The Health Literacy Level among Adult Patients in Rural and Urban

Public Health Centers of Pandalungan Region:

A Dual-Center Comparative Study

Sofyan Nurdiansyah1, Nurfika Asmaningrum2*, Retno Purwandari3 Anisah Ardiana4,

Kholid Rosyidi Muhammad Nur5
1,2,3,4,5
Faculty of Nursing, University of Jember, East Java, Indonesia
*Corresponding Author: nurfika_asmaningrum@unej.ac.id

3. ABSTRACT Submission : 12-01-2022

Introduction: Health literacy is an important component to ensure healthy behavior which is a determinant to a
person’s health and life quality. Health literacy contributes to improving a person's health to make healthy lifestyle Revised : 23-03-2022
choices, prevent disease, seek information about appropriate treatment, and determine the best remedies to treat a
disease. Objective: This study was aimed to determine the differences in the level of adult patients’ health literacy in Accepted : 02-04-2022
rural and urban health centers in Pandalungan region in Jember regency, East Java, Indonesia. Methods: The study
was designed as comparative descriptive research. Purposive sampling was conducted on 216 adults who visited two Kata Kunci : Masyarakat
public health centers (henceforth PHCs) in rural and urban areas which were determined based on the highest visitors
Dewasa, Komparatif,
of 2019 in each rural and urban region. Data was collected using HLS-EU-16Q. The data analysis were descriptive
analysis, Mann Whitney U Test, and chi-square test. The level of statistical significance was set at p<0.05. Results: Literasi Kesehatan,
The study found a significant difference in the level of health literacy among adults who visited urban and rural PHCs Pedesaan, Perkotaan,
(p<0.001). The level of health literacy in respondents who visited PHCs urban areas (132.29) was higher than those Puskesmas
who visited PHCs rural areas (84.71). The three sub domains of health literacy showed a significant difference
between rural and urban areas (p<0.001). The location of PHCs, age, education level, and occupation were the factors Keywords : Adult,
associated with health literacy level. Conclusion: Our findings highlight the impact of geographical areas as a driving Comparative, Health
variable to the level of adults’ personal health literacy. The role of the rural-urban areas affects the individual skills Literacy, Rural, Urban,
and abilities as the precursor to health literacy. Thus, reducing health literacy barriers is an essential element for
Public Health Center
promoting health equity, which further can reduce health disparities and promotes the human rights principles of
nondiscrimination and equality.
Doi : 10.36858/jkds.v10i1.355

ABSTRAK

Latar belakang: Literasi kesehatan merupakan komponen penting untuk memastikan determinan perilaku
kesehatan dan kualitas hidup seseorang. Literasi kesehatan berkontribusi untuk meningkatkan kesehatan
seseorang untuk dapat mempengaruhi pilihan gaya hidup sehat, mencegah penyakit, mencari informasi
tentang pengobatan yang tepat, dan cara mengobati penyakit yang dialami. Oleh karena itu, literasi kesehatan
diakui sebagai penentu kesehatan dan pendukung yang dapat mengembangkan kesehatan masyarakat
pedesaan dan perkotaan.Tujuan: Penelitian ini bertujuan untuk mengetahui perbedaan tingkat literasi
kesehatan pasien di Puskesmas pedesaan dan perkotaan di wilayah Pandalungan. Metode: Desain penelitian
deskriptif komparatif dengan menggunakan teknik purposive sampling pada 216 orang dewasa yang
mengunjungi dua puskesmas di pedesaan dan perkotaan. Pengumpulan data dilakukan dengan menggunakan
kuesioner literasi kesehatan. Teknik analisis data menggunakan analisis univariat dan bivariat. Literasi
kesehatan merupakan temuan utama, analisis deskriptif, uji Mann Whitney, dan uji chi-square digunakan
untuk menganalisis data. Tingkat signifikansi statistic ditetapkan pada p<0.05. Hasil: Studi menemukan
perbedaan tingkat literasi kesehatan yang signifikan antara masyarakat yang berkunjung ke puskesmas
perkotaan dan pedesaan (p<0.001). Tingkat literasi kesehatan pada responden yang berkunjung ke puskesmas
perkotaan (132,29) lebih tinggi dibandingkan responden yang berkunjung ke puskesmas pedesaan (84.71).
ketiga subdomain literasi kesehatan menunjukkan perbedaan yang signifikan antara pedesaan dan perkotaan
(p<0.001). Jenis wilayah puskesmas, tingkat usia, tingkat pendidikan, dan pekerjaan merupakan faktor yang
berhubungan dengan tingkat literasi kesehatan.Kesimpulan: Temuan kami menyoroti dampak delineasi
wilayah geografis sebagai variabel pembeda yang secara signifikan mempengaruhi tingkat literasi kesehatan
pribadi orang dewasa. Peran daerah pedesaan-perkotaan berpengaruh pada keterampilan dan kemampuan
individu yang mempengaruhi literasi kesehatan. Dengan demikian, mengurangi hambatan literasi kesehatan
diakui sebagai elemen penting untuk mempromosikan kesetaraan kesehatan yang selanjutnya dapat
mengurangi kesenjangan kesehatan dan mempromosikan prinsip-prinsip hak asasi manusia tanpa diskriminasi
dan kesetaraan. Literasi kesehatan adalah solusi masalah kesehatan di masyarakat untuk mengendalikan
kesejahteraan mereka sendiri dengan membuat pilihan perawatan kesehatan yang baik. Tampaknya perlu
untuk merancang dan mengimplementasikan berbagai program pendidikan untuk meningkatkan literasi
kesehatan umum.

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Introduction: higher incidence of disease and/or disability,
The potential for gaining health and increased mortality rates, lower life
well-being across the people's lifespan is the expectancies, and higher rates of pain and
vision of healthy people 2030. Healthy suffering.
people 2030 is the fifth edition of 10-year One of the factors affecting the level of
healthy people goals after 2000, 2010, and health literacy is demographic conditions.
2020. To maintain health and well-being for Based on the density of population,
all, one of its overarching goals highlights development, amenities, employment
the values of “eliminating health disparities, opportunities, education, etc., human
achieving health equity, and attaining health settlement is majorly divided into two
literacy. Of these components, health literacy categories i.e., urban and rural areas. Based
(HL) is a central focus of healthy people on demographic conditions, in the eastern
2030 (Office of Disease Prevention and part of East Java province there are
Health Promotion, 2021). Thus, to increase Pandalungan region which are divided into
health equity and reduce health disparities, three groups, West Pandalungan (Pasuruan
an essential element in the effort is and Probolinggo), East Pandalungan
eliminating health literacy barriers (Logan et (Situbondo and Bondowoso), and South
al., 2015). Pandalungan (Lumajang, Jember, and
HL is an important component to ensure Banyuwangi). Among the Pandalungan
healthy behavior which is a determinant to a region, Jember is the most attractive city for
person’s health and life quality (Nurjanah & growth among others (Zoebazary, 2017). The
Mubarokah, 2019). Health literacy is the term “Pandalungan” is a form of cultural
extent to which individuals attain, manage, assimilation between Javanese and Madurese
and understand health information and apply as local community identity, which has high
that information in health decision making level of kinship and potential of social
(Parker et al., 2003; Fleary et al., 2018). cohesion.
Health literacy has been described as both a
‘risk factor’ and an ‘asset’. On the other According to the data from the Central
hand, as an asset, health literacy can be seen Bureau of Statistics of Jember regency in
as a means to empower individuals and 2014 there were 49 Public Health Centers
communities to exert greater control over (PHCs) in the working area of Jember
their health and over a wide range of social regency, East Java, Indonesia. Of these
and environmental determinants of health. public health centers, 6 PHCs were located
Health literacy has a big role in improving in urban areas, and the remaining of 43
one’s health. If an individual has a fairly PHCs located in rural areas. According to
good health literacy, it can influence the data from the most visitors on PHCs in 2019,
choice of a healthy lifestyle on a daily basis, the PHC of Tanggul represented the highest
prevent a disease, and seek information visitors in rural areas, incorporating 176.326
about appropriate treatment and medical care people. Meanwhile, the urban areas were
for treating a disease (Berkman et al., 2011). represented by the PHC of Patrang with the
HL is also seen as an important policy number of visitors incorporated 93.073
issue as it is central to public healthcare people. People in rural and urban areas tend
quality, cost, safety, and informed decision to have different characteristics. People in
making. Equally relevant to health disparities rural areas are relatively calm and gentle,
are the human rights principles of and they tend to be communal; while those
nondiscrimination and equality. Health in urban areas have a mentality and
disparities are differences in health status personality type that is more dynamic,
when compared to the population overall, materialistic, and individual (Zoebazary,
often characterized by such indicators as 2017). Such demographic conditions

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contribute to the differences between rural the validity and reliability test documented
and urban communities. Thus, the Cronbach’s Alpha of 0.77 and item total
comparison between the two is worth further correlation ranging from 0.432 to 0.640 with
investigation. When the level of health r Alpha value >0.3. These statistics implied
literacy in rural and urban communities is that the HLS-EU 16Q were valid and reliable
low, they will face more challenges in their (Nurjanah et al., 2016). The data collection
health problems, one of which is the issues in was carried out from September to October
accessing various kinds of information and 2020 and the second was carried out in
using the health service system. This proves August-September 2021 at Tanggul Health
that health literacy still remains problematic. Center and Patrang Health Center, Jember
Literacy is an important component to ensure regency. The data was obtained by
healthy behavior which is a determinant to a distributing public health literacy
person’s health and life quality (Nurjanah & questionnaires and visiting both PHCs.
Mubarokah, 2019). Thus, predicting a Statistical analysis was operated by a
person's ability to understand basic health computer system. Univariate analysis was
information calls forth appropriate health presented in the distribution frequency table
decisions, and that requires a satisfactory (f) and percentages. Data were also presented
health literacy level. Therefore, this study as mean and standard deviation (SD) as well
aimed to determine differences in the level of as a median and interquartile range (Q1–Q3)
patient health literacy in rural and urban for each subdomain of health literacy. While
health centers in Jember regency. bivariate analysis a non-parametric test was
operative, the Mann Whitney U Test was
Methods: used to determine the difference between 2
The study was a descriptive comparative independent groups. A chi-square test was
analysis gathered from dual centers of PHCs, used for analyzing the type of area Public
each of which represented the rural and Health Center, gender, age level, education
urban area of Pandalungan region in Jember level, and occupation to determine the
regency, East Java, Indonesia. The research contributing factors toward health literacy
sample was conducted by purposive level. Value of p < 0.05 was the threshold to
sampling on 216 adults who visited two identify significant differences.
public health centers as representative of Prior to collecting data, the first author
rural and urban areas which were determined approached patients who met the inclusion
based on the data on the most visitors in each criteria by visiting them at the Public Health
region. The samples were determined using Center and explained the objective and
inclusion and exclusion criteria. The nature of the study. Participants were assured
inclusion criteria were: 1) aged >20 years, 2) of confidentiality and anonymity. If the
willing to participate in the study, 3) patient agreed to participate in the study,
registered at Public Health Centers in urban they signed a written informed consent form.
areas or rural areas of Pandalungan region in Ethical approval for this study was obtained
Jember regency, 4) Adult patients with from the Faculty of Nursing, Jember
vision or hearing impairments and pediatric University with reference number
patients were excluded. 26/UN25.1.14/KEPK/2020.
The research employed a questionnaire
on public health literacy (HLS-EU 16Q), Results:
which consists of three indicators: health The study involved 216 respondents
care, disease prevention, and health who visited the PHCs in rural and urban
promotion, with a total of 16 questions with areas which were divided proportionally
the following choices: very difficult, fairly between each area as shown in Table 1. Most
difficult, easy, and very easy. The results of of the respondents who visited rural PHC

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were aged 21-27 years (31.5%), were mostly 21-27 years old (39.8%), mostly
predominantly female (66.7%), gained high female (51.9%), and earned high school
school education (37%), and worked as education (45.4%). Some respondents
entrepreneurs (27.8%). Some participants indicated that they often used the access to
revealed that they rarely used the access to health information from TV, internet, and
health information from TV, internet and radio.
radio. Meanwhile, the characteristics of
respondents who visited the urban PHC’s

Table 1. Demographics of participants visiting rural and urban PHCs in Pandalungan region (n=216)
Urban (n=108) Rural (n=108)
Demographic characteristics
Frequency Percentage Frequency Percentage
Age (years)
43 39.8 21 – 27 34 31.5
20 18.5 28 – 32 24 22.2
21 19.4 33 – 39 23 21.3
24 22.2 40 – 65 27 25.0
Gender
52 48.1 Male 36 33.3
56 51.9 Female 72 66.7
Education level
0 0 Not completed 11 10.2
1 0.9 Elementary school 10 9.3
5 4.6 Junior high school 23 21.3
49 45.4 High school 40 37.0
13 12.0 Diploma 7 6.5
40 37.0 Bachelor 17 15.7
Occupation
6 5.6 Unemployed 11 10.2
3 2.8 Farmer 27 25.0
28 25.9 Entrepreneur 30 27.8
25 23.1 Civil servant 16 14.8
18 16.7 Private employee 16 14.8
28 25.9 Student 8 7.4
Health Information Access (TV)
36 33.3 Often 25 23.1
50 46.3 Sometimes 39 36.1
22 20.4 Seldom 43 39.8
0 0 No answer 1 0.9
Health Information Access (Internet)
62 57.4 Often 36 33.3
31 28.7 Sometimes 35 32.4
14 13.0 Seldom 32 29.6
1 0.9 No answer 5 4.6
Health Information Access (Radio)
3 2.8 Often 2 1.9
5 4.6 Sometimes 13 12.0
70 64.8 Seldom 75 69.4
30 27.8 No answer 18 16.7

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 Table 2. Sub-domain of Health Literacy across two PHCs in rural and urban areas

Urban (n=108) Sub Variable Rural (n=108)

Mode Median Q1 Q3 Min-Max SD Mean P Mean SD Min-Max Q3 Q1 Median Mode

7 7 6 7 3-7 1.131 6.31

Health Care 5.33 1.658 0-7 7 4 6 7
(p<0.001)
5 5 3 5 1-5 1.285 4.05
Disease Prevention 3.08 1.692 0-5 5 2 3 5
(p<0.001)
Health Promotion
4 4 3 4 1-4 0.815 3.49 2.78 1.285 0-4 4 2 3 4
(p<0.001)
16 15 12.25 16.00 7-16 2.872 13.84 Health Literacy 11.19 3.631 3-16 14.00 8.00 15.00 16

The measures of HL consist of three Although a similar pattern is evident among

sub-domains: health care, disease prevention, those in rural PHC, nearly a half of rural
and health promotion. Of three sub domains, respondents have adequate HL and a quarter
the respondents in urban areas tend to have (25.9%) of respondents have inadequate
higher HL mean scores than those in rural health literacy.
areas. The overall mean score of HL shows
that mean score of HL of adults visiting Table 4. Comparative Analysis of Health
urban PHC is 13.84, which is classified as Literacy between Rural and Urban PHCs
(n=216)
adequate, meanwhile adults visiting PHC in N Mean P-
rural areas mark a mean score of 11.19, Rank Value
classified as problematic. The three sub Rural Health 108 84,71
domains of health literacy document a Literacy
< 0.001
significant difference between rural and Urban Health 108 132,29
urban areas (p<0.001) (Table 2). Literacy

Table 3. Health Literacy Levels across two In comparative analysis, HL among

PHCs in rural and urban areas (n=216) those visiting the urban and rural PHCs is
Urban Rural
(n=108)
Health Literacy
(n=108) marked with a significant difference. The
Freque Perce Freque Perce
ncy ntage ncy ntage
Mann Whitney U Test documented average
9 8.3 Inadequate 28 25.9 rural health literacy level at 84.71 and urban
18 16.7 Problematic 34 31.5 health literacy at 132.29. According to the
81 75.0 Adequate 46 42.6
non-parametric test (p < 0.001), there was a
significant difference in the health literacy
Table 3 displays the HL levels among scores between Rural and Urban Public
respondents who visited PHCs in rural and Health Center (Table 4).
urban areas. In majority, the respondents in
urban PHC have adequate HL, and less than
10% respondents have inadequate HL.

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 Table 5. Contribution of demographic factors to health literacy level

Health Literacy
Characteristics Options X2 p- Value
Inadequate Problematic Adequate
N % N % N %
Area Urban 9 8.3 18 16.7 81 75.0 24.326 <0.001
Rural 28 25.9 34 31.5 46 42.6
Total
Gender Male 14 15.9 22 25.0 52 59.1 .184 0.912
Female 23 18.0 30 23.4 75 58.6
Total
Age (years) 21 – 27 5 6.5 14 18.2 58 75.3 28.153 <0.001
28 – 32 10 22.7 11 25.0 23 52.3
33 – 39 4 9.1 12 27.3 28 63.6
40 – 65 18 35.3 15 29.4 18 35.3
Total
Education level Not completed 9 81.8 1 9.1 1 9.1 108.491 <0.001
Elementary school 8 72.7 3 27.3 0 0.0
Junior high school 9 32.1 14 50.0 5 17.9
High school 8 9.0 25 28.1 56 62.9
Diploma 3 15.0 4 20.0 13 65.0
Bachelor 0 0.0 5 8.8 52 91.2
Total
Occupation Unemployed 1 5.9 5 29.4 11 64.7 87.415 <0.001
Farmer 19 63.3 9 30.0 2 6.7
Entrepreneur 10 17.2 23 39.7 25 43.1
Civil servant 3 7.3 5 12.2 33 80.5
Private employee 3 8.8 8 23.5 23 67.6
Student 1 2.8 2 5.6 33 91.7
Total 37 17.1 52 24.1 127 58.8

To explore the factors toward health literacy of each rural and urban area on the site.
level among adults who visited rural and Personal HL refers to the degree of
urban PHCs in the Pandalungan region, all individuals having the ability to find,
variables were included in the analysis as understand, and use information and services
independent variables using chi-square test. to make health-related decisions and take
The results displayed on Table 5 showed that necessary measures for themselves and
the location of PHC, age, education level, others (Office of Disease Prevention and
and occupation were statistically significant Health Promotion, 2021).
differences (p < 0.05). Hence, these variables The findings showed that there are
were associated with health literacy level differences in health literacy between rural
among adults who visited rural and urban and urban PHCs. This finding was supported
PHCs in Pandalungan region. by Golboni et al., (2017) who found that
health literacy was lower among rural
Discussion: people, compared to their counterparts in
The study investigated personal health urban areas. Another study by Wang et al.,
literacy differences across the two groups of (2020) stated that health literacy status was
adult patients who sought health care at different between urban and rural areas.
PHCs in rural and urban areas in Jember. Higher levels of comprehensive health
The selected PHCs represented the regional literacy in urban areas are commonly
characteristics with regard to the first layer acknowledged in previous works. The level

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of health literacy in rural and urban with lower health literacy are more likely to
communities is affected by multiple hesitate to seek remedies when sick,
determinants. In terms of personal resulting in delayed diagnosis and treatment
characteristics, health literacy is predicted by even at more advanced stages of disease.
age, race, gender, socioeconomic status, This results in higher morbidity and
education, occupation, and income. The mortality rates.
determinants of society and the environment The health literacy in urban and rural
including demographic conditions, culture, areas is believed to have a significant
language, and community systems as well as relationship with the differences in
social determinants (Sorensen et al., 2012). demographic characteristics between these
Univariate results in this study indicate areas, especially on inequalities in socio-
that health literacy in urban areas is higher economic levels and geographical
than that in rural areas. This is related to the conditions, namely the distance to health
demographic conditions in urban areas care centers and remote population
characterized with plenty of access to health settlements (Golboni et al., 2017). Health
information. The use of adequate media is literacy is a solution to health problems in
crucial in the course of various information, the community to take control of their own
especially health information. As such, urban well-being by making good healthcare
communities have high health literacy. High choices. The study suggests various designs
health literacy makes people have greater and implementations of educational
control in improving and maintaining their programs to improve general health literacy.
health (Marinda, 2019). This study is Culturally appropriate interventions, using
supported by Wang et al., (2020) mentioning principles of health literacy in community-
that health literacy status has a clear based settings, can result in improved health
difference between urban and rural areas literacy at the population level.
which shows a higher level of Health literacy is intrinsically linked to
comprehensive health literacy in urban areas. both individuals and a community's
On the other hand, this study indicates socioeconomic context and is deemed a
that health literacy in rural areas tends to be powerful mediator to the social determinants
lower than that in urban areas. This study is of health. Of other evidence-based strategies,
consistent with the research by Zahnd et al., health literacy interventions are viable
(2009), which points out that rural residents options to address social adversity and
have lower literacy rates for all literacy environmental health determinants to
types. Low health literacy can be a barrier to reducing health disparities, which fosters
accessing and receiving safe and effective health equity and social justice (Logan et al.,
healthcare. Those with low health literacy 2015). Health literacy has been used to
are also more likely to make medication describe the ability of individuals to locate,
errors, for example, due to misinterpreting interpret, and apply health information for
labels and health messages, being unable to decision making. In seeking appropriate and
identify medication and misunderstanding relevant health information, one should have
instructions. Low health literacy therefore the ability and skills in obtaining
has negative impacts on the implementation information, such as how to access, search,
of health management plans, self- identify, find, read, understand, evaluate, and
management of disease and individual health utilize the information obtained. In the
behaviors, and health outcomes. Low health healthcare system, there are still some people
literacy is associated with higher use of the with inadequate health literacy in dealing
emergency department, more with disease problems, such as chronic
hospitalizations, and lower rates of diseases.
preventive health service. Furthermore, those

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 As the study was conducted during the https://doi.org/10.1016/j.pec.2020.06.0
first wave of pandemic COVID-19, a 07
previous study in China found that rural Berkman, N. D., Sheridan, S. L., Donahue,
residents were less likely to perform K. E., Halpern, D. J., & Crotty, K.
preventive behaviors, more likely to hold a (2011). Low Health Literacy and
negative attitude toward the effectiveness of Health Outcomes : An Updated
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they had lower levels of information Medicine, 155(2), 97–107.
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2019). Urban Health Information Access and
The study was limited in several ways. Use. Journal of Rural Health, 35(3),
As the data collection occurred during the 405–417.
early wave of the COVID-19 pandemic, it https://doi.org/10.1111/jrh.12335
impacted on decreased adult patients who Fleary, S. A., Joseph, P., &
visited the public health centers in both Pappagianopoulos, J. E. (2018).
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carried out using random sampling behaviors: A systematic review.
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Conclusion: https://doi.org/10.1016/j.adolescence.2
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adult patients in urban PHC are significantly Golboni, F., Nadrian, H., Najafi, S., Shirzadi,
higher than those in rural PHC of S., & Mahmoodi, H. (2017). Urban–
Pandalungan region. Rural communities rural differences in health literacy and
have inadequate health literacy compared to its determinants in Iran: A community-
urban communities who have adequate based study. Australian Journal of
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health literacy in urban communities is https://doi.org/10.1111/ajr.12378
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reduce health disparities, it is important to Report On Health Literacy in Eight EU
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