Non-Communicable Diseases: Risk Factors and other Health Problems 259 Health Literacy
National Health and Morbidity Survey 2019
Technical Report − Volume I
260
Health Literacy
Contributors to this section: Komathi Perialathan, Norrafizah
Jaafar, Teresa Yong Sui Mien, Masitah Ahmad, Nurashma Juatan,
Kamarulzaman Salleh, Manimaran Krishnan, Affendi Isa, Haniza
Abdul Hanit, Wan Shakira Rodzlan Hasani, Emma Mirza Mohamad,
Mohammad Rezal Hamzah, Arina Anis Azlan, Suffian Hadi Ayub.
Introduction
World Health Organization (WHO) defines Health Literacy
as the cognitive and social skills which determines the
motivation and ability of individuals to gain access, to
understand and use information in ways which promote and
maintain good health [1].
According to Sorensen and colleagues [2], health literacy
encompasses an individual competency in accessing,
understanding, appraising and applying health-related
information within the three domains as below:
a. Healthcare - refers to the ability to access information
on medical or clinical issues, to understand medical
information,
to
interpret
and
evaluate
medical
information, and to make informed decisions on medical
issues and comply with medical advice.
b. Disease Prevention - refers to the ability to access
information on risk factors for health, to understand
information on risk factors and derive meaning, to
interpret and evaluate information about risk factors, and
to make informed decisions to protect against risk factors
for health.
c. Health Promotion - refers to the ability to regularly
update oneself on determinants of health in the social and
physical environment and derive meaning, to interpret
and evaluate information on determinants of health in the
social and physical environment, and the ability to make
informed decisions on health determinants in the social
and physical environment.
Health Literacy emphasizes on improving and enabling
people’s access to health information and building their
capacity to use it effectively and build an empowered
individual. The first nationwide study on functional health
literacy among Malaysian adults was conducted in National
Health and Morbidity Survey (NHMS) 2015 using the
translated version of Newest Vital Sign. The survey findings
reported the overall prevalence of adequate functional health
literacy among adults aged 18 years and above was 6.6% with
urban population reporting higher significantly adequate
health literacy (7.8%) compared to the rural population (2.3%)
and with regards to the level of education, adults with tertiary
education were found to be more adequate in health literacy
(11.0%) than those with primary education (2.4%) [3].
Objectives
General objective
To determine health literacy prevalence among Malaysian
adults.
Specific objectives
- To determine the prevalence of overall health literacy by socio-demographic subgroups
- To determine the proportions of health literacy levels; limited; sufficient, and excellent for overall Health Literacy and by domain; disease prevention, healthcare and health promotion
Non-Communicable Diseases: Risk Factors and other Health Problems 261 Methods For National Health Morbidity Survey 2019, Health Literacy assessment was conducted using HLS-M-Q18 [4]. This questionnaire is a compressed and adapted version of the European Health Literacy Survey, HLS-EU-Q47 which was based on the conceptualised model of Health Literacy by European Health Literacy Consortium. The target population for Health Literacy module in this survey were adult respondents aged 18 years and above in Malaysia. Data was obtained through self-administered questionnaires using the HLS-M-Q18. As mentioned before, this questionnaire was adapted from HLS-EU-Q47 and was pretested in Selangor, Kuala Lumpur and Sarawak using ratio-based sampling, which takes into account population characteristics such as population size and race density in a given area. For validation purpose, the face validity process was conducted at three stages among the experts, researchers, stakeholders and the technical team to ensure each item in the questionnaire is a valid measure of the domain being measured. In terms of instrument reliability, all major domains in this questionnaire showed a Cronbach’s alpha value greater than 0.7. The questionnaire contains 18 items covering 9 sub- dimensions (dimensions such as obtaining, understanding or appraising the information and application relevant to healthcare, disease prevention and health promotion). It is a self-reported tool with Likert-type responses (‘very easy’, ‘fairly easy’, ‘fairly difficult’, ‘very difficult’) and final score will be given when respondents completes all the 18 questions. All scores were transformed to a unified metric with a minimum score of 0 and a maximum score of 50, whereby 0 represents the ‘lowest possible’ and 50 represents the ‘highest possible’ health literacy score. The scores are divided into three levels: • Limited Health Literacy Level Scoring range from 0 - 33: Very difficult and fairly difficult to access, understand, appraise and apply health related information within the three domains of healthcare, disease prevention and health promotion. • Sufficient Health Literacy Level Scoring range from >33–42: Fairly easy to access, understand, appraise and apply health related information within the three domains of healthcare, disease prevention and health promotion. • Excellent Health Literacy Level Scoring range from >42–50: Very easy to access, understand, appraise and apply health related information within the three domains of healthcare, disease prevention and health promotion. Findings 21.1 Overall Health Literacy For Health Literacy module, a total 9478 respondents aged 18 years and above participated and completed all the 18 items in HLS-M-Q18. The overall prevalence of health literacy among Malaysian adults aged 18 years and above showed that higher number of Malaysian population, 40.7% (95% CI: 38.89, 42.57) possessed sufficient health literacy level, followed by 35.0% (95% CI: 33.02, 37.11) possessed limited health literacy level and only 24.3% (95% CI: 22.56, 26.02) had excellent health literacy level. Health literacy level by states shows Johor had the highest number of respondents possessing excellent health literacy level at 40.5% (95% CI: 32.83, 48.71). Wilayah Persekutuan Putrajaya had highest number of respondents possessing sufficient health literacy level at 54.9% (95% CI: 49.13, 60.60) and followed closely by Wilayah Persekutuan Labuan at 53.2% (95% CI: 47.19, 59.15), Pulau Pinang [43.8% (95% CI: 35.02, 53.06)] and Sabah [43.2% (95% CI: 37.03, 49.61)] showed the highest prevalence of respondents possessing limited health literacy level. In terms of socio demographic aspects, the proportion of limited health literacy was found higher among respondents from rural [41.5% (95% CI: 38.29, 44.85)], with non-formal education [64.8% (95% CI: 55.71, 72.93)], those who earned less than RM1,000 [49.5% (95% CI: 44.04, 55.02)], among male [37.2% (95% CI: 34.25, 40.28)] and widower or divorcee [48.1% (95% CI: 43.06, 53.15)] respectively. Among the ethnic groups, Others reported the highest prevalence of possessing limited health literacy level [51.2% (95% CI: 42.44, 59.90)], followed by Bumiputera Sarawak [41.9% (95% CI: 34.59, 49.63)] and Bumiputera Sabah [38.6% (95% CI: 32.81, 44.71)]. The findings also showed limited health literacy increase as the age increases, starting from elderly aged 60 and above and the highest prevalence of limited health literacy is among elderly aged 75 years and above [68.0% (95% CI: 60.90, 74.31)]. In comparison with this, the ratio of sufficient health literacy was higher among respondents from urban [41.1% (95% CI: 38.87, 43.33)], within the age group of 40-44 years old [46.1% (95% CI: 40.76, 51.49)], possessing tertiary education level [44.1% (95% CI: 41.25, 47.05)] and Malays [43.9% (95% CI: 42.14, 45.75)].
National Health and Morbidity Survey 2019 Technical Report − Volume I 262 For respondents with excellent health literacy level, the sociodemographic characteristics were similar as respondents with sufficient health literacy level, whereby it was higher among urban population [25.7% (95% CI: 23.66, 27.89)], respondents with tertiary education level [31.2%, 95% CI: 28.11, 34.54)], within the age group 30 to 34 years old [30.4% (95% CI: 24.71, 36.68)], by ethnicity, Indians [33.1% (95% CI: 27.76, 38.81)] and highest among the income group of RM 10,000 and above [27.8% (95% CI: 22.20, 34.18)]. Health Literacy level by household income group shows limited health literacy level were higher among respondents from the B40 group at 36.6% (95% CI: 34.04, 39.14). In sufficient health literacy level, the T20 household group had the highest prevalence [42.0% (95% CI: 35.28, 49.06)] whilst highest prevalence for excellent health literacy level were higher among both household income group of M40 [27.3% (95% CI: 24.27, 30.53)] and T20 [27.3% (95% CI: 22.06, 33.13)]. 21.2 Health Literacy in Health Care, Disease Prevention and Health Promotion Domains In the aspect of Heath Literacy by domains, generally, majority of respondents had sufficient health literacy level for all the domains, Health Care [49.1% (95% CI: 47.22, 51.05)], Disease Prevention [44.2% (95% CI: 42.42, 46.06)] and Health Promotion [47.5% (95% CI: 45.68, 49.26)]. Among these three domains, Disease Prevention domain had the highest prevalence of limited health literacy level group at 32.3% (95% CI: 30.39, 34.20). Health Care domain had highest prevalence of sufficient health literacy level group at 49.1% (95% CI: 47.22, 51.05) and Health Promotion had the highest prevalence of excellent health literacy level group at 25.9% (95% CI: 24.23, 27.64). Conclusion The overall health literacy level in Malaysia records that majority of population were categorised as having sufficient health literacy 40.7% (95% CI: 38.89, 42.57), followed by 35.0% (95% CI: 33.02, 37.11) possessing limited health literacy level and only 24.3% (95% CI: 22.56, 26.02) had excellent health literacy level. However, when compared to the whole spectrum, the average mean score for Malaysian was 35.5 (out of the total score of 50). This score indicates that although the overall population falls under the sufficient category (33-42), a large number of the population belongs to the lower end of the sufficient category. It is recommended that to achieve a comfortable sufficient category in the health literacy index score, it should ideally reach a mean of 37. This highlights that health literacy in Malaysia is considerably unsatisfactory, and there are rooms for improvements to increase the score level. In comparison with other countries using the same instrument, the prevalence of limited health literacy level among populations in Malaysia is relatively within the same level such as Ireland (40%), Germany (46.3%), Taiwan (34.4%), Sri Lanka (32.5%) and Vietnam (32.5%) [5][6][7][8]. A systematic review of 11 papers in Southeast Asian region shows the overall prevalence of limited health literacy in South East Asia varied considerably, 1.6%–99.5% with a mean of 55.3% [9]. This similar pattern indicated challenges faced by countries in improving health literacy in general. Limited health literacy level was more prominent among respondents in older age group, with lower education level and lower household income, whereas majority of respondents possessing sufficient or excellent health literacy level are among younger age group (below 50 years old), having higher education level and income. These findings are similar with findings from other studies globally that highlighted association of health literacy level with social gradients. Factors such as older age, lower formal educational level, lower income, location, unemployment that reflects social disparities are interrelated with limited health literacy.
Non-Communicable Diseases: Risk Factors and other Health Problems 263 Recommendations
- Health literacy enhancement should focus on vulnerable groups who scored limited in the health literacy index, especially those with no formal or lower education levels, unemployed, elderly and B40 income groups.
- Intervention programmes to improve health literacy must be tailored to specific groups and focussed on improving the four competencies i.e.: access, understand, appraise and apply health information.
- Strategic communication planning among various multiple stakeholders are needed in content and message design development that suits various demographic groups.
- Develop health literacy instrument specific for Malaysian context and develop health literacy index.
- Strengthen multi-sectoral collaboration to improve
health literacy in all aspect.
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