Health liter lit acy in Tai Ta wa w n a : A populat popula ion based t s udy

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1 Health literacy in Taiwan: A populationbased study Van Tuyen Duong, MSc 1, I Feng Lin PhD 2, Kristine Sørensen, PhD 3, Jürgen M. Pelikan, PhD 4, Stephan Van Den Brouke, PhD 5, Ying Chin Lin 6, Peter Wushou Chang, MD, ScD 1,7* 1 Taipei Medical University, 2 National Yang Ming University, 3 Maastricht University, 4 Ludwig Boltzmann Institute Health Promotion Research, 5 Université Catholique de Louvain, 6 Taipei Medial University Shuang Ho Hospital, 7 Taipei Hospital, Ministry of Health and Welfare, Taiwan. nlm nih 1

2 Introduction Health literacy (HL) refers to people s competences to access, understand, appraise, and apply health hinformation i in health hcare, disease prevention, and health hpromotion (Sorensen et al., 2012). Health literacy could be influenced by Age, education, and income (Sørensen et al., 2015). Self perceived social status (van der Heide et al., 2013; Watson, 2011). Healthrelated activities and programs in communities and workplaces (Rootman & Gordon El Bihbety Bihbety, 2008). Watching health promoting television series (Chew, Palmer, Slonska, & Subbiah, 2002; Collins, Elliott, Berry, Kanouse, & Hunter, 2003; Do & Kincaid, 2006). HL closely links to health seeking behaviour (Gray, Klein, Noyce, Sesselberg, & Cantrill, 2005), health risk behaviours (Wolf, Gazmararian, & Baker, 2007), health care utilization (Cho, Lee, Arozullah, & Crittenden, 2008). 2

3 Study gaps and objectives A range of assessment tools have been developed, some of these in Asia, for use with patients t in different languages and adapted dto different cultures (Tsai, Lee, Tsai, & Kuo, 2010). The comprehensive questionnaire used for the European Health Literacy Survey was validated and used in Japan (Nakayama et al., 2015), enabling the comparison of the level of HL in the Japanese population to that of 8 European countries. The present study aimed to further validate the HLS EU questionnaire for use in Taiwan, to measure the level of HL in the general Taiwanese population and identify key personal and socio demographic factors that are associated with HL. 11/6/2015 the APACPH 2015 Conference in Bandung, Indonesia 3

4 Research methods Design: A cross sectional design used to conduct a survey in Ti Taiwan by using the HLS EU Qs tool lbt between Fb Feb and Ot Oct Sampling methods: a multistage stratification random sampling Sample size: After deleting those with incomplete responses, 2,989 valid questionnaires were retained for further analysis. Measurements Health literacy (HLS EU Q) Social demographics, health behaviors, healthcare utilization. 4

5 Data Analysis HL indices was standardized, Index = (mean 1)*(50/3) Reliability was established using Cronbach s alpha to examine theinternal consistency. Confirmatory factor analysis was conducted separately for the three HL domains of health care, disease prevention and health promotion. Multivariate regression models to determine the associated factors of Health literacy. IBM SPSS Version 20.0, AMOS version 22.0 p <

6 Table 1. Construct validity of the HLS EU Q47 in Taiwan and Vietnam with goodness of fit indices Absolutemodel fit Incremental fit Parsimonious fit Model a RMSEA GFI AGFI CFI IFI NFI χ 2 /df Taiwan HC HL DP HL HP HL a Four factor model of each domain included finding, understanding, judging, and applying health information. The model fit indices reported after dropping out certain items from whole HLS EU Qs scale; e.g. item 4 from Taiwan survey. Note HLS EU Q47, European Health Literacy Survey Questionnaire with 47 items; HC HL, health care health literacy; DP HL, disease prevention health literacy; HP HL, health promotion health lthliteracy; RMSEA, root mean square error of approximation; GFI, goodness of fit index; AGFI, adjusted goodness of fit index; CFI, comparative fit index; IFI, incremental fit index; NFI, normal fit index; χ 2 /df, relative chi square. 6

7 Table 2. General health literacy associated with the socio demographics and personal behaviors by the multivariate linear regression analysis Men (n=1345) Women (n=1644) Overall (n=2989) Predictors b (95%CI) β p b (95%CI) β p b (95%CI) β p Socio demographics Age with 10 years increment 0.26 ( 0.47, 0.29 ( 0.61, 0.04) ( 0.62, 0.03) ) Marital status Not married (reference) Married, divorced, widow 0.70 ( 1.77, 0.38) ( 0.91, 0.81) ( 1.01, 0.33) Education attainment Junior high school and below (reference) Senior high school 0.52 ( 0.55,1.59) ( 0.48, 1.56) ( 0.23, 1.24) University and above 0.11 ( 1.21, 0.99) ( 0.81, 1.23) ( 0.70, 0.77) Ability to pay for medication Very difficult (reference) Fairly difficult 0.97 ( 2.70, 0.76) ( 0.86, 1.98) ( 1.29, 0.92) Fairly il easy 0.33 ( 1.34, 1.99) (0.36, 3.13) ( 0.01, 2.13) Very easy 1.95 (0.10, 3.81) (2.12, 5.21) (1.65, 4.02).16 <.001 Self perceived social status Low (reference) Middle 1.51 (0.73, 2.29).11 < (0.08, 1.35) (.52, 1.50).08 <.001 High 1.74( ( 0.10, 3.59) (0.33, 3.70) (0.65, 3.12) Personal behaviors Watch health related TV Never (reference) Rarely 0.31 ( 0.88, 1.49) ( 0.30, 1.94) ( 0.39, 1.22) Sometimes 1.80(0.65, 2.96) (1.30, 3.49).20 < (1.13, ).15 <.001 Often 4.62 (2.77, 6.47).16 < (3.24, 5.95).25 < (3.22, 5.34).20 <.001 Community involvement Never (reference) Rarely 1.41 (0.49, 2.32) (0.50, 1.88) (0.69, 1.81).09 <.001 Sometimes 103( ( 0.16, 2.22) 22) ( (1.01, 296) 2.96).10 < ( (0.79, 229) 2.29).08 <.001 Often 1.14 ( 0.19, 2.47) (1.99, 3.90).16 < (1.40, 2.96).11 <.001 b, non standardized coefficient; CI, confidence interval; β, standardized coefficient. 7

8 Table 3. General health literacy (as a predictor) and its associated factors (as dependent variables) via multivariate linear regression analyses. Health literacy index with 10 score increments Regression coefficient b (95%CI) a Men (n=1345) Women (n=1644) Overall (n=2989) Health status Self perceived health status Long term illness Physical limitation related to health problem 024( (0.18, 0.29) *** 031( (0.25, 0.36) *** 027( (0.23, 0.31) *** 0.04 ( 0.08, 0.01) * 0.02 ( 0.05, 0.02) 0.03 ( 0.06, 0.01) * 0.07 ( 0.11, 0.03) *** 0.04 ( 0.08, 0.01) * 0.06 ( 0.08, 0.03) *** Health behaviors Smoking status 0.10 ( 0.13, 0.06) *** 0.02 ( 0.03, 0.01) 0.06 ( 0.08, 0.04) *** Doing exercise 0.17 (0.09, 0.24) *** 0.18 (0.11, 0.25) *** 0.18 (0.12, 0.23) *** Healthcare accessibility and utility Frequencies of visiting iiti doctors Accompany to see doctors 0.09 ( 0.17, 0.01) * 0.11 ( 0.18, 0.03) ** 0.10 ( 0.15, 0.05) *** 0.15 (0.09, 0.21) *** 0.03 ( 0.02, 0.08) 0.08 (0.04, 0.12) *** Significant level at *.01 <p<.05, **.001 < p <.01, *** p <.001 Health literacy index range from 0 to 50; a Non standardized regression coefficient adjusted for age, gender (for overall sample), marital status, education, social status, and ability to pay for medication. 8

9 Conclusions The HLS EU Q was shown to be a valid and useful tool to assess the level lof HL in the general population lti of Ti Taiwan. It demonstrated t dto be a potentially effective tool for future international comparative studies in the Asian countries. The results indicated that higher HL was associated with younger age, higher ability to pay for medication, higher self perceived social status, more frequenciesof watchinghealth relatedhealth TV, and community involvement. Higher HL was also significantly ifi linked to btt better health statuses tt of the individuals, their health behaviors, and healthcare accessibility and utility. 9

10 Thanks for your attention! Have a health literate journey! 10

11 Welcome to 3 rd AHLA conference November 9 th -11 th 2015, Tainan, Taiwan hl 11/6/2015 the APACPH 2015 Conference in Bandung, Indonesia 11

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13 Developing and strengthening health literacy 20+ countries 40+ institutions 80+ global partners 13

14 References Sørensen, K., Pelikan, J. M., Röthlin, F., Ganahl, K., Slonska, Z., Doyle, G.,... Brand, H. (2015). Health literacy in Europe: comparative results of the European health literacy survey (HLS EU). [ /eurpub/ckv043]. / The European Journal of Public Healthckv043. Sorensen, K., Van den Broucke, S., Brand, H., Fullam, J., Doyle, G., Pelikan, J., & Slonszka, Z. (2012). Health literacy and public health: a systematic review and integration of definitions and models. BMC Public Health, 12, 80. Sorensen, K., Van den Broucke, S., Fullam, J., Doyle, G., Pelikan, J., Slonska, Z.,... Consortium Health Literacy Project, E. (2012). Health literacy and public health: a systematic review and integration of definitions and models. BMC Public Health, 12, 80. Lee, S. Y. D., Tsai, T. I., Tsai, Y. W., & Kuo, K. (2010). Health literacy, health status, and healthcare utilization of Taiwanese adults: results from a national survey. BMC Public Health, 10, HLS EU Consortium. (2012). Comparative report of health literacy in eight EU member states, t from literacy.eu. van der Heide, I., Rademakers, J., Schipper, M., Droomers, M., Sørensen, K., & Uiters, E. (2013). Health literacy of Dutch adults: a cross sectional survey. BMC Public Health, 13, Pleasant, A. (2012). Health Literacy Around the World Part 1 Health literacy efforts outside of the United States. Institute of Medicine of the National Academies. 14

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16 Measurements Health literacy The HLS EU Q47 contains 47 items to measure health literacy, the perceived difficulty of each item was rated on 4 point Likert scales (1= very difficult, 2= difficult, 3= easy, and 4= very easy). With the agreement from the HLS EU consortium, the HLS EU Q47 was translated into Traditional Mandarin, and Vietnamese using the translationback translation method. The content of questionnaire was verified by a panel of public health experts in both countries, who took kthe cultural l aspects into account. The questionnaire will be then pre tested for readability and understandability by experienced survey researchers. 16

17 Table 3 Examples of HLS EU questionnaire items per competences and domains Competences / health domains accessing / healthcare On a scale from very difficult to very easy, how easy would you say it is for you to find out what to do in case of a medical emergency? understanding / healthcare... understand what your doctor says to you? appraising / disease prevention... judge which vaccinations you may need? applying / health promotion... make decisions to improve your health? (HLS EU Consortium, 2012.) 17

18 Measurements (cont.) Self rated health status: Participant self reported his or her health status using a five point Likert scale ranging from poor (1) to excellent (5). Other health status variables include longterm illness (None, one, more than one), limitation related to health problem (yes/ no). Personalcharacteristics and socio demographics: age, gender, marital status, highest education attainment, employment status, social status, ability to pay for medication. 18

19 Measurements (cont.) Health behaviors and risks: Alcohol consumption (No, light, moderate, excessive, very excessive), smoking status (non smoker, occasionalsmoker smoker, smoker), exercise (not at all, few times a month, few times a week, daily), and community involvement (not at all, rarely, sometimes, often), watching health related TV series/dramas (not at all, rarely, sometimes, often). Health accessibility and utility: Frequency of Doctor visit over past 12 months, and with accompany to see doctor. 19

20 Participants and data collection procedure In each country, participants were invited to take part in the faceto face interviews facilitated with self administered questionnaire following a standardized protocol by well trained interviewers. Consent form was obtained by each participant. After excluding unsatisfied responses which included significant missingdata in their questionnaire, the overall samples of 5,088 participants were analyzed, including 3,015 from Taiwan, and 2,073 from Vietnam. 20

21 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Table 2. Multivariate regression analyses of effect of socio demographic variables on general health literacy 21

22 Table 3. General health literacy (as a predictor) and its associated factors (as dependent variables) via multivariate linear regression analyses. 22