Associations between health literacy and information-evaluation and decision-making skills in Japanese adults

doi:10.21203/rs.3.rs-537682/v1

Background

Health literacy in Japanese people is often low because people find it difficult to evaluate health information and make informed decisions. Clarifying the association between health literacy and the skills to evaluate information and make appropriate decisions (not necessarily limited to health information) would inform efforts to improve health literacy. Therefore, the study objectives were to investigate the following issues using a nationwide survey in Japan: 1) When obtaining information, to what extent do people appropriately evaluate whether the information is reliable, and when making decisions, to what extent do they seek out available options and compare pros and cons based on their own values? 2) How strongly are these skills associated with health literacy and demographic characteristics? 3) What opportunities are available to learn these skills?

Methods

An online questionnaire survey was conducted using a Japanese Internet research company; 3,914 valid responses were received. The measures comprised health literacy (European Health Literacy Survey Questionnaire), five items on information evaluation, four items on the decision-making process, and items on the availability and location of learning opportunities. Pearson correlations were calculated to explore the association of health literacy with information-evaluation and decision-making skills. Multivariate analyses were also conducted using these factors as dependent variables.

Results

Less than half of respondents always or often evaluated information and engaged in the decision-making process. Health literacy was significantly correlated with information evaluation and the decision-making process (.26 and .30, respectively). More than 40% of respondents had no learning opportunities. Respondents who did have learning opportunities learned on their own, rather than at school or work, using sources such as the Internet and television.

Conclusions

Both information-evaluation and decision-making skills were associated with health literacy. However, these skills are not sufficiently widespread in Japan, because there are few opportunities to learn them. More research is needed to raise awareness of the importance of these skills for improving health literacy, and to provide appropriate learning opportunities. Additionally, an environment must be created in which all individuals can easily receive support at any time, so that they can make appropriate decisions based on reliable information.

Health Policy

Health literacy

Health information

Decision-making process

Shared decision making

Learning opportunities

Health literacy is the ability to access, understand, appraise, and apply health information[1]. Appraisal is the ability to evaluate information, and application refers to the ability to make informed decisions. Health literacy can help people to become more empowered in relation to healthcare, disease prevention, and health promotion. The European Health Literacy Survey Questionnaire[2] has been used around the world [3] and in Japan[4–12] to measure comprehensive health literacy. Health literacy in Japan is associated with health status and appropriate health behaviors in the general population; with social activity, exercise habits, and quality of life in patients; and with a lower risk of atherosclerosis and lower frailty in elderly people.

However, in 2015, it was reported that comprehensive health literacy scores in Japan were lower than in Europe[4], and similar to the health literacy scores of six other Asian countries[13]. A comparison of health literacy in Europe and Japan showed that a higher percentage of respondents in Japan rated as “difficult” items related to evaluating information and decision making. Health literacy is ultimately about the ability to make informed decisions, and requires the identification of quality information.

One reason for the low health literacy in Japan is the lack of reliable, easy-to-understand public websites, and the lack of a standard information source that people can access to obtain information rapidly. One report comparing the quality of cancer information on the Internet in the USA and Japan found that US information was better because it was mainly provided by non-profit organizations and public institutions[14]. Another study in Japan found that the percentage of harmful information was higher than that of reliable information on Internet sites providing information about cancer treatment[15]. In Japan, there is no reliable and comprehensive website comparable to MedlinePlus (US National Library of Medicine), as Japan has neither a National Institute of Health nor a National Library of Medicine.

The most common health information resources for Japanese people are television and radio (77.5%), the Internet (74.6%), and newspapers (60.0%), and these resources are trusted by 70.5%, 55.6%, and 76.2% of respondents, respectively[16]. This high level of trust in mass media such as newspapers and television, and low trust in the Internet, is a characteristic of Japan that is not limited to health information. According to the World Values Survey, trust in newspapers and television is approximately 60–70% in Japan, compared with approximately 10–40% in Western countries[17]. However, another survey showed that trust in the Internet was lowest in Japan (51%), compared with 74% overall in the 25 countries and regions surveyed[18]. Information access is changing, and many people now independently search for reliable information using the Internet. However, perhaps because it is difficult to obtain reliable information from the Internet, people in Japan tend to rely on information from the mass media, which is less reliable than in other countries. This pattern may hinder people from evaluating information for themselves and making decisions based on this information.

It is also possible that the type of education provided in Japan (from childhood onwards) affects the development of information-evaluation abilities. Although Japanese people are able to obtain and understand information, they are less able to evaluate it or make decisions; this is because Japanese education does not aim to develop the latter abilities. Only in the last few years has the ability to evaluate information and make decisions been included as a major pillar in the national curriculum guidelines for elementary through high school[19].

There are clear cultural differences in decision making and the environment that enables it. In a comparison of Japanese and Australian university students, Japanese students expressed lower self-esteem in decision making, higher stress in decision making, and tended to make decisions impatiently and incorrectly without considering other options, or to avoid decision making, rather than thinking a problem through and deciding for themselves[20]. Similarly, in a study comparing university students in Japan and Australia, the USA, New Zealand, Hong Kong, and Taiwan, Japanese students had the lowest self-esteem regarding decision making and tended to be the most avoidant and impulsive[21]. It has been pointed out that this may reflect the difference between Western culture, which promotes individual decision making, and Japanese culture, which values group harmony. Furthermore, a study comparing the decision-making styles of business leaders in Japan, the USA, and China found that in Japan, gathering data and carefully analyzing many options was the least common style, and focusing on intuition and relationships rather than data was the most common style[22].

The ability to make decisions may also be affected by whether or not one has freedom of choice. The World Values Survey contains the item “How much freedom of choice and control you feel you have over the way your life turns out,” which respondents rate on a scale of one to ten. In terms of average score on this item, Japan scored 77th out of 79 countries and regions[17]. This may indicate that Japanese people feel they have insufficient options, insufficient information to make a decision, or lack the skills to make an informed decision.

So what information-evaluation and decision-making skills are needed to make appropriate informed decisions? Many university library websites worldwide have long published methods for evaluating information resources and websites. These methods involve tests and guidelines for judging the quality of information sources. Some of the most widely used are the CRAP (currency, reliability, authority, and purpose) [23] and CRAAP (currency, relevance, authority, accuracy, and purpose) tests[24]. In addition, there are five criteria (accuracy, authority, objectivity, currency, and coverage; abbreviated as AAOCC)[25–27] that include, and are very similar to, the criteria of these tests.

These five criteria can be defined as follows. Accuracy (or reliability) is whether the information is reliable, whether it can be verified by other sources, and whether it is clear what the original sources are and whether they contain sufficient evidence. Authority means that the identity and qualifications of the author or person providing the information are clear. Objectivity (or purpose) refers to whether the information is free from bias, why it is provided, and whether it is biased for advertising or commercial purposes. Currency means that the accuracy of the information source depends on when the information was created and how often it is updated. For topics such as science and medicine, it is particularly important that the information is current. Coverage (or relevance) is the extent to which the information covers what you want to know, whether it is broad in scope or specialized, and how it differs from other information. To determine this, it is necessary to compare the information with other information and clarify the differences, rather than making a judgment based on that information alone. Thus, it is important that people have the skills to identify and confirm these five criteria, so that information can be properly evaluated and reliable information can be used.

Different people make decisions in different ways. There are many studies on the psychology of decision-making styles, and several measurement scales have been developed[28, 29]. Two major decision-making styles have been identified: the rational style and the intuitive style. Consistent with previous studies, Hamilton et al. defined the characteristics of the rational style as a thorough search for information and a systematic evaluation of all choices and potential alternatives, and defined the characteristics of the intuitive style as the use of a quick decision-making process that is primarily based on hunches and feelings[29]. The rational style scale includes the evaluation of information, such as thorough information gathering and investigation of the facts, and thinking carefully about pros and cons or benefits and risks to explore all options and evaluate alternatives. A rational style is needed for informed decision making, which is the process of evaluating information (e.g., evidence and data) and options.

In the fields of business and health, individuals are required to frequently make decisions. In these areas, decision making is a process; better decision making requires the steps of generating options, comparing the pros and cons of the options, and then making a decision[30].

The decision-making process has become integral to the research and practice of informed and shared decision making (SDM) in the field of health[31]. According to a systematic review of SDM, its essential elements are presentation of options, discussion of pros/cons, and patient values/preferences[32]. This reflects the critical role in evidence-based medicine of patients’ values and preferences in decision making[33]. Similarly, patient-centered care takes into account the preferences, needs, and values of each patient, and ensures that the patient’s values guide all clinical decisions[34]. Evidence-based medicine is an essential prerequisite of SDM[35]; as Barry has noted, SDM is the pinnacle of patient-centered care[36].

A US national study to assess the SDM process developed a scale to assess four fundamental aspects (discussion of options, pros, cons, and preferences) that reflect the widely accepted definition of SDM[37, 38]. According to the Ottawa Decision Support Framework, a theory of decisional support for difficult decisions, to improve the quality of decision making, it is necessary to make choices based on what is most important in the option pros and cons[39]. Decision aids (DA) are tools that support decision making, and help people to determine the pros and cons of options and to identify their importance. Such a decision-making process leads to effective decision making; a feeling that the decision is informed, value-based, likely to be implemented; and satisfaction with the decision[40]. Recent research indicates that SDM and DA play an important role in decision making in Japan[41–44].

Effective decision making based on quality information requires the skills to engage in the process of clarifying and evaluating the four aspects of options, pros, cons, and values/preferences. Clarification of the association between health literacy and the skills to appropriately evaluate the credibility of information and make decisions about various types of information (not necessarily limited to health information) would inform strategies to improve health literacy. Therefore, the objectives of this study were to investigate the following issues using a nationwide survey in Japan:

1) When obtaining information, to what extent do people appropriately evaluate whether the information is reliable, and when making decisions, to what extent do they seek out available options and compare pros and cons based on their own values?

2) How strongly are these skills associated with health literacy and demographic characteristics?

3) What opportunities are available to learn these skills?

Participants

Participants were recruited from individuals registered with a Japanese Internet research company that had approximately 1.4 million voluntarily registered participants. We aimed to collect data from a minimum of 4,000 men and women aged 20–69 years. In January 2021, potential respondents (n = 22,115) were randomly invited via email to participate in a cross-sectional Web-based anonymous questionnaire.

In determining potential participants, we tried to match participants’ gender, age group, and region (we divided the country into eight regions) to the results of the 2015 Japanese census[45]. We accepted emailed responses from potential participants until we reached the target number for gender, age group, and region.

Measurements

Japanese version of the European Health Literacy Survey Questionnaire (HLS-EU-Q47)[4]

The survey response categories were all phrased similarly: “On a scale from very easy to very difficult, how easy would you say it is to understand why you need health screenings?” and were ranked on a four-point Likert-type scale (1 = very difficult, 2 = fairly difficult, 3 = fairly easy, 4 = very easy). A “don’t know/not applicable” response option was also included, and was coded as a missing value.

As in the original scale, health literacy scores were standardized on a metric between 0 and 50, using the formula: (MEAN − 1) × (50/3) [4]. MEAN = the mean of all item responses for each participant.

Evaluation of information

Based on the five criteria (accuracy, authority, objectivity, currency, and coverage) from tests and guidelines for judging the quality of information sources[24–27], five items were created to determine how frequently participants evaluated information. In the process of developing the questions, we referred to items measuring student assessment of the reliability of information for school work[46], a guide to evaluating health-related information in a school health education text[47], and points developed for checking health information corresponding to the five criteria[48, 49]. In order of the five criteria, the developed items were “What is the source of the information?”, “What are the qualifications of the people and organizations providing the information?”, “Is the information for advertising products or services?”, “When was the information created?”, and “How does the information differ from other information?” Before responding to the five items, participants were asked, “How often do you check each of the following when accessing information: the Internet, TV, newspapers, magazines, or other media?” Responses to all items were rated on a five-point Likert scale (5 = always, 4 = often, 3 = sometimes, 2 = rarely, 1 = never). Total and item scores were calculated. Higher scores on the scale indicated more skill in evaluating information.

Decision-making process

We measured whether the essential aspects of the process of determining all the available options, knowing the pros and cons of each option, comparing them based on values and preferences, and making a choice were implemented, which is necessary for informed decision making. For this purpose, four items were developed for each aspect (options, pros, cons, and values/preferences), referring to the Shared Decision Making Process scale[37]. Items on this scale are limited to the two options of whether to test or intervention, so we created items that were not limited to health decisions and had a wider range of options. In order of the decision-making process, these items were “Make sure you have all the options,” “Know the pros of each option,” “Know the cons of each option,” and “Compare the pros and cons of each option and clarify what is important to you.” Before responding to the four items, participants were asked, “When making important decisions, how much do the following apply to you?” As with the information-evaluation items, we used a five-point Likert scale (5 = always, 4 = often, 3 = sometimes, 2 = rarely, 1 = never). Total and item scores were calculated. Higher scores indicated greater decision-making skill.

Learning opportunities

Immediately after answering the five information-evaluation items, participants were asked where they had learned the skills of evaluating information: “Have you ever learned how to check information as mentioned in the previous question?” Immediately after answering the four decision-making items participants were asked where they had learned the skills of decision making: “Have you ever learned anywhere about how to determine the pros and cons of all the options and what is important before making a choice?” The response options for these two items were as follows: Never learned, Internet, TV, Newspapers and magazines, Books, Workplace, Home, Elementary school, Junior high school, High school, College/university, Others.

Demographic characteristics

The following demographic characteristics were analyzed: gender (men, women); age group (20–29, 30–39, 40–49, 50–59, 60–69); highest level of education (junior high school, high school, 2-year college, college/university, graduate school); and occupation (self-employed, managerial and administrative, professional and technical, other regular role [routine and manual], part-time, homemaker, student, unemployed).

Statistical analysis

The distribution of responses to the five information-evaluation items and the four decision-making items were examined. Pearson correlations between health literacy and total and item scores were calculated, respectively.

The reliability and validity of the five information-evaluation items and the four decision-making items were checked. Cronbach’s alphas were calculated to examine internal consistency. For construct validity, confirmatory factor analysis (CFA) was conducted. In the CFA, the comparative fit index (CFI), the root mean square error of approximation (RMSEA), and the standardized root mean square residual (SRMR) were used as model fit indices. A CFI value of ≥ .95 represents good fit and a value of ≥ .90 is generally considered to indicate acceptable model fit. RMSEA and SRMR values of < .05 represent good fit, and a value of < .08 is acceptable[50].

To determine the extent to which information evaluation and the decision-making process independently explain health literacy, we conducted a multiple linear regression analysis with health literacy as the dependent variable and information-evaluation and decision-making scores as the independent variables. In addition, demographic characteristics (gender, age group, education, and occupation) were used as control variables in the same analysis. Finally, we calculated the percentage of responses for each of the opportunities for learning about the evaluation of information and the decision-making process.

To determine the association between demographic characteristics and high scores on the information-evaluation and decision-making items, we conducted a multiple linear regression analysis (general linear model) with these item scores as the dependent variables and gender, age group, education, and occupation as the independent variables. For comparison, the same analysis was conducted with health literacy as the dependent variable. In this analysis, we calculated the estimated marginal mean for each category to compare the mean values across categories.

Finally, we calculated the percentage of responses for each of the opportunities for learning about information evaluation and the decision-making process. Data were analyzed using IBM SPSS Statistics (IBM Corp., Armonk, NY, USA) and Amos version 27.0 (IBM SPSS, Chicago, USA).

Participant characteristics

There were 3,191 valid responses, including those with missing values of less than 20% on all health literacy items (sufficient to calculate a health literacy score as per the original HLS-EU-Q)[51]. Data for these individuals were included in the analysis. Demographic characteristics and health literacy scores are shown in Table 1.

Table 1

Characteristics of study participants
	Total (n = 3,914)
Variables	n	%
Gender
Men	1,953	49.9
Women	1,961	50.1
Age group
20 − 29	567	14.5
30 − 39	721	18.4
40 − 49	891	22.8
50 − 59	785	20.1
60 − 69	950	24.3
Age (mean ± SD)	46.9 ± 13.6
Highest level of education
Junior high school	86	2.2
High school	981	25.1
2-year college	858	21.9
College/university	1,806	46.1
Graduate	183	4.7
Occupation
Self-employed	191	4.9
Managerial and administrative	166	4.2
Professional and technical	463	11.8
Other (routine and manual)	1,367	34.9
Part-time	474	12.1
Homemaker	652	16.7
Student	131	3.3
Unemployed	470	12.0
Health literacy (mean ± SD)	27.4 ± 9.4
SD standard deviation

Distribution of responses on information evaluation and decision-making process

Table 2 shows the distribution of information-evaluation and decision-making responses and their correlations with health literacy. Response distribution was similar for the five information-evaluation items. Approximately 10–15% of participants answered “Always” and approximately 25% answered “Often.” Only the Objectivity item had more than 40% of “Always” and “Often” responses combined; approximately 30% of participants answered “Always” and “Often” to the other items. The average score on the five-point scale was approximately 3 (“Sometimes” response option). The distribution was similar for the four decision-making process items. Approximately 10–15% of participants answered “Always,” 30–35% answered “Often,” and 40–50% answered “Always” or “Often.” The average score on the five-point scale was just over 3, slightly higher than the score for the “Sometimes” option.

Table 2 Distribution of responses for information evaluation and decision making and their correlations with health literacy
	Responses						Correlations with health literacy
Variables	Always	Often	Sometimes	Rarely	Never	Mean ± SD	r	P
Information evaluation
(Accuracy) What is the source of the information?	12.5	24.5	27.7	17.5	17.7	3.0 ± 1.3	.24	<.001
(Authority) What are the qualifications of the people and organizations providing the information?	10.5	23.3	30.0	17.9	18.3	2.9 ± 1.2	.22	<.001
(Objectivity) Is the information for advertising products or services?	14.9	28.4	27.8	15.2	13.8	3.2 ± 1.2	.23	<.001
(Currency) When was the information created?	10.3	25.4	28.8	18.9	16.6	2.9 ± 1.2	.21	<.001
(Coverage) How does the information differ from other information?	9.7	24.6	31.0	18.7	16.0	2.9 ± 1.2	.24	<.001
Total score						14.9 ± 5.4	.26	<.001
Decision-making process
(Options) Make sure you have all the options available to me.	8.7	31.0	34.2	19.1	6.9	3.2 ± 1.1	.24	<.001
(Pros) Know the pros of each option	11.9	35.7	32.1	16.1	4.3	3.3 ± 1.0	.28	<.001
(Cons) Know the cons of each option	12.0	34.0	32.3	17.2	4.5	3.3 ± 1.0	.27	<.001
(Values/preferences) Compare the pros and cons of each option and clarify what is important to you	14.6	35.7	31.4	13.9	4.4	3.4 ± 1.0	.30	<.001
Total score						13.2 ± 3.8	.30	<.001

SD standard deviation

Correlations with health literacy

The Pearson correlation coefficients between the five information-evaluation items and health literacy ranged from .21 to .24; the highest correlations (.24) were for the Accuracy and Coverage items (Table 2). The correlation between health literacy and the information-evaluation total score was .26 (slightly higher than the correlations for each item); all correlations were significant. Correlations between health literacy and the four decision-making items ranged from .24 to .30; the highest correlation (.30) was for the Values/preferences item. The correlation between health literacy and the decision-making total score was .30 (larger than the correlations for each item, and the same as the correlation with Values/preferences); all correlations were significant. The correlation between the total information-evaluation score and the total decision-making process score was .60 (P < .0001) (not shown in the table).

Reliability and validity

To confirm the reliability and validity of the total information-evaluation and decision-making scores, we first calculated Cronbach’s alpha coefficients, which were .92 and .93, respectively.

The construct validity of the information-evaluation and decision-making items was confirmed using CFA. For the information-evaluation items, the CFI was 0.995, the RMSEA was 0.067 with a 95% confidence interval (CI) of .055–.081, and the SRMR was .011, which indicated acceptable fit. Error covariance was observed between items with similar texts (Currency and Objectivity items), but CFA factor loadings were > .77 for all items, and a unidimensional structure was confirmed. For the decision-making items, the CFI was 0.998, the RMSEA was 0.061 with a 95% CI of .043–.083, and the SRMR was .007, which indicated acceptable fit. All the CFA factor loadings were > 0.76 for all items, and a unidimensional structure was confirmed.

Multiple linear regression analysis of health literacy

Table 3 shows the results of the multiple linear regression analysis with health literacy as the dependent variable and the information-evaluation and decision-making scores as the independent variables. The standardized regression (beta) coefficients were .13 for information evaluation and .22 for decision-making process, both of which were significant. When demographic characteristics were used as control variables, the coefficients were .15 and .22, respectively, and both were significant.

Table 3

Multiple linear regression analysis of health literacy
	Health literacy			Health literacy controlling for demographic variables^a
Independent variables	Beta^b	t	P	Beta	t	P
Information evaluation	.13	7.01	< .001	.15	8.05	< .001
Decision-making process	.22	12.01	< .001	.22	11.95	< .001
R²		.10			.14
Adjusted R²		.10			.13
F		221.05			33.95
P		< .001			< .001
^aGender, age group, education, occupation
^bStandardized regression coefficients

Multiple linear regression analysis of information evaluation and decision-making process

Table 4 shows the results of the multiple linear regression analysis with the information-evaluation and decision-making item scores as the dependent variables and demographic characteristics as the independent variables. To compare these results, a similar analysis was conducted with health literacy as the dependent variable. Women scored slightly higher on the decision-making process. Participants in their 20s scored slightly higher than those of other age groups on both variables. Participants with a graduate education scored highest, followed by those with college/university education (for information evaluation). Students scored highest on both variables, followed by participants who were self-employed and in managerial and administrative jobs (for the decision-making process).

Table 4

Multiple linear regression analyses of information evaluation, decision-making process, and health literacy
	Information evaluation		Decision-making process		Health literacy
Variables	EMM (95% CI)	F-test	EMM (95% CI)	F-test	EMM (95% CI)	F-test
Gender
Men	15.3 (14.9, 15.7)	F = 0.15	13.5 (13.2, 13.8)	F = 5.44	26.7 (26.0, 27.3)	F = 20.48
Women	15.2 (14.8, 15.6)	P = .70	13.8 (13.6, 14.1)	P = .02	28.3 (27.6, 29.0)	P < .001
Age group
20 − 29	16.2 (15.7, 16.8)	F = 5.19	14.2 (13.8, 14.6)	F = 4.14	27.0 (26.1, 27.9)	F = 15.60
30 − 39	15.4 (14.9, 15.8)	P < .001	13.7 (13.4, 14.1)	P = .002	26.1 (25.2, 26.9)	P < .001
40 − 49	14.9 (14.5, 15.4)		13.5 (13.2, 13.8)		26.9 (26.2, 27.7)
50 − 59	14.8 (14.3, 15.3)		13.3 (13.0, 13.6)		27.8 (26.9, 28.6)
60 − 69	15.1 (14.6, 15.6)		13.6 (13.3, 13.9)		29.5 (28.7, 30.3)
Highest level of education
Junior high school	14.6 (13.5, 15.8)	F = 17.98	13.5 (12.7, 14.3)	F = 10.69	25.6 (23.6, 27.6)	F = 4.30
High school	14.2 (13.9, 14.6)	P < .001	13.0 (12.8, 13.3)	P < .001	27.3 (26.7, 27.9)	P = .002
2-year college	14.7 (14.3, 15.1)		13.3 (13.0, 13.6)		27.0 (26.3, 27.7)
College/university	15.7 (15.4, 16.0)		13.7 (13.5, 13.9)		27.5 (27.0, 28.0)
Graduate	17.1 (16.3, 17.9)		14.8 (14.2, 15.3)		29.9 (28.5, 31.3)
Occupation
Self-employed	15.5 (14.6, 16.3)	F = 2.86	14.3 (13.7, 14.9)	F = 3.63	28.5 (27.1, 29.9)	F = 1.23
Managerial and administrative	15.5 (14.6, 16.4)	P = .006	14.1 (13.5, 14.7)	P < .001	28.4 (26.8, 29.9)	P = .283
Professional and technical	15.7 (15.2, 16.3)		13.5 (13.1, 13.9)		27.0 (26.1, 28.0)
Other (routine and manual)	15.1 (14.7, 15.5)		13.4 (13.2, 13.7)		27.0 (26.4, 27.7)
Part-time	14.8 (14.2, 15.3)		13.3 (13.0, 13.7)		27.7 (26.8, 28.7)
Homemaker	14.7 (14.1, 15.2)		13.2 (12.8, 13.6)		27.4 (26.5, 28.3)
Student	16.4 (15.3, 17.4)		14.3 (13.6, 15.0)		26.7 (24.9, 28.5)
Unemployed	14.6 (14.1, 15.2)		13.1 (12.7, 13.5)		26.9 (26.0, 27.8)
CI confidence interval, EMM estimated marginal mean

The analysis of health literacy showed significant differences for gender, age, and education, with higher scores for women than for men, higher scores for older age groups (except for those in their 20s), and higher scores for graduates. These results were similar to those of a previous study by Nakayama et al.[4]. The health literacy results were similar to those for information evaluation and decision-making, in that scores were slightly higher for participants in their 20s and higher for graduates.

Learning opportunities

Table 5 shows the results for the multiple-choice question asking respondents where they learned about information evaluation and the decision-making process. Responses to both were similar; the most frequent answer was “Never learned” (> 40%). The most frequent way of learning was through the Internet (approximately 40%), followed by television (approximately 30%), newspapers and magazines (approximately 15%), books (just over 10%), and other sources (< 10%).

Table 5

Where participants learned about information evaluation and decision-making process (%)
	Information evaluation	Decision-making process
Never learned	42.4	44.3
Internet	39.9	38.8
TV	32.2	29.0
Newspapers and magazines	15.3	15.0
Books	12.3	13.0
College/university	6.5	6.0
Workplace	5.7	5.8
Home	4.1	5.7
Elementary school or junior high school or high school	4.9	4.4
Others	4.7	4.0

This study showed that information-evaluation and decision-making skills are associated with health literacy. As these skills may lead to interindividual differences in health, it is necessary to provide learning opportunities to eliminate such differences. However, health literacy is a relational concept; therefore, both individual skills and also the interactions between people and their environment must be improved[52]. An environment must be created in which all individuals can easily receive support at any time, so that they can obtain reliable information and engage in appropriate decision-making processes.

Only approximately 30% of participants always or often evaluated information, and 70% sometimes (or even less frequently) evaluated information. This pattern is good if individuals are receiving high-quality information, but potentially risky if they are not. Many people need to increase their ability to identify useful information; this is particularly important for health information (e.g., information about cancer), as much available information is unreliable. It is important for information providers to provide reliable, easy-to-understand information through the information channels of the target audience. For example, efforts to achieve this in the USA have resulted in a “Health Literacy Online[53]” website, which includes information on how to create an easy-to-understand health information website, and the US Centers for Disease Control and Prevention offers a guide to creating easy-to-understand materials[54]. In addition, MedlinePlus has an Easy-to-Read section[55] that provides easily understood materials in an A to Z format. The Health Literacy Universal Precautions Toolkit developed by the US Agency for Healthcare Research and Quality[56] is an evidence-based guide to help healthcare providers provide understandable information for patients. Although equivalent sources have not been fully developed in Japan, there is a need for further research to provide easy-to-understand information.

Both simple correlations and the multivariate regression analysis showed that decision-making skills correlated slightly more highly with health literacy than did information-evaluation skills. In the multivariate analysis, the association between decision-making skills and health literacy was larger after controlling for information-evaluation skills. This indicates that even if the information is properly evaluated, the skill of taking part in a decision-making process is important in health literacy, which is the ability to make informed decisions. This means that the skill to engage in the decision-making process is an important part of health literacy.

If the decision-making process is conceptualized as a skill, we can measure whether people have this skill or not, and whether they require support. In addition, the identification of the processes people engage in during decision-making situations enables these processes to be assessed and evaluated, and shared with others to gain their understanding and cooperation. It can also be useful to make decisions in consultation with family members and others if the outcome of the decision will affect them. However, less than half of respondents always or often engaged in the decision-making process, suggesting that many people lack the skills for, and are not able to perform, informed decision making. In addition to fostering decision-making skills, SDM and the associated DA tool need to be developed and disseminated to support the decision-making process.

Participants in their 20s, those who had completed graduate school, and students scored higher on the decision-making process, but only by approximately one point. Postgraduates and students constituted less than 5% of the sample. There was generally little difference between people of different ages and educational backgrounds. In terms of occupation, participants in the self-employed and managerial and administrative categories scored slightly higher, probably because decision making is a necessary skill for leaders in the workplace. However, there were few demographic differences in the overall results.

This study highlighted the lack of learning opportunities. Only slightly more than half of respondents had ever learned about information evaluation or the decision-making process. Those who had learned about these skills tended to do so through their own efforts, using the Internet, television, or books, and had received limited opportunities to learn in school or at work. Attempts to increase health literacy must take into account individual opportunities and motivation to learn about information evaluation and the decision-making process. As mentioned above, some research shows that Japanese people tend not to make informed decisions on their own[20, 22]. Therefore, an important question is whether Japanese people find value in making independent decisions. The main factors that improve the happiness and life satisfaction of people worldwide are health status, household financial satisfaction, and freedom of choice[57]. One of the ethical principles underlying SDM is that self-determination is a desirable goal and plays an important role in the well-being of individuals[58]. It needs to be established whether Japanese people consider these characteristics desirable.

A nationwide survey of 20,000 people in Japan found that self-determination was the second most important determinant of happiness after health and relationships, and more so than income and education[59]. This is because self-determination leads to greater motivation and satisfaction with one’s chosen actions, which ultimately leads to a greater sense of well-being[58]. Regarding SDM, a Japanese survey found that when deciding how to treat a relatively serious illness, people are more likely to want to make decisions by themselves than to let a doctor make decisions[60]. Another study identified a strong relationship between SDM and effective decision making and satisfaction with physician explanations[44]. Thus, although many people desire self-determination, they may have limited opportunities to learn the relevant skills, or may not have the appropriate support. This makes it difficult for individuals to express themselves and it may be assumed that such individuals have less freedom of choice[17]. It is also possible that the desire of many people for self-determination, and the idea that self-determination leads to happiness, are not widely disseminated. This may need to be addressed to improve health literacy.

What strategies could be used to promote decision-making skills and thus improve health literacy? In the “Ask 3 questions,” a health literacy campaign to promote SDM, participants were asked “What are my options?”, “What are the pros and cons for each option?”, and “What support is available to help me make a decision?” In the “AskShareKnow” framework, the first two questions are almost identical to the “Ask 3 questions” items, and the third is “How likely are each of those benefits and harms to happen to me?” In the “Choosing Wisely” initiative, which promotes better decision making in healthcare, four questions (with the memorable acronym of BRAN) are recommended: “What are the Benefits?”, “What are the Risks?,” “What are the Alternatives?”, and “What if I do Nothing?” These initiatives all contain a question about options and pros and cons, but do not include a question about which pros and cons are important. A question such as “What support is available if I don’t know which pros and cons are important?” would be useful. Findings from recent studies linking health literacy and SDM using the “AskShareKnow” framework are useful[61]; however, intervention studies using these kinds of questions are needed.

This study had several limitations. It is possible that there was some sample selection bias. The sample may have been skewed toward a high level of Internet literacy because this was a Web-based survey. Recruitment of respondents was based on self-selection from a group of individuals who had previously expressed a desire to participate in research projects. The responses were limited to approximately the first 4,000 people, and may therefore have included only those who were most active on the Internet (e.g., those who frequently checked email).

Five items were created from the five information-evaluation criteria. However, these were just representative items, and many alternative, more detailed items could have been chosen (e.g., “What is the affiliation of the author of the information?”). However, rather than covering a wide range of content, the goal was to identify the core aspects of information evaluation associated with health literacy. As the five items were all associated with health literacy, it would be useful to consider what other checkpoints could be created for the five criteria when developing learning content and evaluation scales that include these contents. It is also important to make the evaluation criteria easier to remember (by using fewer acronyms, such as CRAP, CRAAP, and AAOCC) if dissemination is a priority.

These issues also apply to the four decision-making items. For example, decision making includes clarification of the problem before checking the options, as well as action and evaluation after the decision is made. However, because we used the SDM process as a reference, we focused on the process required to make a decision, assuming that the problem was already apparent. The aim was not to create a scale to cover all the skills needed in the decision-making process, but to determine if specific key points were related to health literacy. Although all four items were related to health literacy, it would be advisable to supplement these with other items on the decision-making process when developing more comprehensive learning content and measures. Regarding the memorability of evaluation criteria, the decision-making process of GOFER (Goals: Survey values and objectives, Options: Consider a wide range of alternative actions, Facts: Search for information, Effects: Weigh the positive and negative consequences of the options, Review: Plan how to implement the options) was developed to teach adolescents to make better decisions; therefore, the use of memorable acronyms can sometimes be effective[62].

In terms of scale development, Woudstra et al. have developed a context-based assessment of health literacy and interventions to support informed decision making in colorectal cancer screening[63]. They suggest that health literacy skills are needed for informed decision making according to the stages of the decision-making process. Of these stages, that of “structure decision options and outcomes” requires the skills of understanding information about possible options and outcomes and understanding pros and cons. In the “evaluate options” stage, the skill of weighing up pros and cons for personal relevance is required. These skills are covered by the items used in this study, but also address the stages before and after the decision-making process. They measure the skills needed in the eight stages of the decision-making process, from receiving information about the screening, to undergoing the screening, to interpreting the screening results.

Decision making is not always performed rationally and the various biases associated with it (e.g., framing effects) are often not apparent. Therefore, it is desirable to include such factors in strategies to improve health literacy. Knowing what biases exist and being able to avoid them may be associated with health literacy, but this is an issue for future research.

Another limitation of this study is that we used cross-sectional data, so it is not possible to draw any firm conclusions about the causal effects between the variables.

In this study, we focused on the skills necessary to make informed decisions about health, including the skill of evaluating the reliability of information from various media sources (not necessarily limited to health information) and the decision-making process skills of knowing the available options, knowing the pros and cons of each option, comparing them, and choosing the one that matches one’s values. A Web-based cross-sectional nationwide survey was conducted to measure the extent to which these skills are being implemented and to examine their association with health literacy. Both information-evaluation and decision-making skills were associated with health literacy. However, these skills are not sufficiently widespread in Japan, because there are few opportunities to learn them. Additional research is needed to raise awareness of the need to learn these skills to improve health literacy, and to provide appropriate learning methods and opportunities. It is also necessary to create an environment in which all individuals can easily receive support at any time, so that they can make appropriate decisions based on reliable information.

Ethics approval and consent to participate

The study received prior approval from the research ethics committee of St. Luke’s International University, Japan (approval number: 20-A076) and conducted following the guidelines of the Declaration of Helsinki. Participants voluntarily signed an online informed consent form approved by our institutional review board.

Consent for publication

Not applicable.

Availability of data and materials

Requests for the study materials and dataset used to support the conclusions of this article should be directed to the corresponding author.

Competing interests

The authors declare that they have no competing interests.

Funding

This work was supported by a Grant-in-Aid for Scientific Research from the Japan Society for the Promotion of Science (JSPS) KAKENHI, Grant Number 20H03967.

Authors’ contributions

KN designed the study and contributed to writing the manuscript. KH performed data collection. YY contributed to the study design. All authors contributed to the questionnaire development process. All authors read and approved the final manuscript.

Acknowledgment

We thank Diane Williams, PhD, from Edanz (https://jp.edanz.com/ac) for editing a draft of this manuscript.

AAOCC

Accuracy, Authority, Objectivity, Currency, and Coverage

CFA

Confirmatory Factor Analysis

CFI

Comparative Fit Index

CRAAP

Currency, Relevance, Authority, Accuracy, and Purpose

CRAP

Currency, Reliability, Authority, and Purpose

DA

Decision Aids

HLS-EU

European Health Literacy Survey

RMSEA

Root Mean Square Error of Approximation

SDM

Shared Decision Making

SRMR

Standardized Root Mean Square Residual

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No competing interests reported.

Questionnaireassessinginformationevaluationanddecisionmakingprocessskills.docx

Associations between health literacy and information-evaluation and decision-making skills in Japanese adults

Status:

Journal Publication

Version 1

Abstract

Background

Methods

Results

Conclusions

Background

Methods

Participants

Measurements

Evaluation of information

Decision-making process

Learning opportunities

Demographic characteristics

Statistical analysis

Results

Participant characteristics

Distribution of responses on information evaluation and decision-making process

Correlations with health literacy

Reliability and validity

Multiple linear regression analysis of health literacy

Multiple linear regression analysis of information evaluation and decision-making process

Learning opportunities

Discussion

Conclusion

Declarations

Abbreviations

References

Additional Declarations

Supplementary Files

Status:

Journal Publication

Version 1