Cancer caregivers’ health literacy in Macao: Understanding influencing factors and promoting support – an observational study
Global studies have linked health literacy with various health-related challenges. For instance, inadequate health literacy among patients can lead to increased rates of hospitalization, higher healthcare costs, elevated mortality and morbidity rates,  and heightened caregiver burdens,  impacting the quality of life of patients  and their health outcomes.  Therefore, the health literacy of family caregivers plays a crucial role, particularly in cases involving patients who may struggle to care for themselves.  Cancer, being a chronic condition, often demands long-term management and significant care from friends and family members. Family caregivers of cancer patients should actively seek health information, engage with healthcare professionals, participate in treatment decisions, manage medications, monitor symptoms, provide emotional and social support, and aid in simplifying the treatment process.  Consequently, the health literacy of caregivers significantly influences the diagnosis, treatment, and recovery journey of cancer patients.  Several tools have been developed to measure health literacy for patients. Common ones include the eHealth Literacy Scale,  the Health Literacy Questionnaire (HLQ),  and the Health Literacy Management Scale.  However, the number of tools designed for specific populations and particular diseases is limited. Based on the authors’ knowledge and literature searches across various academic databases, including Google Scholar, PubMed, CINAHL, Scopus, and Web of Science, only one tool aligns with the target population and specific disease of this study which aims to assess the health literacy of Chinese-speaking family caregivers of cancer patients in Macao. The only tool identified was the Chinese version – Health Literacy of Caregivers Scale-Cancer (HLCS-C).  The health literacy of cancer patients and their caregivers has been assessed globally. A study on health literacy was conducted in the Sydney area of Australia, involving 68 cancer patients and 8 caregivers using the HLQ.  Findings revealed that cancer caregivers scored between (2.91 ± 0.27) and (3.63 ± 0.54) on average across health literacy items, indicating a moderate to high level of health literacy. An American study utilised the Family Caregiver Communication Tool and HLCS-C to access 115 cancer caregivers, with results indicating they have a moderate to high level of health literacy.  In this study, the “self-care” domain had the lowest level among all other domains, suggesting a poor ability of caregivers to take care of their own physical, emotional, and mental well-being while caring for a cancer patient. Another American study involving 142 caregivers of newly diagnosed non-metastatic prostate cancer patients and using the eHealth Literacy Scale revealed a significant positive correlation between health literacy levels and their understanding of treatment options.  Regarding the area near Macao where this study was conducted, most research on health literacy predominantly focuses on chronic disease patients and their caregivers.  Currently, there is a lack of studies addressing the health literacy of caregivers of cancer patients undergoing treatment in China. Macao is a culturally diverse city with a rich healthcare heritage, as it was a Portuguese colony for over 400 years, from 1557 to 1999. Following the handover from Portugal to China, Macao’s healthcare system was significantly influenced by Chinese practices, shaping a healthcare system that combines elements of both Portuguese and Chinese traditions, distinct from those observed in Hong Kong and mainland China.  Alongside its unique healthcare system, Macao’s educational system sets it apart from neighboring cities. Despite the prevalence of healthcare information in Chinese and/or Portuguese, Portuguese language lessons are not widely available in Macao’s schools. While Chinese language education is mandatory for most students, the standards vary across different types of schools, including international schools, traditional high schools with Chinese as the primary language of instruction, and traditional high schools with English as the principal medium of instruction. These diverse educational settings may impact the Chinese language proficiency of Macao’s population,  potentially affecting their levels of health literacy. Notably, the only health literacy study available through common academic search engines focused on Filipino domestic workers and was conducted in English,  with no studies identified on health literacy among cancer patient caregivers in Macao. The Theory of Planned Behaviour model posits that the occurrence of behavior is governed by the strength of individuals’ intentions.  These intentions are influenced by three main factors: attitude towards the behavior, subjective norms, and perceived behavioral control. Behavioural intention represents the preparatory phase of behavioral occurrence, reflecting an individual’s subjective likelihood of engaging in a particular behavior. Understanding behavioral intentions can facilitate the prediction of future behavior, rendering this theory a crucial theoretical framework for analyzing behavioral intentions, including those of the caregivers in this study. The conceptual framework in Figure illustrates the investigation of the health literacy of caregivers in this study, built upon the Theory of Planned Behaviour model. Caregivers face healthcare needs arising from their support of cancer patients. This situation drives them to actively acquire, understand, evaluate, and apply health and disease-related information and services. They often assist or make decisions on behalf of the patients, aiming to promote and maintain the optimal health status of the patient. The framework assumes that as caregivers’ healthcare needs intensify, so does their inclination to seek, comprehend, evaluate, and apply health information. Consequently, this study aims to investigate the factors that influence caregivers’ willingness to engage with health information. It also examines potential disparities in these factors among caregivers with diverse backgrounds in Macao, reflecting their level of health literacy.   2.1. Study design This cross-sectional study utilized convenience sampling and was conducted between October 2023 and December 2023. The study included family caregivers of outpatient cancer patients receiving treatment at a designated hospital in Macao, with a total sample size of 376 and a 100% response rate. Demographic data of the participants were collected using a self-designed questionnaire, while data related to the health literacy of the caregivers were collected using the Chinese version of the HLCS-C.  2.2. Study participants This study was aimed to examine caregivers of cancer patients undergoing treatment at different hospitals in Macao. However, due to limited data availability, information was obtained solely from the largest hospital. Analysis of the hospital’s data revealed an average of approximately 1761 cancer patients receiving treatment per month, with the assumption that each patient was accompanied by a caregiver as required by the hospital. Hence, the estimated accessible population for this study was 1761 individuals. The sample size for this study was calculated using the following Equation 1:  S a m p l e S i z e = z 2 × p ( 1 − p ) e 2 1 + ( z 2 × ( 1 − p ) e 2 N ) (1) The calculation considered a confidence interval of 95%, a sampling error of 5%, and a significance level of e = 0.05. With a corresponding z value of 1.96, assuming a p parameter value of 0.50 and a total population of N = 1761, the calculated sample size was determined to be 316. To mitigate errors and account for factors like insufficient sample retrieval and invalid questionnaires, the sample size was increased by 10%, resulting in a minimum of 348 samples. This study included individuals who meet the following criteria: being residents of Macau aged 18 years or older and serving as primary caregivers for patients undergoing cancer treatment. Primary caregivers included parents, adult children (including daughters-in-law or sons-in-law), spouses, siblings, or other relatives. Additionally, participants should have clear consciousness, good cognitive and reading comprehension abilities, and willingly agree to participate in the study by signing the informed consent form. The exclusion criteria consist of individuals with severe physical illnesses and those in an employer-employee relationship with the patient. 2.3. Data collection The questionnaires were distributed electronically to the selected family caregivers directly by the researchers at a designated hospital. Participants were required to scan a QR code and provide informed consent before filling out the questionnaires based on the provided instructions. In most cases, the researcher accompanied the patient throughout the entire data collection process, readily clarifying any questions or uncertainties for the participants. In cases where the researcher was not present, participants could contact the researcher using the provided contact information in the electronic informed consent form. Each participant was limited to completing the questionnaire once. To ensure high-quality responses, the questionnaire was designed to be submitted only after all required fields were filled. 2.4. Variables and measures This study incorporates a demographic questionnaire developed by the researchers, considering the research objectives, literature review, and practical considerations in Macao. The questionnaire comprises two main sections: the caregiver’s basic information and patient-related data. It collects various information, including age, gender, marital status, education level, employment status, physical health status, family economic situation, relationship with the patient, relationship harmony with the patient, patient’s cancer diagnosis, duration of caregiving, frequency of accompanying the patient to cancer medical services, and channels for obtaining health information (Table ). Information concerning the health literacy of caregivers was obtained using the Chinese adaptation of the HLCS-C,  which was developed based on the original version by Yuen et al.  The HLCS-C can be found in Supplementary Material 1, http://links.lww.com/MD/O421 , which has been translated into English solely for the benefit of the readers of this article, while the participants completed the questionnaire in Chinese. The questionnaire comprises 43 items distributed among 10 domains (Table ). 2.5. Reliability and validity The reliability and validity of the HLCS-C were assessed using a convenience sampling method to select 100 caregivers of cancer patients at a hospital in Macao who met the inclusion criteria for the initial survey. The response rate was 100%. Simultaneously, interviews were conducted to assess their comprehension and feelings towards the scale content. Feedback from the study revealed that participants took an average of 5 to 10 minutes to complete the scale, and all found the content to be clearly articulated, requiring no modifications. The internal reliability of HLCS-C was analyzed using Cronbach’s α coefficient, commonly employed for questionnaires with Likert scales. The Cronbach’s α coefficient, which ranges from 0 to 1, is considered acceptable if it exceeds 0.5, good within the 0.7 to 0.8 range, and excellent if it surpasses 0.8.  The results indicated a high level of internal consistency among cancer patient caregivers in Macao, with an overall Cronbach’s α coefficient of 0.956. Individual domain Cronbach’s α coefficients ranged from 0.836 to 0.908 (>0.8), indicating a high level of internal consistency and excellent scale reliability. The content validity of the HLCS-C was evaluated in a previous study using the Item-Level Content Validity Index, yielding results ranging from 0.86 to 1, while the Scale-Level Content Validity Index was 0.97, indicating a high content validity of the scale.  Exploratory factor analysis was employed in this study to assess its structural validity. Before conducting factor analysis, the Kaiser–Meyer–Olkin (KMO) test and Bartlett’s sphericity test were used to determine the suitability of the data for factor analysis. Typically, a KMO value exceeding 0.9 is considered excellent, 0.8 to 0.9 is good, and 0.7 to 0.8 is fair for factor analysis.  A significance level ( P ) less than .05 in Bartlett’s sphericity test indicates that the variables are suitable for factor analysis. In this study, exploratory factor analysis was conducted using a predetermined extraction method. All scale items underwent factor analysis, extracting a fixed number of factors based on the original scale domains. As the scale comprises ten domains, the fixed number of factors extracted was set at 10, retaining common factors with eigenvalues greater than 1. The KMO test results were greater than 0.800, and the P values in Bartlett’s test were all less than .001, indicating the suitability for factor analysis. The results of the factor analysis suggest strong consistency between the number of common factors extracted from the scale and its domain structure. The cumulative variance contribution rate exceeded 50%, and the factor loadings of each item on the scale were all greater than 0.400. Therefore, the HLCS-C demonstrates appropriate reliability and validity. 2.6. Statistical analysis SPSS 27.0 statistical software was used to analyze the data. Independent samples t tests and one-way analysis of variance (ANOVA) were employed to investigate the differences in health literacy scores among participants with various demographic characteristics. If group effects were significant ( P < . 05), further post hoc comparisons were carried out using the Least Significant Difference method to validate differences among groups. Multiple linear regression analysis was utilised to identify the factors influencing the health literacy scores. All data in this study underwent tests of normality using skewness coefficients, kurtosis coefficients, and P-P plots. The results indicated that the skewness and kurtosis coefficients of all data variables were very close to 0, and the scatter points on the P-P plots were mostly situated near the 45-degree line originating from the origin. Therefore, it can be inferred that the sample data in this study follows a normal distribution. 2.7. Ethical considerations This study was approved by the Research Committee of the Faculty of Health Sciences and Sports at the Macao Polytechnic University (FCSD/MSN-0049/2023) and the Ethics Committee of the Conde de São Januário Hospital in Macao (0529/AD/N/2023). This study adhered to the principles outlined in the Declaration of Helsinki. Participants were informed and given consent before the questionnaire survey, ensuring anonymity and confidentiality of responses, and preventing harm during the process.   This cross-sectional study utilized convenience sampling and was conducted between October 2023 and December 2023. The study included family caregivers of outpatient cancer patients receiving treatment at a designated hospital in Macao, with a total sample size of 376 and a 100% response rate. Demographic data of the participants were collected using a self-designed questionnaire, while data related to the health literacy of the caregivers were collected using the Chinese version of the HLCS-C.    This study was aimed to examine caregivers of cancer patients undergoing treatment at different hospitals in Macao. However, due to limited data availability, information was obtained solely from the largest hospital. Analysis of the hospital’s data revealed an average of approximately 1761 cancer patients receiving treatment per month, with the assumption that each patient was accompanied by a caregiver as required by the hospital. Hence, the estimated accessible population for this study was 1761 individuals. The sample size for this study was calculated using the following Equation 1:  S a m p l e S i z e = z 2 × p ( 1 − p ) e 2 1 + ( z 2 × ( 1 − p ) e 2 N ) (1) The calculation considered a confidence interval of 95%, a sampling error of 5%, and a significance level of e = 0.05. With a corresponding z value of 1.96, assuming a p parameter value of 0.50 and a total population of N = 1761, the calculated sample size was determined to be 316. To mitigate errors and account for factors like insufficient sample retrieval and invalid questionnaires, the sample size was increased by 10%, resulting in a minimum of 348 samples. This study included individuals who meet the following criteria: being residents of Macau aged 18 years or older and serving as primary caregivers for patients undergoing cancer treatment. Primary caregivers included parents, adult children (including daughters-in-law or sons-in-law), spouses, siblings, or other relatives. Additionally, participants should have clear consciousness, good cognitive and reading comprehension abilities, and willingly agree to participate in the study by signing the informed consent form. The exclusion criteria consist of individuals with severe physical illnesses and those in an employer-employee relationship with the patient.   The questionnaires were distributed electronically to the selected family caregivers directly by the researchers at a designated hospital. Participants were required to scan a QR code and provide informed consent before filling out the questionnaires based on the provided instructions. In most cases, the researcher accompanied the patient throughout the entire data collection process, readily clarifying any questions or uncertainties for the participants. In cases where the researcher was not present, participants could contact the researcher using the provided contact information in the electronic informed consent form. Each participant was limited to completing the questionnaire once. To ensure high-quality responses, the questionnaire was designed to be submitted only after all required fields were filled.   This study incorporates a demographic questionnaire developed by the researchers, considering the research objectives, literature review, and practical considerations in Macao. The questionnaire comprises two main sections: the caregiver’s basic information and patient-related data. It collects various information, including age, gender, marital status, education level, employment status, physical health status, family economic situation, relationship with the patient, relationship harmony with the patient, patient’s cancer diagnosis, duration of caregiving, frequency of accompanying the patient to cancer medical services, and channels for obtaining health information (Table ). Information concerning the health literacy of caregivers was obtained using the Chinese adaptation of the HLCS-C,  which was developed based on the original version by Yuen et al.  The HLCS-C can be found in Supplementary Material 1, http://links.lww.com/MD/O421 , which has been translated into English solely for the benefit of the readers of this article, while the participants completed the questionnaire in Chinese. The questionnaire comprises 43 items distributed among 10 domains (Table ).   The reliability and validity of the HLCS-C were assessed using a convenience sampling method to select 100 caregivers of cancer patients at a hospital in Macao who met the inclusion criteria for the initial survey. The response rate was 100%. Simultaneously, interviews were conducted to assess their comprehension and feelings towards the scale content. Feedback from the study revealed that participants took an average of 5 to 10 minutes to complete the scale, and all found the content to be clearly articulated, requiring no modifications. The internal reliability of HLCS-C was analyzed using Cronbach’s α coefficient, commonly employed for questionnaires with Likert scales. The Cronbach’s α coefficient, which ranges from 0 to 1, is considered acceptable if it exceeds 0.5, good within the 0.7 to 0.8 range, and excellent if it surpasses 0.8.  The results indicated a high level of internal consistency among cancer patient caregivers in Macao, with an overall Cronbach’s α coefficient of 0.956. Individual domain Cronbach’s α coefficients ranged from 0.836 to 0.908 (>0.8), indicating a high level of internal consistency and excellent scale reliability. The content validity of the HLCS-C was evaluated in a previous study using the Item-Level Content Validity Index, yielding results ranging from 0.86 to 1, while the Scale-Level Content Validity Index was 0.97, indicating a high content validity of the scale.  Exploratory factor analysis was employed in this study to assess its structural validity. Before conducting factor analysis, the Kaiser–Meyer–Olkin (KMO) test and Bartlett’s sphericity test were used to determine the suitability of the data for factor analysis. Typically, a KMO value exceeding 0.9 is considered excellent, 0.8 to 0.9 is good, and 0.7 to 0.8 is fair for factor analysis.  A significance level ( P ) less than .05 in Bartlett’s sphericity test indicates that the variables are suitable for factor analysis. In this study, exploratory factor analysis was conducted using a predetermined extraction method. All scale items underwent factor analysis, extracting a fixed number of factors based on the original scale domains. As the scale comprises ten domains, the fixed number of factors extracted was set at 10, retaining common factors with eigenvalues greater than 1. The KMO test results were greater than 0.800, and the P values in Bartlett’s test were all less than .001, indicating the suitability for factor analysis. The results of the factor analysis suggest strong consistency between the number of common factors extracted from the scale and its domain structure. The cumulative variance contribution rate exceeded 50%, and the factor loadings of each item on the scale were all greater than 0.400. Therefore, the HLCS-C demonstrates appropriate reliability and validity.   SPSS 27.0 statistical software was used to analyze the data. Independent samples t tests and one-way analysis of variance (ANOVA) were employed to investigate the differences in health literacy scores among participants with various demographic characteristics. If group effects were significant ( P < . 05), further post hoc comparisons were carried out using the Least Significant Difference method to validate differences among groups. Multiple linear regression analysis was utilised to identify the factors influencing the health literacy scores. All data in this study underwent tests of normality using skewness coefficients, kurtosis coefficients, and P-P plots. The results indicated that the skewness and kurtosis coefficients of all data variables were very close to 0, and the scatter points on the P-P plots were mostly situated near the 45-degree line originating from the origin. Therefore, it can be inferred that the sample data in this study follows a normal distribution.   This study was approved by the Research Committee of the Faculty of Health Sciences and Sports at the Macao Polytechnic University (FCSD/MSN-0049/2023) and the Ethics Committee of the Conde de São Januário Hospital in Macao (0529/AD/N/2023). This study adhered to the principles outlined in the Declaration of Helsinki. Participants were informed and given consent before the questionnaire survey, ensuring anonymity and confidentiality of responses, and preventing harm during the process.   3.1. Demographic characteristics The majority of the 376 cancer patient caregivers were aged 41 to 50 (27.4%) and female (59.8%) (Table ). Most were married (76.1%) and had a secondary school education (43.1%). Nearly 70% were employed, with many in non-shift roles (42.3%). The majority perceived their family’s finances as “just adequate” (67.3%). Over 90% reported good relationships with patients, with children of the patients being the most common relationship (50.8%). The most prevalent cancer type was breast cancer (23.1%), followed by lung and colorectal cancers. More than half of the participants provided care for less than a year, and over half accompanied the patient to medical care services regularly. They primarily obtained medical information from healthcare providers (63.8%) and the internet (21.3%). 3.2. Least significant difference between groups This study employed the Least Significant Difference method for post hoc comparisons on variables showing statistically significant variations in HLSC-C scores. These variables included age ( F = 2.980, P < . 05), physical health status ( F = 9.289, P < . 001), relationship harmony with the patient ( F = 7.467, P < . 001), and channels for acquiring health information ( F = 2.981, P < . 05). Specifically, caregivers aged 51 to 60 had notably lower scores compared to caregivers in all other age groups (Table ). Concerning physical health status, those in the good physical health category (142.58 ± 12.90) exhibited significantly higher scores than individuals with average physical health (135.78 ± 14.93). In terms of relationship harmony with the patient, caregivers demonstrating excellent interaction displayed markedly higher health literacy levels than their counterparts. Regarding channels for obtaining health information, caregivers who primarily accessed cancer-related information through healthcare professionals demonstrated significantly higher health literacy compared to those relying on the internet (135.45 ± 15.13) or information from the patients themselves (133.04 ± 14.14). 3.3. Health literacy scale for cancer caregivers (HLSC-C) The total score of HLSC-C achieved by the 376 participants was 138.18, with an average score per item of 3.07 (Table ). The domain with the highest average item score was the “Proactive communication with healthcare professionals” (3.65). On the other hand, the domain with the lowest average item score was “Thorough understanding of cancer and cancer management information” (2.76), followed by “Self-care” (2.77) and “Understanding the healthcare system” (2.92). 3.4. Health literacy scale for cancer caregivers (HLSC-C) across different age groups Age is the most significant factor that affects the HLSC-C scores (Table ), and to further analyze this impact, the scores were categorized into high, middle, and low groups across various age groups (Fig. ). The average health literacy score was 138.18 with a standard deviation of 14.64, which is equivalent to half a standard deviation (SD) of 7.32. The low score group was defined as those scoring below the mean minus half of the SD, the high group as those scoring above the mean plus half of the SD, and the middle scores as falling between the high and low score groups. Using these parameters, the score groups are delineated as Low (≤131), Middle (132–145), and High (≥146). Most participants scored in the middle range across all age groups (Fig. ). The 51 to 60 age group had the most participants with low scores and the fewest with high scores. Surprisingly, the over-60 age group had the highest percentage of high scores. To further analyze the impact of age on different domains of the HLSC-C, the Scheffe pairwise method was used for post hoc comparisons (Fig. ). The results reveal significant differences across four domains among caregivers of various ages: Domain 1 – Activeness and determination in seeking information ( F = 2.799, P < . 05), Domain 2 – Comprehensive understanding of cancer and cancer management information ( F = 5.396, P < . 001), Domain 7 – Self-care ( F = 6.861, P < . 001), and Domain 10 – Proactive communication with healthcare professionals ( F = 3.327, P < . 05), highlighting notable disparities. In domain 1, caregivers aged 51 to 60 scored significantly lower (12.17 ± 1.53) compared to those aged 31 to 40 (13.04 ± 1.77, P < . 05). For domain 2, caregivers aged 51 to 60 scored notably lower (10.36 ± 1.59) than those aged 61 and above (11.75 ± 1.93, P < . 001). In domain 7, caregivers aged 61 and above scored significantly higher (15.25 ± 1.96) than those in the age groups 18 to 30 (13.58 ± 2.41), 31 to 40 (13.25 ± 2.69), 41 to 50 (13.66 ± 2.66), and 51 to 60 (13.89 ± 2.32), all showing statistical differences at P < . 05. Lastly, in domain 10, caregivers aged 51 to 60 scored significantly lower (13.90 ± 2.59) than those aged 18 to 30 (15.55 ± 1.80, P < . 05). 3.5. Multiple linear regression analysis Multiple stepwise regression analysis was conducted to investigate the factors influencing the HLSC-C. The total average health literacy score was considered as the dependent variable, with the significant categorical variables age group, physical health status, relationship harmony with the patient, and channels for obtaining health information serving as independent variables (Table ). The final regression equation was set with an inclusion level of α = 0.05 and an exclusion level of α = 0.10, as follows (Equation 2): Y H L S C − C = 132.722 + 5.198 X R e l a t i o n s h i p h a r m o n y w i t h t h e p a t i e n t ( e x c e l l e n t v s p o o r ) + 5.369 X P h y s i c a l h e a l t h s t a t u s ( g o o d v s p o o r ) − 5.894 X A g e g r o u p ( 51 − 61 v s > 61 ) + 3.602 X C h a n n e l s f o r o b t a i n i n g h e a l t h i n f o r m a t i o n ( h e a l t h c a r e p r o v i d e r s v s f a m i l y / f r i e n d s ) (2) The Variance Inflation Factors in the regression equation were all below 5 (Table ), indicating the absence of multicollinearity among the independent variables.  The Durbin-Watson test showed no autocorrelation. The multiple correlation coefficient ( R ) was 0.336, and the coefficient of determination ( R 2 ) was 0.113. A statistically significant F value of 11.842 with P < . 001 suggested that these factors together accounted for 11.3% of the variance in health literacy among caregivers. In terms of the nonstandardized regression coefficients, caregivers aged 51 to 60 scored 5.894 points lower in health literacy compared to those aged 61 and above. Conversely, caregivers with excellent relationship harmony with the patient scored 5.198 points higher, caregivers with good physical health status scored 5.369 points higher, and caregivers who received cancer information through healthcare professionals scored 3.602 points higher in health literacy compared to those who relied on family or friends for information (Table ).   The majority of the 376 cancer patient caregivers were aged 41 to 50 (27.4%) and female (59.8%) (Table ). Most were married (76.1%) and had a secondary school education (43.1%). Nearly 70% were employed, with many in non-shift roles (42.3%). The majority perceived their family’s finances as “just adequate” (67.3%). Over 90% reported good relationships with patients, with children of the patients being the most common relationship (50.8%). The most prevalent cancer type was breast cancer (23.1%), followed by lung and colorectal cancers. More than half of the participants provided care for less than a year, and over half accompanied the patient to medical care services regularly. They primarily obtained medical information from healthcare providers (63.8%) and the internet (21.3%).   This study employed the Least Significant Difference method for post hoc comparisons on variables showing statistically significant variations in HLSC-C scores. These variables included age ( F = 2.980, P < . 05), physical health status ( F = 9.289, P < . 001), relationship harmony with the patient ( F = 7.467, P < . 001), and channels for acquiring health information ( F = 2.981, P < . 05). Specifically, caregivers aged 51 to 60 had notably lower scores compared to caregivers in all other age groups (Table ). Concerning physical health status, those in the good physical health category (142.58 ± 12.90) exhibited significantly higher scores than individuals with average physical health (135.78 ± 14.93). In terms of relationship harmony with the patient, caregivers demonstrating excellent interaction displayed markedly higher health literacy levels than their counterparts. Regarding channels for obtaining health information, caregivers who primarily accessed cancer-related information through healthcare professionals demonstrated significantly higher health literacy compared to those relying on the internet (135.45 ± 15.13) or information from the patients themselves (133.04 ± 14.14).   The total score of HLSC-C achieved by the 376 participants was 138.18, with an average score per item of 3.07 (Table ). The domain with the highest average item score was the “Proactive communication with healthcare professionals” (3.65). On the other hand, the domain with the lowest average item score was “Thorough understanding of cancer and cancer management information” (2.76), followed by “Self-care” (2.77) and “Understanding the healthcare system” (2.92).   Age is the most significant factor that affects the HLSC-C scores (Table ), and to further analyze this impact, the scores were categorized into high, middle, and low groups across various age groups (Fig. ). The average health literacy score was 138.18 with a standard deviation of 14.64, which is equivalent to half a standard deviation (SD) of 7.32. The low score group was defined as those scoring below the mean minus half of the SD, the high group as those scoring above the mean plus half of the SD, and the middle scores as falling between the high and low score groups. Using these parameters, the score groups are delineated as Low (≤131), Middle (132–145), and High (≥146). Most participants scored in the middle range across all age groups (Fig. ). The 51 to 60 age group had the most participants with low scores and the fewest with high scores. Surprisingly, the over-60 age group had the highest percentage of high scores. To further analyze the impact of age on different domains of the HLSC-C, the Scheffe pairwise method was used for post hoc comparisons (Fig. ). The results reveal significant differences across four domains among caregivers of various ages: Domain 1 – Activeness and determination in seeking information ( F = 2.799, P < . 05), Domain 2 – Comprehensive understanding of cancer and cancer management information ( F = 5.396, P < . 001), Domain 7 – Self-care ( F = 6.861, P < . 001), and Domain 10 – Proactive communication with healthcare professionals ( F = 3.327, P < . 05), highlighting notable disparities. In domain 1, caregivers aged 51 to 60 scored significantly lower (12.17 ± 1.53) compared to those aged 31 to 40 (13.04 ± 1.77, P < . 05). For domain 2, caregivers aged 51 to 60 scored notably lower (10.36 ± 1.59) than those aged 61 and above (11.75 ± 1.93, P < . 001). In domain 7, caregivers aged 61 and above scored significantly higher (15.25 ± 1.96) than those in the age groups 18 to 30 (13.58 ± 2.41), 31 to 40 (13.25 ± 2.69), 41 to 50 (13.66 ± 2.66), and 51 to 60 (13.89 ± 2.32), all showing statistical differences at P < . 05. Lastly, in domain 10, caregivers aged 51 to 60 scored significantly lower (13.90 ± 2.59) than those aged 18 to 30 (15.55 ± 1.80, P < . 05).   Multiple stepwise regression analysis was conducted to investigate the factors influencing the HLSC-C. The total average health literacy score was considered as the dependent variable, with the significant categorical variables age group, physical health status, relationship harmony with the patient, and channels for obtaining health information serving as independent variables (Table ). The final regression equation was set with an inclusion level of α = 0.05 and an exclusion level of α = 0.10, as follows (Equation 2): Y H L S C − C = 132.722 + 5.198 X R e l a t i o n s h i p h a r m o n y w i t h t h e p a t i e n t ( e x c e l l e n t v s p o o r ) + 5.369 X P h y s i c a l h e a l t h s t a t u s ( g o o d v s p o o r ) − 5.894 X A g e g r o u p ( 51 − 61 v s > 61 ) + 3.602 X C h a n n e l s f o r o b t a i n i n g h e a l t h i n f o r m a t i o n ( h e a l t h c a r e p r o v i d e r s v s f a m i l y / f r i e n d s ) (2) The Variance Inflation Factors in the regression equation were all below 5 (Table ), indicating the absence of multicollinearity among the independent variables.  The Durbin-Watson test showed no autocorrelation. The multiple correlation coefficient ( R ) was 0.336, and the coefficient of determination ( R 2 ) was 0.113. A statistically significant F value of 11.842 with P < . 001 suggested that these factors together accounted for 11.3% of the variance in health literacy among caregivers. In terms of the nonstandardized regression coefficients, caregivers aged 51 to 60 scored 5.894 points lower in health literacy compared to those aged 61 and above. Conversely, caregivers with excellent relationship harmony with the patient scored 5.198 points higher, caregivers with good physical health status scored 5.369 points higher, and caregivers who received cancer information through healthcare professionals scored 3.602 points higher in health literacy compared to those who relied on family or friends for information (Table ).   This study revealed that a significant portion of participants were married females aged between 31 and 50 years, with an average health status (Table ). This highlights a trend where middle-aged individuals are assuming caregiving responsibilities. In the context of traditional gender roles in China, caregiving is often considered a responsibility of women, especially within this age group where female caregivers bear the significant responsibilities of caring for elderly relatives.  Therefore, when considering interventions to enhance the health literacy of caregivers for cancer patients, these individuals should be prioritized and targeted first. This study showed that several factors were significantly associated with health literacy (Table ). Which, health literacy scores decrease with age, with older adults (over 50) exhibiting significantly lower health literacy levels compared to younger age groups. This aligns with findings from previous research.  The brains of older adults undergo structural and functional changes that can impact their learning abilities, affecting how they receive and interpret health information.  In addition, older adults may hold more traditional healthcare beliefs and cultural values, potentially influencing their approach to caring for cancer patients.  However, this does not necessarily impact their overall performance in caring for patients, as older adults with more interpersonal experiences may excel in understanding the verbal and physical cues of individuals, which may lead to better detection of patient concerns and potentially providing superior care. Yet, further investigation is warranted in this area. Age is a complex factor, and while this study has identified it as a contributing element to health literacy, further research is needed to explore how age impacts health outcomes in the context of caring for cancer patients. In addition to age, individuals in good physical health also demonstrated higher health literacy scores compared to those with average or poor health statuses (Table ), aligning with studies conducted in neighboring regions like Mainland China,  Taiwan,  and Korea.  This trend may be attributed to the proactive nature of those in good health, who tend to engage more actively in managing their well-being, have greater access to health information, and exhibit better cognitive function. Furthermore, this study highlights that a positive and harmonious relationship with the patient, along with frequent attendance at cancer medical services, are positively correlated with health literacy. These factors are related to the caregiver-patient dynamic, suggesting that a strong relationship between carer and patient is linked to higher health literacy levels.  Moreover, this study indicates that caregivers who predominantly source health information from healthcare providers tend to possess higher health literacy compared to those who rely on the Internet or advice from family and friends. This finding indirectly suggests that individuals with elevated health literacy are inclined to seek information from healthcare professionals due to their appreciation of credible expertise, recognition of the value of comprehensive information and possession of effective communication skills.  Prior research has indicated a strong link between education and health literacy;  however, this association was not observed in this study. This discrepancy could be attributed to linguistic variations between this study and others. For instance, health literacy can be influenced by the comprehension of medical terminology, which in turn may be impacted by an individual’s level of education. In many European languages, including English, medical terms are often constructed using prefixes, roots, and suffixes specific to the field, which can differ from everyday language. For example, the terms “heart disease” and “cardiopathy” illustrate this distinction. Higher levels of education might imply greater exposure to and familiarity with such medical vocabulary due to increased reading experience. Conversely, in Chinese, professional medical elements are generally absent, which means that educational attainment may not play a significant role in this study. This is particularly relevant in Macao, where healthcare information is predominantly provided in Chinese. Again, further investigation is warranted in this area. This study revealed that the domain of the HLSC-C with the highest scores pertained to understanding information through explanations from healthcare professionals. However, for the domain “thorough understanding of cancer information,” the scores were the second lowest (Table ). This suggests that caregivers may need assistance in comprehending cancer-related information, indirectly indicating that the existing written materials provided to caregivers may not be appropriate, given the complexity of cancer information.  Therefore, further investigation may be necessary to evaluate the suitability of healthcare information, assessing factors such as readability, attractiveness, and complexity, for potential modifications to enhance understanding. The domain with the lowest scores of the HLSC-C in this study was linked to communication with the patient regarding cancer and self-care (Table ), aligning with previous research findings.  Understandably, discussing terminal illness can be challenging, a difficulty influenced by factors such as gender, ethnic background, and the duration of caregiving.  Previous studies have shown that caregivers lacking in self-care are more prone to experiencing increased levels of stress, anxiety, depression, and mental health issues, potentially leading to poorer cancer prognosis.  Therefore, interventions may be necessary for implementation among cancer caregivers in Macao to enhance their self-care practices, which could include recognizing individual strengths, incorporating mindfulness techniques, and utilising stress reduction methods.  The domain “understanding the healthcare system” also received a low score (Table ). Local health information may encompass details like referrals to specific healthcare professionals or departments, or guidance towards local digital applications for additional information. Insufficient understanding of the healthcare system could hinder caregivers from effectively navigating through it. This study enhances the understanding of health literacy among caregivers in Macao by identifying their specific needs and challenges. It reveals the necessity of targeted interventions to improve their knowledge and skills. The findings highlight the importance of promoting strong relationships between caregivers and patients, which is vital for both health outcomes and caregiver well-being. In addition, this study supports the development comprehensive educational programmes covering practical caregiving techniques, health resource utilisation, and personal development strategies such as stress management. By addressing these areas, stakeholders can better equip caregivers, leading to improved care for cancer patients in Macao. This research serves as a resource for policymakers and health educators in developing initiatives to elevate health literacy and support caregivers effectively.   This study has limitations common to many other cross-sectional studies, including the inability to establish a causal relationship, making it more susceptible to biases such as recall bias and selection bias, which may impact the accuracy of confounding variables. Additionally, this study lacks longitudinal observation of caregivers’ evolving care needs and perceived difficulties over various time points. It is recommended that future research consider implementing a longitudinal study design to capture the progression of care requirements among primary family caregivers from the initial diagnosis stage through the treatment phase and across the entire cancer treatment journey. Due to the high turnover of daily patients, varying treatment durations, and the tendency for patients to leave the hospital after treatment, it was not feasible to randomly assign the participants. Consequently, this study employed a convenience sampling method within the realm of nonrandom sampling. Following this principle, caregivers who met the specified criteria were invited to voluntarily complete the questionnaire. While most caregivers were willing to participate in this study, their readiness to face cancer may differ among those who declined. The participates of this study were exclusively sourced from the only public hospital in Macao. Caregivers from private hospitals in Macao may possess distinct characteristics and health literacy levels, potentially impacting the generalizability of this study. Future research should increase sample size, expand recruitment, and involve diverse professionals such as physicians, social workers, and psychologists to enhance the credibility and applicability of the research findings. Additionally, future studies should assess the psychological well-being of healthcare providers and compare their responses with those of caregivers, thereby enhancing our understanding of the experiences of both groups and their potential effects on patient care.   Caregivers in Macao exhibit a moderate level of health literacy. To enhance the health literacy levels of caregivers, efforts should be strengthened in maintaining good relationships between caregivers and patients, ensuring the well-being of caregivers in terms of physical and mental, and increasing caregivers’ access to channels for obtaining cancer information. These may be achieved by providing courses and support to both caregivers and patients covering caregiving techniques, health resource utilisation, and personal growth aspects such as role adaptation, stress management, and setting realistic caregiving goals. In addition, this study identified that married women aged between 31 and 50 years were the main demographic caring for cancer patients in the sole public hospital in Macao. Consequently, they should be the primary target for any health literacy educational programme.   Conceptualization: Nana Tsai, Fongieng Lam, Qi Zhang, Lirong Meng, Pedro Fong. Data curation: Nana Tsai. Formal analysis: Nana Tsai, Fongieng Lam, Lirong Meng, Pedro Fong. Investigation: Nana Tsai, Lirong Meng, Pedro Fong. Methodology: Nana Tsai, Fongieng Lam, Qi Zhang, Lirong Meng. Validation: Nana Tsai, Qi Zhang, Lirong Meng, Pedro Fong. Writing – original draft: Nana Tsai, Pedro Fong. Writing – review & editing: Nana Tsai, Fongieng Lam, Qi Zhang, Lirong Meng, Pedro Fong.      