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Table of Contents
ORIGINAL ARTICLE
Year : 2018  |  Volume : 7  |  Issue : 3  |  Page : 123-129

The relationship between health literacy and knowledge about heart failure with recurrent admission of heart failure patients


1 Shahriar Imam Sajjad Hospital, Tehran, Iran
2 Faculty of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran
3 Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran

Date of Web Publication10-Sep-2018

Correspondence Address:
Dr. Nasim Naderi
Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Valiasr Avenue, Hashemi-Rafsanjani Highway, Tehran
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/rcm.rcm_12_18

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  Abstract 


Introduction: Having good health literacy can improve quality of life and decrease re-hospitalization of the patients including patients with heart failure (HF). Considering the importance of knowledge about HF and health literacy in these patients and the existence of contradictory texts, this study aimed to determine the relationship between health literacy and knowledge of HF, with re-admission of HF patients. Methods: The present study was a cross-sectional study in which 238 patients aged over 18 years old with an ejection fraction of 35% and less with the ability to read, write, and speak, and no psychological, neurological and cognitive disorders were included in the study after they signed the consent form of the research. Data collection was done through demographic information questionnaire, Short-Test of Functional Health Literacy in Adult-16 standard health literacy questionnaire, and Van Der Wal knowledge about HF questionnaire (2005). Both questionnaires were validated and their reliability was investigated before starting the study. The Chi-square test, Fisher's exact test, or the Mann–Whitney tests were used to compare variables. Results: Most of the patients were male (66%) and married (80%). The results showed that the majority of study population had proper health literacy and about half of them had enough information about HF. This study showed that there is a significant relationship between health literacy and knowledge. In other words, the higher the health literacy of the people, the greater their awareness of their illness (P = 0.02). However, the findings showed that there is no significant relationship between health literacy and awareness of HF with the number of admissions. Conclusion: The results of this study show that the higher the health literacy of the people may lead to the higher their knowledge and awareness about HF and better understanding the recommendations regarding their illness.

Keywords: Cardiac failure, health literacy, knowledge, readmission


How to cite this article:
Razazi R, Aliha JM, Amin A, Taghavi S, Ghadrdoost B, Naderi N. The relationship between health literacy and knowledge about heart failure with recurrent admission of heart failure patients. Res Cardiovasc Med 2018;7:123-9

How to cite this URL:
Razazi R, Aliha JM, Amin A, Taghavi S, Ghadrdoost B, Naderi N. The relationship between health literacy and knowledge about heart failure with recurrent admission of heart failure patients. Res Cardiovasc Med [serial online] 2018 [cited 2018 Nov 18];7:123-9. Available from: http://www.rcvmonline.com/text.asp?2018/7/3/123/240986




  Introduction Top


Chronic diseases account for about half of the global burden of diseases, and it is anticipated that by 2030, out of ten deaths in the world, seven deaths will be due to chronic diseases.[1] Heart failure (HF) is one of the most common and important chronic diseases. Despite the advancement in introducing new effective drugs in treatment, HF continues to be associated with frequent hospitalizations, impaired quality of life, early mortality, and significant economic burden. Recurrence of HF, unnecessary hospitalizations, and loss of life expectancy happens when the patient does not follow the therapeutic recommendations.[2] The results of the research show that patients with self-care at the desired level through lifestyle modification and adherence to the medication regimen reduce the rate of hospitalization and complications of the disease. The implementation of a successful self-care program is influenced by one's knowledge and skill, but many of these patients have a low awareness of self-care, such as monitoring the symptoms and actions needed when symptoms occur.[3]

As stated, one of the factors affecting control of HF is the availability of adequate knowledge of the disease, and at the same time, one of the factors influencing the level of knowledge is health literacy. Today, health literacy is recognized as a vital indicator in the health-care outcomes and expenses.[4] The existence of barriers to knowledge such as low health literacy related to knowledge of the disease is considered as one of the major challenges of these patients.[5],[6] Limited educated people often lack knowledge or have misinformation about their body, the nature, and causes of illnesses. Individuals with a low level of health literacy are less likely to understand the written and spoken information provided by health professionals and do the instructions given and therefore bear more medical costs. They also have poorer health status, and there is a higher rate of hospitalization and use of emergency services and of course less preventive care.[7]

However, there are many contradictions in the studies on the impact of health literacy on different aspects of management and care. For example, in Mahnoosh Reisi et al. study, people with a low level of health literacy were significantly more likely to refer to doctors than others, but at the same time, there was no statistically significant relationship between the level of health literacy and referral to the emergency department. Furthermore, there was no significant relationship between health literacy level and performing mammograms in elderly women.[8] Gazmararian et al. also found that health literacy affects knowledge but does not affect adherence to self-care.[9] Unlike this study, Chen et al. showed that health literacy is an important factor in promoting knowledge of HF and self-confidence in self-care behavior, especially among older people and those with lower education than high school.[10],[11] These contradictory results regarding the effect of health literacy on care dimensions indicate that the body of knowledge needs to do more research in this field. The aim of this study was to determine the association between health literacy and knowledge of HF with re-admission of HF patients referred to the HF clinic of Rajaie Cardiovascular, Medical and Research Center in 2014.


  Methods Top


Study design

The present study was a cross-sectional study which was approved by the Ethics Committee of Iran University of Medical Sciences (approval code: PP/94/17) with the aim of determining the relationship between health literacy and knowledge of HF, with re-admission of HF patients referred to the HF clinic of Rajaie Cardiovascular, Medical and Research Center in 2014.

Sampling

The population of this study included patients diagnosed with chronic HF and documented medical records with an ejection fraction of 35% or less. The sampling method was convenient sampling in this study, so the researcher referred to the heart failure clinic of Rajaie Hospital on a weekly basis in the morning and afternoon from Sunday to Wednesday, and after talking with the patients and granting their permission, they were included in the study according to the criteria for inclusion in the study, including the age range of 18 years and older, ejection fraction of 35% and less, ability to read, write and speak and not having mental, neurological and cognitive disorders. This process continued until completion of the sample. The total sample size was 215 patients, of which 250 patients were enrolled. At the end of the study, 23 patients were dropped. Finally, 238 patients were studied.

Research tools

The data gathering tool contained three questionnaires. At first, a demographic information questionnaire, which included nine questions related to personal and social data and clinical information, including age, sex, occupation, educational level, place of residence, marriage status, left ventricular ejection fraction (LVEF) New York Heart Association (NYHA) class — underlying diseases-duration of the disease.

The second tool was the Short-Test of Functional Health Literacy in Adults-16[12] standard questionnaire which included 16 questions that would measure the health literacy of patients with HF by Likert scale so that the subjects were evaluated as five options (4 – always, 3 – often, 2 – sometimes, 1 – rarely, and 0 – never). Health literacy scores are between 0 and 64 and its classification is such that a score of between 48 and 64 represents sufficient health literacy, the score between literacy 32 and 48 is border health, and a score between 0 and 32 indicates inadequate health literacy.

The knowledge about HF questionnaire, which included 15 questions, was used to determine the level of knowledge of HF. The questionnaire was prepared by van der Wal et al. in 2005;[13] 4 items on general questions of HF, 6 items on treatment for HF, including diet and fluid restriction and physical activity, and 5 other items on signs and diagnostic symptoms. The score for the knowledge of HF is from 0 to 15, where a score between 0 and 7 indicates a lack of awareness and a score between 8 and 15 indicates a complete knowledge of the disease.

To determine the content validity of the questionnaires, the qualitative content validity method was used. At first step, the selected questionnaire for knowledge about HF was translated.

First translation

Translation and cultural adaptation process performed according to guideline published in 2000.[14] Two HF specialists and an expert bilingual translator (Persian as the first language) who were aware of the objective of the study translated the questionnaire to Farsi independently.

Back translations

Back translation was done by two independent bilingual translators who were blinded to objectives of the study.

Then, it was given to 10 faculty members of the Rajaie Cardiovascular, Medical and Research Center. After collecting suggestions and correction points, the final Farsi questionnaire was developed.

In this study, at first step, the validity and reliability of its Farsi translation of both questionnaires were evaluated. The reliability of the tools was evaluated by internal consistency study, and the ratio of Cronbach's alpha for both varieties was more than 0.7. In addition, in order to determine the reliability of the expressions, the test method was also used, in such that the questionnaires were distributed, completed, and collected among the twenty community members, and the same questionnaire was returned to the same people again after 2 weeks. The questionnaire was adapted in both cases. The results for the health literacy questionnaire and knowledge of HF were obtained (r = 0.8, α = 0.78 and α = 0.8, r = 0.8, respectively).

Data collection

After identification of eligible patients based on entry criteria, the purpose of the research was expressed to them, and if they were satisfied and informed consent form was completed, the samples were entered. After granting permission from the patients and ensuring about their mental and physical condition, they were given a questionnaire to complete at the presence of the researcher. If the patient was not able to complete the questionnaire, the researcher would do it on behalf of the patient.

Patients' follow-up

Subsequently, 3 months after enrollment, the readmission status or emergency visits of the study population during the past 3 months were questioned by telephone and recorded.

Statistical analysis

SPSS 20 (IBM Corp, Armonk, NY, USA) was used for all statistical analyses. All data were initially analyzed using the Kolmogorov–Smirnov test to assess normal distribution. Quantitative variables were presented as means (standard deviation [SD]) and categorical variables as counts and percentages. The Chi-square test, Fisher's exact test, or the Mann-Whitney tests were used, as appropriate, to compare variables. The P < 0.05 considered as significant.


  Results Top


In this study, a total of 238 patients were studied. Most of them were male 157 (66%), married 190 (80%), and between 50 and 70 years (42%). The mean (SD) of LVEF was 21.9 (0.8). [Table 1] shows demographic and clinical characteristics of study population.
Table 1: Demographic and clinical characteristic of study population

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Health literacy and knowledge about heart failure

The findings showed that 165 (69.3%) of our study population had appropriate health literacy, and there was no significant difference between men and women regarding health literacy (70% of women and men had appropriate health literacy).

One hundred and twenty six (52.9%) of patients had adequate knowledge of HF. There is also no gender difference regarding knowledge about HF (54.1% of men and 50.6% of women had adequate knowledge of HF, P = 0.3).

Analytical results related to demographic variables showed that there was a significant relationship between health literacy and age (P < 0.001), education level (P < 0.001), and marital status (P < 0.016). Hence, people with <50 years of age had a higher level of education and a higher level of health.

Furthermore, there was a significant relationship between the level of knowledge about HF and age (P < 0.001) and education level (P < 0.001), so that the level of awareness in the age group of 30–50 years, with a high school diploma or higher, was more than other groups. No significant relationship was found between the level of health literacy and knowledge with other demographic data and clinical variables including NYHA class, past medical history, and medications (all P > 0.05).

As shown in [Figure 1], data analysis showed a significant relationship between health literacy and the knowledge about HF (P = 0.02), with increasing level of health literacy, and the level of the knowledge about HF of individuals was also increased.
Figure 1: Distribution of frequency of health literacy among the studied population by the level of heart failure knowledge

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However, the findings showed that there was no significant relationship between the level of health literacy and the level of knowledge of HF with the frequency of admissions due to HF during 3-month follow-up (P < 0.05) [Figure 2], [Figure 3], [Figure 4], [Figure 5].
Figure 2: Distribution of frequency of health literacy by sequence number of admissions to emergency department during follow-up

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Figure 3: Distribution of frequency of knowledge of heart failure by sequence number of admissions to emergency department during follow-up

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Figure 4: Distribution frequency of health literacy by the number of readmissions during follow-up

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Figure 5: Distribution frequency of knowledge of heart failure by the number of readmissions during follow-up

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  Discussion Top


In this study, the level of health literacy and knowledge of HF and its relation with some demographic variables and the frequency of readmission in patients referring to the outpatient HF clinic were evaluated. The results showed that the majority of men and women studied had appropriate health literacy, and about half of the men and women surveyed had sufficient information about HF. In this regard, there were no statistical differences between men and women. The results of studies by Baker et al. also confirmed the lack of gender relations with the level of health literacy.[15],[16] This finding may indicate that today, more appropriate methods are available for patients to receive information that the role of gender is diminished, and the results may also indicate an increase in women's attention to their health and consequently the equality of health literacy with the men of the society. In addition, the results indicate that in today's care and treatment systems, effective methods for transferring health awareness to patients are used and that there is no difference between women and men in this field, and this knowledge is equally being shared with public, while in the past, conventionally, this information was available to men and men had more awareness than women.

Furthermore, the results of this study showed that there is a reverse relationship between health literacy and age of the studied subjects, so that with increasing age, the level of health literacy and their awareness decreased. In the study of Tol et al. that examined the status of health awareness and health in Type 2 diabetic women referring to hospitals affiliated to Tehran University of Medical Sciences, the results indicated that with increasing age, health literacy decreases in patients.[17] Another study by Cho et al., entitled “Health Literacy Effects on General Health and Health Behaviors in the Elderly,” highlighted that with age, the level of health literacy among older people has decreased.[18] In the study of Delavar and Tadayyonfar which was carried out as a survey of knowledge of patients with HF admitted to Sabzevar Hospital, some of the exacerbating factors of the disease were reported between the age group and knowledge level that the age group of 30–49 years old had the highest and the age group of 80–89 years had the lowest level of knowledge about HF.[19] The results of these studies are consistent with the findings of this study. Possible reasons for this finding can be the reduced ability of older people to access and keeping up-to-date with their health and disease and information resources, reduced ability to go to centers timely, and their concentration on other things rather than their diseases, such as family management and related issues, and perhaps, lack of importance of the elderly's health-care needs in the perspective of health-care workers is another issue that can be mentioned which makes the need for further study in this regard more important from the perspective of health-care workers. The results of this study indicated that there was a relationship between the mean of health literacy and the mean of knowledge with different levels of education, that is, people with higher educational levels had higher levels of health literacy and higher awareness. The highest level of health literacy was observed in people with undergraduate degrees and higher education, and the lowest levels of health literacy and awareness were observed among those whose education was limited to only reading and writing. The results of the study by Tehrani Banihashemi et al., which examined the health literacy in 5 provinces of Bushehr, Mazandaran, Kermanshah, Qazvin, and Tehran and its effective factors on 18-year-olds, showed that the level of education has the strongest link with the level of health literacy and the highest score was observed in the level of health literacy in people with over 8 years of education.[7] The high level of health literacy and awareness among people with higher education in this study confirms the role of education in this study, which is consistent with the results of other studies, including that of Macabasco-O'Connell entitled “The Link between Health Literacy, Awareness and Self-Care among Cardiac Patients with the Quality of Their Lives,”[20] and a study of Ghahramani et al. titled “Study of the Relationship between Health Literacy and Self-Care, on Knowledge, Function and Hospitalization of Patients with Heart Failure Hospitalized in Ardabil City Hospitals.”[21] Higher education seems to be affecting people's health literacy because of their relationship to better job opportunities and higher earnings and easier use of various educational facilities (such as the Internet and pamphlets).

The results of health literacy according to marital status showed that there is a significant difference between the mean of health literacy of different groups in terms of marriage. Hence, health literacy scores in single individuals were higher than other groups. The highest level of health literacy was observed in single patients and the lowest in widows. It seems that being single, not having family responsibilities, and spending more time to learn from different sources and updating this information seem to have better health literacy. On the other hand, more single people are likely to be attracted to the follow-up of the disease. Contrary to the current study, a study done by Mahnoosh Reisi et al., entitled “Health Literacy Relationship with General Health and Behaviors in Elderly People in Isfahan,” showed that married people had higher levels of health literacy. According to the results, there was a significant relationship between health literacy and knowledge.[8] In other words, the higher the health literacy of the people, the greater their awareness of their illness. In this study, the majority of people with adequate knowledge have appropriate health literacy. Accordingly, the results of Peerson and Saunders, titled “Health Literacy and Reinvestment,” showed that people with poor health literacy skills had less awareness about health and received less prevention services.[22] The results of the study by Mosher et al., entitled “Health Literacy Relationship with Drug Awareness, Drug Compliance and Drug Misconduct among the Elderly,” showed a significant relationship between health literacy and knowledge of drugs, and the results of this study are in agreement with the present study.[23] Regarding the chronicity of the nature of the disease, it seems that repeated referrals to health centers increase the health literacy of people with this disease. Increasing the level of health literacy increases patient's sensitivity and attention to the consequences and causes of illness, which subsequently increases the level of awareness of the disease and its various issues and dimensions, and therefore they tend to control their disease. Consequently, they show more sensitivity to timely referral to the doctor, scheduled appointments, medications, and the correct way of taking medications, paying attention to drug labels, and they are generally trying to do the right thing.

Furthermore, the findings of this study showed that there is no significant relationship between health literacy and knowledge of HF and the number of visits to emergency services and readmissions. The results of Lee et al., under the title of “The Use of Health Literacy and Health Status in Taiwan's Adults,” also suggested that there was no statistically significant relationship between the level of health literacy and referral to the emergency department.[24] Contrary to the present study, the results of a study done by Baker et al. showed that people with a low level of health literacy referred to doctors more than others and admitted to the hospital. They concluded that low levels of health literacy led to frequent and unnecessary referrals of people to the physician, as well as the lengthy stays of patients in the hospital. This, in turn, increases costs or in other words wastes part of the health sector budget.[16] Findings of Delavar and Tadayyonfar study showed that there is a significant relationship between knowledge and hospitalization due to heart disease. Nearly 27.1% had good knowledge and 59.4% had moderate knowledge and only 6.2% had a good knowledge without a history of hospitalization.[19] Since the main causes of mortality and quality of life in patients with HF are rooted in improper self-care and lack of knowledge about diet and treatment methods, the patient will need to know how to identify risk symptoms and signs of exacerbation of the disease and indications that need to be reported to health-care professionals and have adequate knowledge and illiteracy about their illness because understanding the causes of the cardiac failure that exacerbates the recurrence of untreated HF attacks is important to improve the quality of life and increase the life span of patients.

Study limitation

For as far as we have studied and researched, only a few studies have investigated health literacy in Iranian patients with cardiovascular disease, and the current study is the first study in which the relationship between health literacy and knowledge about the HF has been investigated. The careful selection and uniform nature of study population (HF patients with reduced ejection fraction) can be strength of our study. However, this study has been performed in a tertiary center for HF programs, and most of the referral patients have more advanced disease and frequent hospital visits, so they may have enough time to improve their health literacy as well as their knowledge about HF, so results of this study may not be generalized to all HF population. This fact may be the main limitation of this study.


  Conclusion Top


According to the results of this study, the higher the health literacy of the people, the greater their awareness of their illness, and the understanding of patients will increase their recommendations and health outcomes about their illness. Since nurses and health-care providers play a significant role in the care and treatment of HF patients, they can improve their health literacy by educating them correctly, which can rectify many problems, such as drug errors, recurrent physician referrals, and re-admitting to the hospital and generally affecting the quality of services in the health-care system.

Acknowledgment

In this respect, we would like to thank all the staff of the Rajaie Hospital and the patients who were involved in the project. We would also thank our colleague Dr. Nick Austin for the language editing of the paper.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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