Exploring the Influence of Health and Digital Health Literacy on Quality of Life and Follow-up Compliance in Patients with Primary Non-muscle Invasive Bladder Cancer: A Prospective, Single-Center Study

Exploring the Influence of Health and Digital Health Literacy on Quality of Life and Follow-up Compliance in Patients with Primary Non-muscle Invasive Bladder Cancer: A Prospective, Single-Center Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Exploring the Influence of Health and Digital Health Literacy on Quality of Life and Follow-up Compliance in Patients with Primary Non-muscle Invasive Bladder Cancer: A Prospective, Single-Center Study Ahmet Keles, Umit Furkan Somun, Muhammed Kose, Ozgur Arikan, Meftun Culpan, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4535711/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Jan, 2025 Read the published version in World Journal of Urology → Version 1 posted 10 You are reading this latest preprint version Abstract Objective Given the increasing significance of digital health literacy (DHL) and health literacy (HL) in promoting informed decision-making and healthy behaviors, this study aimed to assess the influence of self-reported HL and DHL on treatment adherence and quality of life among patients who underwent transurethral resection of bladder tumors (TUR-BT) for primary non-muscle invasive bladder cancer (NMIBC). Materials & Methods This observational research involved 107 NIMBC participants. Before the procedure, the patients' DHL and HL were evaluated using the European Health Literacy Survey Questionnaire short version and the eHealth Literacy Scale. Six months after surgery, we surveyed patients’ QoL using the EORTC QLQ-C30. In line with recommendations from the European Association of Urology guidelines, adherence to the treatment plan was assessed along with a follow-up cystoscopy examination for each patient. Results Multivariate analysis revealed that poorer DHL and HL were significantly associated with older age (p < 0.001), lower educational attainment (p < 0.001), and lack of internet access (p < 0.001). Conversely, higher DHL and HL levels were positively correlated with increased treatment adherence, as measured by cystoscopy completion (p < 0.001). Additionally, logistic regression analysis demonstrated significant associations between improved DHL and HL scores and better global health status (DHL, p = 0.022; HL, p = 0.008), higher emotional status (p < 0.001 for both), and social functioning (p < 0.001 for both). Notably, there were no significant differences in the symptom scale scores between the DHL and HL groups. Conclusion To the best of our knowledge, this is the first study to explore the specific effect of HL/DHL on QoL and adherence in this patient population. Our research suggests that there may be a link between self-reported levels of DHL/HL and treatment adherence as well as QoL among patients with NIMBC. digital health literacy patient reported outcome bladder cancer quality of life Figures Figure 1 1. Introduction Bladder cancer (BC) is a malignancy that is prevalent worldwide, with an estimated 573,000 new cases and 213,000 fatalities annually ( 1 ). Most histological stages of BC are Ta and T1. Although many of these tumors are easy to treat, up to 70 percent of the patients experience recurrence after surgery ( 2 ). There is a need to educate more than one million people about the treatment options and processes associated with BC. BC patients should play an active role in their treatment decisions and collaborate with healthcare professionals for better outcomes ( 3 ). The only way to achieve this is to educate them properly about cancer, the different treatment options, and the side effects they may experience as a result. Patients with cancer benefit from social media by receiving health information and emotional support ( 3 , 4 ). The internet has become more widely used to access reliable health information ( 5 ). A large amount of online and offline information has led to an infodemic (information pandemic) according to the World Health Organization (WHO) ( 6 ). This presents a significant challenge for cancer patients, as they must navigate this ocean of misinformation while maintaining their trust in the online medical resources they consult. Therefore, patients must be able to comprehend and manage health-related information online. These essential skills are encompassed by digital health literacy (DHL) ( 7 , 8 ). Health literacy (HL) refers to the ability to access, understand, evaluate, and apply health information (written or oral) to promote health and care. Low levels of HL are linked to challenges in discussing healthcare-related matters, leading to less effective understanding and implementation of medical advice. It is also associated with difficulties in comprehending written medical information in both clinical and surgical settings as well as reduced adherence to care recommendations and screening protocols ( 9 ). We hypothesized that educating patients with BC about disease-related processes, risks, recommendations, and potential post-transurethral resection of bladder tumors (TUR-BT) could significantly improve their DHL/HL, thereby helping them cope with the challenges they face and enhance their quality of life (QoL). However, no study has specifically addressed the connection between HL/DHL and QoL in patients receiving TUR-BT for BC. To fill this gap, we conducted this study at a single institution to examine the effects of HL and DHL on QoL and treatment adherence in patients with primary non-muscle invasive bladder cancer (NIMBC) who underwent TUR-BT. 2. Material and Methods 2.1 Strategy and Ethical Principles This observational study was conducted at a single center and involved patients who had undergone TUR-BT for NIMBC at a tertiary hospital between May 2022 and February 2024. Subsequently, these patients underwent cystoscopic follow-up every three months. The Institutional Review Board of Istanbul Medeniyet University School of Medicine has approved this study (Number: 2022/0324, Date: 18.05.2022). All participants were given a comprehensive overview of the study's aims and methodologies and were requested to provide written consent. The participants were guaranteed confidentiality of their information, and the study followed the ethical guidelines outlined in the Declaration of Helsinki. 2.2 Selection Criteria and Data Collection Figure 1 illustrates the study selection process. Data were collected via in-person interviews in which participants responded to a questionnaire administered by an interviewer. At the beginning of the study, participants were asked various questions to gather sociodemographic data, including age, body mass index (BMI), education level, family income, internet usage, and adherence to cystoscopy. We included the presence of NIMBC in patients who underwent TUR-BT and subsequent pathological examination. Patients were excluded if they met any of the following criteria: those diagnosed with metastasis, pathological results showing invasive bladder cancer, limited follow-up period (< 6 months), participant dropouts, cognitive impairments or difficulties in language and comprehension, declined to participate in the study, or any significant health issues. Additionally, considering that the complexity of regimen maintenance, BCG treatment, and second-look TUR could affect QoL, we excluded these patients. 2.3 Defining the Instruments and Measurement This eight-item e-Health Literacy Scale (e-HEALS) exam assesses consumers' capacity to discover, analyze, and apply electronic health information to their health issues. Each feature of the measure was evaluated using a Likert scale ranging from one to five. Three question scores were added to obtain a DHL score. The scale values vary from 8 to 40, with high scores indicating high DHL ( 8 ). The HLS-Q12, a validated and abridged version of the European Health Literacy Survey Questionnaire, was used to determine the HL levels. It comprises 12 questions intended to assess a person's confidence and competence in handling various health circumstances. Patients rated the complexity of each circumstance on a four-point Likert scale, from simple to complex, with a higher score signifying higher HL proficiency ( 9 , 10 ). The European Organization for Research and Treatment of Cancer (EORTC) QoL Questionnaire (QLQ)-C30 official version of Turkish was administered six months after the TUR-BT. The questionnaire consisted of 30 questions divided into five functional dimensions: physical, role, emotional, cognitive, and social. There were also three symptom measures (fatigue, pain, and nausea/vomiting) and a general health status section. The six sections address various symptoms, including shortness of breath, loss of appetite, sleep difficulties, constipation, diarrhea, and financial concerns ( 11 ). All surveys were examined in accordance with their respective scoring guidelines. The BMI was divided into three groups based on WHO criteria ( 12 ). Educational attainment was classified according to the International Standard Classification of Education (ISCED) of the United Nations Educational, Scientific, and Cultural Organization ( 13 ). The 2023 governmental mandate sets a national minimum wage of $ 10,000 based on income classification. 2.4 Treatment Compliance After discharge, patients were assessed in the outpatient clinic in their third month for routine cystoscopy follow-up, according to the European Association of Urology guidelines. Patients were classified into two groups according to their adherence to the cystoscopy follow-up protocol: compliant and non-compliant. Each patient who did not receive the cystoscopic follow-up was identified: as “non-compliant”. We relaxed the definition to include compliance with cystoscopic follow-up at any time within 90–120 days of TUR-BT. 2.5 Statistical Analysis We used the average and standard deviation to analyze continuous variables, and percentages to assess categorical variables. The normal distribution of continuous variables was assessed using the Shapiro-Wilk and Kolmogorov-Smirnov tests. One-way ANOVA was used to analyze differences between groups in continuous variables. To examine multiple continuous variables, a multivariate analysis of variance was used. Statistical analysis of continuous variables included the application of Mann–Whitney U and Kruskal–Wallis tests, with statistical significance set at p < 0.05. 3. Results 3.1 Patients’ Demographic Characteristics Following the application of inclusion and exclusion criteria, the final analysis included data from 107 participants. The median age at surgery was 67.5 years (range: 40–79 years), and there were 111 males and 15 females with a median BMI of 25.3 kg/m² (range: 21.6–32.3 kg/m²). Marital status assessment revealed that 84.1% of the participants were married, while the remaining 15.9% were single. Baseline HL scores averaged 33.4 ± 2.9, and DHL scores averaged 24.5 ± 1.7. 3.2 Factors Associated with Health Literacy and Digital Health Literacy The close relationship between HL and DHL indicates that strategies designed to improve HL can also help enhance DHL. Individuals with lower HL and DHL scores were more likely to be older (p = 0.016 for HL, p = 0.024 for DHL) and have lower educational attainment (p < 0.003). Additionally, lower income and lack of internet access were negatively correlated with both HL and DHL scores (p = 0.011 for HL and p < 0.001 for DHL). To further understand the detailed results of the factors influencing HL and DHL scores, the study included Table 1 outlining the results of both univariate and multivariate analyses. Table 1 Univariate and multivariate analyses to identify the factors that impact health literacy and digital health literacy scores. Variables N = 107 (%) Health Literacy Digital Health Literacy Multivariate analysis p value** Mean ± SD p value* Mean ± SD p value* Age (yr) ≤ 59 17 (15.9) 37 ± 4.31 0.006 29.21 ± 6.31 0.014 < 0.001 60–69 63 (58.9) 33.53 ± 3.64 24.27 ± 6.74 ≥ 70 23 (32.7) 29.22 ± 4.3 18.31 ± 7.12 BMI (kg/m2) Normal ( < 25) 29 (27.1) 32.68 ± 6.32 0.591 22.61 ± 6.26 0.679 0.732 Overweight (25–30) 56 (52.3) 31.43 ± 6.31 22.77 ± 6.21 Obese (≥ 30) 22 (20.6) 33.68 ± 4.51 23.81 ± 5.52 Education level (ISCED level) Level 1 42 (39.2) 28.11 ± 5.63 0.007 18.31 ± 6.98 < 0.001 < 0.001 Level 2 28 (26.2) 30.6 ± 5.41 24.73 ± 5.43 Level 3 23 (21.5) 33.541 ± 4.71 26.81 ± 4.1 Level 4 14 (13.1) 37.3 ± 4.53 30.63 ± 5.39 Martial Status Single 17 (15.9) 31.35 ± 4.24 0.214 21.12 ± 6.36 0.768 0.945 Married 90 (84.1) 32.03 ± 5.32 21.88 ± 4.97 Smoking Status Yes 75 (70.1) 32.8 ± 5.44 0.873 21.59 ± 3.62 0.822 0.868 No 14 (13.1) 31.83 ± 4.49 21.37 ± 6.41 Ex-smoker 18 (16.8) 32.18 ± 3.21 20.68 ± 4.74 Annual income ($) ≤ 10.000 75 (70.1) 30.47 ± 3.87 < 0.001 20.17 ± 6.19 < 0.001 10.000 32 (29.9) 36.44 ± .73 30.33 ± 4.73 Internet usage Almost everyday 29 (27.1) 33 ± 4.2 0.011 30.63 ± 5.95 < 0.001 < 0.001 Few days a week 36 (33.6) 32.51 ± 6.3 25.74 ± 3.91 Less than 1 day a week 16 ( 15 ) 29.77 ± 5.31 23.5 ± 6.72 Hardly ever 26 (24.3) 29.13 ± 5.81 17.2 ± 5.1 Cystoscopic adherence Compliance 74 (69.1) 33.21 ± 6.18 0.021 26.39 ± 5.88 < 0.001 < 0.001 Non-Compliance 33 (30.9) 29.46 ± 5.44 21.42 ± 6.27 *ANOVA. **MANOVA (Wilk’s Lambda); yr = years; BMI = Body mass index; ISCED = International Standard Classification of Education; Bold font indicates statistically significance 3.3 Quality of Life Outcomes Table 2 presents a comparison of the QoL evaluations derived from the EORTC QLQ-C30 for both the HL and DHL groups. Logistic regression analysis indicated a meaningful positive correlation between elevated DHL levels and global health. (p = 0.043). Furthermore, individuals with higher DHL and HL scores reported improved emotional and social functioning (p < 0.001 for both). However, no statistically significant differences were observed in symptom scale scores across the DHL groups (Table 3 ). Table 2 Investigating the levels of patients' health literacy and edigital health literacy and their relationship to the EORTC QoL subscale scores Endpoint Health Literacy Digital Health Literacy EORTC QLQ-C30 Limited HL (Score ≤ 26) Moderate HL (27 ≤ Score ≤ 39) Advanced HL (Score ≥ 39) p value* Low DHL, (Score ≤ 24) High DHL, (Score >24) p value ** Mean ± SD Mean ± SD Mean ± SD Mean ± SD Mean ± SD Global health status / QoL † Global Health Status (Q29,30) 58.43 ± 15.05 69.16 ± 25.64 81.5 ± 13.86 0.022 61.31 ± 15.44 75.39 ± 25.48 0.008 Functional Scales † Physical Function (Q1 to 5) 66.3 ± 20.64 74.06 ± 20.85 62.5 ± 25.68 0.104 66.14 ± 17.66 66.70 ± 13.82 0.653 Role Function (Q6,7) 71.82 ± 18.13 69.77 ± 24.51 72.4 ± 19.92 0.902 61.42 ± 21.27 60.29 ± 20.46 0.702 Emotional Function (Q21 to 24) 59.43 ± 15.5 66.38 ± 20.92 85.28 ± 15.92 0.017 60.62 ± 19.31 81.08 ± 24.63 0.026 Cognitive Function (Q20,25) 75.93 ± 19.34 74.06 ± 20.85 60.00 ± 16.04 0.066 74.72 ± 20.91 71.77 ± 20.20 0.320 Social Function (Q26,27) 64.69 ± 14.19 66.38 ± 20.92 70.83 ± 26.35 0.734 76.73 ± 20.5 62.65 ± 21.37 0.099 Symptom Scales ‡ Pain (Q9,19) 42.55 ± 19.37 41.07 ± 23.60 35.57 ± 23.29 0.321 33.65 ± 23.68 43.46 ± 27.3 0.074 Nausea and vomiting (Q14,15) 10.31 ± 21.02 12.56 ± 18.09 11.25 ± 13.29 0.745 13.84 ± 22.82 13.07 ± 17.1 0.652 Fatigue (Q10,12,18) 43.05 ± 15.11 34.97 ± 20.36 34.89 ± 26.56 0.311 34.59 ± 21.86 38.34 ± 22.15 0.42 Dyspnoea (Q8) 30.53 ± 21.12 20.25 ± 10.67 15.60 ± 9.77 0.284 17.61 ± 15.82 21.57 ± 19.8 0.13 Insomnia (Q11) 34.88 ± 18.87 25.83 ± 26.51 37.5 ± 37.53 0.424 28.3 ± 28.79 28.10 ± 26.14 0.939 Appetite loss (Q13) 38.75 ± 20.97 25 ± 26.25 23.33 ± 25.2 0.365 26.41 ± 29.5 22.87 ± 20.54 0.912 Constipation (Q16) 26.25 ± 21.56 25 ± 24.59 25 ± 38.83 0.623 28.30 ± 25.65 22.87 ± 25.38 0.24 Diarrhea (Q17) 18.75 ± 15 11.67 ± 19.92 8.33 ± 15.43 0.061 15.09 ± 19.13 10.46 ± 19.43 0.122 Financial difficulties (Q28) 22.42 ± 14.36 19.95 ± 21.33 17.85 ± 22.32 0.022 29.9 ± 23 23.53 ± 22.4 0.043 EORTC QLQ-C30 : European organization for research and treatment of cancer core quality of life questionnaire; * Kruskal Wallis Test; ** Mann Whitney U Test; † Higher scores indicate better functioning (scaled from 0-100); ‡ Lower scores indicate fewer symptoms (scaled from 0-100) Table 3 Comparison of patients' health literacy and electronic health literacy classifications and EORTC QoL subscale scores by multivariate analysis EORTC QLQ-C30 Health Literacy ¥ Digital Health Literacy OR (95% CI)* p value* OR (95% CI)* p value* Global health status / QoL General Health Status (GHS)a 0.95 (0.83–2.97) 0.023 1.99 (0.96–3.03) 0.021 Functional Scales Physical Function (Q1 to 5)a 1.05 (0.81–1.33) 0.109 1.06 (0.94–1.92) 0.653 Role Function (Q6,7)a 1.52 (0.95–2.41) 0.042 1.34 (0.94–1.80) 0.129 Emotional Function (Q21 to 24)a 3.43 (2.69–5.99) < 0.001 3.94 (2.73–5.65) < 0.001 Cognitive Function (Q20,25)a 0.98 (0.83–1.65) 0.859 2.98 (2.95–4.62) 0.878 Social Function (Q26,27)a 1.06 (0.93–1.87) < 0.001 0.93 (0.75–1.11) < 0.001 Symptom Scales Pain (Q9,19)b 1.41 (0.76–1.91) 0.94 1.02 (0.94–1.11) 0.132 Nausea and vomiting (Q14,15)b 1.65 (0.98–1.89) 0.321 0.97 (0.85–1.37) 0.953 Fatigue (Q10,12,18)b 0.81 (0.72–1.69) 0.095 0.96 (0.92–1.23) 0.789 Dyspnoea (Q8)b 1.07 (0.89–1.19) 0.112 1.52 (0.99–1.95) 0.871 Insomnia (Q11)b 0.8 (0.76–1.12) 0.19 1.38 (0.5–1.81) 0.574 Appetite loss (Q13)b 1.08 (0.92–1.21) 0.231 3.96 (0.93–4.46) 0.134 Constipation (Q16)b 1.02 (0.97–1.21) 0.481 2.95 (0.96–5.09) 0.653 Diarrhea (Q17)b 0.99 (0.89–1.06) 0.545 0.94 (0.9–1.08) 0.321 Financial difficulties (Q28)b 1.01 (0.93–1.12) 0.012 1.98 (0.95–2.02) 0.042 OR = Odds ratio; CI = confidence interval; SD = Standard deviation; Q = question; GHS = global health status; QoL = quality of life; a range = 0–100, high values indicate high levels of functioning and quality of life; b range = 0–100, high levels indicate pronounced symptoms and problems.; ¥ HL was classified as nonadequate (limited) and adequate (moderate-advanced) *Binary Logistic Regression-Enter method was used. Age group, educational level, internet usage status, HL and EORTC subscales was added to model. 3.4 Treatment Adherence Among the 107 participants, 74 (69.1%) adhered to the recommended cystoscopy follow-up protocol, whereas 33 (18%) did not. A positive correlation emerged between higher HL/DHL scores and improved treatment adherence, as evidenced by increased cystoscopy completion rates (p < 0.001). 3.5 Follow-Up and Healthcare Utilization Logistic regression was employed to investigate the link between limited and high-level HL/DHL and healthcare utilization within 30 days after surgery. The research uncovered no link between low HL/DHL and increased emergency department visits (p = 0.625, CI: 0.74–1.82) or urology outpatient clinic readmissions (p = 0.821, CI: 0.88–1.4). 4. Discussion The presentation of this second study, which is consistent with our previous study in which HL and DHL were first demonstrated to be effective in urological oncology, opens a new avenue for discussion in patients with low-risk NMIBC ( 14 ). Our research has yielded valuable insights into the relationship between HL/DHL levels in patients with NIMBC, their health-related QoL, and compliance with treatment. Our results indicate that there is a correlation between lower HL/DHL and advancing age, lower levels of education, and limited internet accessibility. The decrease in HL and DHL levels with increasing age could be explained by the fact that, as individuals age, their body functions tend to decline, which can lead to a reduction in the capacity to process and retain new information, ultimately impacting HL/DHL scores. The relationship between older age and hearing loss is especially notable in the context of BC. This is due to the fact that 80% of bladder cancer diagnoses occur in individuals over the age of 65 ( 15 , 16 ). Numerous studies have found a strong link between educational level and HL/DHL scores. Higher levels of education are linked to improved capacity in locating, assessing, and utilizing health-related information for decision-making ( 17 ). Furthermore, lack of Internet access is a major barrier to DHL, as it limits access to a wide range of online health information and resources ( 18 , 19 ). Together, these insights highlight the pressing need for targeted interventions and educational initiatives to enhance DHL and HL among vulnerable patients with BC. Our study revealed that patients with lower HL/DHL experienced more challenges in understanding information, reported worse emotional and social functioning outcomes, and had a lower QoL, whereas those with higher HL/DHL appeared to be better informed and had a higher QoL. Xia et al. discovered that cancer survivors with sufficient health literacy were almost three times more likely to experience a higher QoL compared to those with inadequate HL ( 20 ). The researchers also noted similar findings in other measures of functional well-being. A variety of interventions, including information handouts, audiovisual materials, and online resources, can help improve patients' HL/DHL and treatment adherence ( 21 , 22 ). These interventions not only facilitate better understanding of medical information but also empower patients to actively participate in their own care. Patients with enhanced HL/DHL are more inclined to comply with follow-up schedules and treatment plans, thereby contributing to improved overall health results. Furthermore, disease progression and relapse play significant roles in BC prognosis. Recurrence rates within 5 years range between 30% and 80%, while progression rates vary from 1–45% ( 23 ). Our findings suggest that lower levels of HL and DHL are associated with poorer health-related treatment adherence among NMIBC patients, consistent with a study by Turkoglu et al. Patients with low HL might not possess the necessary numerical abilities to comprehend and apply information about the probability of BC recurrence or the likelihood of cancer remission ( 24 ). As the prognosis of those who fully adhere to the follow-up protocol is expected to be better, informing BC patients with low HL with additional written and visual materials may be a cost-effective and progressive preventive approach ( 25 , 26 ). While the study possesses strengths, acknowledging its limitations is crucial. Firstly, we were unable to determine pre-operative diagnoses of generalized anxiety disorder or clinical depression. Secondly, the study did not consider other potential factors influencing the outcome of the TUR-BT procedure, such as patient performance or frailty status. Thirdly, the sample size was relatively small, and participants belonged to a specific demographic group limiting the applicability of the results. Finally, the accuracy of the questionnaires relied on patient honesty and cooperation, which represents a significant limitation. However, to the best of our understanding, this is the initial investigation focusing on how HL/DHL affects the QoL and adherence of NIMBC patients. In addition, established and validated questionnaires were used in this pioneering study. Future research efforts should address these limitations by employing larger, more diverse patient populations and incorporating additional factors that might influence treatment outcomes. 5. Conclusion The findings underscore the need for healthcare providers to assess and address HL and DHL in their patient populations to deliver more effective and patient-centered care. The idea of including HL/DHL in every aspect of BC care by all healthcare providers is important for providing sufficient support and the best possible information to BC patients with different levels of HL/DHL. This will ultimately improve patient satisfaction, QoL, and adherence to treatment plans. It will also contribute to a more holistic approach to patient care. Declarations Financial disclosure: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author contributions: Study concept and design: Keles, Yildirım Acquisition of data: Keles, Kose, Somun Analysis and interpretation of data: Keles, Culpan, Arikan Drafting of the manuscript: Keles, Arikan,Culpan Critical revision of the manuscript for important intellectual content: Culpan, Keles, Yildirım Statistical analysis : Keles, Arikan Administrative, technical, or material support: Kose, Somun, Keles, Yildirim Supervision: Yildirim Conflict of interest: The authors declare that they have no conflict of interest. References Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, Bray F. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021 May;71(3):209-249. doi: 10.3322/caac.21660. van Straten CGJI, Bruins MH, Dijkstra S, Cornel EB, Kortleve MDH, de Vocht TF, Kiemeney LALM, van der Heijden AG. 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Classification of Education 2021. https://biruni.tuik.gov.tr/DIESS/SiniflamaSatirListeAction.do?surumId=237&seviye=1&detay=H&turId=39&turAdi=%207.%20Eğitim%20Sınıflamaları. Accessed 10 May 2022 Keles A, Kose M, Somun UF, Culpan M, Yaksi N, Yıldırım A. Impact of health and digital health literacy on quality of life following radical prostatectomy for prostate cancer: prospective single-center cohort study. World J Urol. 2024 Apr 17;42(1):241. doi: 10.1007/s00345-024-04960-z. Zhang Y, Xu P, Sun Q, Baral S, Xi L, Wang D. Factors influencing the e-health literacy in cancer patients: a systematic review. J Cancer Surviv. 2023 Apr;17(2):425-440. doi: 10.1007/s11764-022-01260-6. Kobayashi LC, Wardle J, von Wagner C. Limited health literacy is a barrier to colorectal cancer screening in England: evidence from the English Longitudinal Study of Ageing. Prev Med. 2014;61:100–105. 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Relationship between health literacy and quality of life among cancer survivors in China: a cross-sectional study. BMJ Open. 2019 Dec 31;9(12):e028458. doi: 10.1136/bmjopen-2018-028458. Jamieson SC, Mallory CW, Jivanji DR, Perez A, Castro G, Barengo NC, Pereira J, Nieder AM. The Role of Health Literacy in Prostate Cancer Screening. Urology. 2022 May;163:112-118. doi: 10.1016/j.urology.2021.05.100. Sentell TL, Tsoh JY, Davis T, Davis J, Braun KL. Low health literacy and cancer screening among Chinese Americans in California: a cross-sectional analysis. BMJ Open. 2015 Jan 5;5(1):e006104. doi: 10.1136/bmjopen-2014-006104. Datovo JCF, Neto WA, Mendonça GB, Andrade DL, Reis LO. Prognostic impact of non-adherence to follow-up cystoscopy in non-muscle-invasive bladder cancer (NMIBC). World J Urol. 2019 Oct;37(10):2067-2071. doi: 10.1007/s00345-019-02697-8. Turkoglu AR, Demirci H, Coban S, Guzelsoy M, Toprak E, Aydos MM, Ture DA, Ustundag Y. Evaluation of the relationship between compliance with the follow-up and treatment protocol and health literacy in bladder tumor patients. Aging Male. 2019 Dec;22(4):266-271. doi: 10.1080/13685538.2018.1447558. van der Heide I, Uiters E, Jantine Schuit A, Rademakers J, Fransen M. Health literacy and informed decision making regarding colorectal cancer screening: a systematic review. Eur J Public Health. 2015 Aug;25(4):575-82. doi: 10.1093/eurpub/ckv005. Halverson JL, Martinez-Donate AP, Palta M, Leal T, Lubner S, Walsh MC, Schaaf Strickland J, Smith PD, Trentham-Dietz A. Health Literacy and Health-Related Quality of Life Among a Population-Based Sample of Cancer Patients. J Health Commun. 2015;20(11):1320-9. doi: 10.1080/10810730.2015.1018638. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 30 Jan, 2025 Read the published version in World Journal of Urology → Version 1 posted Editorial decision: Revision requested 22 Oct, 2024 Reviews received at journal 28 Aug, 2024 Reviews received at journal 21 Aug, 2024 Reviewers agreed at journal 21 Aug, 2024 Reviewers agreed at journal 20 Aug, 2024 Reviewers agreed at journal 17 Aug, 2024 Reviewers invited by journal 16 Aug, 2024 Editor assigned by journal 06 Jun, 2024 Submission checks completed at journal 06 Jun, 2024 First submitted to journal 05 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4535711","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":315709064,"identity":"501ed97e-b703-49a5-8f34-fa6c81f7c699","order_by":0,"name":"Ahmet Keles","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7UlEQVRIiWNgGAWjYDCCA2wMDA8YGOTYmJkPAukDRGpJYGAw5mdvSzYgSUvizJ4zZhJEaeG7fSzxQUJFHeOGGzlm1Tw1d+T4GZgfPrqBR4vkubTDBglnDjMb3Egru81z7JmxZAObsXEOHi0GZ9jbJBLbDrAZ3EjedpuH7XDihgM8bNIEtLT/SPxXx2NwI8GsmOcfUVrYjjEkNjBLSPYcMWPmbSNCi+QZtmSJhGOHDUCBLDm377CxZDMBv/CdYTP88KGmrr4NGJUf3nw7LMfP3vzwMT4tKICJB0QyE6scBBh/kKJ6FIyCUTAKRgwAABNFUzOtaihGAAAAAElFTkSuQmCC","orcid":"","institution":"Istanbul Medeniyet University","correspondingAuthor":true,"prefix":"","firstName":"Ahmet","middleName":"","lastName":"Keles","suffix":""},{"id":315709065,"identity":"5d9ccbdd-c9fa-4362-84ae-2dd27dfb7c06","order_by":1,"name":"Umit Furkan Somun","email":"","orcid":"","institution":"Istanbul Medeniyet University","correspondingAuthor":false,"prefix":"","firstName":"Umit","middleName":"Furkan","lastName":"Somun","suffix":""},{"id":315709066,"identity":"8a55af01-6ce6-460f-8573-bc59f91a5e56","order_by":2,"name":"Muhammed Kose","email":"","orcid":"","institution":"Istanbul Medeniyet University","correspondingAuthor":false,"prefix":"","firstName":"Muhammed","middleName":"","lastName":"Kose","suffix":""},{"id":315709067,"identity":"1d1ec542-e0cf-4755-85a6-4dabe0b85426","order_by":3,"name":"Ozgur Arikan","email":"","orcid":"","institution":"Istanbul Medeniyet University","correspondingAuthor":false,"prefix":"","firstName":"Ozgur","middleName":"","lastName":"Arikan","suffix":""},{"id":315709068,"identity":"0174283e-02a8-4181-8078-f239ac5b13f6","order_by":4,"name":"Meftun Culpan","email":"","orcid":"","institution":"Istanbul Medeniyet University","correspondingAuthor":false,"prefix":"","firstName":"Meftun","middleName":"","lastName":"Culpan","suffix":""},{"id":315709069,"identity":"135eb667-7967-401a-9bf3-92e00c89182e","order_by":5,"name":"Asif Yildirim","email":"","orcid":"","institution":"Istanbul Medeniyet University","correspondingAuthor":false,"prefix":"","firstName":"Asif","middleName":"","lastName":"Yildirim","suffix":""}],"badges":[],"createdAt":"2024-06-05 17:45:33","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4535711/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4535711/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00345-025-05463-1","type":"published","date":"2025-01-30T15:58:15+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":59120737,"identity":"f601fac5-612a-4ac6-b310-3f5ebe15a96f","added_by":"auto","created_at":"2024-06-26 14:48:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1765805,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version\u003c/p\u003e","description":"","filename":"Figure1HLSBLADDER.png","url":"https://assets-eu.researchsquare.com/files/rs-4535711/v1/4a3aa230f57423409514033a.png"},{"id":75352072,"identity":"5c2b43b0-c88a-43a7-ab18-94d1b6ffa027","added_by":"auto","created_at":"2025-02-03 16:13:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3267469,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4535711/v1/a5afdda6-56c3-4ba5-b444-481d43f72df6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring the Influence of Health and Digital Health Literacy on Quality of Life and Follow-up Compliance in Patients with Primary Non-muscle Invasive Bladder Cancer: A Prospective, Single-Center Study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eBladder cancer (BC) is a malignancy that is prevalent worldwide, with an estimated 573,000 new cases and 213,000 fatalities annually (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Most histological stages of BC are Ta and T1. Although many of these tumors are easy to treat, up to 70 percent of the patients experience recurrence after surgery (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). There is a need to educate more than one million people about the treatment options and processes associated with BC. BC patients should play an active role in their treatment decisions and collaborate with healthcare professionals for better outcomes (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The only way to achieve this is to educate them properly about cancer, the different treatment options, and the side effects they may experience as a result.\u003c/p\u003e \u003cp\u003ePatients with cancer benefit from social media by receiving health information and emotional support (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The internet has become more widely used to access reliable health information (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). A large amount of online and offline information has led to an infodemic (information pandemic) according to the World Health Organization (WHO) (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). This presents a significant challenge for cancer patients, as they must navigate this ocean of misinformation while maintaining their trust in the online medical resources they consult. Therefore, patients must be able to comprehend and manage health-related information online. These essential skills are encompassed by digital health literacy (DHL) (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHealth literacy (HL) refers to the ability to access, understand, evaluate, and apply health information (written or oral) to promote health and care. Low levels of HL are linked to challenges in discussing healthcare-related matters, leading to less effective understanding and implementation of medical advice. It is also associated with difficulties in comprehending written medical information in both clinical and surgical settings as well as reduced adherence to care recommendations and screening protocols (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe hypothesized that educating patients with BC about disease-related processes, risks, recommendations, and potential post-transurethral resection of bladder tumors (TUR-BT) could significantly improve their DHL/HL, thereby helping them cope with the challenges they face and enhance their quality of life (QoL). However, no study has specifically addressed the connection between HL/DHL and QoL in patients receiving TUR-BT for BC. To fill this gap, we conducted this study at a single institution to examine the effects of HL and DHL on QoL and treatment adherence in patients with primary non-muscle invasive bladder cancer (NIMBC) who underwent TUR-BT.\u003c/p\u003e"},{"header":"2. Material and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Strategy and Ethical Principles\u003c/h2\u003e \u003cp\u003eThis observational study was conducted at a single center and involved patients who had undergone TUR-BT for NIMBC at a tertiary hospital between May 2022 and February 2024. Subsequently, these patients underwent cystoscopic follow-up every three months. The Institutional Review Board of Istanbul Medeniyet University School of Medicine has approved this study (Number: 2022/0324, Date: 18.05.2022). All participants were given a comprehensive overview of the study's aims and methodologies and were requested to provide written consent. The participants were guaranteed confidentiality of their information, and the study followed the ethical guidelines outlined in the Declaration of Helsinki.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Selection Criteria and Data Collection\u003c/h2\u003e \u003cp\u003eFigure 1 illustrates the study selection process. Data were collected via in-person interviews in which participants responded to a questionnaire administered by an interviewer. At the beginning of the study, participants were asked various questions to gather sociodemographic data, including age, body mass index (BMI), education level, family income, internet usage, and adherence to cystoscopy.\u003c/p\u003e \u003cp\u003eWe included the presence of NIMBC in patients who underwent TUR-BT and subsequent pathological examination. Patients were excluded if they met any of the following criteria: those diagnosed with metastasis, pathological results showing invasive bladder cancer, limited follow-up period (\u0026lt;\u0026thinsp;6 months), participant dropouts, cognitive impairments or difficulties in language and comprehension, declined to participate in the study, or any significant health issues. Additionally, considering that the complexity of regimen maintenance, BCG treatment, and second-look TUR could affect QoL, we excluded these patients.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Defining the Instruments and Measurement\u003c/h2\u003e \u003cp\u003eThis eight-item e-Health Literacy Scale (e-HEALS) exam assesses consumers' capacity to discover, analyze, and apply electronic health information to their health issues. Each feature of the measure was evaluated using a Likert scale ranging from one to five. Three question scores were added to obtain a DHL score. The scale values vary from 8 to 40, with high scores indicating high DHL (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe HLS-Q12, a validated and abridged version of the European Health Literacy Survey Questionnaire, was used to determine the HL levels. It comprises 12 questions intended to assess a person's confidence and competence in handling various health circumstances. Patients rated the complexity of each circumstance on a four-point Likert scale, from simple to complex, with a higher score signifying higher HL proficiency (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe European Organization for Research and Treatment of Cancer (EORTC) QoL Questionnaire (QLQ)-C30 official version of Turkish was administered six months after the TUR-BT. The questionnaire consisted of 30 questions divided into five functional dimensions: physical, role, emotional, cognitive, and social. There were also three symptom measures (fatigue, pain, and nausea/vomiting) and a general health status section. The six sections address various symptoms, including shortness of breath, loss of appetite, sleep difficulties, constipation, diarrhea, and financial concerns (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). All surveys were examined in accordance with their respective scoring guidelines. The BMI was divided into three groups based on WHO criteria (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEducational attainment was classified according to the International Standard Classification of Education (ISCED) of the United Nations Educational, Scientific, and Cultural Organization (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The 2023 governmental mandate sets a national minimum wage of \u003cspan\u003e$\u003c/span\u003e10,000 based on income classification.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Treatment Compliance\u003c/h2\u003e \u003cp\u003e After discharge, patients were assessed in the outpatient clinic in their third month for routine cystoscopy follow-up, according to the European Association of Urology guidelines. Patients were classified into two groups according to their adherence to the cystoscopy follow-up protocol: compliant and non-compliant. Each patient who did not receive the cystoscopic follow-up was identified: as \u0026ldquo;non-compliant\u0026rdquo;. We relaxed the definition to include compliance with cystoscopic follow-up at any time within 90\u0026ndash;120 days of TUR-BT.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Statistical Analysis\u003c/h2\u003e \u003cp\u003eWe used the average and standard deviation to analyze continuous variables, and percentages to assess categorical variables. The normal distribution of continuous variables was assessed using the Shapiro-Wilk and Kolmogorov-Smirnov tests. One-way ANOVA was used to analyze differences between groups in continuous variables. To examine multiple continuous variables, a multivariate analysis of variance was used. Statistical analysis of continuous variables included the application of Mann\u0026ndash;Whitney U and Kruskal\u0026ndash;Wallis tests, with statistical significance set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Patients\u0026rsquo; Demographic Characteristics\u003c/h2\u003e \u003cp\u003eFollowing the application of inclusion and exclusion criteria, the final analysis included data from 107 participants. The median age at surgery was 67.5 years (range: 40\u0026ndash;79 years), and there were 111 males and 15 females with a median BMI of 25.3 kg/m\u0026sup2; (range: 21.6\u0026ndash;32.3 kg/m\u0026sup2;). Marital status assessment revealed that 84.1% of the participants were married, while the remaining 15.9% were single. Baseline HL scores averaged 33.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9, and DHL scores averaged 24.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Factors Associated with Health Literacy and Digital Health Literacy\u003c/h2\u003e \u003cp\u003eThe close relationship between HL and DHL indicates that strategies designed to improve HL can also help enhance DHL. Individuals with lower HL and DHL scores were more likely to be older (p\u0026thinsp;=\u0026thinsp;0.016 for HL, p\u0026thinsp;=\u0026thinsp;0.024 for DHL) and have lower educational attainment (p\u0026thinsp;\u0026lt;\u0026thinsp;0.003). Additionally, lower income and lack of internet access were negatively correlated with both HL and DHL scores (p\u0026thinsp;=\u0026thinsp;0.011 for HL and p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for DHL). To further understand the detailed results of the factors influencing HL and DHL scores, the study included Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e outlining the results of both univariate and multivariate analyses.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnivariate and multivariate analyses to identify the factors that impact health literacy and digital health literacy scores.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;107 (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eHealth Literacy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eDigital Health Literacy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMultivariate analysis\u003c/p\u003e \u003cp\u003ep value**\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep value*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep value*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eAge (yr)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e\u0026le;\u0026thinsp;59\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (15.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37\u0026thinsp;\u0026plusmn;\u0026thinsp;4.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e0.006\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e29.21\u0026thinsp;\u0026plusmn;\u0026thinsp;6.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e0.014\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e60\u0026ndash;69\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63 (58.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33.53\u0026thinsp;\u0026plusmn;\u0026thinsp;3.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e24.27\u0026thinsp;\u0026plusmn;\u0026thinsp;6.74\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e\u0026ge;\u0026thinsp;70\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (32.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29.22\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18.31\u0026thinsp;\u0026plusmn;\u0026thinsp;7.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eBMI (kg/m2)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNormal ( \u0026lt; 25)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (27.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.68\u0026thinsp;\u0026plusmn;\u0026thinsp;6.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.591\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22.61\u0026thinsp;\u0026plusmn;\u0026thinsp;6.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.679\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.732\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eOverweight (25\u0026ndash;30)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56 (52.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.43\u0026thinsp;\u0026plusmn;\u0026thinsp;6.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22.77\u0026thinsp;\u0026plusmn;\u0026thinsp;6.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eObese (\u0026ge;\u0026thinsp;30)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (20.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33.68\u0026thinsp;\u0026plusmn;\u0026thinsp;4.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e23.81\u0026thinsp;\u0026plusmn;\u0026thinsp;5.52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eEducation level\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(ISCED level)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eLevel 1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42 (39.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.11\u0026thinsp;\u0026plusmn;\u0026thinsp;5.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003e0.007\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18.31\u0026thinsp;\u0026plusmn;\u0026thinsp;6.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eLevel 2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (26.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.6\u0026thinsp;\u0026plusmn;\u0026thinsp;5.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e24.73\u0026thinsp;\u0026plusmn;\u0026thinsp;5.43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eLevel 3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (21.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33.541\u0026thinsp;\u0026plusmn;\u0026thinsp;4.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e26.81\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eLevel 4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (13.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e30.63\u0026thinsp;\u0026plusmn;\u0026thinsp;5.39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eMartial Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSingle\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (15.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.35\u0026thinsp;\u0026plusmn;\u0026thinsp;4.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.214\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21.12\u0026thinsp;\u0026plusmn;\u0026thinsp;6.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.768\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.945\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMarried\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90 (84.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.03\u0026thinsp;\u0026plusmn;\u0026thinsp;5.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21.88\u0026thinsp;\u0026plusmn;\u0026thinsp;4.97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eSmoking Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75 (70.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.873\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21.59\u0026thinsp;\u0026plusmn;\u0026thinsp;3.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.822\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.868\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (13.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.83\u0026thinsp;\u0026plusmn;\u0026thinsp;4.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21.37\u0026thinsp;\u0026plusmn;\u0026thinsp;6.41\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eEx-smoker\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (16.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.18\u0026thinsp;\u0026plusmn;\u0026thinsp;3.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20.68\u0026thinsp;\u0026plusmn;\u0026thinsp;4.74\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eAnnual income ($)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e\u0026le;\u0026thinsp;10.000\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75 (70.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.47\u0026thinsp;\u0026plusmn;\u0026thinsp;3.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20.17\u0026thinsp;\u0026plusmn;\u0026thinsp;6.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e\u0026gt;\u0026thinsp;10.000\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (29.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.44\u0026thinsp;\u0026plusmn;\u0026thinsp;.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e30.33\u0026thinsp;\u0026plusmn;\u0026thinsp;4.73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eInternet usage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAlmost everyday\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (27.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003e0.011\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e30.63\u0026thinsp;\u0026plusmn;\u0026thinsp;5.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFew days a week\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (33.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.51\u0026thinsp;\u0026plusmn;\u0026thinsp;6.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25.74\u0026thinsp;\u0026plusmn;\u0026thinsp;3.91\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eLess than 1 day a week\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29.77\u0026thinsp;\u0026plusmn;\u0026thinsp;5.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e23.5\u0026thinsp;\u0026plusmn;\u0026thinsp;6.72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eHardly ever\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (24.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29.13\u0026thinsp;\u0026plusmn;\u0026thinsp;5.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eCystoscopic adherence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eCompliance\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74 (69.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33.21\u0026thinsp;\u0026plusmn;\u0026thinsp;6.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.021\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e26.39\u0026thinsp;\u0026plusmn;\u0026thinsp;5.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNon-Compliance\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (30.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29.46\u0026thinsp;\u0026plusmn;\u0026thinsp;5.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21.42\u0026thinsp;\u0026plusmn;\u0026thinsp;6.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e*ANOVA. **MANOVA (Wilk\u0026rsquo;s Lambda); yr\u0026thinsp;=\u0026thinsp;years; BMI\u0026thinsp;=\u0026thinsp;Body mass index; ISCED\u0026thinsp;=\u0026thinsp;International Standard Classification of Education; Bold font\u0026nbsp;indicates statistically significance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Quality of Life Outcomes\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents a comparison of the QoL evaluations derived from the EORTC QLQ-C30 for both the HL and DHL groups. Logistic regression analysis indicated a meaningful positive correlation between elevated DHL levels and global health. (p\u0026thinsp;=\u0026thinsp;0.043). Furthermore, individuals with higher DHL and HL scores reported improved emotional and social functioning (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for both). However, no statistically significant differences were observed in symptom scale scores across the DHL groups (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInvestigating the levels of patients' health literacy and edigital health literacy and their relationship to the EORTC QoL subscale scores\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndpoint\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eHealth Literacy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003eDigital Health\u003c/p\u003e \u003cp\u003eLiteracy\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eEORTC QLQ-C30\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLimited HL\u003c/p\u003e \u003cp\u003e(Score\u0026thinsp;\u0026le;\u0026thinsp;26)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate HL\u003c/p\u003e \u003cp\u003e(27\u0026thinsp;\u0026le;\u0026thinsp;Score\u0026thinsp;\u0026le;\u0026thinsp;39)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdvanced HL (Score\u0026thinsp;\u0026ge;\u0026thinsp;39)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003cp\u003evalue*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLow DHL,\u003c/p\u003e \u003cp\u003e(Score\u0026thinsp;\u0026le;\u0026thinsp;24)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHigh DHL,\u003c/p\u003e \u003cp\u003e(Score \u0026gt;24)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003cp\u003evalue **\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGlobal health status / QoL\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026dagger;\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGlobal Health Status (Q29,30)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58.43\u0026thinsp;\u0026plusmn;\u0026thinsp;15.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69.16\u0026thinsp;\u0026plusmn;\u0026thinsp;25.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e81.5\u0026thinsp;\u0026plusmn;\u0026thinsp;13.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.022\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e61.31\u0026thinsp;\u0026plusmn;\u0026thinsp;15.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e75.39\u0026thinsp;\u0026plusmn;\u0026thinsp;25.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.008\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFunctional Scales\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026dagger;\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePhysical Function (Q1 to 5)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66.3\u0026thinsp;\u0026plusmn;\u0026thinsp;20.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74.06\u0026thinsp;\u0026plusmn;\u0026thinsp;20.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62.5\u0026thinsp;\u0026plusmn;\u0026thinsp;25.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e66.14\u0026thinsp;\u0026plusmn;\u0026thinsp;17.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e66.70\u0026thinsp;\u0026plusmn;\u0026thinsp;13.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.653\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRole Function (Q6,7)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71.82\u0026thinsp;\u0026plusmn;\u0026thinsp;18.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69.77\u0026thinsp;\u0026plusmn;\u0026thinsp;24.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72.4\u0026thinsp;\u0026plusmn;\u0026thinsp;19.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.902\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e61.42\u0026thinsp;\u0026plusmn;\u0026thinsp;21.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e60.29\u0026thinsp;\u0026plusmn;\u0026thinsp;20.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.702\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmotional Function\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(Q21 to 24)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59.43\u0026thinsp;\u0026plusmn;\u0026thinsp;15.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.38\u0026thinsp;\u0026plusmn;\u0026thinsp;20.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85.28\u0026thinsp;\u0026plusmn;\u0026thinsp;15.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.017\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e60.62\u0026thinsp;\u0026plusmn;\u0026thinsp;19.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e81.08\u0026thinsp;\u0026plusmn;\u0026thinsp;24.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.026\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCognitive Function (Q20,25)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75.93\u0026thinsp;\u0026plusmn;\u0026thinsp;19.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74.06\u0026thinsp;\u0026plusmn;\u0026thinsp;20.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60.00\u0026thinsp;\u0026plusmn;\u0026thinsp;16.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.066\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e74.72\u0026thinsp;\u0026plusmn;\u0026thinsp;20.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e71.77\u0026thinsp;\u0026plusmn;\u0026thinsp;20.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.320\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSocial Function (Q26,27)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64.69\u0026thinsp;\u0026plusmn;\u0026thinsp;14.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.38\u0026thinsp;\u0026plusmn;\u0026thinsp;20.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70.83\u0026thinsp;\u0026plusmn;\u0026thinsp;26.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.734\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e76.73\u0026thinsp;\u0026plusmn;\u0026thinsp;20.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e62.65\u0026thinsp;\u0026plusmn;\u0026thinsp;21.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.099\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSymptom Scales\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026Dagger;\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePain (Q9,19)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42.55\u0026thinsp;\u0026plusmn;\u0026thinsp;19.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.07\u0026thinsp;\u0026plusmn;\u0026thinsp;23.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35.57\u0026thinsp;\u0026plusmn;\u0026thinsp;23.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.321\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e33.65\u0026thinsp;\u0026plusmn;\u0026thinsp;23.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e43.46\u0026thinsp;\u0026plusmn;\u0026thinsp;27.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.074\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNausea and vomiting\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(Q14,15)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.31\u0026thinsp;\u0026plusmn;\u0026thinsp;21.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.56\u0026thinsp;\u0026plusmn;\u0026thinsp;18.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.25\u0026thinsp;\u0026plusmn;\u0026thinsp;13.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.745\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13.84\u0026thinsp;\u0026plusmn;\u0026thinsp;22.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e13.07\u0026thinsp;\u0026plusmn;\u0026thinsp;17.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.652\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFatigue (Q10,12,18)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43.05\u0026thinsp;\u0026plusmn;\u0026thinsp;15.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.97\u0026thinsp;\u0026plusmn;\u0026thinsp;20.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34.89\u0026thinsp;\u0026plusmn;\u0026thinsp;26.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.311\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e34.59\u0026thinsp;\u0026plusmn;\u0026thinsp;21.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e38.34\u0026thinsp;\u0026plusmn;\u0026thinsp;22.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDyspnoea (Q8)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.53\u0026thinsp;\u0026plusmn;\u0026thinsp;21.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.25\u0026thinsp;\u0026plusmn;\u0026thinsp;10.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.60\u0026thinsp;\u0026plusmn;\u0026thinsp;9.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.284\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17.61\u0026thinsp;\u0026plusmn;\u0026thinsp;15.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e21.57\u0026thinsp;\u0026plusmn;\u0026thinsp;19.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInsomnia (Q11)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34.88\u0026thinsp;\u0026plusmn;\u0026thinsp;18.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.83\u0026thinsp;\u0026plusmn;\u0026thinsp;26.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37.5\u0026thinsp;\u0026plusmn;\u0026thinsp;37.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.424\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e28.3\u0026thinsp;\u0026plusmn;\u0026thinsp;28.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e28.10\u0026thinsp;\u0026plusmn;\u0026thinsp;26.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.939\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAppetite loss (Q13)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38.75\u0026thinsp;\u0026plusmn;\u0026thinsp;20.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u0026thinsp;\u0026plusmn;\u0026thinsp;26.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.33\u0026thinsp;\u0026plusmn;\u0026thinsp;25.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.365\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e26.41\u0026thinsp;\u0026plusmn;\u0026thinsp;29.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e22.87\u0026thinsp;\u0026plusmn;\u0026thinsp;20.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.912\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eConstipation (Q16)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.25\u0026thinsp;\u0026plusmn;\u0026thinsp;21.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u0026thinsp;\u0026plusmn;\u0026thinsp;24.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25\u0026thinsp;\u0026plusmn;\u0026thinsp;38.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.623\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e28.30\u0026thinsp;\u0026plusmn;\u0026thinsp;25.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e22.87\u0026thinsp;\u0026plusmn;\u0026thinsp;25.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiarrhea (Q17)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.75\u0026thinsp;\u0026plusmn;\u0026thinsp;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.67\u0026thinsp;\u0026plusmn;\u0026thinsp;19.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.33\u0026thinsp;\u0026plusmn;\u0026thinsp;15.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.061\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15.09\u0026thinsp;\u0026plusmn;\u0026thinsp;19.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10.46\u0026thinsp;\u0026plusmn;\u0026thinsp;19.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.122\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFinancial difficulties (Q28)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.42\u0026thinsp;\u0026plusmn;\u0026thinsp;14.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.95\u0026thinsp;\u0026plusmn;\u0026thinsp;21.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.85\u0026thinsp;\u0026plusmn;\u0026thinsp;22.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.022\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e29.9\u0026thinsp;\u0026plusmn;\u0026thinsp;23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e23.53\u0026thinsp;\u0026plusmn;\u0026thinsp;22.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.043\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEORTC QLQ-C30\u003c/b\u003e: European organization for research and treatment of cancer core quality of life questionnaire; \u003cb\u003e*\u003c/b\u003eKruskal Wallis Test; \u003cb\u003e**\u003c/b\u003eMann Whitney U Test; \u003cb\u003e\u0026dagger;\u003c/b\u003e Higher scores indicate better functioning (scaled from 0-100); \u003cb\u003e\u0026Dagger;\u003c/b\u003eLower scores indicate fewer symptoms (scaled from 0-100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of patients' health literacy and electronic health literacy classifications and EORTC QoL subscale scores by multivariate analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eEORTC QLQ-C30\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eHealth Literacy \u003csup\u003e\u0026yen;\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eDigital Health Literacy\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR (95% CI)*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep value*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOR (95% CI)*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep value*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eGlobal health status / QoL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral Health Status (GHS)a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.95 (0.83\u0026ndash;2.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.99 (0.96\u0026ndash;3.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.021\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eFunctional Scales\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysical Function (Q1 to 5)a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.05 (0.81\u0026ndash;1.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.06 (0.94\u0026ndash;1.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.653\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRole Function (Q6,7)a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.52 (0.95\u0026ndash;2.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.042\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.34 (0.94\u0026ndash;1.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.129\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotional Function\u003c/p\u003e \u003cp\u003e(Q21 to 24)a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.43 (2.69\u0026ndash;5.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.94 (2.73\u0026ndash;5.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCognitive Function (Q20,25)a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.98 (0.83\u0026ndash;1.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.859\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.98 (2.95\u0026ndash;4.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.878\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial Function (Q26,27)a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.06 (0.93\u0026ndash;1.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.93 (0.75\u0026ndash;1.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eSymptom Scales\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain (Q9,19)b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.41 (0.76\u0026ndash;1.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.02 (0.94\u0026ndash;1.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.132\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNausea and vomiting\u003c/p\u003e \u003cp\u003e(Q14,15)b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.65 (0.98\u0026ndash;1.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.321\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.97 (0.85\u0026ndash;1.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.953\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFatigue (Q10,12,18)b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.81 (0.72\u0026ndash;1.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.095\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.96 (0.92\u0026ndash;1.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.789\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDyspnoea (Q8)b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.07 (0.89\u0026ndash;1.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.52 (0.99\u0026ndash;1.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.871\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInsomnia (Q11)b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.8 (0.76\u0026ndash;1.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.38 (0.5\u0026ndash;1.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.574\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAppetite loss (Q13)b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.08 (0.92\u0026ndash;1.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.231\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.96 (0.93\u0026ndash;4.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.134\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstipation (Q16)b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.02 (0.97\u0026ndash;1.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.481\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.95 (0.96\u0026ndash;5.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.653\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiarrhea (Q17)b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.99 (0.89\u0026ndash;1.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.545\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.94 (0.9\u0026ndash;1.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.321\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinancial difficulties (Q28)b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.01 (0.93\u0026ndash;1.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.012\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.98 (0.95\u0026ndash;2.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.042\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eOR\u0026thinsp;=\u0026thinsp;Odds ratio; CI\u0026thinsp;=\u0026thinsp;confidence interval; SD\u0026thinsp;=\u0026thinsp;Standard deviation; Q\u0026thinsp;=\u0026thinsp;question; GHS\u0026thinsp;=\u0026thinsp;global health status; QoL\u0026thinsp;=\u0026thinsp;quality of life; a range\u0026thinsp;=\u0026thinsp;0\u0026ndash;100, high values indicate high levels of functioning and quality of life; b range\u0026thinsp;=\u0026thinsp;0\u0026ndash;100, high levels indicate pronounced symptoms and problems.; \u003csup\u003e\u0026yen;\u003c/sup\u003eHL was classified as nonadequate (limited) and adequate (moderate-advanced) *Binary Logistic Regression-Enter method was used. Age group, educational level, internet usage status, HL and EORTC subscales was added to model.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Treatment Adherence\u003c/h2\u003e \u003cp\u003eAmong the 107 participants, 74 (69.1%) adhered to the recommended cystoscopy follow-up protocol, whereas 33 (18%) did not. A positive correlation emerged between higher HL/DHL scores and improved treatment adherence, as evidenced by increased cystoscopy completion rates (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Follow-Up and Healthcare Utilization\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eLogistic regression was employed to investigate the link between limited and high-level HL/DHL and healthcare utilization within 30 days after surgery. The research uncovered no link between low HL/DHL and increased emergency department visits (p\u0026thinsp;=\u0026thinsp;0.625, CI: 0.74\u0026ndash;1.82) or urology outpatient clinic readmissions (p\u0026thinsp;=\u0026thinsp;0.821, CI: 0.88\u0026ndash;1.4).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe presentation of this second study, which is consistent with our previous study in which HL and DHL were first demonstrated to be effective in urological oncology, opens a new avenue for discussion in patients with low-risk NMIBC (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Our research has yielded valuable insights into the relationship between HL/DHL levels in patients with NIMBC, their health-related QoL, and compliance with treatment.\u003c/p\u003e \u003cp\u003eOur results indicate that there is a correlation between lower HL/DHL and advancing age, lower levels of education, and limited internet accessibility. The decrease in HL and DHL levels with increasing age could be explained by the fact that, as individuals age, their body functions tend to decline, which can lead to a reduction in the capacity to process and retain new information, ultimately impacting HL/DHL scores. The relationship between older age and hearing loss is especially notable in the context of BC. This is due to the fact that 80% of bladder cancer diagnoses occur in individuals over the age of 65 (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNumerous studies have found a strong link between educational level and HL/DHL scores. Higher levels of education are linked to improved capacity in locating, assessing, and utilizing health-related information for decision-making (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Furthermore, lack of Internet access is a major barrier to DHL, as it limits access to a wide range of online health information and resources (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Together, these insights highlight the pressing need for targeted interventions and educational initiatives to enhance DHL and HL among vulnerable patients with BC.\u003c/p\u003e \u003cp\u003eOur study revealed that patients with lower HL/DHL experienced more challenges in understanding information, reported worse emotional and social functioning outcomes, and had a lower QoL, whereas those with higher HL/DHL appeared to be better informed and had a higher QoL. Xia et al. discovered that cancer survivors with sufficient health literacy were almost three times more likely to experience a higher QoL compared to those with inadequate HL (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The researchers also noted similar findings in other measures of functional well-being.\u003c/p\u003e \u003cp\u003eA variety of interventions, including information handouts, audiovisual materials, and online resources, can help improve patients' HL/DHL and treatment adherence (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). These interventions not only facilitate better understanding of medical information but also empower patients to actively participate in their own care. Patients with enhanced HL/DHL are more inclined to comply with follow-up schedules and treatment plans, thereby contributing to improved overall health results.\u003c/p\u003e \u003cp\u003eFurthermore, disease progression and relapse play significant roles in BC prognosis. Recurrence rates within 5 years range between 30% and 80%, while progression rates vary from 1\u0026ndash;45% (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Our findings suggest that lower levels of HL and DHL are associated with poorer health-related treatment adherence among NMIBC patients, consistent with a study by Turkoglu et al. Patients with low HL might not possess the necessary numerical abilities to comprehend and apply information about the probability of BC recurrence or the likelihood of cancer remission (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). As the prognosis of those who fully adhere to the follow-up protocol is expected to be better, informing BC patients with low HL with additional written and visual materials may be a cost-effective and progressive preventive approach (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhile the study possesses strengths, acknowledging its limitations is crucial. Firstly, we were unable to determine pre-operative diagnoses of generalized anxiety disorder or clinical depression. Secondly, the study did not consider other potential factors influencing the outcome of the TUR-BT procedure, such as patient performance or frailty status. Thirdly, the sample size was relatively small, and participants belonged to a specific demographic group limiting the applicability of the results. Finally, the accuracy of the questionnaires relied on patient honesty and cooperation, which represents a significant limitation. However, to the best of our understanding, this is the initial investigation focusing on how HL/DHL affects the QoL and adherence of NIMBC patients. In addition, established and validated questionnaires were used in this pioneering study. Future research efforts should address these limitations by employing larger, more diverse patient populations and incorporating additional factors that might influence treatment outcomes.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe findings underscore the need for healthcare providers to assess and address HL and DHL in their patient populations to deliver more effective and patient-centered care. The idea of including HL/DHL in every aspect of BC care by all healthcare providers is important for providing sufficient support and the best possible information to BC patients with different levels of HL/DHL. This will ultimately improve patient satisfaction, QoL, and adherence to treatment plans. It will also contribute to a more holistic approach to patient care.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFinancial disclosure:\u003c/strong\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy concept and design:\u003c/strong\u003e Keles, Yildirım\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcquisition of data:\u003c/strong\u003e Keles, Kose, Somun\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalysis and interpretation of data:\u003c/strong\u003e Keles, Culpan, Arikan\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDrafting of the manuscript:\u003c/strong\u003e Keles, Arikan,Culpan\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCritical revision of the manuscript for important intellectual content:\u003c/strong\u003e Culpan, Keles, Yildirım\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e: Keles, Arikan\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdministrative, technical, or material support:\u003c/strong\u003e Kose, Somun, Keles, Yildirim\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSupervision:\u003c/strong\u003e Yildirim\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, Bray F. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021 May;71(3):209-249. doi: 10.3322/caac.21660. \u003c/li\u003e\n\u003cli\u003evan Straten CGJI, Bruins MH, Dijkstra S, Cornel EB, Kortleve MDH, de Vocht TF, Kiemeney LALM, van der Heijden AG. The accuracy of cystoscopy in predicting muscle invasion in newly diagnosed bladder cancer patients. World J Urol. 2023 Jul;41(7):1829-1835. doi: 10.1007/s00345-023-04428-6. \u003c/li\u003e\n\u003cli\u003eGabel P, Larsen MB, Edwards A, Kirkegaard P, Andersen B. Knowledge, attitudes, and worries among different health literacy groups before receiving first invitation to colorectal cancer screening: cross-sectional study. Prev Med Rep. 2019;14:100876. doi: 10.1016/j.pmedr.2019.100876.\u003c/li\u003e\n\u003cli\u003eMorris NS, Field TS, Wagner JL, Cutrona SL, Roblin DW, Gaglio B, et al. The association between health literacy and cancer-related attitudes, behaviors, and knowledge. J Health Commun. 2013;18(Suppl 1):223\u0026ndash;241. doi: 10.1080/10810730.2013.825667.\u003c/li\u003e\n\u003cli\u003eSoto-Perez-de-Celis E, Perez-Montessoro V, Rojo-Castillo P, Chavarri-Guerra Y. Health-Related Information-Seeking Behaviors and Preferences Among Mexican Patients with Cancer. J Cancer Educ. 2018;33(3):505-509. doi:10.1007/s13187-018-1334-8.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Infodemic Management: An Overview of Infodemic Management during COVID-19, January 2020\u0026ndash;May 2021. World Health Organization; Geneve, Switzerland: 2021.\u003c/li\u003e\n\u003cli\u003eSoto-Perez-de-Celis E, Perez-Montessoro V, Rojo-Castillo P, Chavarri-Guerra Y. Health-Related Information-Seeking Behaviors and Preferences Among Mexican Patients with Cancer. J Cancer Educ. 2018;33(3):505-509. doi:10.1007/s13187-018-1334-8.\u003c/li\u003e\n\u003cli\u003eNorman CD, Skinner HA. eHealth Literacy: Essential Skills for Consumer Health in a Networked World. J Med Internet Res. 2006;8(2):e9. Published 2006 Jun 16. doi:10.2196/jmir.8.2.e9.\u003c/li\u003e\n\u003cli\u003eFinbr\u0026aring;ten HS, Wilde-Larsson B, Nordstr\u0026ouml;m G et al (2018) Establishing the HLS-Q12 short version of the European Health Literacy Survey Questionnaire: latent trait analyses applying Rasch modelling and confirmatory factor analysis. BMC Health Serv Res 18:506. https://doi.org/10.1186/s12913-018-3275-7\u003c/li\u003e\n\u003cli\u003eS\u0026oslash;rensen K, Van den Broucke S, Pelikan JM et al (2013) Measuring health literacy in populations: illuminating the design and development process of the European Health Literacy Survey Questionnaire (HLS-EU-Q). BMC Public Health 13:948. https://doi.org/10.1186/1471-2458-13-948\u003c/li\u003e\n\u003cli\u003eAaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ et al (1993) The European organization for research and treatment of cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. JNCI J Natl Cancer Inst 85(5):365\u0026ndash;376. https://doi.org/10.1093/jnci/85.5.365\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Obesity and overweight. https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight. Accessed 10 May 2022\u003c/li\u003e\n\u003cli\u003eTurkish Statistical Institute (TurkStat). Classification of Education 2021. https://biruni.tuik.gov.tr/DIESS/SiniflamaSatirListeAction.do?surumId=237\u0026amp;seviye=1\u0026amp;detay=H\u0026amp;turId=39\u0026amp;turAdi=%207.%20Eğitim%20Sınıflamaları. Accessed 10 May 2022\u003c/li\u003e\n\u003cli\u003eKeles A, Kose M, Somun UF, Culpan M, Yaksi N, Yıldırım A. Impact of health and digital health literacy on quality of life following radical prostatectomy for prostate cancer: prospective single-center cohort study. World J Urol. 2024 Apr 17;42(1):241. doi: 10.1007/s00345-024-04960-z. \u003c/li\u003e\n\u003cli\u003eZhang Y, Xu P, Sun Q, Baral S, Xi L, Wang D. Factors influencing the e-health literacy in cancer patients: a systematic review. J Cancer Surviv. 2023 Apr;17(2):425-440. doi: 10.1007/s11764-022-01260-6. \u003c/li\u003e\n\u003cli\u003eKobayashi LC, Wardle J, von Wagner C. Limited health literacy is a barrier to colorectal cancer screening in England: evidence from the English Longitudinal Study of Ageing. Prev Med. 2014;61:100\u0026ndash;105. \u003c/li\u003e\n\u003cli\u003eScarpato KR, Kappa SF, Goggins KM, Chang SS, Smith JA Jr, Clark PE, Penson DF, Resnick MJ, Barocas DA, Idrees K, Kripalani S, Moses KA (2016) The impact of health literacy on surgical outcomes following radical cystectomy. J Health Commun 21(sup2):99\u0026ndash;104. https://doi.org/10.1080/10810730.2016.1193916\u003c/li\u003e\n\u003cli\u003ePapadakos J, Le LW, Milne VC, Hope AJ, et al. Predictors of high eHealth literacy in primary lung cancer survivors. J Cancer Educ. 2015;30(4):685\u0026ndash;92. https://doi.org/10. 1007/s13187-014-0744-5.\u003c/li\u003e\n\u003cli\u003eDel Giudice P, Bravo G, Poletto M, De Odorico A, Conte A, Brunelli L, et al. Correlation between eHealth literacy and health literacy using the eHealth literacy scale and real-life experiences in the health sector as a proxy measure of functional health literacy: cross-sectional web-based survey. J Med Internet Res. 2018;20(10):e281. https://doi.org/10.2196/jmir.9401.\u003c/li\u003e\n\u003cli\u003eXia J, Wu P, Deng Q, Yan R, Yang R, Lv B, Wang J, Yu J. Relationship between health literacy and quality of life among cancer survivors in China: a cross-sectional study. BMJ Open. 2019 Dec 31;9(12):e028458. doi: 10.1136/bmjopen-2018-028458. \u003c/li\u003e\n\u003cli\u003eJamieson SC, Mallory CW, Jivanji DR, Perez A, Castro G, Barengo NC, Pereira J, Nieder AM. The Role of Health Literacy in Prostate Cancer Screening. Urology. 2022 May;163:112-118. doi: 10.1016/j.urology.2021.05.100. \u003c/li\u003e\n\u003cli\u003eSentell TL, Tsoh JY, Davis T, Davis J, Braun KL. Low health literacy and cancer screening among Chinese Americans in California: a cross-sectional analysis. BMJ Open. 2015 Jan 5;5(1):e006104. doi: 10.1136/bmjopen-2014-006104. \u003c/li\u003e\n\u003cli\u003eDatovo JCF, Neto WA, Mendon\u0026ccedil;a GB, Andrade DL, Reis LO. Prognostic impact of non-adherence to follow-up cystoscopy in non-muscle-invasive bladder cancer (NMIBC). World J Urol. 2019 Oct;37(10):2067-2071. doi: 10.1007/s00345-019-02697-8. \u003c/li\u003e\n\u003cli\u003eTurkoglu AR, Demirci H, Coban S, Guzelsoy M, Toprak E, Aydos MM, Ture DA, Ustundag Y. Evaluation of the relationship between compliance with the follow-up and treatment protocol and health literacy in bladder tumor patients. Aging Male. 2019 Dec;22(4):266-271. doi: 10.1080/13685538.2018.1447558. \u003c/li\u003e\n\u003cli\u003evan der Heide I, Uiters E, Jantine Schuit A, Rademakers J, Fransen M. Health literacy and informed decision making regarding colorectal cancer screening: a systematic review. Eur J Public Health. 2015 Aug;25(4):575-82. doi: 10.1093/eurpub/ckv005. \u003c/li\u003e\n\u003cli\u003eHalverson JL, Martinez-Donate AP, Palta M, Leal T, Lubner S, Walsh MC, Schaaf Strickland J, Smith PD, Trentham-Dietz A. Health Literacy and Health-Related Quality of Life Among a Population-Based Sample of Cancer Patients. J Health Commun. 2015;20(11):1320-9. doi: 10.1080/10810730.2015.1018638. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjur","sideBox":"Learn more about [World Journal of Urology](https://link.springer.com/journal/345)","snPcode":"345","submissionUrl":"https://submission.nature.com/new-submission/345/3","title":"World Journal of Urology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"digital, health, literacy, patient, reported, outcome, bladder, cancer, quality of life","lastPublishedDoi":"10.21203/rs.3.rs-4535711/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4535711/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eObjective\u003c/b\u003e\u003c/p\u003e \u003cp\u003eGiven the increasing significance of digital health literacy (DHL) and health literacy (HL) in promoting informed decision-making and healthy behaviors, this study aimed to assess the influence of self-reported HL and DHL on treatment adherence and quality of life among patients who underwent transurethral resection of bladder tumors (TUR-BT) for primary non-muscle invasive bladder cancer (NMIBC).\u003c/p\u003e\u003cp\u003e\u003cb\u003eMaterials \u0026amp; Methods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis observational research involved 107 NIMBC participants. Before the procedure, the patients' DHL and HL were evaluated using the European Health Literacy Survey Questionnaire short version and the eHealth Literacy Scale. Six months after surgery, we surveyed patients\u0026rsquo; QoL using the EORTC QLQ-C30. In line with recommendations from the European Association of Urology guidelines, adherence to the treatment plan was assessed along with a follow-up cystoscopy examination for each patient.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eMultivariate analysis revealed that poorer DHL and HL were significantly associated with older age (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), lower educational attainment (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and lack of internet access (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Conversely, higher DHL and HL levels were positively correlated with increased treatment adherence, as measured by cystoscopy completion (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Additionally, logistic regression analysis demonstrated significant associations between improved DHL and HL scores and better global health status (DHL, p\u0026thinsp;=\u0026thinsp;0.022; HL, p\u0026thinsp;=\u0026thinsp;0.008), higher emotional status (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for both), and social functioning (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for both). Notably, there were no significant differences in the symptom scale scores between the DHL and HL groups.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTo the best of our knowledge, this is the first study to explore the specific effect of HL/DHL on QoL and adherence in this patient population. Our research suggests that there may be a link between self-reported levels of DHL/HL and treatment adherence as well as QoL among patients with NIMBC.\u003c/p\u003e","manuscriptTitle":"Exploring the Influence of Health and Digital Health Literacy on Quality of Life and Follow-up Compliance in Patients with Primary Non-muscle Invasive Bladder Cancer: A Prospective, Single-Center Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-26 14:48:35","doi":"10.21203/rs.3.rs-4535711/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-22T08:14:44+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-28T10:57:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-21T16:14:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"268570347014970412017462778438165160822","date":"2024-08-21T13:08:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"81829004961353705702649477125152828577","date":"2024-08-20T13:59:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"247808237925648166005874529327163910701","date":"2024-08-17T06:41:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-16T18:51:24+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-06T15:51:30+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-06T07:32:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"World Journal of Urology","date":"2024-06-05T17:44:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjur","sideBox":"Learn more about [World Journal of Urology](https://link.springer.com/journal/345)","snPcode":"345","submissionUrl":"https://submission.nature.com/new-submission/345/3","title":"World Journal of Urology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"2339304f-78be-49c0-be0a-e555101e62d0","owner":[],"postedDate":"June 26th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-02-03T16:10:28+00:00","versionOfRecord":{"articleIdentity":"rs-4535711","link":"https://doi.org/10.1007/s00345-025-05463-1","journal":{"identity":"world-journal-of-urology","isVorOnly":false,"title":"World Journal of Urology"},"publishedOn":"2025-01-30 15:58:15","publishedOnDateReadable":"January 30th, 2025"},"versionCreatedAt":"2024-06-26 14:48:35","video":"","vorDoi":"10.1007/s00345-025-05463-1","vorDoiUrl":"https://doi.org/10.1007/s00345-025-05463-1","workflowStages":[]},"version":"v1","identity":"rs-4535711","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4535711","identity":"rs-4535711","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}