Assessing Health Literacy on Student using online HLS-EU-16

Abstract

Introduction: Health literacy is new term in Indonesia but it has become a health determinant in the world. Health education institutions, such as the Faculty of Health Sciences yields graduates who eventually became a health provider. Assessment of health literacy on students is very important because they come from different high schools, different regions, who have different social backgrounds, cultures and access to information and health services. Methods: This was cross sectional study, used online questionnaire. The study population was first semester 285 students at Faculty of Health Sciences of Dian Nuswantoro University, until the end of the study period, 69 students filled out the online questionnaire form. The questionnaire of health literacy consisted of HLS-EU-16 (Health Literacy Survey-Europe-16 Questions), eHEALS (eHealth Literacy Scale) and NVS (The Newest Vital Sign). Results: Low health literacy problems were happened on 31.9% of respondents. Factors associated with health literacy on student were age, frequency of access to health information through TV and radio, access to health information through the internet and mobile phones, eHEALS, functional health information / NVS. Respondents who had good health literacy tended to use health services actively and more likely to ask questions during a consultation with a doctor. Health literacy correlated with general health conditions.

Full text

International Seminar on Public Health and Education
23rd April 2015; ISBN 978-602-14215-8-1
Assessing Health Literacy on Student using online HLS-EU-16
Nurjanah1, Enny Rachmani1,2, Yusthin M. Manglapy1
1Public Health Program, Faculty of Health Sciences, Dian Nuswantoro University, Indonesia
2Graduate Institute of Biomedical Informatics, Taipei Medical University, Taiwan,. ROC
*Corresponding author: nurjanah@dsn.dinus.ac.id
Abstract
Introduction: Health literacy is new term in Indonesia but it has become a health determinant in
the world. Health education institutions, such as the Faculty of Health Sciences yields graduates
who eventually became a health provider. Assessment of health literacy on students is very
important because they come from different high schools, different regions, who have different
social backgrounds, cultures and access to information and health services.
Methods: This was cross sectional study, used online questionnaire. The study population was
first semester 285 students at Faculty of Health Sciences of Dian Nuswantoro University, until the
end of the study period, 69 students filled out the online questionnaire form. The questionnaire of
health literacy consisted of HLS-EU-16 (Health Literacy Survey-Europe-16 Questions), eHEALS
(eHealth Literacy Scale) and NVS (The Newest Vital Sign).
Results: Low health literacy problems were happened on 31.9% of respondents. Factors
associated with health literacy on student were age, frequency of access to health information
through TV and radio, access to health information through the internet and mobile phones,
eHEALS, functional health information / NVS. Respondents who had good health literacy tended to
use health services actively and more likely to ask questions during a consultation with a doctor.
Health literacy correlated with general health conditions.
Keywords: Health literacy, eHEALS, NVS, students
Introduction
Health literacy is defined as Health literacy represents the cognitive and social skills
determine the motivation and ability of individuals to gain access, understand and use information
in ways which promote and maintain good health. (Nutbeam, 2000; Kickbusch e Maag, 2008;
Nutbeam, 2008). However, health literacy is not well-known in Indonesia. In 2013-2014,
researchers have conducted a survey of health literacy in Semarang which is the first health
literacy research in Indonesia, with 1029 respondents, which became part of a comparative study
of health literacy Asia. Results were very poor, ie 65% of respondents are at a low level of health
literacy (inadequate and problematic). The study also measures of health literacy in three
dimensions, namely health care, disease prevention and health promotion. The results were not
much different from the general health literacy measurement, which 56.4% of respondents have
low health care health literacy, 60.6% low disease prevention health literacy and 58.3% low in
health promotion health literacy (published in the 2nd Conference on Health Literacy in Taipei 6-10
October 2014).

Health education institutions, such as the Faculty of Health Sciences yields graduates who
eventually became a health provider. Health literacy assessment at the beginning of a higher level
of health education is very important because students from different high schools, different
regions, have a wide range of social background, culture and access to information and health
services. Based on the results of health literacy assessment on first-semester-students, the study
program can improve the learning process, curriculum, so graduation students will have a high
level of health literacy so that they can become qualified health provider to increase health status
of the community.
A study among Greece Student in 2013 showed thet economic factors, such as family
income, demographic factors, such as gender, and health behaviours and risks, namely
consumption of alcohol, smoking and physical workout were associated with the level of health
literacy and health status of the participant (Vozikis et al, 2014).
This study aims to assess health literacy level health on first semester-students of Faculty
of Health Sciences Dian Nuswantoro University Semarang
Methods
Studies of health literacy was a survey with cross-sectional approach to describe health
literacy level on first semester students aged over 15 years with different of socio-demographic dan
economic status.
Research subjects were the first semester students at the Faculty of Health Sciences Dian
Nuswantoro University. The number of population was 285 students. All research subjects was
expected to be respondents for online survey with google form and announced through Student
Information System and SMS to all students of 2014 intake. However, until January 23, 2015 the
number of students who responded and filled out online questionnaire were 69 students.
This study used a questionnaire from the EU with short 16 questions (HLS-EU-16)
(Sorenson, et all). Questionnaire translation been done by the team of Faculty of Health Sciences
Dian Nuswantoro University (Nurjanah and Enny Rachmani) collaborated with Taipei Medical
University team in 2013.
Data were collected through an online survey to google form that sent to student email
account (xxx@mhs.dinus.ac.id). This survey was voluntary. Invitation to the survey also
announced on Students Information System, when students log-in students could see the
announcement and expected to open their email. All questions about health literacy and eHEALS
were required to be answered. Responses were analyzed by researchers. Students who filled out
the form completely got Rp 10,000 handphone credit.
Health literacy levels were measured by Likert scale 1-4. The answers were scored by
choosing the answers which higher value indicated the level of health literacy was better (1 = very
difficult), (2 = moderately difficult), (3 = fairly easy), (4 = very easy). Questionnaire of health literacy
consist of 16 questions. It was different from HLS-EU-47, in HLS-EU-16 the answer is the

dichotomous categorization, which is “very difficult” and “moderate difficult” answers were 0 score
and the “fairly easy” and “very easiy” were 1 score. All score were summarised, so the minimum
score was 0 and the maximum score was 16. The scores are categorized as follows: Inadequate
HL (0-8), Problematic HL (9-12), Sufficient HL (13-16).
Furthermore, health literacy scores would be associated with other factors such as age,
social status, attending to health courses, information access, EHEALS and functional health
literacy (NVS). Functional health literacy was measured by asking six questions related to food
nutritional fact label. Scoring ratings ranged from 0-6 points, which can be grouped into limited
literacy level (0-2), possibility of limited literacy (3-4), and adequate ( 5-6). Data were analyzed by
SPSS version 14. Range Spearman test were used to analyze relationship between variables.
Results and Discussions
The online survey was not easy to be conducted. Student had no good motivation to give
responses. The response rate was only 24.2% online. Researcher could not obligate students to fill
the questionnaire because based on experience in faculty performance evaluation survey, that was
obligated, the student will fill in a hurry and it would not be valid, so researchers decided to keep
asking students to fill it by volunteer.
Respondents were students who entered in 2014, with a minimum age of 16 years and
maximum 37 years, most of them in the group of 18 to 24.9 years (82.6%). All the students had
attended a course health, because at the beginning of the course they get a first-aid course and in
the 1st half they get biomedical subjects.
Respondents also often get health information from radio and television (43.5%) and
respondents who answered sometimes as much as 42.0%. However, the majority of respondents
(40.6%) never get health information from the Internet and mobile phones. It was surprising,
because they use gadgets and get the gadget with internet connection in the 1st half but they did
not use it for accessing health information.
Table 1. Description of demography, access to information, e-HEALS, Functional health
literacy, Health Literacy, Health Status
Variable Category f %
Age
(
year
)
<18
3
4.
3
18
-
24.9
57
82
.
6
25
-
29.9
64
5.
8
≥30 5 7.2
Attending health
course Never 0 0.0
Rarely 10 14.5
Sometimes
44
63.
8
Often
15
21.
7
Access health
information from
television and
radio
Never 0 0.0
Rarely 10 14.5
Sometimes 29 42.0
Often
30
43.
5

Variab
le
Category
f
%
Access health
information from
internet &
handphone
Never 28 40.6
Rarely 18 26.1
Sometimes 19 27.5
Often 4 5.8
General health
status
Very poor
0
0.
0
Poor 1 1.4
Moderate 17 24.6
Good 47 68.1
Very good 4 5.8
Functional Health
Literacy / New Vital
Sign (NVS)
Not answer
21
30
.
4
Limited literacy
25
36.
2
Possibility of limited
literacy 15 21.7
Adequate literacy 8 11.6
Health literacy
category
Inadequate
4
5.
8
Problematic
18
26
.
1
Sufficient 47 68.1
Health literacy was measured using a questionnaire of health literacy-Europe-16. This
questionnaire is quite short compared with the original questionnaire totaling 47 questions. Most of
respondents had a good level of health literacy (68.1%). However, there were still 31.9% of
respondents who had low (problematic and inadequate) health literacy levels. This needs serious
attention because of health literacy is a person's ability to access, understand and implement
health information that is known or unknown health literacy is a basic skill needed someone to
make decisions that will have an effect in improving the quality of health (Berkman et al ND.,
2011). A health professional should have good health literacy so that the condition of the health
literacy of the majority of students were still supposed to get attention and intervention, either
through the curriculum, and non-curriculum, for example by making health information more
accessible.
FGD results on January 12, 2015 regarding this condition resulted in the recommendation
that health information should be delivered more frequently, either through existing student
organizations such as “Rumah Sahabat” (for reproductive health) and the Tobacco Free
Community (for tobacco control), as well as by providing access to vary media that exist on
campus. High student health literacy level will provide the ability for students to choose a healthy
lifestyle, prevention of a disease and the search for information to find out the proper medical care
for an illness. According to the American Medical Association, the level of health literacy are less
known stronger influence on a person's health status than age, income, employment status and
ethnicity (Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs of the American
Medical Association, 1999).
Statistical tests on factors related to health literacy can be seen in Table 2.
Age was related to health literacy (p-value: 0.0001, rho 0.465). The older the person, they had
better health literacy scores. Attending health course was not related to health literacy. This was

because all the students had to follow a course of health in the first semester. However, it needs to
be considered the intensity of health training, especially related current health issues.
Intensity accessing health information through TV and radio was related to health literacy
(p-value 0.0001, rho 0.460) as well as internet and mobile phone (p-value 0.0001, rho 0.576).
Strength relationships and access to information via the internet and heandphone was stonger
than TV and radio. These results provide evidence of the importance of motivating students to
access health information on the Internet. Student has to be provided list of websites that are
worthy of reference and provided faculty website which become reference material trustworthy
health information. Nowdays, All information is widely available on the internet but the student's
ability to choose which useful and correct information is very important.
Health literacy was associated with eHEALS (p-value 0.0001, rho 0.468). The eHEALS
defined as the skills needed to obtain health information effectively through information technology.
EHEALS capabilities include the ability to find useful health information on internet, using the
Internet to answer questions about health, evaluate health information found on the internet, find
quality health information, and use information from the internet to make decisions about health.
Health literacy was also related to the respondent's ability to understand the functional
health (using indicators The Newest Vital Sign). In the form of research questionnaire indicated
nutrition information of a food product, then the respondents were asked to answer questions
related to the information. 30.4% of respondents could not answer and 34.2% answer wrong. This
could indicate low ability students understand health information on food packaging. From the
results of statistical tests, functional health information (NVS) associated with health literacy (p-
value: 0.048, rho: 0.239).
Table 2. Correlation between demography, access to information, e-HEALS, Functional
health literacy, Health Literacy, Health Status
Variable p-value Rho
Age 0,0001 0,465**
Attending health course
0,326 0,120
Access health information
from television and radio 0,0001 0,460**
Access health information
from internet &
handphone
0,0001 0,576**
Functional health literacy/
New Vital Sign (NVS) 0,040 0,248*
eHEALS 0,0001 0,468**
Visit to doctor in 12
months 0,019 0,282*
Asking questions with
doctor visit 0,001 0,376**
Self assess health status 0,048 0,239*
Social status 0,039 0,249*

Respondents who have good health literacy tend to be more active use of health services
such as doctors (p-value 0.019, rho 0.282) and were more likely to ask questions during a
consultation with a doctor (p-value 0.001, rho 0.376). With good communication between patient
and doctor, the communication quality will be better so the clarity of information will help patient
healing and health.
Health literacy was associated with health and social status. Although subjective health
assessment conducted by self assess, but statistics result showed that health literacy related to
general health conditions (p-value 0.048, rho 0.239). Students who have a high level of health
literacy, tend to have higher levels of health.
Closing
Low health literacy problems were happened on 31.9% of respondents. Factors associated
with health literacy on student were age, frequency of access to health information through TV and
radio, access to health information through the internet and mobile phones, eHEALS, functional
health information / NVS. Respondents who had good health literacy tended to use health services
actively and more likely to ask questions during a consultation with a doctor. Health literacy
correlated with general health conditions.
Authors suggest improving health literacy of students by increasing providing better access
to health information by posters, leaflets, websites about health issues. Faculty should conduct
discussions, public lectures on the latest health issues and motivate students to access health
information.
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