Acknowledgements We would like to present our special thanks to all participants of this study. This study was supported by the Institute of Endocrinology and Metabolism (IEM) in Iran University of Medical Sciences.Peer reviewedPublisher PD

Asgharifard, Homa

Bahramian, Mehran

Banihashemi, Arash Tehrani

Baradaran, Hamid Reza

Khamseh, Mohammad E.

Mohammadi, Zahra

Medical Journal of the Islamic Republic of Iran

English

PubMed

Background: Health literacy is the ability to obtain, read, understand and use healthcare information to make appropriate health decisions and follow instructions for treatment. The aim of this study was to identify the effect of various factors on health literacy in patients with diabetes. Methods: This was a cross-sectional observational study of 407 Iranian patients older than 15 years of age with type 1 and 2 diabetes identified from the Diabetes Clinic affiliated to the Institute of Endocrinology and Metabolism (IEM) of Iran University of Medical Sciences. We assessed patients' health literacy using the Persian version of Test of Functional Health Literacy in Adults (TOFHLA) questionnaire. Results: The mean age of the patients was 55.85 years, and 251 (61.7) of them were female. Females had lower educational level compared to males (p< 0.001). In total, 18.2, 11.8 and 70.0 of the participants had adequate, marginal and inadequate health literacy scores, respectively. Tukey's post hoc test revealed that employed patients enjoyed (am not sure about enjoy) a high health literacy level compared to housekeepers (p< 0.001). Conclusion: Health literacy score in Iranian patients with diabetes seems low. Therefrom effective interventions should be designed and implemented for this group of patients to improve diabetes outcomes

Mohammadi, Z.

Banihashemi, A.T.

Asgharifard, H.

Bahramian, M.

Baradaran, H.R.

Khamseh, M.E.

eprints Iran University of Medical Sciences

Original Articlehttp://mjiri.iums.ac.ir Medical Journal of the Islamic Republic of Iran (MJIRI)Iran University of Medical Sciences____________________________________________________________________________________________________________________1. MSc. Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran. mimina_13@yahoo.com2. (Corresponding author) MD, MPH, PhD candidate of Epidemiology, Department of Epidemiology, School of Public Health, Iran Universi-ty of Medical Sciences & Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran. tehranib@gmail.com3. MD, Gynecology and Obstetrics specialist, Dezful University of Medical Sciences, Khuzestan, Iran. asgharifard@razi.tums.ac.ir4. MD, Faculty of Medicine, Emergency Department, Alborz University of Medical Sciences, Karaj, Iran. dr_mehran_b@yahoo.com5. MD, PhD,  Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran.baradaran.hr@iums.ac.ir6. MD, Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran.mekhamseh@gmail.comHealth literacy and its influencing factors in Iranian diabeticpatientsZahra Mohammadi1, Arash Tehrani Banihashemi*2, Homa Asgharifard3Mehran Bahramian4, Hamid Reza Baradaran5, Mohammad E Khamseh6Received: 7 March 2015 Accepted: 24 June 2015 Published: 11 July 2015AbstractBackground: Health literacy is the ability to obtain, read, understand and use healthcare informationto make appropriate health decisions and follow instructions for treatment. The aim of this study wasto identify the effect of various factors on health literacy in patients with diabetes.Methods: 407 patients with diabetes older than 15 years of age were identified from the DiabetesClinic affiliated to the Institute of Endocrinology and Metabolism (IEM) of Iran University of Medi-cal Sciences. We assessed patients' health literacy using the Persian version of Test of FunctionalHealth Literacy in Adults (TOFHLA) questionnaire.Results: Mean age of the patients was 55.8 ± 11.3 years, and 61.7% the participants were female..Overall, 18.2% of the patients had adequate health literacy skills, 11.8% had marginal and 70.0%inadequate health literacy skills. Male participants performed better than females (p< 0.01) and olderpatients had lower health literacy score than younger patients (p< 0.001). Furthermore, patients withhigher educational and occupational levels had higher functional health literacy score than those withlower levels (p< 0.001).Conclusion: Health literacy score in Iranian patients with diabetes seems inadequate. Therefromeffective interventions should be designed and implemented for this group of patients to improvediabetes outcomes.Keywords: Health literacy, Diabetes, Influencing Factors.Cite this article as:Mohammadi Z, TehraniBanihashemi A, Asgharifard H, Bahramian M, Baradaran HR, Khamseh ME.Health literacyand its influencing factors in Iranian diabetic patients.Med JIslam RepubIran 2015 (11 July). Vol. 29:230.IntroductionHealth literacy is defined as “the degreeto which individuals have the capacity toobtain, process, and understand basic healthinformation needed to make appropriatehealth decisions (1). Health literacy con-sists of reading, writing, cultural and con-ceptual knowledge, the ability to applynumbers and decision making as needed tomanage health situation (2-3). Recent stud-ies found that health literacy is an im-portant predictor of health behaviors, out-comes and self-care activities (4-9). It isnoteworthy to add that there is a close rela-tionship between poor health outcomesacross chronic diseases and health literacy(10).In 2014, the global prevalence of diabeteswas estimated to be 9% among adults aged18 and older (11). Based on a recent surveyin Iran, the prevalence of diabetes has beenestimated to be 11.3 % (12). Since diabeticpatients need long-term care, health literacycan play an important role in the quality ofHealth literacy in Iranian diabetic patients2 Med J Islam Repub Iran 2015 (11 July). Vol. 29:230.http://mjiri.iums.ac.irthe provided care. Those diabetic patientswith a low literacy level had difficulty inunderstanding their conditions (13-14). Re-searchers have indicated that diabetic pa-tients with low numeracy have higher BMIand cannot control their blood sugarproperly. The most important factor is lowself confidence in numeracy to control dia-betes (15). Diabetic patients with inade-quate health literacy are not able to read theinformation on drug boxes. Therefore, sightproblems are increased among them (16).Illiterates pay significantly less attention tofoot-caring and weight-control compared tothe low-literates and literates (17).Since little is known about health literacyin patients with diabetes in Iran, this studywas conducted to identify the effect of var-ious factors on health literacy in this groupof patients in order to design better educa-tional interventions.MethodsSetting and Study ParticipantsThe study was conducted in the DiabetesClinic affiliated to Institute ofEndocrinology and Metabolism (IEM) ofIran University of Medical Sciences. Thestudy sample consisted of 407 consecutivediabetic patients who referred to thediabetes clinic. All patients were 15 yearsor older with type 1 or 2 diabetes. Weexcluded patients with vision or hearingproblems. Ethical approval was granted byIEM Ethics Committee.MeasuresTo measure health literacy, the Persianversion of TOFHLA (Test of FunctionalHealth Literacy in Adults) was used(18).The first part of the questionnaire dealtwith patients’ demographic information(age, gender, level of education,occupation, marital status). The other twoparts assessed their ability in readingcomprehension and numeracy skill.The TOFHLA takes approximately 30minutes to administer. The TOFHLA andS-TOFHLA are timed readingcomprehension tests that use the modifiedcloze procedure, in which every 5th to 7thword in a passage is omitted and replacedwith a blank space. The patient shouldselect a word to fit into the blank spacesfrom the 4 multiple-choice optionsprovided for each space. The TOFHLA isscored on a scale of 0 to 100.Patients arecategorized as having adequate, marginal,and inadequate health literacy by two pointscores of 59 and 74.The questionnaire measures readingcomprehension ability and consists of threepassages and 50 questions. All participantshad 20 minutes to fill out the blanks withappropriate answers. The first part of thereading passage was about instructions forpreparing  upper gastrointestinal tractradiograph series. The second and thirdparts of reading passages were aboutpatients’ rights and responsibilities ininsurance and hospital consent forms,respectively. The part of numeracy skillconsists of some description aboutmedication, the results of laboratory testsand appointment. After 10 minutes, theparticipants answered 17 questions basedon cue cards. All the individuals signed aninformed consent.Statistical AnalysesData were entered into SPSS (version17). Chi square, ANOVA, and student t-testwere used to compare mean values. Pvalues less than 0.05 were considered asstatistically significant.ResultsFour hundred seven patients with theMean±SD age of 55.85 ±11.3 years,ranging from 18 to 82 years were identifiedby the diabetes clinic as potentially eligiblefor the study. Among them, 251 (61.7%)were female, and 85.9% were married.There was a significant difference ineducational level among genders (Table 1).Females had lower educational levelcompared to males (p<0.001), and 53.1%of them were housekeepers. There was asignificant relationship betweenoccupational status and educational levelZ.Mohammadi, et al.3Med J Islam Repub Iran 2015 (11 July). Vol. 29:230. http://mjiri.iums.ac.ir(p<0.001) (Table2). Health literacy scoremeans were 47.1 and 38.9 out of 100 inmale and female participants, respectively.Patients with higher educational level andemployed patients had higher healthliteracy score (p< 0.001). Tukey’s post hoctest revealed that employed patients hadhigh health literacy compared tohousekeepers (p< 0.001). Tukey’s post hoctest have shown that patients with lowhealth literacy level were significantly lesseducated than others (p< 0.001).of the patients, 70% had inadequatehealth literacy level and 18.2% and 11.8%of the patients had adequate and marginalliteracy levels, respectively (Table3). Therewas a correlation between the ability ofreading comprehension and numeracy skill.(Pearson correlation coefficient=0.61,p<0.001)In this study, health literacy was notassociated with HbA1c. The peak of healthliteracy was observed among the patientswith the age range of 18-29. As shown inFig. 1, adequate health literacy is associatedwith lower ages.DiscussionIn this study, 70% of diabetic patients hadinadequate health literacy level, and 18.2%had adequate health literacy level. Nurss etal. have shown that among 131 African-American diabetic patients, 47% and 25%in new and old cases had adequate practicalhealth literacy (19).Based on a study conducted in IranianTable 1. Frequency of education status in diabetic patients based on genderEducation Status Male N (%) Female N (%) Both N (%) pIlliterate 14(9.0) 49(19.9) 63(15.7) 0.003Incomplete school 73(46.8) 120(62.2) 193(48)Diploma 38(24.4) 52(21.1) 90(22.4)University 31(19.9) 25(10.2) 56(13.9)Total 156(100.0) 246(100.0) 402(100.0)Table 2. Characteristics of patients stratified by two types of health literacyCharacteristics Reading ComprehensionMean±sdp Numeracy SkillMean±sdp Total scoreMean±sdpMale 17.9±16.8 0.07 29.2±14.0 0.001 47.1±27.9 0.006Female 14.9±16.1 24.0±15.7 38.9±29.5Total 16.05±16.43 ------- 26.0±15.3 ------- -------Employed subjects 24.4±18.0 ‹0.001 33.2±14.3 ‹0.001 57.6±29.2 ‹0.001Unemployed subjects 16.5±18.8 27.5±15.7 44.0±32.0House keeper 12.3±14.9 21.9±16.0 34.2±28.1Others 17.69±15.8 29.14±12.6 46.84±25.3Total 15.94±16.42 ------- 25.9±15.3 ------- -------Married 15.9±16.1 0.6 26.3±14.8 0.1 42.2±28.2 0.6Single 16.87±18.4 23.47±17.8 40.4±34.0Total 16.02±16.44 ------- 25.93±15.3 ------- -------Illiterate 0.0±0.0 ‹0.001 0.0±0.0 ‹0.001 0.0±0.0 ‹0.001Incomplete school 10.45±12.0 26.2±1.2 36.65±20.4Diploma 26.98±14.6 35.6±7.39 62.58±19.6University 35.19±12.8 38.25±6.82 73.44±17.3Total 16.0±16.43 ------- 25.9±15.3 ------- -------Health literacy in Iranian diabetic patients4 Med J Islam Repub Iran 2015 (11 July). Vol. 29:230.http://mjiri.iums.ac.irpopulation, 57% of the participants hadinadequate health literacy compared to thegeneral population (18). It seems that thediabetic patients have lower healthknowledge. The level of health literacy waslower in female diabetic patients comparedto the male. Also, level of health literacywas decreased with the increase in age. Thepeak was observed among the patients withthe age range of 18-29.In the present study, no association wasfound between health literacy level andHbA1c. Moreover, another study conductedon Iranian diabetic patients in 2007 foundno significant difference in the level ofHbA1C among the three groups ofparticipants(17).Trief et al. assessed the relationshipbetween marital quality and HbA1c indiabetic patients using three questionnaires,Spanier Dyadic Adjustment Scale, PersonalAssessment of Intimacy in RelationshipsScale and HRQoL found no relationshipbetween them (20).Pala et al. used two generic quality of lifeinstruments(SF-36 and WHOQOL-BREF)in diabetic patients, and HbA1c did notshow any relationship with any of thedomains of the instruments (21).In the present study, there was asignificant association between occu-pational status and health literacy level  asTable 3. Characteristics of Patients Stratified by Health Literacy LevelCharacteristics Inadequate N (%) Marginal N (%) Adequate N (%) Total N (%) pMale 106(67.9) 14(9.0) 36(23.1) 156(100.0) 0.07Female 179(71.3) 34(13.5) 38(15.1) 251(100.0)Employed subjects 34(48.6) 9(12.9) 27(38.6) 70(100.0) ‹0.001Unemployed subjects 8(66.7) 1(8.3) 3(25.0) 12(100.0)House keeper 169(78.2) 24(11.1) 23(10.6) 216(100.0)Others 70(68.6) 13(12.7) 19(18.6) 102(100.0)Married 249(71.6) 39(11.2) 60(17.2) 348(100.0) 0.2Single 35(61.4) 8(14.0) 14(26.4) 57(100.0)Illiterate 63(100.0) 0(0.0) 0(0.0) 63(100.0) ‹0.001Incomplete school 170(88.1) 15(7.8) 8(4.1) 193(100.0)Diploma 35(38.9) 26(28.9) 29(32.2) 0(100.0)University 14(25.0) 6(10.7) 36(64.3) 56(100.0)Fig.1. Distribution of Health Literacy in Age GroupsZ.Mohammadi, et al.5Med J Islam Repub Iran 2015 (11 July). Vol. 29:230. http://mjiri.iums.ac.irall students had adequate health literacylevel. However, the regression analyses didnot show any significant difference inoccupation groups “employed subjects,unemployed and housekeepers”It is noteworthy to mention that housekeepers and those with a high schooldiploma were at risk for diabetes outcomesmore than others due to inadequate healthliteracy. It seems that providing appropriateeducation to patients with inadequate healthliteracy can be useful.National Work Group on Literacy andHealth in United States, addresses thefailure of elementary schools to produceadults who are sufficiently literate toparticipate in health issues(22).In health care services, physicians havethe responsibility to provide enougheducation to the patients(23). It seems thatnon- written tools are useful in learning.Using some methods which include picture,video and computer software are effective.Educational and training packages basedon the patient’s literacy level andknowledge can improve outcomes ofchronic diseases.Our study had several limitations. First,our study participants were a sample ofpatients already enrolled from one hospitalin diabetes clinic and may not berepresentative of all diabetic patients.Second, our sample was small to assess theHbA1c. Finally, the Test of FunctionalHealth Literacy in Adults evaluates theability of reading comprehension andnumeracy skill although health literacyconsists of many parts such as speaking andlistening skill etc.(24-26).In this study, health literacy in Iranianpatients with diabetes was low, and theresults revealed that some other factorswere also involved. Previous studiesrevealed that diabetes education waseffective in improving self-management,diabetes knowledge, and glycemic controlof patients with inadequate and limitedhealth literacy. Therefore, it seems thateffective methods such as using visualequipment are useful.ConclusionHealth literacy score in Iranian patientswith diabetes seems low. Therefore, effec-tive interventions should be designed andimplemented for this group of patients toimprove diabetes outcomes.AcknowledgementsWe would like to present our specialthanks to all participants of this study. Thisstudy was supported by the Institute of En-docrinology and Metabolism (IEM) in IranUniversity of Medical Sciences.References1. Ratzan SC, Parker RM. Introduction. In: Na-tional Library of Medicine Current Bibliographies inMedicine: Health Literacy. Selden CR, Zorn M,Ratzan SC, Parker RM, Editors. NLM Pub. No.CBM 2000-1. Bethesda, MD: National Institutes ofHealth, U.S. Department of Health and human Ser-vices.2. Sihota S, Lennard L. Health literacy: being ableto make the most of health. London: National Con-sumer Council; 2004: 11.3. Zarcadoolas C, Pleasant A, Greer DS. Under-standing health literacy: an expanded model. HealthPromotInt 2005;20:195–203.4. Waldrop-Valverde D, Osborn CY, RodriguezA, Rothman RL, Kumar M, Jones DL. Numeracyskills explain racial differences in HIV medicationmanagement. AIDS Behav 2010;14:799–806.5. Osborn CY, Cavanaugh K, Wallston KA, WhiteRO, Rothman RL. Diabetes numeracy: an over-looked factor in understanding racial disparities inglycemic control. Diabetes Care 2009;32:1614–1619.6. Donelle L, Arocha JF, Hoffman-Goetz L.Health literacy and numeracy: key factors in cancerrisk comprehension. Chronic Dis Can 2008;29:1–8.7. Apter AJ, Cheng J, Small D, Bennett IM, AlbertC, Fein DG, et al. Asthma numeracy skill and healthliteracy. J Asthma 2006;43:705–710.8. Huizinga MM, Carlisle AJ, Cavanaugh KL, Da-vis DL, Gregory RP, Schlundt DG, et al. Literacy,numeracy, and portion-size estimation skills. Am JPrev Med 2009;36:324–328.9. Huizinga MM, Beech BM, Cavanaugh KL,Elasy TA, Rothman RL. Low numeracy skills areassociated with higher BMI. Obes (Silver Spring)2008;16:1966–1968.10. Kutner M, Greenberg E, Baer J. A First Lookat the Literacy of America’s Adults in the 21st Cen-tury. Washington, DC, National Center for Educa-tion Statistics, U.S. Department of Education, 2005.Health literacy in Iranian diabetic patients6 Med J Islam Repub Iran 2015 (11 July). Vol. 29:230.http://mjiri.iums.ac.ir11. WHO. Global status report on noncommuni-cable diseases 2014. Geneva, World Health Organi-zation, 2012.12. Esteghamati A, Etemad K, Koohpayehzadeh J,Abbasi M, Meysamie A, Noshad S, etal. Trends inthe prevalence of diabetes and impaired fasting glu-cose in association with obesity in Iran: 2005-2011.Diabetes Res ClinPract 2014 Feb;103(2):319-27.13. Gazmararian JA, Williams MV, Peel J, BakerDW.Health literacy and knowledge of chronic dis-ease. Patient EducCouns 2003;51:267–275.14. Williams MV, Baker DW, Parker RM, NurssJR. Relationship of functional health literacy to pa-tients’ knowledge of their chronic disease: a studyof patients with hypertension and diabetes. ArchIntern Med 1998;158:166–172.15. Cavanaugh K, Huizinga MM, Wallston KA,Gebretsadik T, Shintani A, Davis D, et al. Associa-tion of numeracy and diabetes control. Ann InternMed 2008;148:737–746.16. Schillinger D, Piette J, Grumbach K, Wang F,Wilson C, Daher C, et al. Closing the loop: physi-cian communication with diabetic patients who havelow health literacy. Arch Intern Med. 2003 Jul28;163(14):1745-6.17. ShahabJahanlou A,AlishanKarami N. The Ef-fect of Literacy Level on Health Related-Quality ofLife, Self-Efficacy and Self-Management Behaviorsin Diabetic Patients. ActaMedicaIranica 2011;49(3):153-158.18. TehraniBanihashemi S, Amirkhani M, Hagh-doost A, Alavian S, Asgharifard H, Baradaran H, etal . Health Literacy and the Influencing Factors: AStudy in Five Provinces of Iran. Strides Dev MedEduc 2007;4(1):1-9.19. Nurss JR, Baker D, Davis T, Parker R, Wil-liams M. Difficulty in functional health literacyscreening in Spanish-speaking adults. Journal ofReading 1995;38:632–637.20. Trief PM, Wade MJ, Britton KD, WeinstockRS. A prospective analysis of marital relationshipfactors and quality of life in diabetes. Diabetes Care2002;25(7):1154-8.21. Pala T, Eser E, Ozmen B, Aydemir O, Boyvo-da S. The eterminants of quality of life includingtreatment satisfaction in patients with type two dia-betes mellitus: are different generic Qol instrumentssensitive to the same determinants? Turkish J Endo-crinolMetab 2004;8(3):91-9.22. National Work Group on Literacy and Health.Communicating with patients who have limited lit-eracy skills.Report of the National Work Group onLiteracy and Health. J of FamPract 1998, 46(2):168-76.23. American College of Physicians: Position Pa-per: Ethics Manual, Fifth Edition. Section on Physi-cian and the Patient (p.561). Ann Intern Med 2005;142:560-582.24. Coonrod BA, Betschart J, Harris MI. Frequen-cy and determinants of diabetes education amongadults in the U.S. population. Diabetes Care1994;17:852– 858.25. Glasgow RE, Toobert D, Hampson SE. Partic-ipation in outpatient diabetes education programs:how many patients takepart and how representativeare they? Diabetes Educ1991;17:376 –380.26. Nielsen-Bohlman L, Panzer AM, Kindig DA,Eds. Washington, D.C. Institute of Medicine: HealthLiteracy: A Prescription to End Confusion, The Na-tional Academics Press, 2004.

Health literacy and its influencing factors in Iranian diabetic patients

Acknowledgements We would like to present our special thanks to all participants of this study. This study was supported by the Institute of Endocrinology and Metabolism (IEM) in Iran University of Medical Sciences.Peer reviewe

Aberdeen University Research

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Health literacy and its influencing factors in Iranian diabetic patients

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