Original Research Article 315

LEVEL OF HEALTH LITERACY IN THAI ELDERS,

BANGKOK, THAILAND
Wansiri Nilnate, Sarunya Hengpraprom*, Piya Hanvoravongchai

Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand

ABSTRACT:
Background: Thailand’s population is rapidly aging as a consequence of sustained declines in fertility
and improvement in longevity. In spite of growing attention among Thai health practitioners for
improving health literacy on health outcome across country, information about the status of health
literacy in Thailand remains scarce. The objectives of this study were to assess the level of health literacy
and determine the demographic characteristics associated with health literacy among Thai older persons.
Methods: The health literacy survey was conducted in 440 Thai older persons. The respondents were
randomly selected. Data collection was based on the Thai elder health literacy questionnaire in paper-
assisted personal interviews. The data were analyzed using descriptive statistics and the status of health
literacy were categorized into three levels included functional, interactive, and critical health literacy.
The Chi-square and Fisher’s exact test were used to determine the associations among the factors related
the health literacy.
Results: The Thai elder health literacy questionnaire covered two levels of health literacy: functional,
and interactive level. The 2 in 440 (0.5%) respondents showed interactive health literacy and 438 in 440
(99.5 %) expressed functional health literacy. None of the participants had critical health literacy.
Results indicated that factors significantly associated with health literacy included education
(P-value=0.001), occupational history (P-value=0.020), visibility (P-value=0.003), and reading ability
(P-value=0.049).
Conclusion: The status of health literacy, especially functional level were considered as having the
limited literacy, among Thai older persons represents an important challenge for Thai health policies and
health practitioners across Thailand. Knowledge of health literacy is needed to provide the foundation
for developing strategies to mitigate effects of low health literacy on health outcome. The social gradient
could be taken into account when developing public health strategies to improve health equity.

Keywords: Elderly, Health literacy, Thailand

DOI: 10.14456/jhr.2016.43 Received: November 2015; Accepted: February 2016

INTRODUCTION declines in fertility and improvement in longevity.

Thailand is among the most rapidly ageing The Foundation of Thai Gerontology Research and
countries in the world. In 2031, Thailand will become Development Institute (TGRI) projects that the
a Super Ageing society and by 2050 approximately percentage of Thai youth (aged under 15) and
30% of the population will be seniors with aged of 65 working-age (aged 15-59) population will decline
years and above [1]. By the speed of population continuously from the year 2010 to 2040 and
ageing in the world from 1980-2050, Thailand is the interestingly the percentage of youth will be equal to
6thplace; 8.5% of population aged 65 years and above that of the elderly population in the year 2017 [2].
increased from 1.7 million to 7 million, next to South This demographic change is very serious and urgently
Korea [1]. This would be attributed to sustained required public health policy responses. Quality of
life of the elderly populations is one of the most
* Correspondence to: Sarunya Hengpraprom critical issue.
E-mail: [email protected] In Thailand, the second National Plan for Older

Nilnate W, Hengpraprom S, Hanvoravongchai P. Level of health literacy in Thai elders, Bangkok,

Cite this article as:
Thailand. J Health Res. 2016; 30(5): 315-21. DOI: 10.14456/jhr.2016.43

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Persons (2001-2021) as a framework for long term the members, aged of 60-year-old or greater and
policy intervention in support of quality of life of become one or more than one-year-member, of the
older persons has been implemented. Emphasis was selected clubs were called on to request as the study
laid on health promoting activities through temples participants and assess the health literacy.
and senior’s club. However, those are underachieved This cross-sectional study included 440 Thai
and unsatisfactory, especially in term of health elderly, eligible men and women. Participants were
promotion, long term care, security, and job well functioning since the exclusion criterias
opportunity [2]. These could be as a consequence of included any self reported hearing impairment,
differences in level of health literacy among older speech impairment, difficulty of performing basic
persons [3]. activities of daily life, or disability. Of participants,
Health literacy is the degree to which individuals 61 out of 440 were men and 379 out of 440 were
have the capacity obtain, process, and understand women. The Institutional Review Board (IRB) of
basic health information and services needed to make Faculty of Medicine, Chulalongkorn University
appropriate health decisions. The Institute of (IRB No.141/56), and the Bangkok Metropolitan
Medicine (IOM) divided the domain of health literacy (031/May26, 2014) approved this study.
into 1) cultural and conceptual knowledge, 2) oral
Health literacy assessment
literacy, including speaking and listening skills,
Thai elderly’s health literacy was assessed using
3) print literacy, including writing and reading skills,
a tool constructed by the authors based on Nutbeam’s
and 4) numeracy. A conceptual framework places
health literacy model [7]. The model includes three
literacy as the foundation of health literacy and health
sequential levels of health literacy: functional,
literacy as the active mediator between individuals
interactive, and critical literacy. The three rounds of
and health contexts. Individuals bring specific sets of
Delphi technique among fifteen Thai elderly experts
factors to the health context, including cognitive
were performed to gather and extract the essential
abilities, social skills, emotional state, and physical
contents suitable for Thai elderly in six aspects.
conditions such as visual and auditory acuity.
Those includes: 1) knowledge of health and disease
Literacy provides the skills that enable individuals to
prevention; 2) access to health information; 3) health
understand and communicate health information and
communication; 4) health decision making; 5) self-
concerns. Literacy is defined as a set of reading,
management; and 6) media literacy [7]. In the first
writing, basic mathematics, speech, and speech
Delphi round, the authors conducted individual face-
comprehension skills. Health literacy is the bridge
to-face in-depth interviews with fifteen experts using
between the literacy skills and abilities of the
open-ended questions in six aspects. In the second
individual and the health context [4]. Understanding
Delphi round, the results of the first round were
in the health literacy among the older persons is
analyzed and synthesized in order to create a series
worldwide-increasing interest [5-8]. Inadequate health
of questionnaires. The questionnaires were sent by
literacy is a major public health concern [7-9]. The
post to the fifteen experts. Each question of the
elderly who tend to have inadequate health literacy
questionnaires was ranked by each expert. In the
are at risk for unsuccessful self-care and poor health
third Delphi round, the authors calculated
outcome [9-17]. However, studies related to health
interquartile range (IQR) for each question. The
literacy of Thai elderly remains are limited, thus the
expert consensus on the data set was determined as
objectives of this study were to determine the level of
follows: a narrow IQR meant that there was
health literacy and the demographic characteristics
accordance of expert opinion, and the authors would
associated with health literacy among Thai elderly.
then conclude the findings. On the other hand, a
wide IQR illustrated difference of opinion among
METHODOLOGY
experts that needed to establish another series of
Study population questionnaires by doing the fourth Delphi round.
Study participants were Thai older persons. The substantial contents of each aspect were
The participants were selected from a random assembled and adopted as the tool. The total scores
sample of Thai senior citizen clubs of Bangkok in of this tool were of 74 in 38 items, including six
designated area surrounding three centre subdistricts aspects along with three level measured questions.
of Bangkok: the inner, the middle, and the outer The functional level (sufficient basic skills in
subdistrict. The three senior citizen clubs within reading, writing, and functioning effectively in
designated subdistricts were randomly selected and everyday situations) refers to participants who got

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Table 1 Demographic characteristics and health literacy level

Level of health literacy level (n = 440)

Overall
Demographic characteristics Functional Interactive
(n = 440)
(n = 438) (n = 2)
Age, mean (SD) 68.8 ± 6.0 68.8 ± 6.0 63.5 ± 2.1
Female, % 379 (86.1) 377 (86.1) 2 (100.0)
Male, % 61 (13.9) 61 (13.9) 0
Education, %
< High school 263 (59.8) 263 (60.0) 0
Health status, %
Hypertension 227 (51.6) 225 (51.4) 2 (100.0)
Dyslipidemia 181 (41.1) 180 (41.1) 1 (50.0)
Diabetes mellitus 93 (21.1) 92 (21.0) 1 (50.0)
Caregiver
No 286 (65.0) 283 (64.6) 1 (50.0)
Yes 154 (35.0) 153 (34.9) 1 (50.0)
Visibility
Fair to good 198 (45.0) 197 (45.0) 1 (50.0)
Hearing ability
Fair to good 300 (68.2) 299 (68.3) 1 (50.0)
Speaking ability
Fair to good 385 (87.5) 383 (87.4) 2 (100.0)
Reading ability
Fair to good 268 (60.9) 266 (60.7) 2 (100.0)
Writing ability
Fair to good 249 (56.6) 247 (56.4) 2 (100.0)
*Health literacy level based on the tool score: 9-33 = functional level, 34-61 = interactive level, ≥62 = critical level.
Participants scoring ≤33 are considered to have limited health literacy, none of the participants had critical literacy.

more than 50 percent of the answers correct in the were similar to the study participants, and its validity
functional level questions (scores of 9 to 33). The and reliability were reported as IOC = 0.93, KR20 =
interactive level (actively participating in everyday 0.47 in the first aspect, Cronbach’s alpha coefficient
activities, extracting and deriving information from = 0.88, 0.86, 0.56, 0.93 and 0.84 in the second to the
different forms of communication and applying new sixth aspect respectively [19] (details of a health
information to changing circumstances) refers to literacy tool development are not shown).
participants who scored full mark in the functional Demographic data included age, sex, level of
level questions and got more than 50 percent of the education, history of occupation, adequacy of
answers correct in the interactive level questions income, history of disease (hypertension, diabetes
(scores of 34 to 61). The critical level (critically mellitus), vision ability, hearing ability, speech
analyzing the information and how to use this ability, reading ability and writing ability were
information to exert greater control over life events collected. The association among the demographic
and situations) refers to participants who scored full factors and the limit health literacy were analyzed by
mark in the functional level and interactive level using Chi-square and Fisher’s exact test. The
questions including getting more than 50 percent of probability, p-value < 0.05, was taken as the
the answers correct in the critical level questions minimum level of significance.
(scores higher than 62). Participant’s testing scores
fall in the level of functional literacy were RESULTS
considered to have limited health literacy [18]. This The mean age of the participant was 68.8 (SD =
tool was noted as the first measuring health literacy 6.0) years (range 60-90). 86% of the participants
tool for Thai elderly and has not yet been were female. 59.8% of all participants reported
implemented elsewhere. education level of less than high school, and 85.9%
Although this tool has not yet been correlated reported as facing chronic diseases in the order of
with other standardized health literacy, it was pre- hypertension (51.6%), dyslipidemia (41.1%), and
tested among thirty Thai elderly whose characteristics diabetes mellitus (21.1%) respectively. 35% of the

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Table 2 Demographic characteristics and health status of study participants by limited health literacy level categorized
by gender

Limited health literacy (n = 438)

Demographic characteristics (n, %) Men Women P-value
(n = 61) (n = 377)
Age, mean ± SD 70.2 ± 6.2 68.8 ± 6.0 0.695+
<70, 34 (55.7) 248 (65.8) 0.129
≥70, 27 (44.3) 129 (34.2)
Education
< High school 25 (41.0) 238 (63.1) 0.001
≥ High school 36 (59.0) 139 (36.9)
History of occupation
No occupation 2 (3.3) 52 (13.8) 0.020
Having occupation 59 (96.7) 325 (86.2)
Adequacy of income
No (debt) 7 (11.5) 27 (7.2) 0.298*
Yes (fairly+saving) 54 (88.5) 350 (92.8)
History of disease
No 8 (13.1) 54 (14.3) 0.802
Yes 53 (86.9) 323 (85.7)
- hypertension 36 (59.0) 189 (50.1) 0.198
- dyslipidemia 20 (32.8) 160 (42.4) 0.155
- diabetes mellitus 13 (21.3) 79 (21.0) 0.949
+independent
*Fisher exact test t-test

Table 3 Ability of vision, hearing, speaking, reading, and writing of the study participants by limited health literacy level
categorized by gender

Limited health literacy (n = 438)

P-value
Communication ability (n, %) Men Women
(Chi-square)
(n = 61) (n = 377)
Visibility
Poor 23 (37.7) 218 (57.8)
0.003
Fair to good 38 (62.3) 159 (42.2)
Hearing ability
Poor 18 (29.5) 121 (32.1)
0.687
Fair to good 43 (70.5) 256 (67.9)
Speaking ability
Poor 8 (13.1) 47 (12.5)
0.887
Fair to good 53 (86.9) 330 (87.5)
Reading ability
Poor 17 (27.9) 155 (41.1)
0.049
Fair to good 44 (72.1) 222 (58.9)
Writing ability
Poor 20 (32.8) 171 (45.4)
0.066
Fair to good 41 (67.2) 206 (54.6)

participants were relied on family caregivers. reflected that most participants had limited level of
Approximately more than 55.0% of the participants baseline health literacy (Table 1). Of 438
did self-rated fair to good hearing, speaking, participants, 86.0 % of female participants showed
reading, and writing ability, whereas 55.0% reported the limited level of health literacy.
poor visibility (Table 1). Participants in the limited health literacy were
According to the health literacy level, none of more likely to be female aged less than 70 year-old.
the participants had critical literacy, 2 participants Mean age, adequacy of income, and history of
(0.5%) had interactive literacy, and 438 participants diseases did not differ between male and female
(99.5%) had functional level of literacy. This (p>0.05) (Table 2). Stratified analyses demonstrated

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the effects of education, history of occupation, knowledge and skill are still an open wound of the
visibility, and reading ability on the rate of limited Thai people, especially among the elderly. The 10th
health literacy (Table 2). year (2004-2014) reports of Thai National Statistical
Among high school graduates, women had Office revealed the average years of education
substantially higher rates of less than a high school among Thais aged greater than 60 year-old as 4.7
graduation than men (63.1% for women and 41.0 % years, which are less than those of other age groups
for men) (p<0.01). Of those with less than a high [22] and those in other countries, the elderly(55-64
school education, only 17.6% of women and 4.0% year-old) in US, UK, Japan and Korea had the
of men had not been working (p<0.05). In addition, average years in formal education as 13.2, 12.2, 10.9
women uniformly had higher rates of poor visibility and 9.1 years, respectively [23].
and reading ability than men (p<0.05) (Table 3). Of these, Thai elderly women uniformly had
The 57.8 % of women did self-rated poor visibility lower average years of education than men (4.3
and 41.1% reported poor reading ability, years for old-women, 5.4 years for old-men). These
approximately 2/3 the proportion observed in men evidences apparently support our study showing that
of similar literacy (p<0.05) (Table 3). the educational attainment and the limited health
literacy were strongly related. However, this finding
DISCUSSION was inconsistent with other studies showing that
This study aimed at to measure the level of years of education do not associate to health literacy
health literacy among Thai elderly by categorizing skill [24-26].
into three level; functional, interactive, and critical The association between sex and educational
level. The participants whose health literacy attainment were also observed in these participants
remained in the functional level were considered as with limited health literacy. Thai elderly women
having the limited literacy [7]. In this study, almost showed less educational level and had more
elderly participants showed the limited health confronted with the difficulty of reading than men
literacy and none of them reached the critical while speaking, writing, and hearing ability did not
literacy. The prevalence of limited health literacy in explain by sex difference. Similar results were found
the overall participants was reported as 99.5%. It in a study revealing that female patient with limited
was the first reported prevalence of health literacy health literacy often have difficulty reading or filling
among the elderly in Thailand. Notably, this number out forms needed to obtain health services [27, 28].
was higher than those found in other prevalence Furthermore, in this study, women with limited
studies with participants aged 60 and older. For health literacy had poor visibility than men. These
example, the results of previous studies, the elderly results may suggest that inadequate communication
in Yanbian of China, the state of Pennsylvania, and skills may be a marker for poor-quality education or
New York US, had limited health literacy 31.3%, access to education, especially for minority group
24% and 24.3%, respectively [13, 20, 21]. with limited health literacy, partially resulting in job
This may be explain that; 1) the tool used to disparity. The disparity in access to job hiring was
measure health literacy in this study was not a also observed in this study revealing that women
standard literacy tool, but was constructed by the with limited health literacy and having less
author of which its validity and reliability was high education showed higher rates of no past job
enough to potentially use as a screening measure, 2) experiences than men. Furthermore, the elderly with
there may also be other socioeconomic factors that limited health literacy in the lower reading ability
did not consider for in this study, therefore the were at greatest risk for the disparity in health status
contamination effects to the measure of participant’s since effective management of chronic health
health literacy were not controlled, and 3) the elderly problems requires a level of understanding of
participants were selected from the elderly club physicians and medication instructions and
solely in Bangkok, even though their baseline appropriate access and close follow-up care [29].
characteristics presumably did not different, the These were consistent with the studies of Bostock
reported health literacy herein may not be and Steptoe [14] who found that a third of older
generalized to the whole elderly in the entire adults in England had difficulties reading and
country. Remarkably, these findings were not understanding basic health related written
surprising to us. In the country baseline of information, and higher health literacy was
educational attainment, the issues of inadequate associated with lower mortality.

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In addition, in this study many chronic illnesses toward the elderly, and preparation for old age in the
were not associated with sex and limited health health, economic, and social aspects to mitigate
literacy. This may be subjected to the sufficient negative impacts in retirement, 2) Improvement of
regular doctors or place of care. Given these, the long term care system for the elderly in the health,
elderly might be more likely to find interactions with economic, and social dimensions to lengthen the
their primary care physicians and to access the period of co-existence with the family and
preventive services and medication consistently. community, and 3) Empowerment and capacity
Therefore, having access to primary care services building for the elderly clubs and older person
for older people with limited health literacy may assembly to be a voice for the elderly.
mitigate the disparity in poor health outcome [8].
Older persons with limited health literacy have STRENGTHS AND LIMITATIONS
commonly encountered with chronic medical To our knowledge this is the first measuring
conditions, including hypertension, dyslipidemia, health literacy in Thai elderly by using a tool
diabetes mellitus, depression, obesity and so on. In constructed by the authors based on Nutbeam’s
addition, the elderly tend to suffer from greater health literacy model. This study has some
chances of chronic health conditions and physical limitations. First, the data collection might cause
disability due to their improved life expectancy [2, bias from interview and recall bias. In addition, the
3]. They seem to have a greater need for complex cross-sectional study design does not allow us to
disease management and require a lot of money for establish causal relationships between health
their expenditure. Remarkably, the study results literacy, demographic characteristics, and health
also showed that the elderly with limited health status. Additionally, assessment of vision, hearing,
literacy had sufficient money for each month speaking, reading, and writing abilities of these
although most of them were retired and had no participants just only used an interview, not
current job. This was subjected to the financial particular measurement. Thus, the results of these
support policy for Thai elderly such as formal abilities might be overestimated.
retirement benefits or social security support.
Additionally, their financial supports were also CONFLICT OF INTEREST
come from gainful employment and transfer The authors have no conflict of interest.
payments from family members.

ACKNOWLEDGEMENTS
CONCLUSION
The authors thank all our participants from the
In summary, limited health literacy is prevalent
senior citizen clubs of Bangkok, Thailand. This
in common Thai elderly. With sex difference, it is
study was supported by the Ratchadapiseksompotch
associated educational attainment, having past job,
Fund, Faculty of Medicine, Chulalongkorn
poor reading ability, and poor visibility, and
University, grant number RA57/033 and CU.
therefore, women elderly with limited health literacy
GRADUATE SCHOOL THESIS GRANT, Graduate
may be at greater risk for worse communication as a
consequence of worse clinical outcomes. Health School, Chulalongkorn University.
literacy may apparently be a better measure than
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