An exploratory study in functional health literacy and health promotion

behavior among foreigner students at three universities in Taipei

ABSTRACT

The aim of this study was to assess the prevalence of health literacy and examined its

association with health promotion behaviors. An on-line survey was conducted in a

convenience sample of (N=240) International college students in Taipei. Participants

completed both the Medical Term Recognition Test (METER) and the Health-

Promoting Lifestyles Profile II (HPLP II). It was found that 43.3 % had functional

health literacy level, 40 % and 16.3% had marginal and low health literacy. Risk of

having limitation in health literacy had been found in female, students with English

not as a first language, low educational level, being Asian and Hispanic/Latino, and

low income. Health literacy is a significant predictor to the overall health promoting

behavior, and for health responsibility, nutrition and interpersonal relations subscales.

The results encourage efforts to monitor health literacy in the young population and

evaluate its association with the engagement in health promotion behavior.

Keywords: Health literacy, health promotion behavior, international college students

Introduction

Today the term of health literacy is considered an important concept also

among those involved in the broader aspects of health promotion. To enhance the

individual capacity to achieve positive health outcomes oriented form health

promotion, WHO has defined health literacy as “the cognitive and social skills that

determine the motivation and ability of individuals to access, understand and use

information in ways that promote and maintain good health” (D. Nutbeam, 1998).

It is possible that individuals with lower health literacy are more prospective

to engage in negative health behaviors, such as smoking, drinking, abuse of illegal

substances, and living a inactive lifestyle because of their limited access to and ability

to understand health and medical information (Y. I. Cho, S.-Y. D. Lee, A. M.

Arozullah, & K. S. Crittenden, 2008).

Young people are generally being considered free of illness and well

nourished. However, researches have shown globally that many college students

engage in various risky health behaviors, for instance according to the Hong Kong

federation of Youth Group (HKFYG), relatively few young people in Hong Kong

practice health-promotion behaviors. Only 58% of young people exercise regularly.

Only 68 and 60 % of males and females respectively, take breakfast or eat fruits daily.

Two –thirds of young people usually do not sleep before midnight (R. L. Lee & Loke,

2005). The instant effects of these unhealthy behaviors are undetected, and usually do

not produce immediate morbidity or mortality. Instead, effects develop over a

lifetime, developing in late life when it is too late to restore health (R. L. Lee & Loke,

2005). When examining health related behavior, researches in health literacy have

mostly adopted a clinical orientation to focus on disease management behaviors

among specific patient populations, for instance, patients who suffer from chronic

diseases such as HIV/AIDS (Seth C., Kalichman & D. Rompa, 2000), diabetics

(Morris, MacLean, & Littenberg, 2006), or hypertension (J.A. Gazmararian et al.,

2006). Furthermore, evidence regarding the association between health literacy and

health promoting behaviors has been inconclusive. Colleges and universities are of the

setting where students experience independence and freedom from direct supervision

by parents for the first time. They enter an environment where normative values may

be different than parental values, therefore, causing them to question individual belief,

values, and goals. This time of searching values, beliefs, and goals may lead to
changes in health promotion as students experiment with their new autonomy and

environment (Rozmus, Evans, Wysochansky, & Mixon, 2005).

The Ministry of Education (MOE) considers international cooperation and

collaboration a cornerstone of its efforts to embrace internationalization, especially for

institution of higher education. This is reflected in the number of international degree

students, language students, and exchange students studying in Taiwan. In 2011,

international students have increased to 44,165, a significant increase from 2006,

when international student enrolment was only 26,488. According to the MOE, the

number of international students in tertiary education (excluding exchange students

and language students) in 2012/2013 was 11,554 (Ministry of Education, 2012/13).

The Ministry of Education in Taiwan, as a part of its ten educational development

policy statements includes the promotion of students’ health literacy and standards for

healthy living. International college students are part of this education system

promotion. International students in Taiwan are required to embrace themselves into a

new country, new environment and different context, which involve a change in their

habits, life conditions and different language. Many researchers suggest that to

maintain stability, individuals should incorporate health-promoting behaviors.

However, sometimes foreign students, for instance, have specific health problems;

they are generally unknowledgeable with the health care systems of their host

countries. The purpose of this study was to investigate the prevalence of functional

health literacy, and examined associations with health promoting behaviors through

an evaluation in the domains of health responsibility, physical activity, nutrition,

spiritual growth, interpersonal relations and stress management, among culturally

diverse international college student at three universities in Taipei.

Methods
 A cross-sectional descriptive self-reported online survey was used in this

study. Data was collected from October 2012 to December 2012. International college

students who were enrolled at bachelor degree, master degree, doctoral degree or

exchange students were included in the study. The study was conducted at three

separate universities located in Taipei city, National Chengchi University (NCCU),

Taipei Medical University (TMU) and Fu Jen Catholic University. The Institutional

review board committee of Taipei Medical University approved the study design for

this project. An e-mail was distributed through the International Student Affair

department of each University, containing an attached link to the online survey. If

potential participants chose to participate, there were direct first to an informed

consent statement describing the research purpose and steps taken to protect

participants’ privacy. Students choosing to participate were then referred to the survey

by clicking on the referent link. There were no risks for those who participated in this

survey. The questionnaire contained no identification data; data obtained from the

survey have been treated with strict confidentiality and participants have remained

anonymous throughout the entire research process.

The online questionnaire includes three sections. The first section was related

to socio-demographic variables that have been shown to be related to health behavior

and health literacy, specifically age, gender, length of residence in Taiwan, marital

status, education level, ethnicity, language, source of financial support and monthly

income.

The primary independent variable we examined was health literacy, which was

measured by Medical Term Recognition Test (METER) (Rawson et al., 2010). The

METER includes 70 words. The participant was given a list of items and asked to

check off those they recognize as actual medical words, and it takes about 2 min to
complete. The format of The Medical Term Recognition (METER) is based on a

battery of tests developed to estimate reader’s prior reading experiences. The METER

showed a high degree of reliability, Cronbach’s  = 0.93 and was strongly correlated

with Rapid Estimate of Adult Literacy (REALM) (r = 0.74, p < 0.001)(Rawson et al.,

2010). For the analyses, the Medical Term Recognition Test was scored as the number

of words correctly recognized by the participant, with performance cutoff points of 0-

20, 21-34, and 35-40 to establish low, marginal, and functional (adequate) health

literacy levels.

The student’s health promotion behavior was measured using the modified

version of the HPLP II. The modification of HPLP II comprised the elimination and

adjustment of certain items, which includes the evaluation of five expert panels. The

final modified version of the HPLP II used in this study retained the six subscales to

measure healthy behaviors in the theorized dimensions of health promoting lifestyle

(Walker & Hill-Polerecky, 1996). The HPLP II was originally developed as the

Health-Promoting Lifestyle Profile (HPLP) within a wellness framework (S. N.

Walker, Sechrist, & Pender, 1987). The final version of the intrument contains a total

of 38 items, which includes items on health responsibility, physical activity, nutrition,

spiritual growth, Interpersonal relations, and stress management. The responses to the

instrument’s items range from 1 to 4 (never, sometimes, often, and routinely) with

possible scores ranging from 38 to 152. The Cronbach alpha for the modified HPLP II

for the present study provides the following results, health responsibility 0.765 (7 -

items); physical activity 0.744 (7 – items), nutrition 0.593 (6-items), interpersonal

relation with 0.675 (7-items), stress management 0.465 (5-items) and spiritual growth

0.774 (6- items). The alpha coefficient of internal consistency for the total scale was

0.882 (38-items).
 The statistical Package for Social Science V18.0 was used for statistical

analyses. Assessment of the potential mediation effect of health literacy was assessed

using the criteria of Barron and Kenney, (1986). The hypothesized mediation model

guiding this analysis is displayed in figure 1. To satisfy the criteria for mediation:

(1) The association of the socio-demographic characteristic with health

literacy must be significant. (2) The association of socio-demographic characteristic

with the health promotion behavior must be significant. (3) Health literacy must be

significantly associated with Health promotion behavior controlling for socio-

demographic characteristics. If these requirements are satisfied in the predicted

direction, and the association between the socio-demographic characteristic and health

promotion behavior is significantly reduced with the inclusion of health literacy in the

model, mediation is said to have occurred.

First descriptive statistics were computed to describe the socio-demographic

attributes of International students, levels of health literacy and the distribution of

each of the health promotion behavior. The association of socio-demographic

characteristics with health literacy and health promotion behavior was analyzed using

independent samples t-test and one-way ANOVA. Stepwise multiple regression

analysis was carried out to determine the best socio-demographic predictor variable of

our dependent variable and its association with our independent variable, for their

subsequent inclusion in the final model. All socio-demographic variables were

initially entered into the multiple regressions to determine their collective contribution

to each of the six-health promotion behavior, overall health promotion and health

literacy. Since age, gender, language and educational level arose as the best predictors

were entered into the final model to determine their contribution in predicting each of

the health promotion behavior.

 A two-step hierarchical multiple regression analysis was used. First, socio-

demographic variables were entered into the model. In the step two, we entered health

literacy into the model to see if that would reduce the associations between socio-

demographic characteristic and health promotion behavior. A P value of 0.05 and 0.01

was used to determine statistical significant.

Results

Table 1 shows the demographic characteristics of the participants. A total of

two hundred forty foreigner students participated in the assessment, whose ages

ranged from 18 to 53, with mean and standard deviation of 25.49(5.131). There were

108(45.0 %) male students and 132 (55.0%) female students. Most of the respondents

were bachelor degree and master degree students and only 37(15.4 %) were

doctoral/PhD degree students. Nearly 191 (80%) of individuals had English as a

second language and 49(21%) had English as their first language. The majority of the

respondents funded their living expenses by government’s scholarships, were single

and they were economically well-off. The same table also shows the distribution of

Functional health literacy scores of the respondents, with a mean score of 29.85. The

majority of the participants had functional and marginal health literacy level with 104

(43.3%) and 97 (40.4%) respectively, and only 39 of the participants had low level of

health literacy. The overall mean score for the HPLP II was 93.81, indicating that the

levels of health promoting lifestyles among these students were moderate. Participants

had highest scores in the subscale of interpersonal relations (M= 19.07), moderate

level of spiritual growth (M=17.98), physical activity (M= 15.63), and nutrition

(M=14.50) and health responsibility (M=14.30) and students scored lower on stress

management (M= 12.33; Table 2).

 Table 3 shows there were a statistical significant difference in health literacy

score, gender and language. Male students had higher mean of health literacy scores

(M=31.25; P=<0.05) and students with English as their first language (M=36.45;

P<0.01). Male students engaged more in physical activity behaviors than did females

(M= 16.50; P<0.01). Students with English as their first language engaged more in

interpersonal relations habits (M=20.29; P<0.01) compared to those with English as

their second language.

Table 4 shows a statistical difference in health literacy scores and educational

level, the mean score of bachelor degree students (M= 27.66; P <0.01) was

significantly different from mean scores of doctoral degree students (M= 33.27; P

<0.01), showing an increment of the scores of health literacy as the educational level

increases. Group of master degree (M= 30.74; P<0.01) did not differ significantly

from either bachelor or doctoral degree. The mean score of North American students

(M= 36.19; P<0.01) was significant different compare to mean score of Asian students

(M=25.76; P<0.01), and mean score of Asian respondents had significant difference

compared to mean scores of European students (M=32.57; P<0.01). Moreover, a

significant difference was revealed in the interpersonal relations and nutrition

subscale for the six different groups of ethnicity. Mean score of North Americans

students (M=21.14; P<0.01) was significantly different from mean score of Asians

students (M=18.13; P<0.01). Europeans students presented slightly higher mean score

in nutrition subscale (M=15.70; P<0.05) compare to the rest of the ethnic groups.

Also we found influence between variable of income and mean scores of

interpersonal relation subscale. Participants with an income of NT$ 15,000 - NT$

19,999 and more than NT$ 30,000 presented higher mean score in this subscale,

(M=20.63; P<0.05) and (M=20.23; P<0.05) and overall HPLP mean score (M=99.11)
and (M=98.86) respectively, indicating often practice of this behavior and higher

engagement in the overall health promotion behavior.

The two- step hierarchical multiple regression analysis displays the

correlations between the variables, for Health responsibility subscale, the model I

display an R2 = .032 and Adj. R2 = 0.11, explaining 3.2% of the variance and had F

(5,234) =1.534, indicating no statistically significant variability. In model II R2 = .079

and Adj. R2 = .051, the model as a whole explains 7.9%. Our independent variable,

explains an additional of 4.7%. The whole model is statistically significant F (7,232)

= 2.830; p<0.01. Education appeared to have a statistically significant unique

contribution in predict health responsibility behavior with master degree category

(β= .197, P<0.05) compared with the category of Phd/Doctoral degree. In addition,

health literacy presented a stronger statistically significant unique contribution in

predicts health responsibility behavior with functional level of health literacy (β= .303

P<0.01). Model I of Physical Activity subscale presented R2 = .062 and Adj. R2 =. 042,

explaining 6.2% of the variance and had an F value of F (5,234) = 3.087, p< 0.05,

model II had an R2 = .067 and Adj. R2 = .039. The Model II indicated a statistically

significant contribution, F (7,232) = 2.392, p<0.05. Gender makes the strongest

significant unique prediction of physical activity behavior after Model I and at the end

of the Model II (β= .206, p< 0.01). For Nutrition subscale, only health literacy

presents a unique contribution to predict nutrition according to standardized (β = 218,

p < 0.05), indicating that students with functional health literacy level had higher

scores in nutrition behavior subscale. For interpersonal relation, the Model I presented

an R2 =. 045, Adj. R2 = .025, explaining 4.5 % of the variance and had an F value of

F(5,234)= 2.230, indicating no statistically significant variability of interpersonal

relation behavior. The Model II exhibited an R2 =. 092, Adj. R2 =. 065 and F (7,232)
=3.370, p < 0.01. Health literacy, explains an additional of 4.7%. We found that only

language make the strongest significant unique prediction of interpersonal relation

behavior. In model II, health literacy presented a statistically significant unique

contribution in predicts interpersonal relation behavior, with functional health literacy

as the strongest predictor (β= .332, p < 0.01). HPLP total score in model I presented

an R2 =.025 explaining 2.5 % of the variance and had an F value of F(5,234) = 1.193.

Model II presented R2 = .063, the model as a whole explains 6.3%. Health literacy

explains an additional of 3.8%. Health literacy is a unique statistically significant

contributor to the total score of HPLP. Health literacy did not have a unique

contribution in predicting stress management and spiritual growth behaviors (table 5).

Discussion

Student’s age, gender, language, educational level, ethnicity, and income had

statistically significant association toward health literacy in this study. The

significance positive correlation of age toward health literacy suggested that high

level of health literacy score is associated with older students. This result were in line

with Rowlands et al., (2013) which found that among 687 patients in 16 General

Practices (GP) in South London, patients with low health literacy were slightly

younger than the patients with adequate health literacy. Male students had slightly

higher mean score of health Literacy compared to scores of female students in our

sample. Unlike the present study, in von Wagner et al. (2007); Young Ik Cho et al.

(2008) researches, men had lower health literacy levels than women. The difference in

this finding may be because previous evaluations were obtained from patients in the

medical setting or sample, which may be over representative of disadvantageous

social groups for instance patients in the chronic disease contexts, such hypertension,

hearth failure or diabetes, (Darren A DeWalt et al., 2011; Osborn et al., 2011) samples
relatively much more older than our sample, and with limit educational attainment

(Brega et al., 2012). Further investigation among the proportion of Doctoral degree

students revealed that the majority were male students (25 out of 37) compared to our

female students (12 out of 37). This may influence the prevalence of Functional

Health Literacy in male respondents. Some studies reported the prevalence of

inadequate health literacy was higher in women than in men due to their low

educational level and the strong correlation between level of health literacy and years

of formal schooling (S.-Y. Lee, Tsai, Tsai, & Kuo, 2010; Reisi et al., 2012).

Students with English as their first language had higher mean score of health

literacy compared with students with English as a second language. Our findings

regarding the high prevalence of low or marginal health literacy among respondents

with English as a second language are consistent with M. V. Williams et al. (1995),

which reported that incorrect responses to the test items of TOFHLA (Test of

Functional Health Literacy in Adults) were least common among English-speaking

patients and most common among Spanish-Speaking patients.

In our study, Asian students presented the lowest mean score of Health literacy

followed by Hispanic American and African students. Respondent such as North

American, Australian/new Zealander and European students, considered as “White”,

had higher mean score of health literacy. Our study findings were supported by

Wilson (2009), who stated that among racial/ethnic groups, the lowest levels of health

literacy were found in Hispanic followed by blacks.

These differences in health literacy among different ethnicity could be

explained owing to differences in language, cultural barriers, and different educational

opportunities position the minority populations at higher risk for low literacy (R. M.

Parker et al., 2003).

 As to six subscales of health-promoting lifestyles, our respondent scored

highest in the interpersonal relation and spiritual growth subscales. This may be

elucidated by the fact that the university is an effective environment for developing

interpersonal relation and spiritual development among college students.

Male students presented a higher mean score of physical activity subscale

compared to female students, indicating that male students were more likely to be

active. Similar to other studies, R. L. Lee and Loke (2005) found in their research

among university student in Hong Kong, male students engaged more frequently in

physical exercise than female students, more male than female students reported

“taking part in leisure-time recreational physical activity”.

For health responsibility subscale, in model I, none of these variables of

interest was found to be significant predictor of health responsibility. Model II,

highlighted the importance of the prediction of education and health literacy,

demonstrating a significant and positive association of education and health literacy

with health responsibility subscale. This study showed the importance of education on

health literacy and in the engaging in health- promoting behaviors. Education was not

only related to the health literacy scores but also significantly related to the health

responsibility subscale. The importance of education also has been supported by

previous studies, Al‐Kandari and Vidal (2007) reported that higher- year students had

higher health responsibility scores. One possible explanation of these positive

relationships is that individuals with a higher level of health literacy are more

knowledgeable of health matters and health risk factors and therefore, are more likely

to take health promotion measures (J.A. Gazmararian et al., 2003). For physical

activity subscale, only gender was found to be a significant predictor in both models,

male students engage more in physical activity behaviors than female students. This
study did not find the significant relationship between health literacy and physical

activity subscale. It was similar with the study conducted by on Wagner et al. (2007),

in which exercise behavior has not been associated with health literacy.

Health literacy was also found to be the only significant predictor factor on

Nutrition subscale. The result is recurrent with Brega et al. (2012) whose results were

such that healthy diet, unhealthy diet and self-monitoring of blood glucose were

significantly associated with health literacy. It is important to mention that the

nutritional status of college students may be influenced by others factors that were not

measured in this study. We found that health literacy is a significant mediating factor

through which language indirectly affect interpersonal relations among students in

this study. Consistent with this finding, Wang & Lai, (2008) debated that adolescents

with high mental health literacy may have capacities to actively seek solutions to

interpersonal problems and build healthy relationships with others. Mulvaney-Day,

Alegria, and Sribney (2007) found in their a study among immigrant Latinos in the

US, that language ability appears to influence the social connection through which

one acquired positive health and mental health benefits. Analyses showed no

significant relation between our selected socio-demographic variables, health literacy,

stress management behavior and spiritual growth. The analysis of Stress management

behavior should include multiple factors, such as level of optimism, which had been

found to be associated with better mental health and less involvement in risky

behaviors (Finkelstein, Kubzansky, Capitman, & Goodman, 2007), rather than

focusing on a single factor because the environmental or psychological factors in the

mental health are complicated and interlinked (Burns & Rapee, 2006). Moreover, the

concept of spirituality is very subjective, is actually a form of philosophy of one’s

life attitudes and value system that originates form culture, education, and personal
experience, therefore spirituality in and of itself, is highly individual, innate and has

the capacity of inner knowledge that may not be influence by health literacy (Tu,

2006).

Although these findings give valuable insight into health promoting behavior

and the prevalence of health literacy among international college students in Taipei,

there were some noted limitations. Participants utilized for this analysis had not even

distribution in their racial background and educational level. A larger scale studies

involving more heterogeneous samples, even distribution of racial background and

with the same mother language will be useful to further examine the association

between this two terms. Second, because our study was based on cross-sectional data,

our ability to establish the causality between health literacy and health promoting

behavior was limited and could not explain changes over time in lifestyle behaviors.

There is a need for research that may follow international students from their first year

to senior years to trace changes in health promotion during their studies in Taiwan.

Conclusion

Health behavior established during adolescence and young adulthood may

have a significant impact on health behavior and the occurrence of diseases later in

life. College students, who are more vulnerable in engaging in risky health behavior,

are prime candidates for health promotion and prevention programs.

These results provide evidence that there is still a proportion of limited functional

health literacy among international college students in Taiwan. Health literacy implies

the achievement of a level of knowledge, personal skills and confidence to take action

to improve personal health by changing personal health lifestyle behaviors and living

conditions. The finding in this research could be tied to health strategies related to
decreasing health literacy barriers to promoting a healthy lifestyle for the youth

population.

Acknowledgements

The authors would like to thanks to Professor Chiung – Hsuan Chiu, who has guided

the whole process of this research, and the committee members who approved this

research, professor Yi-Hsin Elsa Hsu and Dr. Chung-Liang Shih.

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Wilson, Meg. (2009). “Readability and patient education materials used for low-

income populations”. Clinical Nurse Specialist, 23(1), 33-40.

 Table 1: Descriptive statistic of socio-demographic
variables and health literacy variables

Continuous Variable (N=240) M (SD) Range

Age (Years) 25.49 Variable (N=240) Percentage
(5.131) 18-53 N =240
(%)
Categorical Variables Percentage
Income
N =240
(N=240) (%)
Gender Less than 5,000 NT$ 24 10.0
Male 108 45.0 NT$ 5,000 - NT$9,999 29 12.1
Female 132 55.0 NT$ 10,000 - NT$ 14,999 38 15.8
Time living in Taiwan NT$ 15,000 - NT$ 19,999 27 11.3
< 6 months 85 35.4 NT$ 20,000 - NT$ 24,999 29 12.1
6 - 12 months 17 7.1 NT$ 25,000 - NT$ 29,999 58 24.2
1 - 2 years 48 20.0 More than NT$ 30,000 35 14.6
> 2 years 90 37.5
Level of Health Literacy
Education Level
Bachelor Degree Low 39 16.3
100 41.7
Master Degree Marginal 97 40.4
103 42.9
Doctoral /Phd Degree 37 15.4 Functional 104 43.3
Marital Status Continuous Variable M (SD)
Single 207 86.3 Total Score of Health Literacy
Married 31 12.9(METER) 29.85(9.982)
Divorced 1 0.4
Separated 1 0.4
Ethnicity Table 4-2 Descriptive statistic for overall scores of health
promotion behavior and its subscales
North American 21 8.8
Asian 80 33.3
African 24 10.0
Central/South American
(Hispanic/Latino) 64 26.7 Dimensions N M SD
European 46 19.2 Health
Australian / New Zealand 5 2.1 Responsibility 240 14.30 3.94
Language Physical
English as a first Language 49 20.4 Activity 240 15.63 4.12
English not as a first Nutrition 240 14.50 2.96
Language 191 79.6 Interpersonal
Source of Financial Support Relations 240 19.07 3.54
Stress
Government’s Scholarship 100 41.7
Management 240 12.33 2.47
University's Scholarship 57 23.8 Spiritual
Self- income 23 9.6 Growth 240 17.98 3.45
Family Support 49 20.4 Total Score
HPLP 240 93.81 14.39
Others 11 4.6
Table 3 Independent sample T-tests analysis on variable of Gender and Language with Health Literacy, HPLP II and its
subscales

Health
Health Physical Interpersonal Stress Spiritual HPLP: Total
Variables N Literacy Nutrition
Responsibility Activity Relations Management Growth score
Score
Gender
31.25
Male 108 (9.03) 14.28(4.04) 16.50(4.13) 14.61(3.00) 18.94(3.54) 12.20(2.53) 17.88(3.65) 94.42(14.98)
28.70
Female 132 (10.59) 14.31(3.88) 14.92(3.98) 14.42(2.93) 19.17(3.55) 12.42(2.43) 18.07(3.28) 93.32(13.93)
t- value 1.983* -0.064 2.996** 0.505 -0.499 -.0686 -0.420 0.587
Language
English
as a first
language 49 36.45(4.86) 15.20(4.73) 16.12(3.78) 14.33(2.69) 20.29(3.71) 12.39(2.14) 18.27(2.95) 96.59(13.21)
English
not as a
first 28.15
language 191 (10.25) 14.06(3.69) 15.51(4.20) 14.55(3.03) 18.76(3.44) 12.31(2.55) 17.91(3.57) 93.10(14.63)
t- value 8.157** 1.570 0.931 -0.470 2.724** 0.199 0.640 1.519
 Health
Health Physical Interpersonal Stress Spiritual HPLP: Total
Variables N Literacy Nutrition
Responsibility Activity Relations Management Growth score
Score
Ethnicity
North American1 21 36.19 (5.446) 14.90(5.147) 17.00(4.359) 14.43(2.501) 21.14(3.306) 13.10(1.921) 18.19(2.977) 98.76(11.497)
Asian2 80 25.76 (11.416) 13.90(3.389) 14.79(3.781) 14.13(2.399) 18.13(3.070) 12.55(2.599) 17.70(3.156) 91.19(13.683)
African3 24 32.42 (10.325) 14.92(3.586) 15.50(4.170) 13.63(3.424) 20.71(3.316) 11.83(2.078) 19.04(1.853) 95.63(12.974)
Central/South
American
(Hispanic/Latino)4 64 29.61(10.272) 14.41(4.042) 16.13(4.173) 14.53(3.446) 18.34(3.515) 11.98(2.567) 18.27(3.814) 93.66(15.925)
European5 46 32.57 (4.717) 14.11(4.332) 15.96(4.482) 15.70(2.835) 19.89(3.802) 12.28(2.570) 17.13(4.026) 95.07(14.912)
Australian / New
Zealand6 5 34.20 (3.421) 15.40(4.393) 14.80(2.588) 13.80(3.114) 19.40(4.159) 12.60(1.949) 20.80(3.347) 96.80(15.786)
F- value 6.177** .483 1.434 2.296* 5.025** .985 1.925 1.224
Scheffe’s (1,2)(2,5) - - - (1,2) - - -
Table 4 One -way ANOVA analysis on variables of health literacy score, health promotion behavior and demographic variables
Educational level .
Bachelor
Degree1 100 27.66 (10.780) 14.17(4.115) 15.69(4.042) 14.60(2.601) 18.83(3.599) 12.50(2.464) 18.05(3.605) 93.84(15.148)

Master Degree 2 103 30.74 (9.394) 14.63(3.973) 15.88(4.199) 14.55(3.345) 19.50(3.689) 12.43(2.412) 17.95(3.493) 94.94(14.241)
Doctoral /Phd
Degree 3 37 33.27 (8.016) 13.70(3.374) 14.78(4.111) 14.11(2.777) 18.54(2.892) 11.57(2.609) 17.89(2.951) 90.59(12.504)
F- value 5.160** .839 .986 .395 1.386 2.088 .036 1.244
Scheffe’s (1,3) - - - - - - -
Table 4 One -way ANOVA analysis on variables of health literacy score, health promotion behavior and demographic variables

Health
Health Physical Interpersonal Stress Spiritual HPLP: Total
Variables N Literacy Nutrition
Responsibility Activity Relations Management Growth score
Score
Income
Less than 5,000 NT$ 24 26.63 (10.834) 13.67(3.583) 15.21(3.978) 14.75(2.878) 18.71(3.458) 12.88(2.173) 17.88(3.097) 93.08(14.313)
NT$ 5,000 -
NT$9,999 29 28.45 (10.162) 14.07(3.927) 15.28(4.008) 14.14(2.546) 19.00(2.591) 12.76(2.400) 18.14(3.020) 93.38(13.157)
NT$ 10,000 - NT$
14,999 38 28.63 (12.106) 13.79(3.878) 15.21(4.794) 13.82(3.992) 18.03(3.983) 11.34(2.831) 17.00(3.806) 89.18(18.343)
NT$ 15,000 - NT$
19,999 27 31.48 (10.252) 15.52(3.446) 16.11(3.178) 14.78(1.987) 20.63(3.586) 12.81(2.856) 19.26(2.754) 90.11(11.584)
 NT$ 20,000 - NT$
24,999 29 30.83 (6.959) 13.83(3.723) 14.86(3.701) 15.03(3.448) 18.72(3.494) 12.34(2.439) 17.24(4.282) 92.03(14.652)
NT$ 25,000 - NT$
29,999 58 29.95 (9.286) 13.95(4.236) 15.59(4.044) 14.16(2.505) 18.69(3.158) 12.17(2.137) 18.19(3.591) 92.74(13.546)
More than NT$
30,000 35 32.29 (9.587) 15.49(4.182) 17.03(4.566) 15.31(2.857) 20.23(3.993) 12.51(2.430) 18.29(2.896) 98.86(12.057)
F- value 1.126 1.339 1.047 1.214 2.316* 1.616 1.463 2.185*
Scheffe’s --- - - - - - - -

Dependent Variables
HPLP
HR PA NT IR SM SG
Total score
Control variables Model Model Model Model Model Model Model Model
Model II Model II Model II Model II Model II Model II
I I II I I I I I
Age .123 .104 -.105 -.108 -.027 -.044 -.036 -.047 -.041 -.054 -.055 -.063 -.031 -.047
Gender
 Male -.008 -.010 .206** .206** .049 .047 -.052 -.053 -.025 -.027 -.034 -.034 .042 .040
Ref. group: Female
Language
English not as First
language -.103 -0.14 -.067 -.046 .023 .096 -.193** -.120 -.048 -.004 -.062 -.029 -.113 -.034
Ref. group: English
as First language
Education
Bachelor Degree .182 .221 .109 .123 .069 .098 .054 .094 .161 .173 -.012 .001 .133 .169
Master Degree .173 .197* .150 .157 .073 0.91 .134 .156 .158 .168 -.011 -.003 .163 .184
Ref. group: Doctoral
/Phd Degree
Independent variable
Functional .303** .113 .218* .332** .089 .104 .282**
Marginal .098 .080 .037 .196* -.036 .027 .106
Ref. group: Low
F- Value 1.534 2.830** 3.087* 2.392* .310 1.242 2.230 3.370** .968 1.069 .254 .383 1.193 2.246*
R2 .032 .079 .062 .067 .007 .036 .045 .092 .020 .031 .005 .011 .025 .063
Adj. R2 0.11 .051 .042 .039 -.015 .007 .025 .065 -.001 .002 -.016 -.018 .004 .035

Table 5 Hierarchical Multiple regression analysis to predict Health Promotion Behaviors

Figures

Independent Variable

Health Literacy

Control variables
Dependent variable
Socio-demographic
1. Age Health Promotion
2. Gender
3. Length of residency behavior
4. Marital Status 1. Health responsibility
5. Education level 2.Physical activity
6. Ethnicity 3.Nutrition
7. Language 4.Interpersonal relation
8. Source of financial 5.Stress management
support 6. Spiritual growth
9. Income

Figure 1 Conceptual model: the mediation effect of health literacy on socio-demographic

characteristic and health promotion behavior of International student