Assessing and Improving Health Literacy and Wellbeing in Thai families at risk of NCDs: The Development of a Culturally Relevant Health Behavior Model and a Positive Psychology and Health Literacy Program

Ungsinun Intarakamhang1 & Ann Macaskill2


1
Ungsinun Intarakamhang

Associate Professor of Health Psychology and Behavior Science
Address: Behavioral Science Research Institute, Srinakharinwirot University 114 Sukhumvit23 Rd., Wattana district, BANGKOK 10110 Thailand
Email: ungsinun@gmail.com Tel. +66-891653520


2
Ann Macaskill

Professor of Health Psychology, Head of Research Ethics,
Address: Faculty of Development and Society, Unit 8 Science Park, Howard Street, Sheffield S1 2 WB Sheffield Hallam University
Email: a.macaskill@shu.ac.uk Tel. +44 (0)114 225 4604

 

Abstract

The 9th Global Conference on Health Promotion, 2016 focused on health risks and wellbeing for sustainable development. The research aims to address previously identified regional health issues and improve health literacy (HL) and health behavior (HB) through educating adult family members. Via a multi-phase study, to understand the family factors that influence HB by interviewing adult family members (spouses) with good HL to examine how this is achieved; from the literature and the interview data to produce a new culturally relevant Thai health model and examine it by surveying 2,000 spouses at risk of non-communicable diseases in rural and suburban areas; to develop standardized instruments from the survey as screening tools for health services; to implement and evaluate a positive psychology and HL program based on areas of need as identified in the survey. Data will be analyzed via content analysis, CFA, SEM and MANCOVA. Guidelines for the improvement of the quality of community care and a training package for wider distribution will be produced based on the research.

  • Background:

    Thailand has experienced rapid growth and economic transformation resulting in changes in lifestyles and social norms some of which challenge the population's health. Thai families are prone to preventable chronic non-communicable diseases (NCDs), from lack of exercise, malnutrition, stress, smoking, and alcoholism (Theparuk, 2007). In Thailand, in 2000-2010, hypertension prevalence increased five fold and diabetes by 11% (Tienthaworn, 2013). In 2014, Thais had the second highest rate of obesity in ASEAN, with 40% of women classified obese. Research suggests that many problems are related to deficiencies in government health policies (CSSP, 2004). WHO (2009) identified developing health literacy (HL) as core to improving health and well-being. HL is defined as ‘cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health’ (WHO 1998). Social norms influence how health literacy is operationalized. The family is central to developing HL (ASEAN 2009). Research on Thais in 2013 (N= 4401) found that 72% of the sample had low HL, with 54% displaying unhealthy behavior (Intarakamhang, 2013), hence the need for improved HL. This study broadens the definition of health, to include well-being as this is core to quality of life and also measures the character strengths (CSs) that individuals bring to their daily lives as these are resources that can be developed to improve well-being. In Positive Psychology (PP) well-being is, "…a positive state of being with others in society, where needs are met, where one can act effectively and meaningfully to pursue one's goals, and where one is able to experience happiness and feel satisfied with one's life" (McGregor 2007). Previous research reported that family and PP factors like CSs directly influence well-being (Intarakamhang, 2015; Macaskill, 2014). This will be explored to inform later interventions. This mixed methods study aims to understand the influence of changing social norms on HL and healthy behaviors in families in Thailand at risk of NCDs. From this a culturally relevant health model integrating Western models and Thai practice as analyzed from a qualitative study will be identified. A survey will be developed to test the model's applicability and measure HL, behaviors and wellbeing in the general population and to compare causal relationships of culturally social and positive psychology factors affecting good wellbeing of family between heterogeneous married couples in semi-urban and rural areas.   Based on the results, an intervention program to enhance HL and HB by educating parents will be produced and evaluated.

  • Phase 1:

    Aims to explore what is currently possible by interviewing healthy husbands and wives in 6 families with children, living (>5 years) in a suburban community in a province with high levels of  HL as identified in a 2014-2016 survey (Ministry of Public Health). From content analysis a qualitative understanding of the underlying determinants of behaviours and the role of social norms in influencing HL and healthy living will emerge. The interview schedule will be theoretically informed from current models of health e.g. Berkman et al. (2011); Ryan et al (2009) and their fit within Thai culture will be explored.

  • Phase 2:

    From a synthesis of the interview data and literature identified in a systematic review, a new culturally relevant causal relationship model will be developed, identifying the variables that affect HL and family well-being. This provides the model to be assessed, modified and implemented. A questionnaire based on the model content will be developed using standardized measures where possible but with new measures if necessary. It will add to knowledge by including PP outcome measures to capture family well-being and CSs assessment to identify personal resources and inform future interventions. Data analysis using SPSS, CFA and SEM will be used to explore the model. The adequacy and cultural relevance of the model will be explored and modifications made. The survey sample of 2,000 spouses at risk of NCDs will be identified from different regions using stratified random sampling. HL is thought to be lower in rural areas and this allows comparison.

  • Phase 3:

    Informed by Phases 1 and 2 the aim is to implement and evaluate interventions to improve PP & HL, health and family wellbeing for 100 spouses at high risk of NCDs in communities that have experienced the greatest life style changes. The evaluations will utilize baseline measurement, post-intervention and follow-up measures. Data are analyzed by MANCOVA. The evaluation timelines will depend on the nature of the intervention. The outcome of this program will be culturally relevant instruments to assess Thai health, guidelines for families and clinicians and interventions for health professionals to use to improve the quality of community care. Health model applicable to Thai culture, integrating western and Thai perspectives will be produced. The program will function as a training module that can be widely distributed in the health services.

  • Planned research outputs:

    1. Four peer-reviewed quality journal articles on the following topics:

    • a) Qualitative paper on health literacy and behaviour in Thai families with high levels of HL and discussion of how this is achieved in a country where health literacy is generally low.
      b) Adaptation of Western health models to produce a culturally relevant Asian health model with associated measures.
      c) Comparison of health literacy and health behavior in rural and suburban Thai families.
      d) Development and evaluation of a positive psychology based health program to improve health literacy and health behavior in Thailand.
    2. Standardized health literacy and health behavior measurement tools tailored to the needs of an Asian developing country (Thailand, but could be tested elsewhere in Asia).

    3. An empirically evaluated intervention program to develop health literacy incorporating perspectives from positive psychology.

    4. An educational course with relevant materials that can be used to train health professionals (practitioners and students) to deliver the intervention program, including use of the measurement tools.

    5. Health promotion materials as part of the training package on Health Literacy.

    6. Reports for government departments and health care providers as required.

    7. A teaching module on ethics in psychology research for the new Thai MSc health psychology graduate students and which can be used on the wider Applied Behavioral Science curriculum in the BSRI in Thailand.

    8. A book chapter relating the development and application of positive psychology to health literacy covering measurement, intervention and research evaluation.

    9. Opportunities will also be taken to disseminate the findings at research conferences and public talks to relevant health and policy bodies.

  • Plan of action:

    30 September 2017– Late-March 2018:

    Research in Thailand as described in Phase 1 of the study. The overall study will be set up with access agreements finalized for different areas, 2 research assistants briefed and training delivered. Interviews undertaken, analysed and written up to produce a picture of how families with good health literacy achieve this state. Collaborating with Ann by Email on the analysis and writing the paper. Literature reviewing on health models will be on going. Phase 2 of the study. To develop a model applicable to the Thai health context, literature reviewing and developing tools to assess the culturally specific model.

    1 April – June 2018:

    Study in the UK to undertake preparation for Phases 3 of the research. A training program will be prepared for me and meetings with relevant people organised. I will attend Research Ethics and Research Integrity courses and explore the SHU ethics system, academic English and academic writing courses, psychology and health seminars and a conference to enhance my professional development as well as familiarizing myself with the MSc Health Psychology by attending sessions, staff meetings and meeting students. My network of health psychology contacts will be expanded and my knowledge of the discipline will be developed significantly. I work closed with Prof.Ann for a paper publication of the results in Phase 1 and 2. And in June 11-15, 2018- I plan to oral present the research paper at conference in Bulgaria.

    July 2018- November:

    Work with Ann to develop modules on ethical standards required in psychology research and health promotion and organised the training courses. Produce materials for the survey, including translation into Thai, contact gatekeepers and work on locating suitable samples. Train 4 research assistants and by November/ December implement data collection by RAs.

    Late November-December 2018:

    5-day training course for the Thai faculty and graduate students delivered by Ann and health psychologist colleague from SHU. This will update and improve knowledge of research ethics and introduce the concept of Research Integrity and the international agenda on this to significant numbers of Thai psychologists, masters and doctoral students. The second workshop will increase knowledge of Health Psychology, a new discipline in Thailand and Positive Psychology which to date has not been applied much in Thailand. This will also allow time to consider global perspectives of health psychology beneficial to all participants. Time will be allowed for discussion of future research collaboration to ensure we maintain and strengthen our links. Review research to date with Ann and plan for next steps in face-to face meetings.

    January- April 2019:

    Finalize survey data collection then analyse data on the model and the comparison between communities. Write up results and begin on papers. Using results undertake final changes to implementation program at Phase 3.

    April–September 2019:

    Phase 3 implementation involving the delivery and evaluation of a Health Literacy program incorporating Positive Psychology with three measurement points, baseline, end and follow-up. Waiting list controls may also be used if numbers make this feasible. Analyse data and complete write up of journal papers and book chapter. Based on results modify the instruments used in program, produce guidelines for families and clinicians, produce the final intervention program for health professionals and content of the education modules to improve the quality of community care and provide valuable health education resources.

  • Plans for publication /dissemination:

    I will publish with my co-applicant and while specific journals have not been finalised, they are likely to be an Asian journal for the qualitative study to maximize relevance to the readers, the Journal of Health Psychology for the theoretical model, while for the paper on Thai Health Literacy and Health Behavior in different groups, the Journal of Research in Health Science is a possibility while the intervention paper will be targeted at the Journal of Positive Psychology or the Journal of Happiness Studies. The book chapter is likely to be in Thai for the home market. Health and positive psychology conferences will be targeted for the dissemination of the research via conference papers. Opportunities to present the research in talks to relevant health and policy bodies will also be sought. I plan to apply to the National Honorable Award for Research Articles which comes from the Institute of Development Administration of Thailand with some of these papers. I also plan to apply with a report of this research to the honorable award from the National Research Council or the Thailand Research Fund-TRF.

  • Other participants:

    Research assistants in different parts of the country to help with data collection and data management as follows:
    1.Head of Red Cross station at 6 of Thai Red Cross Society, Cambodia border as local researcher.
    2.Dr. Nachima Mah, Lecturer of Yala Rajabhat University, South of Thailand, Malaysia border as local researcher.
    3.Dr. Pichada, Phd. in Applied Behavioral Science Research as Research Assistant.
    4.Dr. Sirinate, Phd. in Applied Behavioral Science Research as Research Assistant. She also works in public health so has access to potential research participants and has relevant knowledge of existing provision to contribute.
    While these research assistants already have a good level of competency in research and data collection, they will be offered further training and support as necessary to help develop their skills in the field and they will gain valuable research experience. They will be offered the opportunity to participate in the training for the intervention program to broaden their knowledge and skills further for their future careers. Their contribution to the research will be acknowledged in publications.
    Advisor:
    Director of Health Education Division, Department of Health Service Support, Ministry of Public Health brings knowledge of current initiatives in public health and also is willing to act as a contact with the health Policy Makers in her Department. Through her, the Ministry of Public Health will be informed of the outcomes of the research at each stage and will benefit from this.
    Gatekeepers: Chief of Medical Officer, Chachoengsao Province and Chief of Medical Officer, SraKao Province, manage the provision of medical services including health education in their areas and will facilitate access to suitable populations. In return they will be kept informed of the results of the research and their areas will benefit from the intervention program.

  • Ethical approval obtained:

    No special ethical issues will arise that are outside the BPS and University Codes of Ethics. Yes, outline ethical approval for this research was given by the institutional review board (IRB) of Srinakharinwirot University in phase 1 and 2 (Certificate of approval no. SWUEC/E -099/2560) with an expiry date of 04/09/2018. This means that it is envisaged that any ethical issues that arise can be addressed satisfactorily in the study. Detailed protocols will be submitted to the IRB of Srinakharinwirot University before each phase of the study and no research will be undertaken until approval from this board has been obtained. My co-applicant is Head of Research Ethics at her university and will collaborate on obtaining ethical approval.

  • Benefits to individuals/institutions:

    Both applicants, their research groups and universities will benefit from the publication of four high quality journal articles. The award will be an important mark of esteem for both universities. It will help me to further develop my research skills and raise the profile of my research within the BSRI, and in Thailand. The success of this project will cement my links with community health services and make access and local funding for future research easier. It will give me the credibility to develop consultancy work so that I can continue to spread the knowledge I gain to health practitioners to benefit the Thai people.
    In terms of teaching, currently health psychology is under developed in Thailand. Next year, my department opens a Master's in Health Psychology which I will lead. I will learn more Health Psychology by attending Sheffield Hallam University with Prof. Ann Macaskill as she is an expert in Health Psychology, a practitioner with the UK Health Professions Council. I can explore the curriculum, attend taught sessions, talk to staff and students and develop in depth knowledge of a BPS approved UK MSc in health psychology. This will contribute to the long term development of my course in the BSRI. Through the Sheffield course team Sheffield I will meet other health psychologists and widen my professional network for future collaborations. The program will allow us to share ideas and assess the relevance of knowledge on positive health psychology from a holistic and global standpoint benefiting us both. We will benefit from gaining knowledge of health concerns in each other's country allowing us to understand health more globally. I will deliver a seminar on this and research within a collectivist culture for the health program in Sheffield and the university. I will benefit from showcasing this research at an international conference on Family Wellbeing and Quality of life in the community in 2018 hosted by the BSRI and a Malaysian University.

  • Benefits to Overseas Country:

    This research will provide knowledge of HL, HB and family wellbeing in Asian people from different socio-economic backgrounds so Thai policy makers and International Development Agencies (WHO, UNDP) can understand the specific issues in Asia and implement policy to tackle these issues. Working with a Newton Fund partner country will add credibility allowing expansion and strengthening existing networks and collaborations with local partners including university personnel, international donors, policy makers, primary health workers and health care providers in Thailand and ASEAN region.
    The research will contribute to advancing the social welfare of Thailand by supporting Thai families to improve their HL and HB. I have already had discussions with the Thai Public Health Ministry and they said the findings will be implemented. For example, they could inform the introduction of health education targets for medical workers, e.g. % improvements in HL, HB by specified ages. They also suggested that policymakers could use it to inform the social welfare provision for clients in the health behavioral change clinics in public hospitals.
    Funding in Thailand will focus more on developing HL and HB as a way of improving Thai health and wellbeing something that is badly needed given the high incidence of non-communicable preventable diseases. If this research is successful, it will help many sectors, locally in Thailand, at the Asian and global level and individual clients, families, communities, health providers, policy makers, students and researchers. They will all benefit. In addition, through the high quality publications that will be produced jointly by the applicants, it will contribute knowledge to international researchers, emphasizing the importance of culture in health and in health models. I plan to disseminate this research to Malaysia, Cambodia and Myanmar at the IPRC Conferences and by teaching Asian undergraduate and graduate students in my University.

  • Benefits to UK:

    The UK is a multi-cultural society, yet the models of health commonly applied regardless of the cultural heritage of ethnic minorities are Western individualised medical models. Integrating knowledge to develop culturally more specific health models applicable to more collectivist cultures such as found in Thailand and other Asian cultures will allow UK health professional to become aware of the differences in health beliefs, practices and behaviours in different cultural groups within the UK. The material could be used to contribute to a training fro health professionals working with different ethnic minorities to improve understanding and ultimately the delivery of health care services. While the research findings will add to the knowledge base of UK researchers, the culturally appropriate approach taken to the research such as always interviewing husbands and wives together as a unitary part of the family challenges the western individualistic approach to research.

  • Training Programme:

    While I will receive specific training to meet my career development needs as outlined in the benefits to individual's section. Specific training on Research Ethics and Integrity and on Health Psychology in a global context will be delivered to a wider Thai audience. The first Thai training program is on Ethical Standards in Health and Psychology Research and Research Integrity, to be attended by Thai University ethics committee members, lecturers in health and psychology and PhD students. While research ethics training was delivered twelve years ago, it seems appropriate to examine more recent international developments as much has changed. The enhanced international emphasis on Research Integrity is relatively new and is an area where no training has been delivered so would definitely be of benefit to Thais researchers to ensure that their research meets the highest international standards of integrity. Professor Ann Macaskill is Head of Research Ethics at SHU so well placed to deliver this training. The training will be in a mainly workshop format held for 3 days in 2 modules. The first module about Ethics and Research Integrity will be delivered over three days with ethics addressed on day one with presentations and applied workshops where participants will be asked to work as review panels and feedback will be given. On day two, research integrity will be addressed. Participants will be asked to consider the research practices they currently follow and to reflect on how these assure the integrity of their research or whether more is required. Case Studies will be presented and discussed. In the third session cultural issues impacting on the research process will be discussed and ethical considerations around concepts such as informed consent in collectivist cultures and Western individualist cultures compared and discussed again with case studies and real life examples from the researchers present. The program will then be made available for the BSRI staff to use in future for new staff and students.
    The remaining two days will focus on Health Psychology with the aim of sharing knowledge and experience of health psychology as it is applied and related research. The three UK visitors, Ann and two other health psychologists will present on positive health psychology and the UK perspective on health and I and other colleagues will talk about the Thai context. One aim is to enhance the new Health Psychology Program and develop the knowledge of health psychology of all participants including staff from the Thai faculties and PhD students and students in the new health psychology program. On the final day, participants will present their own health research as presentations or posters in a mini conference. This will conclude with discussion on opportunities for collaborative research in the future. Professor Macaskill will also give a public lecture for my colleagues and students at the BSRI and Applied Psychology Program of Srinakharinwirot University on the lessons learned from the UK on efforts to achieve health literacy in UK and how positive psychology is being applied. Ann will extend her stay by three days to work with me on the intervention research programme. The costs incurred are for travel to Thailand and subsistence for 3 UK academics. Other costs will cover hire of venue. Catering, advertising, photocopying and supplying materials for the workshops expenses of Thai speakers and RAs to enable their attendance.