From 3T to HLAA: developing a participatory model for health literacy empowerment among older adults in Northeastern Thailand

Thailand’s transition to a super-aged society poses significant challenges for medication safety and rational health product use among older adults, particularly in rural Northeastern communities where health literacy remains limited. This study aimed to develop and refine the HLAA (Health Literacy–Learning–Access–Advocacy) Model, grounded in the culturally embedded 3T (Think–Test–Take Action) behavioral pathway, using a participatory action research (PAR) framework. A community-based PAR design guided by the Plan–Act–Observe–Reflect (PAOR) cycle was conducted in Schools for Older Persons across Northeastern Thailand from March 2021 to November 2022. The study progressed through iterative phases of situational assessment (Plan), participatory co-design (Act), pilot implementation (Observe), and model refinement (Reflect). A mixed-methods approach was applied. Quantitative data were analyzed using paired t-tests after assessing distributional assumptions, and qualitative data were analyzed using reflexive thematic analysis. Pilot testing among 120 older adults demonstrated significant mean improvements in overall health literacy (mean difference = 16.1, p < 0.001), functional literacy (mean difference = 5.9, p < 0.001), critical literacy (mean difference = 2.6, p < 0.001), and safe medication behavior (mean difference = 16.8, p < 0.001), with large effect sizes (Cohen’s d range = 1.02–1.98). The HLAA (3T) Model provides a culturally grounded and system-oriented approach to health literacy empowerment. By aligning individual behavioral change with structural support mechanisms through iterative PAOR cycles, the model connects community learning platforms with local governance structures. This framework provides a context-sensitive pathway to promote rational medication use and active aging within decentralized health systems. Not applicable, as this study did not involve randomization, allocation to intervention groups, or clinical trial procedures.