Health Literacy Among Urban Malaysian Elders: A Descriptive Study

Abstract

Background: Ample evidence shows that health literacy (HL) has a huge impact on health. However, little is known about HL among older adults in low-and middle-income regions, including Malaysia. This study aims to measure the prevalence of HL among urban elders, and describe its level based on different areas and dimensions.

Methods: This was a cross-sectional study, employing descriptive analyses. Conducted in Seksyen 24 of Shah Alam city, 206 older adults were randomly selected though a multi-stage sampling strategy. The Health Literacy Short-Form (HL-SF12) questionnaire was used to assess literacy in three areas (healthcare, disease prevention and health promotion) and four dimensions (finding information, understanding information, judging information and applying information). Analyses were run by SPSS 25.0 for Windows.

Results: More than half respondents (62.6%) had low HL. Older males had higher HL scores than females, and HL declined with increasing age. There was no significant difference in scores between the three HL areas; healthcare, disease prevention and health promotion between the two sex groups. However, across the four HL dimensions, finding health-related information was reported as the most difficult task.

Discussion: Health programs and interventions need to take into account older adults' preferences and behavior in accessing information. Difficulty in finding information can be attributed to older adults' familiarity with traditional channels as opposed to the current trends of using information technology and movement towards digitalization.

Full text

*Corresponding author’s e-mail: raudah.yunus@gmail.com
ASM Sc. J., 13, Special Issue 5, 2020 for APRU2018, 7-12
Health Literacy Among Urban Malaysian Elders:
A Descriptive Study
Raudah M. Yunus1∗, Mohd S.A. Saman1, Aishah Zubillah2, Kerry B. Juni2, Ahmad S.A. Gaairibi2, Alyani N.
Yahaya2, Ameera Zolkaflee2, Amnie F.A. Suhairi2, Dayang F.A.A. Bolhasan2, Falin A. Lesen2, Janet N. Philip2,
Khairatun H.M. Amjaduzzahwi2, Khairunnisa A.M. Fadir2, Lina K.M. Jamal2, Nurin N. Persori2, Qamarina
Z.D.K. Anuar2, Randee E. Stephen2, Sharina Jamaludin2, Suhairy Osman2, Nurhuda Ismail1 and Zaliha
Ismail1,3
1Department of Public Health Medicine, Faculty of Medicine, Universiti Teknologi MARA, Sungai
Buloh Campus, Malaysia
2Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh Campus, Malaysia
3Institute for Pathology, Laboratory and Forensic Medicine (I-PPerForM), Faculty of Medicine,
Universiti Teknologi MARA, Malaysia
Background: Ample evidence shows that health literacy (HL) has a huge impact on health. However,
little is known about HL among older adults in low- and middle-income regions, including Malaysia.
This study aims to measure the prevalence of HL among urban elders, and describe its level based
on different areas and dimensions. Methods: This was a cross-sectional study, employing descriptive
analyses. Conducted in Seksyen 24 of Shah Alam city, 206 older adults were randomly selected
though a multi-stage sampling strategy. The Health Literacy Short -Form (HL-SF12) questionnaire
was used to assess literacy in three areas (healthcare, disease prevention and health promotion) and
four dimensions (finding information, understanding information, judging information and
applying information). Analyses were run by SPSS 25.0 for Windows. Results: More than half
respondents (62.6%) had low HL. Older males had higher HL scores than females, and HL declined
with increasing age. There was no significant difference in scores between the three HL areas;
healthcare, disease prevention and health promotion between the two sex groups. However, across
the four HL dimensions, finding health-related information was reported as the most difficult task.
Discussion: Health programs and interventions need to take into account older adults’ preferences
and behavior in accessing information. Difficulty in finding information can be attributed to older
adults’ familiarity with traditional channels as opposed to the current trends of using information
technology and movement towards digitalization.
Keywords:
Health literacy; older adults; urban elders; descriptive study
I.
INTR
ODUCTION
The World Health Organization (WHO) defines health
literacy (HL) as “the cognitive and social skills which
determine the motivation and ability of individuals to
understand and use information in ways which can promote
and maintain good health” (WHO, 2017). HL also refers to
“the degree to which individuals have the capacity to obtain,
process, and understand basic health information and
services needed to make appropriate health decisions”
(Ratzan and Parker, 2000). As HL requires literacy skills
(reading and writing) and the ability to understand and
utilise health-related information in multiple contexts
(Nutbeam, 2015), it can be a challenge to the aged and to
those with limited formal education.
In line with universal trends, the older population in
Malaysia is rapidly increasing. In the next one or two
decades, Malaysia is projected to become an aged nation

ASM Science Journal, Volume 13, Special Issue 5, 2020 for APRU2018
8
(Ramely et al., 2016). Current social security systems and
health services are largely unprepared to accommodate for
this demographic transition. As the risks of chronic diseases
and morbidities increase with age, older adults are, and will
continue to be the major consumers of healthcare and thus
account for the largest portion of healthcare expenses.
Despite all these, little is known about the degree of literacy
among Malaysian elders in navigating health information
and services.
Ample evidence points to the influence of HL on health
status and outcomes. For instance, studies showed that older
adults with lower HL had greater prevalence of certain types
of chronic diseases (Berkman et al, 2011; Froze et al., 2018).
HL was also reported to affect chronic disease management;
those with lower HL showed less compliance with
medication and follow-up visits (Diemer et al., 2017).
Similarly, low HL was associated with higher frequencies of
hospitalizations and visits to emergency care, and higher
medical costs (Diemer et al., 2017, Haun et al, 2015).
Given the well-established link between HL and various
health-related outcomes – with a background of rapid aging
in Malaysia – our study aims to: 1) measure the prevalence
of HL among older adults, and; 2) describe the level of HL
according to its different areas and dimensions.
II.
MATERIALS AND METHOD
This study employed a cross-sectional design, and was
conducted in Seksyen 24, Shah Alam city. Shah Alam is the
state capital of Selangor, with a population of approximately
750,000 people. There are altogether 56 sections (Seksyen)
in Shah Alam. Seksyen 24 was chosen as the study site
following a series of discussions with the local council; this
section was said to have the highest proportion of older adults
compared to other sections in the city.
A total of 206 older adults were selected through a multi-
stage sampling strategy. First, Seksyen 24 was divided into
five residential neighbourhoods, from which four were
randomly selected. In these four neighbourhoods, houses
were then selected using a systematic random sampling
method, to achieve the required sample size. This was
followed by a house-to-house visit for data collection, which
took place between March and April 2019.
Inclusion criteria were: a) Malaysian citizen; b) resident
aged 60 years or more; c) those who have been residing in
Seksyen 24, Shah Alam for a minimum period of six months,
and; d) those who are able to read and communicate
independently either in English or Malay. We excluded
individuals with cognitive impairment or inability to
communicate due to severe hearing impairment or any other
health conditions, and those with a medical or health-related
professional background.
Health Literacy was measured using the ‘Health Literacy
Short-Form 12 (HL-SF12) Questionnaire’, derived from the
Health Literacy Survey – European Health Literacy
Questionnaire (HLS-EU-Q47). This questionnaire has been
previously validated in several Asian countries including
Malaysia (Duong et al., 2017). The items of HL-SF12 aim to
assess three areas of HL: healthcare, disease prevention and
health promotion. On the other hand, it measures four
dimensions of HL: 1) finding information on health,
represented by the first question in each area; 2)
understanding information on health, represented by the
second question in each area; 3) judging information on
health, represented by the third question in each area, and; 4)
applying information on health, represented by the last
question in each area.
Answers are based on a four-point Likert scale that
determines the level of difficulty in performing each item: 1=
very difficult, 2 = difficult, 3 = easy and 4 = very easy. The
score of all three areas form a General Health Literacy Index
(GEN-HL Index) which range from 0 to 50. The GEN-HL
index score is categorized into: Inadequate (0-24),
problematic (25-33), sufficient (34-42), and excellent (43-50).
Finally, we collapsed the first two categories into ‘low HL’ and
the last two categories into ‘good HL’.
Face-to-face interviews were conducted by Year 4 students
of Universiti Teknologi MARA Faculty of Medicine. The
students went through a series of briefings and trainings prior
to data collection, in order to ensure that questions were
asked in a standard manner, difficulties could be handled,
and older adults’ autonomy and rights were respected.
Data was entered the statistical software using a double-
entry method and analysed using SPSS 25.0 for Windows.
Descriptive statistics were employed; means and standard
deviations were reported for continuous variables, while
frequencies and percentages were reported for categorical
variables. Correlations between two continuous variables
were tested using Pearson’s correlation coefficient, and
associations between two categorical variables were
measured using Chi-squared tests. Statistical significance
was set at 0.05. Ethical approval for this study was granted by
the Universiti Teknologi MARA ethical board.

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III.
RESULT
Males and the younger older adults (60-69) comprised more
than half of study respondents, 51.5% and 75.7% respectively.
The mean respondent age was 66.6 + 5.5 and average GEN-
HL index score was 30.6 + 10.0. Table 1 shows the basic
characteristics of older adults in Seksyen 24, Shah Alam who
participated in this study.
Table 1. Basic characteristics of study respondents (n=206)
Based on the HL-SF12 scores, males on the average had
higher HL than their female counterparts; 32.6 + 8.8 vs. 28.5
+ 10.8. This difference was statistically significant (p<0.01).
HL also corresponded with age – scores decreased as age
increased (r=0.30, p<0.01). Most respondents had
inadequate and problematic HL with 27.7% and 35.0%
respectively. Figure 1 illustrates the distribution of GEN-HL
index scores according to its four categories. Overall, the
prevalence of low HL was 62.6%, and high HL, 37.4%.
When comparing the three areas of HL, average scores did
not differ much. Respondents scores 11.2 + 3.1 for Area 1
(healthcare), 11.2 + 2.5 for Area 2 (disease prevention) and
11.7 + 2.7 for Area 3 (health promotion). However, sub-
analyses revealed that males scored significantly higher than
females in all areas. Table 2 shows the scores of the three HL
areas according to sex group.
Figure 1. Categories of HL (%) among older adults in
Seksyen 24, Shah Alam
Table 2. Scores of HL areas comparing males and females
A similar trend was seen across the four dimensions of HL,
where females scored significantly lower than males except in
one dimension – finding information – in which there was no
score difference between the two groups. Overall,
respondents scored highest in Dimension 2 (understanding
information) and lowest in Dimension 1 (finding
information). In other words, older adults felt it was easy to
understand health information, but difficult to find it. Figure
2 illustrates the scores of each HL dimension among our
study respondents.
Figure 2. Mean scores of study respondents according to the
four HL dimensions

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10
IV.
DISCUSSION
This study aimed to measure the prevalence of HL among
older adults in Shah Alam and describe respondents’ scores
according to HL areas and dimensions. Overall, most older
adults (62.6%) had low HL. The National Health and
Morbidity Survey (NHMS) in 2015 reported that only 6.6% of
Malaysian adults had adequate HL (IKU, 2015). Another
smaller-scale study in Pahang found 50.0% of its adult
respondents having inadequate or low HL (Norrafizah et al.,
2016). The discrepancies in proportion between our findings
and these two studies are most likely due to the differences in
age group and tools employed. However, all point to a similar
trend, that a large percentage or at least half of Malaysian
adults or older adults have low HL.
Our findings are corroborated by surveys among elders in
other countries. For instance, in a study by Smith et al.,
approximately half of American elders had low or inadequate
HL (Smith et al., 2015). Similarly, almost half of Thai older
adults were reported to demonstrate inadequate HL in
another survey (Wannasirikul et al, 2016). Nevertheless,
ultimate comparison is difficult owing to the heterogeneity in
socio-cultural contexts and study methods, namely the
different tools used in assessing HL. One example is that a
number of studies – including the NHMS – utilized the
Newest Vital Sign (NVS) to measure HL while our study used
HL-SF12.
In this study, results showed that HL declined with age, and
that males scored higher than females consistently across all
areas and dimensions of HL. The evidence on the link
between HL and age is well-established and can be explained
in a number of ways. First, getting old is associated with
decline in cognitive ability which affects older adults’ capacity
to understand or recall new topics (Cornett, 2006). Physical
impairments such as hearing and vision loss further pose a
challenge to elders in processing health information (Speros,
2009). In addition, the gap in physical and cognitive ability
between the younger and older generations may cause
embarrassment among elders, limiting effective
communication and affecting health literacy (Speros, 2009).
A few studies reported higher HL among women than men,
but the reason for this has been unclear (Baker et al, 2000,
Lee et al., 2015, Wagner et al, 2007, Clouston et al., 2017). On
the contrary, our findings showed higher scores in men across
all HL areas and dimensions. This can be due to age and
education factors; our female respondents on the average
were older and had lower education than their male
counterparts (data not shown). Age and education have been
consistently shown to affect health literacy (Erdei et al, 2018;
Bodur et al., 2017, Cornett, 2006). Further explanation for
possible gender differences in HL can be a subject of future
research.
Across the four dimensions of HL, the most difficult task for
older adults was finding information. This was surprising, as
older adults were expected to have greater difficulty in
understanding and judging, rather than obtaining relevant
information. Two important points are worth highlighting
here. First, there is a need to understand older adults’
behaviour and preferences in seeking health-related
information, and that current efforts in disseminating health
information may have overlooked this group’s nature and
capacity. Second, the type of intervention to improve HL
among older adults should perhaps focus on making access to
health information more age-friendly.
In a survey that ranked older adults’ trusted sources of
health information, Chaudhuri et al found that most elders
preferred a person with whom they can actively discuss,
compared to a non-living source. Health care providers came
first in their list of preference, and the internet, TV and radio
came last (Chaudhuri et al, 2013). This is in contrast with
current movements in digitalizing information and
minimizing physical contact with the aim of increasing
efficiency and saving time. Today’s trends of excessive
reliance on the internet perhaps suits the younger generation,
while creating more difficulties for older adults to obtain
health-related information. Such dilemma should be
considered in the designation of health programs and
interventions for older adults.
Our study has several limitations. First, most of our
respondents were Malay. Little representation by other
ethnic groups may affect generalizability of results. Second,
we excluded those with cognitive impairment. However,
cognitive capacity was not assessed by objective
measurements or validated scales. Each interviewer made an
independent judgment based on their communication with
respondents and reports from family members or caregivers.
Third, there were few proxy respondents who helped older
adults during the interview due to minor communication
issues. However, the number was small and unlikely to cause
substantial bias to the results.

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V. CONCLUSION
This study found a high prevalence of low HL among urban
elders in Malaysia. Males had higher HL scores than females,
and HL decreased with age. The most difficult task across the
four HL dimensions was finding information, and this was
consistent in both sex groups. As existing evidence has
documented the impact of HL on health outcomes, health
policies and programs targeting this group need to take
several factors into consideration, such as possible gender
differences in HL and difficulty to obtain information which
may be a result of today’s excessive reliance on information
technology.
VI. ACKNOWLEDGEMENTS
The authors would like to thank all Year 4 (Rotation 4) UiTM
medical students, and all lecturers and staff of Department of
Public Health Medicine for their assistance, cooperation and
continuous support throughout this research project.
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