Factors Associated with Adequate Health Literacy among At-Risk Groups in Sam Sung District, Khon Kaen Province

1. BACKGROUND

With 1.3 billion adults affected, hypertension is a major global public health issue and a major cause of death globally, giving it the moniker “the silent killer.” Moreover, it is a major risk factor for heart failure, myocardial infarction, stroke, coronary heart disease, and renal failure. Only one in five hypertensive individuals are able to effectively control their disease, although hypertension therapies are reasonably priced [1]. In addition, people have been forced to modify their daily routines and lives due to rapid changes in today's social, economic, political, and cultural contexts as well as information technology developments. This is especially noticeable when it comes to adopting high-paced work schedules that prioritize the ease of fast food or prepared meals. Thais are more likely to have Non-Communicable Diseases (NCDs), such as hypertension, as a result of these diets, which are mostly heavy in calories [2].

The Thai National Health Examination Survey 2019-2020 found that 25.4% of people over the age of 15 have hypertension. The rate of change increased by 18.69% during the 2008-2009 and 2019-2020 surveys [2]. Additionally, the incidence rates of newly diagnosed hypertension patients from 2022 to 2024 were 1,160.44, 1,243.07, and 1,362.03 per 100,000 population, respectively, according to statistics from the Ministry of Public Health's Health Statistics Center, indicating a consistent increasing trend [3]. The at-risk group had a 42.9 per 1,000 chance of becoming the ill group, while the prevalence of hypertension in the Northeastern region was 841.32 per 100,000 people [2, 3]. Concurrently, in Khon Kaen Province, the new incidence rates of hypertension from 2022 to 2024 were 1,090.74, 1,085.49, and 1,211.82 per 100,000 people, respectively. In Khon Kaen, screening data for those 35 years of age and older who were at risk for hypertension from 2022 to 2024 revealed rates of 4.97%, 5.52%, and 8.65%, respectively, indicating a steady rise [3]. One of the districts in Khon Kaen Province is Sam Sung District, which has 23,196 residents and consists of 35 villages and 5 subdistricts. Between 2022 and 2024, the district's incidence rates of new instances of hypertension were 2,102.93, 1,965.91, and 1,944.80 per 100,000 people, respectively [3]. The fact that these rates exceed the provincial incidence as a whole is noteworthy. Similarly, from 2022 to 2024, the district's screening results for those 35 years of age and older who were at risk for hypertension showed rates of 3.18%, 2.04%, and 6.83%, respectively. The “3E 2S” health promotion principles—Eating, Exercise, Emotion, Non-Smoking, and Alcohol Abstinence—are being used to prevent disease, although new cases are still occurring [3]. Cultural upheavals, living conditions, and dietary patterns marked by imbalanced consumption—excessively sugary, fatty, and salty foods—are all directly and indirectly impacted by socioeconomic changes. These factors are the main causes of Non-Communicable Diseases (NCDs). There is a linear relationship between the risk of hypertension and cardiovascular mortality and a persistently high intake of salt and sodium that exceeds physiological requirements. The WHO recommends a daily sodium intake of no more than 2,000 milligrams, which is comparable to less than 5 grams, or just under one teaspoon, of salt [3]. Global data shows an average daily salt consumption of 8-10 grams [4].

The ability of a person to meet health-related demands in contemporary culture is referred to as health literacy. According to a review of the literature, health literacy is related to general literacy and includes public knowledge, motivation, and the ability to obtain, comprehend, evaluate, and use health information [5]. In order to preserve or enhance quality of life, this ability is used to make decisions about healthcare, disease prevention, and health promotion in daily life [5]. Due to its strong correlation with socioeconomic determinants of health, health behaviors, healthcare utilization, the quality of the health system, and professional capacity building, this idea has drawn more and more attention in both research and practice [6]. A prior study used social support and the 3E-2S principles to lower the incidence of diabetes and hypertension in newly identified at-risk populations [7]. According to the findings, participants' mean scores for social support and health behaviors were considerably higher following the training (p-value < 0.001) [7]. Furthermore, Village Health Volunteers' (VHVs) mean post-experimental skill score for home blood pressure measuring was significantly higher than the pre-experimental score (p-value < 0.001) in a study assessing the effects of a phone follow-up program combined with home blood pressure measuring on health behaviors and blood pressure levels of hypertensive patients [8]. The patients' post-experiment mean health behavior score was significantly higher than their pre-experiment score (p-value < 0.001) [8]. Blood pressure levels were lowered by 83.55% when food consumption was modified in accordance with the Buddhist Medicine method. 90.91% of hypertension patient groups were able to control their blood pressure, and 27.50% [9]of them were able to reduce their salt intake adequately. Additionally, ongoing communication can generate incentive to sustainably modify attitudes and behaviors, according to an assessment of the second year of the Thai salt reduction program conducted by Mahidol University's Institute of Nutrition [10].

Goal 1 of the 13th National Health Development Plan (2023-2027) shows that the Thai Ministry of Public Health now prioritizes public health literacy (HL): “Citizens display proper health practices and possess health literacy for self-care.” [11] As a result, improving health literacy has emerged as a crucial issue that calls for more tangible mobilization. The World Health Organization (WHO), which defines public health literacy as the cognitive and social skills that determine people's motivation and ability to obtain, comprehend, and use information in ways that promote and maintain good health, has called on member nations to give public health literacy top priority [12]. Inadequate health literacy also contributes to riskier behaviors, fewer preventive behaviors, more frequent hospitalizations, and a lack of knowledge about proper adherence to medical advice [13], according to American studies. Increased healthcare costs are a result of all these variables, both on a personal and national level. Consequently, considering the large number of people who are at risk for hypertension, increasing health literacy is an essential way to treat the underlying cause of the issue.

A survey of the literature shows that several theories have been used to modify behavior, but there has been little work done on developing a health behavior promotion model that incorporates Sorensen et al.’s health literacy concept [5]. To stop new cases from occurring and postpone the morbidity from NCDs, the researcher must raise awareness.

2. METHODS

3. RESULTS

According to Table 1, among the 1,215 participants, the majority were female (71.85%) with an average age of 50.83 years (Standard Deviation = 6.61 years). Most had a Body Mass Index (BMI) within the normal range (52.10%) and had completed primary education (51.11%). The primary occupation was agriculture (84.20%), with a median monthly income of 3,000 THB (min = 0 THB, max = 80,000 THB). The majority had no underlying diseases (83.87%), though 62.72% had a family history of hypertension. Most were non-smokers (86.42%) and non-drinkers of alcohol (70.21%). Regarding disease-specific baseline measures, half of the participants demonstrated a moderate level of hypertension preventive practices (65.68%). Furthermore, the assessment of baseline hypertension knowledge revealed that a substantial majority possessed a low level of knowledge (76.13%).

According to Table 2, after adjusting for other covariates, six factors were significantly associated with sufficient health literacy regarding hypertension. Females were less likely to have sufficient health literacy compared to males (AOR = 0.51; 95% CI: 0.35-0.75). Individuals engaged in agriculture were less likely to have sufficient health literacy than those who were unemployed (AOR =

0.29; 95% CI: 0.13-0.65). Conversely, those with an average income of 5,001-10,000 Baht were 1.44 times more likely to have sufficient health literacy than those earning less than 5,000 Baht (AOR = 1.44; 95% CI: 1.03-2.00). Regarding health status, individuals with diabetes had lower health literacy than those without comorbidities (AOR = 0.24; 95% CI: 0.12-0.47). Meanwhile, individuals with a high level of hypertension prevention behaviors were 4.21 times more likely to achieve sufficient health literacy than those with a low level (AOR = 4.21; 95% CI: 2.27-7.81). Lastly, individuals with a high level of hypertension knowledge showed a lower likelihood of sufficient health literacy compared to those with a low knowledge level (AOR = 0.13; 95% CI: 0.05-0.33).

According to Table 3, after adjusting for other covariates, six factors were significantly associated with sufficient health literacy regarding hypertension. Females were less likely to have sufficient health literacy compared to males (AOR = 0.53; 95% CI: 0.38-0.71). Regarding occupation, individuals engaged in agriculture (AOR = 0.27; 95% CI: 0.13-0.60) and those employed as laborers (AOR = 0.40; 95% CI: 0.17-0.95) were less likely to have sufficient health literacy than those who were unemployed. Conversely, individuals with an average income of 5,001-10,000 Baht were 1.45 times more likely to have sufficient health literacy than those earning less than 5,000 Baht (AOR = 1.45; 95% CI: 1.07-1.96). For health status, individuals with diabetes had lower health literacy than those without comorbidities (AOR = 0.31; 95% CI: 0.17-0.58). Meanwhile, individuals with a high level of hypertension prevention behaviors were 5.05 times more likely to achieve sufficient health literacy than those with a low level (AOR = 5.05; 95% CI: 2.82-9.06). Lastly, individuals with a high level of hypertension knowledge showed a lower likelihood of sufficient health literacy compared to those with a low knowledge level (AOR = 0.15; 95% CI: 0.06-0.36). Model selection was performed using a backward elimination procedure based on the Likelihood Ratio test. Variables such as age, BMI, education level, family history of hypertension, smoking status, and alcohol consumption were removed as they did not significantly contribute to the final model (p > 0.05).

4. DISCUSSION

This study revealed that Females were significantly less likely to have adequate health literacy compared to males. (AOR = 0.53; 95% CI: 0.38-0.71). This finding contrasts with some conventional literature but aligns with recent community-based studies highlighting gender disparities in rural developing regions [15, 16]. In rural agricultural contexts, women frequently bear a double burden of domestic caregiving and agricultural labor, leading to time constraints that impede their active participation in health education programs and information seeking [15]. Furthermore, structural socioeconomic disadvantages, including lower formal educational attainment among older rural women, further diminish their functional and critical health literacy capacities [16, 17]. Recent evidence from Xie, Y. et al. [15] and Acquah, I. et al. [16] confirms that lower health literacy among women in rural settings is heavily driven by limited access to health information and cognitive overload from managing household wellness alongside chronic disease risks [16, 18]. Therefore, health promotion strategies in primary care must prioritize women as a vulnerable subgroup by deploying tailored, simplified, and accessible educational interventions within community networks. Regarding occupation, individuals engaged in agriculture (AOR = 0.27; 95% CI: 0.13-0.60) and wage laborers (AOR = 0.40; 95% CI: 0.17-0.95) demonstrated a significantly lower likelihood of adequate health literacy compared to the unemployed. In line with a study by Bawornthip et al. [18], educational level, occupation, family medical history, and access to health information from healthcare personnel significantly influenced participants' health literacy. Moreover, this study found that individuals with a monthly income of 5,001-10,000 THB had a higher proportion of adequate health literacy than those earning less than 5,000 THB (AOR = 1.45; 95% CI: 1.07-1.96). Consistent with Singh et al. [19], low literacy levels and excessive wealth were correlated with hypertension, whereas higher educational attainment was inversely associated with hypertension.

Interestingly, regarding health status, participants in the high-risk group with diabetes as a comorbidity were significantly less likely to achieve adequate health literacy compared to those without comorbidities (AOR = 0.31; 95% CI: 0.17-0.58) [20]. This finding contradicts the assumption that living with a chronic condition automatically improves health literacy; instead, it indicates that diabetic comorbidities pose additional challenges. This result is consistent with recent studies by Bekele F and Feyisa I [21]. and Vågenes ST et al. [22], which observed high rates of limited health literacy among chronic and diabetic patients. Managing diabetes involves multiple self-care protocols—such as dietary restrictions, blood glucose monitoring, and medication adherence—which can create information overload and cognitive fatigue for high-risk individuals [23]. Consequently, healthcare providers should design simplified, continuous, and tailored educational programs to better support individuals managing comorbid chronic conditions. In terms of hypertension preventive behaviors, participants with high levels of preventive practices had a significantly higher proportion of adequate health literacy compared to those with low levels (AOR = 5.05; 95% CI: 2.82-9.06). Interestingly, participants with high levels of hypertension knowledge were significantly less likely to demonstrate adequate health literacy compared to those with low knowledge levels (AOR = 0.15; 95% CI: 0.05-0.33) [24]. This inverse relationship highlights the well-documented 'knowledge-behavior gap' in chronic disease management [23, 24]. Possessing factual knowledge about hypertension—such as identifying cut-off blood pressure numbers—does not inherently guarantee functional skills for accessing, appraising, or applying health advice in daily routines [22, 24]. Recent findings by Ozyuncu and Erol [25] confirm that despite population awareness and theoretical disease knowledge, non-adherence and health literacy gaps often stem from the inability to translate information into practical self-management and lifestyle modifications [25]. Furthermore, individuals with higher disease knowledge may possess greater awareness of the complexities and barriers associated with lifestyle modifications, leading them to perceive health-seeking tasks as more challenging on health literacy assessment scales [24]. Therefore, healthcare providers must transition from passive health information dissemination toward interactive, skill-based interventions that empower patients to apply their knowledge effectively.

5. STUDY LIMITATIONS

This study has certain limitations. First, the cross-sectional design precludes causal inferences between variables; therefore, future prospective longitudinal studies are warranted to establish causal relationships regarding factors associated with adequate health literacy among high-risk hypertensive individuals. Another limitation is the use of purposive sampling, as the high-risk hypertensive group was selected from a single district, potentially limiting the generalizability of the findings to the broader population. Consequently, more comprehensive sampling strategies should be employed in future research.

CONCLUSION

Our findings demonstrate that the majority of individuals at risk for hypertension still exhibit inadequate health literacy. This underscores an urgent need to educate and empower these high-risk groups to enhance their health literacy and promote healthier lifestyles, which serves as a core component of community health promotion. Furthermore, appropriate follow-up strategies should be implemented to modify the health behaviors of at-risk individuals. Such measures are vital for preventing new cases within the community and ultimately reducing the financial burden associated with hypertension treatment.

REFERENCES