Using the Korea Health Panel 2021 survey data, we identify factors associated with health literacy (HL) among older adults aged 65 years and older.

A secondary data analysis of the 2021 Korea Health Panel survey.

Korea Health Panel survey.

Data were from 3410 older adults ≧65 years of age, drawn from the 2016 registration census of the Korea Health Panel 2021 survey, with a stratified selection approach for participants.

To explore the factors associated with HL within the framework of the Andersen behavioural model, considering predisposing factors (age, gender, region and spouse), enabling factors (National Basic Livelihood Security recipient, education level, economic activity, usual source of care) and need factors (subjective health status, usual activities, depression/anxiety and chronic disease).

Stepwise multiple regression analysis was employed to examine the factors associated with HL among the study participants within the framework of the Andersen behavioural model.

Statistically significant associations with HL were found for predisposition factors (age, gender and residential area), enabling factors (National Basic Livelihood Security recipient, educational background and usual source of care) and need factors (subjective health status, usual activities and the presence of chronic diseases). While the National Basic Livelihood Security recipient was significant in model 2 (p=0.011), it became nonsignificant in model 3 after adding need factors (p=0.093). Adding enabling factors to model 1 significantly increased the explanatory power (ΔR²=0.084, p<0.001). Similarly, incorporating need factors into model 2 improved the model fit for model 3 (F=113.21, p<0.001) and significantly enhanced explanatory power (ΔR²=0.017, p<0.001).

This study highlights the importance of enabling factors, such as education level and usual source of care, and need factors, such as subjective health status and chronic disease management, in improving HL among older adults. Strategies addressing these factors could enhance HL and support healthy ageing by improving access to care and tailored health information.

Data are available on reasonable request.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

In 2023, Korea became an aged society; moreover, the average life expectancy has also increased from 76.0 years in 2000 to 83.6 years in 2021.1 2 84.0% of older adults aged 65 or older in Korea have one or more chronic diseases, with an average of 2.1 chronic diseases.3 As many older adults maintain their lives with chronic diseases, social interest in maintaining a healthy and high-quality life is increasing.4 5 Since chronic diseases mainly focus on symptom control and prevention of complications, efficient long-term observation and management are required.6

To this end, older adults need an accurate understanding of their health status and the ability to obtain necessary health information.5 7 The Centers for Disease Control and Prevention (CDC) defines this ability as ‘health literacy’ (HL), which is described as an individual’s ability to find, understand and use information and services to inform themselves about health-related decisions and actions.8 HL is one’s knowledge about health, medical care and health systems. It involves the ability to process and use information in various formats related to health and healthcare and consists of three components, including the ability to maintain health through self-care and collaboration with healthcare providers.9 Therefore, HL affects self-health management, access to medical care and the interaction between medical service providers and patients and acts as a major influencing factor in health behaviour, medical use behaviour and health outcomes.10 In a Korean systematic literature review study, the higher the HL, the higher the possibility of health promotion behaviour and the higher the likelihood of positive health information-seeking behaviour. Moreover, a higher HL influences the positive correlation among older adults’ cancer prevention behaviour, practice of proper hand washing, participation in quarantine and intention to receive vaccines.11 International systematic literature reviews and meta-analysis studies have also shown that the lower the HL, the higher the risk of death12 and that HL has a positive and statistically significant relationship with medication compliance.13

Reflecting the importance of this ability to understand health information, the main goal of CDC Healthy People 2030 is to ‘improve the health and well-being of everyone by eliminating the health gap, achieving health equity and obtaining health information understanding ability’.14 Additionally, the WHO has presented health information understanding as one of the main strategies for promoting health and achieving health equity through the Shanghai Declaration,15 and the National Health Promotion Comprehensive Plan 2030 in Korea aims to ‘improve health information understanding’.10 16

Although HL acts as a major factor related to health behaviour, medical use and health outcomes, a Korean study of more than 1000 adults found that only 29.1% of people possessed an appropriate level of HL.10 On average, 21.4% of respondents said they had difficulty with HL.17 In a study of older adults over 60 years of age, HL was better in those who were 60 years old than in those who were 70 years old, and the presence or absence of a spouse, education and subjective economic status, subjective health status and chronic disease affected HL.18 A study of more than 1000 older adults conducted in Switzerland found that older adults with one or more chronic conditions had lower HL levels than those without chronic conditions.19 HL acts as a major determinant of self-management of chronically ill patients.20 There is a positive and significant correlation between HL and the quality of life of older adults,21 and it is necessary to improve HL to improve the quality of life of older adults along with a reduction in pain caused by illnesses such as chronic diseases.

In this study, we extend the application of the Andersen behavioural model beyond its traditional use in healthcare access research by systematically categorising factors influencing HL among older adults. Unlike previous studies that analysed health literacy factors in isolation, our research provides a structured theoretical framework, highlighting interrelations between predisposing, enabling and need factors.22 23 This approach allows for a more comprehensive understanding of the social and economic determinants of health literacy in older populations.24 Furthermore, previous studies have shown that older adults with higher education levels and chronic diseases tend to have better health literacy due to repeated exposure to medical information and health services.25 26 By integrating these findings, our study aims to further analyse how Andersen’s model can be used to design targeted public health programmes that improve health literacy in ageing populations.27

The Andersen behavioural model proposes an explanatory or causal relationship with healthcare utilisation,22 making it a useful framework for examining older adults’ access to healthcare services, particularly in the context of rising medical costs associated with an increasing ageing population and chronic disease prevalence.28 First, predisposing factors include demographic, social and psychological characteristics such as age, gender, education level, occupation, income level, values and health beliefs.22 29 Studies indicate that ageing is associated with lower HL,30 and medication adherence varies significantly with age.31 32 Second, enabling factors refer to economic and structural conditions such as personal and family resources, residential area, health insurance coverage and healthcare knowledge, which can either facilitate or hinder access to healthcare services.29 Individuals with low socioeconomic status, disabilities, limited English proficiency or lower education levels tend to have lower HL.33 In addition, older adults living in small-sized and medium-sized cities or farming and fishing villages were significantly more likely to suffer from a lack of HL than residents of large cities.34 Third, need factors are the most direct factors influencing healthcare utilisation and include whether a person has a disease, whether they have depression, and their subjective health status, which are related to situations where health behaviour is recognised as necessary.22 29 35 Compared with older adults without chronic diseases, those with two or more chronic diseases were more than twice as likely to have difficulties in HL related to hospital information use, indicating that need factors significantly influence HL.34 As such, Andersen’s behavioural model can be used as a theoretical framework for identifying predictors that affect HL by presenting explanatory or causal relationships. Several studies using this model have confirmed that individual HL is an important factor in using medical services.36–39

International systematic literature reviews and meta-analyses on HL involving more than 1000 participants have primarily focused on adults, particularly those with specific diseases (eg, diabetes, heart failure, chronic kidney disease, kidney transplant patients and chronic vascular disease). However, studies specifically targeting older adults as a distinct population remain limited, highlighting a gap in the research. Most of these studies have used standardised tools such as the Brief HL Screen or the Short Test of Functional HL in Adults.12 13 40 Meanwhile, in the European Union, the use of the European Health Literacy Survey (HLS-EU) tools has been increasing.41 42 As the use of HLS-EU-Q16 is active in Europe, it is being translated into each country’s language to confirm reliability and validity.43–47 However, the number of international studies targeting more than 1000 older adults using the HLS-EU-Q16 tool is small.19 48 Similarly, most Korean studies have used samples of fewer than 300 participants.49 Furthermore, as these studies often target specific groups, there is a lack of research on nationally representative samples in Korea.7 A recent Korean study applied Andersen’s behavioural model to HL among older adults aged 65 and over; however, the HL assessment tool used in this study consisted of only a single verbal comprehension question and a single textual comprehension question, presenting methodological limitations.50 This suggests that such a simplified measures approach may not fully capture the complexities of HL.

Therefore, this study aimed to identify factors associated with HL levels among older adults aged 65 and over, using data from the Korea Health Panel released in the first half of 2023, to provide foundational data for establishing future healthcare services and policies tailored to this population.

In this study, a step-by-step regression analysis was performed to identify the factors associated with the HL of older adults aged 65 and above, using the Andersen behavioural model as a theoretical framework. The analysis revealed that predisposing factors (age, gender and residential area), enabling factors (National Basic Livelihood Security recipient, educational background and usual source of care) and need factors (subjective health status, usual activities and the presence of chronic diseases) were significantly associated with HL. The explanatory power of the model increased as enabling and need factors were sequentially added to the predisposing factors, reinforcing findings from previous studies that highlight the multidimensional nature of HL.26 Previous research has applied the Andersen behavioural model to study HL, significant variables associated with the HL of older adults included personality factors (age, gender and spouse), enabling factors (education level) and need factors (subjective health status).50 However, prior studies were limited in HL measurement, as they relied on only one or two items assessing comprehension. To address these limitations, this study employed a 16-item tool for a more comprehensive understanding of HL. These findings highlight that HL is not solely determined by predisposing factors but is also associated with modifiable factors, suggesting the potential for improvement through targeted interventions.

Among predisposing factors, younger age, male and urban residence (‘dong’ residents) were associated with higher HL levels. ‘Dong residents’ refer to individuals living in urban areas, as defined in the Korea Health Panel survey. These findings are consistent with studies reporting that urban residents generally have better access to health information and healthcare services than their rural counterparts.18 26 53 54 However, the observation that males had higher HL levels contradicts prior findings using the HLS-EU-Q16 tool, which reported lower HL levels in males.48 This discrepancy may be attributed to sociocultural and historical factors unique to Korea, where older men historically had greater access to education due to gender-based educational disparities.55 56 Given that education level is one of the predictors of HL, this disparity may explain the higher HL observed among males in this study. Consequently, gender-sensitive educational interventions are needed to address HL disparities among older women.

Among enabling factors, educational level and usual source of care were significantly associated with HL. A usual source of care refers to a doctor or medical institution primarily visited for health counselling and treatment, providing continuity and comprehensiveness in healthcare delivery.57 Older adults often rely on medical personnel such as doctors, nurses and pharmacists for health information rather than actively seeking it independently.7 Therefore, having a usual source of care is closely linked to HL. Additionally, having a usual source of care is associated with reduced unmet medical needs, making it a critical factor in health management for older adults. However, structural barriers within the Korean healthcare system may limit the effectiveness of a usual source of care in improving HL. These barriers include short consultation times, difficulty understanding doctors’ explanations and limited opportunities to ask questions.58 Moreover, approximately 40% of usual sources of care in Korea are hospital-level institutions, indicating an underdeveloped community-based primary care system.59 Strengthening the primary care system and enhancing patient–provider communication through tailored educational programmes could improve HL outcomes.

Meanwhile, National Basic Livelihood Security status was a significant factor in model 2 (p<0.05), but its significance disappeared in model 3. This suggests that need factors, such as subjective health status and chronic diseases, may have a stronger association with HL than enabling factors. Previous research has shown that individuals with poor health conditions often experience greater difficulties in accessing, processing and using health information; however, they also demonstrate a higher likelihood of actively seeking health-related information, particularly through online sources.60 These findings underscore the importance of further examining the relationships between HL and need factors to develop targeted interventions for vulnerable populations.

Among need factors, better subjective health status and the absence of chronic diseases were associated with higher HL levels. While these variables were significant for overall HL, prior studies have reported their non-significance in specific domains, such as disease prevention and health promotion.18 This suggests that the impact of health conditions on HL may vary depending on the specific aspect of HL being examined. Older adults with chronic conditions may struggle with complex health information, leading to inadequate or problematic HL levels that hinder proper disease management.19 As ageing progresses in older adults, the prevalence of chronic diseases increases, making the enhancement of HL crucial for improving treatment adherence and health outcomes.13 61 Therefore, community-based interventions such as medication counselling, nutrition education and physical activity programmes can provide substantial benefits for older adults with chronic diseases.

The findings offer several policy implications. First, targeted HL interventions are necessary to address disparities among vulnerable groups, including older women, individuals with lower educational levels and rural residents. Given that HL influences medication adherence, chronic disease management and preventive health behaviours, tailored HL education should be incorporated into community-based healthcare service. Simplified educational materials and clear communication strategies should be used to enhance accessibility for older adults with limited literacy skills. Second, public health centres in Korea, as stipulated in Article 11 of the Local Health Act,62 should expand their services to provide education programmes and chronic disease management interventions for older adults. These centres can deliver community-based education programmes on medication adherence, chronic disease management and healthy lifestyles, with nurses playing a key role in planning, delivering and evaluating these programmes.63 Lastly, strengthening primary care infrastructure and reducing reliance on hospital-centred care are critical to mitigating HL disparities and promoting health equity among older adults. Policy-makers should consider implementing integrated primary care models that provide continuity of care and health education to older populations, particularly in medically underserved areas.

This study identified the factors associated with the HL of older adults by applying them to the Andersen behavioural model using the 2021 annual data of the 2021 Korea Health Panel survey. The findings indicate that HL was significantly associated with age, gender, residential area, receipt of the National Basic Livelihood Security System, educational background, the presence of usual source of care, subjective health status, usual activities and the presence of chronic diseases. Based on these findings, targeted HL interventions and policy initiatives should be developed to improve HL among older adults, particularly those in vulnerable socioeconomic groups. Enhancing health education programmes, improving accessibility to health information and integrating HL strategies into primary care services may help older adults better manage their health and improve their quality of life. However, as this study is cross-sectional, the observed relationships cannot establish causality. These results provide foundational data for designing healthcare services and policies aimed at improving HL in older adults. Furthermore, policy-makers and health authorities should consider implementing community-based healthcare and education programmes that leverage the role of nurses to address HL disparities within this population.

Data are available on reasonable request.

We would like to thank Editage (www.editage.co.kr) for English language editing.