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

2. 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

3.  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

4. 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

5. Sorensen’s HL Model

6. 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

7. 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 | (9 +11 +1 - 1Qs) Health Literacy Survey (47 Qs) Personal Health Info (15 +4 with 3 sub Qs) Social and Economics info (7 + 3 +3 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

8. 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.  Q1.19 - is deem irrelevant, omitted from questionnaire – Have you attended educational course in educational institution?  Q 3.4 - 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.4.0 - added to suit MyHeart project – State your current occupation  Q.4.1 - 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 & 4.12 - 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.  Q1.19 - is deem irrelevant, omitted from questionnaire – Have you attended educational course in educational institution?  Q 3.4 - 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.4.0 - added to suit MyHeart project – State your current occupation  Q.4.1 - 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 & 4.12 - added to fit MyHearts – How many ppl in your household & What’s your household income

9. 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

11. Descriptive Data VARIABLESVALUEFREQUENCYPERCENTAGE Age Group 18-2538263.6 26-3313722.8 34-41396.5 42-49162.7 50-57183 58-6520.3 66-7330.5 74-8110.1 Marital Status Not Married47679.3 Married11519.2 Divorced/Separated50.8 Widowed40.7 Gender Male24440.7 Female35559.2 Highest Education Elementary School81.3 Junior High School203.3 Senior High School7913.2 University/College38664.3 Master Degree9415.7 Doctoral Degree50.8 Other81.3

12. 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 0.729.  Overall, all domains are showing moderate high alpha cronbach value (0.729 -0.837).  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 0.729.  Overall, all domains are showing moderate high alpha cronbach value (0.729 -0.837). Domain/subdomainAccessing/Finding Health Information (FHI) Understanding Health Information (UHI) Appraising/Judging Health Information (JHI) Applying Health Information (AHI) Healthcare (HC) 0.7850.7820.7730.729 Disease Prevention (DP) 0.8130.8020.8370.740 Health Promotion (HP) 0.8210.8280.7600.837

13. 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 2.9860.8120.8720.8730.857.058 (p=0.000)

14. 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

15. GOF Indexχ2/df/ CMINGFICFIIFITLIRMSEA Value 2.546 0.8880.926 0.912 0.049 (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)

16. 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 Q2-11 0.576 0.635 0.594.745.726.698 0.7680.7670.523 0.6100.422 HC-FHI Q2-1 Q2-2 Q2-3 0.667 0.679 0.531.818.800.630 0.785 0.796 0.568 0.4770.333 HC-UHI Q2-5 Q2-6 Q2-8 0.626 0.558 0.517.717.682.700 0.741 0.742 0.490 0.6100.479 HC-AHI Q2-14 Q2-15 Q2-16.566.550.660.702.642.630 0.758 0.769 0.529 0.4480.279 DP-FHI Q2-18 Q2-19 Q2-20.592.675.639.666.796.783 0.792 0.794 0.564 0.7530.505 DP-UHI Q2-21 Q2-22 Q2-23.576.693.683.705.749.754 0.802 0.803 0.576 0.7740.490 DP-JHI Q2-24 Q2-25 Q2-28.532.602.495.705.716.633 0.722 0.726 0.470 0.7740.528 DP-AHI Q2-29 Q2-30 Q2-31.478.619.612.629.754.755 0.740 0.757 0.511 0.6790.524 HP-FHI Q2-33 Q2-34 Q2-36.560.589.471.735.709.680 0.718 0.726 0.470 0.7480.536 HP-UHI Q2-37 Q2-39 Q2-40.630.681.654.758.774.758 0.807 0.582 0.7780.543 HP-JHI Q2-41 Q2-42 Q2-43.536.637.601.727.718.704 0.760 0.759 0.513 0.7780.544 HP-AHI Q2-44 Q2-45 Q2-46 Q2-47.620.639.715.698.738.693.797.777 0.836 0.839 0.566 0.7280.413

17. Factor Correlation matrix with square root of the AVE on the diagonal HCJHIHCFHIHCUHIHCAHIDPFHIDPUHIDPJHIDPAHIHPFHIHPUHIHPJHIHPAHI HCJHI0.723 HCFHI 0.680 0.754 HCUCI0.7810.6800.700 HCAHI 0.5090.4320.669 0.727 DPFHI 0.6400.6910.7110.496 0.751 DPUHI 0.5690.5750.6540.5370.868 0.759 DPJHI 0.6670.5100.6710.5660.7710.880 0.686 DPAHI 0.7090.6130.7310.4710.7540.6730.807 0.715 HPFHI 0.6470.5550.6820.5340.7770.7320.7970.824 0.686 HPUHI 0.6430.5780.7410.5690.7180.7570.7560.8200.865 0.763 HPJHI 0.6810.5150.6850.5460.7080.7300.8010.7900.8290.882 0.716 HPAHI 0.5740.4510.5890.4410.6200.6280.6810.6940.7270.6990.853 0.752 those marked in yellow. Off diagonal values > diagonal values. This indicates lack of discrminant validity between the paired constructs

18. Modification Indicies  Items of concern e41 e4235.5720.064 Q43-Q44 e40 e4120.9850.048 Q42-Q43 e28 e2931.2320.086 Q28-Q29 e25 e2922.9760.065 Q25-Q29 e21 e2235.7460.064 Q23-Q22

19. 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.

20. Thank you Email: emmamohamad@ukm.edu.my