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.

[1]  Dušanka Krajnović,et al.  Cross-Cultural Adaptation and Validation of the Functional, Communicative and Critical Health Literacy Instrument (FCCHL-SR) for Diabetic Patients in Serbia , 2022, Healthcare.

[2]  N. Bogavac-Stanojević,et al.  The Instruments Used to Assess Health Literacy and Pharmacotherapy Literacy of Diabetes Mellitus Type 2 Patients: A Scoping Review , 2021, Frontiers in Public Health.

[3]  K. Chinna,et al.  Prevalence of limited health literacy and its associated factors in patients with type 2 diabetes mellitus in Perak, Malaysia: a cross-sectional study , 2020, BMJ Open.

[4]  G. Nordström,et al.  Explaining variance in health literacy among people with type 2 diabetes: the association between health literacy and health behaviour and empowerment , 2020, BMC public health.

[5]  K. Chinna,et al.  Prevalence of limited health literacy among patients with type 2 diabetes mellitus: A systematic review , 2019, PloS one.

[6]  A. Albatineh,et al.  Prevalence of health literacy and its correlates among patients with type II diabetes in Kuwait: A population based study. , 2018, Diabetes research and clinical practice.

[7]  N. Bogavac-Stanojević,et al.  Understanding of Information about Medicines Use among Parents of Pre-School Children in Serbia: Parental Pharmacotherapy Literacy Questionnaire (PTHL-SR) , 2018, International journal of environmental research and public health.

[8]  D. Schillinger,et al.  The impact of health literacy on diabetes self-management education , 2018 .

[9]  Linda M Harris,et al.  The U.S. National Action Plan to Improve Health Literacy: A Model for Positive Organizational Change. , 2017, Studies in Health Technology and Informatics.

[10]  Ruey-Hsia Wang,et al.  Pathways of empowerment perceptions, health literacy, self-efficacy, and self-care behaviors to glycemic control in patients with type 2 diabetes mellitus. , 2016, Patient education and counseling.

[11]  V. Marinković,et al.  THE COMPLEXITY OF ADHERENCE ISSUE: A REVIEW OF ITS SCOPE AND DETERMINANTS , 2016 .

[12]  S. Majumdar,et al.  Association of Inadequate Health Literacy with Health Outcomes in Patients with Type 2 Diabetes and Depression: Secondary Analysis of a Controlled Trial. , 2015, Canadian journal of diabetes.

[13]  G. Waverijn,et al.  Functional, communicative and critical health literacy of chronic disease patients and their importance for self-management. , 2015, Patient education and counseling.

[14]  Yi-Sun Yang,et al.  Patient perception of understanding health education and instructions has moderating effect on glycemic control , 2014, BMC Public Health.

[15]  D. Schillinger,et al.  Update on Health Literacy and Diabetes , 2014, The Diabetes educator.

[16]  P. Schulz,et al.  The relationship between functional health literacy and the use of the health system by diabetics in Switzerland , 2013, European journal of public health.

[17]  Gerardine Doyle,et al.  Measuring health literacy in populations: illuminating the design and development process of the European Health Literacy Survey Questionnaire (HLS-EU-Q) , 2013, BMC Public Health.

[18]  P. Spreeuwenberg,et al.  The Relationship Between Health, Education, and Health Literacy: Results From the Dutch Adult Literacy and Life Skills Survey , 2013, Journal of health communication.

[19]  Jeffrey A. Johnson,et al.  Measuring Health Literacy in Individuals With Diabetes , 2013, Health education & behavior : the official publication of the Society for Public Health Education.

[20]  Jolie N Haun,et al.  Measurement Variation Across Health Literacy Assessments: Implications for Assessment Selection in Research and Practice , 2012, Journal of health communication.

[21]  C. Drossaert,et al.  Validation of the Dutch functional, communicative and critical health literacy scales. , 2012, Patient education and counseling.

[22]  Gerardine Doyle,et al.  Health literacy and public health: A systematic review and integration of definitions and models , 2012, BMC Public Health.

[23]  Stacey L. Sheridan,et al.  Low Health Literacy and Health Outcomes: An Updated Systematic Review , 2011, Annals of Internal Medicine.

[24]  L. Egede,et al.  Associations between health literacy, diabetes knowledge, self-care behaviors, and glycemic control in a low income population with type 2 diabetes. , 2011, Diabetes technology & therapeutics.

[25]  Chandra Y. Osborn,et al.  Diabetes Numeracy , 2009, Diabetes Care.

[26]  J. D. Coyle,et al.  Screening Questions to Predict Limited Health Literacy: A Cross-Sectional Study of Patients With Diabetes Mellitus , 2009, The Annals of Family Medicine.

[27]  L. Fuchs,et al.  Association of Numeracy and Diabetes Control , 2008, Annals of Internal Medicine.

[28]  S. Pang,et al.  Health literacy, complication awareness, and diabetic control in patients with type 2 diabetes mellitus. , 2008, Journal of advanced nursing.

[29]  Natasa Maksimovic,et al.  The burden of disease and injury in Serbia. , 2007, European journal of public health.

[30]  Barry D. Weiss,et al.  Brief Report: screening items to identify patients with limited health literacy skills , 2006, Journal of General Internal Medicine.

[31]  Kathleen N. Lohr,et al.  A Systematic Review of the Literature , 2004 .

[32]  L. Osterberg,et al.  Adherence to medication. , 2005, The New England journal of medicine.

[33]  E. Ford Risks for all-cause mortality, cardiovascular disease, and diabetes associated with the metabolic syndrome: a summary of the evidence. , 2005, Diabetes care.

[34]  T. Valle,et al.  Prevalence of diabetes and impaired glucose regulation in 45‐ to 64‐year‐old individuals in three areas of Finland , 2005, Diabetic medicine : a journal of the British Diabetic Association.

[35]  Judy A Shea,et al.  Association of health literacy with self-management behavior in patients with diabetes. , 2004, Diabetes care.

[36]  J. Peters,et al.  Evaluating the performance of the Framingham risk equations in a population with diabetes , 2004, Diabetic medicine : a journal of the British Diabetic Association.

[37]  D. DeWalt,et al.  The Relationship Between Literacy and Glycemic Control in a Diabetes Disease-Management Program , 2004, The Diabetes educator.

[38]  Mark V. Williams,et al.  Health literacy and knowledge of chronic disease. , 2003, Patient education and counseling.

[39]  D. Schillinger,et al.  Association of health literacy with diabetes outcomes. , 2002, JAMA.