HEALTH LITERACY IN MALAYSIA: HLS-ASIA QUESTIONNAIRE VALIDATION Emma Mohamad, Tin Tin Su, Hazreen Abdul Majid, Karuthan Chinna and Reena Balan

Introduction  Health literacy studies in Malaysia  No national or population representative data  Available data focused on either particular study population and/or specific disease – mostly show poor health literacy  Health literacy studies in Malaysia  No national or population representative data  Available data focused on either particular study population and/or specific disease – mostly show poor health literacy

 Studies on health literacy in Malaysia are still very limited, often focused on specific illness / demographic groups  The word ‘health literacy’ is vaguely utilized in research, not defined in standard measurement / instrument  Studies on health literacy at national level is still non-existent  This presents a huge potential and benefit for this study to be conducted nationwide in Malaysia  Studies on health literacy in Malaysia are still very limited, often focused on specific illness / demographic groups  The word ‘health literacy’ is vaguely utilized in research, not defined in standard measurement / instrument  Studies on health literacy at national level is still non-existent  This presents a huge potential and benefit for this study to be conducted nationwide in Malaysia

AHLS Questionnaire  2013 The First International Conference on Health Literacy and Health Promotion – First introduced to the HLS-Q  Malaysia as one of the 20 countries involved in the AHLS network  Adopting and adapting the AHLS Questionnaire to Malaysian context  2013 The First International Conference on Health Literacy and Health Promotion – First introduced to the HLS-Q  Malaysia as one of the 20 countries involved in the AHLS network  Adopting and adapting the AHLS Questionnaire to Malaysian context

Sorensen’s HL Model

Why Validation?  Before planning for a national survey, AHLS-Q needs to be tested for compatibility (Validity and Reliability testing)  Instead of exploring the factor analysis (EFA) we opted to test the current domains and measurement (Confirmatory Factor Analysis)  To see whether the instrument is compatible with Malaysian setting – comprehension, context suitability with health delivery system in Malaysia  To see whether the 7 domains measures correctly in Malaysian context – existing Qs belong to the right domains but not measuring the same thing / redundant  Before planning for a national survey, AHLS-Q needs to be tested for compatibility (Validity and Reliability testing)  Instead of exploring the factor analysis (EFA) we opted to test the current domains and measurement (Confirmatory Factor Analysis)  To see whether the instrument is compatible with Malaysian setting – comprehension, context suitability with health delivery system in Malaysia  To see whether the 7 domains measures correctly in Malaysian context – existing Qs belong to the right domains but not measuring the same thing / redundant

The Process  Examined the AHLS-Q Face validation among peers  Made several adjustments to suit Malaysian context  Examined the AHLS-Q Face validation among peers  Made several adjustments to suit Malaysian context Demographics | ( Qs) Health Literacy Survey (47 Qs) Personal Health Info (15 +4 with 3 sub Qs) Social and Economics info ( Qs) Functional Health Info (7 Qs) Total:109 Questions HLS-Msia-Q Demographics | (9 +11 Qs) Health Literacy Survey (47 Qs) Personal Health Info (15 +4 with 3 sub Qs) Social and Economics info (7 + 3 Qs) Functional Health Info (7 Qs) Total:106 Questions HLS-Asia-Q Health Literacy Survey (47 Qs) Personal Health Info (15 Qs) Functional Health Info (7 Qs) Demographics (9 Qs) Social and Economics info (7 Qs) Total:86 Questions HLS-EU-Q

Details of adjustments made  Q1.0 - Added Question on Race distribution  Q1.8 - Define serious relationship as engaged/ thinking of permanent relationship/ future partner or spouse & include option for Married but living separately  Q1.10 – Rearrange the answer options. Religion to reflect Malaysian.  Q is deem irrelevant, omitted from questionnaire – Have you attended educational course in educational institution?  Q answer options were adjusted for Malaysian context  Q3.5B - Replace Chinese medicine with traditional medicine  Q3.5D – Omitted dentist  Q3.7 - Replace Chinese medicine with traditional medicine  Q3.8 – Replace Chinese medicine with traditional medicine  Q3.8 - Omitted Internet booking system – not applicable in Malaysia  Q3.10 – Add in Shisha  Q3.11 – Add in Shisha and Electronic Cigarette  Q added to suit MyHeart project – State your current occupation  Q adjusted answer options to suit Malaysian context and MyHearts project  Q4.3 - is adjusted so that each item (cost, health insurance, time and transport) will have their own scale  Q4.6 - adjusted to fit with MyHearts – income bracket  Q4.11 & added to fit MyHearts – How many ppl in your household & What’s your household income  Q1.0 - Added Question on Race distribution  Q1.8 - Define serious relationship as engaged/ thinking of permanent relationship/ future partner or spouse & include option for Married but living separately  Q1.10 – Rearrange the answer options. Religion to reflect Malaysian.  Q is deem irrelevant, omitted from questionnaire – Have you attended educational course in educational institution?  Q answer options were adjusted for Malaysian context  Q3.5B - Replace Chinese medicine with traditional medicine  Q3.5D – Omitted dentist  Q3.7 - Replace Chinese medicine with traditional medicine  Q3.8 – Replace Chinese medicine with traditional medicine  Q3.8 - Omitted Internet booking system – not applicable in Malaysia  Q3.10 – Add in Shisha  Q3.11 – Add in Shisha and Electronic Cigarette  Q added to suit MyHeart project – State your current occupation  Q adjusted answer options to suit Malaysian context and MyHearts project  Q4.3 - is adjusted so that each item (cost, health insurance, time and transport) will have their own scale  Q4.6 - adjusted to fit with MyHearts – income bracket  Q4.11 & added to fit MyHearts – How many ppl in your household & What’s your household income

After adjustments made  The questionnaire was sent for translation to Bahasa Malaysia by a certified translator  The questionnaire was again checked by researchers to make sure the translation was correct  The HLS and Demographic sections were piloted  Pilot survey conducted in Klang Valley utilizing race quota sampling, Malay, Chinese and Indian 200 respondents each (N=600)  Respondents must able to make decisions for themselves / for their family  Employed enumerators conducted the survey in June 2014  The questionnaire was sent for translation to Bahasa Malaysia by a certified translator  The questionnaire was again checked by researchers to make sure the translation was correct  The HLS and Demographic sections were piloted  Pilot survey conducted in Klang Valley utilizing race quota sampling, Malay, Chinese and Indian 200 respondents each (N=600)  Respondents must able to make decisions for themselves / for their family  Employed enumerators conducted the survey in June 2014

Descriptive Data VARIABLESVALUEFREQUENCYPERCENTAGE Age Group Marital Status Not Married Married Divorced/Separated50.8 Widowed40.7 Gender Male Female Highest Education Elementary School81.3 Junior High School203.3 Senior High School University/College Master Degree Doctoral Degree50.8 Other81.3

Findings  First, a simple reliability test was performed and results showed moderate level of reliability of items in each domains.  The highest reliability was seen in items in the ‘Applying health information at health promotion level’ (value of alpha cronbach 0.837),  while the lowest is seen in the ‘Applying health information at health care level’ quadrant (value alpha cronbach  Overall, all domains are showing moderate high alpha cronbach value ( ).  First, a simple reliability test was performed and results showed moderate level of reliability of items in each domains.  The highest reliability was seen in items in the ‘Applying health information at health promotion level’ (value of alpha cronbach 0.837),  while the lowest is seen in the ‘Applying health information at health care level’ quadrant (value alpha cronbach  Overall, all domains are showing moderate high alpha cronbach value ( ). Domain/subdomainAccessing/Finding Health Information (FHI) Understanding Health Information (UHI) Appraising/Judging Health Information (JHI) Applying Health Information (AHI) Healthcare (HC) Disease Prevention (DP) Health Promotion (HP)

CFA : COMFIRMATORY FACTOR ANALISIS (AMOS)  Result : Analysis shows that constructed model in terms of discriminant validity did not match findings perfectly. Criteria used are as according to sources: (Hair et al., 2010; Byrne, 2010; Shumacker & Lomax, 2004; Kline, 1998, 2010; Hu & Bentler, 1999; Bentler, 1990)  Results of the analysis show that the measurement model used is suitable and acceptable, but at a moderate level.  Result : Analysis shows that constructed model in terms of discriminant validity did not match findings perfectly. Criteria used are as according to sources: (Hair et al., 2010; Byrne, 2010; Shumacker & Lomax, 2004; Kline, 1998, 2010; Hu & Bentler, 1999; Bentler, 1990)  Results of the analysis show that the measurement model used is suitable and acceptable, but at a moderate level. Index Suitability Criteria Acceptable ValueInterpretation Normed chi-square (χ2/df)/CMIN ( 0 ≤.50) Value of.50 or less shows suitability of model with the colected data GFI0(not suitable) to 1 (Perfectly suitable) Value that is close to.90 shows suitability of model with the colected data. Value that is greater than.90 shows high suitability level AGFI0(not suitable) to 1 (Perfectly suitable) Value that is close to.90 shows suitability of model with the colected data. Value that is greater than.90 shows high suitability level CFI0(not suitable) to 1 (Perfectly suitable) Value that is close to.90 shows suitability of model with the colected data. Value that is greater than.90 shows high suitability level TLI0(not suitable) to 1 (Perfectly suitable) Value that is close to.90 shows suitability of model with the colected data. Value that is greater than.90 shows high suitability level NFI0(not suitable) to 1 (Perfectly suitable) Value that is close to.90 shows suitability of model with the colected data. Value that is greater than.90 shows high suitability level RMSEA(0 ≤.08) Value greater than.08 shows unsuitability between model and the collected data. Indeks GOFχ2/df/ CMIN GFICFIIFITLIRMSEA Value (p=0.000)

Model 2: This Model is constructed by omitting several items from the original instrument ( e1, e6, e9, e13, e16, e20,e26, e27, e29, e30, e31, e32, e33, e34, e35, e36, e37, e38, e39, e40, e 41, e 46, e47) Model 1: This Model following HLS instrument

GOF Indexχ2/df/ CMINGFICFIIFITLIRMSEA Value (p=0.000) According to the analysis results, the 2nd model display a better suitability index with RMSEA value of less than 0.05 and GFI value close to 0.9, as well as CFI, IFI and TLI greater than 0.9 Ommitted qs from instrument ( e1, e6, e9, e13, e16, e20,e26, e27, e29, e30, e31, e32, e33, e34, e35, e36, e37, e38, e39, e40, e 41, e 46, e47)

Domian /ITEM Corrected Item- Total Correlation Standardized factor loading (>0.5) Cronbach's Alpha (>0.7) Convergent Validity Discriminant Validity (MSV < AVE) (ASV < AVE) CR (>0.6) AVE (>0.5) MSVASV HC-JHI Q2-9 Q2-10 Q HC-FHI Q2-1 Q2-2 Q HC-UHI Q2-5 Q2-6 Q HC-AHI Q2-14 Q2-15 Q DP-FHI Q2-18 Q2-19 Q DP-UHI Q2-21 Q2-22 Q DP-JHI Q2-24 Q2-25 Q DP-AHI Q2-29 Q2-30 Q HP-FHI Q2-33 Q2-34 Q HP-UHI Q2-37 Q2-39 Q HP-JHI Q2-41 Q2-42 Q HP-AHI Q2-44 Q2-45 Q2-46 Q

Factor Correlation matrix with square root of the AVE on the diagonal HCJHIHCFHIHCUHIHCAHIDPFHIDPUHIDPJHIDPAHIHPFHIHPUHIHPJHIHPAHI HCJHI0.723 HCFHI HCUCI HCAHI DPFHI DPUHI DPJHI DPAHI HPFHI HPUHI HPJHI HPAHI those marked in yellow. Off diagonal values > diagonal values. This indicates lack of discrminant validity between the paired constructs

Modification Indicies  Items of concern e41 e Q43-Q44 e40 e Q42-Q43 e28 e Q28-Q29 e25 e Q25-Q29 e21 e Q23-Q22

Discussion and Conclusion  Although there are ways to improve the model in order to fit Malaysian context (refer model 2), there were too many questions need to be omitted (N=23) about 50%.  The reliability test performed earlier did not display major problems and Cronbach Alpha value fits the minimum requirement (average high value, all measuring >.72)  Therefore, we conclude that the instrument used to measure Health literacy (47 Qs in HLS- Q) can be utilized in Malaysian context with an average high reliability.  Although there are ways to improve the model in order to fit Malaysian context (refer model 2), there were too many questions need to be omitted (N=23) about 50%.  The reliability test performed earlier did not display major problems and Cronbach Alpha value fits the minimum requirement (average high value, all measuring >.72)  Therefore, we conclude that the instrument used to measure Health literacy (47 Qs in HLS- Q) can be utilized in Malaysian context with an average high reliability.

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