This study found that difficulties in the consumer protection aspect vary among health competencies, with communicating being the most difficult and understanding being the least difficult. Thai citizens felt that it is relatively difficult to inquire about healthcare providers about medicine, cosmetic products, herbal products and food supplements. They were also unable to or had some difficulties in accessing reliable information about medicine, cosmetic products, herbal products and food supplements. Each health literacy competency requires different skill sets and knowledge to practice. For accessing, a person requires proficient skills and knowledge to use technology to access resources (12). For understanding, a person requires to understand meanings of words and terms as well as having experiences, to interpret information correctly (13). To be able to communicate confidently, a person has to understand the situation, realize the impact of using health products on themselves and their relatives, know how to formulate questions and has enough self-confidence to ask or start a conversation with others (13). For making decisions, a person needs to have enough relevant information about the issue as well as self-determination and to be able to critically analyse possible consequences of different choices (13). On the other hand, the context of a person plays a role in determining the degree of difficulties in practising health literacy (13). If a person responds to stimuli very well, the same person might respond differently in another context with different stimuli and different level of difficulties. Possible reasons that Thais do not ask or have difficulties in asking or communicating with healthcare providers about health-related products relate to norms, beliefs, perception, prior experiences as well as lack of question formulation and communication skills. The paternalistic nature of the patient-doctor relationship in the Thai context could also be another explanation. Health care providers are the authority who responsible for diagnosis and treatment, while patients are viewed as passive and are not expected to actively participate in the process of decision making on their care or to ask any questions (14, 15). Doctors normally do not promote health-related products such as herbal supplements or food supplements and asking questions about health-related products or supplements may offend them, leading to arguments and negatively affect the patient-doctor relationship. Some people think that having arguments with their doctors might affect how the doctors treat them or their relatives. This finding is in line with a previous study in Thailand that showed hypertensive patients did not ask for information from medical staffs because they felt obligated to their physicians, thereby missing an opportunity to gain related knowledge to take care of themselves (16).
This study confirms that health literacy levels can reflect responses as a result of interaction between individual skills required to practice health literacy competencies and the complexity of health care contexts. For optimal improvement of health literacy, there should be a match between individual skills and system demands. Skills such as searching for reliable sources and appraising reliability of information as well as asking for clarification from healthcare providers are needed to be addressed and trained. A system should be designed in a way that reduces barriers for practising these skills. Healthcare providers should encourage patients to ask questions in hospitals and primary care setting to improve patients’ understanding of relevant health information on health-related products. A good example is ‘Ask Me Three’ approach, a practice that encourages patients and family members to ask three specific questions to better understand their health conditions. The practice was found to be effective in improving patient’s understanding, communication skills, and compliance with health-related advice (17). In addition, there should be a mass communication to create a new norm that asking is a necessary action to protect one's benefits. Also, reliable sources of information are important to gain knowledge about health-related products and supplements. Another important recommendation is to promote and build skills and knowledge of the population for evaluating health information on health-related products and supplements. Finally, a monitoring and alert system for consumers about untrustworthy information of health-related products on the Internet and communities should be developed.
Our study found that people with a lower level of education, could not read, did not receive health screening, were living in poverty, did not hold leading roles in the community, were male, or have a hearing impairment or were at older age experienced more difficulties when practising health literacy competencies. The findings are similar to prior small-scale studies in Thai patients (18, 19). The extent of the association varies among competencies. These factors associated in a greater extent with accessing, followed by communicating, understanding and making decisions. The level of education influences development of health literacy competencies in a way that students have the opportunity to acquire and practice sets of skills and knowledge, especially literacy, numeracy, and critical thinking, which are crucial for practising health literacy competencies (13). Under the Thai national health education curricula for primary and secondary schools, there are sets of literacy skills, knowledge, and health-related practices that students are required to have. A lower level of education indicates fewer practices in health literacy competencies in the classroom, potentially leading to experiencing more difficulties in practising health literacy competencies in health-related contexts. The level of reading difficulty has a stronger association with health literacy competencies than the level of writing difficulty. Reading ability is crucial for accessing and understanding information, as most health-related information is presented in written forms. In Thailand, those with higher educations are more likely to have higher incomes and employed in companies with either private insurance or social security scheme or both (20). This could explain the differences that those with more income experienced less degree of difficulties in practising health literacy competencies. People who hold leading roles in the community may have more exposure to health-related information and events, and people who received an annual health screening may have more experiences in coping with various demands of the health service systems, which then helps to improve their health literacy competencies at a faster rate compared to those who did not have one.
Strengths and limitations of the study
The Thai Health Literacy Survey 2019 included health literacy measures that were relevant in Thai contexts. It measured the health literacy skills in four health domains; health care, disease prevention, health promotion and consumer protection. As the consumption of health-related products and supplements in Thailand has been increasing (5, 6), the improvement of health literacy in the consumer protection aspect might help Thai citizens make healthy choices during their life course.
Another strength comes from the sampling methods. The survey used a three-stage sampling technique based on health regions, provinces, enumeration areas and households. With the questionnaire administered face to face, the survey results ensured a better representation of Thai citizens in remote areas throughout the nation including some minorities who might have inadequate reading and writing abilities in Thai language.
A limitation of this study is that the sample overrepresented the elderly, which might have affected other factors such as adequacy of income, level of education, occupation, and ability to read and write (4). The questionnaire did not include some variables that might have affected the opportunities to gain and practice health literacy skills such as experiences of taking care of ill people in the family and duration of living with the current disease (21).