Prevalence of limited health literacy among patients with type 2 diabetes mellitus: A systematic review

Social and Structural Determinants of Cardiovascular Complications of Diabetes

PURPOSE OF REVIEW

Cardiovascular disease (CVD) is the leading cause of mortality in people who have diabetes. Racial and ethnic minorities with diabetes have suboptimal management of cardiovascular risk factors, leading to higher mortality. Social and structural determinants of health are external factors that influence an individual's ability to choose positive health behaviors. In this review, we will discuss cardiovascular complications in people who have diabetes and their relationship to social determinants of health (SDOH).

RECENT FINDINGS

Recent innovations in diabetes treatment, including new devices and medications, have improved care and survival. However, disparities in the availability of these treatments to racial and ethnic minorities may contribute to continued inequities in CVD outcomes. Racial/ethnic disparities in CVD relate to inequities in economic opportunity, education and health literacy, neighborhoods and social cohesion, and health care access and quality driven by structural racism.

Health literacy and tuberculosis control: systematic review and meta-analysis

Objective

To identify literature on health literacy levels and examine its association with tuberculosis treatment adherence and treatment outcomes.

Methods

Two authors independently searched Pubmed®, Embase, CINAHL, PsycINFO, Scopus, LILACS, Global Health Medicus and ScienceDirect for articles reporting on health literacy levels and tuberculosis that were published between January 2000 and September 2023. We defined limited health literacy as a person's inability to understand, process, and make decisions from information obtained concerning their own health. Methodological quality and the risk of bias was assessed using the JBI critical appraisal tools. We used a random effects model to assess the pooled proportion of limited health literacy, the association between health literacy and treatment adherence, and the relationship between health literacy and tuberculosis-related knowledge.

Findings

Among 5813 records reviewed, 22 studies met the inclusion criteria. The meta-analysis revealed that 51.2% (95% confidence interval, CI: 48.0-54.3) of tuberculosis patients exhibit limited health literacy. Based on four studies, patients with lower health literacy levels were less likely to adhere to tuberculosis treatment regimens (pooled odds ratio: 1.95; 95% CI: 1.37-2.78). Three studies showed a significant relationship between low health literacy and inadequate knowledge about tuberculosis (pooled correlation coefficient: 0.79; 95% CI: 0.32-0.94).

Conclusion

Health literacy is associated with tuberculosis treatment adherence and care quality. Lower health literacy might hamper patients' ability to follow treatment protocols. Improving health literacy is crucial for enhancing treatment outcomes and is a key strategy in the fight against tuberculosis.

The effect of bolus advisors on glycaemic parameters in adults with diabetes on intensive insulin therapy: A systematic review with meta-analysis

AIM

To conduct a systematic review with meta-analysis to provide a comprehensive synthesis of randomized controlled trials (RCTs) and prospective cohort studies investigating the effects of currently available bolus advisors on glycaemic parameters in adults with diabetes.

MATERIALS AND METHODS

An electronic search of PubMed, Embase, CINAHL, Cochrane Library and ClinicalTrials.gov was conducted in December 2022. The risk of bias was assessed using the revised Cochrane Risk of Bias tool. (Standardized) mean difference (MD) was selected to determine the difference in continuous outcomes between the groups. A random-effects model meta-analysis and meta-regression were performed. This systematic review was registered on PROSPERO (CRD42022374588).

RESULTS

A total of 18 RCTs involving 1645 adults (50% females) with a median glycated haemoglobin (HbA1c) concentration of 8.45% (7.95%-9.30%) were included. The majority of participants had type 1 diabetes (N = 1510, 92%) and were on multiple daily injections (N = 1173, 71%). Twelve of the 18 trials had low risk of bias. The meta-analysis of 10 studies with available data on HbA1c showed that the use of a bolus advisor modestly reduced HbA1c compared to standard treatment (MD -011%, 95% confidence interval -0.22 to -0.01; I2 = 0%). This effect was accompanied by small improvements in low blood glucose index and treatment satisfaction, but not with reductions in hypoglycaemic events or changes in other secondary outcomes.

CONCLUSION

Use of a bolus advisor is associated with slightly better glucose control and treatment satisfaction in people with diabetes on intensive insulin treatment. Future studies should investigate whether personalizing bolus advisors using artificial intelligence technology can enhance these effects.

Relationship between health literacy and health-related quality of life in Korean adults with chronic diseases

Inadequate health literacy is a risk factor for poor health outcomes and health-related quality of life (HRQoL). So far, the impact of health literacy on HRQoL has been examined for only a few chronic conditions. In this contribution, the relationship between health literacy and HRQoL in Korean adults with chronic conditions is examined using data of the cross-sectional Korea Health Panel Survey from 2021. Health literacy was measured with the 16-item European Health Literacy Survey Questionnaire (HLS-EU-Q16) and HRQoL with the European Quality of Life-5 Dimensions (EQ-5D). Multiple linear regression model was run for the EQ-5D index as the dependent variable. Multiple logistic regression models were implemented for responses to the individual EQ-5D items. 30.8%, 24.6%, and 44.6% of participants had inadequate, marginal, and adequate levels of health literacy, respectively. The EQ-5D index increases with marginal (B = 0.018, p<0.001) and adequate literacy (B = 0.017, p<0.001) compared to inadequate literacy. People with adequate or marginal literacy were more likely to report no problem with mobility (odds ration [OR] = 1.5; p<0.001), self-care (OR = 1.6; p<0.05), and usual activities (OR = 1.6 for adequate; OR = 1.4 for marginal; p<0.01) than those with inadequate literacy. Adequate health literacy was associated with an increased likelihood of having no problem with anxiety and depression (OR = 1.4; p<0.05). In conclusion, inadequate health literacy is prevalent among Korean adults with chronic diseases. Adequate health literacy is associated with better HRQoL and a protective factor for four dimensions of EQ-5D (mobility, self-care, usual activities, and anxiety/depression).

Social Support, eHealth Literacy, and mHealth Use in Older Adults With Diabetes: Moderated Mediating Effect of the Perceived Importance of App Design

Mobile healthcare has emerged as a prominent technological solution for self-management of health. However, the development and utilization of tailored mobile healthcare applications for older adults with diabetes mellitus remain limited. This study examined the relationship between social support and mobile healthcare use and further explored how this relationship varies with eHealth literacy and application design among older adults with diabetes mellitus. A descriptive cross-sectional trial was conducted with a structured self-report questionnaire, surveying 252 South Korean older adults with diabetes mellitus via offline and online modes. The mediating effect and moderated mediating effect were analyzed with the PROCESS macro of SPSS. eHealth literacy mediated the relationship between social support and mobile healthcare use. High levels of eHealth literacy and social support may increase mobile healthcare use among older adults with diabetes. Application design aesthetics facilitated mobile healthcare use. Future researchers, healthcare providers, and developers can contribute to the development of tailored mobile healthcare applications for older adults with diabetes mellitus by considering application design aspects such as font size, color, and menu configuration.

Health literacy and diabetic retinopathy

Health literacy (HL) is defined as a cognitive and social skill that determines the motivation and ability of individuals to understand and use information to promote and maintain proper health. Inadequate HL has been associated with worse outcomes in diabetes control, poor self-care, and higher hospitalization rates for some chronic diseases. We hypothesized that HL influences the prevalence of diabetic retinopathy (DR) among individuals with type 2 diabetes mellitus (T2DM) and that inadequate glycemic control would mediate this association. This was a cross-sectional study carried out with 288 participants of the "Brazilian Diabetes Study" cohort. Inclusion criteria were people diagnosed with T2DM aged between 40 and 70 years and ability to read and write. In the adequate HL group, DR was found in 16.5% of participants and in the inadequate HL group, it was found in 32.8% (P=0.0081). Individuals with inadequate HL had a higher risk of having DR, and this association was still statistically significant after adjusting for HbA1c, low-density lipoprotein cholesterol, systolic blood pressure, and diastolic blood pressure. In conclusion, HL is related to DR without the mediation of classical clinical variables.

Health Literacy Among Non-Communicable Disease Service Seekers: A Nationwide Finding from Primary Health Care Settings of Bangladesh

BACKGROUND

Considering the health literacy status of service seekers is crucial while developing programs and policies to improve service delivery in primary health care settings.

OBJECTIVE

Our aim was to assess health literacy among adults seeking non-communicable disease (NCD)-related services in primary health care centers (PHC) of Bangladesh and identify its contributing factors and its preventive effect on risky behaviors.

METHODS

In this cross-sectional study, 2,793 NCD service seekers were interviewed face-to-face from eight rural and three urban PHCs selected by a multi-stage random sampling method. We used the European Health Literacy Survey Questionnaire to collect data on health literacy. We applied logistic regression analysis to identify the contributing factors related to adequate health literacy. Odds ratios were used to calculate the preventive fraction of health literacy for NCD risk behaviors.

KEY RESULTS

Limited health literacy was found among 43% of the respondents. Adequate health literacy was associated with younger age, male sex, having a formal education, living in an extended family, hailing from a high socioeconomic group, and attending urban PHC. After adjusting the sociodemographic factors, the prevalence of smoking, smokeless tobacco usage, and inadequate fruits and vegetables consumption among participants were found to be 25%, 51%, and 18% lower for people with sufficient health literacy.

CONCLUSIONS

NCD service seekers have a high rate of inadequate health literacy. Adequate health literacy has the potential to lower the behavioral risk factors of NCDs. [HLRP: Health Literacy Research and Practice. 2024;8(1):e12-e20.].

Factors associated with poor health literacy in older adults: A systematic review

OBJECTIVES

To identify factors associated with poor health literacy in older adults.

METHODS

A systematic literature review was conducted, employing the descriptors "Aged" and "Health Literacy".

PROSPERO - CRD

42022350140.

RESULTS

Out of 23,500 articles screened, 176 were selected. Several factors associated with poor health literacy in older adults were identified, such as sociodemographic (e.g., advanced age, low educational level, non-white population, and others), social (e.g., poor family/social support, loneliness, social isolation, few social activities, and others), economic (e.g., lower income and/or lower socioeconomic status) and health aspects (e.g., poor health, chronic conditions, mental health challenges, hospitalizations, frailty, physical inactivity, cognitive impairment, and others).

CONCLUSIONS

The factors associated with poor health literacy in older adults identified in this review could contribute to future research, support interventions to improve health literacy, and assist professionals in planning educational activities and public policies.

Type 2 Diabetes Mellitus and Sarcopenia as Comorbid Chronic Diseases in Older Adults: Established and Emerging Treatments and Therapies

Type 2 diabetes mellitus (T2DM) and sarcopenia (low skeletal muscle mass and function) share a bidirectional relationship. The prevalence of these diseases increases with age and they share common risk factors. Skeletal muscle fat infiltration, commonly referred to as myosteatosis, may be a major contributor to both T2DM and sarcopenia in older adults via independent effects on insulin resistance and muscle health. Many strategies to manage T2DM result in energy restriction and subsequent weight loss, and this can lead to significant declines in muscle mass in the absence of resistance exercise, which is also a first-line treatment for sarcopenia. In this review, we highlight recent evidence on established treatments and emerging therapies targeting weight loss and muscle mass and function improvements in older adults with, or at risk of, T2DM and/or sarcopenia. This includes dietary, physical activity and exercise interventions, new generation incretin-based agonists and myostatin-based antagonists, and endoscopic bariatric therapies. We also highlight how digital health technologies and health literacy interventions can increase uptake of, and adherence to, established and emerging treatments and therapies in older adults with T2DM and/or sarcopenia.

Effects of Mental Illness Amongst Adults in the United States Living With Diabetes Mellitus on Hospital Admissions

OBJECTIVE

To examine the influence of comorbid mental illness on hospitalization among adults reporting diabetes mellitus.

METHODS

This cross-sectional observational study used National Health Interview Survey (NHIS) data from 2000-2018 to examine hospitalization. Mental illness was defined as no to low psychological distress (NLPD), moderate psychological distress (MPD), and serious psychological distress (SPD) as per the Kessler-6 scale. Socio-demographic factors and health status were added as covariates in binary logistic regression.

RESULTS

This study involved 48,807 survey participants and reflected an estimated population of 17,524,418 adults with diabetes in the United States, of whom 19.9% were hospitalized in the year prior to the survey. Among those who were hospitalized, 71.5% exhibited None to Low Psychological Distress (NLPD), 17.7% reported Moderate Psychological Distress (MPD), and 10.8% reported Serious Psychological Distress (SPD). Conversely, among non-hospitalized individuals, the percentages were as follows: 83.2% had NLPD, 11.4% had MPD, and 5.3% had SPD. The odds ratio (OR) for hospitalization was found to be OR=1.31 (95% CI: 1.20, 1.43, p<0.0001) for MPD and OR=1.42 (95% CI: 1.28, 1.58, p<0.0001) for SPD, in comparison to those with no or low psychological distress.

CONCLUSION

Among adults with diabetes mellitus, those with mental illness were more likely to be hospitalized than those without mental illness. Programs and policies to improve care among adults with both mental illness and diabetes may help to reduce hospitalizations.

Examining Health Literacy in Taiwanese Smoking Cessation Populations: A Multidimensional Evaluation of Sociodemographic Factors and Domain-Specific Competencies

BACKGROUND

Cigarette smoking is a serious global health issue. Limited studies previously analyzed health literacy components in patients undergoing smoking cessation interventions. This study focuses on individuals enrolled in smoking cessation services and investigates the distribution of health literacy in three domains (health care, disease prevention, and health promotion) and four abilities (access, understand, appraise, and apply health information). The study also explores the correlation between background factors (age, BMI, etc.) and health literacy, as well as the differences in health literacy levels among different background variables (gender, etc.).

METHODS

228 individuals completed the health literacy questionnaire. Descriptive statistical analysis, Pearson Correlation, and a Chi-Squared Test were employed to investigate the various health literacy levels and background variables.

RESULTS

68% had excellent or sufficient health literacy. A total of 32% were considered problematic or to have inadequate health literacy. Of the three domains of health literacy, participants performed better in the healthcare domain. More than one-third were problematic in accessing and appraising information.

CONCLUSIONS

this paper, being the pilot study in providing an analysis of health literacy components in individuals undergoing smoking cessation, could serve as a useful reference for devising interventions for different population groups in trying to maximize successful cessation rates.

Can Waist-to-Height Ratio and Health Literacy Be Used in Primary Care for Prioritizing Further Assessment of People at T2DM Risk?

BACKGROUND

To identify people at risk of type 2 diabetes. Primary health care needs efficient and noninvasive screening tools to detect individuals in need of follow-up to promote health and well-being. Previous research has shown people with lower levels of health literacy and/or well-being scores are vulnerable but may benefit from intervention and follow-up care.

AIMS

This cross-sectional study, aimed to identify people at risk for type 2 diabetes by comparing the Finnish Diabetes Risk instrument with the waist-to-height ratio. Further, the difference was examined in health literacy and well-being scale scores in the countryside versus town areas, respectively.

RESULTS

In total, 220, aged 18-75 years, participated. Thereof, 13.2% displayed biomarkers at prediabetes level of HbA1c (39-47 mmol/mol); none had undiagnosed diabetes. Of the participants, 73% were overweight or obese. Waist-to-height ratio demonstrated 93.1% of the prediabetes group at moderate to high health risk and 64.4% of the normal group, with an area under the curve of 0.759, sensitivity of 93.3%, and specificity of 63.1%. Residency did not influence prediabetes prevalence, health literacy, or well-being.

CONCLUSION

Waist-to-height ratio and the Finnish Diabetes Risk instrument may be suitable for identifying who need further tests and follow-up care for health promotion in primary care.

Cost-Effectiveness of Health Literacy Enhancement Intervention on Patients with Type II Diabetes

Background

Type II diabetes is considered a chronic disease that influences the affected person's quality of life and imposes a high economic burden on the patient and society. The enhancement of health literacy seems essential for self-management and disease control in patients with type II diabetes. Consequently, this study was performed to evaluate the cost-effectiveness of enhanced health literacy in type II diabetes patients.

Methods

This study was of quantitative and economic evaluation type. A population of 232 patients was selected among those referred to the Tafihan Shiraz clinic based on the quality of entry and exit. The health literacy educational intervention was carried out for three months. In order to collect information, researchers used the SF36 questionnaire and the checklist of costs. The Cost Effectiveness Ratio (CER) and Incremental Cost Effectiveness Ratio (ICER) were calculated. Moreover, the costs of each unit of increasing the quality of life before and after the intervention were calculated. A decision was made to determine the cost-effectiveness of the intervention.

Results

According to the results, 40% of the participants were females, and 34.5% were 30-40 years old. Examination of the quality of life in patients before the intervention indicated that the mean and standard deviation of the patients' quality of life before the intervention was 18.43±44.99, and the mean and standard deviation of the quality of life after the intervention was 49.57±16.21. Moreover, the patients' quality of life increased after the educational intervention. The total direct medical costs were $717,484 and $685,620 before and after the intervention, respectively. The total indirect medical costs were $604,122 and $493,011 before and after the intervention, respectively. Moreover, the total indirect costs were $122,535 and $122,119 before and after the intervention, respectively. The study was cost-effective with CER=0.9 and ICER= - 140,000 per increase in the quality of life.

Conclusion

Improving health literacy can have a range of benefits and improve the quality of life of patients with type II diabetes and reduce their treatment costs, and thereby, this may be seen as an effective step toward the recovery of patients with type II diabetes.

Knowledge about diabetes and its association with adherence to self-care and glycemic control in patients with type 1 diabetes in Southern Brazil

Objective

To evaluate the association between knowledge about the disease, adherence to self-care, and glycemic control in people diagnosed with type 1 diabetes mellitus.

Subjects and methods

A cross-sectional study of patients aged over 18 years diagnosed with type 1 diabetes mellitus, treated at an outpatient clinic of a Brazilian university hospital. Participants with other types of diabetes, cognitive impairment, pregnancy, and outpatient discharge were excluded. Data were collected from January to March 2021 (by telephone call), with questions about the participants' profile, diabetes knowledge questionnaire (DKN-A), and self-care inventory revised (SCI-R) translated into and adapted for Brazilian Portuguese. Data analysis involved chi-square associations, Mann-Whitney U tests, and Poisson regression.

Results

Among 198 adult participants, the mean age was 42 ± 12 years, 53.5% were women, the mean glycated hemoglobin was 8.6 ± 1.6%, 140 (70.8%) had satisfactory knowledge about diabetes, 65 (32.8%) had adherence to self-care, and 46 (23.2%) had adequate glycemic control. We found an association between knowledge and adherence to self-care (p < 0.001). Knowledge was not associated with glycemic control (p = 0.705).

Conclusion

Knowledge about diabetes was associated with greater adherence to self-care in people with type 1 diabetes mellitus, but it did not reflect in better glycemic control.

Inadequate diabetes knowledge is associated with poor glycemia control in patients with type 2 diabetes

OBJECTIVE

To identify the association between glycemia control with level of diabetes knowledge, diabetes education, and lifestyle variables in patients with type 2 diabetes.

DESIGN

Cross-sectional analytical study. SITE: Clinics of the Mexican Institute of Social Security (IMSS), Mexico.

PARTICIPANTS

Patients with type 2 diabetes.

MAIN MEASUREMENTS

Glycated hemoglobin (HbA1c), glucose, and lipid profile levels were measured from fasting venous blood samples. Assessment of disease knowledge was performed using the Diabetes Knowledge Questionnaire (DKQ-24). Systolic and diastolic blood pressure was measured. Weight and abdominal circumference were measured, as well as body composition using bioimpedance. Sociodemographic, clinical, and lifestyle variables were obtained.

RESULTS

A total of 297 patients were included, sixty-seven percent (67%) were women with a median of six years since the diagnosis of diabetes. Only 7% of patients had adequate diabetes knowledge, and 56% had regular knowledge. Patients with adequate diabetes knowledge had a lower body mass index (p=0.016), lower percentage of fat (p=0.008), and lower fat mass (p=0.018); followed a diet (p=0.004) and had received diabetes education (p=0.002), and to obtain information about their illness (p=0.001). Patients with low levels of diabetes knowledge had a higher risk of HbA1c≥7% (OR: 4.68; 95% CI: 1.48,14.86; p=0.009), as well as those who did not receive diabetes education (OR: 2.17; 95% CI: 1.21-3.90; p=0.009) and those who did not follow a diet (OR: 2.37; 95% CI: 1.01,5.55; p=0.046).

CONCLUSION

Inadequate knowledge of diabetes, lack of diabetes education, and dietary adherence are associated with poor glycemia control in patients with diabetes.

Predictors of Inadequate Health Literacy among Patients with Type 2 Diabetes Mellitus: Assessment with Different Self-Reported Instruments

INTRODUCTION

Obtaining, understanding, interpreting, and acting on health information enables people with diabetes to engage and make health decisions in various contexts. Hence, inadequate health literacy (HL) could pose a problem in making self-care decisions and in self-management for diabetes. By applying multidimensional instruments to assess HL, it is possible to differentiate domains of functional, communicative, and critical HL.

OBJECTIVES

Primarily, this study aimed to measure the prevalence of inadequate HL among type 2 diabetes mellitus patients and to analyze the predictors influencing health literacy levels. Secondly, we analyzed if different self-reported measures, unidimensional instruments (Brief Health Literacy instruments (BRIEF-4 and abbreviated version BRIEF-3), and multidimensional instruments (Functional, Communicative and Critical health literacy instrument (FCCHL)) have the same findings.

METHODS

The cross-sectional study was conducted within one primary care institution in Serbia between March and September 2021. Data were collected through Serbian versions of BRIEF-4, BRIEF-3, and FCCHL-SR12. A chi-square test, Fisher's exact test, and simple logistic regression were used to measure the association between the associated factors and health literacy level. Multivariate analyses were performed with significant predictors from univariate analyses.

RESULTS

Overall, 350 patients participated in the study. They were primarily males (55.4%) and had a mean age of 61.5 years (SD = 10.5), ranging from 31 to 82 years. The prevalence of inadequate HL was estimated to be 42.2% (FCCHL-SR12), 36.9% (BRIEF-3) and 33.8% (BRIEF-4). There are variations in the assessment of marginal and adequate HL by different instruments. The highest association was shown between BRIEF-3 and total FCCHL-SR12 score (0.204, p < 0.01). The total FCCHL-SR12 score correlates better with the abbreviated BRIEF instrument (BRIEF-3) than with BRIEF-4 (0.190, p < 0.01). All instruments indicated the highest levels for the communicative HL domain and the lowest for the functional HL domain with significant difference in functional HL between the functional HL of FCCHL-SR12 and both BRIEF-3 and BRIEF-4 (p = 0.006 and 0.008, respectively). Depending on applied instruments, we identified several variables (sociodemographic, access to health-related information, empowerment-related indicators, type of therapy, and frequency of drug administration) that could significantly predict inadequate HL. Probability of inadequate HL increased with older age, fewer children, lower education level, and higher consumption of alcohol. Only high education was associated with a lower probability of inadequate HL for all three instruments.

CONCLUSIONS

The results we obtained indicate that patients in our study may have been more functionally illiterate, but differences between functional level could be observed if assessed by unidimensional and multidimensional instruments. The proportion of patients with inadequate HL is approximately similar as assessed by all three instruments. According to the association between HL and educational level in DMT2 patients we should investigate methods of further improvement.

Self-management of type 2 diabetes among Turkish immigrants in Norway: A focus group study

The prevalence of Type 2 Diabetes Mellitus (T2DM) is higher among Turkish immigrants than the general population in Norway. The aim of the study is to describe the challenges and experiences faced by Turkish immigrants in Norway in the self-management of T2DM. The study design is based on descriptive research using a qualitative approach. The sample group contained 13 persons participating in three focus group interviews: nine women and four men. A phenomenological-hermeneutical approach was employed to achieve a deeper understanding of the experience of self-management of T2DM among Turkish immigrants in Norway with regard to HL. The participants described experiences of the T2DM self-management with regard to HL and revealed three major themes: (1) understanding the role and responsibility of health care staff in T2DM treatment, (2) assessing T2DM education course and information and (3) applying knowledge and motivation to adapt to life with T2DM. Findings from this study revealed that self-management of patients with T2DM among Turkish immigrants is related to their cultural, religious and socio-economical background and experiences. By understanding the cultural features, a well-tailored intervention according to the needs of Turkish immigrants regarding self-management can be developed. Health care staff are recommended to consider patients' HL when interventions are developed.

Methods to assess adults' learning styles and factors affecting learning in health education: A scoping review

OBJECTIVES

To develop learner-centered education, knowledge about learning styles and factors that affect the ability to learn in patients and their significant others are essential. The present scoping review aims to identify current evidence on 1) how learning styles are assessed within health education, for adult patients as well as their significant others and 2) factors affecting learning in adult patients and their significant others who receive health education.

METHODS

Systematic literature searches were performed in ERIC, PubMed, Web of Science and PsycINFO.

INCLUSION CRITERIA

1) participants ≥ 18 years; 2) participants were patients or significant others; 3) assessment of learning style and/or factors affecting learning; and 4) health education as context.

RESULTS

45 articles were included. Learning style within health education can be assessed with multiple choice questions, qualitative methods and a validated questionnaire. Health literacy was the most reported factor affecting learning, followed by anxiety and illness condition.

CONCLUSIONS

Prior to the development of learner-centered education for patients and significant others, learning styles as well as factors affecting learning should be assessed in both patients and significant others.

PRACTICE IMPLICATIONS

The process of learning is complex, and it is a shared responsibility of both the learner and the educator.

Influence of Educational Level and Healthy Habits on the Prevalence of Diabesity in a Spanish Working Population

Background: Diabesity is a growing problem internationally. Taking into account the importance of physical activity and diet in its prevention and treatment, the objective of this study was to delve into the impact of healthy habits on diabesity. Methods: A descriptive, cross-sectional study was carried out in 386,924 Spanish adult workers. Obesity was determined according to eleven different formulas. Life habits were also valued; sociodemographic variables; and educational level; as well as analytical and clinical variables such as blood pressure and blood glucose levels. The association between the different variables was performed using the chi-square and the Student’s t-tests when the samples were independent. A multivariate analysis was performed using the multinomial logistic regression test by calculating the odds ratio and a 95% confidence interval. The Hosmer–Lemeshow goodness-of-fit test was also performed. Results: The overall prevalence of diabesity ranged between 0.3% (95% CI 0.3–0.4) when obesity was assessed according to the abdominal volume index and 8.3% (95% CI 8.2–8.4) when evaluated according to the CUN-BAE (Clínica Universitaria de Navarra Body Adiposity Estimator) formula. The prevalence of diabesity was also higher in workers with a non-heart-healthy diet and in those who did not exercise regularly. Conclusions: The most disadvantaged socioeconomic classes are those with the highest prevalence of diabesity. It is important to prioritise prevention in populations and communities with the most unfavourable social and environmental conditions to reduce the burden of diabesity.

Factors affecting the health literacy status of patients with type 2 diabetes through demographic variables: A cross-sectional study

BACKGROUND

Health literacy (HL) is the ability of a person to acquire the process, understand the necessary health information, and make the health services needed for conscious health decisions. Besides, diabetes is the most common metabolic disorder that affects patients' quantity and quality of life. This study focused on determining the factors that affect the HL status of patients with type 2 diabetes (T2D) through the role of the demographic variables.

MATERIALS AND METHODS

This descriptive-analytical research survey recruited a sample based on 280 patients with T2D at the Diabetes Research Center of Ayatollah Taleghani Hospital in Kermanshah in 2020. This study selected patients with T2D using a simple random sampling technique. The study applied the demographic information questionnaire and the Functional, Communicative, and Critical HL Scale to collect data from patients with T2D. This study used the SPSS version 23 on the received data sets to perform statistical analysis, including t-test, analysis of the variance, and multiple regression, to predict the factors affecting HL among diabetes patients.

RESULTS

The study results showed that the mean age of the participating patients with T2D was 55.80 ± 13.04. The results indicated the mean score and standard deviation of total HL score in patients with T2D 2.70 ± 0.44. The findings specified a statistically significant relationship between HL, gender, education, occupation, income, and place of residence. Results indicated that β-coefficients of the multiple regression analysis and the income variable (β = 0.170), age (β = 0.176), and employment variable (β = 0.157). These are the most predictive of the HL of patients with T2D.

CONCLUSION

The results of this study specified that the HL rate of individuals with diabetes type 2 is average. The potential communicative and critical HL influence is essential for communication and education for diabetes patients in the primary health-care system settings. The findings indicate that communicative and critical HL related to patients' management and functional HL looks passable in this study.

Health literacy, illness perception, depression, and self-management among African Americans with type 2 diabetes

BACKGROUND

Type 2 diabetes mellitus (T2DM) causes significant morbidity and mortality. Compared with non-Hispanic Whites, African Americans are more likely to suffer and die from T2DM.

PURPOSE

This study examines the associations between health literacy, illness perception, depression, working memory, executive function, and self-management among African Americans (18-65 years) with T2DM.

METHODOLOGY

A descriptive cross-sectional design was used. Data were collected through Research Electronic Data Capture and transferred to the Statistical Package for the Social Sciences software version 26 for statistical analysis. Fifty-three participants met study eligibility criteria.

RESULTS

Health literacy was associated with depression ( r = -0.433, p = .003), more concerns about illness ( r = -0.357, p = .02), and better medication adherence ( r = 0.487, p = .001). Higher levels of depression were inversely associated with medication adherence ( r = -0.449, p = .002; r = 0.449, p = .003). Higher concern about illness was associated with lower medication adherence ( r = -0.414, p = .005).

CONCLUSIONS

Lower health literacy coupled with illness perception and depression is associated with lower self-management behaviors among African Americans which can lead to complications of T2DM. More studies are needed to examine the association of cognitive factors with self-management activities among African Americans with T2DM.

IMPLICATIONS

Limited health literacy is associated with lower medication adherence among African Americans with T2DM. Illness perception is a significant factor that influences self-management of T2DM among African Americans. Using screening tools that assess health literacy and illness perception may address underlying concerns regarding adherence to T2DM treatment regimens in African Americans.

Association between Health Literacy and Prevalence of Obesity, Arterial Hypertension, and Diabetes Mellitus

Background: Health literacy (HL) is linked to many health outcomes, including self-management of chronic diseases. The aim of this study was to assess the association of health literacy with the prevalence of obesity, arterial hypertension (AH), and type 2 diabetes mellitus (T2DM). Methods: This cross-sectional, single-center study included 500 patients (42.2% male and 57.8% females; median age, 63 years (interquartile range, 42−73)) hospitalized at General County Hospital in Požega, Croatia, between July and October 2020. The Short Assessment of Health Literacy for Croatian Adults (SAHLCA-50) questionnaire was used. Descriptive statistics (median with interquartile range (IQR), frequency, and percentages) and binary logistic regression were utilized. Results: Patients with AH had an inadequate level of health literacy as compared to those without AH (32 vs. 40 points; Mann−Whitney U test, p < 0.001). Patients with T2DM scored 31 points versus 39 points in patients without T2DM (Mann−Whitney U test, p < 0.001). Patients suffering from both AH and T2DM scored 31 points versus 33 points in those with either AH or T2DM and 41 points in patients without AH and T2DM (Kruskal−Wallis test, p < 0.001). There were no statistically significant differences in SAHLCA-50 scores according to the patient body mass index. Conclusions: An inadequate level of health literacy is significantly associated with AH and T2DM but not with obesity. Male gender, low level of education, rural place of residence, retirement, and older age are significant predictors of inadequate health literacy.

Development and Evaluation of the Clinical Trial HEalth Knowledge and Beliefs Scale (CHEKS)

Patient health literacy is vital to clinical trial engagement. Knowledge and beliefs about clinical trials may contribute to patient literacy of clinical trials, influencing engagement, enrollment and retention. We developed and assessed a survey that measures clinical trial health knowledge and beliefs, known as the Clinical trial HEalth Knowledge and belief Scale (CHEKS). The 31 survey items in CHEKS represent knowledge and beliefs about clinical trial research (n = 409) in 2017. We examined item-scale correlations for the 31 items, eliminated items with item-scale correlations less than 0.30, and then estimated internal consistency reliability for the remaining 25 items. We used the comparative fit index (CFI) and the root mean squared error of approximation (RMSEA) to evaluate model fit. The average age of the sample was 34 (SD = 15.7) and 48% female. We identified 6 of the 31 items that had item-scale correlations (corrected for overlap) lower than 0.30. Coefficient alpha for the remaining 25 items was 0.93 A one-factor categorical confirmatory factor analytic model with 16 correlated errors was not statistically significant (chi-square = 10011.994, df = 300, p < 0.001) but fit the data well (CFI = 0.95 and RMSEA = 0.07). CHEKS can assess clinical trial knowledge and beliefs.

Diabetic health literacy and associated factors among diabetes mellitus patients on follow up at public hospitals, Bale Zone, South East Ethiopia, 2021

Objective

This study was aimed to assess diabetic health literacy and associated factors among adult diabetic patients in public hospitals, Bale Zone, Southeast Ethiopia.

Methods

A hospital-based cross-sectional study was conducted among 402 diabetic patients in three public hospitals and the samples were selected using simple random sampling technique. The comprehensive functional, communicative, and critical health literacy questionnaire was used to measure diabetic health literacy. Descriptive statistics and Ordinary logistic regression analyses were conducted, and a P-value of < 0.05 was considered to declare a result as statistically significant.

Result

A total of 402 diabetic patients were involved in the study. Of all respondents, 41.8%, 27.9%, and 30.3% had low, moderate, and high diabetic health literacy respectively. Educational status; can’t read and write (AOR = 0.085;95% CI: 0.03,0.26), can read and write (AOR = 0.10; 95% CI: 0.04,0.30), primary school (AOR = 0.25; 95% CI: 0.09,0.67), secondary school (AOR = 0.37; 95% CI: 0.14,0.99), duration of onset ≤5 years (AOR = 2.05; 95% CI:1.09,4.19), being not member of DM association (AOR = 0.43; 95% CI: 0.26,0.73), having ≤ 3 diabetes mellitus information sources (AOR = 0.15; 95% CI: 0.03,0.77), social support; poor (AOR = 0.40;95% CI: 0.21,0.79), and moderate (AOR = 0.50; 95% CI: 0.28,0.92) were significantly associated with diabetic health literacy.

Conclusion

A substantial number of diabetic patients had low diabetic health literacy. Educational status, Sources of diabetic information, Member of DM association, and social support were significantly and positively associated with diabetic health literacy. But, duration of diabetes onset was negatively associated with diabetic health literacy of respondents. So, we recommend providing readable and picturized printed materials, and diabetic patient education to be considered.

Preferences Regarding Self-Management Intervention Outcomes of Dutch Chronically Ill Patients With Limited Health Literacy

Background:

For many chronically ill patients self-management of their disease is difficult. This may be especially true for people with limited health literacy as they are faced with additional challenges in the day-to-day management of their disease. Research has shown that self-management support is most effective when tailored to the needs and preferences of patients. Therefore, this study explores the preferences regarding self-management outcomes of chronically ill patients with limited health literacy.

Methods

A total of 35 patients with limited health literacy were invited to a concept-mapping procedure consisting of two card sorting tasks. Patients ranked 60 outcomes, which are often found in literature in relation to self-management, to the level that was important for themselves. Means were calculated for each outcome and domain, and differences within the group were analyzed.

Results

For patients with limited health literacy, satisfaction with care is the most important outcome domain. This domain includes overall satisfaction, the communication with health care providers, the provision of information and trust. At an outcome level, outcomes related to symptom management and improving competences to self-management scored very high. No differences between patient groups for age and sex were found.

Conclusion

Chronically ill patients with limited health literacy prefer a wide variety of outcomes for their self-management. Next to health related outcomes, patients mostly prefer to work on their competences for self-management. For health care professionals, acting on these patient preferences and building a solid relationship will enhance successful self-management.

Cognition, educational attainment and diabetes distress predict poor health literacy in diabetes: A cross-sectional analysis of the SHELLED study

Objectives

To identify factors that predict poor health literacy amongst people with diabetes.

Design

Cross-sectional analysis of baseline data from a prospective study of diabetic foot disease.

Setting

Patients attending a tertiary hospital diabetes outpatient clinic in Tasmania, Australia.

Participants

222 people with diabetes mellitus, aged >40 years, with no history of foot ulceration, psychotic disorders or dementia.

Outcome measures

Health literacy was measured using the short form Test of Functional Health Literacy in Adults (functional health literacy), and the Health Literacy Questionnaire (HLQ), which measures nine domains of health literacy. Predictors included demographic characteristics, cognition, diabetes distress, depression, and educational attainment.

Results

In multivariable analysis, greater educational attainment (OR 0.88, 95% CI 0.76, 0.99) and poorer cognition (OR 0.71, 95% CI 0.63, 0.79) were associated with poorer functional health literacy. Age was negatively associated with domains of appraisal of health information and ability to find good health information (both beta = -0.01). Educational attainment was positively associated with four domains, namely having sufficient information to manage my health, actively managing my health, appraisal of and ability to find good health information (beta ranging from +0.03 to 0.04). Diabetes distress was negatively associated with five domains: having sufficient information to manage my health, social support for health, ability to actively engage with healthcare providers, navigating the healthcare system and ability to find good health information (beta ranging from -0.14 to -0.18).

Conclusion

Poorer cognition and poorer educational attainment may be detrimental for an individual’s functional health literacy, and education, diabetes distress and older age detrimental across multiple health literacy domains. Clinicians and policy makers should be attuned to these factors when communicating with people with diabetes and in designing healthcare systems to be more health-literacy friendly in order to improve diabetes outcomes.

The Impact of Health Literacy on Kidney Transplant Listing

Introduction: Limited health literacy has been associated with poor health outcomes in the general population, but there have been few studies investigating the association between functional health literacy and kidney transplant listing. The primary objective of this study was to determine if functional health literacy was associated with kidney transplant listing after controlling for demographic, psychosocial, and medical variables, which were secondarily examined for correlation with transplant listing. Design: We retrospectively reviewed 423 kidney transplant candidates who were prospectively administered the Test of Functional Health Literacy in Adults during their transplant evaluation. Results: The functional health literacy scores were found to correlate with transplant listing (P = 0.013). Unexpectedly, a subset of patients (n = 14 out of 36) who had scores < 59 was still able to obtain approval for listing. The probability of approval decreased when functional health literacy scores ranged from 0 to 59 and increased when functional health literacy scores varied between 60 to 100. Multivariable analysis found transplant listing to also be associated with substance use (OR = 0.15, P < 0.001), ESKD etiology other than diabetes or hypertension (OR = 2.62, P < 0.001), time on dialysis (P = 0.012), and pace of transplant evaluation (P < 0.001). Conclusion: Functional health literacy was associated with kidney transplant listing. Programmatic interventions that can help overcome the impact of functional health literacy and improve access to transplantation should be explored.

Social Media-Delivered Patient Education to Enhance Self-management and Attitudes of Patients with Type 2 Diabetes During the COVID-19 Pandemic: Randomized Controlled Trial

Background

The use of mobile health technologies has been necessary to deliver patient education to patients with diabetes during the COVID-19 pandemic.

Objective

This open-label randomized controlled trial evaluated the effects of a diabetes educational platform—Taipei Medical University–LINE Oriented Video Education—delivered through a social media app.

Methods

Patients with type 2 diabetes were recruited from a clinic through physician referral. The social media–based program included 51 videos: 10 about understanding diabetes, 10 about daily care, 6 about nutrition care, 21 about diabetes drugs, and 4 containing quizzes. The intervention group received two or three videos every week and care messages every 2 weeks through the social media platform for 3 months, in addition to usual care. The control group only received usual care. Outcomes were measured at clinical visits through self-reported face-to-face questionnaires at baseline and at 3 months after the intervention, including the Simplified Diabetes Knowledge Scale (true/false version), the Diabetes Care Profile–Attitudes Toward Diabetes Scales, the Summary of Diabetes Self-Care Activities, and glycated hemoglobin (HbA_1c) levels. Health literacy was measured at baseline using the Newest Vital Sign tool. Differences in HbA_1c levels and questionnaire scores before and after the intervention were compared between groups. The associations of knowledge, attitudes, and self-care activities with health literacy were assessed.

Results

Patients with type 2 diabetes completed the 3-month study, with 91 out of 181 (50.3%) patients in the intervention group and 90 (49.7%) in the control group. The change in HbA_1c did not significantly differ between groups (intervention group: mean 6.9%, SD 0.8% to mean 7.0%, SD 0.9%, P=.34; control group: mean 6.7%, SD 0.6% to mean 6.7%, SD 0.7%, P=.91). Both groups showed increased mean knowledge scores at 12 weeks, increasing from 68.3% (SD 16.4%) to 76.7% (SD 11.7%; P<.001) in the intervention group and from 64.8% (SD 18.2%) to 73.2% (SD 12.6%; P<.001) in the control group. Positive improvements in attitudes and self-care activities were only observed in the intervention group (attitudes: mean difference 0.2, SD 0.5, P=.001; self-care activities: mean difference 0.3, SD 1.2, P=.03). A 100% utility rate was achieved for 8 out of 21 (38%) medication-related videos. Low health literacy was a significant risk factor for baseline knowledge scores in the intervention group, with an odds ratio of 2.80 (95% CI 1.28-6.12; P=.01); this became insignificant after 3 months.

Conclusions

The social media–based program was effective at enhancing the knowledge, attitudes, and self-care activities of patients with diabetes. This intervention was also helpful for patients with low health literacy in diabetes knowledge. The program represents a potentially useful tool for delivering diabetes education to patients through social media, especially during the COVID-19 pandemic.

Trial Registration

ClinicalTrials.gov NCT04876274; https://clinicaltrials.gov/ct2/show/results/NCT04876274

Patients' Views on the Design of DiabeText, a New mHealth Intervention to Improve Adherence to Oral Antidiabetes Medication in Spain: A Qualitative Study

Background: Type 2 Diabetes Mellitus (T2DM) is a long-term condition affecting around 10% of people worldwide. This study aimed to explore T2DM patients’ views on DiabeText, a new text messaging intervention to be developed to support adherence to diabetes medication. Methods: A total of four focus groups were conducted with a purposive sample of people with T2DM (n = 34). The data were analysed by multiple researchers independently, and coded using thematic analysis. Results: There were two main themes that emerged: (1) “patients’ perspectives on unmet needs for diabetes self-management”, and (2) “acceptability and perceived utility of DiabeText”. The patients identified a number of barriers for diabetes self-management, including lack of appropriate information and support with diet and physical activity. Support for medication-taking was not perceived as urgently needed, although several barriers were identified (eating outside, traveling, polymedication, dispensation at the pharmacy). The participants anticipated that the proposed intervention would present high levels of patient acceptability and perceived utility as long as its content addresses the barriers that were identified, and includes specific features (short and clear messages, and personalized information). Conclusion: The proposed intervention has the potential to be well accepted and perceived as useful by T2DM patients who require support not only in terms of medication-taking, but more prominently of lifestyle behaviour.

2022 National Standards for Diabetes Self-Management Education and Support

PURPOSE

The National Standards for Diabetes Self-Management Education and Support (DSMES) provide guidance and evidence-based, quality practice for all DSMES services. Due to the dynamic nature of health care and diabetes research, the National Standards are reviewed and revised approximately every 5 years by key stakeholders and experts within the diabetes care and education community. For each revision, the Task Force is charged with reviewing the current National Standards for appropriateness, relevance, and scientific basis and making updates based on current evidence and expert consensus. In 2021, the group was tasked with reducing administrative burden related to DSMES implementation across diverse care settings.

CONCLUSION

The evidence supporting the 2022 National Standards clearly identifies the need to provide person-centered services that embrace cultural differences, social determinants of health, and the ever-increasing technological engagement platforms and systems. Payers are invited to review the National Standards as a tool to inform and modernize DSMES reimbursement requirements and to align with the evolving needs of people with diabetes (PWD) and physicians/other qualified health care professionals. The American Diabetes Association and the Association of Diabetes Care & Education Specialists strongly advocate for health equity to ensure all PWD have access to this critical service proven to improve outcomes both related to and beyond diabetes. The 2022 National Standards update is meant to be a universal document that is easy to understand and can be implemented by the entire health care community. DSMES teams in collaboration with primary care have been shown to be the most effective approach to overcome therapeutic inertia.

Online health information-seeking behaviour of patients attending a primary care clinic in Malaysia: a cross-sectional study

BACKGROUND

The internet has become a common source of health information; however, little is known about online health information-seeking behaviour (HISB) among patients in low- and middle-income countries (LMICs).

OBJECTIVES

This study aimed to determine the prevalence of online health information-seeking and its associated factors among patients in primary care in Malaysia. We also examined the reasons for, and the sources of, online health information-seeking, patients' level of trust in the information found and what the information was used for.

METHODS

A cross-sectional study using a self-administered questionnaire was conducted on patients who attended a primary care clinic. The questionnaire included the use of the internet to seek health information, sources and types of health information, eHealth literacy, patients' trust in online information, and how patients appraise and use online health information.

RESULTS

Out of 381 patients in this study, 54.7% (n = 208) used the internet to search for health information. Patients mainly sought information via Google (96.2%) and the most common websites that they visited were Wikipedia (45.2%) and MyHEALTH (37.5%). Higher levels of education, longer duration of internet use, and higher eHealth literacy were significantly associated with online HISB. Patients' trust in websites (45.6%) and social media (20.7%) was low when compared to trust in healthcare professionals (87.9%). Only 12.9% (n = 22) of patients had discussed online health information with their doctors.

CONCLUSION

Online HISB was common among primary care patients; however, their eHealth literacy was low, with suboptimal appraisal skills to evaluate the accuracy of online health information.

Determinants of Poor Treatment Adherence among Patients with Type 2 Diabetes and Limited Health Literacy: A Scoping Review

Prevention of complications and successful control of diabetes require preventive and therapeutic measures. Patients' nonadherence to medication and diet regimens and healthcare protocols is associated with significant therapeutic and economic consequences. The present scoping review aims to identify determinants of poor treatment adherence among patients with type 2 diabetes and limited health literacy in 2021. This scoping review was conducted in five stages: designing a research question, searching and extracting related studies, selecting related studies, tabulating information, and reporting results. Data were collected from six foreign electronic databases (Embase, Science Direct, PubMed, Google Scholar, Scopus, and Web of Science) and four Iranian electronic databases (MagIran, SID, IranDoc, and IranMedex) using keywords "Type 2 diabetes", "barriers", "treatment", "medication", "adherence", "non-adherence", "limited adherence", and "limited health literacy" from January 2010 to November 2021. From an initial 146 articles, 18 articles were eligible for review. Eighteen studies involving 3925 patients with T2DM from eight countries were included. The prevalence of nonadherence ranged from 42% to 74.3%. Barriers to treatment adherence, which were common among the articles, included economic problems, poor communication with healthcare team, lack of family support, lack of knowledge, misconceptions, and limited health literacy. The results of the present study provided modifiable and nonmodifiable factors affecting treatment adherence among patients with type 2 diabetes. Modifiable factors are essential by performing appropriate interventions with the target group and health professionals.

Influence of Literacy, Self-Efficacy, and Social Support on Diabetes-Related Outcomes Following Hospital Discharge

OBJECTIVE

To evaluate the relationship between health literacy, social support, and self-efficacy as predictors of change in A1c and readmission among hospitalized patients with type 2 diabetes (T2D).

METHODS

This is a secondary analysis of patients with T2D (A1c >8.5%) enrolled in a randomized trial in which health literacy (Newest Vital Sign), social support (Multidimensional Scale of Perceived Social Support), and empowerment (Diabetes Empowerment Scale-Short Form) was assessed at baseline. Multivariable models evaluated whether these concepts were associated with A1c reduction at 12 weeks (absolute change, % with >1% reduction, % reaching individualized target) and readmission (14 and 30 days).

RESULTS

A1c (N=108) decreased >1% in 60%, while individualized A1c target was achieved in 31%. After adjustment for baseline A1c and potential confounders, health literacy was associated with significant reduction in A1c (Estimate -0.21, 95% CI -0.40, -0.01, p=0.041) and >1% decrease in A1c (OR 1.37, 95% CI 1.08, 1.73, p=0.009). However, higher social support was associated with greater adjusted odds of reaching the individualized A1c target (OR 1.63, 95% CI 1.04, 2.55, p=0.32). Both higher empowerment (OR 0.23, 95% CI 0.08, 0.64, p=0.005) and social support (OR 0.57, 95% CI 0.36, 0.91, p=0.018) were associated with fewer readmissions by 14 days, but not 30 days.

CONCLUSION

The study indicates that health literacy and social support may be important predictors of A1c reduction post-discharge among hospitalized patients with T2D. Social support and diabetes self-management skills should be addressed and early follow-up may be critical for avoiding readmissions.

CLINICAL TRIAL

NCT03455985.

Equity in the Provision of Diabetes Self-Management Education and Support

Diabetes self-management education and support (DSMES) interventions must be accessible to all people with diabetes. To address equity in the delivery of DSMES, interventions should consider the unique needs of various populations. This article outlines the needs of a wide range of populations, including people with diabetes who are racially or ethnically diverse; have limited English proficiency or literacy; are deaf or hard of hearing; are blind or have low vision; are neurodiverse; live with learning disabilities or intellectual or developmental disabilities; have dementia or cognitive impairment; or are of sexual and/or gender minority. The authors discuss how best to tailor DSMES to meet the needs of these diverse groups.

Association between Health Literacy, Self-care Behavior, and Blood Sugar Level among Older Patients with Type 2 Diabetes in Rural Thai Communities

Background

Diabetes mellitus is a major problem worldwide. Moreover, older patients with significantly limited health literacy (HL) tend to have worse self-care behaviors and health outcomes. This study aimed to describe the associations of HL, self-care behavior, and blood sugar levels among older patients with type 2 diabetes in rural Thai communities.

Methods

This cross-sectional study included 415 patients with diabetes who were purposively selected from rural Thai communities. Data were collected using questionnaires and analyzed using descriptive statistics, Pearson correlation, Spearman rho, and stepwise multiple linear regression.

Results

The results revealed that most participants were women (66.50%). The respondents had moderate overall HL (2.68±0.64). On average, the respondents had fair overall self-care behavior (4.0±0.33). We discovered that HL was significantly positively correlated with self-care behavior (r=0.90) but not with blood sugar level. In addition, self-care behavior was significantly negatively correlated with blood sugar level (r=-0.50). Self-care behaviors and blood sugar levels were significant predictors of HL in patients with type 2 diabetes (total variance, 28.4%).

Conclusion

The results suggested increased HL in patients with diabetes would improve self-care behavior and, consequently, decrease their blood sugar level. Our findings indicate the need to involve nurses and multidisciplinary healthcare teams when developing health promotion programs to encourage blood sugar control.

The Impact of COVID-19 Lockdown on Diabetes Complication and Diabetes Management in People With Diabetes in Indonesia

Aims: As the country with the seventh largest number of People with Diabetes (PWD) in the world, the Coronavirus disease 2019 (COVID-19) pandemic, and the Large Social Scale Restriction (LSSR) policy taken by the Indonesian government to reduce the number of COVID-19 transmissions is estimated to interfere diabetes management and will increase the incidence of diabetes complications. This study aims to determine the difficulties of diabetes management and its impact on diabetes morbidity during the COVID-19 pandemic in Indonesia. Methods: This study is a cross-sectional study using a national scale web survey. This research was conducted in Indonesia enrolling 1124 PWD aged 18 years or older. Diabetes complications are defined as self-assessed incidence of hypoglycemia, or Diabetic Foot Ulcer (DFU), or hospital admission experienced by PWD in Indonesia during the COVID-19 pandemic. The correlation between diabetes management difficulties and diabetes-related complications was measured using a modified cox regression test. Results: Diabetes management difficulties were experienced by 69.8% of PWD in Indonesia. The difficulties include attending diabetes consultation 30.1%, access to diabetes medication 12.4%, checking blood glucose levels 9.5%, controlling diet 23.8%, and performing regular exercise 36.5%. Diabetes-related complications occurred in 24.6% of subjects. Those who had diabetes management difficulties during the COVID-19 pandemic are prone to have diabetes complications by 1.4 times greater (PR: 1.41, 95% CI: 1.09-1.83) than those who did not. Conclusion: The COVID-19 pandemic and LSSR have impact on diabetes management and diabetes-related complications as assessed by PWD in Indonesia.

Association between health literacy and mortality: a systematic review and meta-analysis

BACKGROUND

To identify the relationship between health literacy (HL) and mortality based on a systematic review and meta-analysis.

METHODS

Literature published from database inception until July 2020 was searched using the PubMed and Web of Science databases, using relevant keywords and clear inclusion and exclusion criteria. The search was limited to English language articles. Two reviewers independently selected studies and extracted data. Pooled correlation coefficients and their 95% confidence intervals (CI) between HL and mortality were estimated using Stata 15.0 software. Potential sources of heterogeneity were explored using subgroup analysis, sensitivity analysis, and meta-regression. Quality of the original studies that were included in the meta-analysis was evaluated using the Newcastle-Ottawa Scale. A funnel plot and Egger's test were used to determine whether significant publication bias was present.

RESULTS

Overall, 19 articles were included, reporting on a total of 41,149 subjects. Eleven were prospective cohort studies, and all articles were considered "good" quality. The most used screening instruments were the short Test of Functional Health Literacy (S-TOFHLA) in Adults and the Brief Health Literacy Screen (BHLS). Among 39,423 subjects (two articles did not report the number of patients with low HL), approximately 9202 (23%) had inadequate or marginal HL. The correlation coefficient between HL and mortality was 1.25 (95%CI = 0.25-0.44).

CONCLUSION

Lower HL was associated with an increased risk of death. This finding should be considered carefully and confirmed by further research.

Association between health literacy, general psychological factors, and adherence to medical treatment among Danes aged 50-80 years

BACKGROUND

Understanding behavioral factors associated with low health literacy (HL) is relevant for health care providers to better support their patients' health and adherence to preventive treatment. In this study, we aim to study associations between low HL and socio-demographic characteristics, medication-related perceptions and experience, as well as general psychological factors among patients aged 50-80 years.

METHODS

We used a cross-sectional survey design based on a representative group of 6,871 Danish citizens aged 50-80 years returning a web-based questionnaire with socio-demographic data added from a national registry. Chi-square tests were conducted to analyze associations between low HL and daily use of medication and self-rated health. Chi-square tests and binary logistic regression were conducted for analyzing data from respondents using prescribed medicines daily (N = 4,091).

RESULTS

Respondents with low HL were more often on daily medications (19 % [777/4,091] vs. 16 % [436/2,775]; P < 0.001) and were more likely to have poorer self-rated health (P < 0.001). Among patients on daily medications, low HL was significantly higher among men and those with lower educational attainment and lower family income. Low HL was independently and positively associated with perceptions that taking prescribed medicines daily is difficult and time-consuming, with forgetting to take prescribed medicines, and with lower satisfaction with life and poor self-assessed health.

CONCLUSIONS

Our study provides information that patients aged 50-80 years with low HL are challenged on their adherence to treatment plans which is not only related to traditional sociodemographic factors but also on perceptions related to taking medication per se.

Health literacy and health-promoting behaviors among adults at risk for diabetes in a remote Filipino community

Background

Diabetes risk assessment is an essential preboarding tool before implementing health literacy programs to change an adult's health behavior positively. Research has shown an association between health literacy and health behaviors, but there is a dearth of literature that delineates the difference between the health literacy and health behaviors of adults according to their diabetes risks; high risk vs. low risk.

Objective

This study aimed to determine the difference between the health literacy and health behaviors of adults and establish the relationship between the two variables when classified according to their diabetes risks.

Methods

This study utilized a descriptive cross-sectional design with 400 adults in a remote Filipino community in November 2019. Data were gathered using the Health Promoting Lifestyle Profile II (HPLP II) and Health Literacy Survey-Short Form 12 (HLS-SF12) questionnaires. Descriptive statistics, independent t-test, and Pearson's r were used to analyze the data.

Results

There is a significant difference between the health literacy index scores (p < .05); but no significant difference between the health behavior mean scores (p > .05) of adults when grouped according to their diabetes risks. Health literacy is significantly (p < .05) correlated with health behaviors of adults, with a moderate positive correlation in the high-risk group (r = .43), and both weak positive correlation in the low-risk group (r = .13) and entire group (r = .17).

Conclusion

All adult inclusion efforts in promoting health literacy, with emphasis on the high-risk group, are needed to improve awareness of the degree of diabetes risks. Nurses should take an active role in the assessment of diabetes risks, evaluation of results, and implementation of interventions that could increase health literacy to facilitate the development of healthy behaviors. Stakeholders are urged to advance the availability of evidence-based lifestyle interventions to reduce the growth in new cases of diabetes.

Cultural Adaptation of Health Literacy Measures: Translation Validation of the Newest Vital Sign in Arabic-Speaking Parents of Children With Type 1 Diabetes in Kuwait

PURPOSE

The purpose of the study was to assess the feasibility of use and reliability of the Arabic version of the Newest Vital Sign (NVS-Ar) in parents of children with type 1 diabetes (T1D).

METHODS

The final translated version of NVS-Ar was administered to 175 adult caregivers of children with T1D who are native Arabic speakers. The association between NVS-Ar scores for the parents/legal guardians and A1C for their children was assessed. The internal consistency was evaluated by Cronbach's α, and reliability was assessed by test-retest method.

RESULTS

The median (interquartile range) score was 4.0 (3-5). The internal consistency of the NVS-Ar was moderate (α = .58). The intraclass correlation coefficient was .61. There was no correlation between NVS-Ar score and A1C (Spearman's ρ = .055; P = .62). Furthermore, there was significant inverse association between adequate health literacy and optimal glycemic control among the children, which remained evident even after adjusting for the duration of T1D, age, or education of the parents/guardians. However, it lost statistical significance after adjustment for treatment regimen.

CONCLUSION

Study findings indicate that the NVS is unlikely to be a predictive tool for functional health literacy in Arabic settings and that there is a need to properly translate and validate other tools such as the Test of Functional Health Literacy in Adults or, alternatively, to develop a reliable tool.

Estimating the Economic Burden of Low Health Literacy in the Blacktown Community in Sydney, Australia: A Population-Based Study

Evidence shows that inadequate or low health literacy (LHL) levels are significantly associated with economic ramifications at the individual, employer, and health care system levels. Therefore, this study aims to estimate the economic burden of LHL among a culturally and linguistically diverse (CALD) community in Blacktown: a local government area (LGA) in Sydney, Australia. This study is a secondary analysis of cross-sectional data from publicly available datasets, including 2011 and 2016 census data and National Health Survey (NHS) data (2017–2018) from the Australian Bureau of Statistics (ABS), and figures on Disease Expenditure in Australia for 2015–2016 provided by the Australian Institute of Health and Welfare (AIHW). This study found that 20% of Blacktown residents reported low levels of active engagement with health care providers (Domain 6 of the Health Literacy Questionnaire (HLQ)), with 14% reporting a limited understanding of the health information required to take action towards improving health or making health care decisions (Domain 9 of the HLQ). The overall extra/delta cost (direct and indirect health care costs) associated with LHL in the Blacktown LGA was estimated to be between $11,785,528 and $15,432,239 in 2020. This is projected to increase to between $18,922,844 and $24,191,911 in 2030. Additionally, the extra disability-adjusted life year (DALY) value in 2020, for all chronic diseases and age-groups—comprising the extra costs incurred due to years of life lost (YLL) and years lived with disability (YLD)—was estimated at $414,231,335. The findings of our study may enable policymakers to have a deeper understanding of the economic burden of LHL in terms of its impact on the health care system and the production economy.

Building a House of Skills-A Study of Functional Health Literacy and Numeracy among Patients with Type 2 Diabetes in Hungary

The purpose of this study is to explore functional health literacy (FHL) and numeracy skills in an insulin-treated, type 2 diabetes mellitus (T2DM) patient population, and their impact on diabetes self-care activities. A non-experimental, cross-sectional quantitative design was used for this study. The sample consisted of 102 T2DM patients on insulin therapy, including 42 males and 60 females, with a mean age of 64.75 years (SD = 9.180) and an average diabetes duration of 10.76 years (SD = 6.702). Independent variables were sociodemographic variables (e.g., age, educational level, etc.) and diabetes and health-related factors (e.g., duration of diabetes (years), the frequency of blood glucose testing/day, etc.). For this study, the participants completed the reading comprehension exercise from the Short Test of Functional Health Literacy (S-TOFHLA) and the Shortened Version of the Diabetes Numeracy Test (DNT-15), which specifically evaluates the numeracy skills of patients living with diabetes. The associations between the variables were examined with Spearman’s rank correlation. Multivariate regression analysis was performed to examine whether measured FHL skills impact diabetes self-care activities. We found that DNT-15 test (β = 0.174, t(96) = 2.412, p < 0.018) had significant effect on the frequency of blood glucose testing/day. Moreover, the problem areas for patients with T2DM mostly included multi-step calculations according to food label interpretations, and adequate insulin dosage based on current blood glucose levels and carbohydrate intake. The results of regression analyses and Spearman’s rank correlation indicated that limited FHL and diabetes numeracy skills not only influenced the participants’ behaviors related to self-management, but they also affected their health outcomes. Thus, besides the personalization of insulin treatment, it is indispensable to provide more precise information on different types of insulin administration and more refined educational materials based on medical nutrition therapy.

Prevalence of limited health literacy and its associated factors in patients with type 2 diabetes mellitus in Perak, Malaysia: a cross-sectional study

OBJECTIVE

Limited health literacy in patients with type 2 diabetes mellitus (T2DM) led to poorer diabetes knowledge, less medication adherence and increased healthcare cost. The purpose of this paper was to report the prevalence of limited health literacy in patients with T2DM and to identify factors that are associated with it.

DESIGN

A cross-sectional study was conducted from January to March 2018; data on patients' sociodemographic characteristics, diabetes knowledge, perceived social support and health literacy level were collected. Health literacy level was measured using the European Health Literacy Survey Questionnaire (HLS-EU-Q47).

SETTING

Patients were recruited from four primary care clinics in Perak, Malaysia.

PARTICIPANTS

Adult patients diagnosed with T2DM who attended the study clinics during the study period.

PRIMARY OUTCOME VARIABLE

Patients with HLS-EU-Q47 General Index of ≤33 points were classified as having limited health literacy.

RESULTS

The prevalence of limited health literacy was 65.3% (n=279). In bivariate analysis, patients' ethnicity (p=0.04), highest education level (p<0.001), monthly income (p=0.003), having health insurance (p=0.007), English language fluency (p<0.001), Malay language fluency (p=0.021), attending diabetes education sessions (p<0.001), perceived social support (p<0.001) and diabetes knowledge (p=0.019) were factors associated with limited health literacy. In logistic regression, not being fluent in English was associated with limited health literacy (OR=2.36, 95% CI 1.30 to 4.30) whereas having high perceived social support (OR=0.52, 95% CI 0.40 to 0.69) and having attended diabetes education sessions (OR=0.42, 95% CI 0.27 to 0.68) were associated with adequate health literacy.

CONCLUSION

The prevalence of limited health literacy is high among patients with T2DM in Perak, Malaysia. Strategies to improve health literacy in these patients must consider the influences of English fluency, attendance at diabetes education sessions and social support, and may need to adopt a universal approach to addressing limited health literacy.

Vulnerability of poorly literate adult consumers regarding over-the-counter drugs

Purpose

This study aims at verifying the impact of literacy on over-the-counter (OTC) drug consumer vulnerability as evaluated by health literacy and label comprehension.

Design/methodology/approach

The item response theory (IRT) was used to estimate the health literacy of two groups and the two-way analysis of variance tests was used to test the hypotheses for the existence of mean differences between the two populations. The convenience sample involved 188 OTC consumers: 94 (50%) poorly literate and 94 (50%) university students/graduates.

Findings

University consumers/graduates have a level of health literacy and label comprehension that is superior to those presented by poor literate consumers. Also, age does not influence the level of health literacy by OTC drug users but has a significant impact on the understanding of OTC drug labels. Finally, the level of schooling and the “age group,” simultaneously, does not impact the understanding of OTC drug labels or health literacy.

Research limitations/implications

This study has added in the field of knowledge by investigating the behavior of poor literate consumers in Brazil, a developing country. The results may be relevant to Marketing professionals, especially those in the pharmaceutical industry, and to police makers, as they help identify the main problems faced by poorly literate consumers.

Practical implications

It is necessary to raise awareness of the dangers of self-medication and wrong use of medications, mainly focused on people with low literacy. As a suggestion, a simple glossary presented along with the label could provide explanations of scientific terms, thus increasing health literacy and reducing the vulnerability of the consumers.

Social implications

This study showed that when using common words such as gastritis to define a health problem, there is a higher degree of correctness. These results suggest the adoption of a more straightforward language and more precise explanations. By doing that, the pharmaceutical industry and policymakers will improve their social impact by increasing consumer power and taking care of the health of the most vulnerable population: the illiterate people.

Originality/value

This study contributes to the international literature, as it enhances and clarifies the knowledge about the customers’ power and vulnerability in developing countries. It fills a gap by evaluating label comprehension and heath literacy at the same time, giving an academic contribution for pharmaceutical consumers’ studies.

Association of Health Literacy and Nutritional Status Assessment with Glycemic Control in Adults with Type 2 Diabetes Mellitus

While the role of medical and nutrition factors on glycemic control among adults with type 2 diabetes mellitus (T2DM) has been well-established, the association between health literacy (H.L.) and glycemic control is inconsistent. This study aims to determine the association of H.L. and nutritional status assessments with glycemic control in adults with type 2 diabetes mellitus. A total of 280 T2DM respondents (mean (SD) age = 49.7 (10.3) years, Glycated hemoglobin (HbA1c) = 9.9 (2.6) %, and Body Mass Index = 32.7 (15.1) kg/m²) were included in this study. A short-form Test of Functional Health Literacy in Adults (S-TOFHLA) assessed the H.L. levels. Nutritional status assessments included client history, glycemic control, anthropometric, and biochemical data. The mean (S.D.) H.L. score was 45.7 (24.6), with 56% of the respondents had inadequate H.L. Inadequate H.L. was more common among those females; housewives, low education, received oral antidiabetic therapy, and shorter diabetes duration. Respondents with inadequate H.L. were significantly older and had higher HbA1c than those with marginal and adequate H.L. Meanwhile, respondents with inadequate and marginal H.L. levels had significantly higher total cholesterol, LDL-cholesterol, and systolic blood pressure than the respondents with adequate H.L. Low H.L. scores, self-employment status, received dual antidiabetic therapy (insulin with oral agents), received insulin alone, and had higher fasting blood glucose explained about 21% of the total variation in HbA1c (adjusted R² = 0.21; p < 0.001). Respondents with inadequate H.L. had poor glycemic control. The H.L. scores, together with nutritional status assessments, were the factors that predicted poor glycemic control among adults with T2DM.

Health Literacy and Blood Glucose Level in Transitional Albania

Aim: Our aim was to assess the independent association between blood glucose level and health literacy (HL) adjusting for many socio-demographic characteristics and body mass index (BMI) in an adult population in Albania, a transitional country in the South Eastern Europe.

Methods: A cross-sectional study was carried out in Tirana in 2012–2014 including a population-based sample of 1,154 individuals aged ≥18 years (57% women; mean age: 45.5 ± 16.4 years; response rate: 88.6%). HL was assessed by use of HLS-EU-Q instrument. Blood glucose level was measured in a fasting state by use of rapid finger stick method. Information on socio-demographic characteristics was collected, and BMI was calculated based on measurement of height and weight in all participants. General Linear Model (GLM) and binary logistic regression were used to assess the independent association of blood glucose level and HL adjusting for all socio-demographic factors and BMI.

Results: One-third of participants had pre-diabetes (100–125.9 mg/dl) and further 11% had diabetes (≥126 mg/dl) based on the measured blood glucose level. In fully-adjusted GLM, mean blood glucose level was significantly lower among individuals with excellent HL compared with their counterparts with inadequate HL (99.3 vs. 106.0, respectively). Furthermore, the odds for the presence of diabetes in the group of study participants whose HL was “inadequate” were 2.6 times higher (95% CI = 1.3–5.4) compared to those whose HL was “excellent.”

Conclusion: We obtained evidence of a strong and significant inverse relationship between measured blood glucose level and HL, independent of many socio-demographic characteristics and measured BMI in a population-based study in a country of the Western Balkans.