Is Health Literacy of Dialyzed Patients Related to Their Adherence to Dietary and Fluid Intake Recommendations?

Role of health literacy profiles in fluid management of individuals receiving haemodialysis: A cross-sectional study

AIMS

To identify health literacy profiles in individuals receiving haemodialysis and to explore how these profiles interact with individuals' self-efficacy, engagement with traditional dietary habits, self-reported fluid restriction and relative-interdialytic weight gain.

DESIGN

A cross-sectional study engaging nephrology departments from four hospitals in Guangdong Province, China.

METHODS

A sample of 433 individuals receiving haemodialysis participated between December 2018 and July 2019. We assessed health literacy, self-efficacy and self-reported fluid restriction using the Health Literacy Questionnaire, the Fluid Self-efficacy Scale and the Fluid Adherence Subscale, respectively. Traditional dietary habits, including daily tea drinking, soup drinking and preserved food consumption, were measured using three yes/no questions. Relative-interdialytic weight gain was calculated by dividing the mean interdialytic weight gain (from three recent intervals) by dry weight. Latent profile analysis and structural equation modelling were performed.

RESULTS

Three health literacy profiles were identified: low, moderate and high. Compared to those in the low health literacy profile, individuals in high and moderate health literacy profiles demonstrated an indirect association with reduced relative-interdialytic weight gain. This reduction can be attributed to their higher self-efficacy levels, decreased reliance on dietary habits and higher self-reported fluid restrictions.

CONCLUSIONS

Most participants exhibited either low or moderate levels of health literacy. Improving health literacy has the potential to promote self-efficacy and foster effective fluid restriction, ultimately leading to a reduction in relative-interdialytic weight gain in individuals receiving haemodialysis.

IMPACT

This study reveals heterogeneity in health literacy levels among individuals receiving haemodialysis and illuminates the connections between an individual's entire spectrum of health literacy and fluid management. These findings provide valuable insights for developing person-centred fluid management interventions, especially for individuals with diverse cultural dietary backgrounds within the haemodialysis population.

REPORTING METHOD

We adhered to the STROBE guideline.

PATIENT OR PUBLIC CONTRIBUTION

Patients were included only for collecting their data.

Examining the Relationship between Dietary Intake, Socioeconomic Status, and Systolic Blood Pressure of Adults on Hemodialysis in Quito, Ecuador

Background

In Ecuador, the number of adults on hemodialysis (HD) continues to rise. Currently, the effect dietary habits and socioeconomic status (SES) have on blood pressure is not known for those on HD.

Objectives

The objectives of this study focused on adults on HD in Quito, Ecuador to 1) assess the relationship between dietary intake and SES; 2) compare dietary intake to the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines; and 3) explore the relationship between dietary intake and systolic blood pressure.

Methods

This cross-sectional study was conducted at the dialysis center within Eugenio Espejo Specialties Hospital in Quito, Ecuador between May and June 2022 among 50 adults on HD. Three 24-h recalls were used to determine average dietary intake and the 25-item Instituto Nacional de Estadística y Censos-Stratification of SES was used to determine SES. Electrolytes and 2 blood pressure readings were collected. Qualitative narrative data analysis was performed to identify themes using NVivo v12. T-tests of independence, simple, and multiple linear regressions using age and sex as confounders were conducted using R and a P < 0.05 was deemed as statistically significant.

Results

On an average, 76% of participants consumed <25 kcal/kg body weight energy and 64% consumed <1 g protein/kg body weight. Participants consumed less energy and protein compared with the KDOQI guidelines (P < 0.05). Positive relationships were observed with potassium and blood pressure (β = 0.020, P < 0.05) and SES with energy, protein, and phosphorus (P < 0.05). Themes that were identified as contributing to dietary intake were limited knowledge, lack of consistency with dietary information, and limited appetite.

Conclusions

Findings from this study indicate that the focus should be on improving energy and protein intake for this population.

Exploring the relationships between health literacy, social support, self-efficacy and self-management in adults with multiple chronic diseases

BACKGROUND

Self-management in chronic diseases is essential to slowing disease progression and preventing complications. However, empirical research on the associations of critical factors, such as health literacy, social support, and self-efficacy with self-management in the context of multiple chronic diseases is scarce. This study aimed to investigate these associations and provides insights for healthcare providers to develop effective educational strategies for people with multiple chronic diseases.

METHODS

Using a cross-sectional survey design, adults (n = 600) diagnosed with at least two chronic diseases were conveniently recruited. To measure health literacy, social support, self-efficacy, and chronic disease self-management behaviours, the Health Literacy Questionnaire (HLQ), Medical Outcome Study - Social Support Survey, Self-efficacy in Managing Chronic Disease, and Self-management in Chronic Diseases instruments were utilized respectively. Comorbidity status was assessed using Age-adjusted Charlson Comorbidity Index (ACCI). A generalised linear regression model was used with a backward technique to identify variables associated with self-management.

RESULTS

Participants' mean age was 61 years (SD = 15.3), 46% were female, and most had up to 12 years of education (82.3%). Mean scores for HLQ domains 1-5 varied from 2.61 to 3.24 (possible score 1-4); domains 6-9 from 3.29 to 3.65 (possible score 1-5). The mean scores were 52.7 (SD = 10.4, possible score 0-95), 5.46 (SD = 1.9, possible score 0-10) and 82.1 (SD = 12.4, possible score 30-120) for social support, self-efficacy, and self-management, respectively. Mean ACCI was 6.7 (SD = 2.1). Eight factors (age > 65 years, being female, 4 health literacy domains, greater social support, and higher self-efficacy levels) were significantly associated with greater self-management behaviours while comorbidity status was not. The factors that showed the strongest associations with self-management were critical health literacy domains: appraisal of health information, social support for health, and healthcare provider support.

CONCLUSIONS

Developing critical health literacy abilities is a more effective way to enhance self-management behaviours than relying solely on self-confidence or social support, especially for people with multiple chronic diseases. By facilitating communication and patient education, healthcare providers can help patients improve their critical health literacy, which in turn can enhance their self-management behaviours.

Exploring the influencing factors of unmet palliative care needs in Chinese patients with end-stage renal disease undergoing maintenance hemodialysis: a cross-sectional study

BACKGROUND

The role of palliative care for end-stage renal disease (ESRD) patients have been proven in some developed countries, but it is still unclear in the mainland of China. In fact, patients with ESRD experience many unmet palliative care needs, such as physical, psychological, social and spiritual needs, but the factors influencing these needs have not investigated.

METHODS

A cross-sectional study was conducted at two hemodialysis centers in the mainland of China from January to September 2022. Convenience sampling was used to collect data on the participants' socio-demographics, clinical characteristics, the Palliative Care Outcome Scale (POS), the Dialysis Symptom Index (DSI), the Karnofsky Performance Status Scale (KPS), the Patient Health Questionnaire-9 item (PHQ-9), and the Social Support Rate Scale (SSRS). Data were analyzed using latent profile analysis, Kruskal-Wallis test, one-way analysis of variance (ANOVA), the chi-square test and multinomial logistic regression analysis.

RESULTS

Three hundred five participants were included in this study, and divided palliative care needs into three categories: Class 1, mild palliative care needs (n = 154, 50.5%); Class 2, moderate palliative care needs (n = 89, 29.2%); Class 3, severe palliative care needs (n = 62, 20.3%). Based on the analysis of three profiles, the influencing factors of unmet needs were further analyzed. Compared with Class 3, senior high school education, the household per capita monthly income < 2,000, low KPS scores, high PHQ-9 scores, and low SSRS scores were less likely to be in Class 1 (OR = 0.03, P = 0.012; OR = 0.003, P < 0.001; OR = 1.15, P < 0.001; OR = 0.55, P < 0.001; OR = 1.35, P = 0.002; respectively) and Class 2 (OR = 0.03, P = 0.007; OR = 0.05, P = 0.011; OR = 1.10, P = 0.001; OR = 0.60, P = 0.001; OR = 1.32, P = 0.003; respectively), and high symptom severity were less likely to be in Class 1 (OR = 0.82, P = 0.001). Moreover, compared with Class 1, the household per capita monthly income < 2,000 (OR = 16.41, P < 0.001), high symptom severity scores (OR = 1.12, P = 0.002) and low KPS scores (OR = 0.95, P = 0.002) were more likely to be in Class 2.

CONCLUSIONS

This study showed that almost half of ESRD patients receiving MHD presented moderate to severe palliative care needs, and the unmet needs were mainly affected by education level, financial pressure, functional status, symptom burden and social support. In the future, it is important to identify the populations with the greatest need for palliative care and consider the influencing factors of unmet needs from a comprehensive perspective, so as to help them improve health-related quality of life.

Associations of health literacy with self-management behaviours and health outcomes in chronic kidney disease: a systematic review

INTRODUCTION

Low health literacy is widely reported in people with chronic kidney disease (CKD) and has been associated with reduced disease self-management, poor health outcomes, increased mortality and poorer quality of life. However, these associations are still not well understood.

METHODS

Electronic-based systematic searches were performed to identify studies examining associations between health literacy and self-management behaviours and/or health outcomes in patients with CKD. A tabular and narrative synthesis of the data was performed. Meta-analysis was not appropriate due to the heterogeneity of study designs and methods.

RESULTS

Searches identified 48 studies that met the inclusion criteria. A total of 41 published articles, six conference abstracts, and one thesis were included. Of the 48 studies, 11 were cohort and 37 were cross-sectional. In total there were 25,671 patients; 16,952 from cohort studies. Median study sample size was 159 (IQR 92-275). Study quality was high (5), moderate (24) and poor (19). Thirteen measures of health literacy were used. Despite the limitations of the available evidence, there appear to be consistent relationships between higher health literacy and favourable self-management behaviours for patients with CKD. Definitive relationships between health literacy and patient outcomes are far less clear and remain incompletely understood.

DISCUSSION

Conclusive evidence describing a causal link between health literacy and patient outcomes remains limited, but for many outcomes, a consistent association is described. In addition to associations with mortality, hospitalisation and clinical events, there were consistent associations between health literacy and favourable self-management behaviours which could support the development of patient education aimed at improving health literacy.

Evaluation of the relationship between health literacy and self-efficacy: A sample of hemodialysis patients

PURPOSE

The aim of this study was to evaluate self-efficacy and health literacy of patients undergoing hemodialysis, to investigate the relationship between health literacy and self-efficacy, and to determine the factors affecting self-efficacy.

METHODS

The study was conducted in Eskisehir and Gumushane state hospitals affiliated to the Public Hospitals Association with the participation of 198 patients receiving hemodialysis treatment for chronic renal failure. The inclusion criteria were as follows: being ⩾18 years old, receiving hemodialysis, and agreeing to participate in the study. The study data were collected using face-to-face interview technique, and they were analyzed using descriptive statistics, correlation, and regression analysis.

RESULTS

The mean age of the patients was 59.73 ± 16.32 years. Of the patients, 46% were primary school graduates, and 63.6% reported having other chronic diseases. The mean health literacy and self-efficacy scores were found to be 79.43 ± 26.09 and 23.98 ± 7.42, respectively. The results showed that the self-efficacy scores of the patients increased as the general health literacy scores increased, with a strong linear correlation between these variables (r = 0.712; p ˂ 0.001). Patients with advanced age, low educational level, and widowed patients had lower self-efficacy and health literacy scores than others (respectively eta² = 0.263, 0.116, 0.268, 0.141).

CONCLUSION

High score of health literacy positively affects the self-efficacy score of hemodialysis patients.

Letramento funcional em saúde de usuários da atenção primária de Altamira, Pará

Introdução: O Letramento Funcional em Saúde (LFS) está associado à capacidade dos pacientes em compreender e utilizar seus conhecimentos em saúde no âmbito do autocuidado e na promoção a saúde. Por isso, torna-se essencial reconhecer o nível de LFS e identificar os fatores que o influenciam. Objetivo: Analisar o nível de letramento funcional em saúde (LFS) de usuários de Unidades de Saúde da Família (USF) na área urbana de Altamira (PA). Métodos: Estudo transversal no qual a coleta de dados ocorreu entre agosto de 2018 e dezembro de 2019 em 12 USF da área urbana. O cálculo amostral foi realizado com base na população urbana de Altamira registrada pelo Censo de 2010. Utilizou-se intervalo de confiança de 95% com margem de erro de 5% e prevalência de achados de 50% em uma população semelhante, encontrando-se assim o valor de 382. Os participantes foram entrevistados a fim de se coletarem informações sobre dados sociodemográficos, e posteriormente foi aplicado um questionário baseado na versão brasileira do Short Test of Functional Health Literacy (S-TOFHLA), instrumento utilizado para a mensuração do LFS. O coeficiente de correlação de Pearson, o teste qui-quadrado, o teste G e a odds ratio foram utilizados para verificar a relação entre a pontuação do S-TOFHLA e os dados sociodemográficos. Além disso, uma análise de regressão múltipla foi realizada para predizer os fatores que interferem no LFS. Por fim, o teste ANOVA buscou diferenças entre os níveis de LFS dos usuários nas USF analisadas. Resultados: Foram incluídos no estudo 400 participantes, dos quais 59% apresentaram LFS adequado, 16,5% limítrofe e 24,5% inadequado. As variáveis, grau de escolaridade, idade e renda foram associadas ao LFS na população estudada, predizendo, respectivamente, em 46, 26 e 17% o desempenho no teste S-TOFHLA. Baixa escolaridade e baixa renda aumentam o risco de indivíduos possuírem LFS insatisfatório em cinco e quatro vezes, nessa ordem. Por fim, foram encontradas diferenças entre os níveis de LFS dos usuários das USF analisadas. Conclusões: A população da área urbana de Altamira apresentou alta prevalência de LFS insatisfatório. Sendo assim, no intuito de aumentar os resultados satisfatórios em saúde, os profissionais da região devem adequar as suas formas de comunicação e linguagem às necessidades dos usuários das USF, observando que a adequação da equipe pode trazer melhorias para o entendimento das informações e oportunizar melhores condições de recuperação e autocuidado em saúde.

The worldwide prevalence of non-adherence to diet and fluid restrictions among hemodialysis patients: A systematic review and meta-analysis

BACKGROUND

Non-adherence to diet and fluid restrictions in hemodialysis (HD) patients can lead to undesired health outcomes. This systematic review and meta-analysis aim to estimate the pooled prevalence of non-adherence to diet and fluid restrictions in HD patients.

METHODS

Research papers from PubMed, CINAHL, and Google Scholar on non-adherence to diet and fluid restrictions in HD patients published between 2000 and 2020 were selected for this study. The methodological quality of each study was graded, and the estimates were pooled using the random-effects model of meta-analysis. Analyses of subgroups and meta-regression were carried out. Egger's test and visual analysis of the symmetry of funnel plots were used to assess the publication bias.

RESULTS

Eight hundred sixty-eight potential records were identified during the search. Twenty-three studies that met inclusion criteria were considered for meta-analysis and comprised 11,209 HD patients (mean age 55.85 years± SD 6.86, males 57.74%). The estimated worldwide prevalence of non-adherence to diet and fluid restrictions was 60.2% (95% CI: 47.3- 72.5) and 60.6% (95% CI: 50- 70.7), respectively. The meta-regression found that the income category was negatively, and the risk of bias score was positively associated with the prevalence of non-adherence to fluid restrictions (p<0.05). The funnel plot of studies included pooling the prevalence of non-adherence to fluid restrictions revealed asymmetry, and a significant publication bias was also noted as assessed by Egger's test (P = 0.004). However, the pooled estimate should be interpreted with caution because the prevalence of individual studies varies considerably due to methodological or measurement discrepancies.

CONCLUSION

The pooled prevalence of non-adherence to diet (47.3 - 72.5%) and fluid (50 - 70.7%) restrictions were substantially high. The health care team must recognize the factors and barriers influencing adherence behavior and develop holistic interventions to improve it.

Adherence to Therapy, Physical and Mental Quality of Life in Patients with Multiple Sclerosis

Ensuring multiple sclerosis (MS) patients' adherence to therapy is often challenging, but it is crucial to their survival and health-related quality of life (HRQoL). The aim of the present study was to outline connections between adherence, physical and mental HRQoL, levels of psychological readiness to engage in a treatment, levels of social support, anthropometric, socio-demographic and clinical factors in patients suffering from MS. This cross-sectional study involved a sample of 237 Italian MS patients. A survey was conducted with a structured self-administered online questionnaire using validated measures of quality of life, adherence to therapy and anthropometric, socio-demographic, psychological and clinical variables. A path analysis was used to test the overall structure of the associations between the variables. The pathway indicates a positive association between mental health index and a stronger degree of engagement and being or having been in a long-term relationship. Physical health index was positively associated with age, having an occupation, and having a specific form of MS. Having had relapses in the previous year raised the odds of better adherence to therapy, while an increase in Body Mass Index (BMI) reduced them. Our findings could help in the management of MS patients, promoting behavioral interventions that take the psychological and socio-demographic peculiarities of each patient into account with a view to improving their adherence to therapy.

A scoping review of the role of health literacy in chronic kidney disease self-management

BACKGROUND

Chronic kidney disease is a serious health condition and is increasing globally. Effective self-management could slow disease progression and improve health outcomes, although the contribution of health literacy and knowledge for self-management is not well known.

AIM

To investigate the recent evidence of health literacy and the relationship between health literacy, knowledge and self-management of chronic kidney disease.

METHODS

Arksey and O'Malley's framework informed this scoping review. Eligible studies involving adults with any grade of chronic kidney disease, measuring all dimensions of health literacy (i.e., functional, communicative, and critical), disease-specific knowledge and self-management, published in English between January 2005 and March 2020, were included.

RESULTS

The scoping review found 12 eligible studies, with 11 assessing all dimensions of health literacy. No study examined health literacy, knowledge and self-management. When individuals had greater health literacy, this was associated with greater knowledge about the disease. Communicative health literacy was a significant predictor of medication, diet and fluid adherence, and overall self-management behaviours.

CONCLUSION

This scoping review shows that disease-specific knowledge is important for health literacy and that health literacy is essential for effective self-management of chronic kidney disease. The implications of these relationships can inform strategies for the development of evidence-based patient education to support increased self-management. There is also a need for further research to explore these associations.

Health Literacy, eHealth Literacy, Adherence to Infection Prevention and Control Procedures, Lifestyle Changes, and Suspected COVID-19 Symptoms Among Health Care Workers During Lockdown: Online Survey

Background

The COVID-19 pandemic has imposed a heavy burden on health care systems and governments. Health literacy (HL) and eHealth literacy (as measured by the eHealth Literacy Scale [eHEALS]) are recognized as strategic public health elements but they have been underestimated during the pandemic. HL, eHEALS score, practices, lifestyles, and the health status of health care workers (HCWs) play crucial roles in containing the COVID-19 pandemic.

Objective

The aim of this study is to evaluate the psychometric properties of the eHEALS and examine associations of HL and eHEALS scores with adherence to infection prevention and control (IPC) procedures, lifestyle changes, and suspected COVID-19 symptoms among HCWs during lockdown.

Methods

We conducted an online survey of 5209 HCWs from 15 hospitals and health centers across Vietnam from April 6 to April 19, 2020. Participants answered questions related to sociodemographics, HL, eHEALS, adherence to IPC procedures, behavior changes in eating, smoking, drinking, and physical activity, and suspected COVID-19 symptoms. Principal component analysis, correlation analysis, and bivariate and multivariate linear and logistic regression models were used to validate the eHEALS and examine associations.

Results

The eHEALS had a satisfactory construct validity with 8 items highly loaded on one component, with factor loadings ranked from 0.78 to 0.92 explaining 76.34% of variance; satisfactory criterion validity as correlated with HL (ρ=0.42); satisfactory convergent validity with high item-scale correlations (ρ=0.80-0.84); and high internal consistency (Cronbach α=.95). HL and eHEALS scores were significantly higher in men (unstandardized coefficient [B]=1.01, 95% CI 0.57-1.45, P<.001; B=0.72, 95% CI 0.43-1.00, P<.001), those with a better ability to pay for medication (B=1.65, 95% CI 1.25-2.05, P<.001; B=0.60, 95% CI 0.34-0.86, P<.001), doctors (B=1.29, 95% CI 0.73-1.84, P<.001; B 0.56, 95% CI 0.20-0.93, P=.003), and those with epidemic containment experience (B=1.96, 95% CI 1.56-2.37, P<.001; B=0.64, 95% CI 0.38-0.91, P<.001), as compared to their counterparts, respectively. HCWs with higher HL or eHEALS scores had better adherence to IPC procedures (B=0.13, 95% CI 0.10-0.15, P<.001; B=0.22, 95% CI 0.19-0.26, P<.001), had a higher likelihood of healthy eating (odds ratio [OR] 1.04, 95% CI 1.01-1.06, P=.001; OR 1.04, 95% CI 1.02-1.07, P=.002), were more physically active (OR 1.03, 95% CI 1.02-1.03, P<.001; OR 1.04, 95% CI 1.03-1.05, P<.001), and had a lower likelihood of suspected COVID-19 symptoms (OR 0.97, 95% CI 0.96-0.98, P<.001; OR 0.96, 95% CI 0.95-0.98, P<.001), respectively.

Conclusions

The eHEALS is a valid and reliable survey tool. Gender, ability to pay for medication, profession, and epidemic containment experience were independent predictors of HL and eHEALS scores. HCWs with higher HL or eHEALS scores had better adherence to IPC procedures, healthier lifestyles, and a lower likelihood of suspected COVID-19 symptoms. Efforts to improve HCWs’ HL and eHEALS scores can help to contain the COVID-19 pandemic and minimize its consequences.

Does Depression and Anxiety Mediate the Relation between Limited Health Literacy and Diet Non-Adherence?

Limited health literacy (HL), depression and anxiety are common in dialyzed patients and affect health outcomes and self-management. We explored whether depression and anxiety mediate the association of HL with diet non-adherence (DN-A) in dialyzed patients. We performed a cross-sectional study in 20 dialysis clinics in Slovakia (n = 452; mean age: 63.6 years; males: 60.7%). Hierarchical cluster analysis was performed to create three HL groups. Logistic regression adjusted for age, gender and education was used to explore whether depression and anxiety mediate the association of HL with DN-A. Patients in the moderate HL group were more likely to be non-adherent to diet (OR (Odds Ratio)/95% CI: 2.19/1.21-3.99) than patients in the high HL group. Patients in the low HL and moderate HL group more likely reported depression or anxiety. Patients reporting depression (OR/95% CI: 1.94/1.26-2.98) or anxiety (OR/95% CI: 1.81/1.22-2.69) were more likely to be non-adherent with diet. Adjustment for depression reduced the association between moderate HL and DN-A by 19.5%. Adjustment for anxiety reduced the association between moderate HL and DN-A by 11.8%. Anxiety and depression partly mediated the association of HL with DN-A. More attention should be paid to treating patients' psychological distress to ensure adequate adherence with recommended diet.

Understanding How Nutrition Literacy Links to Dietary Adherence in Patients Undergoing Maintenance Hemodialysis: A Theoretical Exploration Using Partial Least Squares Structural Equation Modeling

Dietary non-adherence is pervasive in the hemodialysis (HD) population. Health literacy is a plausible predictor of dietary adherence in HD patients, but its putative mechanism is scarcely studied. Thus, this study aimed to establish the causal model linking nutrition literacy to dietary adherence in the HD population. This was a multi-centre, cross-sectional study, involving 218 randomly selected multi-ethnic HD patients from nine dialysis centres in Klang Valley, Malaysia. Dietary adherence and self-management skills were assessed using validated End-Stage Renal Disease Adherence Questionnaire and Perceived Kidney/Dialysis Self-Management Scale, respectively. Validated self-developed scales were used to gauge nutrition literacy, dietary knowledge and Health Belief Model constructs. Relationships between variables were examined by multiple linear regressions and partial least squares structural equation modeling. Limited nutrition literacy was evident in 46.3% of the HD patients, associated with older age, lower education level, and shorter dialysis vintage. Dietary adherence rate was at 34.9%. Nutrition literacy (β = 0.390, p < 0.001) was an independent predictor of dietary adherence, mediated by self-efficacy (SIE = 0.186, BC 95% CI 0.110-0.280) and self-management skills (SIE = 0.192, BC 95% CI 0.103-0.304). Thus, nutrition literacy-enhancing strategies targeting self-efficacy and self-management skills should be considered to enhance dietary adherence in the HD population.