Health Information Communication and Functional Health Literacy: A Mix Method Study
- Nisansala Abeygunasekara
- Wijayananda Rupasinghe
- 2525-2542
- Jun 6, 2025
- Health
Health Information Communication and Functional Health Literacy: A Mix Method Study
Nisansala Abeygunasekara*, Wijayananda Rupasinghe
Department of Mass Communication University of Kelaniya, Kelaniya, Sri Lanka
*Corresponding author
DOI: https://dx.doi.org/10.47772/IJRISS.2025.905000196
Received: 02 May 2025; Accepted: 13 May 2025; Published: 06 June 2025
ABSTRACT
This study is about the Functional Health Literacy Levels (FHL) of individuals in the context of health information communication. The purpose of this research is to identify the Functional Health Literacy of the population, using a mixed method approach. Questionnaires were used to collect quantitative data from two hundred participants. According to the Test of Functional Health Literacy in Adults (TOFHLA) prepared the questionnaire. Don Nutbeam’s Health Literacy model provided the theoretical framework for this study. Descriptive Statistics Analyze was used to analyze quantitative data to identify health literacy levels among different demographic groups. Qualitative data were gathered through interviews with healthcare providers. Thematic analysis was used to analyze qualitative data. There are three themes used to analysis qualitative data. Ability to find good quality health information, having sufficient information to manage health and understanding health information, are the themes of this analysis. The results Indicate that Functional Health Literacy are in three levels among the people. According to Inadequate, Marginal and Adequate health literacy level most people are in inadequate level. The findings of this study underscore the urgent need improving Functional Health Literacy is essential for understanding health information. Additionally, there is a need for ongoing monitoring and evaluation of FHL levels to ensure that interventions are effective and sustainable. Expanding future research to include broader demographics and longitudinal studies could provide further insights into the evolution of FHL and its impact on health outcomes.
Keywords: Health, Health Information Communication, Health Communication, Health Literacy, Functional Health Literacy Level
INTRODUCTION
Good health is one of the basic needs of every person to live. Health is the complete physical, mental and social well-being of a person. Health is an important factor in the social existence of the individual. The measurement of social development focuses on health-related factors associated with individual well-being. A healthy lifestyle directly helps in building the physical and spiritual development of the individual. Factors related to health and survival of life should be controlled so that socio-economic development of the individual can be achieved. Mental health should be achieved through proper handling of mental and emotional factors as it pertains to spiritual development. Both the above-mentioned aspects lead to a healthy social life for the individual. We can investigate and indicate what constitutes a healthy existence, which is conducive to the physical and spiritual development of the individual. Here it is important to recognize the definition provided by the World Health Organization for the health of the person in 1948. Health is not merely the absence of disease or infirmity, but the fullness of physical, mental and social well-being ^WHO” 1948)’ This makes it clear that almost all the physical and spiritual factors related to the healthy existence of the person are covered under health.
Understanding the health literacy of the public in Sri Lanka is critical to promoting public health, improving health service delivery and strengthening health communication. Limited health literacy poses health challenges and problems, Impeding individual’s ability to effectively understand and act on health information. Attention should be paid to the need for literacy in a country where many health problems have arisen, including non-communicable diseases, communicable diseases, maternal and child health problems, and the use of substandard medicines. Infectious diseases such as dengue fever, tuberculosis, epidemics, as well as non-communicable diseases such as heart disease, diabetes, cancer and respiratory diseases account for a significant percentage of deaths annually. Addressing these health challenges requires a multifaceted approach that includes effective health communication strategies and comprehensive health literacy initiatives ^Denuwara et al.”2017&’
The health status of the people in Sri Lanka is diverse based on factors such as ethnicity, topography, professionalism and economic criteria. Estate people, rural people, minorities and socio-economically disadvantaged populations face various barriers in accessing and understanding health information ^Chandrasekara et al.”2022&’ These barriers not only affect individual health outcomes but also contribute to wider health disparities in society. Cultural beliefs, norms, and practices influence individuals’ perceptions of health and disease, as well as their trust in various sources of health information. Understanding the cultural diversity of different population groups is essential to communicating health with the public, building trust in health care information sources, and promoting culturally sensitive health messages ^Herath et al.” 2017)’ The language proficiency of the multilingual community in different parts of the country is also significant here. Health literacy affects individuals’ ability to understand health information provided in the official language as well as access information in their preferred language. Poverty is also a factor influencing health conditions. Access to quality health care is more difficult for poor people.
Sri Lanka has seen an increase in the elderly population and a clear increase in non-communicable diseases. This is a time when the health of the country should be the main focus. Changes in population composition, social, economic, environmental changes and changing epidemiological trends have contributed to the rapid increase in non-communicable diseases (Directorate of Healthcare Quality and Safety, 2019). One out of every eight Sri Lankans is aged 60 or over and that proportion is expected to double by 2041. According to the 2022 Sri Lanka Performance and Progress Report, the risk of non-communicable diseases will increase with the increase in the elderly population in the future. Furthermore, the adoption of unhealthy lifestyles due to a wide range of factors such as globalization, free market, economy, rapid urbanization, improved transportation facilities and migrant population have also strongly influenced this situation. In addition, environmental change has also been shown to increase the risk of chronic non-communicable diseases among all population groups. According to a calculation made in 2010, approximately 83% of annual deaths in Sri Lanka are caused by non-communicable diseases. Cardiovascular, cancer, diabetes, and chronic respiratory diseases are the four main causes of these deaths, while other non-communicable diseases account for 18% of deaths. And the probability of premature death between the ages of 30 and 70 due to one of the four major chronic non-communicable diseases mentioned above is estimated at 17%. In such a situation, understanding the current state of health literacy of the community will enable us to manage these problems.
Limited health literacy affects personal health outcomes as well as broader public health challenges. Limited health literacy can also lead to misinterpretation of health information, delays in seeking medical care, nonadherence to treatment, adoption of unhealthy behaviours, and ultimately poor health outcomes. Ineffective communication of public health messages can hinder efforts to prevent and control communicable and noncommunicable diseases, respond to health emergencies, and promote healthy behaviours at the population level (Perera et al., 2017). Understanding the public’s health literacy in health information communication is essential to promote accurate access to health information, empower people to make informed health decisions, and improve health.
This study is about the Functional Health Literacy Levels (FHL) of individuals in the context of health information communication. The purpose of this research is to identify the Functional Health Literacy of the population, using a mixed method approach. Don Nutbeam’s Health Literacy model provides the theoretical framework guiding the analysis.
Health Communication
Health communication is the strategies and processes to make health information accessible of patients, physicians and other stake holders. In the realms of public health recent research depicted that effective health communication ensures actual desired health outcomes. Effective health communication strategies are essential for disseminating accurate information, fostering community engagement, and addressing health disparities (Su et al., 2022 :Olaoye & Onyenankeya, 2023). One of the key findings from recent studies is the importance of developing transparent and accountable messaging. emphasize that health officials should utilize fact-based communication that is empathetic and people-centered to effectively engage the public during health crises (Su et al., 2022). It builds confidence and motivates people to follow or adhere to recommended healthy practices or measures. Furthermore, the need for culturally nuanced communication strategies has been underscored, particularly in diverse regions such as Sub-Saharan Africa, where participatory approaches are vital for addressing public health risks and promoting healthy living (Olaoye & Onyenankeya, 2023).
Ignorance of the public about health information, inability to properly understand health messages, lack of access to health information, emergence of interpretation barriers, problems in communication technology lead to various communicable and non-communicable diseases. Communicating or studying general health information that affects the individual can be called health communication. Health communication is defined as the systematic and planned practice of changing the health habits of a large number of people. The main objective of health communication is to bring about a favorable change in the health-related behavior of the public, thereby improving the health status of the public ^ Kreps,1990). Health communication is a communication process used to systematically improve people’s health habits. Providing information, creating awareness in society, empowerment, motivating people for health information and promoting participation are the main objectives of health communication (Brown et al., 2005). The purpose of the health communication process can be to improve the healthy practices of the public and make them into higher health conditions. Health communication can also be called as a process that plays an important role in providing health services and promoting public health.
Health communication is an important field that encompasses a variety of approaches aimed at promoting health and preventing unhealthy behaviors. Clarity and consistency of message, cultural appropriateness and community involvement and the use of technology for communication campaigns are very valuable in this era (Abel & McQueen, 2020). Such areas of health communication work optimally to address public health issues and move the public through a process of positive health change.
Health Information
Health information can be defined as data and knowledge related to health diseases and health services accessible to people through various media channels, including traditional media, Mass Media and new media. Each of these media plays a unique role in the dissemination of health information, influencing public health literacy and shaping health behaviors. Traditional media have historically been a major source of health information for the general public. Television, radio, newspapers and magazines are often used to communicate health messages through public service announcements or health campaigns. For example, studies show that a significant portion of adults still rely on traditional media for health information. Television and print sources are particularly influential among them. (Fagnano et al., 2011) The structured format of traditional media can improve public awareness and understanding of health issues, but the interactivity of traditional media is limited. It can interfere with audience feedback (Ishikawa & Yano, 2008).
In contrast, the rise of online health-related websites and mobile applications has enabled people to search for the right health information according to their needs. This change empowers users to take an active role in managing their health by providing effective access to health information to understand and apply their health conditions (Multas et al., 2018; Manganello, 2007). As the frequently changing nature of new media allows for updates and a wider range of information, it can be a new experience for users.
Health Literacy
Health communication and health literacy are very important in the delivery of health care and health status of patients. Health literacy is defined as the skills needed to acquire, process, and apply accessible health information for decision-making, which determines patient’s ability to manage care systems for themselves (Dickens et al., 2013). According to Liu et al., (2020) current studies have shown that health literacy has gained more attention and is associated with the course and the level of acceptance by family and community. According to the World Health Organization, HL is the knowledge, motivation and skills needed to identify, understand and apply information to make good decisions about health issues to promote one’s health (WHO, 2015). Therefore, this broad definition helps to establish that health literacy does not only include printed text about various health issues, but also knowledge about obtaining and using health care, as well as the conditions an individual needs.
There is sufficient evidence that health literacy can be defined in terms of ability to relate to health outcomes such as chronic disease management. A research found that limited health literacy predisposes individuals to poor health, including diabetes and or COPD (Bailey et al., 2014; Stellefson et al., 2019). HL improves diabetes medication adherence, diabetes control activities, and increases the risk of adverse effects of glucose level and its complications (Bailey et al., 2014).Similarly, patients with COPD with low health literacy have significantly poorer health-related quality of life and more frequent use of emergency health services (Stellefson et al., 2019). It was found that health communication strategies should be developed to increase patient knowledge and interest and increase patient literacy.
Moreover, the readability of patient education materials plays a significant role in health literacy. Studies have consistently shown that many educational resources exceed the average reading level of patients, which can hinder comprehension and effective self-management of health conditions (Kakazu et al., 2018; Eltorai et al., 2015).
The strategies that are used in the health communication process has to consider the literacy levels of the people. This involves not only simplifying language and improving the readability of materials but also employing various communication channels to reach different audiences (Panjaitan, 2023; “Health Communication: A Key Component of Public Health”, 2016)
Functional Health Literacy
Functional health literacy is a person’s ability to understand and use health-related information to make informed decisions about their health and well-being. Functional health literacy is the ability to read, understand, and apply health-related information such as medical instructions, prescription drug labels, health education materials, and other health care resources (Nutbeam, 2000). Functional health literacy goes beyond basic reading skills and includes the ability to interpret and process information, assess risks, and take appropriate action. Individuals with high levels of functional health literacy have been shown to be better able to navigate the health care system, communicate effectively with health care providers, and engage in self-care practices that promote their overall health.
Measurement of Functional Health Literacy
Various health literacy measures around the world have been created to quantitatively assess an individual’s ability to understand and apply health-related information. But such health literacy measures do not seem to be used in Sri Lanka. These health literacy measurement index tools help measure the level of health literacy. Health literacy tools also help to overcome communication deficits and message comprehension deficits that can affect an individual’s health care practices (Ishikawa et al.,2015). Rapid Estimate of Adult Literacy in Medicine, Test of Functional Health Literacy in Adults- TOFHLA and the New Vital Sign (NVS) are the leading international tools for measuring health literacy (Ishikawa et al.,2015). Health literacy measures can be expressed as indicators.
Functional Health Literacy (FHL) and Health Outcomes
Low FHL was linked to negative health consequences across a spectrum. For example, those with low FHL are at a disadvantage in comprehending written medical instructions and this ultimately results on error of medications administration as well as poor disease control (Berkman et al., 2011). Research by Schillinger et al. (2002) found that patients with low FHL were more likely to have poor glycemic control in diabetes, highlighting the link between FHL and chronic disease management.
The quality of healthcare and its successful management are related to understanding the information that is relevant to the patients’ conditions, whether these conditions are acute or chronic (Rawson et al., 2010). Therefore, it is necessary to raise the individuals’ FHL level, in view of the fact that the inquiries reveal that, both in developed countries and in developing ones, there is a large number of illiterate people in this specific context (WHCA, 2010; Kutner et al., 2006; IOM, 2004). But who would be in charge of this function? Who is responsible for keeping the population healthy? The answer to this questioning is necessarily related to the reflection on the purposes of public health, established as a field that aims at the promotion of populations’ health and which has always been articulated with medicine (Czeresnia, 2009). The biomedical model, based on scientific medicine, has always structured medical education and the health practices (Almeida Filho, 2010; Barros, 2002; Koifman, 2001).
Theoretical Framework of The Research
Several theoretical frameworks have been developed to guide research on health literacy. Nutbeam’s Health Literacy model is particularly influential, providing a comprehensive approach to understanding how literacy impacts health outcomes across functional, interactive, and critical dimensions (Nutbeam, 2000). This model has been instrumental in shaping health literacy interventions and policies that aim to improve public health by addressing the literacy needs of various populations.
This conceptual framework demonstrates the relationship between general literacy, personal skills, health literacy and the health context. This chart demonstrates that general literacy, basic reading, writing and comprehension skills, is the foundation for health literacy. Personal skills, including cognitive abilities, social skills, and emotional states, also significantly affect health literacy. It is clear that health literacy is the basis of the processes of using health information, communicating with health professionals and accessing health services. Health literacy is presented in three levels of increasing complexity.
- Basic/Functional Literacy
- Communicative/Interactive Literacy
- Critical Literacy
Figure 1: Nutbeam’s Model of Health Literacy (2000)
Figure 1: Nutbeam’s (2000) Health Literacy Model. This framework illustrates the layered development of health literacy from basic comprehension to critical analysis in relation to health outcomes and public health engagement (1)
Research Limitation
- This research is limited to the adult community above 18 years of age only.
- According to the population and housing census report conducted in the year 2012, the 3 divisions with the highest population in the 3 districts with the highest population according to the districts are selected.
- Only functional health literacy of adults is studied for conducting the research.
MATERIALS AND METHODS
Mixed method was used as the research methodology. Accordingly, primary data collection was done through quantitative and qualitative research methods to collect data related to the research. According to the research methodology, questionnaires and interviews were used to collect primary data. In collecting data through questionnaires, through purposive sampling, 147, 35, 18 data were collected from the Grama Niladari Division* of Mattakkuliya of Colombo Divisional Secretariat, Kandaliyadda Paluvua West of Mahara Divisional Secretariat, and Alabadagama East of Pannala Divisional Secretariat respectively through 200 questionnaires using Yamane Formula.
Figure 2: Census of Population and Housing of Sri Lanka- 2012
Figure 2 – Census of Population and Housing of Sri Lanka. (2012). Percentage distribution of population according to district by sector. Provisional data based on the 5% sample.
* Grama Niladhari Divisions (GN Divisions) are the smallest administrative units in Sri Lanka, functioning under the authority of the Divisional Secretariat. Each GN Division is managed by a Grama Niladhari, an official responsible for administrative tasks such as maintaining population records, issuing certificates, and ensuring law and order within the community. These divisions are crucial for local governance, playing a key role in the implementation of government policies and services at the grassroots level. GN Divisions help in organizing and managing public administration efficiently across the country’s various regions.
For this study conducted to identify the level of health literacy of the public, the adult community above the age of 18 years. According to the United Nations definition, a person is generally considered an adult if he or she is over 18 years of age. Adulthood is mainly recognized in 3 stages. The 3 stages are young adult, middle aged and elderly. The questionnaire consists of 8 questions on functional health literacy of the public. It is adapted from the Functional Health Literacy Test of Adults, an international health literacy index. Questionnaire was analysed through Descriptive statistics analysis.
The interview has been used to obtain qualitative data for the research. Accordingly, 5 doctors from the Sri Lankan Community Health Promotion Unit of the Health Promotion Bureau were interviewed. Qualitative data obtained in the research were analysed through thematic analysis. For the thematic analysis, three major themes proposed by the World Health Organization on Functional Health Literacy were used.
RESULTS
Quantitative Findings
Sample Area
The crosstabulation data provided presents the distribution of 200 individuals across three districts (Colombo, Gampaha, and Kurunegala) and their corresponding Divisional Secretariats (Colombo, Mahara, and Pannala). The percentage of data contributors in the Mattakkuliya Grama Niladari Division of the Colombo Divisional Secretariat who submitted questionnaires for the study is 73%. The percentage of data contributors in the Kandaliyadda Paluwa West Grama Niladari Division in Mahara Divisional Secretariat is 17%. The percentage of data contributors in Alabadagama East Grama Niladari Division of Pannala Divisional Secretariat is 10%. According to the entire sample, the highest number of data contributors can be seen from the Mattakkuliya Grama Niladari Division.
Table 1: Sample Area Distribution by District and Division
Note: The data indicate that the majority of the responses were obtained from Mattakkuliya, Kandaliyadda Paluwa, Alabadagama East Grama Niladari Divisions.
Age and Gender Distribution
Gender Distribution:
- Male: 140 participants (70% of the total sample)
- Female: 60 participants (30% of the total sample)
Overall Age Distribution:
- 40-49 years: The largest age group overall, with 61 participants (30.5% of total).
- 50-59 years: The second largest, with 50 participants (25.0%).
- 18-29 years: 39 participants (19.5%).
- 30-39 years: 36 participants (18.0%).
- 60-69 years: 12 participants (6.0%).
- 70+ years: The smallest group, with only 2 participants (1.0%).
The data reveals a higher representation of males compared to females in the sample, with both genders showing the highest concentration in the 40-49 age group. Notably, the 70+ age group is underrepresented, particularly among females, where no participants were recorded. This distribution indicates that the majority of study participants are in their middle age, specifically between 40-59 years. To enhance the representativeness of the study, it may be necessary to adopt strategies that include a larger number of elderly participants, specially women, to achieve a more comprehensive age distribution.
Table 2: Age and Gender Distribution of Participants
Note: Male participants dominate across all age groups. No female respondents were recorded in the 70+ category.
Levels of Education
The data reveals that across the three GN divisions—Mattakkuliya, Kandaliyadda Paluwa West, and Alabadagama East the majority of participants have completed Primary/Secondary Education, with 58.5% overall. In Mattakkuliya, 61.2% of participants have this level of education, while in Kandaliyadda Paluwa West, 34.3% have completed Primary/Secondary Education, and in Alabadagama East, this figure is the highest at 83.3%. Senior Secondary Education is the next most common level, particularly in Kandaliyadda Paluwa West, where 45.7% of participants have reached this level, compared to 19.0% in Mattakkuliya and 11.1% in Alabadagama East. A smaller portion of the population across all divisions has no formal education (14.5% overall), with Mattakkuliya having the highest percentage at 17.7%, and only a minimal portion has obtained an undergraduate degree (4.0% overall), with Kandaliyadda Paluwa West showing the highest proportion at 14.3%. This data indicates that while most participants have achieved at least Primary/Secondary Education, there is a significant drop-off in the progression to higher educational levels, particularly undergraduate degrees.
Table 3 – Levels of Education
Occupation
The data on occupational status among the 200 participants shows that the majority are employed, comprising 53.0% of the sample. An additional 21.5% of participants fall into unspecified “other” occupations. Unemployed individuals account for 10.0% of the total, while domestic workers make up 9.0%. Smaller segments include students, who represent 3.5%, and both retired individuals and those unable to work, each constituting 1.5% of the participants. This distribution underscores that while most participants are employed, there is notable diversity in occupational status across the sample.
Table 4 – Occupation
Functional Health Literacy
The Functional Health Literacy Questionnaire was adapted from the Functional Health Literacy Test in Adults ^Test of Functional Health Literacy in Adults -TOFHLA), an international health literacy index. This helped identify the public’s numeracy skills related to functional health literacy.
The first question asked about a drug label provided by a physician. If the doctor advises to take 2 pills every 8 hours, the number of pills to be taken per day is asked under the medication instructions. According to the analysis, 66% gave correct answers. 33% gave wrong answer. It is 33 numerically. Accordingly, it is interpreted that the majority has given the correct answer. According to the analysis, it is clear that the majority of respondents have basic numerical skills to follow simple medication instructions. The 33% who gave incorrect responses indicates that problems may arise in understanding and following medication guidelines, which may lead to inappropriate medication use. This underscores the need for clearer communication from health care providers, as well as the importance of giving medication instructions well during consultations.
The second question assessed people’s ability to interpret blood pressure readings to measure functional health literacy. The problem was your blood pressure was 140/90bpm. If a normal blood pressure reading is 120/80 bpm, is your blood pressure higher or lower than normal? The number of correct responses for this is 31% which is 62 in number. A percentage of 69% gave the wrong answer to this. It is 138 in number. It is interpreted that the majority gave incorrect responses. This analysis shows that a significant portion of the population lacks the ability to understand critical health indicators that are essential for managing chronic medical conditions such as hypertension. An incorrect response rate of 69% indicates a lack of ability to understand basic health information. This emphasizes the need for more effective public education on the interpretation of public health indicators.
The next question posed to analyze the functional health literacy of the public examined the ability to calculate the duration of medication based on the correct dose of medication. If you are being treated for a chronic disease and your doctor prescribes you to take one pill twice a day from a medicine bottle containing 60 pills, you are asked here how many days the medicine you have is enough. The percentage of correct answers to this is 46%. It is 92 numerically. Majority have given the wrong answer to this and its percentage is 54%. Numerically it is 108 people. With only 46% giving the correct answer, gaps in the public’s functional health literacy are further highlighted. This highlights that the majority (54%) are unable to accurately calculate how long a prescription will last, which can lead to problems such as underdosing or overdosing. This finding indicates that improving numerical and perceptual skills related to medication management is critical for patient safety and effective disease management.
The next 4 questions of the Functional Health Literacy Questionnaire are presented specifically for a health information poster published by Sri Lanka health ministry. A health information poster was given to the public in the sample unit of the study area, read it and responded to the questions asked here. Accordingly, the percentage of correct responses to the first question is 39%. Numerically it is 78. The percentage of incorrect responses given is 61%. Numerically it is 122.
The percentage of correct responses to the second question asked from the health poster was 23%. Numerically it is 45. The percentage of incorrect responses is taken to be 77%. Numerically it is 155.
The percentage of correct responses to the third question asked from the health poster is 29%. Numerically it is 57. The percentage of incorrect responses given is 71%. Numerically it is 143.
To understand the functional health literacy of the public, the percentage of correct responses to the last question asked from the health poster was 27%. Numerically it is 54. The percentage of wrong respondents is 73%. Numerically it is 146.
In the analysis of the responses given to the questions asked in connection with the health poster, it is analysed that the majority have given incorrect responses.
Accordingly, it is analysed that a higher percentage of the entire sample gave correct answers to only one of the eight questions asked to analyse the functional health literacy of the public.
These results indicate that there are problems with understanding basic numbers associated with medication instructions, as well as accurately understanding health information. It is clear that this low level of functional health literacy is a factor affecting individuals’ ability to effectively manage their health, follow medical advice, and make informed decisions about their care.
Table 5 – Functional Health Literacy Test in Adults
Functional Health Literacy Test Scores in Adults
Responses of the public to questionnaires designed to measure the functional health literacy of the public were scored according to the Functional Health Literacy Test of Adults. The total score is 16 points. The number of points obtained by the data contributors by giving correct responses to the questionnaire can be analysed as follows.
Participants with zero score (10%)
There were 21 people who did not get any marks for the questionnaire. 10% as a percentage. It shows that a significant portion of the population has low functional health literacy. This finding is important for the study as a segment of the population may be at higher risk of poor health outcomes due to their inability to understand health information.
Low scorers (2-6 points: 56%)
The number of data contributors who scored 2 points for the questionnaire is 29 in number. It is 14% as a percentage. The number of data contributors who scored 4 points is 42. It is 21% as a percentage. 42 data contributors scored 6 which is a percentage of 21%. These scores suggest that these individuals have some level of functional health literacy, but it is limited. This group may benefit significantly from targeted health education initiatives aimed at improving basic numeracy and cognitive skills related to health.
Moderate scorers (8-10 points: 19%)
19% of respondents scored between 8 and 10, reflecting a moderate level of functional health literacy. The number of data contributors who have scored 8 points is 31. It is 15% as a percentage. The number of data contributors who scored 10 points for the questionnaire is 9. It is 4% as a percentage. These individuals can understand health information but are more likely to have problems understanding more detailed or complex health information.
High scorers (12-14 points: 7%)
Only 7% of respondents scored between 12 and 14 points. This group demonstrates a relatively high level of functional health literacy. It analyzes that they are able to understand and use health information effectively. These people are able to manage their health more effectively.
Perfect score (16 marks: 5%)
Only 5% of respondents scored perfect, indicating that only a very small portion of the population has fully developed functional health literacy. These individuals are capable of understanding and applying health information at a level that ensures optimal health management. That this group represents a small percentage of the overall population highlights the lack of functional health literacy in the wider community.
Table 6 – Functional Health Literacy Test Scores in Adults
Functional Health Literacy Level in Adults
Inadequate health literacy (82%)
It is analyzed that majority of the participants, 82% numerically 165 people, have limited health literacy. This classification indicates that these individuals have a poor level of basic health functions such as understanding prescription labels, following medical instructions, or reading and understanding health information accurately. The prevalence of limited health literacy in a large part of the population is significant because many people may suffer from poor health conditions due to the inability to understand health information. This group is more likely to experience medication errors, poor disease management, and increased hospitalizations.
Marginal health literacy (8%)
16 people, 8% of the population, are classified as having marginal health literacy. These individuals are more knowledgeable about health information than those with limited literacy, but are more likely to face challenges in understanding more complex health-related information.
Adequate health literacy (10%)
It is analyzed that only 10% of the participants representing 19 people have adequate health literacy. These people have the ability to read health information. They are able to follow medical advice correctly, understand health risks, and make informed decisions about health care. The low percentage of people with adequate health literacy highlights a significant gap in public health and communication strategies.
Table 7 – Functional health literacy level in adults
Gender And Literacy Level
Cross-sectional analysis of gender and literacy levels highlighted significant disparities in health literacy among participants, with the majority exhibiting adequate health literacy. Specifically, 85.0% of men and 76.7% of women fall into this category, indicating a pervasive challenge in effectively accessing, processing, and understanding health information. This disparity suggests that men and women need to tailor health communication strategies differently to effectively address these gaps.
While there is an equal percentage of both genders with adequate health literacy (7.9% males and 8.3% females), a marked difference emerges in the high health literacy category. Only 7.1% of men achieve high health literacy, while 15.0% of women reach this level, suggesting that women, although outnumbered, may be more adept at engaging with health information when they have access to it.
This finding may be attributed to a variety of factors, such as differences in education, social roles, or access to health information resources between genders. The high percentage of women with high health literacy may reflect their potential role as primary caregivers, which requires them to navigate and understand health information more effectively.
The overall prevalence is relevant and underscores the need for targeted interventions aimed at improving health literacy across the population, as 82.5% of the total participants had insufficient health literacy. This may include developing more accessible health communication tools, improving education on health-related topics, and providing tailored support to those who struggle to understand health information.
Table 8 – Gender and Literacy Level
Age and Literacy Level
The analysis of age and literacy levels reveals a clear trend of declining health literacy with increasing age. Younger participants, particularly those aged 18-29 and 30-39, demonstrate higher levels of health literacy, with 17.9% and 16.7% respectively achieving high health literacy. However, these age groups still have a majority with inadequate health literacy, at 71.8% and 66.7% respectively.
As age increases, the percentage of participants with inadequate health literacy rises significantly. The 40-49 age group has 86.9% with inadequate literacy, while this figure climbs to 96.0% among those aged 50-59. Notably, the 60-69 age group shows a slight decrease in inadequate health literacy at 83.3%, yet only 16.7% achieve high health literacy, and none reach an adequate level.
The most striking finding is within the 70+ age group, where 100% of participants fall into the inadequate health literacy category, with no representation in either adequate or high literacy levels. This suggests that older adults, particularly those over 50, face significant challenges in understanding and utilizing health information effectively.
This trend highlights the need for targeted health communication strategies that address the specific needs of older adults, who may require more tailored and accessible health education resources. Interventions could focus on improving digital literacy among older populations, as well as providing more straightforward, easy-to-understand health information. Additionally, programs that engage younger adults as potential health literacy mentors within families could help bridge the gap, fostering a more health-literate society across all age groups.
Table 9 – Age and Literacy Level
Education and Literacy Level
The crosstabulation analysis between levels of education and health literacy levels reveals a strong correlation between higher educational attainment and higher health literacy. Participants with no formal education are entirely within the inadequate health literacy category, with 100% falling into this group, indicating a complete lack of adequate or high literacy levels.
As the level of education increases, there is a noticeable improvement in health literacy. Among those with primary or secondary education, 92.3% have inadequate health literacy, with small proportions achieving adequate (5.1%) and high (2.6%) literacy levels. The trend becomes more positive at the senior secondary education level, where 56.5% have inadequate literacy, but a significant portion reaches adequate (19.6%) and high (23.9%) health literacy levels.
The most substantial shift occurs among participants with an undergraduate degree, where only 25.0% have inadequate health literacy. Impressively, 62.5% of this group achieve high health literacy, and 12.5% reach adequate literacy. This indicates that higher education is strongly associated with better health literacy, enabling individuals to more effectively access, understand, and use health information.
Overall, the data underscores the critical role of education in enhancing health literacy. It suggests that improving educational opportunities, particularly at higher levels, could be a key strategy in addressing health literacy challenges. This also highlights the need for targeted health communication efforts for those with lower educational attainment, ensuring that health information is accessible and comprehensible to all segments of the population.
Table 10 – Education and Literacy Level
Qualitative Analysis
The qualitative aspect of this study involved interviews with five doctors from the Health Promotion Bureau in Sri Lanka, who provided insights into the functional health literacy of patients. The analysis was structured around three key themes: the ability to find health information, having sufficient information, and understanding health information.
Theme 1: Ability to Find Health Information
The physicians interviewed identified the ability to find health information as a significant challenge. Dr.Ashan Pathirana emphasized that patients often face a tough challenge to find health information. “People are more likely to follow wrong information by placing more trust in the information available on Media specially social media. Although younger patients tend to use the Internet, they are not always good at identifying the correct information on the Internet. On their own, they have seen a lack of reading information”. This sentiment was echoed by Dr. Teshan Eranda Said that The need for accessible and important sources of health information is an essential factor for the modern Sri Lankan community. “Access to health information in rural areas is very limited. Also, because these people do not have access to technical tools such as social media, it is very important to bring reliable traditional health information to them. They should be informed when visiting doctors about the important facts in accessing their own reliable sources.” Further more Dr Natasha Dissanayake Pointed out The main reason for the spread of communicable and non-communicable diseases in Sri Lanka is that people are not aware of this information. “Patients who come to the doctor often expect everything from the doctor himself. They do not engage in successful empathy with the physician. Then it is difficult for the doctor to understand the patient. People think that doctor can understand everything. But for that, the patient should communicate successfully with the doctor.”
Theme 2: Having Sufficient Information
Another critical issue identified was the sufficiency of health information available to patients. Dr. Sanjeewa Rajapaksha observed that “there’s a gap in the information patients have before they come to us,” indicating that patients often arrive with only partial knowledge of their health conditions. This gap in information can lead to misconceptions, as noted by Dr. Supun Wijesinghe, who stated that patients “often know the symptoms but lack understanding of underlying causes.”
Dr. Natasha Dissanayake added that “patients need more than just diagnosis; they need clear, actionable advice,” underscoring the importance of providing comprehensive information that extends beyond mere diagnosis to include practical guidance on managing health conditions. Dr.Ashan Pathirana supported this view, suggesting that “information is out there, but it’s not always presented in a way that’s easy to grasp,” calling for more step-by-step guidance, particularly for chronic illnesses. These findings indicate a significant need for more detailed and accessible health information.
Theme 3: Understanding Health Information
Understanding health information was highlighted as perhaps the most critical component of functional health literacy. Dr. Teshan Eranda noted that “even when given correct information, many patients lack the health literacy to fully comprehend what they need to do,” particularly for complex treatment regimens. This issue was further elaborated by Dr Natasha Dissanayake, who pointed out that the “technical language used in health communication is a major barrier,” emphasizing the need for simplification of medical jargon.
Moreover, Dr. Supun Wijesinghe, observed that “there’s a significant gap in understanding among patients, especially those with lower education levels,” suggesting that tailored communication strategies are necessary to bridge this gap. Dr. Ashan Pathirana concluded that “we need to emphasize understanding as much as providing the information itself,” highlighting that effective communication should focus not only on delivering information but ensuring that it is understood by patients.
DISCUSSION
Quantitative data revealed significant variation in the health literacy levels of the sample. The majority of the sample showed limited health literacy (82.5%), with only 8% having moderate health literacy and only 9.5% showing high health literacy. A gender-based analysis showed that males had limited health literacy (85%) compared to females (76.7%). A higher proportion of women (15%) achieved high health literacy compared to men (7.1%). The analysis of these results shows that both women and men face different problems in accessing and understanding health information.
Age was also significant in the analysis of functional health literacy levels. Respondents aged 50–59 and 70+ exhibited the highest levels of limited health literacy (96% and 100%, respectively). In contrast, younger participants (18–29) showed slightly better distribution across literacy levels, with 17.9% achieving high health literacy. These findings suggest that the group without basic education is particularly vulnerable to low health literacy, possibly due to a combination of factors such as reduced access to information and cognitive decline. Data suggest that targeted interventions are needed for older populations to improve their ability to navigate and understand health information.
Education level was strongly associated with health literacy levels. Data contributors with no formal education showed 100% limited health literacy and those with primary or secondary education also had higher rates of limited health literacy (92.3%). In contrast, individuals with a bachelor’s degree had a markedly higher level of health literacy, with 62.5% achieving high literacy. This highlights the importance of education as an essential factor in increasing health literacy and underscores the importance of improving educational opportunities as a long-term strategy for improving public health outcomes.
Qualitative interviews provided further insights into functional health literacy and communication of health information to the public. The theme of health information discovery was emphasized by health care professionals, who revealed that patients often rely more on less reliable sources and are more likely to follow wrong practices if misinformed. It was revealed that more communicable and non-communicable diseases develop in rural areas where access to quality health information is limited. The data analysis suggests that health communication strategies in underserved areas should focus on improving access to reliable information.
Adequacy of information was another key theme. Physicians reported that patients often came to the clinic unable to provide accurate information or self-reports of health. It was found that it can lead to misunderstandings and hinder effective treatment. This finding is supported by quantitative data, where inadequate literacy is high among those with low levels of education. Bridging this gap highlights the need for healthcare providers to present more comprehensible information.
Understanding health information has been identified as the most important challenge. Even when patients have the right information, their ability to understand and act on it is often limited. Especially among those with less educational background. This finding underscores the importance of simplifying medical communication and tailoring it to patients’ health literacy levels. Qualitative data reinforce the need for healthcare professionals to focus not only on providing information but also on ensuring that it is understood and acted upon.
CONCLUSION
Overall, this study highlights significant disparities in the public’s functional health literacy in health information communication, with older, less educated, and male participants being particularly vulnerable. In functional health literacy, people face various challenges in reading and understanding health information. These findings suggest that tailored interventions are needed to improve health literacy, particularly for vulnerable populations. Improving health communication, improving access to information, and providing understandable and actionable education are essential steps to address these disparities and improve overall health outcomes. Additionally, there is a need for ongoing monitoring and evaluation of FHL levels to ensure that interventions are effective and sustainable. Expanding future research to include broader demographics and longitudinal studies could provide further insights into the evolution of FHL and its impact on health outcomes.
Ethical Approval
Ethical clearance was obtained from the Department of Mass Communication of the University of Kelaniya
Conflict Of Interest
The authors declare no conflict of interest.
Table with Caption
Table 1 – Sample Area
Table 2 – Age and Gender Distribution
Table 3 – Levels of Education
Table 4 – Occupation
Table 5 – Functional Health Literacy Test in Adults
Table 6 – Functional Health Literacy Test Scores in Adults
Table 7 – Functional health literacy level in adults
Table 8 – Gender and Literacy Level
Table 9 – Age and Literacy Level
Table 10 – Education and Literacy Level
Figures
Figure 1 – Don Nutbeam’s Health Literacy Modal
Figure 2- Census of Population and Housing of Sri Lanka.
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