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 . 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 .
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 . 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 .
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 , 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 .
People who live in rural areas potentially have lower health literacy . 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 .
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.
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) . 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 .
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.
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.
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).
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.
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.
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%).
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. People who live in the rural areas potentially have lower health literacy, 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. 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.
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. 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.
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.
This study was approved by the Ethics Committee, Faculty of Public Health Diponegoro University, number 33/EC/FKM/2014.