{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,17]],"date-time":"2026-07-17T06:06:46Z","timestamp":1784268406264,"version":"3.55.0"},"reference-count":46,"publisher":"MDPI AG","issue":"7","license":[{"start":{"date-parts":[[2026,7,16]],"date-time":"2026-07-16T00:00:00Z","timestamp":1784160000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Health literacy (HL), recognized as a modifiable social determinant, influences the autonomy and clinical outcomes of the elderly population, so that low levels of HL contribute to worse health outcomes, including frailty. The objective was to analyze the factors associated with frailty, with a focus on HL, in elderly people from two municipalities in the interior of S\u00e3o Paulo. In this cross-sectional study of 219 elderly individuals (\u226560 years) from Jundia\u00ed and Ara\u00e7atuba, frailty was measured using the FRAIL-BR scale and the Clinical-Functional Vulnerability Index (IVCF-20), and HL was measured using the 14-item Health Literacy Scale (HLS-14). Sociodemographic, clinical, and behavioral variables were included. Bivariate analyses and multinomial logistic regression were performed, with a significance level of 5%. Women predominated (64.8%), with an average age of 71.8 (\u00b17.55). Low HL remained associated with frailty according to the FRAIL scale (OR = 3.66; 95% CI: 1.51\u20138.85) and the IVCF-20 (OR = 5.65; 95% CI: 1.83\u201317.44). Other factors common to both scales were advanced age (FRAIL: OR = 4.24; 95% CI: 1.26\u201314.28; IVCF-20: OR = 28.67; 95% CI: 5.31\u2013154.89) and family dysfunction (FRAIL: OR = 3.67; 95% CI: 1.06\u201312.68; IVCF-20: OR = 6.81; 95% CI: 1.72\u201327.06). Living alone and diabetes were associated with the IVCF-20, while depression was associated with the FRAIL scale. This research constitutes the first empirical study conducted in Brazil to provide evidence that low levels of health literacy are significantly associated with frailty in older adults.<\/jats:p>","DOI":"10.3390\/ijerph23070913","type":"journal-article","created":{"date-parts":[[2026,7,17]],"date-time":"2026-07-17T05:32:17Z","timestamp":1784266337000},"page":"913","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Association Between Health Literacy and Frailty in Older Adults: A Study in Two Brazilian Municipalities"],"prefix":"10.3390","volume":"23","author":[{"given":"Theda Manetta da Cunha","family":"Suter","sequence":"first","affiliation":[{"name":"Department of Health, Centro Universit\u00e1rio Toledo Wyden, Ara\u00e7atuba 16015-270, SP, Brazil"},{"name":"Graduate Program in Health Sciences Faculdade de Medicina de Jundia\u00ed, Jundia\u00ed 13202-550, SP, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Manoelito Ferreira","family":"Silva Junior","sequence":"additional","affiliation":[{"name":"Department of Health I, Universidade Estadual do Sudoeste da Bahia, Jequi\u00e9 45208-409, BA, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0379-3742","authenticated-orcid":false,"given":"Mar\u00edlia Jesus","family":"Batista","sequence":"additional","affiliation":[{"name":"Graduate Program in Health Sciences Faculdade de Medicina de Jundia\u00ed, Jundia\u00ed 13202-550, SP, Brazil"},{"name":"Department of Public Health, Faculdade de Medicina de Jundia\u00ed, Jundia\u00ed 13202-550, SP, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,7,16]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"Shin, H.R., Choi, E.Y., Kim, S.K., Lee, H.Y., and Kim, Y.S. (2021). Health Literacy and Frailty in Community-Dwelling Older Adults: Evidence from a Nationwide Cohort Study in South Korea. Int. J. Environ. Res. Public Health, 18.","DOI":"10.3390\/ijerph18157918"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"e70010","DOI":"10.1111\/psyg.70010","article-title":"Health literacy and frailty: The mediating role of instrumental activities of daily living","volume":"25","author":"Nakamura","year":"2025","journal-title":"Psychogeriatrics"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"81","DOI":"10.1016\/j.arr.2019.01.010","article-title":"Transitions between frailty states among community-dwelling older people: A systematic review and meta-analysis","volume":"50","author":"Kojima","year":"2019","journal-title":"Ageing Res. Rev."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"17s","DOI":"10.11606\/s1518-8787.2018052000616","article-title":"Frailty profile in Brazilian older adults: ELSI-Brazil","volume":"52","author":"Andrade","year":"2018","journal-title":"Rev. Sa\u00fade Publica"},{"key":"ref_5","first-page":"e0278","article-title":"Idade prospectiva e as novas medidas de envelhecimento populacional: Indicadores para o Brasil e suas cinco regi\u00f5es","volume":"41","author":"Alves","year":"2024","journal-title":"Rev. Bras. Estud. Popul."},{"key":"ref_6","unstructured":"Organiza\u00e7\u00e3o das Na\u00e7\u00f5es Unidas (2025, April 24). Envelhecimento\u2014Na\u00e7\u00f5es Unidas\u2014ONU Portugal. Available online: https:\/\/unric.org\/pt\/envelhecimento\/."},{"key":"ref_7","first-page":"e230233","article-title":"Chronic diseases and longevity: Future challenges","volume":"26","author":"Veras","year":"2023","journal-title":"Rev. Bras. Geriatr. Gerontol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1345","DOI":"10.1093\/aje\/kwx387","article-title":"The Brazilian Longitudinal Study of Aging (ELSI-Brazil): Objectives and Design","volume":"187","author":"Neri","year":"2018","journal-title":"Am. J. Epidemiol."},{"key":"ref_9","unstructured":"Brasil (2025, May 09). Censo: N\u00famero de Idosos no Brasil Cresceu 57,4% em 12 Anos, Available online: https:\/\/www.gov.br\/secom\/pt-br\/assuntos\/noticias\/2023\/10\/censo-2022-numero-de-idosos-na-populacao-do-pais-cresceu-57-4-em-12-anos."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"e8590","DOI":"10.1590\/2358-289820241408590p","article-title":"The Social Determinants of Health inside and outside the household: Capturing a new approach","volume":"48","author":"Ribeiro","year":"2024","journal-title":"Sa\u00fade Debate"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"e463","DOI":"10.1093\/geront\/gnaa061","article-title":"A Systematic Review of Frailty Trajectories: Their Shape and Influencing Factors","volume":"61","author":"Welstead","year":"2021","journal-title":"Gerontologist"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"392","DOI":"10.1016\/j.jamda.2013.03.022","article-title":"Frailty consensus: A call to action","volume":"14","author":"Morley","year":"2013","journal-title":"J. Am. Med. Dir. Assoc."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1053","DOI":"10.1093\/eurpub\/ckv043","article-title":"Health literacy in Europe: Comparative results of the European Health Literacy Survey (HLS-EU)","volume":"25","author":"Pelikan","year":"2015","journal-title":"Eur. J. Public Health"},{"key":"ref_14","unstructured":"Suter, T.M.C., Valentin, C.A.S., Oliveira, A.P.M., Domingues, M.A., and Mota, M.J.B.B. (2025). Scope review on the association of health literacy with frailty in the elderly. Ci\u00eanc. Sa\u00fade Colet., accepted."},{"key":"ref_15","first-page":"e221106","article-title":"Brazilian population aging from a regional and urban perspective","volume":"28","author":"Faria","year":"2024","journal-title":"GEOUSP"},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Huang, C.H., Lai, Y.C., Lee, Y.C., Teong, X.T., Kuzuya, M., and Kuo, K.M. (2018). Impact of Health Literacy on Frailty among Community-Dwelling Seniors. J. Clin. Med., 7.","DOI":"10.3390\/jcm7120481"},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Son, Y.J., Shim, D.K., Seo, E.K., and Seo, E.J. (2018). Health Literacy but Not Frailty Predict Self-Care Behaviors in Patients with Heart Failure. Int. J. Environ. Res. Public Health, 15.","DOI":"10.3390\/ijerph15112474"},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Tsai, M.D., Tsai, J.P., Chen, M.L., and Chang, L.C. (2022). Frailty, Health Literacy, and Self-Care in Patients with Chronic Kidney Disease in Taiwan. Int. J. Environ. Res. Public Health, 19.","DOI":"10.3390\/ijerph19095350"},{"key":"ref_19","unstructured":"(2025, May 11). Popula\u00e7\u00e3o no \u00daltimo Censo no Munic\u00edpio de Jundia\u00ed. IBGE, Available online: https:\/\/cidades.ibge.gov.br\/brasil\/sp\/jundiai\/panorama."},{"key":"ref_20","unstructured":"(2025, May 11). Popula\u00e7\u00e3o no \u00daltimo Censo no Munic\u00edpio de Ara\u00e7atuba, Available online: https:\/\/cidades.ibge.gov.br\/brasil\/sp\/aracatuba\/panorama."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"e00255420","DOI":"10.1590\/0102-311x00255420","article-title":"Frailty in elderly individuals and perception of problems in indicators of attributes of primary healthcare: Results of the ELSI-Brasil","volume":"37","author":"Silva","year":"2021","journal-title":"Cad. Sa\u00fade P\u00fablica"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"527","DOI":"10.5935\/1414-8145.20140075","article-title":"Analysis of psychometric properties of family APGAR with elderly in northeast Brazil","volume":"18","author":"Silva","year":"2014","journal-title":"Esc Anna Nery"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"e20200257","DOI":"10.36416\/1806-3756\/e20200257","article-title":"Charlson Comorbidity Index and other predictors of in-hospital mortality among adults with community-acquired pneumonia","volume":"47","author":"Bahlis","year":"2021","journal-title":"J. Bras. Pneumol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"290","DOI":"10.5020\/575","article-title":"Confiabilidade da vers\u00e3o brasileira da escala de atividades instrumentais da vida di\u00e1ria","volume":"21","author":"Santos","year":"2008","journal-title":"RBPS"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"918","DOI":"10.1590\/S0034-89102005000600008","article-title":"Validation of geriatric depression scale in a general outpatient clinic","volume":"39","author":"Paradela","year":"2005","journal-title":"Rev. Sa\u00fade P\u00fablica"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"4","DOI":"10.1002\/gps.4282","article-title":"Using temporal orientation, category fluency, and word recall for detecting cognitive impairment: The 10-point cognitive screener (10-CS)","volume":"31","author":"Apolinario","year":"2016","journal-title":"Int. J. Geriatr. Psychiatry"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"222","DOI":"10.1590\/0103-1104202313716","article-title":"Edentulismo, necessidade de pr\u00f3tese e autopercep\u00e7\u00e3o de sa\u00fade bucal entre idosos institucionalizados","volume":"47","author":"Ribeiro","year":"2023","journal-title":"Sa\u00fade Debate"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"2847","DOI":"10.1590\/1413-81232020257.22282018","article-title":"Translation, cross-cultural adaptation and psychometric evaluation of Brazilian Portuguese version of the 14-item Health Literacy Scale","volume":"25","author":"Batista","year":"2020","journal-title":"Cienc. Saude Coletiva"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"592","DOI":"10.1016\/j.jamda.2017.01.009","article-title":"Screening for Frailty with the FRAIL Scale: A Comparison with the Phenotype Criteria","volume":"18","author":"Aprahamian","year":"2017","journal-title":"J. Am. Med. Dir. Assoc."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"81","DOI":"10.1590\/s1518-8787.2016050006963","article-title":"Clinical-Functional Vulnerability Index-20 (IVCF-20): Rapid recognition of frail older adults","volume":"50","author":"Moraes","year":"2016","journal-title":"Rev. Sa\u00fade P\u00fablica"},{"key":"ref_31","unstructured":"World Health Organization\u2014WHO (2025, December 23). Health Literacy. Available online: https:\/\/www.who.int\/news-room\/fact-sheets\/detail\/health-literacy."},{"key":"ref_32","doi-asserted-by":"crossref","unstructured":"Sagong, H., and Yoon, J.Y. (2021). Pathways among Frailty, Health Literacy, Acculturation, and Social Support of Middle-Aged and Older Korean Immigrants in the USA. Int. J. Environ. Res. Public Health, 18.","DOI":"10.3390\/ijerph18031245"},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Liu, Y., Meng, H., Tu, N., and Liu, D. (2020). The Relationship Between Health Literacy, Social Support, Depression, and Frailty Among Community-Dwelling Older Patients with Hypertension and Diabetes in China. Front. Public. Health, 8.","DOI":"10.3389\/fpubh.2020.00280"},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Sciacchitano, S., Carola, V., Nicolais, G., Sciacchitano, S., Napoli, C., Mancini, R., Rocco, M., and Coluzzi, F. (2024). To Be Frail or Not to Be Frail: This Is the Question\u2014A Critical Narrative Review of Frailty. J. Clin. Med., 13.","DOI":"10.3390\/jcm13030721"},{"key":"ref_35","first-page":"e6390","article-title":"Social Determinants and Literacy in Health of the Elderly: Walk to Well-Being","volume":"7","author":"Vaz","year":"2020","journal-title":"Rev. Bibl. Acesso Aberto"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"102243","DOI":"10.1016\/j.arr.2024.102243","article-title":"The measurement properties and feasibility of FRAIL scale in older adults: A systematic review and meta-analysis","volume":"95","author":"Ng","year":"2024","journal-title":"Ageing Res. Rev."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"e180021","DOI":"10.1590\/1980-549720180021.supl.2","article-title":"Frailty in older adults in the city of S\u00e3o Paulo: Prevalence and associated factors","volume":"21","author":"Duarte","year":"2018","journal-title":"Rev. Bras. Epidemiol."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"3483","DOI":"10.1590\/1413-812320152111.23292015","article-title":"Fen\u00f3tipo de fragilidade: Influ\u00eancia de cada item na determina\u00e7\u00e3o da fragilidade em idosos comunit\u00e1rios\u2014Rede Fibra","volume":"21","author":"Silva","year":"2016","journal-title":"Ci\u00eanc. Sa\u00fade Coletiva"},{"key":"ref_39","first-page":"e20210375","article-title":"Family insufficiency and the condition and the physical frailty\u2019s components of elderly in ambulatorial care","volume":"26","author":"Setoguchi","year":"2022","journal-title":"Esc Anna Nery"},{"key":"ref_40","first-page":"e20210106","article-title":"Relationship between family functionality and the quality of life of the elderly","volume":"75","author":"Viana","year":"2021","journal-title":"Rev. Bras. Enferm."},{"key":"ref_41","doi-asserted-by":"crossref","unstructured":"Liu, J., Zhu, Y., Tan, J.K., Ismail, A.H., Ibrahim, R., and Hassan, N.H. (2024). Factors Associated with Frailty in Older Adults in Community and Nursing Home Settings: A Systematic Review with a Meta-Analysis. J. Clin. Med., 13.","DOI":"10.3390\/jcm13082382"},{"key":"ref_42","first-page":"e250025","article-title":"Association of nutritional status and oral health with frailty in community-dwelling older adults","volume":"28","author":"Valentim","year":"2025","journal-title":"Rev. Bras. Geriatr. Gerontol."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"e050","DOI":"10.1590\/1807-3107bor-2025.vol39.0050","article-title":"Caries and edentulism trends among Brazilian older adults: A comparative analysis of 2003, 2010, and 2023 surveys","volume":"39","author":"Ferreira","year":"2025","journal-title":"Braz. Oral Res."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"159","DOI":"10.1146\/annurev-publhealth-090419-102529","article-title":"Understanding and responding to health literacy as a social determinant of health","volume":"42","author":"Nutbeam","year":"2021","journal-title":"Annu. Rev. Public Health"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"104401","DOI":"10.1016\/j.archger.2021.104401","article-title":"Transitions in frailty phenotype states and components over 8 years: Evidence from The Irish Longitudinal Study on Ageing","volume":"95","author":"Hartley","year":"2021","journal-title":"Arch. Gerontol. Geriatr."},{"key":"ref_46","doi-asserted-by":"crossref","unstructured":"Cesar, F.C.R., Oliveira, L.M.A.C., Galv\u00e3o, M.C., and Lacerda, A.L.A. (2024). How Do Healthcare Professionals Develop the Communication Process to Promote Patients\u2019 Health Literacy?. Int. J. Environ. Res. Public Health, 21.","DOI":"10.3390\/ijerph21050536"}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/23\/7\/913\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,17]],"date-time":"2026-07-17T05:33:12Z","timestamp":1784266392000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/23\/7\/913"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,16]]},"references-count":46,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2026,7]]}},"alternative-id":["ijerph23070913"],"URL":"https:\/\/doi.org\/10.3390\/ijerph23070913","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,16]]}}}