Electronic Health Literacy, Health Literacy, and Predictors of Self-Care Behavior Among Risk Groups of Hypertension and Diabetes Mellitus in Chang Klang Community, Nakhon Si Thammarat, Southern Thailand

1. Background

Diabetes and Hypertension is one of the significant NCDs recognized by the United Nations as a global public health issue requiring stringent control measures by all countries. It is estimated that by 2040, the prevalence of diabetes will increase to 5.3 million people. Poor diabetes management may lead to severe complications such as kidney disease or limb amputations [1,2]. Hypertension is also a prominent NCD that significantly contributes to premature mortality worldwide. Many patients are unaware of their condition, and untreated hypertension can double the risk of myocardial infarction and quadruple the risk of stroke. Globally, hypertension accounts for 7.5 million deaths, or 12.8% of all deaths. Key risk factors for diabetes and hypertension include reduced physical activity, high salt and fat intake, alcohol consumption, and smoking, all of which significantly increase the disease burden [2].

Recognizing the importance of NCD prevention, the Ministry of Public Health has implemented an integrated approach through the National NCD Prevention and Control Plan. This plan focuses on reducing risk factors and lifestyle-related diseases through public screening programs that categorize individuals into four groups: normal, risk, diagnosed, and diagnosed with complications [3]. From 2022 to 2024, screening data from the Health Data Center (HDC) [4]. revealed a high prevalence of at-risk individuals in Nakhon Si Thammarat Province. For instance, the risk of hypertension was observed in 9.74%, 9.47%, and 9.95% of the population, respectively, across the years, while suspected cases accounted for 4.92%, 5.07%, and 5.20%. In Chang Klang District, these figures were higher, with 11.44%, 13.54%, and 10.15% of the population at risk, and suspected cases at 3.75%, 3.73%, and 2.55%. Similarly, for diabetes, the risk population in Nakhon Si Thammarat was 23.88%, 20.58%, and 19.10%, with suspected cases at 0.73%, 0.84%, and 0.89%. Changklang District again showed higher numbers, emphasizing the need for targeted health interventions.

Advances in technology have made the internet a critical source of health information, enabling individuals to access knowledge conveniently. While online health information empowers users to take better care of themselves and their families, inaccurate or misleading information can pose risks. Therefore, the ability to evaluate and apply reliable health information is crucial. In 2020, the global internet user population was 4.54 billion, accounting for 59% of the world's population. In Thailand, internet usage increased from 34.9% (21.8 million users) in 2013 to 56.8% (36 million users) in 2018, highlighting the growing importance of e-health literacy [5].

Health literacy [6]. is defined as the ability of individuals, groups, or communities to access, comprehend, and effectively use health information in various contexts. It involves six core competencies: 1) Accessing health information. 2) Understanding health information. 3) Communicating health information. 4) Decision-making. 5) Self-management. 6) Media and information literacy. These skills are essential for enhancing personal and family health and addressing public health challenges. E-health literacy, the ability to utilize electronic health information effectively, plays a critical role in improving health management, preventing health issues, and promoting behavioral changes. It reduces healthcare costs and unnecessary hospital visits while enhancing the quality of life [7,8,9]. Findings from this study can guide strategies to promote the effective use of electronic health information, enabling individuals to make informed health decisions and maintain a lifestyle that reduces the risk of diabetes and hypertension.

1.1. Objectives

• To explore electronic health literacy, health literacy, and self-care behavior among people at risk of diabetes and hypertension in Chang Klang community, Nakhon Si Thammarat Province.
• To examine the relationships between electronic health literacy, health literacy, and self-care behavior among people at risk of diabetes and hypertension in Chang Klang community, Nakhon Si Thammarat Province.
• To identify the predictor of self-care behaviors among people at risk of diabetes and hypertension in Chang Klang community, Nakhon Si Thammarat Province.

2. Materials and Methods

This study employed a cross-sectional analytical survey design. The target population consisted of individuals at risk of diabetes and hypertension within the service area of sub-district health promoting hospitals in Chang Klang District, Nakhon Si Thammarat Province. The sample size was determined using the G*Power software. A proportionate stratified sampling method for recruiting 472 participants was performed. The study was conducted in the Chang Klang community, Nakhon Si Thammarat Province, between October and November 2024. Inclusion criteria were individuals at risk of diabetes and hypertension within the service area of sub-district health-promoting hospitals in Chang Klang District, aged 35 years or older, able to read, write, or communicate in Thai, and possessing a smartphone or a device capable of internet connectivity during the research period. Exclusion criteria were individuals with specific characteristics that prevented participation in the research, such as unwillingness to provide information or refusal to cooperate with the research project. Participants completed a self-assessment questionnaire via Google Forms, which took approximately 15–20 minutes to complete.

The inclusion criteria included individuals at risk for diabetes and hypertension in the service areas of sub-district health-promoting hospitals in Chang Klang District, aged 35 years or older, able to read, write, or communicate in Thai, and possessing a smartphone or a device with internet connectivity during the research period. Exclusion criteria included individuals unwilling to provide information or refusing to cooperate with the research project. Participants completed a self-assessment questionnaire via Google Forms, which took approximately 15–20 minutes to complete.

The instruments used in this study were adapted from tools developed by Ruangrattanatrai et al [10]. and were divided into four parts as follows:

1) General Information: This section consisted of nine closed-ended and fill-in-the-blank questions covering demographic data, such as gender, age, marital status, education level, occupation, income, and medical history of chronic diseases.

2) Assessment of Electronic Health Literacy: This section included 8 items related to Electronic Health Literacy on diabetes and hypertension. The questions were based on a 5-point Likert scale: 5 = Strongly agree, 4 = Agree, 3 = Neutral, 2 = Disagree, and 1 = Strongly disagree. The scoring was interpreted based on Best, & John's criteria [11].: High level =3.67–5.00, Moderate level= 2.34–3.66, and Low level= 1.00–2.33.

3) Assessment of health literacy: This section consisted of 14 items assessing health literacy regarding diabetes and hypertension, divided into five domains: (1) Access to health information and services, (2) Understanding health information for self-care, (3) Evaluating information for decision-making, (4) Communicating and inquiring about health information, and (5) Managing personal health. These items were also measured on a 5-point Likert scale, with interpretation based on Best, & John's criteria [11].: High level =3.67–5.00, Moderate level= 2.34–3.66, and Low level= 1.00–2.33.

4) Assessment of self-care behavior for diabetes and hypertension prevention: This section included 13 items assessing self-care behaviors to prevent diabetes and hypertension. Responses were measured using a 5-point Likert scale: 5 = Always (7 days/week), 4 = Frequently (5–6 days/week), 3 = Sometimes (3–4 days/week), 2 = Rarely (1–2 days/week), 1 = Never (0 days/week). Interpretation of scores followed Best, & John's criteria [11].: High level =3.67–5.00, Moderate level= 2.34–3.66, and Low level= 1.00–2.33.

The research instruments were validated by three experts with expertise in Electronic Health Literacy, health literacy, and self-care or self-management among individuals at risk for diabetes and hypertension. Content validity was evaluated using the Index of Item Objective Congruence (IOC), with values ranging from 0.67 to 1.00. Furthermore, the instruments were piloted with 30 individuals who shared similar characteristics with the research participants but were not included in the main study. This pilot test was conducted in Chang Klang District, Nakhon Si Thammarat Province. Reliability was determined using Cronbach's alpha coefficient, yielding a score of 0.82.

Statistical methods included percentages, means, standard deviations, Pearson’s product-moment correlation, and multiple regression analysis. The Kolmogorov-Smirnov test was used to assess data distribution, confirming normality (P > 0.05).

The research protocol was approved by the Human Research Ethics Committee of Sirindhorn College of Public Health, Trang (Approval No. P111/2024). All data were used exclusively for research purposes. Confidentiality was strictly maintained to protect participants, ensuring no harm or adverse effects occurred during the study.

2.1. Study Results

The study revealed the following characteristics of the participants, who were individuals at risk of diabetes and hypertension in the service area of sub-district health-promoting hospitals in Chang Klang District, Nakhon Si Thammarat Province: The majority were female (68.22%), average age: 53.60 ± 11.18 years, Most were married (70.55%), the highest education level was primary school (31.77%), the majority had no chronic illnesses (61.02%), among those with chronic illnesses (32.4%), conditions included obesity, diabetes, hypertension, high cholesterol, heart disease, cancer, kidney disease, and bone and joint disorders.

The results revealed that mean scores of Electronic Health Literacy, self-care behavior, participation in health education activities, and learning from observing health role models were at a moderate level (3.44 ± 0.88, 3.56 ± 0.68, 3.44 ± 0.94, and 3.56 ± 0.71, respectively). The overall score of health literacy was at a high level (3.77 ± 0.67), with the highest score observed in the dimension of accessing health information and services (3.91 ± 0.76) and the lowest in understanding self-care information (3.67 ± 0.76) (Table 1)

The study found that all examined variables demonstrated a strong positive relationship with self-care behaviors, underscoring the interconnected nature of health literacy, active participation, and observational learning in promoting effective self-care among individuals at risk. Electronic Health Literacy on diabetes and hypertension, health literacy on diabetes and hypertension, participation in health education activities, observational learning from role models, and self-care behaviors of individuals at risk of diabetes and hypertension were positively and significantly correlated at the 0.01 significance level (p < 0.001). The Table 2 shows significant positive correlations between all variables and self-care behaviors (Y). Specifically, X2 (health literacy) and X3 (participation in health education activities) showed the strongest correlations with self-care behaviors (r = 0.56 and r = 0.48, respectively).

The results of the multiple regression analysis showed that the key predictors of self-care behaviors among individuals at risk for diabetes and hypertension were: participation in health education activities (β = 0.41, p < 0.001), observational learning from health role models (β = 0.23, p < 0.001), and health literacy on self-management (β = 0.13, p = 0.004). These variables accounted for 40% of the variance in self-care behavior (r² = 0.40). the regression model is statistically significant (f = 104.06, p < 0.001) (Table 3).

3. Conclusions

The study found that electronic health literacy, health literacy, and self-care behaviors among at-risk populations for diabetes and hypertension were at moderate levels. A significant positive correlation was observed between electronic health literacy, health literacy, and self-care behaviors. Participation in health education activities and learning from role models were identified as key predictors influencing self-care practices. The findings suggest the need for targeted health communication and interventions to enhance the understanding and application of health information in this population.

4. Discussion

This study found that the sample of risk groups of diabetes and hypertension exhibited moderate Electronic Health Literacy, consistent with Nutbeam's study, highlighting that health literacy requires continuous development.¹ Overall health literacy was rated at a high level, aligning with the findings of Wannapha Jaidee et al.² However, the study also revealed that while the sample group was proficient in accessing information, they faced challenges in understanding and applying it, a finding consistent with Somchai Kanchanapraphat's study. To address these limitations, it is recommended to develop health communication systems regarding diabetes and hypertension that are easy to understand, design programs to enhance self-care comprehension, and promote continuous health learning.

Underscoring the need to enhance self-health management capacity. Bandura's theory⁴ emphasizes that learning from role models and self-efficacy significantly influence health behavior. Similarly, participation in health education activities was at a moderate level, suggesting opportunities to design more effective and engaging learning programs. Hawkins et al.⁵ highlighted the importance of participation in health activities to improve health literacy and behavior.

Electronic Health Literacy in diabetes and hypertension self-care management reflected a moderate ability to access, understand, and utilize electronic health information, an essential skill for promoting health management in the digital era⁶

In contrast, overall health literacy was rated highly, indicating that the sample demonstrated strong abilities in comprehending and applying essential health information in daily life. High health literacy is positively correlated with improved health behaviors and a reduced risk of chronic diseases⁷.

For self-care management behavior, the average score was observed at a moderate level. This result underscores the need for measures or supportive programs to improve health self-management, such as practical knowledge-sharing activities, community support groups, and the use of digital technology to stimulate health behaviors [1]. The study supports the notion that health literacy and access to health information are key factors in promoting self-care behaviors. Further study should explore strategies to enhance health literacy in diverse populations and evaluate the effectiveness of health behavior promotion programs over the long term.

This study demonstrated positive relationships among several factors, including Electronic Health Literacy, health literacy, participation in health education activities, learning from health role models, and self-care behaviors. These relationships were statistically significant at p < 0.001, highlighting clear connections between factors that support self-care behaviors [6]. The findings revealed that Electronic Health Literacy positively correlates with self-care behavior [7]. The ability to access and utilize health information through digital technologies enhances health awareness and enables informed decision-making regarding self-care. Health Literacy and Self-Care Behavior Higher health literacy enables individuals to comprehend health information and appropriately apply it in daily life. This finding aligns with previous studies indicating that health literacy is a crucial variable influencing improved health behaviors. Participation in health education activities and learning from role models engaging in health education activities and learning from health role models, such as experts or exemplary individuals in the community, enhances understanding and encourages behavioral changes in self-care management [4,8]. Prior studies demonstrated that interactive learning and positive role models contribute to sustainable behavioral modifications in target groups [6].

Key factors influencing self-care behavior include participation in health education activities, observational learning from role models and self-health management literacy. The relative weights (Beta) of these factors highlight their varying importance: Participation in Health Education Activities (Beta = 0.41). This factor had the highest coefficient, indicating its pivotal role in improving self-care behavior. Participating in activities such as workshops and interactive training enhances knowledge, skills, and motivation for better health management, consistent with prior studies showing that interactive activities promote long-term health behavior improvements.

Learning from Role Models (Beta = 0.23) Observational learning from role models, such as community health experts, significantly contributes to the development of self-care behavior. Observing and emulating appropriate behaviors fosters confidence and motivation, consistent with Bandura’s Social Learning Theory [4]. Self-Health Management Literacy (Beta = 0.13) although this factor had the lowest coefficient, it remains essential for predicting self-care behavior. The ability to manage one’s health, such as understanding symptoms, medication use, and treatment follow-up, plays a crucial role in preventing and managing chronic diseases. These findings emphasize the importance of promoting health literacy and designing tailored health literacy and education activities to support sustainable health behaviors in Chang Klang community.

5. Recommendation

Efforts should prioritize improving understanding of health information on diabetes and hypertension self-care, the lowest-scoring aspect of health literacy. This can be achieved through simple, practical educational materials tailored to at-risk groups. Active learning activities, such as workshops, group sessions, and digital tools, should encourage engagement and personal responsibility. Community role models, including health advocates and individuals with healthy behaviors, can inspire and sustain lasting behavior change.

The study indicated that, although people can effectively access health information about diabetes and hypertension, they often struggle to understand and apply it. This underscores the need for effective health communication and learning systems focused on diabetes and hypertension self-care management. In the digital era, electronic health literacy is crucial for promoting healthy behaviors. Observational learning from role models, combined with participation in health activities related to diabetes and hypertension self-care, plays a key role in fostering sustainable behavior change.