I.BackgroundChild health is an essential indicator of the quality of life in developing countries. Mothers’ literacy is often positively associated with improved child health and nutritional status (Glewwe, 1999). The possession of literacy increases the ability of a mother or a family to acquire more knowledge. Improvements in child health are considered as the consequences of enhanced of mother’s knowledge.
In short, literacy affects health, and health affects educational achievement (Grosse, 1989). Because the correlation between literacy, health, wealth and well-being is becoming increasingly important, it is crucial to include health literacy as skills required for an adult ‘to function’ in a community (Kickbusch, 2001).
Health literacy has been recognized as a key outcome measure of health promotion interventions (Nutbeam, 1996). It can be categorized as basic/functional health literacy, communicative/interactive health literacy and critical literacy. Each level has different ‘autonomy and personal empowerment’. Individual attention is focused on developing the skills and confidence to make choices that enhance individual health outcomes (Nutbeam, 2000).
As the highest level, critical literacy ideally will be achieved in which people have this capability to search for information, assess the reliability of that information and use that information to have a better control over their health determinants (Nutbeam and Renkert, 2001). Following this health literacy concept, Nutbeam and Renkert (2001) define mother’s health literacy as ‘the cognitive and social skills which determine the motivation and ability of women to gain access to, understand and use the information in ways that promote and maintain their health and that of their children’.
In terms of literacy, Indonesia has a relatively high of literacy rate of 90% (UNICEF, 2007). However, people with adequate literacy for dealing with familiar concepts and practices, such as household management can discover a considerable difficulty to understand unfamiliar issues, such as health care information (Kalichman and Rompa, 2000).
For mothers, health literacy skills are important factors in predicting child health outcomes. Indonesia as a developing country still faces many child health problems. Infant, neonatal and under-5 mortality rate was relatively high (26, 17 and 34 per 1000 live births, respectively) in 2006. Child immunization coverage is still considerably low with measles coverage of 66.2%, MCV (80%), DPT (75%) and hepatitis (74%) among one-year-olds (WHO, 2009).
Many studies show that low literacy is related with several adverse health outcomes (DeWalt, 2004). One of the ways to improve child health is likely by improving mother’s health literacy. Many recent studies have examined the impact of mother’s health literacy on child health (Sandiford, 1995). However, there are few studies focused on the barriers to mother’s health literacy. This study will investigate barriers are there to improve mother’s health literacy on child health and find solutions might overcome the barriers.
II. Objectives1. To investigate the level of mother’s health literacy in province of Aceh (functional, interactive or critical health literacy of mothers toward child health care, participation in child care programme in villages or sub districts, health seeking behaviours, efforts to gain access to health services). 2. To explore what barriers are there to improve mother’s health literacy on child health 3. To evaluate solutions that might overcome the barriers in order to enhance mother’s health literacy. 4. To create a model of intervention to improve maternal health literacy
III.MethodologyThis research will be conducted in quantitative and qualitative methods. The quantitative methods will investigate the data about the mothers’ functional, interactive and critical health literacy toward the child health care, the utilisation of primary health care by mothers in terms of health seeking behaviour, child immunization coverage and monitoring of children’s nutritional status. The data will be collected by using structured questionnaires.
The functional literacy will use the structured questionnaires of Test of Functional Health Literacy in Adults (TOFHLA) (Baker, 1999) and Rapid Estimate of Adult Literacy in Medicine (REALM) (Bass, 2003) while the interactive and critical health literacy questionnaires will be designed by modifying the existing researches that study of maternal health literacy. Then, the results will be categorized by scoring into Inadequate, Marginal and Adequate health literacy. Before the questionnaire is used for the investigation, the validity and reliability tests will be performed.
In the qualitative stage, I will conduct personal interviews and focus group discussions to find out the barriers and solutions to improve maternal health literacy. Semi-structured personal interviews will be used for mothers and health care staff (physicians, nurses and midwifes) from villages and sub-district health services. Respondents will be interviewed individually and privacy will be maintained during the interview.
For focus group discussions, they will be purposively selected to ensure the maximum variation to ensure a diversity of views about barriers to improve mothers’ health literacy within the sample. For each group, initial contact will be made by a gatekeeper such as co-ordinator of village mother’s association, wife of head of village and village midwife. All groups will be facilitated by the researcher, recorded with the participants’ permission and will be fully transcribed.
Sampling strategyParticipant will be recruited from women who have children (younger or older children) in disparate geographical areas (social/cultural/ethnic mix) to look for contextual difference and from different level of education (no education, basic, advanced and higher education).
The sample will be recruited purposively from the population data of department of health in Aceh. Women who are willing to participate, speak either Indonesia or Acehnese, and are articulate will be purposively selected for the qualitative study. For the quantitative study, respondents will be selected using the multi-stage random sampling method. All respondent selected will be assured that participation is voluntary.
Data analysisThe recorded interviews will be transcribed word for word into the language of the interview (Bahasa Indonesia, but Acehnese will be used as many people in rural areas cannot speak bahasa) and then translated into English. Categories for analysis of data will be identified at the beginning. The transcripts will be analyzed and allocated from each subject to various categories. Data will then be analyzed according to these categories. The quantitative data will be analized using SPSS statistical software version 19.0 (SPSS, Inc, Chicago, Ill).
IV.SignificanceIndonesia is a developing country with a population of nearly 250 million. Low literacy and high fertility coupled with poor economy translates into high morbidity and mortality. Women and children are the most vulnerable segments in terms of health. It is important to improve maternal health literacy and other factors related to health services in order to increase child health care.
It is a multi sector program that involves many stake holders including health department, medical education and community. It is important for medical education institution to educate their graduations of health promotion and health education against the current trend of medical education that is more likely to be a curative and specialist view.
V.OthersUSA is a developed country and well known for its reputable universities especially for public health subjects. Health system in the US is different from Indonesia that will allow me to learn more about health education especially maternal health literacy in the US health system. The project will be conducted in three years. The detail of timeline can be found in the table below.
Table 1. The timeline of researchNo| Years| Year 1| Year 2|| MonthsTasks| 1| 2| 3| 4| 5| 6| 7| 8| 9| 10| 11| 12| 1| 2| 3| 4| 5| 6| 7| 8| 9| 10| 11| 12| 1| Refineresearch question| | | | | | | | | | | | | | | | | | | | | | | | | 2| Preparation of proposal| | | | | | | | | | | | | | | | | | | | | | | | | 3| Literature review and process the local and university ethical issues| | | | | | | | | | | | | | | | | | | | | | | | | 4| Produce the questioners | | | | | | | | | | | | | | | | | | | | | | | | | 5| Data collection| | | | | | | | | | | | | | | | | | | | | | | | | 6| Data analysis| | | | | | | | | | | | | | | | | | | | | | | | |
No| Years| Year 3|| MonthsTasks| 1| 2| 3| 4| 5| 6| 7| 8| 9| 10| 11| 12| 6| Data analysis (continued)| | | | | | | | | | | | | 8| Writing initial draft| | | | | | | | | | | | | 9| Proof reading | | | | | | | | | | | | |
10| Revision and hand in| | | | | | | | | | | | |
ReferencesBaker DW, Williams MV, Parker RM, Gazmararian JA, Nurss J. Development of a brief test to measure functional health literacy. Patient Education and Counseling. 1999, 38:33-42.
Bass PF, Wilson JF, and Griffith CH. A Shortened Instrument for Literacy Screening. Journal of General Internal Medicine. 2003,18:1036-1038.
Glewwe. P. Why does mother’s schooling raise child health in developing countries? evidence from Morocco. The Journal of Human Resources. 1999; 34 (1): 124 – 159.
Grosse R.N. Literacy and health status in developing counties. Annual Review Public Health. 1989; 34: 281 – 97.
Kickbusch I.S. Health literacy: addressing the health and education divide. Health Promotion International. 2001; 16 (3): 289 – 97.
Nutbeam D. Achieving ‘best practice’ in health promotion: improving the fit between research and practice. Health Education Research. 1996; 11 (3): 317 – 26.
Nutbeam D. Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century. Health Promotion International. 2000; 15 (3): 259 – 67.
Nutbeam D and Renkert S. Opportunities to improve maternal health literacy through antenatal education: an exploratory study. Health Promotion International. 2001; 16 (4): 38 – 88.
Kalichman S.C and Rompa D. Functional health literacy is associated with health status and health-related knowledge in people living with HIV-AIDS. Journal of Acquired Immune Deficiency Syndromes. 2000; 25: 337 – 44.
The World Health Organization (WHO). WHO Statistical Information System (WHOSIS) for Indonesia. 2009. Retrieved on Jan 7, 2009. Available from: http://www.who.int/whosis/data/Search.jsp?indicators=[Indicator].Members
DeWalt D.A et.al. Literacy and health outcomes. Journal of General Internal Medicine. 2004; 19: 1228 – 39.
Sandiford P, Cassel J, Montenegro M and Sanchez G. The impact of women’s literacy on child health and its interaction with access to health services. Population Investigation Committee. 1995; 49 (1): 5 – 17.
Health Canada. Toward a Healthy Future: Second Report on the Health of Canadians. 1999. Retrieved Jan 7, 2009. Available from: http://www.phac-aspc.gc.ca/ph-sp/report-rapport/toward/pdf/toward_a_healthy_english.PDF
Provincial health office Aceh province. Health profile of Aceh province in 2007. Banda Aceh-Indonesia. 2007.
Rahmad Y. 2008, menurunkan angka kematian ibu dan bayi. The Globe Journal Banda Aceh. 2008. Retrieved Jan 8, 2009. Available from: http://www.theglobejournal.com/detilberita.php?id=1586
Serambi news, Di aceh masih banyak perempuan buta huruf. Serambi Indonesia. 2/12/2008. Retrieved Jan 8, 2009. Available from: http://www.serambinews.com/old/index.php?aksi=bacaberita&beritaid=59771&rubrik=1&topik=13
The United Nation Children’s Fund (UNICEF). Statistics Basic Indicator for Indonesia. 2007. Retrieved on Jan 7, 2009. Available from: http://www.unicef.org/infobycountry/indonesia_statistics.html