Effectiveness of a health literacy intervention based on transformative learning and incorporating positive psychology on health behavior and well-being of Thai families with NCDs risk

  • Ungsinun Intarakamhang
    Behavioral Science Research Institute, Srinakharinwirot University, Bangkok, Thailand.
  • Ann Macaskill
    Centre for Behavioral Science and Applied Psychology, Faculty of Social Science and Humanities, Sheffield Hallam University, Sheffield, United Kingdom.


Background: Thailand has a higher global NCD mortality rate in comparison to the rest of the world, accounting for 75% and 71% of all deaths. WHO focused increasingly on health literacy (HL) in order to decrease NCDs. This study aimed to assess the effectiveness of an HL intervention utilizing transformative learning and positive psychology with mindfulness training in terms of changing levels of HL, health behavior (HB), and health outcomes.

Design and Methods
: The study was a randomized control trial from May to September 2019.  The participants were a rural Thai population with low levels of HL, living in an area with high levels of NCDs. The 200 participants were cluster randomly allocated to an eight-week intervention, and the control group. The data were collected by Likert questionnaires and physical exams, and analyzed via ANOVA.

: The intervention group mean scores for HL, psychological capital, HB, and family well-being increased from baseline to post-intervention, but decreased during the follow-up but were still significantly higher than the control group and baseline scores. The increases in HL and HB were matched by improvements in physiological measurement. The BMI scores of the intervention group decreased in each phase, while the control group scores remained largely unchanged. An intervention group had significantly lower fasting blood sugar than the controls at the intervention and in the follow-up. There was no interaction between social support and any other variables.

: This program demonstrated improvements in HL, HB and the well-being of Thai families at risk of NCDs in rural communities.


Bohanny W, Wu S, Liu C, et al. Health literacy, self-efficacy, and self-care behaviors in patients with type 2 diabetes mellitus. J Am Assoc Nurse Pract 2013; 25:495-502. DOI: https://doi.org/10.1111/1745-7599.12017

Osborne RH, Batterham RW, Elsworth GR, et al. The grounded psychometric development and initial validation of the health literacy questionnaire (HLQ). BMC Public Health 2013;13:658-64. DOI: https://doi.org/10.1186/1471-2458-13-658

WHO. The mandate for health literacy, 9th global conference on health promotion, held in Shanghai. Geneva; 2016. Available from http://who.int/healthpromotion/conferences/9gchp/health-literacy/en/

Thai Ministry of Public Health. 5-year national NCDs prevention and control strategic and action plan (2017- 2021). Nonthaburi: Bureau of Non-Communicable Disease, Ministry of Public Health; 2017.

Intarakamhang U, Kwanchuen Y. The development and application of the ABCDE-health literacy scale for Thai adults. Asian Biomed 2016;10:587-94.

Park N, Peterson C, Seligman MEP. Strengths of character and well-being. J Soc Clin Psychol 2004;23:603–19. DOI: https://doi.org/10.1521/jscp.23.5.603.50748

Edwards M, Wood F, Davies M, Edwards A. The development of health literacy in patients with a long-term health condition: the health literacy pathway model. BMC Public Health 2012;12:1-15. DOI: https://doi.org/10.1186/1471-2458-12-130

Manganello JA. Health literacy and adolescents: A framework and agenda for future research. Health Educ Res 2008:23:840-7. DOI: https://doi.org/10.1093/her/cym069

Nutbeam D. Defining and measuring health literacy: what can we learn from literacy studies? Int J Public Health 2009;54:303-5. DOI: https://doi.org/10.1007/s00038-009-0050-x

Ownby RL, Acevedo A, Waldrop-Valverde D, et al. Abilities, skills and knowledge in measures of health literacy. Patient Educ Couns 2014;95:211–7. DOI: https://doi.org/10.1016/j.pec.2014.02.002

Mezirow J. Transformative learning as discourse. J Transform Educ 2003;1:58-63. DOI: https://doi.org/10.1177/1541344603252172

Hein SF. Embodied reflexivity in qualitative psychological research: The disclosive capacity of the lived body. In: S. P. Shohov, Editor. Advances in Psychological Research. Nova Publishers; 2004. p. 57-74.

Bandura A. Social foundations of thought & action: A social cognitive theory. Upper Saddle River: Prentice Hall;1986.

Seligman MEP, Csikszentmihalyi M. Positive psychology: An introduction. Am Psychol 2000;55:5–14. DOI: https://doi.org/10.1037/0003-066X.55.1.5

Luthans F. Avolio BJ, Avey JB. Psychological capital questionnaire manual. Menlo Park: Mind Garden, Inc; 2014.

Macaskill A, Denovan A. Assessing psychological health: The contribution of psychological strengths. Br J Guid Counc 2014;42:320-37. DOI: https://doi.org/10.1080/03069885.2014.898739

Scheier MF, Carver CS, Bridges M. Optimism, pessimism, and psychological wellbeing. In: E.C. Chang, Editor. Optimism and pessimism: Implications for theory, research, and practice. Washington: APA; 2001. p. 189-216. DOI: https://doi.org/10.1037/10385-009

Snyder CR. Handbook of hope: Theory, measures, and applications. San Diego: Academic Press; 2000.

Rogers JM, Ferrari M, Mosley K, et al. Mindfulness-based interventions for adults who are overweight or obese: a meta-analysis of physical and psychological health outcomes. Obesity Rev 2017;18:51-67. DOI: https://doi.org/10.1111/obr.12461

Intarakamhang U, Macaskill A, Prasittichok P. Mindfulness interventions reduce blood pressure in patients with non-communicable diseases: A systematic review and meta-analysis. Heliyon 2020;6:e03834. DOI: https://doi.org/10.1016/j.heliyon.2020.e03834

Reblin M, Uchino BN. Social and emotional support and its implications for health. Curr Opin Psychiatry 2008;21:201-5. DOI: https://doi.org/10.1097/YCO.0b013e3282f3ad89

Intarakamhang U, Macaskill A. Multi-group causal model of health literacy and behaviors on family well-being among Thai adults at risk of non-communicable diseases (NCDs). JRHS 2018;18:e00429. DOI: https://doi.org/10.20472/AHC.2019.005.012

Seligman MEP. Authentic happiness: Using the new positive psychology to realize your potential for lasting fulfilment. New York: Free Press; 2002.

Ariyasripong A, Phoowachanathipong K. A causal relation model of environment and positive psychology factors towards Buddhist holistic health of families in the high-rise community, Bangkok. J MCU Nakhondhat 2018;5:233-49.

Intarakamhang U, Ekpanyaskul C. Effect of positive psychology and cultural social norm on healthy behavior and family well-being by mediated health literacy of family in the semi-urban community: Mixed methods. J Behav Sci 2018;24:1-22.

Bas G, Sijmen AR, Carel JM, Andrea FW. Health literacy is associated with health behaviors and social factors among older adults: Results from the life lines cohort study. J Health Commun 2016;21(s2):45-53. DOI: https://doi.org/10.1080/10810730.2016.1201174

Singhasem P, Krinara P, Tiparat W. Correlation between health literacy and health behaviors in older people: A survey research in a community in Trang province. Boromarajonani College of Nursing, Uttaradit Journal 2019;11:37-51.

Nutbeam D. The evolving concept of health literacy. Soc Sci Med 2008;67:2072-78. DOI: https://doi.org/10.1016/j.socscimed.2008.09.050

Nitri D, Stewart M. Transformative learning intervention: effect on functional health literacy and diabetes knowledge in older African adults. Gerontol Geriatr Educ 2009;30:100-13. DOI: https://doi.org/10.1080/02701960902911265

Chiangkhong A, Intarakamhang U, Duangchan P, Macaskill A. Effectiveness of health literacy through transformative learning on glycemic control behavior in adult diabetes patients: A mixed methods approach. J Behav Sci 2019;14:49-61.

Stewart DW, Reitzel LR, Correa-Fernandez V, et al. Social support mediates the association of health literacy and depression among racially/ethnically diverse smokers with low socioeconomic status. J Behav Med 2014;37:1169-79. DOI: https://doi.org/10.1007/s10865-014-9566-5

Waldrop-Valverde D, Guo Y, Raymond L, et al. Risk and protective factors for retention in HIV care. AIDS Behav 2014;18:1483-91. DOI: https://doi.org/10.1007/s10461-013-0633-7