Cost Barriers and Health Literacy on Cholangiocarcinoma Rescreening Intention in Khon Kaen, Thailand: A Causal Mediation Analysis

Phimha, Surachai; Roobsung, Jitlada; Senahad, Nopparat; Padchasuwan, Natnapa Heebkaew; Bouphan, Prachak; Sirikarn, Prapassara

doi:10.31557/APJCP.2026.27.8.3055

Cost Barriers and Health Literacy on Cholangiocarcinoma Rescreening Intention in Khon Kaen, Thailand: A Causal Mediation Analysis

Document Type : Research Articles

Authors

¹ Department of Public Health Administration, Health Promotion, and Nutrition, Faculty of Public Health, Khon Kaen University, Khon Kaen Province, Thailand.

² Master of Public Health Program, Faculty of Public Health, Khon Kaen University, Khon Kaen Province, Thailand.

³ Former Lecturer, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand.

⁴ 4Department of Epidemiology and Biostatistics, Faculty of Public Health, Khon Kaen University, Khon Kaen Province, Thailand.

10.31557/APJCP.2026.27.8.3055

Abstract

Background: Cholangiocarcinoma (CCA) is a major public health issue in Southeast Asia and has the highest global incidence in Northeast Thailand. Thailand has implemented cholangiocarcinoma screening; nonetheless, public access to screening remains limited. This study aims to examine the impact of cost barriers on cholangiocarcinoma rescreening intention with a mediating effect of health literacy. Methods: This cross-sectional study was conducted with participants who received cholangiocarcinoma screening in four community hospitals between November and December 2024. The association between costs, health literacy, and rescreening intention was investigated through causal mediation analysis. Results: This study examined 171 participants; most participants were female (57.9%). Participants’ rescreening intention was 71.9% (95%CI: 65.2% to 78.7%). Males intend to rescreen 75% more than females (69.7%). When quantifying the effect of costs channeled through health literacy to rescreening intention, 1) direct non-medical costs in the natural indirect effect showed statistically significant results at the lower to moderate cost levels. The results showed a statistically significant negative indirect effect at 300 THB (probability difference = -0.118, 95% CI: -0.182 to -0.055) and 500 THB (probability difference -0.135, 95% CI: -0.244 to -0.027). 2) Indirect costs in the natural indirect effect showed statistically significant results at the lowest levels. A statistically significant negative indirect effect was observed at 300 THB (probability difference -0.059, 95% CI: -0.095 to -0.023). Conclusion: Using health literacy as a mediator, direct non-medical costs and indirect cost expenses affect cholangiocarcinoma screening decisions. Expanding screening to communities, minimizing costs, and increasing health literacy on cholangiocarcinoma may increase screening.

Keywords