Health Literacy Influences Heart Failure Knowledge Attainment but Not Self-Efficacy for Self-Care or Adherence to Self-Care over Time

Insight into global research on health literacy and heart diseases: A bibliometric analysis

Background

Health literacy (HL) has shown its important role on reducing the burden of heart diseases. However, no study has provided a comprehensive worldwide view of the data regarding HL and heart diseases. The study aimed to provide insight into: (1) the intellectual structure, (2) research trends, and (3) research gaps on HL and heart diseases; and (4) to explore HL scales commonly utilized in heart studies.

Materials and methods

Studies related to HL and heart diseases were retrieved from Web of Science, Scopus, and PubMed. All publications published between 2000 and 2021 were included after conducting keyword searches on "heart diseases" in general or on specific types of heart diseases (e.g., "heart failure") and "health literacy". Bibliometric analyses were carried out using the Bibliometrix R package and VOSviewer 1.6.14.

Findings

A total of 388 original research articles and reviews on HL and heart diseases were included in our study. The studies were primarily conducted in the United States and developed countries. A total of 337 studies (86.9%) focused on heart failure (200 studies, 51.5%) and ischemic heart diseases (137 studies, 35.3%). Sixty-two studies (16.0%) focused on other heart diseases (e.g., valvular diseases and rheumatic heart diseases). The number of interventional studies was limited (52 studies, 13.4%) and fluctuated from 2000 to 2021. The most common questionnaires measuring health literacy among patients with heart diseases were the Test of Functional Health Literacy in Adults (TOFHLA), Short Test of Functional Health Literacy in Adults (STOFHLA), and Brief Health Literacy Screen (BHLS). Use of the eHealth Literacy Scale (eHEALS) has become the latest trend among patients with heart diseases.

Conclusion

Health literacy and heart diseases were most often studied in the United States and developed countries. Several HL tools were used; eHEALS has been lately used in this field. These findings suggest the need to conduct more empirical studies on HL and heart diseases in different settings (e.g., developing or poor countries) and with different types of heart diseases (e.g., valvular and rheumatic disorders). Additionally, it is necessary to develop heart disease-specified HL scales for research and practice.

The Relationship Between Health Literacy, Self-Efficacy, and Self-Care Behaviors in Older Adults With Hypertension in the North of Iran

BACKGROUND

Hypertension is the main risk factor for cardiovascular disease. Low level of health literacy is more common in people with hypertension. Evidence suggests that hypertension is preventable and can be controlled by modifying lifestyle and improving self-care behaviors.

OBJECTIVE

This study aimed to determine the relationship between health literacy, self-efficacy, and self-care behaviors in older adults with hypertension.

METHODS

The present study was a cross-sectional study conducted with 150 older adult patients with hypertension admitted to the Cardiac Care Unit (CCU) and post-CCU wards in East Guilan public hospitals in the north of Iran in 2020. Sampling was conducted using a convenience method based on inclusion criteria (age 60 years and older, high blood pressure and taking antihypertensive drugs for at least 6 months, ability to speak and communicate, having the suitable physical condition (not ill) to participate in research and answer questions, and having informed consent to participate in the study). The research instruments included a Health Literacy Questionnaire for Iranian Adults, a self-efficacy questionnaire in patients with hypertension, and a self-care behavior questionnaire for patients with hypertension. Descriptive statistics and multiple linear regression were used to analyze the data using SPSS software version 19.

KEY RESULTS

The results showed that most patients had adequate health literacy with a mean score of 116.77 (standard deviation [SD] = 8.34), excellent self-efficacy with a mean score of 23.06 (SD = 1.99) and relatively desirable self-care behaviors with a mean score of 51.79 (SD = 4.37). Findings also indicated that health literacy can predict self-efficacy (beta = 0.262, p = .001) and self-care behaviors (beta = 0.639, p = .000).

CONCLUSIONS

Based on results, health literacy is a predictor of self-efficacy variables and self-care behaviors. Therefore, planning to improve the health literacy of the older adult to promote self-efficacy and self-care behaviors and ultimately their health is recommended. [HLRP: Health Literacy Research and Practice. 2022;6(4):e262-e269.] Plain Language Summary: This study sought to determine the role of health literacy in predicting self-efficacy and self-care behaviors in older adults with hypertension admitted to CCU and post-CCU wards in East Guilan public hospitals in the north of Iran. Findings of this research demonstrate health literacy can predict self-efficacy and self-care behaviors.

Literacy critical to heart failure management: a scoping review

Heart failure is a complex clinical syndrome most commonly encountered among older adults. This complex clinical syndrome is associated with poor health outcomes such as frequent admissions and mortality. These adverse outcomes are commonly associated with poor self-care and lower health literacy. Literacy is a combination of knowledge and skills and often reflected by appropriate interaction with the community, while health literacy is the cognitive and social skills reflected by accessing and comprehending health information and making appropriate health decisions. These decisions are common and challenging to patients with heart failure. Poor outcomes are said to be reduced by adequate self-care, which is associated with health literacy among heart failure patients. Better self-care was also shown to be associated with self-efficacy and self-confidence that were in turn associated with health literacy. Hence, enhancing health literacy among patient with heart failure is critical to enable them to increase control over their disease by better understanding and participating in health care, while being empowered to take part in designing health care services and even tailoring research to serve their needs and consequently improve outcome at the individual and community level. In clinical practice, assessing health literacy, measuring health literacy, and identifying patients at risk of low nutrition literacy is important to enhance health literacy and health outcomes. Hence, developing reliable and valid methods and tools for assessment and developing tailored and targeted interventions is of critical importance.

Reading Level and Suitability of Congestive Heart Failure (CHF) Education in a Mobile App (CHF Info App): Descriptive Design Study

Background

Education at the time of diagnosis or at discharge after an index illness is a vital component of improving outcomes in congestive heart failure (CHF). About 90 million Americans have limited health literacy and have a readability level at or below a 5th-grade level, which could affect their understanding of education provided at the time of diagnosis or discharge from hospital.

Objective

The aim of this paper was to assess the suitability and readability level of a mobile phone app, the CHF Info App.

Methods

A descriptive design was used to assess the reading level and suitability of patient educational materials included in the CHF Info App. The suitability assessment of patient educational materials included in the CHF Info App was independently assessed by two of the authors using the 26-item Suitability Assessment of Materials (SAM) tool. The reading grade level for each of the 10 CHF educational modules included in the CHF Info App was assessed using the comprehensive online Text Readability Consensus Calculator based on the seven most-common readability formulas: the Flesch Reading Ease Formula, the Gunning Fog Index, the Flesch-Kincaid Grade Level Formula, the Coleman-Liau Index, the Simplified Measure of Gobbledygook Index, the Automated Readability Index, and the Linsear Write Formula. The reading level included the text-scale score, the ease-of-reading score, and the corresponding grade level.

Results

The educational materials included in the CHF Info App ranged from a 5th-grade to an 8th-grade reading level, with a mean of a 6th-grade level, which is recommended by the American Medical Association. The SAM tool result demonstrated adequate-to-superior levels in all four components assessed, including content, appearance, visuals, and layout and design, with a total score of 77%, indicating superior suitability.

Conclusions

The authors conclude that the CHF Info App will be suitable and meet the recommended health literacy level for American adult learners. Further testing of the CHF Info App in a longitudinal study is warranted to determine improvement in CHF knowledge.

Patient Activation in Acute Decompensated Heart Failure

BACKGROUND

Recent data suggest that patient activation, or having the knowledge, skills, and confidence to engage and manage one's own health, favorably impacts patient behaviors and health outcomes. However, the role of activation in patients with heart failure is unknown.

OBJECTIVES

The aims of this study are to measure the level of activation of patients hospitalized with acute decompensated heart failure (ADHF) and to determine whether activation is associated with in-hospital and early postdischarge outcomes.

METHODS

We prospectively recruited Southeastern Minnesota residents hospitalized at Mayo Clinic hospitals with ADHF from January 2014 to July 2015. Activation was measured using the Patient Activation Measure questionnaire.

RESULTS

Among the 302 patients enrolled, the mean age was 77.3 years, 57.3% were men, and 46.8% had preserved ejection fraction. The median (25th-75th percentile) length of stay was 4 (3-7) days. In total, 7 (2.3%) patients died before discharge. Most survivors were discharged to home (73.6%) or skilled nursing facilities (23.7%). The number of patients in each activation level from highest to lowest was 9 (3.0%), 121 (40.1%), 122 (40.4%), and 50 (16.6%). Patients with lower activation were older, were less educated, had lower patient satisfaction, and had worse health literacy. They were more often discharged to skilled nursing facilities and had higher 30-day mortality, although 30-day readmission did not differ by activation.

CONCLUSIONS

Patients hospitalized with ADHF with lower activation are less satisfied, have worse health literacy, more often require skilled care, and are at increased risk for early postdischarge mortality. Activation can be easily measured and may help clinicians identify high-risk patients.

Health Literacy and Cardiovascular Disease: Fundamental Relevance to Primary and Secondary Prevention: A Scientific Statement From the American Heart Association

Health literacy is the degree to which individuals are able to access and process basic health information and services and thereby participate in health-related decisions. Limited health literacy is highly prevalent in the United States and is strongly associated with patient morbidity, mortality, healthcare use, and costs. The objectives of this American Heart Association scientific statement are (1) to summarize the relevance of health literacy to cardiovascular health; (2) to present the adverse associations of health literacy with cardiovascular risk factors, conditions, and treatments; (3) to suggest strategies that address barriers imposed by limited health literacy on the management and prevention of cardiovascular disease; (4) to demonstrate the contributions of health literacy to health disparities, given its association with social determinants of health; and (5) to propose future directions for how health literacy can be integrated into the American Heart Association's mandate to advance cardiovascular treatment and research, thereby improving patient care and public health. Inadequate health literacy is a barrier to the American Heart Association meeting its 2020 Impact Goals, and this statement articulates the rationale to anticipate and address the adverse cardiovascular effects associated with health literacy.

Relationship between self-care behaviors and health literacy among elderly women in Iran, 2015

Background and aim

Self-care is a basic concept in health promotion, regarding the importance of health literacy as a key factor in self-care. This study aimed to identify the relationship between self-care behaviors and health literacy among elderly women in Iran.

Methods

This descriptive and analytic study was performed between October and December 2015. A total of 360 participants were selected from elderly women referred to health centers. Data was collected by test of functional health literacy in adults (S-TOFHLA) and a checklist for assessment of self-care behaviors, and health information seeking. Data were analyzed by SPSS software (version 22) with One-Way Analysis of Variance, and the Pearson correlation coefficient, t-test and regression test.

Results

The mean score of functional health literacy was 41.30±6.29. Of the participants, 73.6% had inadequate health literacy, 20.8% borderline health literacy, and 5.6% enough health literacy. The mean score of health information seeking was 1.791. Also, 31.9% of elderly women had poor self-care behaviors, 56.9% moderate, and 11.1% high. A significant difference was observed in mean score of health literacy between different levels of self-care (F=30.087, p<0.001). Based on regression analysis, health literacy and health information seeking predicted 19.9% of the variance of self-care behaviors.

Conclusion

This study highlights the necessity of promoting health literacy and attention to its influencing factors to improve self-care ability of elderly women. In conclusion, Planning interventions to improve health literacy is essential for health promotion among elderly women.

[Health literacy in patients with heart failure treated in primary care]

OBJECTIVES

The level of health literacy is examined, as well as its conditioning factors in patients with heart failure who are seen routinely in a Primary Health Care Area.

DESIGN

A multicentre cross-sectional study.

SETTING

10 Primary care centres from the metropolitan area of Barcelona.

PARTICIPANTS

Patients diagnosed with heart failure.

INCLUSION CRITERIA

to have visited the Primary Health Care centre in the last year, being able to arrive at the primary care setting independently, and voluntarily participation.

MAIN MEASUREMENTS

Health Literacy Survey-European Union - Questionnaire (HLS-EU-Q) and Spanish version of the European Heart Failure Self-care Behaviour Scale. An analysis was made of the relationships between health literacy, self-care practices, sociodemographic, and clinical variables using ANOVA test and a multiple linear regression model.

RESULTS

The study included 318 patients (51.2% women) with a mean age of 77.9±8.7 years. The index of health literacy of 79.6% (n=253) of the participants indicated problems in understanding healthcare information. Health literacy level was explained by academic level (P<.001), the extent of heart failure (P=.032), self-care, and age (P<.04).The academic level explained 61.6% of the health of literacy (95% bootstrap: 44.58%; 46.75%).

CONCLUSIONS

In patients with stable heart failure, it is important to consider all factors that help patients to understand the healthcare information. Health literacy explains patient self-care attitude in heart failure.

Self Managing Heart Failure in Remote Australia - Translating Concepts into Clinical Practice

Congestive heart failure (CHF) is an ambulatory health care condition characterized by episodes of decompensation and is usually without cure. It is a leading cause for morbidity and mortality and the lead cause for hospital admissions in older patients in the developed world. The long-term requirement for medical care and pharmaceuticals contributes to significant health care costs. CHF management follows a hierarchy from physician prescription to allied health, predominately nurse-led, delivery of care. Health services are easier to access in urban compared to rural settings. The differentials for more specialized services could be even greater. Remote Australia is thus faced with unique challenges in delivering CHF best practice. Chronic disease self-management programs (CDSMP) were designed to increase patient participation in their health and alleviate stress on health systems. There have been CDSMP successes with some diseases, although challenges still exist for CHF. These challenges are amplified in remote Australia due to geographic and demographic factors, increased burden of disease, and higher incidence of comorbidities. In this review we explore CDSMP for CHF and the challenges for our region.

Health literacy and mortality: a cohort study of patients hospitalized for acute heart failure

Background

More than 30% of patients hospitalized for heart failure are rehospitalized or die within 90 days of discharge. Lower health literacy is associated with mortality among outpatients with chronic heart failure; little is known about this relationship after hospitalization for acute heart failure.

Methods and Results

Patients hospitalized for acute heart failure and discharged home between November 2010 and June 2013 were followed through December 31, 2013. Nurses administered the Brief Health Literacy Screen at admission; low health literacy was defined as Brief Health Literacy Screen ≤9. The primary outcome was all-cause mortality. Secondary outcomes were time to first rehospitalization and, separately, time to first emergency department visit within 90 days of discharge. Cox proportional hazards models determined their relationships with health literacy, adjusting for age, gender, race, insurance, education, comorbidity, and hospital length of stay. For the 1379 patients, average age was 63.1 years, 566 (41.0%) were female, and 324 (23.5%) had low health literacy. Median follow-up was 20.7 months (interquartile range 12.8 to 29.6 months), and 403 (29.2%) patients died. Adjusted hazard ratio for death among patients with low health literacy was 1.34 (95% CI 1.04, 1.73, P=0.02) compared to Brief Health Literacy Screen >9. Within 90 days of discharge, there were 415 (30.1%) rehospitalizations and 201 (14.6%) emergency department visits, with no evident association with health literacy.

Conclusions

Lower health literacy was associated with increased risk of death after hospitalization for acute heart failure. There was no evident relationship between health literacy and 90-day rehospitalization or emergency department visits.

Implementing guideline based heart failure care in the Northern Territory: challenges and solutions

The Northern Territory of Australia is a vast area serviced by two major tertiary hospitals. It has both a unique demography and geography, which pose challenges for delivering optimal heart failure services. The prevalence of congestive heart failure continues to increase, imposing a significant burden on health infrastructure and health care costs. Specific patient groups suffer disproportionately from increased disease severity or service related issues often represented as a "health care gap". The syndrome itself is characterised by ongoing symptoms interspersed with acute decompensation requiring lifelong therapy and is rarely reversible. For the individual client the overwhelming attention to heart failure care and the impact of health care gaps can be devastating. This gap may also contribute to widening socio-economic differentials for families and communities as they seek to take on some of the care responsibilities. This review explores the challenges of heart failure best practice in the Northern Territory and the opportunities to improve on service delivery. The discussions highlighted could have implications for health service delivery throughout regional centres in Australia and health systems in other countries.