Media Health Literacy on Preventive Health Behaviour Among Indonesian Women

The understanding of media health literacy has been increasing for several decades, along with the basic concept of health literacy among women of the reproductive age group in Indonesia. Media health literacy has been advancing and becoming a strong concept based on the use of technology and the level of education in modern society. Media health literacy has been significantly connected to health behavior. In contrast, this type of interaction creates a new meaning of media within the context of health literacy, which embodies the new definition of media health literacy. The study aims to distinguish one’s health literacy by the depth of educational background and their perspective on media to their preventive behaviors and health decisions. The problem of this study is to determine the abilities to either reinforce or inhibit preventive health behaviours among Indonesian women based on their educational background. As many as 12 Indonesian women with various educational backgrounds were involved in this study. The method of this study is FGD, which consist 12 respondents that divided into two groups based on their living situation; urban or sub-urban area. It showed that the perspective and preventive health behavior on cervical cancer are highly associated with their media health literacy. Furthermore, the result of this study also suggested the media health literacy model, which stated that level of educational background plays a vital role in influencing preventive health behaviors in order to make informed health decisions.


INTRODUCTION
The beginning of the health literacy concept originated in the United States in 1970 in partnership with the educational field of the United States, meanwhile the concept of health literacy started to arise in Europe around the 1990s under the World Health Organization's European Office which admitted the term health literacy into the technical glossary of the Health Promotion according to (Rychetnik et al., 2012).
Furthermore, (Broder, 2019) mentioned that to enhanced the perspective of one's health literacy, it needs to fit their developments and social elements.Regardless of the attention gained towards this concept, many definitions of health literacy have been developed since it is still a new area of research, and each study provides a slightly different perspective of the definition.It is essential to acknowledge that the term literacy needs to be differentiated from the word literate, by which the latter was defined as 'well educated', 'learned', and 'familiar with literature' by the United Nations Education, Science, and Culture Organisation (UNESCO).Some of the most widely accepted definitions of health literacy have been developed by several resources such as the World Health Organisation (WHO), the American Medical Association (AMA), and the Institute of Medicine (IOM) as mentioned by the founder of modern health literacy study (Sorensen et al., 2012).
Furthermore, the degree of civilization in a society is primarily measured by their literacy.Thus, (Sorensen et al., 2018) in her current study brought up the degree of internet use as social tool, has magnificently influenced the level of health literacy.This influenced the development of media health literacy in a broader ways.Meanwhile, literacy in the old days was recognized as dealing with a few necessary activities, mainly in the relevant capabilities of reading, writing, and arithmetic.UNESCO, however, defines literacy as the ability to identify, understand, interpret, create, communicate, and compute any materials associated with their different layers of context, according to (Montoya, 2018).In the broader sense among society, literacy is used as part of the process of learning to enable individuals to accomplish their goals and have the potential to share their knowledge.Despite the term media literacy itself, which has been used since the 19th century, media literacy is explicitly defined as the ability to access, analyse, evaluate, and channel information, whether in print or electronic form, as stated firstly by (Mcluhan, 1965).This creates gap in betweeen of media usage and health literacy level to promote the preventive health behavior.
Media Health Literacy (MHL) integrates media and health literacy, similar to the approaches used to understand the importance of e-Health Literacy (EHL).The media cooborates the health literacy level as mentioned in the study (Levin-Zamir, 2018).While, health literacy used to explain the skills, competencies to describe their abilities to gain access to, media health literacy is more to empowering the enggagement and navigating the source of health information based on the target needed.However, the concept is unique since not only does it consider information expressed in the media, to provide a direction towards health; but it also identifies various types and forms of mass media content, developed by usual media platforms or health systems, that could either compromise or improve health.Therefore, this study aims to see how media health literacy influenced Indonesian women's perspectives and health behaviors.

METHOD
The study was conducted with qualitative method, by running the Focus Group Discussion (FGD).FGD is a qualitative research technique in the field of social sciences that concentrates on the application of the developmental initiative region (O.Nyumba, 2018).The interviewer pre-defined FGD as directed by the moderator in the process of discussion.FGD enables the researcher to understand a problem from a deeper perspective of respondents as compared to a survey.They are used to add meaning and for enhancing comprehension of the existing knowledge or get the how or why of the respondent perspective on media-health literacy in the dynamic of their health literacy skills and media literacy enggagment.
Furthermore, the FGD in this study is divided into two groups based on the living place; either urban or sub-urban.Each group consists of six respondents with two different educational background categories.The respondent is selected from the inclusive criteria of women between the ages of 25-35 years old, with the parity less than or equal to two times.Each respondents has signed the consent which they were fully informed of the study.The disussions took 60 minutes, with the help of a moderator, the interviewer posed 10 questions to each respondents to discuss.The objective of the FGD study is to corroborate the media health literacy level to preventive health behavior on cervical cancer among women in Indonesia.To analyse the FGD result, researcher use several steps which incudes transcribing and synthesizing the discussion.The next step is conducting content analysis, which enables the researcher to code the data systematically by arranging the information into categories which discover unpredictable data by reading and listening to the transcripts and records.

FGD IN URBAN SETTING
The FGD of this study involved six respondents for the urban setting and six for the sub-urban stage.The description of the FGD urban's respondents is as follows: three urban FGD were housewives following the high school educational level.These respondents were found to have minimal literacy skills but had an eagerness for awareness of promotions relating to cervical cancer.Also, they all claimed to be using their hand-phone more for media information, which only accessed social platforms such as WhatsApp, Facebook, and Instagram.This limited them from getting knowledge and from developing a passion for traditional media such as TV, radio, and newspapers.As mentioned by Ms.Puji: "Yes, I do.Several times I've seen health promotions, not only about cervical cancer.It's quite rare for me to see cervical cancer content on Instagram or Facebook.Usually, we have to find it ourselves from Google about the cervix and other related health issues.It could be preventive and promotions ad, or whatever content which formerly we searched.(Ms.Puji, Urban)" Meanwhile, the other three respondents had bachelor's degrees and worked in the corporate world.They all claimed to be using social media platforms as well, but one of the respondents also watched television on some occasions.They seemed to be more knowledgeable about cervical cancer and related issues such as screening, prevention, and promotions through media than those whose highest education level was high school.They were also eager to be more literate on cervical cancer issues and expected to get such information from experts, as mentioned by Ms.Mamay: Therefore, the urban FGD result showed that education level plays a more significant role in media literacy on cervical cancer awareness and promotional campaigns.Since those who proceeded beyond high school got to be exposed to the professional world, therefore it's widening their literacy over those who stopped at high school and became housewives.

FGD IN SUB-URBAN SETTING
In the sub-urban group, the FGD result consisted of 3 respondents who had associate degrees as their highest education level and worked with stable incomes.The remaining three respondents were housewives following their senior high school education level, and their income levels were low.From the discussion, it came out that all of the six respondents were using social media platforms such as Facebook, Instagram, Twitter, YouTube, and WhatsApp.In addition, the results showed that only one respondent who is a housewife watched TV when not using her hand-phone.The rest of the respondents rarely used traditional media platforms, as they claimed it was boring.The ones with associate degrees claimed to have no time to sit down and watch TV following their busy occupational schedules, as mentioned by Ms. Arline and Ms. Betty:

"Usually the one I use most, social media right, usually I open Instagram and then there is
YouTube.Oftentimes also scrolling on websites, like Google.(Ms.Arline, Sub-urban)" " On Instagram I like to follow channels with health content.So, whatever shows up on my feed is mostly whatever about health, including cervical cancer (Ms.Betty, Sub-urban)." Furthermore, the three respondents with associate degrees proved to have advanced knowledge of cervical cancer, courtesy of the media platforms they were using.Apart from that, they also more aware about cervical cancer compared to the three respondents who had a high school education level, as mentioned by Ms. Eberra:

"I have awareness because we are women. To be honest for women we have complicated diseases, and most of them are deadly. Additionally, I'm a very sensitive person to health issues. So, by seeing the ads, I go straight away to find out what and how to help our private parts to always be clean and healthy; not only by food but by every aspect. (Ms. Eberra, Suburban)"
Meanwhile, those with a high school education level claimed that they rarely understood the cervical cancer content being placed on their respective media platforms.Several did not pay close attention to it, as they saw it as not essential, as mentioned by Ms. Efti: "When we see pictures just in passing, the information isn't really clear."Therefore, from the FGD Sub-Urban discussion result, it's concluded that media literacy plays a more prominent role in creating awareness about cervical cancer screening, prevention, and treatment.Also, it's concluded that educational level plays a more significant role in understanding cervical cancer issues in society as presented in the media.
Meanwhile, most current media is progressively only accessible in a digital format.Therefore, digital skills are required to access it.Educating women to utilize their digital talents carefully and with a sense of obligation or civic-mindedness in creating, consuming, and distributing media is just as important as teaching them to acquire digital skills.As a result, the digital experience should be taught alongside rational reasoning and civic abilities.Otherwise, they will remain mere technical skills for using digital tools (Adunlin et al., 2019).In addition, communication skills and language are essential since they are the tools to express and articulate an opinion or a thought.By sharing personal views on online media, people feel a part of society; and that feeling of belonging is vital for their social inclusion.
"When we see pictures just in passing, the information isn't really clear.For me, I've seen more on the news and normally I straightaway go to the websites so I have the more accurate information.(Ms.Efti, Sub-urban)" "Yes, I do.Several times I've seen health promotions, not only about cervical cancer.It's quite rare for me to see cervical cancer content on Instagram or Facebook.Usually, we have to find it ourselves from Google about cervix and other related health issues.It could be preventive and promotions ad, or whatever content which formerly we searched.(Ms.Puji, Urban)" One can contribute to the generation of material, and reproduce or fabricate it.For instance, citizens can contribute factual information, even their own content for the media.This is true with digital technology, pervasive internet connections, digital newspapers and TV channels.As a result, the generation of information and analysis is no longer limited to reporters but rather something everyone can do.However, producing knowledge and research is often not done responsibly or professionally (Wong et al., 2019).This is just one of many examples that demonstrate why media level of knowledge is more crucial than ever.Therefore, based on this study result, we consider that the role of media literacy in creating awareness and promoting the essential values of social inclusion in the cervical cancer health issue has been strongly affecting women's perspective and preventive health behaviors.

CONCLUSION
The result of the study stated that most of the respondents with higher education, such as an associate degree, would possess higher knowledge and awareness on cervical cancer.They also show their eagerness to find more promotions and prevention programs through media with health content.Meanwhile, the respondents with lower education backgrounds claimed they have open access to media with health content.However, they have not understood how to progress from using the device to obtain cervical cancer promotion content.
According to (Jolls, 2018), the role of the media as one of the independent resources for information is well-positioned to bring new levels of impact towards effective literation.Furthermore, the study described how access to new technology has ultimately extended the lead to make it easily accessible.This means that the latest critical thinking era has already been firmly established in the 21st century, where everybody has control and access to information through the new technology.Despite the easy access, authoritative information should have been scrutinized using critical thinking to evaluate the information obtained.Therefore, media literacy must be carefully used in line with the information distribution to ensure that only relevant information is given to the audience.To quote the media literacy Founding Father (Mcluhan et al., 1992), who stated that the medium is the message, it emphasizes media health literacy in the foundation of critical thinking; not only in health promotion and education but also in health preventive and promotive behavior.Therefore, to highlight, this study strongly affirms that one's media health literacy level predisposes preventive health behavior with the level of education as it's foundation, as mentioned in the Figure 1 of the media health literacy model.The media health literacy model that extracted from this study, showing that each individual would have a different perspective and comprehension regarding the health subject, based on their level of education.It defines education as the foundation for more health knowledge engagement.In addition, these two elements have significantly impacted media health literacy, which acts as a booster to preventive health behaviors.This finding is also in line with (Shinta, 2019), which stated that level of education is the moderating element of preventive health behavior.The comprehension ideas of the global village concept, firstly introduced by (Mc. Luhan, 1964), which strongly predisposes education due to media literacy, which is attached to each knowledge holder and influences one's media health literacy level.
The MHL model suggested that the level of education also affects the media literacy penetration and bridges the gap between the scope of health literacy and media literacy to support the goal of health preventive behaviors.This study's central finding is essential in building the whole media health literacy comprehension model to generate preventive health behaviors.At the same time, the promotive and preventive health behaviors can be quickly drawn from each level of education to strike the understanding of health issue subjects more precisely.

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Yes, thus far I have been learning about cervical cancer based on YouTube, Instagram or WhatsApp content, that's it.I've never gotten anything directly from the doctors or the experts or going to a seminar, something like that.So probably if there are any doctors or experts who could give us support "Hey, you don't need to worry about cervical cancer diagnosis.This is how to prevent it."Since I knew it from my own findings "Ah, what if I got cervical cancer?(Ms.Mamay, Sub-urban)"