Introduction
Pain acceptance is a concept that has gained considerable attention in pain management literature. It involves acknowledging the presence of pain without attempting to reduce, change, or avoid it, thereby focusing on living a meaningful life despite the pain [1-5]. The theoretical framework of pain acceptance originates from mindfulness and acceptance-based approaches, suggesting that struggling against pain can exacerbate suffering, whereas accepting pain can lead to reduced pain-related distress and improved functioning [6-12]. Studies have shown that higher levels of pain acceptance are associated with lower levels of disability, depression, and pain intensity [13-18]. As the concept of pain acceptance has been increasingly recognized for its role in chronic pain management, studies have consistently shown that individuals who adopt an accepting stance toward their pain experience less psychological distress, better emotional functioning, and greater engagement in life activities despite pain [1, 2, 4, 13, 19]. This shift away from a traditional focus on pain reduction toward acceptance and coexistence with pain marks a significant evolution in chronic pain treatment paradigms.
Health literacy, as another key variable in this study, encompasses not only the capacity to access and understand health information but also the competence to use such information in making informed health decisions [20-25]. In the context of chronic pain, health literacy includes understanding pain management strategies, medication instructions, and the healthcare system’s navigation [25]. Research indicates that inadequate health literacy is linked to worse pain outcomes and an increased risk of misinterpreting pain-related information, which can lead to ineffective pain management strategies [20, 26].
Pain intensity, the subjective experience of pain, is a crucial measure in pain research and management. It is influenced by various factors, including biological, psychological, and social components. Chronic pain’s pervasive nature can significantly impact an individual’s physical and psychological well-being, highlighting the need to understand the factors that modulate pain perception and intensity [27, 28]. Thus, understanding the factors that influence pain intensity—including psychological components like pain acceptance and health literacy—is essential for developing comprehensive pain management strategies that address the multifaceted nature of chronic pain.
The literature review reveals a complex interplay between pain acceptance, health literacy and pain intensity. For instance, Boer et al. highlighted the role of mindfulness and acceptance in mitigating the effects of catastrophizing on pain perception, suggesting that acceptance could serve as a protective factor against intense pain experiences [1]. Similarly, Ferreira-Valente et al. found that pain acceptance could buffer the negative effects of catastrophizing on function in individuals with chronic pain, emphasizing acceptance’s potential as a therapeutic target [6]. The role of health literacy in pain management has also been explored, with studies indicating that higher levels of health literacy are associated with better pain outcomes and less pain-related distress [21, 26]. Furthermore, the impact of health literacy on the understanding and application of pain management strategies suggests that enhancing health literacy could improve chronic pain management [29]. The relationship between pain acceptance and health literacy with pain intensity is complex, with evidence suggesting that these factors may interact to influence pain experiences. Pain acceptance may facilitate better engagement with health information and adherence to pain management strategies, potentially moderating the relationship between health literacy and pain outcomes [30]. Conversely, high levels of health literacy could empower individuals to seek out and engage with acceptance-based pain management approaches, further influencing their pain perception and intensity [31].
This study’s rationale is underpinned by the hypothesis that pain acceptance and health literacy are inversely related to pain intensity. That is, higher levels of pain acceptance and health literacy are expected to be associated with lower levels of pain intensity (Figure 1). This hypothesis is based on the premise that acceptance of pain may lead to less psychological resistance and, consequently, a lower perception of pain intensity. Similarly, higher health literacy may enable individuals to better manage their pain through informed decision-making and effective use of pain management strategies, potentially reducing pain intensity. Therefore, this study aimed to explore these dynamics further by examining the associations between pain acceptance, health literacy and pain intensity in a cross-sectional study of individuals with chronic pain.

Methods 
Study design and participants
This study utilized a cross-sectional design to explore the relationship between pain acceptance, health literacy, and pain intensity in individuals with chronic pain. A total of 350 participants were recruited from Richmond Hill, Ontario, Canada. The sample size was determined based on the Morgan and Krejcie table to ensure statistical reliability and validity for the analysis of correlations and regression models within the study population. Eligibility criteria for participants included individuals aged 18 years or older, diagnosed with chronic pain for at least six months, and residents of Richmond Hill. Participants were excluded if they had cognitive impairments that could interfere with their ability to complete the study questionnaires or if they were non-English speakers, due to the English language format of the assessment tools. 

Measures
Numeric pain rating scale (NPRS)
NPRS is a widely utilized tool for the assessment of pain intensity in individuals with chronic pain. Created as a straightforward method for evaluating pain levels, the NPRS asks patients to rate their pain on a numeric scale typically ranging from zero (no pain) to ten (the worst possible pain). This scale, lacking subscales due to its direct and singular focus on pain intensity, offers a quick and easily comprehensible means for both patients and healthcare providers to gauge pain levels. The validity and reliability of the NPRS have been confirmed in numerous studies since its introduction, making it a standard measure in clinical settings for assessing pain intensity. 

Chronic pain acceptance questionnaire (CPAQ)
The CPAQ, developed by McCracken et al. [32] in 2004, is a standardized tool designed to measure the degree of pain acceptance in individuals experiencing chronic pain. The CPAQ contains 20 items divided into two subscales: activity engagement, which measures the extent to which individuals engage in life activities despite pain, and pain willingness, which assesses the degree to which individuals cease attempts to avoid or control pain. Scores are calculated by summing responses, with higher scores indicating greater pain acceptance. The validity and reliability of the CPAQ have been thoroughly examined in prior studies, confirming its efficacy as a measure of pain acceptance in chronic pain populations. 

Health literacy questionnaire (HLQ)
HLQ, developed by Osborne et al. [33] in 2013, is a comprehensive tool designed to assess health literacy in a wide range of populations. Comprising 44 items across nine distinct subscales, the HLQ covers various dimensions of health literacy, including the ability to understand health information, navigate the healthcare system, and engage in self-care practices. The subscales include areas, such as feeling understood and supported by healthcare providers, having sufficient information to manage my health, and ability to actively engage with healthcare providers. Scoring for the HLQ is based on a four-point scale for some subscales and a five-point scale for others, with higher scores reflecting higher levels of health literacy. 

Data analysis
Data analysis was conducted using SPSS software, version 27. Initial analyses included descriptive statistics to characterize the study sample in terms of demographic and clinical variables. The relationship between pain intensity (dependent variable) and each of the independent variables (pain acceptance and health literacy) was assessed using Pearson correlation coefficients. These analyses aimed to identify the strength and direction of associations between pain intensity and the two independent variables. 
Subsequently, a linear regression analysis was performed to further explore the predictive value of pain acceptance and health literacy on pain intensity. This analysis incorporated both independent variables simultaneously to assess their unique contribution to explaining the variance in pain intensity among the participants. Assumptions of linear regression, including normality, linearity, multicollinearity, and homoscedasticity, were tested to ensure the appropriateness of the model.
The level of significance was set at P<0.05 for all statistical tests. The findings from the Pearson correlation and linear regression analyses were interpreted to understand the relationships between pain intensity, pain acceptance, and health literacy, providing insights into how these variables interact in the context of chronic pain management.

Findings and results
Among the 350 participants recruited for the study, 207(59.14%) were female, and 143(40.86%) were male. The participants’ ages ranged from 18 to 65 years, with a Mean±SD age of 42.37±11.23 years. The majority of the sample (112 participants, 32.00%) fell within the 36-45 year age group. Regarding education level, 138 participants (39.43%) had completed college, 94(26.86%) held a university degree and the remaining 118(33.71%) had a high school diploma or less. Employment status revealed that 210 participants (60.00%) were employed full-time, 70(20.00%) were employed part-time, and the remainder were either unemployed or retired (70 participants, 20.00%).
As shown in Table 1, the descriptive statistics for the study variables provided an overview of the sample characteristics in terms of pain intensity, pain acceptance, and health literacy.


The mean pain intensity score among participants was 5.67±2.45 on a scale from zero to ten, indicating a moderate level of pain across the sample. Pain acceptance scores had a mean of 30.54±8.76, suggesting variability in the degree to which individuals accept their chronic pain condition. Health literacy scores averaged 25.32±5.12, reflecting a range of health literacy levels among participants. These descriptive statistics offer a foundational understanding of the sample’s profile regarding their pain experience, acceptance, and health literacy levels. 
Before conducting the linear regression analysis, we checked for assumptions to ensure the appropriateness of the model. The assumption of normality was verified by inspecting the distribution of residuals, which were found to be normally distributed (Kolmogorov-Smirnov test, P=0.15; Shapiro-Wilk test, P=0.12), indicating no violation of normality. Linearity was assessed through scatterplots of standardized predicted values against standardized residual values, which displayed a linear pattern. The assumption of homoscedasticity was confirmed by visual inspection of a plot of residuals versus predicted values, showing a constant spread of residuals across the range of predicted values (Breusch-Pagan test, P=0.14). Multicollinearity was assessed using variance inflation factor (VIF) values for the independent variables, which were 1.08 for pain acceptance and 1.11 for health literacy, well below the commonly used threshold of 5, indicating no multicollinearity issues. These checks confirmed that the data met the necessary assumptions for linear regression, allowing us to proceed with the analysis. 
The correlation analysis in Table 2 revealed significant relationships between pain intensity and the independent variables. Specifically, pain acceptance showed a negative correlation with pain intensity (r=-0.45, P<0.01), indicating that higher levels of pain acceptance were associated with lower levels of pain intensity.


Similarly, health literacy was negatively correlated with pain intensity (r=-0.38, P<0.01), suggesting that individuals with higher health literacy experienced less intense pain. These findings highlight the potential influence of psychological and educational factors on the perception of pain among individuals with chronic conditions.
The summary of regression results in Table 3 demonstrates the predictive power of pain acceptance and health literacy on pain intensity.


The regression model accounted for 26% of the variance in pain intensity (R²=0.26, adjusted R²=0.24), with an F-value of 19.56, indicating the model’s significance (P<0.001). The regression analysis highlights the combined effect of pain acceptance and health literacy in explaining variations in pain intensity among the study participants, providing empirical support for the conceptual model proposed in this research.
According to Table 4, the multivariate regression analysis demonstrated the individual contributions of pain acceptance and health literacy to predicting pain intensity.


The analysis indicated that pain acceptance significantly predicted pain intensity (B=-0.15, β=-0.25, t=-5.00, P<0.001), as did health literacy (B=-0.10, β=-0.20, t=-4.00, P<0.001), after controlling for the other variable. These results underscore the importance of both accepting pain and understanding health information in managing the intensity of chronic pain, suggesting potential pathways for intervention in clinical settings.

Discussion
In this study, we examined the associations between pain acceptance, health literacy, and pain intensity among individuals with chronic pain. Our findings reveal that both pain acceptance and health literacy significantly predict pain intensity, underscoring the pivotal roles these variables play in the experience and management of chronic pain. 
Our results indicated a significant negative correlation between pain acceptance and pain intensity (r=-0.45, P<0.01). This finding supports the notion that higher levels of pain acceptance are associated with lower levels of pain intensity. The significant predictive relationship between pain acceptance and pain intensity found in our study echoes the findings of Boer et al. who highlighted the beneficial effects of mindfulness and acceptance on reducing catastrophizing and mitigating pain experiences [1]. Consistent with the theoretical framework that suggests acceptance can lead to decreased pain-related distress and improved functioning [6, 13], our results support the notion that embracing pain without struggle may be a critical component in managing chronic pain effectively. This is particularly relevant considering the substantial burden of chronic pain on individuals’ daily lives, as evidenced by Breivik et al. and Burgess et al., who document the profound impact of chronic pain on physical capabilities, emotional well-being, and overall quality of life [27, 28]. 
Similarly, we found a significant negative correlation between health literacy and pain intensity (r=-0.38, P<0.01). Our findings regarding health literacy’s predictive power over pain intensity contribute to the burgeoning evidence on the importance of health literacy in chronic pain management [21]. Higher health literacy levels were associated with lower pain intensity, suggesting that the ability to understand, process, and apply health information effectively is crucial in navigating pain management strategies and healthcare systems. This aligns with Lacey et al., who emphasized the negative impact of inadequate health literacy on pain outcomes and highlighted the need for targeted interventions to enhance health literacy among individuals with chronic pain [20].
The relationship between pain acceptance and health literacy in predicting pain intensity also sheds light on the potential synergistic effects of these variables. Our findings suggest that individuals who accept their pain and possess the skills to engage with health information actively may be better positioned to manage their pain intensity. This resonates with the studies by Probst et al. and Yu et al. who discuss the importance of acceptance in engaging with health information and treatment options [30, 31]. 

Conclusion
This study aimed to explore the associations between pain acceptance, health literacy and pain intensity in individuals with chronic pain. Our findings indicated that both pain acceptance and health literacy significantly predict pain intensity, underscoring their importance in the experience and management of chronic pain. These results highlight the potential of targeting these factors in interventions to improve outcomes for individuals suffering from chronic pain. 
In conclusion, this study contributes to the understanding of pain acceptance and health literacy as significant predictors of pain intensity in chronic pain populations. Highlighting the importance of these factors, it underscores the need for comprehensive approaches that incorporate psychological and educational strategies into chronic pain management. Addressing the limitations and building on the suggestions for future research and practice could lead to more effective interventions, ultimately improving the lives of those affected by chronic pain. 
Despite its contributions, this study is not without limitations. First, the cross-sectional design precludes causal inferences, limiting our ability to determine the directionality of the relationships observed. Second, the sample was drawn from a single geographic area, which may restrict the generalizability of the findings to other populations and settings. Third, reliance on self-reported measures for pain acceptance, health literacy, and pain intensity could introduce bias, as these are subject to individual interpretation and reporting accuracy. Future studies could address these limitations by employing longitudinal designs, diversifying the participant pool and incorporating objective measures where possible. 
Future research should aim to overcome these limitations and build on the findings of this study. Longitudinal studies could elucidate the causal relationships between pain acceptance, health literacy and pain intensity, providing clearer insights into how these factors interact over time. Exploring these associations in diverse populations and settings would enhance the generalizability of the results. Additionally, investigating the mechanisms, through which pain acceptance and health literacy impact pain intensity could offer valuable information for developing targeted interventions. Incorporating qualitative methods could also provide a deeper understanding of individuals’ experiences with pain acceptance and health literacy in managing chronic pain. 
The findings of this study have several implications for clinical practice. Healthcare providers should consider incorporating strategies to enhance pain acceptance and health literacy into chronic pain management programs. For instance, acceptance and commitment therapy (ACT) could be utilized to improve pain acceptance, while educational interventions designed to boost health literacy may empower patients to more effectively manage their condition. Tailoring these interventions to individual needs and contexts is crucial for optimizing outcomes. Additionally, fostering a collaborative care model that emphasizes the role of psychological and educational strategies alongside medical treatment could significantly benefit individuals with chronic pain. 

Ethical Considerations
Compliance with ethical guidelines
The study protocol adhered to the principles outlined in the Helsinki Declaration, which provides guidelines for ethical research involving human participants. The study received Ethical Approval from the KMAN Research Institute Ethics Committee (Code: KEC.2023.7A2), ensuring adherence to ethical standards for research involving human participants. 

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 

Authors contributions
All authors contributed equally to the conception and design of the study, data collection and analysis, interpretation of the results, and drafting of the manuscript. Each author approved the final version of the manuscript for submission.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to express their gratitude to all individuals who helped them with the project.


References

1. de Boer MJ, Steinhagen HE, Versteegen GJ, Struys MM, Sanderman R. Mindfulness, acceptance and catastrophizing in chronic pain. PLoS One. 2014; 9(1):e87445. [DOI:10.1371/journal.pone.0087445] [PMID]
2. Ebrahimi E, Hatami M, Seirafi M. Comparison of the effectiveness of emotional self-regulation strategies and coping strategies with pain on emotional process regulation in female patients with coronary heart disease. Applied Family Therapy Journal (AFTJ). 2022; 3(3):66-79. [DOI:10.61838/kman.aftj.3.3.5]
3. Goli ZS, Mirseify Fard LS. The role of metacognitive beliefs and resilience on predicting marital adjustment in both groups of patients with chronic and acute pain. Journal of Assessment and Research in Applied Counseling (JARAC). 2021; 3(3):55-63. [DOI:10.61838/kman.jarac.3.3.6]
4. Hooshmandi R, Aljaberi MA, Hammadi F, Ma J. The impact of interoceptive awareness on pain catastrophizing and illness perception. Journal of Personality and Psychosomatic Research (JPPR). 2024; 2(2):4-10. [DOI:10.61838/kman.jppr.2.2.2]
5. Law EF, Kim A, Ickmans K, Palermo TM. Sleep health assessment and treatment in children and adolescents with chronic pain: State of the art and future directions. Journal of Clinical Medicine. 2022; 11(6):1491. [DOI:10.3390/jcm11061491] [PMID]
6. Ferreira-Valente A, Solé E, Sánchez-Rodríguez E, Sharma S, Pathak A, Jensen MP, et al. Does pain acceptance buffer the negative effects of catastrophizing on function in individuals with chronic pain? Clinical Journal of Pain. 2021; 37(5):339-48. [DOI:10.1097/AJP.0000000000000930] [PMID]
7. Alizadeh P, Kooshki S, Tarvirdizadeh H. The effectiveness of acceptance and commitment therapy and on pain intensity, childhood trauma, perfectionism and psychological flexibility in patients with chronic pain. Journal of Assessment and Research in Applied Counseling (JARAC). 2023; 5(2):123-36. [DOI:10.61838/kman.jarac.5.2.15]
8. Changi Ashtiani M, Fattahi N, Balali D, Alavi SH, Mahmoudzadeh M. Effectiveness of mindfulness-based schema therapy on mental pain and experiential avoidance in patients with cardiovascular diseases. Journal of Assessment and Research in Applied Counseling (JARAC). 2024; 6(1):90-6. [DOI:10.61838/kman.jarac.6.1.10]
9. Charmi A, Zoghi L. Prediction of life expectancy based on pain self-efficacy, death obsession, general health with the mediation of emotion regulation in indigent dialysis women. Journal of Assessment and Research in Applied Counseling (JARAC). 2023; 5(1):104-11. [DOI:10.61838/kman.jarac.5.1.14]
10. Lee A, Wong Y, Neo XS. Coping mechanisms among patients with terminal illnesses. KMAN Counseling & Psychology Nexus. 2024; 2(1):91-7. [DOI:10.61838/kman.psynexus.2.1.14]
11. Pirasteh Motlagh AK, Nikmanesh Z. [The relationship of spirituality with the pain and quality of life in patients with HIV/AIDS (Persian)]. Armaghane Danesh. 2012; 17(4):337-48. [Link]
12. Roshandel Z, Ghaffari A, Kazemi R, Nadermohammadi M. Effectiveness of acceptance and commitment based therapy on pain severity, fatigue, and alexithymia in female patients with rheumatic diseases. Applied Family Therapy Journal (AFTJ). 2022; 3(5):84-100. [DOI:10.61838/kman.aftj.3.5.6]

13. Jensen MP, Smith AE, Alschuler KN, Gillanders DT, Amtmann D, Molton IR. The role of pain acceptance on function in individuals with disabilities: A longitudinal study. Pain. 2016; 157(1):247-54. [DOI:10.1097/j.pain.0000000000000361] [PMID]
14. Kratz AL, Hirsh AT, Ehde DM, Jensen MP. Acceptance of pain in neurological disorders: Associations with functioning and psychosocial well-being. Rehabilitation Psychology. 2013; 58(1):1-9. [DOI:10.1037/a0031727] [PMID]
15. Emami AS, Peymani J, Aghajanihashjin T. Structural relationships of pain intensity and self-efficacy with fear of movement mediated by psychological distress in women with rheumatoid arthritis. Applied Family Therapy Journal (AFTJ). 2022; 3(3):1-19. [DOI:10.61838/kman.aftj.3.3.1]
16. Rostami M, Bulut S, Coelho O, Riyono B. Living with fibromyalgia: A phenomenological study of pain, fatigue, and coping. Journal of Personality and Psychosomatic Research (JPPR). 2024; 2(1):16-23. [DOI:10.61838/kman.jppr.2.1.4]
17. Sayed Alitabar SH, Goli F. The interplay of neuroticism and self-efficacy in pain catastrophizing: A quantitative analysis. Journal of Personality and Psychosomatic Research (JPPR). 2023; 1(2):19-24. [DOI:10.61838/kman.jppr.1.2.4]
18. Yusefi R, Hafezi F, Bakhtiarpoor S, Makvandi B. Comparing the effectiveness of cognitive- behavioral hypnotherapy and mindfulness therapy on pain perception and self-efficacy in women with breast cancer in Gorgan. Applied Family Therapy Journal (AFTJ). 2022; 3(5):209-27. [DOI:10.61838/kman.aftj.3.5.13]
19. Givi F, Meschi F, Zhian Bagheri M, Farhood D. Structural equation modeling of pain management based on rumination mediating resiliency and vitality in women with breast cancer. Applied Family Therapy Journal (AFTJ). 2023; 4(1):447-65. [DOI:10.61838/kman.aftj.4.1.22]
20. Lacey RJ, Campbell P, Lewis M, Protheroe J. The impact of inadequate health literacy in a population with musculoskeletal pain. Health Literacy Research and Practice. 2018; 2(4):e215-20. [DOI:10.3928/24748307-20181101-01] [PMID]
21. Miller-Matero LR, Santullano D, Rich M, Valler M, Hecht LM, Tobin ET, et al. Association of health literacy with chronic pain and pain-related distress. Professional Psychology Research and Practice. 2024; 55(2):89-94. [Link]
22. Heidari H, Doshman Ziari E, Barzegar N, Faghiharam B, Mehdizadeh AH. Designing an E-Learning Model for Health Tourism Marketing Case Study: Educational Healthcare Centers of Islamic Azad University, Tehran. International Journal of Innovation Management and Organizational Behavior (IJIMOB). 2024; 4(1):20-7. [DOI:10.61838/kman.ijimob.4.1.3]
23. Hoseini M. Patient Experiences with AI in Healthcare Settings. AI and Tech in Behavioral and Social Sciences. 2023; 1(3):12-8. [DOI:10.61838/kman.aitech.1.3.3]
24. Rezvani SR, Abolghasemi S, Farhangi A. Presenting the model of self-care behaviors of pregnant women based on health literacy and mindfulness with the mediation of a health-oriented lifestyle. Applied Family Therapy Journal (AFTJ). 2022; 3(5):176-95. [DOI:10.61838/kman.aftj.3.5.11]
25. Saadati N, Yousefi Z, Saadati SA. E-health Literacy and Older Adults: Challenges, Opportunities, and Support Needs. AI and Tech in Behavioral and Social Sciences. 2023; 1(1):12-9. [DOI:10.61838/kman.aitech.1.1.3]
26. Oosterhaven J, Pell CD, Schröder CD, Popma H, Spierenburg L, Devillé WLJM, et al. Health Literacy and Pain Neuroscience Education in an Interdisciplinary Pain Management Programme: A qualitative study of patient perspectives. Pain Reports. 2023; 8(6):e1093. [DOI:10.1097/PR9.0000000000001093] [PMID]
27. Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment. European Journal of Pain. 2006; 10(4):287-333. [DOI:10.1016/j.ejpain.2005.06.009] [PMID]
28. Burgess HJ, Burns JW, Buvanendran A, Gupta RK, Chont M, Kennedy M, et al. Associations between sleep disturbance and chronic pain intensity and function. Clinical Journal of Pain. 2019; 35(7):569-76. [DOI:10.1097/AJP.0000000000000711] [PMID]
29. See CYK, Smith H, Car LT, Protheroe J, Wong WC, Bartlam B. Health literacy and health outcomes in patients with back pain - A scoping review. 2020. [DOI:10.21203/rs.3.rs-52106/v1]
30. Probst T, Jank R, Dreyer N, Seel S, Wagner R, Hanshans K, et al. Early Changes in pain acceptance predict pain outcomes in interdisciplinary treatment for chronic pain. Journal of Clinical Medicine. 2019; 8(9):1373. [DOI:10.3390/jcm8091373] [PMID]
31. Yu L, Inspector Y, McCracken LM. Preliminary investigation of the associations between psychological flexibility, symptoms and daily functioning in people with chronic abdominal pain. British Journal of Pain. 2021; 15(2):175-86. [DOI:10.1177/2049463720926559] [PMID]
32. Vowles KE, McCracken LM, McLeod C, Eccleston C. The Chronic Pain Acceptance Questionnaire: Confirmatory factor analysis and identification of patient subgroups. Pain. 2008; 140(2):284-91. [DOI:10.1016/j.pain.2008.08.012]
33. Osborne RH, Batterham RW, Elsworth GR, Hawkins M, Buchbinder R. The grounded psychometric development and initial validation of the Health Literacy Questionnaire (HLQ). BMC Public Health. 2013; 13(1):658. [DOI:10.1186/1471-2458-13-658]