Original ResearchImpact of health literacy on diabetes outcomes: a cross-sectional study from Lahore, Pakistan
Introduction
Health literacy (i.e. a constellation of skills required to obtain, process, understand and communicate health-related information to make informed health decisions) has received much attention and is considered a risk factor for poor medication adherence, improper drug usage and adverse outcomes.1, 2, 3 Studies have shown that patients with poor health literacy have difficulties in reading drug labels, dosing schedules, educational brochures related to health, and informed consent forms; interpreting self-managed laboratory values; processing oral communication; and conceptualising disease and therapy risks.4, 5 Similarly, low health literacy has been documented as a stronger predictor of a person's health than age, education, socio-economic status and employment status affecting health care and disease management outcomes.6, 7 In this context, poor health literacy is observed more frequently in minority populations, people with English as a second language, elderly people, and people with a low income and poor education.7, 8
Interestingly, the same populations (i.e. elderly, low income and poorly educated) with low health literacy carry the highest burden of chronic conditions, such as diabetes and hypertension.5, 8 Diabetes is a chronic disease with profound complexity requiring rigorous self-care, education and management, often relying on printed education materials regarding diet and self-care practices complemented by verbal instructions, and therefore requiring advanced health literacy skills.9 Studies in patients with diabetes have shown that limited health literacy coupled with poor knowledge of the disease is associated with a poorer outcome.10, 11 Similarly, studies have shown that adherence to diet, exercise and pharmacotherapy is pivotal for optimal glucose control in patients with diabetes and is related to patient knowledge about self-care, self-efficacy and self-management of diabetes.12, 13 More precisely, differences in self-care and self-management are associated with inconsistencies in treatment outcomes.14
In developing countries, such as Pakistan, where the majority of people have low incomes and do not have easy access to education, health literacy is an unexplored entity, created and refined by the developed world. The literature indicates that the prevalence of diabetes is higher in South Asians compared with Caucasians, and the estimated prevalence of diabetes in Pakistan is 7.1%, placing this in the seventh highest position globally.15, 16, 17 However, to the authors' knowledge, no studies to date have evaluated the association between functional health literacy and diabetes outcomes in Pakistan. Therefore, the authors used Short Test of Functional Health Literacy (s-TOFHLA) to assess the impact of health literacy on glycaemic control of patients with diabetes in Lahore, Pakistan, and estimated the relationships between patient characteristics and glycated haemoglobin (HbA1C) level.
Section snippets
Ethical approval
Ethical approval for this study was obtained from the Ethics Committee of University College of Pharmacy, University of the Punjab (Reference No. EC/UCP/092/2015) and Hospital Committee of Ethics on Human Research.
Study design
Two hundred and four patients with diabetes were enrolled into this six-month cross-sectional study from hospitals in Lahore, Pakistan. Patients with diabetes of more than 12 months' duration were identified from four tertiary care hospitals based on clinician reports. Type 2 diabetes
Results
Six hundred forty-two patients were identified from the diabetes clinics of four tertiary care hospitals. Of these, 229 patients had not visited their physician in the preceding year, 137 patients did not meet the inclusion and exclusion criteria, 27 patients did not have type 2 diabetes and 24 patients were no longer alive. In total, 225 subjects were approached regarding enrolment in the study, and 21 did not provide informed consent. As such, 204 eligible patients were evaluated in terms of
Discussion
These data demonstrated that inadequate health literacy is likely to be associated with poor glycaemic control, with higher odds of diabetes complications, particularly retinopathy. Furthermore, only patients with adequate health literacy reported no complications and had higher socio-economic status. It appears that the socio-economic status of patients might be one independent variable that could affect health literacy, directly via education and indirectly via access to digital medical
Acknowledgements
The authors wish to thank the study participants and hospital staff for their cooperation.
Ethical approval
Ethical approval for the study was obtained from the Ethics Committee of University College of Pharmacy, University of the Punjab (Reference No. EC/UCP/092/2015) and Hospital Committee of Ethics on Human Research.
Funding
None declared.
Competing interests
None declared.
References (29)
- et al.
Health literacy and knowledge of chronic disease
Pat Educ Counsel
(2003) - et al.
Inadequate literacy is a barrier to asthma knowledge and self-care
Chest J
(1998) Promoting health literacy
J Am Med Inform Assoc
(2005)- et al.
Health literacy: implications for family medicine
Fam Med
(2004) - et al.
The prevalence of limited health literacy
J Gen Intern Med
(2005) - et al.
Health literacy: the gap between physicians and patients
Am Fam Physician
(2005) - et al.
Improving patient education for patients with low literacy skills
Am Fam Physician
(1996) - et al.
Association of health literacy with diabetes outcomes
JAMA
(2002) - et al.
Low health literacy and health outcomes: an updated systematic review
Ann Intern Med
(2011) - et al.
Health literacy and health outcomes in diabetes: a systematic review
J Gen Intern Med
(2013)
Limited literacy in older people and disparities in health and healthcare access
J Am Geriatr Soc
Addressing health literacy and numeracy to improve diabetes education and care
Diabet Spect
Relationship of functional health literacy to patients' knowledge of their chronic disease: a study of patients with hypertension and diabetes
Arch Intern Med
Effectiveness of self-management training in type 2 diabetes a systematic review of randomized controlled trials
Diabetes Care
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