Health Literacy and Self-Care in Diabetes Disease; a Systematic Review | ||
| Health Education and Health Promotion | ||
| Article 20, Volume 10, Issue 1, 2022, Pages 145-153 PDF (510.19 K) | ||
| Document Type: Systematic Review | ||
| Authors | ||
| H. Izadirad1; M.H. Delshad2; F. Pourhaji3 | ||
| 1Department of Health, Khash School of Health, Zahedan University of Medical Sciences, Zahedan, Iran | ||
| 2“Department of Public Health, School of Health” and “Health Sciences Research Center”, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran | ||
| 3“Department of Health Promotion and Education, School of Health” and “Student Research Committee”, Mashhad University of Medical Sciences, Iran | ||
| Abstract | ||
| Aims: The present study was conducted to review the relationship between health literacy and self-care of diabetic patients. Information & Methods: This study is a systematic review based on the PRISMA statement (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and was implemented systematically through an electronic search in Iran Medex, SID, Magiran databases, Web of Science, PubMed, Scopus, Google Scholar, and Science Direct from January 2011 to April 2020. The terms were used, including health literacy, self-care, diabetes and their combinations. To maximize the comprehensiveness of the search in Persian references, general and general Persian keywords, including health literacy, self-care, diabetes self-care, health literacy, and self-care, health literacy, and diabetes and their possible combinations in the abstract, title, and keywords were used “AND” and “OR” operators were used for this purpose. For the English equivalent of Latin and MESHE, the words were searched, including “Health literacy”, “diabetes”, “self-care”, “Diabetes self-care”, and a combination of the “AND” and “OR” operators. Findings: The results showed that in most studies there is a significant relationship between health literacy and self-care in patients with diabetes. Conclusion: Health literacy plays an important and key role in promoting self-care behaviors in diabetic patients. It requires paying attention to health literacy and adopting strategies to improve the health literacy of diabetic patients. | ||
| Keywords | ||
| Diabetes; Health Literacy; Self-care; Systematic Review | ||
| Full Text | ||
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Introduction
Over the decades, much research has been done to answer how health literacy affects people's health [1-3]. Health literacy is the capacity and ability to obtain, process, and understand health information and services they need for decision-making about their health [4-7]. In these studies, health literacy has been introduced as an influencing factor in the health status, treatment outcome, and physician-patient relationship. The increasing health literacy of diabetic patients makes it easier to understand dietary information, insulin injections, and glucose control. On the other hand, health literacy plays a vital role in accepting their illness. The results of these studies show that health literacy helps people to be more involved in therapeutic decisions. Also, individuals with higher health literacy pay more attention to their health literacy status [4, 8-12]. Other research examined the relationship between health literacy and patients' self-care behaviors. These studies have shown that physicians 'attention to patients' health literacy levels, training classes, and various audiovisual media to transfer information about the illness have effectively improved self-care behaviors, self-efficacy, and understanding of the complexity of diabetes [4, 13]. Health literacy is widely regarded as a determinant of health and a priority on the public health policy agenda, and it has the greatest impact on diabetes prevention [14-16]. Low health literacy is more common in the elderly, immigrants, illiterate and low-income people, individuals with low mental health, and patients with chronic diseases such as diabetes type 2 and hypertension. These individuals are considered at-risk groups with adverse effects on low levels of health literacy [17]. Individuals with low health literacy suffer higher medical costs, have poorer health status, and are more likely to be hospitalized and use emergency services. These people have less preventive care. The research suggested that a low level of health literacy is associated with a low level of health, wider inequalities, and higher costs of the health system, addressing the issue of health literacy. It seems essential to use strategies to promote it in society [4]. Diabetes is a metabolic disorder caused by non-secretion or decreasing the hormone insulin [18]. According to World Health Organization (WHO), diabetes is a silent epidemic [13]. This disease is the leading cause of mortality worldwide, so it is estimated that the number of people with diabetes will increase from 171 million in 2000 to more than 366 million in 2030 worldwide [18]. Studies show that patients suffer from side effects of diabetes after 15 years of morbidity (10% with severe visual impairment, 50% with retinopathy, and 75% from heart disease [19, 20]. The American Diabetes Association (ADA) classifies diabetes into four subgroups: type 1 diabetes, type 2 diabetes, gestational diabetes, and other types of diabetes. It depends on obesity, insulin resistance, physical inactivity, genetics, and environmental factors [19, 20]. Self-care improves the quality of life and reduces treatment costs. On the other hand, self-care is influenced by one's beliefs, attitudes, and the values and culture of the society in which one lives. Self-improvement is possible through education. Patient education is an essential component of diabetes control. Many scholars consider the control and treatment of diabetes as the main task of the individual and family and believe patients must accept responsibility to control their disease. One of the important goals in diabetes control is to empower patients to take care of themselves [21]. Self-care in diabetes includes proper and timely insulin injections, diet, regular exercise, detection of high or low blood sugar symptoms, regular use of medications, foot care, and quality of life [13]. Due to the studies performed in a geographical area and limited population about health literacy and self-care of diabetic patients with various tools, methods, procedures, and contexts in the world, It makes necessary to conduct a systematic review and prepare a more accurate report. The result of this study can be a good basis for the expertise of specialists and the decision of health officials to improve the level of health literacy and consequently improve self-care and improve the quality of life in diabetic patients ultimately. Since the introduction of health literacy, several studies have been conducted on its application. There is little research about self-care in diabetic patients and its effect on health literacy. Then, it seems necessary a review health literacy and self-care in the diabetic patient. Therefore, the present study was conducted to review the relationship between health literacy and self-care of diabetic patients. Information and Methods The present study is a systematic review based on the PRISMA statement and was conducted in 2020. An electronic search was implemented for articles in Persian and English in Iran Medex, SID, Magiran databases, Web of Science, PubMed, Scopus, Google Scholar, and Science Direct from January 2011 to April 2020. The terms were used including health literacy, self-care diabetes, health literacy, and diabetes. To maximize the comprehensiveness of the search in Persian references, general and general Persian keywords, including health literacy, self-care, diabetes self-care, health literacy, and self-care, health literacy, and diabetes and their possible combinations in the abstract, title, and keywords were used “AND” and “OR” operators were used for this purpose. For the English equivalent of Latin and MESHE, the words were searched, including “Health literacy”, “diabetes”, “self-care”, “Diabetes self-care”, and a combination of the “AND” and “OR” operators. In the Google Scholar database, the keywords were entered in the title field, and all the articles in the database were reviewed. Inclusion criteria included 1- Quantitative and cross-sectional design in study 2-Both health literacy and self-care in patients with type II diabetes studied, 3- The full text of the article should be available. Short articles and letters to the editor were deleted. Guidelines developed at the PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses, included a checklist and a flow chart. First, the members of the systematic review team were determined including the supervisor, consultant group, researcher, extractor, data collector, article seeker, and final browser. Firstly, the articles were searched in the title and their abstracts. Then irrelevant and duplicate items were removed. In the next step, the texts of the remaining articles were reviewed, and removed the unrelated items. Finally, 18 selected articles [1, 4, 13, 17, 21, 24-29, 33, 37, 41, 42, 45, 51, 52, ] (Figure 1). To prevent bias in the study, searching, selecting studies, evaluating qualitative, and extracting data were conducted independently by two researchers, and any disagreement between the two researchers was evaluated by a third. Then, All articles that entered the study process were reviewed with a predefined checklist. The checklist included the title, journal name, type of study, target group, volume, sampling method, and results  Figure 1) Flow Chart of study entry to a systematic review
Findings
The results showed different sampling methods so that 14 studies (77.77%) used simple random sampling, 1 study (5.55%) census, 2 The study (11.11%) was performed using the multistage sampling, and one study (5.55%) was performed by the cluster sampling. In these studies, patients with type 2 diabetes were studied from different age groups so that the minimum age of the patients was 28 years and the maximum age was 87 years. To assess health literacy, various assessment tools such as a short survey of adult functional health literacy (STOFHLA) in 4 studies (22.22%), a communication and Persian critical versionin1 study (5.55%), and European health literacy were used. Questionnaire (47 cases) in a study (5.55%), version of the Japanese Functional, Communication and Critical Health Literacy Questionnaire (Ishikawa), in five studies (27.77%), in one study (5.55%) of the Adult Functional Literacy Test, Questionnaire Chewing health literacy screening in two studies (11.11%), in two studies (11.11%) the Adult Functional Health Literacy Questionnaire (TOFHLA), in two studies (11.11%) the Iranian Adult Health Literacy Questionnaire (HELIA) was used. In 27.77% of the studies, there was no statistically significant relationship between health literacy and self-care of type2 diabetic patients. The findings of the selected studies are reported in Table 1. Table 1) Characteristics and information related to studies based on health literacy and self-care of diabetic patients  Continue of Table 1) Characteristics and information related to studies based on health literacy and self-care of diabetic patients  Discussion the present study was conducted to review the relationship between health literacy and self-care of diabetic patients. One of the largest challenges is the increasing burden of chronic diseases such as diabetes in today's world. Health literacy is a global issue, and according to the World Health Organization (WHO), it plays a key role in determining health equality, both in high and low-income countries [14-16]. Despite the growing importance of health literacy in improving and promoting community health, studies have been conducted limited worldwide, especially self-care in patients with diabetes. Generally, the results of various studies show the level of health literacy is not desirable in the community worldwide [14, 22, 23]. The review of the present study showed a different relationship between health literacy and self-care in patients with type 2 diabetes so, in some of the studies, there was no significant relationship between health literacy and self-care of patients with type 2 diabetes [13, 14, 24-26]. The reasons for different results in the studies may be due to the following: Various studies have used different tools to measure health literacy in patients with diabetes. Overall, the design and implementation of health literacy assessment tools are typically limited in time and population. In other words, a significant number of these tools are designed for certain nationalities and languages, including the native versions of TOFHLA and S-TOFHLA [27]. Also, some health literacy assessment tools are designed in a specific language, which is limited due to the specificity of the language spoken in some parts of the world and the limited number of people who speak only this language. These tools include functional, critical, and communicative health literacy assessment tools, and adult health literacy review tools that are available in a variety of languages [28]. It seems that the lack of a valid international standard tool for measuring the level of health literacy, which can measure people's health literacy in a wide range of scientific disciplines in different countries and a certain class, can be one of the causes of differences in the results of various studies. Another reason can be attributed to differences in the scope of measurement of different instruments, as several existing instruments only focus on measuring basic skills such as reading and counting, while several other instruments, such as TOFHLA, have a relatively complex structure to answer and to measure functional health literacy or the HLIA tool, which measures five areas of health literacy on a larger scale, including access, reading skills, comprehension, evaluation and decision making, and the use of health information. As a result, due to the different levels of difficulty of different tools, the level of health literacy of communities and, therefore, the relationship between health literacy and self-care can be effective. Therefore, since the basis for developing health literacy assessment tools is theoretical or practical, defined in scientific documents, it seems that in practice, this index is not measured by a fixed or definite approach or concept. As a result, despite these differences and the incompleteness of definitions, the inevitable result is different and it denies researchers and decision-makers to compare and draw conclusions on a wide range. Various studies applied different tools to measure health literacy in patients with type 2 diabetes. Overall, it has limited assessment tools for designing and implementing health literacy in terms of time and population. In other words, a significant number of these tools are designed for certain nationalities and languages, including the native versions of TOFHLA and S-TOFHLA [27]. Also, some health literacy assessment tools are designed in a specific language, which is limited due to the specificity of the language spoken in some parts of the world and the limited number of people who speak only this language. These tools include functional, critical, and communicative health literacy assessment tools, and adult health literacy review tools that are available in a variety of languages [28]. It seems the lack of an internationally valid and standard tool for measuring the level of health literacy-measure people's health literacy in a wide range of scientific disciplines in different countries and a certain class= can be one of the causes of different results in the various studies. Another reason is different in the scope of measurement in instruments because the number of existing instruments only focus on measuring basic skills such as reading and counting. In contrast, some other instruments such as TOFHLA have a relatively difficult structure to answer the audience and measure functional health literacy or the HLIA scale measures five areas of health literacy on a larger scale, including access, reading skills, comprehension, evaluation and decision making, and the use of health information. Then, because of the different levels of difficulty in health literacy scales of communities, therefore, the relationship between health literacy and self-care can be effective. Therefore, since in scientific documents, the basis of health literacy scales is theoretical or practical defined, it seems that this concept is not measured by a fixed or definite approach. As a result, despite these differences and the incompleteness of definitions, the inevitable result is different and it denies researchers and decision-makers to compare and draw conclusions on a wide range. It also appears differences in the self-care status of diabetic patients are a reason for conflicting results. Because factors such as differences in self-care training programs, the level of self-care knowledge and attitudes, as well as differences in how self-care for diabetic patients, can cause self-care behavior was different in various countries and even regions of the country. It seems different age groups in diabetic patients could be another reason for the discrepancy between the results examined in studies. For example, problems related to vision and other complications that are affecting factors on skills related to functional health literacy are more common in older patients with type 2 diabetes [29-32], They can be a contributing factor to self-care and health literacy. These disorders can also affect the completion of the questionnaire and self-report. It seems previous studies examined only one or two variable concepts of health literacy and self-care behaviors and they had contradictory results. Conducting studies in different countries with cultural, social, and economic differences education level, place of residence and economic status have been the most important factors that have been studied in different studies on different population groups. In most studies the level of education and economic status have been mentioned as two factors affecting health literacy [33-40]. Studies have also shown that residents of developed areas are more likely to follow health behaviors. Also, social and cultural characteristics have the greatest impact on people's health behaviors. In addition, political and economic characteristics, directly and indirectly, affect health and health behaviors [29, 41-44]. It seems that because studies on health literacy and diabetes self-care have been conducted in different countries with different cultural, social, political, and economic characteristics, these differences can be another reason for the contradictory results of health literacy on self-care diabetic. It also seems that one of the important and effective factors in contradictory results is the effect of health literacy on self-efficacy as an important mediating factor affecting self-care. Because, skills related to health literacy, including communicative and critical skills, are essential and effective factors in improving self-care behaviors in diabetic patients. Because these skills can increase self-confidence and self-efficacy and help them build effective relationships with health care providers. Such capabilities could eventually allow patients to receive necessary information from various communication channels and evaluate and practice [45-47]. Also, in the study of Reisi et al. [22], self-efficacy was introduced as a strong determinant of diabetes care, so that patients with a high level of self-efficacy had better self-care in diabetes [29]. It seems that the indirect effect of health literacy on the self-care of diabetic patients is achieved through self-efficacy. Also, the study of Panahi et al. [48] showed that health literacy as a facilitating factor directly affects self-efficacy and indirectly influences the adoption of preventive behaviors [48-51]. It can be understood that health literacy is a set of skills, capabilities, and capacities in several dimensions. The skills and capacities, sometimes in the dimension of obtaining medical information and health, reading them, understanding, processing, and interpretation, and decision-making and implementation of this information emerge and in this way can affect both self-efficacy as an important mediator and self-care. Conclusion Health literacy plays an important and key role in promoting self-care behaviors in diabetic patients. It requires paying attention to health literacy and adopting strategies to improve the health literacy of diabetic patients. Acknowledgments: The authors sincerely appreciate all the researchers whose studies have been used in the present study. Ethical permissions: This article was reviewe and has no human or animal examples. Conflicts of Interest: We declare that we have no conflicts of interest. Authors' contribution: Izadirad H (First Author), Methodologist/Statistical Analyst (30%); Delshad MH (Second Author), Introduction Writer/Discussion Writer (25%); Pourhaji F (Third Author), Introduction Writer (25%); Pourhaji F (Forth Author) Assistant Researcher (20%). Funding/Support: No funding. | ||
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