KnE Life Sciences | The 3rd International Meeting of Public Health and the 1st Young Scholar Symposium on Public Health | pages: 8–16


1. Introduction

Health literacy is a critical component to assure healthy behavior which is determinant of health and quality of life. In many studies, health literacy significantly affects self-reported health [1,2]. Health literacy represents the cognitive and social skills determining the motivation and ability of individuals to gain access, understand and use information in ways which promote and maintain good health [3]. More recently definitions have been expanded to include the cognitive and social skills which determine the motivation and ability of individuals to access, understand, appraise and apply health information in order to make judgements and take decisions in everyday life concerning health care, disease prevention and health promotion to maintain or improve quality of life during the life course [2].

Health literacy is a very important skill to navigate people doing health behavior and achieving good quality of life. Health literate people were more likely to get sufficient health information from multiple sources, less likely to have risky habits of smoking, regular drinking, and lack of exercise, and in turn, more likely to report good self-rated health [4]. On the other hand, health literacy as outcome, strongly influenced by income and years of education, may play a key role in determining health, beyond socio-demographic variables [5].

Health literacy survey in Semarang City in 2013-2014, which is part of the Health Literacy Asia comparative study, used HLS-47Q-Indonesia questionnaires translated from HLS-EU-47Q [6], got inferior results, 65% of respondents were in a low level of health literacy (inadequate and problematic). In this survey, 60.25% of people in the rural areas of Semarang City had low health literacy [7].

People who live in rural areas potentially have lower health literacy [8]. The rural people usually have limited access to health information and healthcare. Rural people were less likely than urban people to obtain certain preventive health services [9].

Limbangan is one of the subdistricts in Kendal located in Mount Ungaran area, AND IT IS A border between Semarang City and Semarang District. The location is in a remote area, so it is relatively difficult to access to the health care. The study aims to assess the health literacy and health behavior of family leader (father or mother) of Limbangan residents.

2. Methods

The was a survey with cross-sectional design. the respondents were fathers or mothers in every family in Limbangan, the families selected by stratified random sampling, and the number of respondents were 583 respondents. Data were collected by the students who attended field learning and community services of Public Health Program, Faculty of Health Sciences Dian Nuswantoro University in Limbangan Sub District, Kendal, during November 2015.

The instrument for health literacy assessment was called HLS-EU-Q16 that translated into Bahasa Indonesia. The questionnaire consisted of demographic variables, illness history, health behavior and health literacy that used 16 questions of Health Literacy Survey from EU (HLS-EU-16) [10]. Health literacy levels measured by Likert scale 1-4. The answers score by choosing the solutions with a higher value indicating that the level of health literacy was better (1=very difficult), (2=moderately difficult), (3=fairly easy), (4=very easy). The code for "very difficult" and "moderately difficult" answers was 0 scores and the "fairly easy" and "very easy" were one score. All score were summarized and then categorized into inadequate HL (0-8), problematic HL (9-12), sufficient HL (13-16). For the bivariate analysis, the health literacy was re-categorized to two groups: low (inadequate and problematic) and adequate [11].

Beside health literacy, the survey also appraised the health behavior such as hand washing, tooth brushing, physical activity, and smoking.

Data were analyzed by chi-square test to examine the relationship between variables with p-value 0.05 for statistical significance.

3. Results

The study included a total of 583 respondents, as described in table 1, about half of them in the group of 49 years old (52.1%), most of them were male (82.2%), only 28.1% of the respondents experienced in high education ( > 12 years), married (85.6%), and 27.3% of them were farmers. Most of the respondents were fathers since, in the rural areas, the father has an essential role in making decisions.

Table 1

Description of characteristics variables.

Variable Category f %
Age < 49 279 47.9
49 304 52.1
Sex male 479 82.2
female 104 51.5
Education 12 years 419 71.9
> 12 years 164 28.1
Marital status Married 499 85.6
Not Married 6 1.0
Widow/widower 78 13.4
Occupation Government employees 37 6.3
Private employees 135 23.2
Farmers 159 27.3
Entrepreneurs 61 10.5
Laborers 125 21.4
Driver 6 1.0
Others 26 4.4
Not work 34 5.8

The health literacy assessment used HLS-EU-Q16 Indonesian version that contained sixteen items as described in table 2 covering respondent appraisal about finding, understanding, judging and using health information for health issues in everyday life. The answers were scored and then categorized into inadequate HL, problematic HL, sufficient. The finding was most of the respondents (63.5%) experienced low health literacy (inadequate and uncertain).

Table 2

Description of health literacy items and category.

Health Literacy items tough (%) fairly difficult (%) fairly easy (%) very easy (%)
1. find information on treatments of illnesses that concern you 5.3 28.6 57.1 8.9
2. find out where to get professional help when you are ill 2.2 23.2 64.2 10.5
3. understand what your doctor says to you 1.2 25.3 64.6 8.9
4. understand your doctor's or pharmacist's instruction on how to take a prescribed medicine 2.2 21.3 59.9 16.6
5. judge when you may need to get a second opinion from another doctor 2.2 32.9 56.1 8.7
6. use information the doctor gives you to make decisions about your illness 4.1 25.2 63.3 7.4
7. follow instructions from your doctor or pharmacist 1.5 25.4 61.9 11.1
8. find information on how to manage mental health problems like stress or depression 3.8 35.3 51.6 9.3
9. understand health warnings about behavior such as smoking, low physical activity and drinking too much 1.4 25.7 59.9 13.0
10. understand why you need health screenings 2.9 38.4 48.4 10.3
11. judge if the information on health risks in the media is reliable 2.1 30.4 60.7 6.9
12. decide how you can protect yourself from illness based on information in the media 1.5 32.2 59.5 6.7
13. find out about activities that are good for your mental well-being 1.9 29.8 59.3 8.9
14. understand advice on health from family members or friends 1.9 19.9 62.1 16.1
15. understand information in the media on how to get healthier 1.2 22.0 66.2 10.6
16. judge which everyday behavior is related to your health 2.2 24.0 63.8 9.9
Health literacy category: f (%)
1. inadequate 112 19.2
2. problematic 258 44.3
3. sufficient 213 36.5

In the issue of health behaviors, table 2 shows low physical activity experienced by 54.2% respondent. In the part of personal hygiene behavior, only 14.4% of them had adequate tooth brushing habit. Otherwise, 81.5% of them had sufficient handwashing behavior before eating and after having had defecation.

Table 3

Description of health behaviors and attitude toward health.

Variable Category f %
Physical activity inadequate (never or rarely) 316 54.2
adequate (30 minutes, 2-7 time/week) 267 45.8
Tooth brushing in day One time/day 497 85.2
Two times/day 84 14.4
Hand washing before eat inadequate (never, rarely) 108 18.5
Adequate (frequently, always) 475 81.5
Hand washing after defecation inadequate (never, rarely) 108 18.5
Adequate (frequently, always) 475 81.5
Salt consumption > 1 teaspoon 264 45.3
One teaspoon 314 53.9
Sugar consumption > 4 spoon 83 14.2
Four spoon 498 85.4
MSG use in food always 234 40.1
never or sometimes 347 59.5
Family member smoking behavior yes 369 63.3
no 213 36.5
Attitude to health not important or very not important 34 5.8
as necessary, important or very important 548 94.2

The high salt consumption happened on 45.3% of respondents, while high sugar consumption experienced by 14,2% of them and 40.1% always used monosodium glutamate (MSG) in their food. The biggest problem of risk behavior was smoking, while 63.3% of respondents had smokers in their family, that meant most of the family members were taking the risk to become passive smokers. Most of the respondents thought that health was as important as other issues or more important (94.2%), but unfortunately, 5.8% of them said that health was not necessary or not very important.

Table 4

Correlation between variables and health literacy.

Variable Category <Inadequate & Problematic Sufficient X 2 p-value PR CI 95%
f % f %
Age 55 years 248 61.1 158 38.9 0.086 0.708 0.486-1.030
> 55 years 122 68.9 55 31.1
Sex male 300 62.6 179 37.4 0.432 0.814 0.519-1.276
female 70 67.3 34 32.7
Education 12 years 260 62.1 159 37.9 0.3 0.803 0.549-1.175
> 12 years 110 67.1 54 32.9
Physical activity inadequate 207 65.5 109 34.5 0.304 1.212 0.864-1.699
Adequate 163 61.0 104 39.0
Tooth-brushing in a day < 2 times 327 65.8 170 34.2 0.004 2.017 1.266-3.216
Two times 41 48.8 43 51.2
Hand washing before eating Inadequate 83 76.9 25 23.1 0.002 2.175 1.341-3.527
adequate 287 60.4 188 39.6
Hand washing after defecation Inadequate 83 76.9 25 23.1 0.002 2.175 1.341-3.527
adequate 287 60.4 188 39.6
Salt consumption > 1 teaspoon 162 61.4 102 38.6 0.418 0.856 0.610-1.202
1 teaspoon 204 65.0 110 35.0
Sugar consumption > 4 spoon 48 57.8 35 42.1 0.316 0.763 0.476-1.224
4 spoon 320 64.3 178 35.7
MSG use always 142 60.7 92 39.3 0.283 0.816 0.579-1.150
Sometimes or never 227 65.4 120 34.6
Smoking Yes 244 66.1 125 33.9 0.088 1.374 0.971-1.946
No 125 58.7 88 41.3
Attitude to health Bad 18 52.9 16 47.1 0.253 0.626 0.312-1.256
Good 352 64.2 196 35.8
Sickness in 3 months Yes 81 51.3 77 48.1 0.001 0.495 0.341-0.719
No 289 68.0 136 32.0

The age, sex and education characteristics did not show the correlation to health literacy significantly, but there was a tendency that the older age, the lower health literacy they got and the female had lower health literacy than male did. But surprisingly, higher educated people ( > 12 years) had lower health literacy level (22.2%).

Health literacywas not associated with physical activity (p value0.304). However respondents who had sufficient health literacy were more likely to have adequate physical activity, 30 minutes per day and 2-3 days a week or more (39%) than those who had inadequate physical activity (34.2%).

Health literacy affected personal hygiene behavior. Health literacy related to tooth brushing behavior (p-value 0.004). People who had sufficient health literacy were more intent to have good tooth-brushing behavior, two times per day or more (51.2%) than those who had less than < 2 times per day brushing behavior (34.2%). People who had sufficient health literacy were more likely to have good personal hygiene behavior such as washing hands before eating and after defecation (39.6%) than those who had terrible or inadequate hand washing (23.1%). Nevertheless, health literacy did not show the relationship to high salt, sugar and MSG consumption. Moreover, attitude to health not also correlated to health literacy. People who had sufficient health literacy tended to have family members who did not smoke (41.3%) although it was not associated significantly (p value0.374).

Experience of having sick family members in 3 months had a relationship with health literacy (p value0.001). People who had no experience in having ill family members tended to have low health literacy, it was bigger (68.0%) than people who had experience in having sick family members (51.3%).

4. Discussion

The proportion of the respondents who experienced low health literacy (inadequate and problematic) was still high (63.5%), almost the same as Semarang health literacy survey in 2014 that found 64% people to have low health literacy[7]. People who live in the rural areas potentially have lower health literacy[8], but now in the information technology era, both people in rural and urban have the same opportunity to access health information from the internet, especially for young adult group[12]. However, low health literacy has to get more attention and intervened. Health literacy can improve through the provision of information, effective communication and structured education and the improvements that can assess through the measurement of changes to the knowledge and skills that enable well-informed and more autonomous health decision-making[13].

The older people ( > 55 years old) tend to have lower health literacy, like finding in the other surveys[1,7], so it needs to fix since the older adults usually face more health problems than the younger ones and they need more health literacy skills to maintain good health.

In rural areas, the male had a strategic position in making a decision, and it can be a potential agent to improve healthy behavior[14]. In this survey, men had a better sufficient health literacy level (37.4%) than females did (32.7%). Usually, the intervention of family related to health only focused on the women. In the rural areas, it has to be directed to males, too, such as father and community leader, because they are more likely the people who make the decisions. Moreover, female health literacy has to be enhanced because they play an essential role in taking care of family member health and health behavior.

Health literacy not associated with physical activity (p value0.304), however people with sufficient health literacy tend to do more physical activity (39.0%) than those who had low health literacy. Health Literacy correlated to personal hygiene behavior, such as tooth brushing behavior (p value0.004), and hand washing before eating and after defecation (0.004), and people who had sufficient health literacy tended to have family members who do not smoke (41.3%). These showed that health literacy could contribute to their healthy behavior that affected their quality of life[15,16].

Experience of having sick family members in 3 months had a relationship with health literacy (p value0.001). People who have no experience in having ill family members tend to have low health literacy, and this is proven bigger (68%) than people who had experience in having sick family members (51.3%). By having experience in taking care of the ill family members, they more likely have access to health care and try to understand the health problem. However, they should not be allowed to get sick to gain an understanding of health problems, but rather should be with sufficient health promotion efforts.

5. Conclusions

Most respondents had low (inadequate and problematic) health literacy and inadequate health behavior such as physical activities, tooth brushing, and smoking. health literacy was correlated to personal hygiene behaviors and tend to reduce smoking behavior and increase physical activities. further multivariate analysis are needed because this study has not conducted an advance analysis of its data.


The Field Learning Student Teams of Public Health Program, Faculty of Health Sciences Dian Nuswantoro University, in Limbangan Sub District Kendal, 2015 that conducted the survey and services in regards to health behavior for communities.

Ethical Approval

This study was approved by the Ethics Committee, Faculty of Public Health Diponegoro University, number 33/EC/FKM/2014.

Competing Interest

The authors declare that we have no competing interest to any organizations that might have an interest in the submitted; no other relationships or activities that could appear to have influenced the proposed work.



S.-Y. D. Lee, T.-I. Tsai, Y.-W. Tsai, and K. N. Kuo, “Health Literacy, Health Status, and Healthcare Utilization of Taiwanese Adults: Results from A National Survey.,” BMC Public Health, vol. 10, no. 1, p. 614, 2010.


I. Kickbusch, J. Pelikan, F. Apfel, and A. Tsouros, “Health Literacy: The Solid Facts,” Copenhagen, Denmark, 2013.


D. Nutbeam, “Health Literacy as A Public Health Goal: A Challenge for Contemporary Health Education and Communication Strategies into The 21st Century,” Health Promot. Int., vol. 15, no. 3, pp. 259–267, 2000.


M. Suka, T. Odajima, M. Okamoto, and M. Sumitani, “Relationship between Health Literacy, Health Information Access, Health Behavior and Health Status in Japanese People,” Patient Educ. Couns., vol. 98, no. 5, pp. 660–668, 2015.


D. Levin-zamir et al., "The Association of Health Literacy with Health Behavior, Socioeconomic Indicators, and Self- Assessed Health from a National Adult Survey in Israel The Association of Health Literacy with Health Behavior, Socioeconomic Indicators, and Self-Assessed Health From a National Adult Survey in Israel," J. Health Commun., vol. 00, no. 00, pp. 1–8, 2016.


T. V. Duong et al., “Measuring Health Literacy in Asia: Validation of the HLS-EU-Q47 Survey Tool in Six Asian Countries,” J. Epidemiol., pp. 1–7, 2016.


N. Nurjanah and E. Rachmani, “Demography and Social Determinants of Health Literacy in Semarang City Indonesia,” in International Conference on Health Literacy and Health Promotion, 2014.


W. E. Zahnd, S. L. Scaife, and M. L. Francis, “Health Literacy Skills in Rural and Urban Populations,” Am. J. Health Behav., vol. 33, no. 5, pp. 550–557, 2010.


M. M. Casey, K. T. Call, and J. M. Klingner, "Are Rural Residents Less Likely to Obtain Recommended Preventive Healthcare Services?" vol. 21, no. 3, 2010.


The HLS-EU Consortium, “Measurement of Health Literacy in Europe: HLS-EU-Q47; HLS-EU-Q16; and HLS-EU-Q86 The HLS-EU Consortium 2012 The European Health Literacy Project 2009-2012,” 2012.


J. M. Pelikan, F. Röthlin, and K. Ganahl, “Measuring Comprehensive Health Literacy in General Populations: Validation of Instrument, Indices And Scales Of The HLS-EU Study.,” 6th Annu. Heal. Lit. Res. Conf., 2014.


G. Fergie, S. Hilton, and K. Hunt, “Young Adults’ Experiences of Seeking Online Information about Diabetes and Mental Health in The Age Of Social Media,” Heal. Expect., vol. 19, no. 6, pp. 1324–1335, Dec. 2016.


D. Nutbeam, B. Mcgill, and P. Premkumar, “Improving Health Literacy in Community Populations: A Review Of Progress,” pp. 1–11, 2017.


E. B. Turinawe et al., “Traditional Birth Attendants ( TBA's ) As Potential Agents in Promoting Male Involvement in Maternity Preparedness: Insights from A Rural Community in Uganda,” Reprod. Health, pp. 1–11, 2016.


L. C. Kobayashi, J. Wardle, M. S. Wolf, and C. Von Wagner, “Health Literacy and Moderate to Vigorous Physical Activity during Aging, 2004–2013,” Am. J. Prev. Med., pp. 1–10, 2016.


D. M. Fernandez, J. L. Larson, and B. J. Zikmund-fisher, “Associations between Health Literacy and Preventive Health Behaviors among Older Adults: Findings from the Health and Retirement Study,” BMC Public Health, pp. 1–8, 2016.



  • Downloads 4
  • Views 44



ISSN: 2413-0877