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Ispoglou T, Wilson O, McCullough D, Aldrich L, Ferentinos P, Lyall G, Stavropoulos-Kalinoglou A, Duckworth L, Brown MA, Sutton L, Potts AJ, Archbold V, Hargreaves J, McKenna J. A Narrative Review of Non-Pharmacological Strategies for Managing Sarcopenia in Older Adults with Cardiovascular and Metabolic Diseases. BIOLOGY 2023; 12:892. [PMID: 37508325 PMCID: PMC10376679 DOI: 10.3390/biology12070892] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 06/12/2023] [Accepted: 06/13/2023] [Indexed: 07/30/2023]
Abstract
This narrative review examines the mechanisms underlying the development of cardiovascular disease (CVD) and metabolic diseases (MDs), along with their association with sarcopenia. Furthermore, non-pharmacological interventions to address sarcopenia in patients with these conditions are suggested. The significance of combined training in managing metabolic disease and secondary sarcopenia in type II diabetes mellitus is emphasized. Additionally, the potential benefits of resistance and aerobic training are explored. This review emphasises the role of nutrition in addressing sarcopenia in patients with CVD or MDs, focusing on strategies such as optimising protein intake, promoting plant-based protein sources, incorporating antioxidant-rich foods and omega-3 fatty acids and ensuring sufficient vitamin D levels. Moreover, the potential benefits of targeting gut microbiota through probiotics and prebiotic fibres in sarcopenic individuals are considered. Multidisciplinary approaches that integrate behavioural science are explored to enhance the uptake and sustainability of behaviour-based sarcopenia interventions. Future research should prioritise high-quality randomized controlled trials to refine exercise and nutritional interventions and investigate the incorporation of behavioural science into routine practices. Ultimately, a comprehensive and multifaceted approach is essential to improve health outcomes, well-being and quality of life in older adults with sarcopenia and coexisting cardiovascular and metabolic diseases.
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Affiliation(s)
| | - Oliver Wilson
- Carnegie School of Sport, Leeds Beckett University, Leeds LS6 3QQ, UK
| | | | - Luke Aldrich
- Carnegie School of Sport, Leeds Beckett University, Leeds LS6 3QQ, UK
| | | | - Gemma Lyall
- Carnegie School of Sport, Leeds Beckett University, Leeds LS6 3QQ, UK
| | | | - Lauren Duckworth
- Carnegie School of Sport, Leeds Beckett University, Leeds LS6 3QQ, UK
| | - Meghan A Brown
- Carnegie School of Sport, Leeds Beckett University, Leeds LS6 3QQ, UK
| | - Louise Sutton
- Carnegie School of Sport, Leeds Beckett University, Leeds LS6 3QQ, UK
| | - Alexandra J Potts
- Carnegie School of Sport, Leeds Beckett University, Leeds LS6 3QQ, UK
| | - Victoria Archbold
- Carnegie School of Sport, Leeds Beckett University, Leeds LS6 3QQ, UK
| | - Jackie Hargreaves
- Carnegie School of Sport, Leeds Beckett University, Leeds LS6 3QQ, UK
| | - Jim McKenna
- Carnegie School of Sport, Leeds Beckett University, Leeds LS6 3QQ, UK
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2
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Akinmoladun OF, Femi FA, Nesamvuni CN. Implication of knowledge, lifestyle and self-efficacy in the prevention of cardiovascular diseases' risk factors among the urban elderly. Nutr Health 2022:2601060221138894. [PMID: 36377358 DOI: 10.1177/02601060221138894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Background: Cardiovascular disease (CVD) is preventable by effectively managing its risk factors. Such risk factors (smoking, unhealthy eating habits, sedentary lifestyles, etc.) are judged to reflect an individual's self-efficacy, lifestyle modification, and CVD knowledge. Objectives: To evaluate the relationship between lifestyle practices, self-efficacy, and knowledge of CVDs risk factors among the elderly. Methods: A descriptive cross-sectional study was conducted on 424 randomly individuals whose age is ≥60 years. A questionnaire-based survey was administered on the self-efficacy rate, lifestyle practices, and respondents' knowledge of CVDs risk factors. Respondents with a score of ≤50%, 51%-74.99%, and ≥75% were classified as having low, medium, or high self-efficacy. Similarly, the same score was used to classify poor, fair, or good lifestyle; and low, average, or high knowledge. Data were analysed using Statistical Package for Social Sciences, while association among variables was determined using chi-square. Results: Few respondents were involved in physical exercise (1.7%), cigarette smoking (4.5%), regular soft drinks (18.2%), and alcohol consumption (13.2%). Many respondents used excess salt during cooking (92.7%) or ate outside their homes (64.6%). 58.5%, 30.0%, and 11.6% of the respondents had fair, good, and poor lifestyle practices. 11.3%, 58.7%, and 30.0% had low, medium, and high self-efficacy scores. A total of 45.3%, 35.4%, and 19.3% had low, average, and high knowledge. Knowledge and self-efficacy scores were significantly different (P = 0.001). Conclusion: High self-efficacy and its significant relationship with knowledge could mean that CVD risk factors can be checked if the elderly have a proper lifestyle, positive attitudes, and nutrition education.
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Affiliation(s)
- Oluwaseun F Akinmoladun
- Department of Nutrition, School of Health Sciences, 56868University of Venda, Thohoyandou, South Africa
- Nutrition and Dietetics Unit, Department of Food Science and Technology, College of Agriculture, Food Science and Technology, 398081Wesley University, Ondo, Ondo State, Nigeria
| | - Fortune A Femi
- Department of Food Science and Technology, School of Agriculture and Agricultural Technology, 119054Federal University of Technology, Minna, Niger State, Nigeria
| | - Cebisa N Nesamvuni
- Department of Nutrition, School of Health Sciences, 56868University of Venda, Thohoyandou, South Africa
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3
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Zhang X, Chen H, Liu Y, Yang B. Influence of chronic illness resources on self-management and the mediating effect of patient activation among patients with coronary heart disease. Nurs Open 2021; 8:3181-3189. [PMID: 34498405 PMCID: PMC8510723 DOI: 10.1002/nop2.1031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 07/12/2021] [Accepted: 07/25/2021] [Indexed: 12/22/2022] Open
Abstract
Aim The aim of this study was to explore the relationship between chronic illness resources, patient activation and self‐management behaviour among middle‐aged and older patients with CHD. Design A cross‐sectional, descriptive correlational study was performed. Methods A convenience sample of 296 participants were recruited in Tianjin, China. Data were collected by using the Chronic Illness Resource Survey (CIRS), Patient Activation Measure (PAM) and Coronary Artery Disease Self‐Management Scale (CSMS). Descriptive statistics and Pearson's correlation analysis were used to data analysis. Linear regression analysis was performed to explore the mediating role of patient activation. Results The results showed that chronic illness resources and patient activation were significantly and positively correlated with self‐management behaviours (p < .01). Patient activation had a partial intermediary between chronic illness resources and self‐management behaviours, and the mediation effect was 0.230. Patient activation mediated the relationship between chronic illness resources and self‐management. In order to improving the self‐management behaviours, medical staff need to pay attention to the importance of chronic illness resources and patient activation.
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Affiliation(s)
- Xiaohong Zhang
- Tianjin University of Traditional Chinese Medicine, Tianjin, China.,Research Group Healthy Ageing, Allied Health Care and Nursing, Hanze University of Applied Sciences, Groningen, the Netherlands
| | - Hongbo Chen
- Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yanhui Liu
- Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Bing Yang
- Chongqing Traditional Chinese Medicine hospital, Chongqing, China
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Nguyen P, Schiaffino MK, Lipton BJ. Disparities in self-management outcomes by limited English proficiency among adults with heart disease. Prev Med Rep 2021; 23:101407. [PMID: 34136340 PMCID: PMC8178122 DOI: 10.1016/j.pmedr.2021.101407] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 04/21/2021] [Accepted: 05/08/2021] [Indexed: 01/19/2023] Open
Abstract
There are significant disparities in cardiovascular health outcomes by limited English proficiency (LEP). Self-management plans (SMPs) are associated with better patient outcomes, however little is known about the association of LEP with having an SMP among adults with heart disease. This study examined this association using 2013–2016 California Health Interview Survey data. Among adults that received an SMP, we also examined whether they had a hard copy SMP (print or electronic vs. none), and whether they reported confidence in their ability to manage their heart disease. Our sample included a total of 9102 adults, including 1232 LEP and 7870 English proficient (EP) adults. LEP was associated with significantly lower odds of SMP receipt (Adjusted Odds Ratio [AOR] 0.46, 95% Confidence Interval [CI] 0.31 to 0.68). LEP and EP adults who received an SMP were similarly likely to have a hard copy SMP and report confidence in heart disease management. The finding that LEP adults were less likely than EP adults to receive an SMP may represent a missed opportunity to improve heart health outcomes for this group.
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Affiliation(s)
- Phuong Nguyen
- School of Public Health, San Diego State University, 5500 Campanile Drive, San Diego, CA 92182, USA
| | - Melody K Schiaffino
- School of Public Health, San Diego State University, 5500 Campanile Drive, San Diego, CA 92182, USA.,Center for Health Equity, Education and Research (CHEER), University of California, San Diego, La Jolla, CA, USA
| | - Brandy J Lipton
- School of Public Health, San Diego State University, 5500 Campanile Drive, San Diego, CA 92182, USA.,Center for Health Economics & Policy Studies, San Diego State University, San Diego, CA, USA
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Nurses' Experiences in Managing Cardiovascular Disease in Selected Rural and Peri-Urban Clinics in Limpopo Province, South Africa. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18052570. [PMID: 33806589 PMCID: PMC7967373 DOI: 10.3390/ijerph18052570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 02/25/2021] [Accepted: 03/01/2021] [Indexed: 11/17/2022]
Abstract
Deaths caused by cardiovascular diseases (CVDs) account for 60% of all deaths that occur in rural and remote areas. Disease management programs are increasingly used to improve the effectiveness of chronic care. Nurses are a key component of the health workforce and have an important role to play in CVD prevention, treatment, and the care of sick people in remote areas. Due to the nature of their work, nurses are prone to working hard, and to experience burnout, sleep, or eating disorders. This is often exacerbated by a shortage of staff and equipment. The objectives of the study were to explore and describe the experiences of professional nurses in managing CVDs in South African rural and peri-urban clinics. A qualitative, explorative-descriptive design and a contextual research approach were adopted for the present study. Purposive sampling was employed to recruit nurses who were managing patients with CVD from 11 primary health care facilities. Data were collected through semi-structured individual interviews and analyzed using Tesch's open coding method. Interview transcripts were coded and analyzed for common themes. The following two major themes emerged from the data: perceived institutional challenges affecting the management of CVDs and nurses' perceptions of patient challenges that impede the effective management of CVD. The study concludes by highlighting that apart from a resource challenge, the shortage of nurses in rural clinics is the biggest reason behind overcrowding, waiting long hours for consultations, and an increase in the workload, resulting in medical errors and poor quality care. It is, therefore, recommended that, for improved care and management of CVD in rural populations, local governments need to employ more skilled nurses whilst availing the necessary material resources.
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Allam MM, El-Zawawy HT, Ibrahim Ismail I, Ghazy RM. Cross-Cultural Reliability of an Arabic Version of the Self-Efficacy for Managing Chronic Disease 6-Item Scale in Arab Patients with Diabetes mellitus. Prim Care Diabetes 2020; 14:305-310. [PMID: 31786157 DOI: 10.1016/j.pcd.2019.11.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 10/15/2019] [Accepted: 11/02/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Arab nations have the second highest diabetes mellitus (DM) prevalence in the world. There is a growing interest in self-management programs that emphasize patient's central role in managing type 2 DM. AIM OF THE STUDY To validate an Arabic version of the Self-Efficacy for Managing Chronic Disease 6-Item Scale (SEM6S) among Arab type 2 DM patients and to explore factors associated with self-efficacy measured with the SEM6S. METHODS Cross-sectional study on 302 Arab patients with T2DM of three different nationalities (Egyptian, Saudi, Kuwaiti).The SEM6S was translated using forward-backward method, and its reliability was determined by calculating Cronbach's alpha. A regression model was used to examine variables associated with self-efficacy in Arab patients with T2DM. RESULTS Questionnaire was successfully translated without language or content-related problem. The mean age of participants was 47.71±14.7 years with equally represented sexes. The mean total score of the SEM6S was 5.99±1.86. The scale psychometric properties was reproducible (ICC=0.61-0.71) with good reliability (Cronbach's alpha=0.79). Statistically significant increase in self-efficacy was observed in patients <30 years, uncomplicated DM, DM with hypertension, and in patients who had physical activity > 60min per day. Also, a bimodal increase in self-efficacy was detected in patients with DM<5 years and 10.1-15 years. After regression analysis, physical activity was significantly positively correlated with self-efficacy (β=0.8, P=0.01), and duration of diabetes was significantly negatively correlated with self-efficacy (β = -0.23, P=0.03). CONCLUSION Arabic SEM6S is acceptable, reliable and repeatable metric for self-efficacy.
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Affiliation(s)
- Magdy Mohamed Allam
- Internal Medicine department, Alexandria University Student Hospital (AUSH), Egypt
| | | | | | - Ramy Mohamed Ghazy
- Tropical Health department, High Institute of Public Health, Alexandria University, Egypt
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Kańtoch A, Gryglewska B, Wójkowska-Mach J, Heczko P, Grodzicki T. Treatment of Cardiovascular Diseases Among Elderly Residents of Long-term Care Facilities. J Am Med Dir Assoc 2019; 19:428-432. [PMID: 29402648 DOI: 10.1016/j.jamda.2017.12.102] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 12/29/2017] [Indexed: 01/02/2023]
Abstract
BACKGROUND The prevalence of cardiovascular diseases among nursing home residents is high but little is known whether pharmacologic therapy recommended by actual medication guidelines is followed by facility's staff. AIM To evaluate the adherence to actual guidelines for treatment of cardiovascular diseases among older adult residents of long-term care (LTC) facilities. MATERIAL AND METHODS The cross-sectional study was performed from December 2009 to November 2010 among 189 elderly residents aged ≥60 years in 3 LTC facilities in Poland: 1 long-term care hospital (LTCH) and 2 nursing homes (NHs). The initial evaluation included analysis of medical documentation (all diagnosed diseases and used drugs), blood pressure (BP) measurements and performance of Mini Nutritional Assessment Short-Form (MNA-SF), Abbreviated Mental Test Score (AMTS), Activities of Daily Living (ADL) score, and Barthel Index. Prescribed medication for hypertension (HT), heart failure (HF), and coronary heart disease (CHD) were compared to current European Cardiology Society (ESC), and European Society of Hypertension (ESH) medication guidelines. Residents were divided into 3 subgroups: with HT, HF, and CHD. Results were presented as means and standard deviation. Groups were compared using Mann-Whitney U test for nonparametric data and chi-square test to assess differences in distribution of categorical variables. P values <.05 were considered statistically significant. RESULTS CHD was diagnosed among 114 residents (60.3%) but only 60.5% of them were treated with aspirin (ASA), 45.6% with beta-blockers (BBs), 60.5% with angiotensin-converting enzyme inhibitor (ACEI), and 24.6% with statins. HF observed in 75% of cases was treated by using ACEI (54.7%), BBs (45.3%), loop diuretics (LDs, 36%), mineralocorticoid-receptor antagonists (MRAs, 21.3%). HT was diagnosed among 98 study participants (51.9%) and in the majority of cases (76.6%) was well controlled (mean BP: 133.7 ± 17.6/73.8 ± 10.2 mmHg). The most popular antihypertensive drugs were ACEIs (77.6%), BBs (40.8%) and calcium channel blockers (CCBs, 26.5%) whereas thiazides, alpha-blockers (ABs), and angiotensin receptor blockers (ARBs) were used less frequently. CONCLUSION In summary, the study showed that insufficient treatment of cardiovascular diseases among elderly residents of LTC facilities could be a potential risk factor of poor prognosis.
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Affiliation(s)
- Anna Kańtoch
- Department of Internal Medicine and Gerontology, Faculty of Medicine, Jagiellonian University Medical College, University Hospital in Kraków, Kraków, Poland.
| | - Barbara Gryglewska
- Department of Internal Medicine and Gerontology, Faculty of Medicine, Jagiellonian University Medical College, University Hospital in Kraków, Kraków, Poland
| | - Jadwiga Wójkowska-Mach
- Department of Microbiology, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Piotr Heczko
- Department of Microbiology, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Tomasz Grodzicki
- Department of Internal Medicine and Gerontology, Faculty of Medicine, Jagiellonian University Medical College, University Hospital in Kraków, Kraków, Poland
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8
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Cardiovascular Risks Associated with Gender and Aging. J Cardiovasc Dev Dis 2019; 6:jcdd6020019. [PMID: 31035613 PMCID: PMC6616540 DOI: 10.3390/jcdd6020019] [Citation(s) in RCA: 371] [Impact Index Per Article: 74.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 04/19/2019] [Accepted: 04/23/2019] [Indexed: 12/12/2022] Open
Abstract
The aging and elderly population are particularly susceptible to cardiovascular disease. Age is an independent risk factor for cardiovascular disease (CVD) in adults, but these risks are compounded by additional factors, including frailty, obesity, and diabetes. These factors are known to complicate and enhance cardiac risk factors that are associated with the onset of advanced age. Sex is another potential risk factor in aging adults, given that older females are reported to be at a greater risk for CVD than age-matched men. However, in both men and women, the risks associated with CVD increase with age, and these correspond to an overall decline in sex hormones, primarily of estrogen and testosterone. Despite this, hormone replacement therapies are largely shown to not improve outcomes in older patients and may also increase the risks of cardiac events in older adults. This review discusses current findings regarding the impacts of age and gender on heart disease.
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9
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Banta JE, Segovia-Siapco G, Crocker CB, Montoya D, Alhusseini N. Mental health status and dietary intake among California adults: a population-based survey. Int J Food Sci Nutr 2019; 70:759-770. [PMID: 30773065 DOI: 10.1080/09637486.2019.1570085] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
California Health Interview Survey (2005-2015) data were used to examine the association between dietary intake frequencies and mental health - Kessler-6 scores categorised as no/low (NLPD), moderate (MPD) or serious psychological distress (SPD). The 245,891 surveys represented 27.7 million adults annually, with 13.2% having MPD and 3.7% SPD. Survey-adjusted regression adjusting for gender, age, race, education, poverty, marital status, BMI, geography and year found MPD and SPD associated with lower consumption of fruits (adjusted odds ratio 0.79 and 0.65, respectively), vegetables (AOR 0.81 and 0.68), and increased consumption of French fries (AOR 1.24, 1.30), fast food (AOR 1.32, 1.27), soda (AOR 1.23, 1.26) and variance-adjusted daily teaspoons of sugar (coefficients 3.05, 4.21), all p-values less than 0.001. In this large population-based sample, moderate and SPD were independently associated with unhealthy diet. Targeted public health interventions could focus on young adults and those with less than 12 years of education.
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Affiliation(s)
- Jim E Banta
- a School of Public Health , Loma Linda University , Loma Linda , CA , USA
| | | | - Christine Betty Crocker
- a School of Public Health , Loma Linda University , Loma Linda , CA , USA.,b Child Nutrition Services, Redlands Unified School District , Redlands , CA , USA
| | - Danielle Montoya
- a School of Public Health , Loma Linda University , Loma Linda , CA , USA
| | - Noara Alhusseini
- a School of Public Health , Loma Linda University , Loma Linda , CA , USA
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10
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McKenna VB, Sixsmith J, Barry MM. A Qualitative Study of the Development of Health Literacy Capacities of Participants Attending a Community-Based Cardiovascular Health Programme. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:E1157. [PMID: 29865222 PMCID: PMC6025538 DOI: 10.3390/ijerph15061157] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 05/17/2018] [Accepted: 05/30/2018] [Indexed: 12/13/2022]
Abstract
Health literacy is a critical determinant of health, which can empower individuals and lead to engagement in collective health promotion action and is also a crucial component in the self-management of illness. The current study moves beyond a focus on functional health literacy and presents findings from a longitudinal qualitative (LQ) study consisting of three phases. This paper presents findings from the second phase of the study, which assessed the development of health literacy capacities of individuals attending a structured cardiovascular risk reduction programme in Ireland. The study objectives were to: explore perceptions of changes in interactions and information exchange within health consultations; identify the facilitators associated with changes in health literacy capacities; assess developments in engagement with broader contexts for health literacy capacities. A LQ study design was undertaken, which employed repeat interview methodology with 19 participants (aged 36⁻76 years) 12 weeks after beginning a structured cardiovascular risk reduction programme. Health literacy levels were assessed using the HLS-EU 47 item instrument in phase 1 (68% limited health literacy (HL), 32% adequate health literacy). A semi-structured interview guide, (informed by Sørensen's conceptual model of health literacy), was used to explore the development of health literacy and to identify changes in knowledge, attitudes and experiences over time. Thematic analysis was used, informed by aspects of Saldaña's framework for longitudinal qualitative data analysis. All participants reported having acquired increased understanding of issues relevant to their health and self-care. Participants described health literacy capacities that incorporate aspects of all levels of health literacy (functional, interactive and critical). Core themes were identified corresponding to changes in these levels: re-engagement with health information and increased understanding of risk and protective factors (changes in functional health literacy); changes in interactions with healthcare providers (HCP) (changes in interactive health literacy); enhanced psychological insights and understanding the broader determinants of health (changes in critical health literacy). Findings support the development of health literacy capacities across the functional, interactive and critical health literacy domains. Participants are capable of locating responsibility for health beyond the individual level and are making sense of knowledge within their own social contexts. Individuals, regardless of their initial health literacy levels, are capable of engaging with broader issues that can impact on their health and can be supported to develop these critical health literacy capacities.
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Affiliation(s)
- Verna B McKenna
- Health Promotion Research Centre, Discipline of Health Promotion, National University of Ireland Galway, H91 CF50 Galway, Ireland.
| | - Jane Sixsmith
- Health Promotion Research Centre, Discipline of Health Promotion, National University of Ireland Galway, H91 CF50 Galway, Ireland.
| | - Margaret M Barry
- Health Promotion Research Centre, Discipline of Health Promotion, National University of Ireland Galway, H91 CF50 Galway, Ireland.
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