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Abstract
Objectives Personal health literacy is the degree to which individuals have the ability to find, understand and use information and services to inform health-related decisions and actions for themselves and others. Health literacy levels remain low, despite the many measures that have been taken to improve it. In addition, the number of patients with chronic diseases is increasing. Our study aimed to explore the different aspects and factors influencing health literacy among patients with chronic diseases in Chongqing, China.
Design Cross-sectional study.
Setting and patients This study was conducted in Chongqing using the 2018 National Questionnaire on Health Literacy of Residents administered to 27 336 patients with chronic diseases.
Outcome measures The prevalence and factors of health literacy in patients with chronic diseases.
Results Among the patients who participated in the study (n=27 336), 51.3% were males. Only 21.6% of the patients with chronic diseases had adequate health literacy (questionnaire score was equal to or exceeded 80% of the total questionnaire score). Patients with chronic diseases aged 25–34 years (OR=1.18, 95% CI 1.02 to 1.36) and 35–44 years (OR=1.18, 95 % CI 1.03 to 1.35) had higher health literacy than patients aged 65–69 years. Patients from rural areas had higher health literacy levels than those from urban areas (OR=0.92, 95% CI 0.86 to 1.00). Furthermore, married patients had lower health literacy than unmarried patients (OR=0.88, 95% CI 0.80 to 0.97). Patients who were illiterate or slightly literate (OR=0.10, 95% CI 0.08 to 0.12) had lower health literacy than patients who were in junior college or had a bachelor’s degree or above. In addition, non-farmers had higher health literacy levels than farmers (OR=1.18, 95% CI 1.08 to 1.28). In terms of inadequate health literacy, patients who self-rated themselves as healthy had higher health literacy than those who self-rated as unhealthy (OR=1.80, 95% CI 1.33 to 2.43).
Conclusions The health literacy of patients with chronic conditions remains at a low level and varies significantly with their demographic and social characteristics. These findings indicate that targeted interventions may be useful to improve health literacy in patients with chronic conditions in China.
- Health Literacy
- Chronic Disease
- Patient
- China
Data availability statement
No data are available.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
This study aimed to explore the relationship between self-rated health status and health literacy level in patients with chronic diseases.
The sample is sufficient and covered a wide range of persons (in terms of age) with chronic disease.
Instead of using a specific health literacy questionnaire for chronic diseases, the Chinese population health literacy questionnaire was used to study the population and then screen out those with chronic diseases.
Limitations of the study include that the questionnaire was administered through a self-assessment method (including the question: Do you have a doctor-identified chronic disease?) that may be subjective and may bias the data, and that causality cannot be ascertained and only prevalence rates can be obtained, due to the cross-sectional nature of the study.
Introduction
Chronic diseases, also known as non-communicable diseases, tend to last longer and are the result of a combination of environmental, behavioural, physiological and genetic factors.1 Chronic diseases account for an increasing number of deaths worldwide.2 The WHO has reported that 74% of deaths globally are due to chronic diseases in 2019.3 Premature mortality caused by chronic diseases accounts for 80% and is often concentrated in low/middle-income countries.4 In China, chronic diseases have become the main cause of death among Chinese residents, and the prevalence rate is on the rise. From 2003 to 2013, the growth rate of chronic diseases among rural residents was 70.7%, while that of urban residents was 28.3% according to the number of patients.5 In 2019, the number of deaths caused by chronic diseases among Chinese residents accounted for 88.5%,6 and the ratio was only 86.6% in 2012.7 Chronic diseases are long-lasting conditions that can usually be controlled but not cured, thereby causing a heavy financial burden to individuals, families and society, and even reducing the quality of life in many cases.8–10 Moreover, chronic diseases have been often overlooked as important contributory risk factors for cancer.11
Chronic disease prevention and improved interventions pose a complex and long-term challenge. Many risk factors exist for chronic diseases. Conditions such as musculoskeletal disorders,11 sedentary behaviour,12 and failing to meet recommendations for fruits and vegetables and sugar-sweetened beverage intake13 may increase the risk of chronic diseases. However, existing chronic disease management programmes, such as the National Basic Public Health Service Program, the Health Literacy Promotion Action, Health China Walk, the 3-year health literacy promotion action in poor areas and other special health literacy promotion projects,14 15 have all failed to adequately meet the most critical needs of patients.16
‘Personal health literacy’ refers to the degree to which individuals have the ability to find, understand and use information and services to inform health-related decisions and actions for themselves and others.17 Annual household income, education level and age have been shown to have significant correlations with health literacy levels for chronic disease prevention and treatment among residents.18–20 Improving health literacy is a strategy for disease prevention, but it does not solve other issues related to the social determinants of health that also impact disease prevention, such as education, income and housing. Health literacy should be assessed and addressed in adults with chronic conditions for intervention or self-management.15 21 Another study suggested that low levels of health literacy were major barriers preventing a number of patients from managing their chronic illnesses.21 Many might argue that in clinical practice, we do not need to assess the individual level of health literacy for every patient but rather change the demands in the healthcare system so that what we ask patients to do is clearly understandable—regardless of their literacy level. Therefore, evaluating the levels and influencing factors of health literacy among patients with chronic diseases is extremely necessary.
Thus far, there is a growing body of research assessing health literacy in patients with chronic disease, including a number of systematic reviews.22–24 However, there are few effective measures for the level and factors of health literacy among patients with chronic diseases. Accordingly, the present study aimed to explore the different aspects and influencing factors of health literacy among patients with chronic diseases in Chongqing, China. The findings will provide a reference for designing effective health education and health promotion programmes for patients with chronic diseases.
Methods
Study design, setting and participants
A cross-sectional study was carried out from July 2018 to September 2018 in Chongqing, China. Multistage stratified sampling was used to randomly select 234 study sites from 19 districts and 20 counties in Chongqing. Six study sites (including street offices and towns) were randomly selected for each district or county, while two communities or villages were randomly selected for each street office and town, respectively. Seventy families were randomly selected in each community or village. One inhabitant from each family aged 15–69 years was selected using the Kish table method for study. Residents who self-reported being diagnosed with chronic diseases were selected from all the respondents.
The sample size was estimated based on the health literacy level of 17.06% of urban and rural residents in China in 2018 (p=0.1706). The allowable relative error was 15%, while the allowable absolute error was δ=0.1706×15%=0.02559; in addition, μα=1.96, deff=3. This was calculated according to the following formula: N=μα2×p (1–p)/δ2×deff, n=2490. Considering invalid questionnaires and rejection rates, the actual sample size was expanded by 10%, n=2490 (1+10%)=2739. A total of 27 336 patients with chronic diseases completed this study after excluding the missing data. A questionnaire was judged as invalid when more than 15% of the options or answers in total did not provide a clear understanding of the respondent’s opinion on the question. The patients self-reported being diagnosed with chronic diseases, including hypertension, heart disease, hyperlipidaemia, cerebrovascular diseases (eg, stroke, cerebral infarction and cerebral thrombosis), diabetes mellitus, malignant tumours, depression/anxiety, chronic obstructive pulmonary disease, bronchial asthma, interstitial lung disease and sleep disorder-related breathing problems. A combination of a face-to-face interview and an on-site self-administered questionnaire was adopted in the questionnaires. The informed consent of all respondents was obtained. The inclusion criteria were as follows: (1) volunteered to participate in this research activity and (2) participated fully in the entire research process without withdrawing, while the exclusion criterion was applied to people who cannot express their thoughts clearly. Informed consent information was dictated to illiterate people so that the study can be conducted with their consent. Six assistant researchers who were trained through the form of lecture knowledge collected the data. The sample size of interviewees was reached until the data began to be repeated, or when the information was saturated, and the data analysis was no longer presenting new themes. Through literature review, expert consultation and the formulation of an interview outline based on the research purpose, the interview outline of this study was modified after a pre-interview with three respondents and was agreed upon by all members of the research team.
Questionnaires
The 2018 National Questionnaire on Health Literacy of Residents was adopted in the study. This questionnaire was based on the knowledge, attitude and practice model and ‘Chinese Citizens’ Health Literacy-Basic Knowledge and Skills (Trial)’.25 The questionnaire included two sections: demographic and socioeconomic characteristics and health literacy questions.
Demographic and socioeconomic characteristics
This part included 10 items: gender (male/female), registered permanent residence (local/non-local), residence (urban/rural), age (15–24, 25–34, 35–44, 45–54, 55–64 and 65–69 years old), nationality (Han nationals/minorities), marital status (unmarried/married), educational level (illiterate or slightly literate, primary school, secondary school, high school/vocational high school/technical secondary school, junior college/bachelor’s degree or above), vocation (farmer/not farmer), annual average family income (<¥3000/¥3000–¥4999/¥5000–¥9999/¥10 000–¥14 999/≥¥15 000) and self-rated health status (healthy/neutral/unhealthy).
Health literacy
The part of health literacy questionnaire consisted of 50 items, in which the items on the three aspects of health literacy and six categories had overlapped. The correct answers to the true or false questions (8 items in total), single-choice questions (26 items in total) and multiple-choice questions (16 items in total) were assigned 1, 1 and 2 points, respectively. Therefore, the total score of the questionnaire was 66. The evaluation of residents’ health literacy level included three parts that aimed to evaluate the following: (1) the overall health literacy level of urban and rural residents in China, (2) the health literacy levels of residents in three aspects (ie, basic health knowledge and concept, healthy lifestyle and behaviour and basic skill literacy) based on the ‘Chinese Citizens’ Health Literacy-Basic Knowledge and Skills (Trial)’, and (3) the health literacy level was evaluated using six categories of literacy: scientific health concept, infectious disease prevention and control, chronic disease prevention and control, safety and first aid, basic medical and health information literacy using public health issues as the guide. The residents’ overall health literacy level was evaluated.
‘Health literacy level’ refers to the proportion of people with basic health literacy in the total population.14 For each participant in the current study, a questionnaire score of 80% (the total scores of=53) or more of the total score is considered to have the basic health literacy level.
Three aspects of health literacy
In this questionnaire, 50 items were divided into three aspects of health literacy: basic knowledge and ideas (22 items), healthy lifestyle and behaviour (16 items) and health skills (12 items). The total scores of the three items (28, 22 and 16 points) were more than 22, 18 and 13 points, respectively, which were judged to have adequate health literacy (the questionnaire score was equal to or exceeded 80% of the total questionnaire score).
Six types of health issues literacy
In this questionnaire, 50 items were divided into six types of health issues literacy: scientific health view (8 items), prevention and control of infectious diseases (6 items), prevention and treatment of chronic diseases (9 items), safety and first aid (10 items), primary care (11 items), health information (6 items) and public health problems in China. The total scores of these items (11, 7, 12, 14, 14 and 8 points) were more than 9, 6, 10, 11, 11 and 6 points, respectively, which were judged to have adequate health literacy.
Internal reliability
The overall level of the health literacy was assessed by the internal reliability and the Kuder-Richardson-20 (KR-20) value of 0.922. The basic knowledge and ideas, healthy lifestyle and behaviour, and health skills literacy demonstrated acceptable internal consistency, with KR-20 values of 0.836, 0.773 and 0.775, respectively. The literacy levels regarding scientific health view, prevention and control of infectious diseases, prevention and treatment of chronic diseases, safety and first aid, primary care and health information demonstrated acceptable internal consistency, with KR-20 values of 0.676, 0.506, 0.669, 0.737, 0.684 and 0.606, respectively.
Data analysis
All data analyses were conducted using statistical software (IBM SPSS V.23.0). The demographic and socioeconomic characteristics of patients with chronic diseases were calculated using descriptive statistics, including frequency and percentage. Pearson χ2 tests were used to compare the differences in categorical variables. In addition, logistic regression analysis was used to investigate the association between health literacy among patients with chronic diseases and social characteristics. A two-sided test was performed to check all statistics, and a p value of <0.05 was regarded as having statistical significance.
Patient and public involvement
There are patients participated in this study and written informed consent was obtained from all patients.
Results
Demographic and socioeconomic characteristics
This study included 27 336 patients with chronic diseases, and the response rate was 99.75%. Summarising the demographic characteristics of patients, a total of 14 023 (51.3%) patients were males, and 24 801 (90.7%) were Han nationals. The mean, SD and minimum and maximum values of age were 48.56, 13.34, 15.00 and 70.00, respectively. The mean, SD and minimum and maximum values of the annual average family income (¥) were 114 975.89, 16 780 698.12, 0.00 and 2 774 465 785.00, respectively (online supplemental table 1).
Supplemental material
Health literacy
As shown in online supplemental table 2, 21.6% of the respondents had adequate health literacy. In addition, 31.1%, 22.6% and 24.2% had adequate health literacy levels in the dimensions of basic knowledge and ideas, healthy lifestyle and behaviour and health skills, respectively. Among the six types of health issues literacy, 34.1%, 21.6%, 23.1%, 51.4%, 26.7% and 28.2% of the respondents had adequate literacy levels in the dimensions of scientific health view, prevention and control of infectious diseases, prevention and treatment of chronic diseases, safety and first aid, primary care and health information, respectively.
Supplemental material
Online supplemental table 2 shows the statistically significant differences found between the demographic characteristics of registered permanent residence, age, nationality, marital status, educational level, vocation, annual average family income, self-rated health status and the overall level of health literacy (p<0.05). The health literacy levels of patients with chronic diseases are as follows: (1) A1: basic knowledge and ideas=31.1, (2) A2: healthy lifestyle and behaviour=22.6, (3) A3: health skills=24.2, (4) B1: scientific health view=34.1, (5) B2: prevention and control of infectious diseases=21.6, (6) B3: prevention and treatment of chronic diseases=23.1, (7) B4: safety and first aid=51.4, (8) B5: primary care=26.7, (9) B6: health information=28.2 and (10) Overall: overall level of health literacy=21.6. The health literacy level of patients with chronic diseases aged more than 65 years was the lowest in all age groups, whereas that in the 25–34 age group was the highest (p<0.001). The health literacy level among patients with chronic diseases from rural areas was lower than those from urban areas (p<0.001), while those who were Han nationals had a higher health literacy level than minorities (p<0.001). The literacy level of married patients was lower than that of unmarried patients (p<0.001), while farmers had statistically lower levels of health literacy than those who were non-farmers (p<0.001). Furthermore, the literacy level was lower in patients who were locally registered permanent residents compared with permanent residents who were not locally registered (p<0.001). Patients with an average annual household income of less than ¥3000 had the lowest health literacy level among all income groups, whereas those with more than ¥15 000 had the highest health literacy level (p<0.001). In terms of education, the literacy level of patients who were in junior college or had a bachelor’s degree or above was the highest among all educational level groups, whereas the health literacy level of illiterate or slightly literate patients was the lowest (p<0.001). Finally, the health literacy level of patients with self-rated good health was the highest in all health status groups, whereas that of patients who self-rated as unhealthy was the lowest (p<0.001).
Logistic regression model for association between health literacy social characteristics
Several factors were viewed in the modelling of the effects of the overall health literacy level among Chinese patients with chronic diseases, including residence, age, nationality, marital status, educational level, vocation, annual average family income and self-rated health status (online supplemental table 3).
Supplemental material
Patients with chronic diseases aged 25–34 years (OR=1.18, 95% CI 1.02 to 1.36) and 35–44 years (OR=1.18, 95 % CI 1.03 to 1.35) had higher health literacy levels than patients aged 65–69 years. Patients from rural areas had higher health literacy levels than those from urban areas (OR=0.92, 95% CI 0.86 to 1.00). Those who were Han nationals had a higher health literacy level than patients who were minorities (OR=1.31, 95% CI 1.17 to 1.48), while married patients had a lower health literacy level than unmarried patients (OR=0.88, 95% CI 0.80 to 0.97). Illiterate or slightly literate patients (OR=0.10, 95% CI 0.08 to 0.12), and those with primary education (OR=0.20, 95% CI 0.18 to 0.23), secondary education (OR=0.46, 95% CI 0.41 to 0.51) and high school or vocational high school or technical secondary school education (OR=0.72, 95% CI 0.65 to 0.80) had inadequate health literacy levels than patients who were in junior college or with bachelor’s degree or above. Patients who were non-farmers had higher health literacy levels than those who were farmers (OR=1.18, 95% CI 1.08 to 1.28). In terms of income, patients with an average annual household income of less than ¥3000 (OR=0.65, 95% CI 0.58 to 0.73), between ¥3000 and ¥4999 (OR=0.74, 95% CI 0.66 to 0.84) and between ¥5000 and ¥9999 (OR=0.79, 95% CI 0.72 to 0.86) had inadequate health literacy levels than patients with an average annual household income of more than ¥15 000. Finally, patients with self-rated health had higher health literacy than patients who self-rated as unhealthy (OR=1.80, 95% CI 1.33 to 2.43).
Discussion
As indicated in this cross-sectional study, the overall level, as well as the three aspects of health literacy and six types of health issues literacy among patients with chronic diseases, were inadequate; the total health literacy level among them was less than 22.0%. Nevertheless, our study yielded higher health literacy among patients with chronic diseases (21.6%) in Chongqing compared with the health literacy levels of urban and rural residents (17.06%) in 2018, and the three aspects of health literacy, except for scientific health view of six types of health issues literacy.25 A study on health literacy among patients with chronic cardiovascular diseases in the city of Juiz de Fora found that less than half (49.3%) of those with chronic cardiovascular conditions had adequate functional health literacy.26 Without considering the different contents and standards of health literacy assessment tools in different studies, the total health literacy level among patients with chronic diseases in China may be lower than those in other countries.
Moreover, the current study found that the proportion of patients who had adequate health literacy in the ‘healthy lifestyle and behaviour’ dimension was lower than in the ‘basic knowledge and ideas’ dimension. A research study on smoking-related knowledge, attitudes and behaviours among young adult male smokers found that respondents had better health knowledge; however, that particular knowledge did not necessarily translate into healthy behavioural outcomes.27 This indicates that specific knowledge may not necessarily translate into behaviour due to certain reasons (eg, lack of resources that can impede change, lack of support, ambivalence, different values, different priorities, culture and social norms). In the future, effective strategies to transform existing health knowledge into healthy behaviours should be emphasised. In addition, among the six types of health issues literacy, the level of disease prevention and control literacy in patients with chronic diseases remains limited. Previous findings have demonstrated that patients with chronic illness with insufficient knowledge of chronic diseases may not achieve self-management.28 Therefore, formulating targeted measures to improve the level of disease prevention and control literacy among patients with chronic diseases is necessary.
The association between educational level and health literacy levels (ie, health literacy is linked to educational level) is the primary focus of this study. This result is consistent with the study on health literacy in familial hypercholesterolaemia showing educational level-related variations in health literacy.29 One possible reason is that patients with higher education possibly may have had additional learning opportunities and, therefore, additional knowledge. The relationship between age and health literacy level is also observed in this study, indicating the link between low health literacy and the elderly. A previous study on the assessment of health literacy among patients in primary healthcare centres has also reported this relationship.30 Poor educational conditions and situations in the past may possibly explain the elderly’s low level of health education, which has also been mentioned in a related study.31 Therefore, the level of health education has an important impact on health literacy among patients, and health education is an important means to improve the health literacy among patients.
This study also explored the relationship between self-rated health status and health literacy level in patients with chronic diseases. Our finding revealed that patients who self-rated themselves as healthy were more likely to have adequate health literacy than the patients who self-rated themselves as unhealthy. However, further studies are needed to determine the causes of this relationship. This study also found that patients with a high annual average family income were more likely to have adequate health literacy than those with a low annual average family income. Previous studies have shown that the related health benefits and services are less likely to be accessed by economically disadvantaged groups than by economically affluent groups.32 33 Thus, income level is possibly one of the economic determinants linked to health literacy among patients with chronic diseases.29
The current study further determined that married patients had lower health literacy than unmarried patients, and locally registered permanent residents had higher health literacy than permanent residents who were not locally registered. Notably, this study also found that patients from rural areas had higher health literacy levels than those from urban areas. This finding, though surprising, may possibly be due to their relative stability. However, further studies are needed to determine the causes of these phenomena.
A few suggestions are proposed to improve the health literacy levels in patients with chronic diseases and help them meet self-care demands. First, effective strategies to transform existing health knowledge into healthy behaviours should be emphasised. Second, developing and adopting appropriate health education programmes are necessary to improve the health literacy levels of different patients with chronic diseases. Third, the results of health self-evaluation should be valued. Finally, theory-based interventions to promote health literacy in clinical settings should be designed, implemented and evaluated for efficacy and effectiveness.
Conclusions
Among patients with chronic diseases in Chongqing, China, inadequate health literacy was observed in approximately 78.4% of the respondents; especially, the level of disease prevention and control literacy remained limited. Inadequate health literacy was associated with a lower educational level, higher age, being a farmer, having a low annual average family income and having self-rated unhealthy status. This study provides implications that can help in the formulation of targeted interventions offered to certain groups of patients. However, this study did not identify the specifics of how or what kinds of intervention entailed.
Data availability statement
No data are available.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by the Ethics Committee of the Chongqing Medical University (2017021). Written informed consent was obtained from all patients.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
HL, YW and CW are joint first authors.
Contributors HL, YW and CW wrote the draft of this paper together. HL, YW, CW, HZ and YC contributed to the design, data analysis, data interpretation and revision of the paper. HL, YW, CW, YZ, WL, YL and XZ conducted an on-site investigation, database establishment and data entry. JY and YZ contributed to data analysis, data interpretation and revision of the paper. MS edited and provided critical comments on the entire manuscript. HZ as an author responsible for the overall content as the guarantor. All authors helped in the revision of the paper. All authors have read and approved the final version of the paper.
Funding This work was supported by the Technology Foresight and System Innovation Project in Yuzhong District of Chongqing (20180161).
Competing interests None declared.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.