Health literacy in Taiwan: A population based studyapacph2015.fkm.ui.ac.id/ppt/22 October 2015/4. FP Health Promotion... · Health literacy in Taiwan: A population based study

Health literacy in Taiwan: A population based studyHealth literacy in Taiwan: A population based study

Van Tuyen Duong, MSc1, I‐Feng Lin PhD2, Kristine Sørensen, PhD3, Jürgen M. Pelikan, PhD4, Stephan Van Den

Brouke, PhD5, Ying‐Chin Lin6, Peter Wushou Chang, MD, ScD1,7*

1Taipei Medical University, 2National Yang Ming University, 3Maastricht University, 4Ludwig Boltzmann

Institute Health Promotion Research, 5Université Catholique de Louvain, 6Taipei Medial University‐Shuang‐

Ho Hospital, 7Taipei Hospital, Ministry of Health and Welfare, Taiwan.

http://www ncbi nlm nih gov/pubmed/26419635http://www.ncbi.nlm.nih.gov/pubmed/26419635

111/6/2015 the APACPH 2015 Conference in Bandung, Indonesia

Introduction

• Health literacy (HL) refers to people’s competences to access, understand, appraise, and apply

h l h i f i i h l h di i d h l h ihealth information in health care, disease prevention, and health promotion (Sorensen et al., 2012).

• Health literacy could be influenced by

A d ti d i– Age, education, and income (Sørensen et al., 2015).

– Self‐perceived social status (van der Heide et al., 2013; Watson, 2011).

– Health related activities and programs in communities and workplaces (Rootman & Gordon‐El‐Bihbety 2008)Health related activities and programs in communities and workplaces (Rootman & Gordon El 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).


Study gaps and objectives

• A range of assessment tools have been developed, some of these in Asia, for

ith ti t i diff t l d d t d t diff t ltuse with patients in different languages and adapted to 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 Taiwaneseuse 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 HLassociated with HL.

311/6/2015the APACPH 2015 Conference in Bandung, Indonesia

Research methods

• Design: A cross‐sectional design used to conduct a survey in

T i b i th HLS EU Q t l b t F b d O tTaiwan by using the HLS‐EU‐Qs tool between Feb and Oct

2013.

• Sampling methods: a multistage stratification random

samplingsampling

• Sample size: After deleting those with incomplete responses,

2,989 valid questionnaires were retained for further analysis.

• MeasurementsMeasurements

– Health literacy (HLS‐EU‐Q)

– Social‐demographics, health behaviors, healthcare utilization.


Data Analysis

• HL indices was standardized, Index = (mean – 1)*(50/3)

• Reliability was established using Cronbach’s alpha to examine

the internal consistencythe internal consistency.

• Confirmatory factor analysis was conducted separately for the

three HL domains of health care, disease prevention and health

promotion.promotion.

• Multivariate regression models to determine the associated

factors of Health literacy.

• IBM SPSS Version 20.0, AMOS version 22.0 p < 0.05.IBM SPSS Version 20.0, AMOS version 22.0 p < 0.05.


Table 1. Construct validity of the HLS‐EU‐Q47 in Taiwan and Vietnam with goodness‐of‐fit indicesg

Absolute model fit Incremental fit Parsimonious Absolute model fit Incremental fit fitModela RMSEA GFI AGFI CFI IFI NFI χ2/dfTaiwan

HC‐HL 0.07 0.94 0.91 0.93 0.93 0.92 17.37DP‐HL 0.08 0.94 0.91 0.94 0.94 0.93 17.74HP‐HL 0.07 0.95 0.92 0.95 0.95 0.95 14.26

• 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

ti h lth lit RMSEA t f i ti GFIpromotion health literacy; 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; χ2/df, relative chi‐square.


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 pSocio‐demographics

Age with 10 years increment ‐0.29 (‐0.61, 0.04) ‐.07 .087 ‐0.33 (‐0.62, ‐0.03) ‐.08 .029 ‐0.26 (‐0.47, ‐0.05) ‐.06 .016)

Marital status Not married (reference)Married, divorced, widow ‐0.70 (‐1.77, 0.38) ‐.05 .204 ‐0.05 (‐0.91, 0.81) ‐.01 .911 ‐0.34 (‐1.01, 0.33) ‐.03 .321

Education attainmentJunior high school and below (reference)Senior high school 0.52 (‐0.55,1.59) .04 .344 0.54 (‐0.48, 1.56) .04 .297 0.51 (‐0.23, 1.24) .04 .175University and above ‐0.11 (‐1.21, 0.99) ‐.01 .843 0.21 (‐0.81, 1.23) .02 .688 0.03 (‐0.70, 0.77) .01 .928

Ability to pay for medicationVery difficult (reference)Fairly difficult ‐0.97 (‐2.70, 0.76) ‐.06 .272 0.56 (‐0.86, 1.98) .04 .441 ‐0.19 (‐1.29, 0.92) ‐.01 .739i l ( ) ( ) ( )Fairly easy 0.33 (‐1.34, 1.99) .02 .699 1.74 (0.36, 3.13) .14 .014 1.06 (‐0.01, 2.13) .08 .051

Very easy 1.95 (0.10, 3.81) .10 .039 3.67 (2.12, 5.21) .21 .000 2.84 (1.65, 4.02) .16 <.001Self‐perceived social statusLow (reference)Middle 1.51 (0.73, 2.29) .11 <.001 0.71 (0.08, 1.35) .06 .027 1.01 (.52, 1.50) .08 <.001Hi h 1 74 ( 0 10 3 59) 05 064 2 01 (0 33 3 70) 06 019 1 89 (0 65 3 12) 06 003High 1.74 (‐0.10, 3.59) .05 .064 2.01 (0.33, 3.70) .06 .019 1.89 (0.65, 3.12) .06 .003

Personal behaviorsWatch health related TVNever (reference)Rarely 0.31 (‐0.88, 1.49) .02 .615 0.82 (‐0.30, 1.94) .06 .153 0.41 (‐0.39, 1.22) .03 .313Sometimes 1 80 (0 65 2 96) 13 002 2 39 (1 30 3 49) 20 < 001 1 91 (1 13 2 69) 15 < 001Sometimes 1.80 (0.65, 2.96) .13 .002 2.39 (1.30, 3.49) .20 <.001 1.91 (1.13, 2.69) .15 <.001Often 4.62 (2.77, 6.47) .16 <.001 4.59 (3.24, 5.95) .25 <.001 4.28 (3.22, 5.34) .20 <.001

Community involvementNever (reference)Rarely 1.41 (0.49, 2.32) .09 .003 1.19 (0.50, 1.88) .09 .001 1.25 (0.69, 1.81) .09 <.001Sometimes 1 03 (‐0 16 2 22) 05 091 1 99 (1 01 2 96) 10 < 001 1 54 (0 79 2 29) 08 < 001

7

b, non‐standardized coefficient; CI, confidence interval; β, standardized coefficient.


Sometimes 1.03 (‐0.16, 2.22) .05 .091 1.99 (1.01, 2.96) .10 <.001 1.54 (0.79, 2.29) .08 <.001Often 1.14 (‐0.19, 2.47) .05 .092 2.94 (1.99, 3.90) .16 <.001 2.18 (1.40, 2.96) .11 <.001

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 coefficientb (95%CI)a

Men (n=1345) Women (n=1644) Overall (n=2989)Men (n=1345) Women (n=1644) Overall (n=2989)

Health status

Self‐perceived health status 0 24 (0 18 0 29)*** 0 31 (0 25 0 36)*** 0 27 (0 23 0 31)***0.24 (0.18, 0.29) 0.31 (0.25, 0.36) 0.27 (0.23, 0.31)

Long‐term illness ‐0.04 (‐0.08, ‐0.01)* ‐0.02 (‐0.05, 0.02) ‐0.03 (‐0.06, ‐0.01)*

Physical limitation related to health problem ‐0.07 (‐0.11, ‐0.03)*** ‐0.04 (‐0.08, ‐0.01)* ‐0.06 (‐0.08, ‐0.03)***health problem

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

F i f i iti d t

• Significant level at * 01 <p< 05 ** 001 < p < 01 *** p < 001

Frequencies of visiting doctors ‐0.09 (‐0.17, ‐0.01)* ‐0.11 (‐0.18, ‐0.03)** ‐0.10 (‐0.15, ‐0.05)***

Accompany to see doctors 0.15 (0.09, 0.21)*** 0.03 (‐0.02, 0.08) 0.08 (0.04, 0.12)***

8

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.


Conclusions

• The HLS‐EU‐Q was shown to be a valid and useful tool to assess the

l l f HL i th l l ti f T i It d t t d tlevel of HL in the general population of Taiwan. It demonstrated to

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 frequencies of watching health‐related TV, andstatus, more frequencies of watching health related TV, and

community involvement.

Hi h HL l i ifi tl li k d t b tt h lth t t f• Higher HL was also significantly linked to better health statuses of

the individuals, their health behaviors, and healthcare accessibility

9

and utility.


Thanks for your attention!Thanks for your attention!

Have a health literate journey!


Welcome to 3rd AHLA conferenceWelcome to 3 AHLA conferenceNovember 9th-11th 2015, Tainan, Taiwanh // hl ihttp://www.ahla-asia.org

11/6/2015 11the APACPH 2015 Conference in Bandung, Indonesia

11/6/2015 the APACPH 2015 Conference in Bandung, Indonesia 12

Developing and strengthening health literacyDeveloping and strengthening health literacy

20+ countries 20+ countries 4040+ institutions 80+ global partners+ institutions 80+ global partners


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). [10.1093/eurpub/ckv043]. The European Journal of Public Healthckv043. [ / p / ] p f

• 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, 614–622. HLS EU C ti (2012) C ti t f h lth lit i i ht EU b t t f• HLS‐EU Consortium. (2012). Comparative report of health literacy in eight EU member states, from http://www.health‐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, 1‐11.

• Pleasant A (2012) Health Literacy Around the World Part 1 Health literacy efforts outside of the• 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.



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 g

translated into Traditional Mandarin, and Vietnamese using the translation‐

back‐translation method.back translation method.

• The content of questionnaire was verified by a panel of public health

t i b th t i h t k th lt l t i t t Thexperts in both countries, who took the cultural aspects into account. The

questionnaire will be then pre‐tested for readability and understandability

by experienced survey researchers.


Table 3 Examples of HLS‐EU questionnaire items per competences and domains

Competences / health domains On a scale from very difficult to very easy, how easy would you say it is for you to . . .

accessing / healthcare . . . 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.)


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 long(1) to excellent (5). Other health status variables include long‐

term illness (None, one, more than one), limitation related to

health problem (yes/ no).

• Personal characteristics and socio demographics:• Personal characteristics and socio‐demographics:

age, gender, marital status, highest education

attainment, employment status, social status, ability to pay for

medicationmedication.


Measurements (cont.)

• Health behaviors and risks: Alcohol consumption (No, light,

moderate, excessive, very excessive), smoking status (non‐

smoker occasional smoker smoker) exercise (not at all fewsmoker, occasional 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 sometimeshealth 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.1911/6/2015 the APACPH 2015 Conference in Bandung, Indonesia

Participants and data collection procedure

• In each country, participants were invited to take part in the face‐

to‐face interviews facilitated with self‐administered questionnaire

following a standardized protocol by well trained interviewersfollowing a standardized protocol by well‐trained interviewers.

Consent form was obtained by each participant.

• After excluding unsatisfied responses which included significant

missing data in their questionnaire the overall samples of 5 088missing data in their questionnaire, the overall samples of 5,088

participants were analyzed, including 3,015 from Taiwan, and

2,073 from Vietnam.


Table 2. Multivariate regression analyses of effect of socio‐demographic variables on general health literacy

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


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Health literacy in Taiwan: A population based studyapacph2015.fkm.ui.ac.id/ppt/22 October 2015/4. FP Health Promotion... · Health literacy in Taiwan: A population based study