1. Health literacy and health-related outcomes among people with mental illness in Hong Kong Dr. Phoenix Mo School of Public Health and Primary Care, The Chinese University of Hong Kong Dr. Winnie Mak Department of Psychology, The Chinese University of Hong Kong

2. Prevalence of mental illness About ¼ of people will experience some kind of mental health problem in the course of a year (Mental Health Foundation, 2014) Depression and anxiety most common type of mental illness 6.7% of US adult experienced a major depressive episode in the past 12 months (Kessler et al, 2005) Estimated lifetime prevalence of any anxiety disorder over 15%, 12-month prevalence more than 10% (Kessler et al, 2005) Estimated lifetime prevalence of bipolar disorder is 4% (Andreasen et al., 2006) In Hong Kong, 12-month prevalence of depressive episode among adults is 8.4% (Lee et al, 2007)

3. Burden of mental illness Mental illness is extremely detrimental to daily functioning Unipolar depression was the third most important cause of disease burden worldwide in 2004 (WHO, 2008) By 2020, major depression will become the second leading cause of disease burden in the world (WHO, 2011) Annual cost of anxiety disorders in US was $42.3 billon in 1990s Inpatient hospitalisation rate of bipolar patients (39.1%) greater than the 4.5% characterising all other patiensi with behavioral health care diagnosis

4. Physical health and lifestyle of people with mental illness (PMI) PMI have increased risk of physical illness (e.g. coronary heart diseases, diabetes, hypertension, stroke, and emphysema) and early mortality (Joukamaa et al., 2001) 65% of PMI reported having at least one lifetime physical medical condition and 36% having more than one (Lambert et al., 2003) PMI more likely to smoke, have a poorer diet, consume more salt and alcohol, and exercise less than the general population (McCreadie et al., 2003; McCreadie et al., 2003). General physical health needs are often overlooked

5. Health literacy “The 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. Health literacy means more than being able to read pamphlets and successfully make appointments…”(Nutbeam 1998). Function literacy –To have basic skills to reading and writing and to be able to function effectively to everyday situations Critical literacy –To critical analyse information and use the information to exert greater control over life events and situations Interactive literacy –To extract information and derive meaning from different forms of communication, and to apply new information to changing circumstances

6. Health literacy and outcomes The WHO Commission on the Social Determinants of Health (CSDH) suggests that countries should monitor and devise strategies to enhance health literacy Critical to empowerment (Nutbeam, 1998) Associated with various positive outcomes (Nutbeam, 2000): –Healthier lifestyle choices –More effective use of the health services –Effective community action for health

7. Purpose of the study To examine the association between health literacy, health-related quality of life, psychiatric symptoms, and health promoting behaviors among people with mental illness in Hong Kong

8. Sampling and procedure Targeted participants –Adult Chinese aged 18 or above who are currently living in the community and have a psychiatric history Inclusion criteria –Adults 18 or above –Permanent residents of Hong Kong –Being able to understand Cantonese –Having at least one DSM-IV-TR Axis I diagnosis –Currently living in the community Exclusion criteria –Living in community residential services –Pregnancy or lactation –Mental retardation –Dementia –Low comprehension and low cooperation

9. Sampling and procedure 550 PMI recruited from Community Mental Health Care Services of various non-governmental organizations Stratified sampling based on sex, age, education level, and types of diagnosis Participants interviewed using a structured questionnaire

10. Measures Background characteristics –Sex, age, level of education, income, type of diagnosis Health literacy –Single item “are you clear about your mental health condition and the information about your treatment?” –From the Camberwell Assessment of Needs Short Appraisal Schedule (CANSAS) (Slade et al., 1999) Health-related quality of life –12-item Short Form Health Survey-12 (SF-12) (Ware et al., 1996) –Measures 8 domains: Physical functioning, role limitation – physical, bodily pain, general health, vitality, social function, role limitation – emotional, mental health –Cronbach’s alpha =.84

11. Measures Psychiatric symptoms –24-item Behavior and Symptom Identification Scale (BASIS-24) (Eisen et al., 2004) –Measures 6 domains: Depression/ functioning, relationships, self- harm, emotional liability, psychosis, substance –Cronbach’s alpha =.86 Health promoting behaviors –16-item Health Promoting Practices Questionnaire (Vickers et al., 1987) –Measures 5 domains: health responsibility, exercise, nutrition, interpersonal support, and stress management –Cronbach’s alpha =.68

12. Participants Monthly income –79.2% HKD4,000 or below –18.9% HKD4,000-8,000 –1.9% HKD8,000 or above Type of mental illness –48.7% Schizophrenia –22.3% Depression –6.0% Bipolar disorder –23.0% Others Duration of mental illness –M=16.6 years (SD=10.9) Age –Range = 20 – 70 –M = 45.8, S.D. = 9.96 Gender –44.7% male Employment –66.9% employed Education –23.6% Primary or below –68.9% Secondary –7.5% College or above Marital Status –54.3% Single –22.6% married/cohabited –23.1% divorced/ separated/ widowed

13. Results Level of health literacy among participants –About half (47.7%, N=262) were classified as having low level of health literacy Association between background variables and health literacy Background variable Univariate odds ratio Gender Male1 Female.98 Age.99 Level of education1.13* Income.99 *p<.05

14. Results MANCOVA on quality of life (SF-12) # –Pillai’s trace=0.05, F(8, 536)=3.20, p<0.01 SF-12 Domain High HL (N=287)Low HL (N=262) Difference M (SD) F(1, 543) Physical functioning70.99 (29.29)64.79 (29.00)6.12* Role limitation – physical66.29 (25.14)59.69 (23.82)9.49* Bodily pain62.72 (29.26)57.92 (30.67)3.30 General health48.95 (27.35)38.72 (26.91)19.49*** Vitality52.70 (27.56)48.09 (26.64)4.03* Social functioning68.61 (27.75)60.97 (28.05)10.15** Role limitation – emotional68.30 (26.47)62.60 (25.29)6.25* Mental health63.50 (21.69)59.02 (21.94)5.48* # Controlled for age, sex, education; *p<.05, **p<.01, ***p<.001

15. Results MANCOVA on psychiatric symptoms (BASIS-24) # –Pillai’s trace=0.08, F (6, 543)=7.58, p<0.001 # Controlled for age, sex, education; *p<.05, ***p<.001 BASIS domain High HL (N=287)Low HL (N=262)Difference M (SD) F(1, 548) Depression/ functioning1.17 (.71)1.54 (.76)34.77*** Relationships1.88 (.81)2.20 (.79)22.77*** Self-harm.32 (.62).40 (.65)1.97 Emotional lability1.22 (.86)1.46 (.85)10.37*** Psychosis.68 (.71).79 (.69)3.85* Substance.08 (.27).12 (.35)2.88

16. Results ANCOVA on health promoting behaviors (Health Promoting Practices Questionnaire) # # Controlled for age, sex, education; **p<.01 Variable High HL (N=287) Low HL (N=262) Difference M (SD) F(1, 548) Health promoting behaviors2.71 (.32)2.62 (.35)8.78**

17. Discussion and conclusion Large proportion of PMI reported inadequate level of health literacy Higher level of health literacy was associated with better quality of life, lower level of psychiatric symptoms, and higher level of health promoting behaviors among PMI

18. Conclusion Health literacy is associated with better health among PMI Intervention to improve health literacy so as to improve PMI’s health and quality of life More research is needed to investigate the role health literacy on health in other populations

19. © Faculty of Medicine The Chinese University of Hong Kong Thank you! Email: phoenix.mo@cuhk.edu.hk