Health Literacy Research in Malaysia: A Scoping Review

Full text

Sains Malaysiana 49(5)(2020): 1021-1036
http://dx.doi.org/10.17576/jsm-2020-4905-07
Health Literacy Research in Malaysia: A Scoping Review
(Penyelidikan Literasi Kesihatan di Malaysia: Suatu Ulasan Penskopan)
ADINA ABDULLAH, LIEW SU MAY*, HANI SYAHIDA SALIM, NG CHIRK JENN & KARUTHAN CHINNA
ABSTRACT
Research on health literacy is expanding worldwide. Health literacy has been recognised as a critical determinant of
health at the 2016 Shanghai Declaration. Little is known about health literacy research in Malaysia. This scoping review
aims to identify and summarise published studies on health literacy in Malaysia. PubMed, Scopus and the Malaysian
Medical Repository (MyMedR) databases were searched for published work by Malaysian researchers. Searches were
conducted up to November 2019. The search terms used are related to ‘health literacy’ and ‘Malaysia’. Studies included
were those involving Malaysian citizens and reporting on various aspects of health literacy. Studies were reviewed by
two independent reviewers to determine their eligibility. Data extraction for the year of publication, name of authors,
geographical location, research focus, and summary of ndings from the full-text articles was carried out independently
and any disagreement was resolved by consensus. A total of 29 articles were included with the earliest article published
in 1985. Fifteen of the articles are on general health literacy, four on medication literacy, ve on mental health literacy,
three on media and e-health literacy and four on oral health literacy. Four articles are qualitative studies and the rest are
quantitative studies. A few of the studies used validated health literacy tools such as Newest Vital Signs and HLS-EU-Q47.
Therefore, we can conclude that there are only a limited number of articles published in the eld of health literacy in
Malaysia. Future work using validated international tools to allow comparison of the ndings should be considered.
Keywords: Health literacy; Malaysia; medication literacy; mental health literacy
ABSTRAK
Penyelidikan literasi kesihatan semakin mendapat perhatian di seluruh dunia. Literasi kesihatan telah diiktiraf
sebagai penentu kesihatan yang kritikal pada Deklarasi Shanghai 2016. Amat sedikit yang diketahui tentang
penyelidikan literasi kesihatan di Malaysia. Kajian ini bertujuan untuk mengenal pasti dan meringkaskan
terbitan kajian tentang literasi kesihatan di Malaysia. Pangkalan data PubMed, Scopus dan Malaysian Medical
Repository (MyMedR) digunakan sebagai sumber untuk kajian yang diterbitkan oleh penyelidik Malaysia. Carian
telah dijalankan sehingga November 2019. Terma carian yang digunakan berkaitan adalah ‘literasi kesihatan’
dan ‘Malaysia’. Kajian yang terlibat adalah dalam kalangan rakyat Malaysia tentang pelbagai aspek literasi
kesihatan. Kajian dikaji semula oleh dua pengulas bebas untuk menentukan kelayakan mereka. Pengekstrakan
data melibatkan tahun penerbitan, nama pengarang, lokasi geogra, fokus penyelidikan dan ringkasan penemuan
daripada artikel teks penuh dijalankan secara bebas dan sebarang perselisihan diselesaikan melalui persetujuan.
Sebanyak 29 artikel disertakan dengan artikel terawal yang diterbitkan pada tahun 1985. Lima belas artikel itu
adalah tentang literasi kesihatan umum dengan empat literasi perubatan, lima literasi kesihatan mental, tiga di
media dan literasi e-kesihatan dan empat literasi kesihatan mulut. Empat artikel adalah kajian kualitatif dan
selebihnya adalah kajian kuantitatif. Beberapa kajian menggunakan alat literasi kesihatan yang disahkan seperti
Newest Vital Signs dan HLS-EU-Q47. Oleh itu, secara kesimpulan, terdapat hanya sedikit artikel yang diterbitkan
dalam bidang literasi kesihatan di Malaysia. Pada masa hadapan penggunaan alat antarabangsa yang disahkan
untuk membolehkan perbandingan penemuan harus dipertimbangkan.
Kata kunci: Celik kesihatan mental; literasi kesihatan; literasi perubatan; Malaysia
INTRODUCTION
River
INTRODUCTION
Health literacy plays an important role in empowering
citizens to make healthy choices and participate in their
healthcare. Health literacy is often dened as people’s
ability to access, understand, appraise and apply health
information to make judgement and decisions concerning
their health (Nielsen-bohlman et al. 2004). Population
studies showed that nearly half of European adults
have less than sucient health literacy and only 12% of
American adults have procient health literacy. People with
limited health literacy are less likely to use preventive
services (Scott et al. 2002) to seek help when they are sick,
(Bennett et al. 1998), and more likely to overuse healthcare
services with higher rate of hospitalisation and use of

1022
emergency services (Baker et al. 2002, 1998; Gordon et
al. 2002). As a result, this leads to higher healthcare costs
(Howard et al. 2005). Limited health literacy in patients
with non-communicable diseases such as high blood
pressure (Williams et al. 1998), diabetes (Schillinger
et al. 2003, 2002; Williams et al. 1998a)or HIV/AIDS
(Kalichman & Rompa 2000; Kalichman et al. 2000) have
less knowledge of their illnesses and how to manage them.
There is an increasing number of health literacy
studies published each year (Kondilis et al. 2008). Health
literacy research published in the United States and
Europe (EU) had been used to draw up documents which
shaped health system policy and law. In the United
States, the rst of these documents is ‘Health Literacy: A
Prescription to End Confusion’ which was published by
the Institute of Medicine in 2004 and led to the formation
of the Plain Writing Act of 2010 (Nielsen-bohlman et al.
2004). In recent years, several EU Member States such
as Germany, Ireland, Scotland, Austria, and Switzerland
published their own policy documents relating to health
literacy (Heijmans et al. 2014).
Recently, at the Ninth Global Conference on Health
Promotion in Shanghai, member countries endorsed
the Shanghai declaration (which recognised health
literacy as a critical determinant of health) and made a
commitment to invest in its development (World Health
Organization 2017). Malaysia is one of the signatories
of this declaration, committed to develop, implement
and monitor intersectoral, national and local strategies
for strengthening health literacy in all populations
and in all educational settings. Unfortunately, little is
known about the studies on health literacy done in our
country, Malaysia. Results from health literacy research
done in other countries are not transferable to our local
setting. Health literacy is a social construct and greatly
inuenced by culture (Shaw et al. 2009). Culture gives
signicance to health information and can shape an
individual’s perception and denition of health and
illness. This, in turn, inuences the understanding of
health literacy in dierent countries and settings.
So far, ndings on the levels of population health
literacy are alarming. In 2015, the National Health
and Morbidity survey measured the population health
literacy for the rst time. It was found that only 6.6% of
Malaysian adults have adequate health literacy (Institute
for Public Health (IPH) 2015). This nding warrants
further examination of research already done in the area
of health literacy in Malaysia. This scoping review aims
to identify and synthesise published health literacy
research done in Malaysia thus far. It will be the rst
review to summarise published work in this area and to
provide recommendations for future research.
MATERIALS AND METHODS
We searched databases archiving published work by
Malaysian researchers, the PubMed, Scopus and the
Malaysian Medical Repository (MyMedR) databases.
MyMedR is an open-access database of published
Malaysian health and biomedical research. The
materials are imported from PubMed and MyJurnal.
The search terms used for health literacy were (‘health
literacy’ OR ‘health literate’ OR ‘medical literacy’) OR
‘sexual health literacy’) OR ‘mental health literacy’)
OR (‘health’[Title/Abstract] AND ‘literacy’[Title/
Abstract])) OR ‘numeracy’) OR ‘health literacy’[MeSH
Terms] and Malaysia (all elds). These were restricted
to English and Malay language. The searches were
conducted up to November 2019. Two papers were found
by tracking authors known for their research on health
literacy in Malaysia.
Two unanimous reviewers assessed the articles
to see if they full the inclusion criteria. The inclusion
criteria were as follow: the study was conducted in
Malaysia, on Malaysian populations, and the study
reported on health literacy. Any disagreement was
resolved by consensus. Denitions of health literacy had
gone through many evolutions; the one used in this review
was “the capacity of individuals to obtain, process, and
understand basic health information and services needed
to make appropriate health decisions” (Nielsen-bohlman
et al. 2004). Therefore, only studies that measured
patients’ capability to obtain, process and understand
health information will be included. Studies focused
solely on measuring disease knowledge were excluded.
Only original studies published in full manuscript were
included.
Full-text articles were obtained for those that
fullled the inclusion criteria. Duplicates were excluded.
Reviewers carefully read the articles and extracted relevant
information. Study quality was not assessed as the focus
of this review was to know the breadth of health literacy
research in Malaysia rather than excluding studies based
on their quality. The reason for this was to be as inclusive
as possible. Data on the year of publication, authors, state
in Malaysia where the research was conducted, area of
health literacy tackled, and summary of ndings were
extracted.
RESULTS
STUDY SELECTION AND CHARACTERISTICS
Figure 1 shows the ow chart of the article selection
process. The search resulted in 203 articles and another
2 articles were found through authors’ tracking. We
assessed 126 articles for eligibility after excluding 79
duplicates. Only 29 fullled the inclusion criteria and
were included in this review. These studies could be
grouped into ve main areas of health literacy, mainly:
general health literacy, mental health literacy, medication
literacy, media and e-health literacy, and oral health
literacy. Articles from the same area will be discussed
together.

1023
DATA EXTRACTION AND SYNTHESIS
Table 1 summarised articles that were reviewed. Four
studies used a qualitative study design, one used a mixed
methods design and the rest employed a quantitative
study design. Table 2 provides information on health
literacy tools used in the quantitative studies included in
this review. The rst article we identied was published
in 1985. However, majority of the articles were published
after 2010. Most studies were conducted in the states
of Peninsular Malaysia (n=27) and in Klang Valley,
namely the urban states of Kuala Lumpur and Selangor
(n=12). Two papers published data from multi-country
collaboration studies, allowing direct comparison of
health literacy ndings in Malaysia to that in other
countries.
FIGURE 1. Flow chart of study selection
TABLE 1. Summary of included studies
Author(s) Location Main aim Study design Setting Results
General Health Literacy
(Bee 1985) Sarawak NR Cross-
sectional
study
Community The study population experienced a
moderate prevalence of morbidity, the
bulk of which were mild conditions easily
treated by primary health care workers.
The interviews on health literacy also
show large gaps in the knowledge of the
respondents with regards to the causation,
spread and prevention of diseases. Another
important nding stemmed from the study
is the possible deleterious eects of food
taboos on the diets of women during the
post-partum period.

1024
(Khan et al.
2010)
Pulau
Pinang
to evaluate and
compare the
knowledge,
attitude and
perception about
breast cancer
among the
students from
dierent ethnic
groups
Qualitative
study
Malaysian public
university
The ndings demonstrate that the Thai
students had comparatively better
knowledge than the other groups. In
terms of diagnosis, mammography and
physical examination were recommended
by a majority of the students. Surgery
and radiation therapy were the preferred
options to treat breast cancer. Thai students
had good knowledge about the symptoms
of breast cancer. However, the knowledge
level on the diagnosis of breast cancer was
the best among the Malays and the Arabs.
(Cheah &
Su 2012)
Pulau
Pinang
to investigate the
impact of socio-
demographic
factors on the
acquisition
of health
information
on Non-
Communicable
Diseases
(NCDs) among
Malaysian adults
Cross-
sectional
study
Public area including
university, shopping
malls, oces and
cafes,
The results suggest that old individuals,
rural dwellers, those having chronic
disease and with history of serious family
illnesses are 0.19%, 2.39%, 2.2% and
2.71% less likely to acquire poor health
information on NCDs than others, whereas
Malays, Chinese, males and those of low
education are 8.76%, 6.22%, 2.94% and
21.62% more likely to acquire poor health
information on NCDs than others.
(Norrazah
et al. 2016)
Pahang to determine
the use of the
Newest Vital
Sign (NVS) in the
Malay language
as a tool to
measure the
level of health
literacy among
adults in the rural
population in
Malaysia
Cross-
sectional
study
Community The study showed that, of the 111
respondents, 34 completed the
questionnaire within three minutes. Seven
(20.6%) adults were of adequate literacy
having the ability to answer a minimum
of four questions correctly within three
minutes given. Meanwhile, 17 (50.0%)
adults were of limited possible literacy
and 10 (29.4%) were of the limited likely
group.
(Skau et al.
2016)
Negeri
Sembilan
to evaluate
the ecacy
of a complex
behavioural
change
intervention
combining
behaviour change
counselling
provided by
community
health promoters
(CHPs) and
utilisation of an
E-health platform
to enhance
women’s
health prior to
pregnancy
RCT Community This study protocol describes the rst
community-based randomised controlled
trial, to examine the ecacy of a complex
intervention in improving the pre-
pregnancy health of young Malaysian
women and their spouses. Results from
this trial will contribute to improved
policy and practices regarding complex
behavioural change interventions to
prevent diabetes in the pre-conception
period in Malaysia and other low- and
middle-income country settings.

1025
(Azreena et
al. 2016)
Selangor to determine the
level of health
literacy and its
associated factors
among type 2
diabetes mellitus
patients attending
a government
health clinic
Cross-
sectional
study
Government health
clinic
Majority of the respondents have limited
health literacy level (85.8%). There
is a signicant association between
ethnic group and health literacy level
(χ2=6.317, P=0.042), level of education
and health literacy level (χ2=6.304,
P=0.043) and diabetes knowledge score
and health literacy level [Odds Ratio
(OR)=1.254, 95% Condence Interval
(CI) (1.063,1.479)]. Finally, the signicant
predictors for adequate health literacy
level were the Chinese ethnic group
[Adjusted OR (AOR)=4.441, 95% CI
(1.472,13.392)] and diabetes knowledge
score [AOR=1.238, 95% CI (1.031,1.488)].
(Hamzah
et al. 2016)
Malaysia,
multi-states
to determine
the inuence of
health literacy
towards health
information-
seeking
behaviour among
Malaysian
university
students
Cross-
sectional
study
University The level of health literacy among
Malaysian university students is moderate.
Results also showed that 23.6 percent of
the studied factor contributed to health
information-seeking behaviour model.
(Chuen et
al. 2016)
States in
Malaysia
to examine the
inuences and
eectiveness
of newspaper
in conveying
health literacy of
obesity among
Malaysian youth
Cross-
sectional
study
NR It was found that newspaper-oriented
respondents have a higher awareness of
obesity than non-newspaper-oriented
respondents. However, awareness among
the overall respondents is still mainly
average.
(Duong et
al. 2017)
Kuala
Lumpur,
Selangor,
Perak
to validate a
comprehensive
health literacy
survey tool
European
health literacy
questionnaire
(HLS-EU-Q47)
for the general
public in several
Asian countries
Validation
study
Public secondary
school
The questionnaire was shown to have
good construct validity, satisfactory
goodness-of-t of the data to the
hypothetical model in three health literacy
domains, high internal consistency
(Cronbach’s alpha>0.90), satisfactory
item-scale convergent validity (item-scale
correlation=0.40), and no oor/ ceiling
eects in these countries.
(Shahrir et
al. 2018)
Klang
Valley
to assess limited
health literacy
level and its
associated factors
among obese
and overweight
housewives
Sub-analysis
of RCT
ndings
Public low-costs ats The mean (SD) NVS score was 1.07(1.19)
with most (87.5%) housewives having
limited health literacy. Factors that were
signicantly associated with limited health
literacy were older age of 45 to 59 years
old (p = 0.040), primary education and
below (p = 0.001) and absence of internet
connectivity (p = 0.001). In the nal
model, absence of internet connectivity
(OR 2.61; 95% CI 1.31 to 5.22) was
associated with limited health literacy.

1026
(Hagger et
al. 2018)
Malaysia,
multi
ountry
to examine
the prevalence
and predictors
of HL in FH
patients attending
clinics in seven
countries
Cross-
sectional
study
Familial
hypercholesterolemia
(FH) clinics
Inadequate HL was lowest in the UK
(7.0%), Australia (10.0%), Hong Kong
(15.7%), and Taiwan (18.0%) samples,
with higher rates in Brazil (22.0%),
Malaysia (25.0%), and China (37.0%)
samples. Income was an independent
predictor of HL levels, accounting for
eects of age. HL was also independently
related to China national group
membership.
(Hamzah et
al. 2018)
Klang
Valley
to research the
inuence of
parental and peer
attachment on the
health literacy of
adolescents
Cross-
sectional
study
Secondary School The level of health literacy among these
adolescents was moderate (M = 3.61, SD
= 0.51 on a scale of 5). While the level of
peer attachment among them was moderate
(M = 3.48, SD = 0.58), the level of parental
attachment was high (M = 3.73, SD = 0.83
on a scale of 5). Both parental attachment
(b = 0.30, p < 0.05) and peer attachment
(b = 0.37, p < 0.05) were shown to have
signicant independent eects on the level
of adolescents’ health literacy.
(Cheong et
al. 2018)
Kuala
Lumpur
to determine
the change of
HL scores and
to investigate
the dierence
of intervention
outcomes at the
weight loss (WL)
intervention and
WL maintenance
phase between
the HL groups
RCT Low-cost at Both intervention and control participants
have low HL. The intervention group
increased the NVS mean score from
baseline (1.19 scores) to the end of the WL
maintenance phase (1.51 scores) compared
to the control group. There was no
signicant dierence in sociodemographic
characteristics between the group with HL
improvement and the group without HL
improvement at baseline. Most of the
dietary intake measurements at WL
intervention were signicantly dierent
between the two HL groups among
intervention participants. Physical activity
and body composition did not dier
signicantly between the two HL groups
among both intervention and control
groups.
(Froze et
al. 2019)
Sarawak to identify the
determinants of
health literacy
and healthy
lifestyle practice
against metabolic
syndrome among
the multi-ethnic
group of Sarawak
based on health
literacy skills
framework
Cross-
sectional
study
NR Female respondents and those with higher
education status were more likely to have
a better healthy lifestyle practice. A greater
level of health literacy was positively
signicant with both disease knowledge
and healthy lifestyle practice. Participants
with a good understanding of disease
knowledge can directly inuence healthy
lifestyle. Health literacy and metabolic
syndrome knowledge can mediate the
relationship between sociodemographic
variables, service accessibility, medical
and family history with the practice of a
healthy lifestyle.

1027
(Duong
et al.
2019)024
Kuala
Lumpur,
Selangor,
Perak
to develop
and validate
a short-form
HL instrument
derived from
the 47-item
European
Health Literacy
Questionnaire
(HLS-EU-Q47)
Validation
study
NR The HLS-SF12 was demonstrated to
have adequate psychometric properties,
including high reliability (Cronbach’s
alpha = .85), good criterion-related
validity, a moderate and high level of
item-scale convergent validity, no oor
or ceiling eect, and good model-data-
t throughout the populations in these
countries.
Medication Literacy
(Chan et al.
2015)
Kedah to explore the
health literacy
of the Malaysian
caregivers
who received
medications for
their children
by using a
validated tool.
Besides, the
inuences of
their health
literacy on
comprehension
of information on
medication labels
were examined
Cross-
sectional
study
A government-
funded tertiary
hospital
Health literacy was measured using
the Newest Vital Sign, and only 5.8%
of caregivers demonstrated adequate
health literacy skills. Caregivers with
only primary or secondary educational
levels (adjusted odds ratio: 36.44; 95%
condence interval: 6.2, 214.08; P <
0.001) and monthly incomes below the
poverty threshold (adjusted odds ratio:
11.12; 95% condence interval: 1.13,
109.75; P = 0.039) are more likely to have
limited health literacy skills.
The majority (81.2%) of caregivers
reported diculty in reading
medication labels, which was signicantly
associated with their health literacy (phi
coecient = 0.46; P < 0.001).
(Tan et al.
2015)
Pulau
Pinang
to evaluate
Malaysian
consumers’
practices,
perceptions and
understanding
regarding the use
of acetaminophen
Qualitative
study
University based
health and outpatient
clinics and two
selected community
pharmacies.
Consumers have a positive attitude
towards the popularity, safety and
ecacy of acetaminophen. Consumers
predominantly used acetaminophen
for pain and fever. Some consumers
tend to increase the frequency and
dosage of acetaminophen consumption
if their condition persisted. Consumers
have diculty recognising generic
acetaminophen-containing products
available in the market. Health
literacy investigations found that
consumers lack knowledge of the
correct dosing regimen for acetaminophen
in adults and children. Consumers are not
aware of the precautions and toxicities of
acetaminophen. To increase awareness
of acetaminophen poisoning in Malaysia,
educational tools regarding the proper use
of acetaminophen are needed from the
Ministry of Health and policy-makers.

1028
(Zulkii et
al. 2016)
Klang
Valley
Why the public
is still buying
unregistered
drugs in
Malaysia
although there
are awareness
campaigns
throughout
Malaysia?
How are the
performances
of the current
awareness and
educational
programmes?
How can these
awareness and
educational
programmes
be improved
and be targeted
to reduce
unregistered
drugs purchases
amongst the
public?
Mixed-
method
NR Most of the participants believed that
the best tools for educating people about
the dangers of unregistered drugs are
television, Facebook (social media) and
the internet. The majority of participants,
75% (n=12) also believed that raising
awareness about the bad impact of
unregistered drugs may discourage public
purchase of unregistered drugs. The
majority of pharmacists believed that
health literacy is the most important aspect
of developing a good sense of consumer
understanding of unregistered drugs in
consumers. The pharmacists believed that
low health literacy would inuence the
public to purchase unregistered drugs.
(Nazatul
Yusrina et
al. 2017)
Negeri
Sembilan
to study the
predictors of
health literacy
on childhood
immunisation
among antenatal
women
Cross-
sectional
study
Health clinics 81.2% of antenatal mothers have
inadequate health literacy. The predictors
were maternal education (AOR= 2.608,
95% CI 1.477-4.604), parity (AOR= 1.067,
95% CI 1.103-3.876), residential area
(AOR= 2.344, 95% CI 1.184-4.641) and
utilisation of government hospital (AOR=
2.344, 95% CI 1.184-4.641).
Mental Health Literacy
(Khan et al.
2010)
Pulau
Pinang
to determine
the level of
knowledge
of depression
among students
at a Malaysian
university
Cross-
sectional
study
Public university Overall, the ndings demonstrate a
moderate level of knowledge among
students. Of the dierent cultural groups,
the ndings showed that Chinese students
have the best knowledge of the symptoms
of depression, followed by the Malays and
Indians. Regarding beliefs on the causes
of depression, the majority identied
educational issues such as failures in
achievement and education-related
problems (such as examinations and
projects) as the major cause of depression.
However, the death of a loved one,
relationship problems and home/family
disharmony were found to be perceived
as signicant causes of depression. The
ndings showed only a cursory knowledge
of the medications used in the treatment
of depression among respondents. The
majority recommended alternative
treatments, such as yoga, massage and
traditional medicines. Ethnic background
and religion have been observed as
underpinning the belief in traditional ways
of curing depression, such as yoga and
meditation.

1029
(Loo et al.
2012)
Malaysia,
multi
country
to examine the
ability of
British,
Malaysian and
Hong Kong
participants
to identify
nine dierent
psychiatric
vignettes. The
second aim
of the study
is to compare
treatment
preferences
in the form of
recommended
help for the
person in the
vignette
Cross-
sectional
study
Community The British were the most adept at
correctly identifying the cases of mental
disorders in the vignettes followed by
the Hong Kong Chinese and Malaysians.
Overall, depression cases were the
best identied and social phobia was
the least identied. In terms of help
recommendation, a higher percentage of
British participants endorsed professional
help as useful for the person in the vignette
compared to Hong Kong and Malaysian
participants.
(Mohamad
et al. 2012)
Northern
states
to identify
caregivers’
mental health
literacy in
Malaysia
Qualitative
study
Community clinics Most of the caregivers have some
understanding of their relatives’ mental
illnesses. More than half of the participants
found that the doctors were considered
as their primary source of information
about mental health. Most of the
caregivers used religious and traditional
coping mechanisms in their help-seeking
processes. Each ethnic group had its own
strong cultural beliefs
about mental illness.
(Siti
Fatimah et
al. 2016)
Selangor to investigate the
eectiveness of a
4-week
Web-based
sychoeducational
intervention
program for
depressive and
anxiety
symptoms
in the community
of Selangor,
Malaysia
RCT Community The program aims to address the predictors
that contribute to depression and anxiety
in our community. This brief Web-based
program will enable the community
to use easy, user-friendly, valid, and
reliable tools for assessing their mental
health status. Second, the availability of
the program in both English and Malay
languages is an additional plus point.
Participants can choose their preferred
languages to complete the sessions. Third,
the assessments are available in both
languages and have been validated in
our population. Fourth, the intervention
program was designed to be as brief as
possible to increase the acceptability
of the program versus other lengthier
interventions, which could further increase
the dropout rates.
(Ibrahim et
al. 2019)
Malaysia,
multi-states
to examine the
factors associated
with a mental
help-seeking
attitude among
students from
the B40 income
bracket
Cross-
sectional
study
Secondary school
and University
Mental help-seeking attitude had a
signicant relationship with self-stigma on
seeking help (r = −.258, p < .001), general
help-seeking attitude (r = .156, p = .027),
and age (r = .187, p < .001). However, the
strongest predictor for mental help-seeking
attitude was self-stigma on seeking help (F
(2,199) = 8.207, p < .001 with R2 of .076).
University students had better depression
literacy and lower levels of self-stigma
and negative beliefs toward mental illness
compared to secondary school students.

1030
Media and e-Health literacy
(Zalma et
al. 2015)
Selangor to determine
the reliability
and validity of
television food
advertising
questionnaire
Validation
study
Primary school The questionnaire on television food
advertising is reliable and valid to assess
the eect of media literacy education
on television food advertising on
schoolchildren.
(Mohamad
et al. 2015)
Klang
Valley
to examine the
media’s role in
health literacy
and mothers’
ability to access,
understand,
appraise
and apply
information on
children growing
up milk
Qualitative
study
NR Media could contribute towards mothers’
health literacy, particularly through
the information portrayed. However,
the access, level of understanding and
judgement of this information do not
guarantee their health behaviours.
(Yilma et
al. 2019)
NR to assess the
search behaviour
of consumers
and identify
contextual factors
aecting health
information
searching on the
Web
Cross-
sectional
study
xperimental
design)
University campus Frequent health information seeking led
to more queries and long query length.
English as a mother tongue and being
healthy contributed to long query length.
Queries with spelling errors and those
formulated outside task descriptions were
found to be ineective.
Oral health literacy
(Fabillah et
al. 2015)
Kuala
Terengganu
to assess the oral
health literacy
among carers
of special needs
children
Cross-
sectional
study
Community- Based
Rehabilitation
Centres
Majority of the participants had ‘marginal’
and ‘adequate’ OHL level of 32.5% and
52.5%, respectively. Only four (10%)
participants had ‘inadequate’ OHL
level. The ‘reading comprehension’ and
‘numeracy’ sections’ mean scores were
37.54 (95% CI 35.7-39.4) and 38.17
(95% CI 34.8-41.6). The total OHL
mean score was 75.7 (95% CI 71.2-80.2).
(Ismail et
al. 2018)
Pahang to assess the
parental Oral
Health Literacy
(OHL) and its
association
with the oral
health status
of preschool
children
Cross-
sectional
study
Preschool The negative correlation between parental
OHL and the oral health status of children
indicates that when parental OHL level
increases, the total dental caries
experience (dmft) and oral hygiene status
(visible plaque index: VPI) decreases
(p<0.05). Lower dmft and VPI scores were
also observed among preschool children
of parents in the group with high parental
OHL (p<0.05).

1031
(Rani et al.
2019)
Kuala
Lumpur
to evaluate
the oral
health literacy
level among
adolescents,
prior to and
after the oral
health education
program using
visual oral health
literacy tool
Cross-
sectional
study
Secondary schools At the baseline, the students had a low
visual oral health literacy score for
both gingival, and tooth scores with the
gingival score being signicantly lower.
The upper tooth and gingival scores were
higher than the lower tooth and gingival
scores. Comparison of scores before
and after oral health education showed
that both the tooth and gingival scores
improved signicantly. Visual oral health
literacy tool allows evaluation of students’
oral health literacy both visually and
quantitatively.
NR = Not reported
TABLE 2. Health literacy tools used in Malaysia
Measure Type of Measure No of items/
questions
Administration mode/
time
Scoring Validation study Language
available
NVS (Newest
Vital Signs)
Reading,
comprehension;
numeracy
6 questions on
an ice-cream
nutrition label
Self-administered;
3 min
Each item
answered
correctly is
given a score of
1. Scores range:
1-6 (score <4 =
limited HL)
(Norrazah et al.
2016)
Malay
HLS-EU-Q47
(European
Health
Literacy
uestionnaire)
Prose:
Comprehension,
Information
seeking:
Document,
Application/
function
47 items across
3 domains
(healthcare,
disease
prevention,
and health
promotion)
Self- or interview
administered; 15 min
The 47 items
are adapted
to a 50-point
scale: 0–25:
inadequate
health literacy,
26–33:
problematic
health literacy,
33–42:
sucient
health literacy,
and 42–50:
excellent health
literacy
(Duong et al.
2017)
Malay
HLS-SF12
(the Health
Literacy
Short-Form
12)
Prose:
Comprehension,
Information
seeking:
Document,
Application/
function
12 items Self- or interview
administered
The HL
indices were
standardised to
unied metrics
from 0 to 50.
An index
value was
thus obtained
in which 0
represented the
lowest HL and
50 the highest
HL
(Duong et al.
2019)024
Malay

1032
HeLD-14 (14
items Health
Literacy in
Dentistry)
Functional oral
health literacy
14 items (seven
conceptual
domains of
HL: access
understanding,
support,
utilisation,
economic
barriers,
receptivity, and
communication)
Self-reported; Each item
was scored
using a 5-point
Likert scale
ranging from 1
(“without any
diculty”) to
5 (“Unable to
do”). After re-
coding of 5 to
0, 4 to 1, 3 to 2,
2 to 3, and 1 to
4, the possible
range of
summary scores
is from 0-56
(HeLD-14).
Higher scores
indicate higher
oral health
literacy.
(Muhd Noor et al.
2019)
Malay
SYNTHESIS OF RESULTS
The articles were grouped into ve important areas of
health literacy namely; general health literacy (n=15),
medication literacy (n=4), mental health literacy (n=5),
media and e-health literacy (n=3) and oral health
literacy (n=4). The earliest study (1985) on general
health literacy explored patients’ perception of disease
causation, choice of treatment, preventive measures
and food taboo related to infectious disease (Bee 1985).
Four studies reported the validation of health literacy
tools in a local language, one on NVS, HeLD-14 HLS-
EU-Q47 and HLS-SF12. (Duong et al. 2017; Norrazah
et al. 2016). The NVS was used the most to measure
the level of health literacy in Malaysia. However, the
Malay version of NVS was found to be inappropriate and
inadequate to measure health literacy among adults in the
rural population and its validity among urban adults has
not been tested (Norrazah et al. 2016).
For medication literacy, one study measured the
health literacy levels of Malaysian caregivers and
parents and tested the inuence of their health literacy
on the comprehension of medication information and
childhood immunisation score (Chan et al. 2015; Nazatul
Yusrina et al. 2017). Other studies explored Malaysian
consumer’s practices, perceptions and understanding
regarding the use of acetaminophen and the use of
unregistered drugs (Tan et al. 2015; Zulkii et al. 2016).
Studies on mental health literacy focused on
measuring mental health literacy among caregivers,
students from the B40 income bracket and university
students (Ibrahim et al. 2019; Khan et al. 2010; Mohamad
et al. 2012). In one study, psychiatric vignettes were
used to examine the mental health literacy of British,
Malaysian, and Hong Kong participants (Loo et al.
2012). Another study is a randomised control trial
investigating the eectiveness of a 4-week Web-based
psychoeducational intervention program for those with
depressive and anxiety symptoms in the community of
Selangor, Malaysia (Siti Fatimah et al. 2016).
Studies in the last ve years concentrated on new
areas of health literacy, namely oral health literacy
and media and e-health literacy. Given that the eld of
media and e-health literacy is a fairly new area of health
literacy research in Malaysia, studies were focused
on the validation of food advertising tool (Zalma et al.
2015) and exploration of media’s role on health literacy
(Mohamad et al. 2015). A recent study on e-health literacy
looked at the search behaviour of students and identied
contextual factors aecting health information searching
on the Web (Yilma et al. 2019).
Another area of health literacy that is of research
interest in Malaysia is on oral health literacy. Research
in oral health literacy is catalysed by the availability of
validated tools to measure oral health literacy, such as
the Malay Health Literacy in Dentistry (HeLD-14) (Muhd
Noor et al. 2019). Oral health literacy was measured in
children with special needs (Fabillah et al. 2015), and the
association between parental oral health literacy and
oral health status of preschool children was tested (Ismail
et al. 2018). There is also an intervention study looking
at the eect of an oral health education program using
visual oral health literacy tool on adolescents oral health
literacy (Rani et al. 2019).
DISCUSSION
There were two major ndings from this review. First,
research on health literacy in Malaysia is limited and
second, most published studies focused on general health
literacy. Health literacy research done in developing
countries trailed behind that of developed countries,

1033
such as the United States and European countries. In
a bibliometric analysis of published papers on health
literacy by authors in the European Union from 1991 to
2005, Kondilis et al. (2008) identied 13,710 articles.
More articles were published by researchers in the
United States, approximately three times the number
of articles published in Europe. Developing countries
may be focusing on economic development for the
improvement of health rather than tackling issues related
to health literacy. Since its independence, health reforms
in Malaysia focused on restructuring community and
eradication of poverty (Sebastian et al. 2016). Health
literacy which focuses on patient empowerment and
individual attributes, such as knowledge and attitudes
are often overlooked. In developing countries where
there is rapid economic development, societal resources
such as literacy and educational attainment may not have
caught up with the expansion in healthcare infrastructure
and human resource. Health literacy research needs to be
expanded in these countries to adequately deal with this
shortfall.
This review identied ve main areas of health
literacy research in Malaysia. General health literacy
was the most studied with fteen papers published. Five
studies used a local language adapted functional health
literacy tool, Newest Vital Sign to measure health literacy
levels in a variety of populations (Azreena et al. 2016;
Chan et al. 2015; Cheong et al. 2018; Norrazah et al.
2016; Shahrir et al. 2018). Levels of adequate health
literacy vary according to the population surveyed; with
the highest proportion reported in community-dwelling
adults and lowest in caregivers of sick children. As for
patients with type 2 diabetes mellitus in primary care,
only 14.2% of Malaysian patients have adequate health
literacy compared to 23.7% in Taiwan (Tseng et al. 2018).
There could be many reasons for this observed dierence.
Critical examinations of health education interventions
delivered to patients with type 2 diabetes mellitus in
Taiwan compared to Malaysia and comparing the factors
associated with lower health literacy levels in these two
settings may show some answers. So far, public health
researchers have resorted to these small cross-sectional
studies to inform them about the burden of limited health
literacy in the Malaysian populations.
Health literacy had been measured using dierent
tools in the Asia-Pacic regions, thus making the
comparison of health literacy levels across countries
dicult. This review identied two studies validating
international and regionally used health literacy
measurement tools, the HLS-EU-Q47 and HL-SF12. Both
validation studies recruited patients from six Asia-Pacic
countries (Duong et al. 2019, 2017). The Malay version
of the HLS-EU-Q47 was validated in 462 Malaysian and
was shown to have good construct validity, satisfactory
goodness-of-t of the data to the hypothetical model in
three health literacy domains, high internal consistency
(Cronbach’s alpha >0.80), satisfactory item-scale
convergent validity (item-scale correlation =0.40), and
no oor/ceiling eects. In the same study, Malaysia
was found to have the second-highest general health
literacy index, 1.5 points behind Taiwan (32.9 vs. 34.4)
(Duong et al. 2017). The Malay version of the HLS-SF12
index score was 32.7 ± 7.9 in Malaysia. The correlation
between HL index scores of HLS-SF12 and HLS-EU-Q47
by the Pearson correlation coecient was satisfactory
with a rho-value of 0.96. The variance of the full form
was explained by the HLS-SF12, with 93% in Malaysia
(Duong et al. 2019).
Mental health literacy and medication literacy
are two important areas of health literacy research in
Malaysia. Mental health literacy is dened as “the
knowledge and beliefs about mental disorders, which
aids their recognition, management or prevention” (Jorm
et al. 1997). Studies included in this review focused more
on the assessment of mental health literacy in common
mental health conditions, such as anxiety and depression.
We identied only one study testing the eectiveness of
a web-based psychoeducational intervention program
for those with depressive and anxiety symptoms. Future
studies should be focusing more on the development of
interventions to improve mental health literacy and to
include other important mental health conditions, such
as schizophrenia. The intervention studies should be
carried out by researchers championing mental health
literacy in Malaysia.
Lower health literacy scores are associated with
patients forgetting to take their medications (Pouliot &
Vaillancourt 2016). Patients with non-communicable
diseases in Malaysia were found to have low medication
adherence. Studies on medication literacy will be
valuable to help tackle this problem. Unfortunately,
studies included in this review are limited and have a
narrow focus on one drug (i.e. acetaminophen) or one
group of drugs only (i.e. unregistered drugs). More
studies should be conducted in this area to further our
understandings of the role of health literacy in medication
adherence in Malaysia.
This review has several limitations. Only three
databases were used in this review and given that the
MyMedR partly extracts articles from PubMed, there
may be duplications. In this review, we wanted to focus
on articles dealing with the greater concept of health
literacy, which is adequately identied by the review’s
search term. Quality assessment of the included studies
was not done in order to be more inclusive. Future
reviews should look into this aspect and may include
contacting authors whose work were included in this
review to obtain an update of their work in health literacy.
CONCLUSION
Articles published in the eld of health literacy in
Malaysia are limited. Future work may be required to
build on previous work and to study the challenges
faced by these researchers. There are issues with some
of the health literacy tools used in recently published

1034
studies. Therefore, a locally well-validated tool used
internationally will enable better measurement of health
literacy levels and comparison across countries. There is
still much work to be done in the area of health literacy
in Malaysia.
ACKNOWLEDGEMENTS
We thank University Malaya Research Grant (special
grant provision No. BKS047-2017) for funding this study
and Ms Ranita Hisham Shanmugan, Librarian at the
University of Malaya Central Library for her assistance
in obtaining full-text articles for the review.
REFERENCES
Azreena, E., Suriani, I., Juni, M.H. & Fuziah, P. 2016. Factors
associated with health literacy among Type 2 diabetes
mellitus patients attending a government health clinic.
International Journal of Public Health and Clinical Sciences
3(6): 50-64.
Baker, D.W., Gazmararian, J.A., Williams, M.V., Scott, T., Parker,
R.M., Green, D., Ren, J. & Peel, J. 2002. Functional health
literacy and the risk of hospital admission among medicare
managed care enrollees. American Journal of Public Health
92(8): 1278-1283.
Baker, D.W., Parker, R.M., Williams, M.V. & Clark, W.S. 1998.
Health literacy and the risk of hospital admission. Journal
of General Internal Medicine 13: 791-798.
Bee, Y.S. 1985. Health literacy and food beliefs among Ibans,
Sarawak. The Medical Journal of Malaysia 40(4): 294-300.
Bennett, C.L., Ferreira, M.R., Davis, T.C., Kaplan, J., Weinberger,
M., Kuzel, T., Seday, M.A. & Sartor, O. 1998. Relation
between literacy, race, and stage of presentation among
low-income patients with prostate cancer. Journal of Clinical
Oncology: Official Journal of the American Society of
Clinical Oncology 16(9): 3101-3104.
Chan, H.K., Hassali, M.A., Lim, C.J. & Saleem, F. 2015.
Exploring health literacy and diculty in comprehending
pediatric medication labels among caregivers in Malaysia:
A pilot study. Journal of Pharmaceutical Health Services
Research 6(3): 165-168.
Cheah, Y.K. & Su, T.T. 2012. The determinants of consumer
health information on chronic non-communicable disease:
An exploratory study in Penang, Malaysia. Journal of the
University of Malaya Medical Centre 15(2): 1-7.
Cheong Siew Man, Noor Saza Mohamad Nor, Mohamad
Hasnan Ahmad, Mala Manickam, Rashidah Ambak, Siti
Nurbaya Shahrir. & Tahir Aris. 2018. Improvement of health
literacy and intervention measurements among low socio-
economic status women: Findings from the MyBFF@home
study. BMC Women’s Health 18(1): 99.
Chuen, E.M., Michael, E. & Teh, B.T. 2016. The role of media
socialization agents in increasing obesity health literacy
among Malaysian youth. Jurnal Komunikasi: Malaysian
Journal of Communication 32(2): 691-714.
Duong, T.V., Aringazina, A., Kayupova, G., Nurjanah, Pham,
T.V., Pham, K.M., Truong, T.Q., Nguyen, K.T., Oo, W.M., Su,
T.T., Hazreen Abdul Majid, Sørensen, K., Lin, I.F., Chang,
Y., Yang, S-H. & Chang, P.W.S. 2019. Development and
validation of a new short-form Health Literacy Instrument
(HLS-SF12) for the general public in six Asian countries.
Health Literacy Research and Practice 3(2): e91-e102.
Duong, T.V., Aringazina, A., Baisunova, G., Nurjanah, Pham,
T.V., Pham, K.M., Truong, T.Q., Nguyen, K.T., Oo, W.M.,
Emma Mohamad, Su, T.T., Huang, H-L., Sørensen, K.,
Pelikan, J.M., Van den Broucke, S. & Chang, P.W.S. 2017.
Measuring health literacy in Asia: Validation of the HLS-
EU-Q47 survey tool in six Asian countries. Journal of
Epidemiology 27(2): 80-86.
Fabillah, N.S.A., Mustapa, N., Rohani, M.M. & Esa, R. 2015.
Oral health literacy among carers of special needs children
in Kuala Terengganu, Malaysia. Annals of Dentistry 22(1):
15-20.
Froze, S., Arif, M.T. & Saimon, R. 2019. Determinants of health
literacy and healthy lifestyle against metabolic syndrome
among major ethnic groups of Sarawak, Malaysia: A multi-
group path analysis. Open Public Health Journal 12(1):
172-183. https://doi.org/10.2174/1874944501912010172.
Gordon, M.M., Hampson, R., Capell, H.A. & Madhok, R. 2002.
Illiteracy in rheumatoid arthritis patients as determined by
the Rapid Estimate of Adult Literacy in Medicine (REALM)
Score. Rheumatology 41(7): 750-754.
Hagger, M.S., Hardcastle, S.J., Hu, M., Kwok, S., Lin, J.,
Nawawi, H.M., Pang, J., Santos, R.D., Soran, H., Su, T-C.,
Tomlinson, B. & Watts, G.F. 2018. Health Literacy in familial
hypercholesterolemia: A cross-national study. European
Journal of Preventive Cardiology 25(9): 936-943. https://
doi.org/10.1177/2047487318766954.
Hamzah, M.R., Mohamad, E. & Abdullah, M.Y. 2016. Inuence
of health literacy on health information seeking behavior
among students in public university. Jurnal Komunikasi:
Malaysian Journal of Communication 32(2): 405-424.
Hamzah, S.R., Ismail, M. & Mohd Nor, Z. 2018. Does
attachment to parents and peers inuence health literacy
among adolescents in Malaysia? Kontakt 20(4): e348-e355.
https://doi.org/10.1016/j.kontakt.2018.10.006.
Heijmans, M., Uiters, E., Rose, T., ter Hofstede, J., Devillé, W.,
van der Heide, I., Boshuizen, H.C. & Rademakers, J. 2014.
Study on sound evidence for a better understanding of health
literacy in the European Union: Final Report. Luxembourg.
https://doi.org/10.2818/150402.
Howard, D.H., Gazmararian, J. & Parker, R.M. 2005. The impact
of low health literacy on the medical costs of medicare
managed care enrollees. The American Journal of Medicine
118(4): 371-377.
Ibrahim, N., Amit, N., Shahar, S., Wee, L.H., Ismail, R.,
Khairuddin, R., Siau, C.S. & Mohd Saen, A. 2019. Do
depression literacy, mental illness beliefs and stigma
inuence mental health help-seeking attitude? A cross-
sectional study of secondary school and university students
from B40 households in Malaysia. BMC Public Health
19(4): 544.
Institute for Public Health (IPH). 2015. National Health and
Morbidity Survey 2015 (NHMS 2015). Volume II: Non-
Communicable Diseases, Risk Factors & Other Health
Problems.
Ismail, A.F., Ardini, Y.D., Mohamad, N. & Bakar, H.A. 2018.
Association between parental oral health literacy and
children’s oral health status. Revista Latinoamericana de
Hipertension 13(3): 305-309.
Jorm, A.F., Korten, A.E., Jacomb, P.A., Christensen, H., Rodgers,
B. & Pollitt, P. 1997. Mental health literacy’: A survey of the
public’s ability to recognise mental disorders and their beliefs
about the eectiveness of treatment. The Medical Journal of
Australia 166(4): 182-186.
Kalichman, S.C., Benotsch, E., Suarez, T., Catz, S., Miller,

1035
J. & Rompa, D. 2000. Health literacy and health-related
knowledge among persons living with HIV/AIDS. American
Journal of Preventive Medicine 18(4): 325-331.
Kalichman, S.C. & Rompa, D. 2000. Functional health
literacy is associated with health status and health-related
knowledge in people living with HIV-AIDS. Journal of
Acquired Immune Deciency Syndromes 25(4): 337-344.
Khan, T.M., Sulaiman, S.A. & Hassali, M.A. 2010. Mental health
literacy towards depression among non-medical students at
a Malaysian University. Mental Health in Family Medicine
7(1): 27-35.
Kondilis, B.K., Kiriaze, I.J., Athanasoulia, A.P. & Falagas, M.E.
2008. Mapping health literacy research in the European
Union: A bibliometric analysis. PLoS ONE 3(6): e2519.
Loo, P.W., Wong, S. & Furnham, A. 2012. Mental health
literacy: A cross-cultural study from Britain, Hong Kong and
Malaysia. Asia-Pacic Psychiatry 4(2): 113-125.
Mohamad, E., Hani, N.A.M., Salleh, S.M., Ahmad, A.L. &
Hashim, H. 2015. Health and media literacy: The choice
of milk amongst mothers for the growth of children. Jurnal
Komunikasi: Malaysian Journal of Communication 31(2):
83-97.
Mohamad, S., Zabidah, P., Fauziah, I. & Sarnon, N. 2012. Mental
health literacy among family caregivers of schizophrenia
patients. Asian Social Science 8(9): 74-82.
Muhd Noor, N., Rani, H., Zakaria, A.S.I., Yahya, N.A. &
Sockalingam, S.N. 2019. Sociodemography, oral health
status and behaviours related to oral health literacy. Pesquisa
Brasileira Em Odontopediatria e Clinica Integrada 19(1):
https://doi.org/10.4034/PBOCI.2019.191.120.
Nazatul Yusrina Mohamad Yusof, Nor Aah Mohd Zulkei,
Suriani Ismail. & Mohammad Faid Abd Rashid. 2017.
Inadequate health literacy on childhood immunization and
its predictors among antenatal mothers. Malaysian Journal
of Medicine and Health Sciences 13(3): 51-59.
Nielsen-bohlman, L., Panzer, A.M. & Kindig, D.A. 2004. Health
Literacy: A Prescription to End Confusion. Washington: The
National Academic Press.
Norrazah, J., Nor Asiah, M., Suraiya, S.M., Zawaha, H.I. &
Normawati, A. 2016. Assessment of health literacy among
people in a rural area in Malaysia using newest vital signs
assessment. Journal of Education, Society and Behavioural
Science 16(2): 1-7.
Pouliot, A. & Vaillancourt, R. 2016. Medication literacy: Why
pharmacists should pay attention. Canadian Journal of
Hospital Pharmacy 69(4): 335-336.
Rani, H., Su, M.Y.H., Ding, A.D.A., Yahya, N.A. & Jaafar, A.
2019. Comparison of visual oral health literacy level pre and
post oral health education among adolescents. Journal of
International Dental and Medical Research 12(2): 640-644.
Schillinger, D., Piette, J., Grumbach, K., Wang, F., Wilson, C.,
Daher, C., Leong-grotz, K., Castro, C. & Bindman, A.B. 2003.
Closing the loop: Physician communication with diabetic
patients who have low health literacy. Archives of Internal
Medicine 163(13): 83-90.
Schillinger, D., Grumbach, K., Piette, J. & Al, E. 2002.
Association of health literacy with diabetes outcomes.
JAMA: The Journal of the American Medical Association
288(4): 475-482.
Scott, T.L., Gazmararian, J.A., Williams, M.V. & Baker, D.W.
2002. Health literacy and preventive health care use among
medicare enrollees in a managed care organization. Medical
Care 40(5): 395-404.
Sebastian, A., Mohamed Ali Alzain, Asweto, C.O., Mahara, G.,
Guo, X.H., Song, M., Wang, Y.X. & Wang, W. 2016. The
Malaysian health care system: Ecology, plans, and reforms.
Family Medicine and Community Health 4(3): 19-29.
Shahrir, S.N., Shamsuddin, K., Mohamad Nor, N.S., Man, C.S.,
Omar, M.A., Ahmad, M.H. & Ambak, R. 2018. Limited
health literacy and its associated factors among overweight
and obese housewives living in Klang Valley low cost ats:
Findings from the my body is t and fabulous at home
(Myb@Home) study. Malaysian Journal of Public Health
Medicine 18(1): 19-27.
Shaw, S.J., Huebner, C., Armin, J., Orzech, K. & Vivian, J. 2009.
The role of culture in health literacy and chronic disease
screening and management. J. Immigrant Minority Health
11(6): 460-467.
Skau, J.K.H., Awatef, A.N., Cheah, J.C.H., Roslinah, A., Ramli,
Z., Tahir, A., Zainudin M.A., Priya, M., Regien, B., Aagaard-
Hansen, J., Hanson, M.A. & Norries, S.A. 2016. A complex
behavioural change intervention to reduce the risk of diabetes
and prediabetes in the pre-conception period in Malaysia:
Study protocol for a randomised controlled trial. Trials 17:
215. https://doi.org/10.1186/s13063-016-1345-x.
Siti Fatimah Kader Maideen, Sherina Mohd-Sidik, Lekhraj
Rampal, Firdaus Mukhtar, Normala Ibrahim, Cheng-Kar
Phang., Kit-Aun Tan. & Rozali Ahmad. 2016. A web-based
psychoeducational intervention program for depression
and anxiety in an adult community in Selangor, Malaysia:
Protocol of a randomized controlled trial. JMIR Research
Protocols 5(2): e112.
Tan, S.F., Chong, C.P. & Chooi, W.T. 2015. An evaluation
of practices, perceptions and understanding about use
of acetaminophen (paracetamol) among Malaysian
consumers: A qualitative study. Malaysian Journal of
Pharmaceutical Science 13(1): 25-41. http://mymedr.afpm.
org.my/publications/46167.
Tseng, H-M., Liao, S-F., Wen, Y.P. & Chuang, Y.J. 2018.
Adaptation and validation of a measure of health literacy in
Taiwan: The newest vital sign. Biomedical Journal 41(4):
273-278.
Williams, M.V., Baker, D.W., Honig, E.G., Lee, T.M. & Nowlan,
A. 1998a. Inadequate literacy is a barrier to asthma
knowledge and self-care. CHEST 114(4): 1008-1015.
Williams, M.V., Baker, D.W., Parker, R.M. & Nurss, J.R.
1998b. Relationship of functional health literacy to patients’
knowledge of their chronic disease: A study of patients with
hypertension and diabetes. Archives of Internal Medicine
158(2): 166-172.
World Health Organization. 2017. Shanghai declaration on
promoting health in the 2030 agenda for sustainable
development.
Yilma, T.M., Inthiran, A., Reidpath, D.D. & Orimaye, S.O. 2019.
Context-based interactive health information searching.
Information Research 24(2): 1-22.
Zalma, A.R., Saah, M.Y., Ajau, D. & Khairil Anuar, M.I.
2015. Reliability and validity of television food advertising
questionnaire in Malaysia. Health Promotion International
30(3): 523-530.
Zulkii, N.W., Aziz, N.A., Hassan, Y., Hassali, M.A. & Bahrin,
N.L.Z. 2016. Do current awareness and educational
program towards unregistered drugs eective for public?
Pharmacists’ perceptive. International Journal of Pharmacy
and Pharmaceutical Sciences 8(7): 81-85.

1036
Adina Abdullah, Liew Su May* & Ng Chirk Jenn
Department of Primary Care Medicine
University Malaya Primary Care Research Group (UMPCRG)
Faculty of Medicine
University of Malaya
50603 Kuala Lumpur, Federal Territory
Malaysia
Hani Syahida Salim
Department of Family Medicine
Faculty of Medicine and Health Science
Universiti Putra Malaysia
43400 UPM Serdang, Selangor Darul Ehsan
Malaysia
Karuthan Chinna
School of Medicine
Faculty of Health and Medical Sciences
Taylor’s University, Kuala Lumpur, Federal Territory
Malaysia
*Corresponding author; email: su_mayliew@um.edu.my
Received: 5 April 2019
Accepted: 15 January 2020