JMIR Publications

ABSTRACT

Background:

Previous studies revealed that functional health literacy played a less important role than communicative and critical health literacy, and communicative and critical health literacy contributed more to better patient self-management. Although improving health literacy has been identified as an approach to fostering community involvement and empowerment, critical health literacy may be regarded as the neglected domain of health literacy, rarely achieving any focus or interventions that claim to be working towards this outcome. In this state of research, close scholarly attention needs to be paid to CHL and associated factors.

Objective:

This study aimed to assess critical health literacy and identify significant factors closely associated with the status of critical health literacy among Chinese patients, to provide some implications for clinical practice, health education, medical research, and public health policy-making.

Methods:

We designed a 4-section survey questionnaire information including (1) age, gender, and education; (2) self-reported disease knowledge; (3) 3 validated health literacy assessment instruments (ie, All Aspects of Health Literacy Scale (AAHLS), the eHealth Literacy Scale (eHEALS), and the General Health Numeracy Test (GHNT-6)); and (4) the Multidimensional Health Locus of Control (MHLC) Scales (MHLC) Form A. We hypothesized that the participants’ CHL status could be closely associated with other information solicited via the questionnaire. The study participants were recruited from Qilu Hospital Affiliated to Shandong University, China, using randomized sampling, following the inclusion criteria of (1) age of 18 years or older, (2) Year 6 or higher educational attainment to understand the questionnaire items, and (3) voluntary participation in the survey. We then administered the questionnaire via wenjuanxing between July 20, 2022, and August 19, 2022. After double checking the validity of the returned questionnaires, we coded valid data using the predefined coding schemes based on Likert scales with varying score ranges for different questionnaire items. Finally, we used latent class modelling to classify the patient participants into different clusters according to their CHL status, and identified factors potentially associated with different CHL levels among Chinese patients.

Results:

All data in the 588 returned questionnaires were valid. The patients had a mean age of 39.20 (SD=11.59) years. 62% (n=366) of them were women. The mean score for education was 3.68 (SD=1.45), showing that their average educational level was between Year 12 schooling and junior college. They assessed the status of their disease knowledge as between ‘knowing a lot’ and ‘knowing some,’ with a mean score of 2.53 (SD=0.90). The mean scores of the functional and communicative items in the AAHLS were as follows: 2.09 (SD=0.71), 3.04 (SD=0.90), and 2.15 (SD=0.73) for the 3 functional health literacy items; 1.61 (SD=0.72), 1.80 (SD=0.72), and 1.79 (SD=0.73) for the 3 communicative health literacy items. These mean scores indicate that they ‘sometimes’ needed help to read and comprehend health information and complete official documents, but were ‘rarely’ able to identify and secure others’ help. The average score of the 8 items on the eHEALS was around 3, with SD around 1.10, indicating their uncertainty about their skills to use eHealth resources and interventions. The mean score for each item on the GHNT scale was 1.58 (SD=0.49), 1.25 (SD=0.43), 1.29 (SD=0.46), 1.89 (SD=0.31), 1.77 (SD=0.42), and 1.68 (SD=0.47), respectively, showing that a large proportion of participants answered the 6 questions on the GHNT scale wrongly, especially Questions 1, 4, 5, and 6. As with their scoring performance on the Multidimensional Health Locus of Control (MHLC) Scales (MHLC) Form A, they averagely scored 21.15 (SD=5.65), 16.23 (SD=4.48), and 19.74 (SD=4.50) on the ‘Internal,’ ‘Chance,’ and ‘Powerful Others’ subscales, respectively. The average score determined between responses of ‘slightly disagree’ and ‘slightly agree’ for the ‘Internal’ subscale indicates that they were not sure of their internal drivers to maintain healthy. The average score determined between responses of ‘moderately disagree’ and ‘slightly disagree’ for the ‘Chance’ subscale implies that they were generally less likely to attribute their health to a matter of luck. The average score determined between responses of ‘moderately disagree’ and ‘slightly disagree’ for the ‘Powerful Others’ subscale means that they were generally uncertain about the role of others in the maintenance of their own health. Based on these collected data, we classified the patient participants into 3 latent classes of critical health literacy (i.e., limited, moderate, and adequate) and identified 4 factors associated with limited critical health literacy, including (1) middle and old age, (2) the male gender, (3) lower educational attainment, and (4) low internal drive to maintain one’s own health.

Conclusions:

Using latent class modelling, we identified 3 classes of critical health literacy (i.e., limited, moderate, and adequate) among the Chinese study participants and 4 factors associated with limited critical health literacy. These literacy classes and predicting factors ascertained in this study can provide some implications for clinical practice, health education, medical research, and health policy-making.