The present study aimed at determining the relationship between hookah use and health literacy skills among university students. The results showed that the frequency of hookah use among the students was 17.3%, which was a relatively high prevalence. Considering the fact that the low level of health literacy in decision-making and the use of health information compared to other dimensions of health literacy, could lead to the fact that appropriate measures were not taken in applying health knowledge [30]. Moreover, considering that the average score of health literacy in decision-making and use of health information was lower than other dimensions of health literacy, it could be concluded that the relatively high prevalence of hookah use was probably caused by the low average score of health literacy in decision-making and use of health information. Another reason could be a lack of entertainment in free time due to the spread of the COVID-19 epidemic. Staying away from family and loneliness, and maintaining social relations only with friends could also be other influential factors. Rahimzadeh et a., showed that the prevalence of hookah use among male students was 17.2% [31] which is in line with the results of this study, but the results of Babaei Heidarabadi et al. [10], Taraghi Jah et al. [32], Tarmian et al. [33], Makvandi et al. [8] and Dehdari et al. [11] in which the prevalence of smoking was 42.9%, 40.3%, 34%, 32% and 29% respectively which is not consistent with our findings. Among the possible reasons for this inconsistency, it can be pointed out that the tendency towards smoking is greater in larger cities, but the city where the present study was conducted in is almost smaller than the cities where those studies were conducted. In other words, the number of coffee houses or canteens is less in this city, and more monitoring has been done to prevent the use of hookah in these places. Another reason could be the closure of hookah supply centers due to the spread of the Covid-19 epidemic.
The results also showed that among the five health literacy skills, understanding and access had the highest average score. These results were consistent with the results of Panahi et al. [24]. Panahi et al. [34], Khoshravesh et al. [35] and Ansari et al. [36] reported the highest average health literacy score for comprehension skill, which was in line with our findings. Also, these results are consistent with the results of Mahmoudi and Taheri's study [37], in which the highest average score was for access skill. Since the participants in the present study were medical students, it was possible that in addition to access, they also had more understanding than other people in health-related issues. On the other hand, the lowest average score belonged to the two skills of decision-making and the use of health information and reading in this study. These results were consistent with the results of Ziapour and Kianipour's study (38]. and Panahi et al. in which the lowest average score was for decision-making and the use of health information skills [34]. However, these results were not consistent with the results of Mahmoudi and Taheri's study [37], in which information evaluation skills had the lowest average score. The possible reasons for this inconsistency can be attributed to their lower evaluation power of health-related issues compared to the students of medical sciences in the present study, the less accuracy of the students of medical sciences when answering the items of the two parts of reading and decision-making and use of health information, as well as the difference in the level of health literacy in the aforementioned study compared to the present study.
Also, the results showed that health literacy was at an average level in this study. Considering the field of study of the students here, these results can be justified to some extent. These results were consistent with the results of Panahi et al. [39] and Dehghankar et al. [40]. And they were not consistent with the results of the study by Sajadi et al. (18] who reported an optimal level of health literacy among their participants. The higher educational levels of the students in this study is the possible reason for the difference between the results in the present study. In addition, the results of the present study were not consistent with the results of Vozikis et al. which could be due to the difference in the measurement tool and the higher academic years of the students in this study compared to the present study.
Moreover, the results showed that gender was one of the factors influencing the use of hookah here. This finding was consistent with the results of the studies of Rahimzadeh et al. [31], Taraghi Jah et al. [32] and Panahi et al. [39]. The lower use of hookah among Iranian female students can be due to the social stigma that targets women’s smoking in Islamic countries [41]. Also, boys are more ready to be attracted to smoking than girls, and smoking by women is considered an anti-social behavior [31]. Another possible reason can be the higher level of health literacy among girls than boys [17]. In addition, adherence to health principles and following medical recommendations is more common in women than men.
The results of the present study showed that smoking was one of the factors influencing the use of hookah. it can be said that researchers consider smoking as a gateway to the use of narcotics and illegal drugs [42]. In other words, with smoking, little by little, the social stigma of this behavior disappears among smokers, and as a result, it is easier to start using hookah and other drugs. In line with this finding, there was a statistically significant relationship between cigarette smoking and hookah use in Dehdari et al. study [11].
The results also showed that the amount of physical activity per week was one of the factors influencing the use of hookah. It can be said that doing physical activity is considered a preventive behavior [15] and can prevent the use of hookah among students. Studies showed that lack of entertainment in free time [11] and lack of enough fun and entertainment [43, 44] were factors affecting the use of hookah among students. Therefore, designing activities to fill students' free time, such as sports and facilitating sports activities, can decrease hookah use, especially among dormitory students.
In addition, the three skills of decision-making and the use of health information, understanding, and evaluation were the factors influencing the use of hookah. Panahi et al. [21] and Martin et al. [23] showed that the two skills of understanding and using information were effective factors in adopting preventive behaviors of smoking and smoking cessation, which is consistent with our findings. Also, in Panahi et al.'s study, decision-making and the use of health information and evaluation were among the factors influencing the adoption of preventive behaviors against smoking [24] which is consistent with our findings. The results of the Sadeghi et al. study [25] also were in line with our findings, in which in addition to these three influential dimensions, the two dimensions of reading and access also affected tobacco consumption. Factors such as the difference in the research population, the difference in the prevalence of hookah use, and the difference in the level of health literacy might justify these differences. In addition, the relationship between health literacy skills and the prevalence of smoking (both cigarettes and hookah) was measured in tier study, while only the use of hookah was investigated in the present study.
Regarding the effect of the three skills of decision-making and the use of health information, understanding and evaluation on the behavior of hookah use, it can be added that the skill of decision-making and the use of health information is somehow related to behavior of the participants. Therefore, it can be effective on the use of hookah. The impact of the two skills of understanding and evaluation on the behavior of hookah use is justifiable by considering the students' education in medical sciences and the having courses on tobacco and its harmful effects on health. Also, regarding the lack of influence of other dimensions of health literacy on the use of hookah, it can be said that health literacy is a collection of skills, abilities, and capacities in various dimensions. These skills and capacities are sometimes manifested in acquiring and obtaining medical and health information, sometimes in reading them, sometimes in understanding and comprehending them, sometimes in processing and interpreting them, and sometimes in decision-making and applying this information [45], which can variably affect the adoption of preventive behaviors [46] such as smoking prevention [21, 24]. In other words, these skills and capacities have probably been able to appear only in the three dimensions of decision-making and application of health information, understanding, and evaluation and affected the use of hookah in the present study.
To our knowledge, the present study was the first study that evaluated the relationship between health literacy skills and hookah use in the world. Among the limitations of this study, was that the present study was conducted only among associate and bachelor degree students of medical sciences. Therefore, the results cannot be generalized to students from other parts of the country and other age and student groups. Therefore, it is recommended to conduct this study in different populations and groups (in terms of age, education, residential area, and graduate levels). Other limitations of this study included ignoring other dimensions related to health literacy, such as self-efficacy, communication, and calculation. If these dimensions were present, it would have been possible to conduct a wider and more comprehensive assessment of the relationship between the dimensions of health literacy and hookah use. Ignoring cultural contexts and skills such as speaking, listening, and having contextual and cultural knowledge of people was also another limitation of this study because the mentioned skills are the skills that should be examined when measuring health literacy. Also, data were collected by self-reporting, and this along with the small number of samples were other limitations of the present study.