical thinking skills in acquiring, processing, and evaluating nutrition-related information [48]. This literacy encompasses understanding basic nutritional knowledge and assessing the sources of nutrition information, understanding the scientific basis and potential conflicts of interest behind nutritional advice, and making informed nutritional choices in everyday life. Most people are deficient in nutritional knowledge judgment. People focus mainly on nutritional knowledge but do not make good use of this knowledge in their lives and work, such as how to use nutritional labels to judge the nutritional value of food [49]. However, the presence of this phenomenon among medical personnel will also hinder the transmission of nutritional information to patients or their families. In an era where information is abundant and food advertising is ubiquitous, the development of critical NL competencies, such as information assessment skills, scientific understanding, health decision-making, and advocacy and action, is essential for improving public health and helping people make informed and rational nutritional choices in a complex and variable information environment. Healthcare providers and the education sector should strengthen NL education in their daily work, focusing on capacity-building, while feedback and evaluation mechanisms should be put in place to ensure that educational activities are in line with the actual improvement of the capacity of healthcare workers to critical assess NL.

There is a close relationship between educational level and NL [50]. Individuals with higher education levels tend to be more health-conscious, including in their diet and nutrition. Higher medical education usually includes nutrition courses, enabling healthcare professionals with higher education levels to better understand the importance of nutrition both theoretically and in practical application. Such courses often cover various aspects, including the functions of NL, the establishment of healthy eating habits, and the relationship between nutrition and diseases [51, 52]. Medical personnel often participate in continuing education and professional development courses throughout their careers. These courses help them update and expand their knowledge of nutrition. Healthcare professionals with higher education levels are more likely to enhance their professional skills through such courses.

One of the interesting things about our results is that the level of interactive NL of administrative personnel was higher than that of other personnel. This was not present in the other studies. Administrative personnel may have more opportunities to communicate with colleagues about food choices and which diets are healthier. However, the study did not show a correlation between nutrition literacy and working years or average monthly income. In addition, they are exposed to more nutrition-related policies [53].

Limitations

In this study, the NL-SF12 was first used to comprehensively assess the level of NL among medical personnel and to capture the main factors influencing the level of NL. There are also some limitations in this study. Firstly, the study sample was mainly from tertiary hospitals in the Bengbu area, and the results may not apply to other areas or different levels of healthcare organizations; secondly, this is a cross-sectional study, which is not able to determine causality, but can only reveal associations between the variables; and thirdly, the healthcare professionals who took part in the study may have a higher level of health awareness, which may lead to positive bias in the results. Fourthly, the sample size should be expanded to allow for more accurate identification of NL levels for different characteristics. Finally, clarifying these limitations not only helps to interpret the results more objectively, but also provides directions for improvement in future studies.

Conclusions

The study found that female medical personnel reported higher levels of total NL, cognition domain, skill domain, and interactive NL compared to males. Therefore, gender significantly influences NL levels among medical personnel. Medical personnel with a master’s degree or above demonstrated higher levels of total NL and cognition domain compared to those with an associate degree or lower. This indicates that higher education levels contribute to a better understanding and application of nutrition knowledge among healthcare professionals. Pharmacists, inspectors, and other technicians exhibited higher levels of total NL and functional NL. This may be associated with the nature of their professions and their specific needs for nutrition knowledge. Gender, education level, and career were identified as significant influencing factors of nutrition literacy among medical personnel. Understanding and considering these factors are crucial for developing targeted strategies to enhance nutrition literacy among healthcare professionals. Future efforts to improve nutrition literacy through training and interventions should be tailored to the characteristics of different groups, e.g., focusing on groups such as males and those with less than a master’s degree in education, in order to effectively improve the competence and capacity of healthcare workers in terms of nutritional knowledge and practice.