The association of health literacy with illness perceptions, medication beliefs, and medication adherence among individuals with type 2 diabetes

Considering health literacy in communication about medications between nurses and patients with heart failure: A cross sectional observational study

OBJECTIVES

To explore the content, style, and initiation of medication-related discussions between nurses and patients to understand how nurses support patients with heart failure, especially those with inadequate health literacy.

METHODS

A cross-sectional design was conducted to observe medication-related conversations between nurses and patients with heart failure in four Dutch outpatient clinics. Conversations were audio-recorded and analyzed using MEDICODE, focusing on content, communication style (monologue or a dialogue), and initiation of the content themes. Health literacy was assessed using the NVS-D and the SBSQ. Results between health literacy groups were compared with descriptive analyses.

RESULTS

A total of 56 patients and 14 nurses participated in the study. Patients classified by one or both of the instruments as having inadequate health literacy (n = 33; 59 %) were generally older, had lower educational levels, and were more often accompanied by informal caregivers. Key themes discussed in the medication-related conversations included how the medication was identified ('medication designation), its dosage and instruction, main effects, side effects, attitude or emotions and other ('various') themes. The 'medication designation' theme was significantly more frequently discussed in the group with adequate health literacy, whereas 'attitude or emotions' and 'various themes' were more commonly discussed among those with inadequate health literacy. Most conversations were nurse-initiated and tended to be monologues, with nurses mainly serving as information providers.

CONCLUSIONS

Nurses primarily initiated and dominated medication-related discussions with a focus on factual aspects of medication, while patients initiated more discussions about their concerns regarding medication. While there was overlap in the topics discussed, notable differences emerged between patients with adequate and inadequate health literacy.

PRACTICE IMPLICATIONS

Improving communication strategies, such as structuring conversations and adopting dialogic approaches may improve patients' engagement and understanding of medication use, leading to more effective management of their condition, particularly benefiting patients with lower health literacy.

Association of health literacy with illness perception of Chinese community patients with chronic disease

BACKGROUND

This study aimed to examine the association between health literacy and illness perception among Chinese patients with chronic disease in the community through a national cross-sectional study.

METHODS

This cross-sectional study was conducted in China from June 20, 2022, to August 31, 2022, and used a multistage sampling approach to select patients with chronic diseases. The study included 5,525 participants from 15 provinces, drawn from the Psychology and Behavior Investigation of Chinese Residents in 2022. We constructed univariate analysis, smooth curve fitting, threshold saturation effect analysis, and forest plot of subgroup analysis to evaluate the association between health literacy and illness perception.

RESULTS

The analysis revealed an inverted J-shaped association between health literacy and illness perception (P < 0.001). Moreover, the identified inflection point was 22.22. When the health literacy score was below 22.22, illness perception exhibited a positive association with health literacy (β = 0.12, 95%CI = 0.03, 0.21, P = 0.009). When the health literacy score was higher than 22.22, illness perception decreased with the increasing health literacy (β=-0.23, 95%CI=-0.27, -0.19, P < 0.001). The significant association between health literacy and illness perception did not differ significantly across subgroups, except for the Hukou subgroup.

CONCLUSIONS

This study determined a threshold of health literacy that was associated with the illness perception of Chinese chronic disease patients. Additionally, an inverted J-shaped association between health literacy and illness perception was observed, suggesting that targeted health literacy intervention measures should be tailored to specific chronic disease groups rather than a uniform approach.

CLINICAL TRIAL NUMBER

Not applicable.

A Quantitative Study Exploring and Comparing Key Factors in Medication Management in the Irish Healthcare Setting

BACKGROUND

Shared decision-making in the context of medication management has been shown to be contingent on information-seeking behaviours such as patient knowledge, self-efficacy and engagement.

OBJECTIVE

The aim of this study was to: (i) compare differences in perceptions of patients' knowledge, capabilities and engagement across healthcare professionals (HCPs) and patients and family caregivers and (ii) investigate associations between these factors and patients' medication beliefs using a cross-sectional survey study of patients, family caregivers and community and hospital HCPs in Ireland.

METHODS

Two cross-sectional surveys measuring key factors in medication management were distributed to patients and family caregivers taking three or more medicines and HCPs involved in medicines management. χ2 tests were used to investigate differences between HCPs and patients and family caregivers. Multivariable linear regression with adjustment for the socio-demographic covariates was used to examine key factors in medication management and beliefs about medicine (BMQ-General) in patients and family caregivers.

RESULTS

Overall, 636 responses were received; patients and family caregivers (N = 134, 21%), community (N = 313, 49%) and hospital HCPs (N = 189, 30%). A higher proportion of patients and family caregivers self-reported as 'knowledgeable' about medications (N = 76; 56.7%) than community (N = 75, 24%) and hospital HCPs (N = 44, 23.3%) (p < 0.01). The majority of patients and family caregivers were 'fairly/very confident' they could maintain an accurate medication list without assistance (N = 78; 58.2%), compared to the majority of the community (N = 213, 68.1%) and hospital HCPs (N = 114, 60.3%) who were 'not at all/somewhat confident' (p < 0.01.) These patients and family caregivers also had significantly lower overall beliefs in medication harm (β = -1.23, 95% CI: -2.34, -0.13). Patient and family caregivers who asked HCPs about their medication frequently (> 7 times per year) had higher overall beliefs in medication overuse (β = 1.88, 95% CI: 0.06, 3.69) and medication harm (β = 2.65, 95% CI: 1.10, 4.20), compared to those who never asked.

CONCLUSION

There was divergence between HCPs and patients and family caregivers in their assessments of patients' medication knowledge and capabilities. Engagement between HCPs and patients around medication should be purposeful rather than frequent, to alleviate fears about overuse and harm.

PATIENT OR PUBLIC CONTRIBUTION

The patient and family caregiver survey was developed in partnership with members of the Patient and Public Involvement (PPI) group. Feedback was provided by the group to increase accessibility of survey and maximise distribution. In addition, the survey was piloted among members of the public involved in medication management.

Illness perceptions among individuals with endometriosis and their longitudinal associations with psychological distress and pain

This study examined the illness perceptions held by individuals living with endometriosis, and their associations with psychological distress and chronic pain, over time. At baseline, 408 participants provided demographic and clinical information and completed measures of illness perceptions, anxiety and depression, and pain. One-year later, 283 of these participants completed the same measures again. Results showed that participants held largely negative perceptions of their endometriosis, perceiving adverse consequences, enduring timeline, and negative emotional representations of their condition. Additionally, participants felt a lack of personal control over the condition. Multiple regression analyses (controlling for demographics, clinical factors, and baseline levels of the outcome variables) showed that illness perceptions do not predict anxiety and depression at 12-month follow-up. However, the perception of illness timeline did significantly predict pain intensity at follow-up.

Health literacy and medication adherence in adults from ethnic minority backgrounds with Type 2 Diabetes Mellitus: a systematic review

BACKGROUND

For people living with Type 2 Diabetes Mellitus (T2DM), achieving optimal health outcomes requires optimal self-management and adherence to medical treatment. While some studies suggest an association between poor medication adherence and lower levels of health literacy, the evidence for this association remains inconclusive. This systematic review aimed to synthesise the evidence on the association between health literacy and medication adherence among adults from ethnic minority backgrounds living with T2DM.

METHODS

Medline (Ovid), The Cochrane Library, Embase (Ovid), PsycInfo (EBSCO), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO) were searched systematically for peer-reviewed literature, published until January 2024. Studies were included in this review if they assessed health literacy and medication adherence among ethnic minority people with T2DM. Two reviewers independently screened and selected the studies, extracted data from the included articles, and assessed the methodological quality of the studies. The methodological quality and bias in designing, conducting, and analysis of each study were evaluated using a standardised JBI critical appraisal tool.

RESULTS

Of the total 6,318 identified studies, seven studies were included in the review. The total participant sample sizes across these studies varied from 53 to 408 participants. All included studies incorporated cross-sectional design for the research, with the majority conducted in the USA. Of the seven unique studies, only one study observed a significant association between health literacy and medication adherence among people from an ethnic minority background.

CONCLUSIONS

Evidence on the association between health literacy and medication adherence in ethnic minority adults with T2DM is weak and inconsistent. To understand this association more clearly in ethnic minority populations and to address the disparities in cultural and linguistic considerations, well-designed studies are required.

TRIAL REGISTRATION

This review is registered with PROSPERO (CRD42022328346).

The influence of family health on self-efficacy in patients with chronic diseases: the mediating role of perceived social support and the moderating role of health literacy

BACKGROUND

Chronic diseases are a global health challenge, and therefore, more attention should be paid to improving self-efficacy in people with chronic diseases. This study examined the relationship between family health and self-efficacy, and explored the mediating role of perceived social support and the moderating role of health literacy. The aim is to enhance the self-efficacy of chronic patients by improving family health, social support, and health literacy, thereby improving their physical and mental state.

METHODS

A cross-sectional study based on psychological and behavioural factors was conducted, namely, the 2022 China Residents Survey, which included 5150 Chinese patients with chronic diseases. The General Self-Efficacy Scale-Short Form was used to assess self-efficacy, the Health Literacy Questionnaire-short form was used to assess health literacy, the Perceived Social Support Scale-Short Form was used to evaluate perceived social support, and the Chinese version of the Family Health Scale-Short Form was used to assess family health status.

RESULTS

Family health of patients with chronic diseases had a significant positive effect on self-efficacy. Perceived social support was identified as a partial mediator between family health and self-efficacy, accounting for 59.39% of the total effect. Health literacy moderated the impact of family health on perceived social support and self-efficacy.

CONCLUSIONS

Chronic diseases have become a global health challenge, and more attention should be paid to improving the self-efficacy of the chronically ill population. Our results not only facilitate the understanding of the relationship mechanisms between family health and self-efficacy in chronic patients but can also serve as a guide for healthcare workers and policymakers who wish to provide better care for patients.

Correlation between Illness Perception and Medication Adherence among Adult Patients with Type 2 Diabetes Mellitus in Saudi Arabia

Objectives

This study aimed to assess the level of illness perception and medication adherence among adult patients with type 2 diabetes mellitus (T2DM) in Jeddah, Saudi Arabia, with a specific focus on understanding how these two factors may be related.

Materials and Methods

This descriptive correlation study included all adult patients with T2DM attending the Jeddah Care Centre for Diabetes and Hypertension at King Abdulaziz Hospital between January and April 2022. Data were collected using a questionnaire that elicited sociodemographic and clinical information, and the Arabic versions of the Brief Illness Perception Questionnaire and the Morisky Medication Adherence Scale. Descriptive statistics and Pearson's correlation analysis were used for data analysis.

Results

A total of 365 patients were included (mean age: 50.9 ± 15.9 years), with the majority being female (53.4%). Overall, the level of medication adherence was moderate (mean score: 5.36 ± 1.73). Patients with lower medication adherence perceived the consequences of T2DM as more severe, had a stronger association with the illness identity, and experienced more intense emotional responses (for all, P < 0.001). Conversely, patients with higher adherence had a greater sense of personal control, a stronger belief in treatment effectiveness, and a better understanding of the illness (for all, P < 0.001).

Conclusion

The study found a correlation between illness perception and medication adherence in patients with T2DM. Addressing patients' perceptions may enhance their ability to manage the condition more effectively.

Health literacy and self-management among middle-aged and young hypertensive patients: a parallel mediation effect of illness perception and self-efficacy

Background

Hypertension is increasingly prevalent among young and middle-aged populations in rural China, accompanied by suboptimal self-management. Given that this population forms the backbone of the labor force, enhancing their self-management capabilities is crucial for improving overall population health. Studies indicate that individuals with good health literacy are more likely to effectively manage their health.

Methods

Grounded in the health literacy skills framework, a model was constructed in this study to examine the impact of health literacy on self-management among young and middle-aged hypertensive patients in rural China. Meanwhile, the mediating roles of illness perception and self-efficacy were also verified. Using a multi-stage stratified random sampling method, 338 patients were recruited to participate in the study. Structural equation modeling was utilized to establish the relationship model, and bootstrap tests were carried out to examine the mediating effects.

Results

The average self-management score was 70.45 ± 11.36. Health literacy exhibited a positive correlation with self-management (standardized β = 0.372, p < 0.001). The mediating effects through illness perception and self-efficacy were 0.040 and 0.236, constituting 6.68 and 39.31% of the total effect, respectively.

Conclusion

Illness perception and self-efficacy serve as parallel mediators amid the association between health literacy and self-management. Implementing psychological counseling and health education is imperative for augmenting self-management competence and cultivating an adaptive coping mentality.

Self-reported knowledge of tetrahydrocannabinol and cannabidiol concentration in cannabis products among cancer patients and survivors

PURPOSE

Cannabis use may introduce risks and/or benefits among people living with cancer, depending on product type, composition, and nature of its use. Patient knowledge of tetrahydrocannabinol (THC) or cannabidiol (CBD) concentration could provide information for providers about cannabis use during and after treatment that may aide in risk and benefit assessments. This study aimed to examine knowledge of THC or CBD concentration among patients living with cancer who consume cannabis, and factors associated with knowledge of cannabinoid concentrations.

METHODS

People living with cancer who consumed cannabis since their diagnosis (n = 343) completed an anonymous, mixed-mode survey. Questions assessed usual mode of delivery (MOD), knowledge of THC/CBD concentration, and how source of acquisition, current cannabis use, and source of instruction are associated with knowledge of THC/CBD concentration. Chi-square and separate binary logistic regression analyses were examined and weighted to reflect the Roswell Park patient population.

RESULTS

Less than 20% of people living with cancer had knowledge of THC and CBD concentration for the cannabis products they consumed across all MOD (smoking- combustible products, vaping- vaporized products (e-cigarettes), edibles-eating or drinking it, and oral- taking by mouth (pills)). Source of acquisition (smoking-AOR:4.6, p < 0.01, vaping-AOR:5.8, p < 0.00, edibles-AOR:2.6, p < 0.04), current cannabis use (edibles-AOR:5.4, p < 0.01, vaping-AOR: 11.2, p < 0.00, and oral-AOR:9.3, p < 0.00), and source of instruction (vaping only AOR:4.2, p < 0.05) were found to be variables associated with higher knowledge of THC concentration.

CONCLUSION

Self-reported knowledge of THC and CBD concentration statistically differed according to MOD, source of acquisition, source of instruction, and current cannabis use.

HbA1c control in type 2 diabetes mellitus patients with coronary artery disease: a retrospective study in a tertiary hospital in South Africa

Background

Type 2 diabetes mellitus (T2DM) patients with coronary artery disease (CAD) have an increased risk of recurrent cardiovascular events. These patients require optimal glucose control to prevent the progression of atherosclerotic cardiovascular disease (ASCVD). Contemporary guidelines recommend an HbA1c ≤7% to mitigate this risk. The aim of this study was to evaluate HbA1c control in T2DM patients with angiographically proven ASCVD.

Methods

We conducted a cross-sectional, retrospective study on consecutive T2DM patients with acute and chronic coronary syndromes managed in a tertiary academic hospital in South Africa. Glycaemic control was assessed by evaluating the glycated haemoglobin (HbA1c) level measured at index presentation with acute and chronic coronary syndromes and during the most recent follow-up visit.

Results

The study population comprised 262 T2DM patients with a mean age of 61.3 ± 10.4 years. At index presentation, 110 (42.0%) T2DM patients presented with ST-segment elevation myocardial infarction, 69 (26.3%) had non-ST-segment elevation myocardial infarction, 43 (16.4%) had unstable angina, and 40 (15.3%) had stable angina. After a median duration of 16.5 months (IQR: 7-29), 28.7% of the study participants had an HbA1c ≤7%. On multivariable logistic regression analysis, females were less likely to have poor glycaemic control (HbA1c above 7%) [odds ratio (OR): 0.42, 95% confidence interval (CI): 0.19-0.95, p=0.038]. Also, T2DM patients prescribed metformin monotherapy (OR: 0.34, 95% CI: 0.14-0.82, p=0.017) and patients with ST-segment depression on the electrocardiogram (OR: 0.39, 95% CI: 0.16-0.96, p=0.041) were less likely to have poor glycaemic control.

Conclusion

After a median duration of 16.5 months, only 28.7% of T2DM patients with CAD had an HbA1c ≤7%. This finding underscores the substantial unmet need for optimal diabetes control in this very high-risk group.

Using the theoretical domains framework to determine the barriers and facilitators to medication adherence in Parkinson's disease

Background

Patient medication adherence in Parkinson's Disease (PD) is often suboptimal. This may lead to poor symptom management, greater disease burden, decreased quality of life and increased healthcare costs. Use of psychological theory such as the Theoretical Domains Framework (TDF) has effectively captured barriers and facilitators to medication adherence in other long-term conditions. Applying this framework to medication adherence in PD could provide a better understanding of the challenges to inform the development of effective interventions.

Objectives

The aim of the study was to apply the TDF to determine the barriers and facilitators to medication adherence in people with PD.

Methodology

This qualitative study employed online interviews to explore medication adherence in a small group of people with PD recruited via Parkinson's UK and social media. A semi-structured interview schedule was designed informed by the 14 TDF domains. All interviews were audio-recorded, transcribed verbatim and mapped to the TDF using Framework Analysis.

Results

Twelve participants diagnosed with PD were interviewed, 11 of whom were currently taking prescribed medication plus another self-medicating with Vitamin B1. All TDF domains were evident in the data. Predominant facilitators were Domains 1 - Knowledge, 6 - Social Influence, and 12 - Beliefs about Consequences and barriers were 7 - Reinforcement, 10 - Memory, Attention and Decision Processes, and 11 - Environmental Context and Resources. Other themes were not related to medication adherence.

Conclusion

In this small group, all data relating to the barriers and facilitators for medication adherence in PD were successfully mapped onto the TDF. This indicates the utility of the framework for determining and structuring the factors to consider when providing medication support for this patient population in an accessible and coherent way. Further quantitative studies are needed to determine the extent to which these factors can be generalised to other PD patients.

Medication self-management in predominantly African American and Caribbean American people with epilepsy: The role of medication beliefs and epilepsy knowledge

INTRODUCTION

Suboptimal medication adherence is common in people with epilepsy (PWE) and disproportionally prevalent among racially/ethnically diverse patients. Understanding reasons and risks of suboptimal adherence is critical to developing interventions that reduce negative health outcomes. This cross-sectional study characterized common barriers to medication self-management, prevalence of negative medication beliefs, and gaps in epilepsy knowledge among predominantly African American and Caribbean American PWE and examined their interrelationships.

MATERIALS AND METHODS

Sixty-three PWE (Age = 42.1 ± 13.2; 60% female; 79% Black; 19% Hispanic/Latino) completed validated self-report questionnaires about medication self-management, medication beliefs, and epilepsy knowledge. Correlations and t-tests examined interrelationships.

RESULTS

Four barriers to medication self-management were common, including not taking antiseizure medications at the same time every day, forgetting doses, not planning refills before running out, and spreading out doses when running low. More than half the sample believed medications were overused by prescribers. Nearly one-third believed medications were harmful, and nearly a quarter believed their antiseizure medications were minimally necessary with almost half reporting elevated concerns about negative consequences of antiseizure medications. Poorer medication self-management was associated with stronger beliefs that medications in general are harmful/overused by prescribers. Individuals who were "accepting" of their antiseizure medications (i.e., high perceived necessity, low concerns) were less likely to spread out time between doses when running low compared to non-accepting counterparts. Knowledge gaps related to the cause of seizures/epilepsy, chronicity of epilepsy treatment, and seizure semiology/diagnosis were common. Nevertheless, epilepsy knowledge was unrelated to medication self-management and medication beliefs.

CONCLUSIONS

In these PWE, the most prevalent reasons for suboptimal medication self-management were behaviorally mediated and potentially modifiable. Negative medication beliefs and misconceptions about epilepsy and its treatment were common. Results further suggest that interventions addressing negative medication beliefs will be more effective than knowledge-based psychoeducation alone to improve medication self-management in this patient population.

The Mediating Effect of Self-Efficacy on the Relationship Between Medication Literacy and Medication Adherence Among Patients with Type 2 Diabetes

Background

Patients with type 2 diabetes have poor medication adherence. Medication literacy is one of the influencing factors of medication adherence among patients with type 2 diabetes. However, the mechanism by which medication literacy affects medication adherence among patients with type 2 diabetes is unclear. The aim of this study was to verify the mediating role of self-efficacy in the relationship between medication literacy and medication adherence.

Methods

A total of 402 patients with type 2 diabetes were enrolled in this study. The Chinese versions of the Medication Literacy Scale, the Self-Efficacy for Appropriate Medication Use Scale and the Morisky Medication Adherence Scale-8 were used in the survey. Pearson correlation analysis was used to find correlations among medication literacy, self-efficacy and medication adherence. The PROCESS macro (Version 4.1) with Model 4 for SPSS was used to verify the mediating role of self-efficacy.

Results

Twenty-four percent of the participants had poor medication adherence. Self-efficacy and medication literacy (r=0.499, p < 0.01) and medication adherence (r=0.499, p < 0.01) were significantly and positively correlated. Self-efficacy partially mediated the relationship between medication knowledge and medication adherence among patients with type 2 diabetes, accounting for 36.7% of the total effect.

Conclusion

Self-efficacy had a partial mediating effect on the relationship between medication literacy and medication adherence among patients with type 2 diabetes. Self-efficacy should be improved through effective measures to increase patients' confidence in adherence to antihyperglycemic drugs.

Psychosocial and behavioral correlates of self-efficacy in treatment adherence in older patients with comorbid hypertension and type 2 diabetes

BACKGROUND

Adhering to clinical prescriptions is known to protect against the effects of uncontrolled hypertension and of acute and chronic cardiovascular diseases, including diabetes. Contextually, positive associations between self-care behaviors and psychological constructs, such as self-efficacy, are widely acknowledged in the literature. However, still little is known about the psychological factors underlying the patient's self-efficacy. This study aimed to investigate the psychosocial and behavioral correlates of self-efficacy related to treatment adherence in older patients with comorbid hypertension and type 2 diabetes mellitus.

PARTICIPANTS AND PROCEDURE

Italian and Polish patients (≥ 65 years; N = 180) consecutively responded to self-report questionnaires measuring psychosocial (i.e., beliefs about medicines, perceived physician's communication effectiveness, medication-specific social support, self-efficacy) and behavioral factors (i.e., pharmacological adherence, medications refill adherence, intentional non-adherence) related to treatment adherence. Between-group comparisons and regression analyses were performed.

RESULTS

Fisher's least significant difference (LSD) test showed significant differences between the Italian and Polish groups in all questionnaires (p < .01) with the Italian patients reporting more satisfactory scores. Younger age (β = .08, p = .045), female gender (β = 1.03, p = .042), higher medication refills adherence (β = -.07, p = .024), lower intentional non-adherence (β = -.03, p = .009), positive beliefs about medications (β = .13, p < .001), better quality of communication with the physician (β = .09, p < .001), and stronger perceived medication-specific social support (β = .06, p = .001) were significantly associated with self-efficacy related to treatment adherence.

CONCLUSIONS

Future research and interventions should leverage psychosocial and behavioral factors to address self-efficacy contributing to enhancing adherence to clinical prescriptions.

Association between health literacy and medication adherence in chronic diseases: a recent systematic review

BACKGROUND

Poor medication adherence is a serious barrier to successful chronic disease management. Previous reviews reported that low health literacy could be associated with medication non-adherence but conclusions were uncertain.

AIM

The aim of this systematic review was to clarify the relationship between health literacy and medication adherence in adults with chronic diseases. A secondary objective was to identify the factors that influence medication adherence.

METHOD

Publications analyzing the relationship between health literacy and adherence in adults with chronic diseases were identified through 6 databases between 2015 and 2020. A quality assessment was conducted in order to improve the interpretation of the relationship between health literacy and medication adherence. A narrative synthesis was then performed to describe the relationship between health literacy and medication adherence. The factors influencing medication adherence were then analyzed as a secondary outcome.

RESULTS

Among the 27 studies, 17 and 10 were considered to be of good and medium methodological quality, respectively. Concerning the relationship between health literacy and adherence, 14 reported a positive relationship, 1 study suggested a negative relationship, 3 found mixed results, and 9 reported not finding a relationship. Patient-related factors such as medication beliefs, self-efficacy, or medication knowledge, as well as demographic factors such as ethnic minority and incomes influence medication adherence.

CONCLUSION

The present review confirms an unclear relationship between health literacy and medication adherence. Although health literacy plays a substantial role in medication adherence, other factors must be taken into account when addressing non-adherence.

Illness Perception and Medication Adherence among Adult Patients with Type 2 Diabetes Mellitus: A Scoping Review

(1) Background: Type 2 diabetes mellitus (T2DM) is a global disease with a compelling impact on developed and developing economies across the globe. The World Health Organization (WHO) (2020) reported a global prevalence of 8.5% in 2014 among adults aged at least 18 years. Consequently, the condition led to a 5% increase in premature mortality from 2000 to 2016. Aim: The scoping review sought to examine illness perception and medication adherence among adult patients with T2DM. (2) Methods: The study was conducted in 2021 and covered articles published in English in the last five years. PubMed, MEDLINE, CINAHL, and ScienceDirect were the primary search engines used to generate the required scholarly records. A total of 20 studies met the inclusion criteria. (3) Results: The 20 studies selected for the scoping review covered different themes on the overall concept of illness perception and medication adherence in adults with Type 2 Diabetes Mellitus. Each study presented unique implications for research and influence on the policymaking relating to the treatment or the management of type 2 diabetes mellitus in adults of different aged groups. (4) Conclusions: The studies reveal both high and low adherence to medications in adults with type 2 diabetes mellitus. The management and treatment of the condition depend on the uptake of oral hypoglycemic agents or insulin as well as the recommended therapies to enhance the clinical outcomes of the patients.

Attrition and social vulnerability during 2-year-long structured care in type 2 diabetes, the ERMIES randomized controlled trial

BACKGROUND

Diabetes self-management education is exposed to attrition from services and structured ambulatory care. However, knowledge about factors related to attrition in educational programs remains limited. The context of social vulnerability due to low income may interfere. The aim of this study was to identify the sociodemographic, clinical, psychometric, and lifestyle factors associated with attrition from the ERMIES multicentre randomized parallel controlled trial (RCT) that was interrupted due to the combination of both slow inclusion and high attrition.

METHODS

The ERMIES trial was performed from 2011 to 2016 on Reunion Island, which is characterized by a multicultural population and high social vulnerability. The original objective of the RCT was to test the efficacy of a2-year structured group self-management education in improving blood glucose in adult patients with nonrecent, insufficiently controlled type 2 diabetes. One hundred participants were randomized to intensive educational intervention maintained over two years (n = 51) versus only initial education (n = 49). Randomization was stratified on two factors: centres (five strata) and antidiabetic treatment (two strata: insulin-treated or not). Sociodemographic, clinical, health-care access and pathway, psychometric and lifestyle characteristics data were collected at baseline and used to assess determinants of attrition in a particular social context and vulnerability. Attrition and retention rates were measured at each visit during the study. Multiple correspondence analysis and Cox regression were performed to identify variables associated with attrition.

RESULTS

The global attrition rate was 26% during the study, with no significant difference between the two arms of randomization (9 dropouts out of 51 patients in the intervention group and 17 out of 49 in the control group). Male gender, multiperson household, low household incomes (< 800 euros), probable depression and history of hospitalization or medical leave at inclusion were associated with a higher risk of attrition from the study in multivariate regression.

CONCLUSIONS

Social context, vulnerability, and health care history were related to attrition in this 2-year longitudinal comparative study of structured care. Considering these potential determinants and biases is of importance in scaling up interventions aimed at the optimization of long-term care in type 2 diabetes mellitus.

TRIAL REGISTRATION

ID_RCB number: 2011-A00046-35, Clinicaltrials.gov number: NCT01425866 (Registration date: 30/08/2011).

SOURCE OF FUNDING

Ministry of Health, France.

Health literacy, illness perception, depression, and self-management among African Americans with type 2 diabetes

BACKGROUND

Type 2 diabetes mellitus (T2DM) causes significant morbidity and mortality. Compared with non-Hispanic Whites, African Americans are more likely to suffer and die from T2DM.

PURPOSE

This study examines the associations between health literacy, illness perception, depression, working memory, executive function, and self-management among African Americans (18-65 years) with T2DM.

METHODOLOGY

A descriptive cross-sectional design was used. Data were collected through Research Electronic Data Capture and transferred to the Statistical Package for the Social Sciences software version 26 for statistical analysis. Fifty-three participants met study eligibility criteria.

RESULTS

Health literacy was associated with depression ( r = -0.433, p = .003), more concerns about illness ( r = -0.357, p = .02), and better medication adherence ( r = 0.487, p = .001). Higher levels of depression were inversely associated with medication adherence ( r = -0.449, p = .002; r = 0.449, p = .003). Higher concern about illness was associated with lower medication adherence ( r = -0.414, p = .005).

CONCLUSIONS

Lower health literacy coupled with illness perception and depression is associated with lower self-management behaviors among African Americans which can lead to complications of T2DM. More studies are needed to examine the association of cognitive factors with self-management activities among African Americans with T2DM.

IMPLICATIONS

Limited health literacy is associated with lower medication adherence among African Americans with T2DM. Illness perception is a significant factor that influences self-management of T2DM among African Americans. Using screening tools that assess health literacy and illness perception may address underlying concerns regarding adherence to T2DM treatment regimens in African Americans.

Health literacy in context: struggling to self-manage diabetes - a longitudinal qualitative study

OBJECTIVES

Considering health literacy needs is a key component of health services responsiveness to diabetes self-management among vulnerable individuals. The purpose of this qualitative study was to provide a detailed analysis of the health literacy of people with type 2 diabetes in relation to their daily self-care practices.

DESIGN

Nested qualitative study in the ERMIES randomised controlled trial testing a 2-year structured care in type 2 diabetes. First round of semidirected interviews at the beginning of the trial with thematic analysis of content. Second round at the completion with directed interviews guided by the first round's themes together with Health Literacy Questionnaire.

SETTINGS

Interviews conducted at home.

PARTICIPANTS

Forty-four (31 females/13 males, 30-79 years, glycated haemoglobin (HbA1c)≥7.5%) consecutive participants out of 100 recruited in the ERMIES trial from 4 diabetology outpatient settings (Reunion Island). Forty-two respondents to the second round interviews.

RESULTS

Three poles structured into eight themes characterised practices in context: health knowledge, disease management, expertise and social support. The relationships of participants in each of the eight themes were differentiated, ranging from functional to interactive and critical. Treatment and follow-up were essentially functional, while diet and exercise remained more interactive. Social support and relationship to health professionals were important determinants of disease management.

CONCLUSIONS

Treatment management and disease monitoring remain primarily the job of health professionals, as opposed to diet, physical activity and social support being part of ordinary practice. Decision-making, as a shared social task, as well as resources for participation in health services, should be considered for relevant interventions in type 2 diabetes.

TRIAL REGISTRATION NUMBER

NCT01425866.

Association of Health Literacy With Medication Adherence Mediated by Cognitive Function Among the Community-Based Elders With Chronic Disease in Beijing of China

Background

Although health literacy was considered to play a crucial role in non-communicable chronic disease (NCD) prevention and control, the relationship of health literacy and medication adherence has rarely given attention among older adult Chinese population in previous studies, especially considered that they might be with cognitive impairment.

Purpose

This study aimed to investigate the association between health literacy and medication adherence and mediation by cognitive ability among community-based older adults with chronic disease in Beijing of China.

Methods

The older adults aged 60 years old or over were recruited in a cross-sectional survey conducted in Beijing of China by using multistage, stratified sampling method. Of those, the participants with chronic disease and need to take long-term medicine were included in our study. The information about sociodemographic characteristics, health literacy, cognition ability, and medication adherence was collected by the questionnaire. The univariate and multiple logistic regression analysis were used to measure the association of health literacy and adherence medication, and mediate effect by cognitive ability.

Results

The total of 4,166 older adult populations (average age: 70.61 ± 7.38 years) was included in this study, 1,395 participants (33.49%) were non-adherence, 1,983 participants (47.60%) had two chronic conditions or more, and 1,459 participants (35.02%) screened as cognitive impairment. The health literacy was negatively associated with medication adherence. The lower total scores of health literacy were found with a high risk of non-adherence [p < 0.01, adjusted odds ratio (OR) = 0.988 per one point increase, 95% CI: 0.982–0.993] controlling other covariates. However, their association tended to be weakened or even disappeared among the older adults with cognitive impairment compared with the populations with normal cognitive.

Conclusion

Improving health literacy might be a public health strategy to increase the medication adherence of older adults, but need to first identify the potential target population based on their cognitive ability.

Exploring a New Theoretical Model to Explain the Behavior of Medication Adherence

Medication adherence is essential for optimal therapeutic outcomes. However, non-adherence with long-term therapy is at 50%. Several theoretical models have identified several key factors that could explain medication adherence. Though numerous interventions have been developed based on these theoretical models, the success rates with interventions are not the best. This paper proposes a new Hierarchical Model for Medication Adherence. In this model, we propose medication adherence as a five-tier model with medication adherence as the desirable behavior on the top of the pyramid. From the bottom of the hierarchy upwards, the skills/beliefs/behaviors to be achieved are: health literacy, belief in illness (impacted by perceived susceptibility and severity of illness), belief in medicines (impacted by treatment satisfaction), and self-efficacy (impacted by social support). The model further proposes that each individual will achieve or already have these skills/beliefs/behaviors at various levels. Screening patients for these benchmarks will enable providers to decide where to target interventions.

The Relationships Among Health Literacy, Illness Perception, and Diabetes Self-Care in Korean-Speaking Immigrants With Diabetes

Diabetes self-care is explained as an illness-related coping behavior. Health literacy is an important predictor in self-care behaviors. However, little is known about their association with illness perception in Korean immigrants with diabetes. This study aimed to examine the relationships among health literacy, illness perception, and diabetes self-care in Korean-speaking immigrants with diabetes. This cross-sectional study was conducted in 2020. A convenience sample of 52 Korean adults with diabetes in Dallas-Fort Worth areas completed a survey. Data were analyzed using SPSS (version 25) with statistical significance at α < .05. The mean of health literacy was high (11.1, SD = 1.1, ranges 0-12) although risk of type II error with the small sample size. There were no statistically significant associations between health literacy, illness perception, and diabetes self-care. Language barriers are considered a literacy issue, but health literacy and limited English proficiency must be approached differently by health care providers.

Relationship Between Family Functioning and Medication Adherence in Chinese Patients With Mechanical Heart Valve Replacement: A Moderated Mediation Model

Background: Medication adherence is crucial for patients with mechanical heart valve replacement. Although families functioning is positively associated with medication adherence, little is known about the underlying mechanisms. Objective: To test whether family functioning affects medication adherence through illness perceptions and whether this mediating effect was moderated by medication literacy. Methods: 319 patients after mechanical heart valve replacement were included in this cross-sectional study from June 2021 to October 2021. Data regarding family functioning, illness perceptions, medication adherence, and medication literacy were collected through questionnaires. The moderated mediation model was examined by Hayes's PROCESS macro, based on the bootstrapping method. Results: The results revealed illness perceptions partially mediated the association of family functioning on medication adherence [β = 0.08, 95% confidence intervals: (0.04, 0.12)], and this effect was stronger for patients with low medication literacy than those with high literacy [β = -0.36, 95% CI: (-0.50, -0.22)]. Furthermore, the relationship between family functioning and medication adherence was only significant in patients with low medication literacy [β = 0.36, 95% CI: (0.23, 0.50)]. Conclusion: The mediating effect of illness perceptions between family functioning and medication adherence was moderated by medication literacy. Efforts to improve medication adherence by targeting at improving family functioning may be more effective when considering illness perceptions, especially for patients with limited medication literacy.

Caregiver status and illness self-efficacy during the COVID-19 pandemic among older adults with chronic conditions

OBJECTIVES

Older adults providing unpaid care to a relative or friend during the COVID-19 pandemic may have diminished self-efficacy in managing their own chronic illness, especially in the context of more complex self-management. We evaluated whether adults aged 50 and older with caregiving roles are more likely to report reduced illness self-efficacy since the pandemic, and whether this link is exacerbated by a higher number of conditions.

METHODS

Participants (105 caregivers and 590 noncaregivers) residing in Michigan (82.6%) and 33 other U.S. states completed one online survey between May 14 and July 9, 2020.

RESULTS

Controlling for sociodemographic and health characteristics, stressors related to COVID-19, and behavioral and psychosocial changes since the pandemic, caregivers were more likely than noncaregivers to report reduced illness self-efficacy when they had a higher number of chronic conditions.

CONCLUSION

These findings highlight the importance of maintaining caregivers' self-care during the COVID-19 pandemic and in future public health crises.

Feasibility of a Randomized Controlled Mixed Methods Trial to Address Health Literacy, Beliefs, Medication Adherence, and Self-Efficacy (ADHERE) in a Clinical Pharmacist-Led Clinic

PURPOSE

To assess the feasibility and acceptability of a health literacy-psychosocial support intervention - ADHERE and explore changes in glycemic values and medication adherence.

PATIENTS AND METHODS

Thirty-one participants with hemoglobin A1c (HbA1c) ≥ 8% were randomly allocated to control (usual care) or intervention groups (receiving usual care plus a 6-session pharmacist-led intervention focusing on the modifiable psychosocial factors that may influence medication adherence). Feasibility metrics evaluated recruitment, retention, and intervention adherence. Questionnaires were administered to collect psychosocial factors and self-reported medication adherence at baseline, the end of the intervention, 3 months, and 6 months post intervention. HbA1c values were extracted from electronic medical records. Repeated measures analysis of variance was used to compare differences in mean outcomes between the control and intervention groups. To assess intervention acceptability, eleven individuals participated in semi-structured interviews about their intervention experiences. Qualitative content analysis was used for analyzing the interviews.

RESULTS

Thirty participants completed the study. Overall, the findings support the feasibility of the intervention. There were significant differences in HbA1c values. Participants in the intervention group had lower A1C (8.3 ± 1.4) than in the control group (9.2 ± 1.3) at the time of 6-month follow-up (p = 0.003). In addition, the participants in the intervention group showed improved HbA1c at 6-month follow-up (8.3 ± 1.4), compared to baseline (9.4 ± 1.5, p = 0.011) and after 6-session intervention (8.9 ± 1.6, p = 0.046). However, there were no significant differences in medication adherence between groups over time. Qualitative themes suggest participants liked the intervention and perceived the additional support from the pharmacist as beneficial.

CONCLUSION

A pharmacist-led intervention to provide additional health literacy-psychosocial support may contribute to long-term improvements in HbA1c. Equipping pharmacists with patient-specific diabetes medication adherence information and building in additional follow-up support for patients may improve patient health outcomes.

Differences in health literacy level of patients from public and private hospitals: a cross-sectional study in Turkey

OBJECTIVES

Policy-making based on a health literacy approach makes it a priority to develop people-centered public health strategies and programs, particularly in the time of COVID-19 across the world. This is the first study to assess health literacy levels of patients visiting public and private hospitals in Turkey and also compares these levels with sociodemographic and health-related variables by hospital type to suggest health policies aimed at improving the health literacy skills for patients with different socio-economic backgrounds.

STUDY DESIGN

This is a cross-sectional study.

METHODS

The study was conducted on 948 outpatients from both hospital types in 2018. Health literacy was assessed using the validated Turkish version of the European Health Literacy Survey Questionnaire with 47 items. The level of health literacy and sociodemographic factors influencing it were analyzed using correlation and binary logistic regression tests. Patients from private hospital had better health literacy index score compared with the public hospital.

RESULTS

The health-related variables, such as self-reported health and the presence of long-term illness, and sociodemographic characteristics, including education, age, and gender, were associated with health literacy for both public and private hospitals. Age and education were important predictors, whereas gender, long-term disease condition, self-reported health, and perceived income status were statistically significant variables for adequate health literacy in both hospital types.

CONCLUSIONS

Participants from private hospital had better health literacy than that of public hospital. These findings could be used to help health policy makers to improve the current health literacy policy for patients and develop strategies by stakeholders for reducing barriers to obtaining health-related information.

Investigation of Barriers and Facilitators to Medication Adherence in Patients With Type 2 Diabetes Across Different Health Literacy Levels: An Explanatory Sequential Mixed Methods Study

Type 2 diabetes (T2D) incurs tremendous healthcare costs associated with various complications due to poor blood sugar control. Medication adherence, which is correlated with patients’ health literacy, should be consistently practiced to achieve optimal control of blood sugar. A comprehensive understanding of specific communication and psychosocial factors related to medication-taking behaviors across different levels of health literacy among people with T2D will guide the development of effective interventions and strategies to enhance medication adherence. To understand barriers and facilitators to medication adherence in people with T2D across different health literacy levels, the Health Literacy Pathway Model was used to identify the psychosocial and communication factors that may influence medication adherence. This mixed methods study used an explanatory sequential design, including a quantitative survey followed by qualitative semi-structured interviews. Two hundred and five participants completed the survey questionnaire, and 23 participants completed semi-structured interviews. Confirmed by quantitative and qualitative data, having stronger self-efficacy and fewer concerns about medications, as well as experiencing fewer perceived barriers to medication-taking, are necessary for better medication adherence among those with low adherence. Our findings will be useful to tailor interventions for diabetes care through addressing concerns among low-adherent patients with low health literacy and emphasizing self-efficacy and perceived barriers to medication adherence among all low-adherent patients with T2D.

Beliefs about Polypharmacy among Home-Dwelling Older Adults Living with Multiple Chronic Conditions, Informal Caregivers and Healthcare Professionals: A Qualitative Study

Although home-dwelling older adults are frequently assisted with polypharmacy management by their informal caregivers, they can still face medication-related problems. Identifying older adults’ and their informal caregivers’ beliefs about medication is a gateway to understanding and improving medication adherence. This study aimed to analyse beliefs about polypharmacy among home-dwelling older adults with multiple chronic conditions and their informal caregivers, focusing on their daily medication practices. Semi-structured interviews were conducted with 28 older adults, 17 informal caregivers, but also 13 healthcare professionals. Based on an inductive methodological approach, data were analysed using thematic content analysis. Interviews revealed the different attitudes adopted by older adults and their informal caregivers in relation to the treatment information provided by healthcare professionals. A variety of beliefs were identified and linked to medication adherence by examining daily medication practices. Polypharmacy was experienced as a habit but also an obligation, highlighting some of the strategies and negotiations underlying medication use at home. Collecting viewpoints from multiple stakeholders is an innovative way of accessing and analysing beliefs about polypharmacy. Daily medication practices provided information about medication beliefs and may contribute to developing targeted professional interventions that improve medication adherence.

Ideal instruments used to measure health literacy related to medication use: A systematic review

BACKGROUND

Prior studies showed the association between inadequate health literacy (HL) and poor medication-related skills, while none of the published studies have reviewed and compared the existing instruments used to measure medication-related HL. This systematic review comprehensively summarizes the existing instruments that assess medication-related HL.

OBJECTIVES

To identify appropriate HL instruments related to medication use as screening tools for enhancing patients' ability to use medications correctly.

METHODS

This review retrieved medication-related HL instruments that were published between 2000 and 2019 from three databases (i.e., PubMed, Scopus, EMBASE) and by hand-searching. The PRISMA procedure was followed as well as the SURGE guideline to assess the quality of studies. Psychometric properties, HL dimensions, and types of medication information gleaned from the items in three types of HL instruments (i.e., general, disease-specific, medication-specific) were compared to identify appropriate medication-related HL instruments.

RESULT

Forty-eight instruments were identified from 44 studies, whereas 70.8% instruments were either disease- or medication-specific HL instruments. Most instruments with different sample sizes showed certain an extent of reliability and validity. The distributions of HL dimensions and types of medication information among the relevant items were varied across different types of instruments. The five instruments (named as the 16SQ, AKQ-CQ, DHLKI, AKT, and ChMLM) were identified as the most appropriate instruments for three types of medication-related HL, respectively. These appropriate instruments consistently covered items related to HL dimensions of literacy and comprehension and medication-related information regarding dosing, treatment indication, and side effects/precautions.

CONCLUSION

Of 48 identified instruments mainly derived from disease- or medication-specific studies, the five most appropriate medication-related HL instruments were identified to support clinicians in facilitating patients' correct medication use. Further confirmation to explore the usefulness among these instruments are needed.

The impact of health literacy on beliefs about medication in a Dutch medication-using population

PURPOSE

Medication beliefs are likely contingent on aspects of health literacy: knowledge, motivation, and competences to access, understand, appraise, and apply health information. An association between medication beliefs and health literacy is expected as they both influence self-management. The aim of this study was to examine the association between health literacy and the beliefs about overuse and harmful effects of medication and to examine modifying effects of age, gender, and number of medications on this association.

METHODS

The data were collected using the online "Medication panel" of the Dutch Institute for Rational Use of Medicine. A linear regression model was used to examine the association between health literacy and beliefs about medication and the modifying effects of age, gender, and number of medications on this association.

RESULTS

Respondents with a lower level of health literacy had more concerns about overuse (β adj.= -.174, p<.001) and harmful (β adj.= -.189, p<.001) effects of medication. This study found no modifying effects.

CONCLUSIONS

A lower health literacy level is associated with more concerns about the overuse and harmful effects of medication. The results of this study suggest that extra attention should be given to persons with low health literacy level by healthcare professionals, to decrease their concerns about overuse and harmful effects, and improve adherence to self-management behavior.

Diabetes status modifies the efficacy of home-based kidney care for Zuni Indians in a randomized controlled trial

BACKGROUND

Home-Based Kidney Care (HBKC) is a pragmatic treatment approach that addresses patient preferences and cultural barriers to healthcare. We previously reported the results of a clinical trial of HBKC vs. usual care in a cohort of Zuni Indians in New Mexico. This study investigated the potential for differential efficacy of HBKC vs. usual care according to type 2 diabetes (T2DM) status.

METHODS

We analyzed the data from all individuals who participated in a randomized clinical trial that compared HBKC to usual care among patients with CKD, and assessed whether the effect of the HBKC intervention affected the subset of patients with T2DM differently than those individuals without T2DM. We used linear regression models to estimate the effect of HBKC on improvement in Patient Activation Measure (PAM) total scores within the groups of participants defined by T2DM status, and to compare the effects between these two groups. We used generalized estimating equations (GEE) to account for household clustering.

RESULTS

The original study enrolled 63 participants into the HBKC group, and 62 into the usual care. Ninety-eight of these individuals completed the 12-month intervention, 50 in the HBKC group and 48 in the usual care group. The present study compared the intervention effect in the 56 participants with T2DM (24 participants in the HBKC group and 32 in usual care) to the intervention effect in the 42 participants without T2DM (26 participants in the HBKC group and 16 in usual care). Those with T2DM who received the HBKC intervention experienced an average increase in PAM total scores of 16.0 points (95% Confidence Interval: 8.8-23.1) more than those with T2DM who were in the usual care group. For those without T2DM, the intervention had essentially no effect, with those who received the HBKC intervention having an average PAM total scores that was 1.4 points (95% C.I.: -12.4 to 9.6) lower than those who received usual care. There was a significantly different HBKC treatment effect by T2DM status (p = 0.02).

CONCLUSION

This secondary analysis suggests that the effectiveness of this HBKC intervention on increasing patient activation is most notable among those CKD patients who also have T2DM.

Association between illness perception and health behaviour among stroke patients: The mediation effect of coping style

AIMS

This study aims to explore illness perception and coping style in relation to health behaviour and the mediating role of coping style between illness perception and health behaviour among stroke patients.

DESIGN

Cross-sectional study.

METHODS

This survey was conducted with 515 stroke patients aged ≥18 years from September 2019 to January 2020 in Zhengzhou, China. The demographic and clinical characteristics questionnaire, Stroke Illness Perception Questionnaire-Revised, Simplified Coping Style Questionnaire, and Health Behavior Scale for Stroke Patients were included in this study. Data analysis was performed by correlation analysis, multiple linear regression analysis, and structural equation modelling.

RESULTS

The valid questionnaires were 495 (effective response rate: 96.1%). Low negative illness perception, high positive coping style, and low negative coping style are related to high level of health promoting behaviour (all p < 0.01). The results revealed that the effect of illness perception on health behaviour was partly mediated by coping style. It also confirmed that the mediation effect accounts for 43.7% (-0.169/-0.387) of the total effect.

CONCLUSION

Illness perception may influence health behaviour partly because of coping style.

IMPACT

This study implies that targeted interventions for stroke patients' illness perception are needed to motivate them to take proactive coping strategy to ultimately improve their health behaviours.

Impact of Health Literacy on Medication Engagement Among Adults With Diabetes in the United States: A Systematic Review

PURPOSE

The purpose of this systematic review is to assess evidence of a relationship between health literacy and medication engagement (formerly referred to as medication adherence) among adults with diabetes mellitus in the United States.

METHODS

Literature searches were conducted in PubMed, Ovid Medline, CINAHL, Embase, PsycInfo, and Scopus from the inception of each database to April 2020. Studies were included if they met all of the following criteria: (1) conducted in the United States, (2) the population of interest was adults ≥18 years with a diagnosis of type 1 or type 2 diabetes, (3) medication engagement was an outcome variable, (4) a direct and not a mediating relationship between health literacy and medication engagement was assessed, (5) a quantifiable measure of association was reported, and (6) a full-text journal article or dissertation was available. Quality of published evidence was graded according to Joanna Briggs Institute Critical Appraisal Checklists appropriate for the respective study designs identified.

RESULTS

Thirteen articles from 11 unique studies were retained in the review, most of which used a cross-sectional design. Four out of 11 studies found a direct positive association between health literacy and medication engagement. Two of the 4 studies with positive findings had significant methodological shortcomings.

CONCLUSIONS

There is some evidence that health literacy is associated with medication engagement among adults with diabetes in the United States. Properly designed and executed longitudinal studies are needed to better elucidate the relationship between health literacy and medication engagement among adults with diabetes.

Moderating Role of Health Literacy on the Association between Alexithymia and Depressive Symptoms in Middle School Students

Depression is a common psychological problem in adolescents. At present, few studies have described the moderating role of health literacy on the association between alexithymia and depressive symptoms among adolescents. The purpose of this study was to explore the relation among health literacy, alexithymia, and depressive symptoms and the moderating role of health literacy in middle school students. In December 2017, data were collected from a school in Shenyang by the convenient sampling method using a questionnaire including demographic information, health literacy, alexithymia, and depressive symptoms. A total of 1068 junior and senior high school students were selected as subjects, and 1062 valid questionnaires were retained for analysis. Logistic regression models were used to examine the association between health literacy and alexithymia with depressive symptoms. The prevalence of depressive symptoms was 48.2%, and the prevalence of alexithymia was 17.9%. Low health literacy was significantly associated with depressive symptoms (odds ratio (OR) (95% confidence interval (CI)) = 3.648 (2.493–5.338)). Alexithymia was significantly correlated with depressive symptoms (OR (95% CI) = 3.091 (2.156–4.429)). Low health literacy was related to a greater increase in the risk of depressive symptoms for students with alexithymia (OR (95% CI) = 10.566 (5.175–21.570)). The findings suggest that alexithymia and health literacy are important factors influencing depressive symptoms and health literacy has a moderating role on the association between alexithymia and depressive symptoms. Enhancing health literacy of middle school students with alexithymia may improve their mental health.

Effects of a Classroom Training Program for Promoting Health Literacy Among IT Managers in the Workplace: A Randomized Controlled Trial

OBJECTIVE

IT managers have received limited attention in health literacy research, although they are subject to special professional demands. The aim of this study was to evaluate a training program designed to promote health literacy among managers.

METHODS

A randomized controlled trial with a sample of 171 industry managers from one IT company was conducted. Effects of classroom training on health literacy, psychological well-being, self-rated health, and cortisol awakening response were investigated using pre- (t0), post- (t1), and follow-up (t2) surveys.

RESULTS

The intervention effects (time and group) were not significant for the primary outcome of health literacy. At the second measuring point, psychological well-being and self-rated health significantly decreased, and cortisol awakening response significantly increased.

CONCLUSION

Our study did not show beneficial intervention effects of a training program on promoting health literacy.

An Electronic Medication Module to Improve Health Literacy in Patients With Type 2 Diabetes Mellitus: Pilot Randomized Controlled Trial

BACKGROUND

In primary care, patients play a crucial role in managing care processes and handling drug treatment. A decisive factor for success is their health literacy, and several interventions have been introduced to support patients in fulfilling their responsibility.

OBJECTIVE

The aim of this study is to assess the influence of such an intervention (ie, a medication module) within a patient-led electronic health record on patients' health literacy.

METHODS

We conducted a randomized controlled study among community-dwelling patients with type 2 diabetes mellitus. Patients were recruited from primary care practices. After randomization, patients either had access to an internet-based medication module allowing them to store their medication information, look up drug information, and print a medication schedule (intervention group), or they received an information brochure on the importance of medication schedules (control group). After 4-8 weeks, all patients were invited to attend a structured medication review (ie, follow-up visit). Data were collected via questionnaires before the start of the intervention and during the follow-up visit. The main outcome measure was the mean difference in health literacy between baseline and follow-up assessments of patients in the control and intervention groups.

RESULTS

Of 116 recruited patients, 107 (92.2%) completed the follow-up assessment and were eligible for intention-to-treat analyses. Only 73 patients, of which 29 were in the intervention group, followed the study protocol and were eligible for per-protocol analysis. No differences in overall health literacy were observed in either the intention-to-treat or in the per-protocol cohorts. Reasons for a null effect might be that the cohort was not particularly enriched with participants with low health literacy, thus precluding measurable improvement (ie, ceiling effect). Moreover, the success of implementation was considered poor because both the correct application of the study procedure (ie, randomization according to the protocol and dropout of 29 patients) and the actual interaction with the medication module was modest (ie, dropout of 9 patients).

CONCLUSIONS

The conduct of this randomized controlled study was challenging, leaving it open whether inadequate implementation, too short of a duration, or insufficient efficacy of the intervention, as such, contributed to the null effect of this study. This clearly outlines the value of piloting complex interventions and the accompanying process evaluations.

Patient factors associated with diabetes medication adherence at different health literacy levels: a cross-sectional study at a family medicine clinic

BACKGROUND

Type 2 diabetes (T2D) incurs tremendous health costs associated with various complications due to poor diabetes control. Medication adherence, which is correlated with patients' health literacy, should be consistently practiced achieving optimal diabetes control. A deeper understanding of the specific communication and psychosocial factors related to medication-taking behaviors across different levels of health literacy among people with T2D will guide the development of effective interventions and strategies to enhance medication adherence.

OBJECTIVES

This cross-sectional study aimed to identify salient patient factors associated with diabetes medication adherence across different levels of health literacy.

METHODS

A questionnaire was administered via a face-to-face approach with 205 participants at a family medicine clinic. Study participants were all above 20 years of age with T2D, were prescribed at least one oral diabetes medication, and understood English. The questionnaire assessed participants' health literacy, self-efficacy for medication use, beliefs in medicines, patient-provider communication, perceived barriers to medication adherence, and self-reported medication adherence. Separate analysis of covariance was used to compare the mean scores of patient factors related to medication adherence across people with different health literacy levels.

RESULTS

The mean age of participants was 61 years old, and the majority of the participants were female (57%), White (75%), and college educated (62%). Thirty-three percent of the participants had adequate health literacy, but only 43% of them reported high adherence to their diabetes medications. Analysis of covariance showed that having stronger self-efficacy (P < 0.001), lower concern beliefs about medication (P = 0.047), and fewer perceived barriers to medication-taking (P < 0.001), are necessary for better medication adherence.

CONCLUSION

Findings suggest that practitioners should address concern beliefs among low-adherent patients with low health literacy, help improve self-efficacy, and address perceived barriers to medication adherence among all low-adherent patients to optimally support patients' diabetes care.

Perceptions in Type 1 Diabetes Mellitus with or Without the Use of Insulin Pump: An Online Study

BACKGROUND

Technological developments concerning the treatment of Type 1 Diabetes Mellitus have been rapid in the latest years. Insulin infusion systems along with continuous glucose monitoring, as well as long-acting insulin analogues, are part of this progress.

OBJECTIVE

The aim of this study is to present the illness perceptions in type 1 diabetes mellitus, with or without the use of an insulin pump. Sexual life and body image among therapy groups subjected to subcutaneous insulin infusion (CSII) therapy and multiple daily injections (MDI) therapy were also examined.

METHODS

A modified version of the Brief Illness Perception Questionnaire was used. One hundred and nine adults with type 1 diabetes mellitus, (males / females ratio 1:2.3) completed the online survey. Thirty six of them (33%) used CSII therapy and 73 of them (67%) used MDI therapy.

RESULTS

Statistically important differences among the CSII and MDI therapy groups were found in treatment control, illness comprehensibility, representations of control, representation of body image and in the perception of sex life. There was no statistically significant difference among the different types of therapy for participants' negative perception of diabetes.

DISCUSSION AND CONCLUSION

Negative perceptions of MDI users in treatment control, illness comprehensibility, representations of control, body image and sex life with the insulin pump, differentiate CSII and MDI therapy groups to a significant degree. According to the research, these parameters seem to interfere with accepting CSII therapy for MDI users and discourage them.

The impact of personal and cultural beliefs on medication adherence of patients with chronic illnesses: a systematic review

BACKGROUND

Patients' adherence to therapeutic regimes may be influenced by subjective beliefs about chronic conditions. One of the challenges for health professionals in enhancing adherence is taking patients' understanding into account when giving health advice and/or providing medical treatment.

PURPOSE

This review aimed to evaluate the consequent effects of personal and cultural beliefs on medication adherence, in patients with chronic conditions such as hypertension, diabetes mellitus, chronic obstructive pulmonary disease and asthma.

METHOD

A systematic review methodology was used. PubMed, CINAHL, EMBASE and PsychINFO, databases were searched for relevant articles. The main terms analyzed were illness perceptions, health beliefs, cultural beliefs, chronic conditions and medication adherence.

RESULTS

From 2,646 articles, 127 were retained for further assessment, and finally 25 met the inclusion criteria. A cross-sectional questionnaire survey research design was conducted in all included articles. Of these most (n=22) targeted hypertension or diabetes mellitus. A number of personal and cultural based factors were identified as being associated with adherence to medication regimes - 40% of articles (n=10) examined perception of illness, 20% (n=5) health literacy, 16% (n=4) cultural beliefs, 12% (n=3) self-efficacy, 16% (n=4) spiritual and religious beliefs, as well as 20% (n=5) illness knowledge. Statistically significant associations between medication adherence and these personal and cultural factors were found in 80% (n=20) of the included studies. However, the direction of associations varied between studies depending on the factor that was examined.

CONCLUSION

This review has evaluated the impact of personal and cultural factors on medication adherence and highlighted the gaps in literature regarding adherence. Further research is required to fully identify the associations between religious beliefs, control beliefs and illness knowledge and medication adherence.

Design and rationale of a mixed methods randomized control trial: ADdressing Health literacy, bEliefs, adheRence and self-Efficacy (ADHERE) program to improve diabetes outcomes

BACKGROUND

Improving medication adherence is one of the most effective approaches to improving the health outcomes of patients with diabetes. To date, enhancing diabetes medication adherence has occurred by improving diabetes-related knowledge. Unfortunately, behavior change often does not follow knowledge change. Enhancing communication between patients and healthcare professionals through addressing health literacy-related psychosocial attributes is critical.

OBJECTIVE

Examine whether a patient-centered intervention augmenting usual care with a health literacy-psychosocial support intervention will improve medication adherence for patients with diabetes, compared to usual care.

METHODS

This study is a randomized controlled trial with an intervention mixed methods design. Fifty participants being enrolled are English-speaking, 18-80 years old with diagnosed diabetes, take at least one diabetes medication, have low diabetes medication adherence (proportion of days covered less than 80% or based on clinical notes), and have poor diabetes control (hemoglobin A1c of ≥8%). Participants will be allocated to either a control group receiving usual care (n = 25) or an intervention group (n = 25) receiving usual care and a 6-session intervention focusing on the modifiable psychosocial factors that may influence medication adherence. A questionnaire will be administered at baseline and at the end of the intervention to all participants to assess the effectiveness of the intervention. Fifteen participants from the intervention group will be interviewed to explore participants' experiences and perceptions of the intervention processes and outcomes.

CONCLUSIONS

The trial will examine if a patient-centered intervention that addresses patients' health literacy and focuses on modifiable psychosocial factors will improve medication adherence among patients with diabetes.

Lack of Treatment Persistence and Treatment Nonadherence as Barriers to Glycaemic Control in Patients with Type 2 Diabetes

Treatment persistence (continuing to take medication for the prescribed period) and treatment adherence (complying with the prescription in terms of drug schedules and dosage) are both important when treating chronic diseases such as type 2 diabetes (T2D). They can be indicators of patient satisfaction with treatment. In T2D, the achievement of optimal outcomes requires both persistence with and adherence to prescribed therapy. Poor persistence with and adherence to T2D medication can have profound consequences for the patient, including non-achievement of glycaemic goals and an increased risk of long-term complications and mortality. Therefore, poor treatment persistence and adherence may also have economic consequences, including increased healthcare resource utilization and healthcare costs. Treatment persistence and adherence are affected by several factors, including the mode of administration, administration frequency/regimen complexity, and patient expectations. The aims of this review are as follows: to provide an overview of persistence with and adherence to different antidiabetes therapies for patients with T2D in the real-world setting; examine factors contributing to poor treatment persistence and adherence; and assess available data on the impact of poor treatment persistence and/or adherence on clinical and economic outcomes. Numerous potential targets for improving treatment persistence and/or adherence are identified, including developing less complex treatment regimens with lower pill burdens or less frequent injections, improving the convenience of drug-delivery systems, such as the use of insulin pen devices rather than the conventional vial and syringe, and developing therapies with an improved safety profile to alleviate patient fears of adverse effects, such as weight gain and risk of hypoglycaemia.Funding: Sanofi.

Effect of ecological momentary assessment, goal-setting and personalized phone-calls on adherence to interval walking training using the InterWalk application among patients with type 2 diabetes-A pilot randomized controlled trial

OBJECTIVES

The objective was to investigate the feasibility and usability of electronic momentary assessment, goal-setting and personalized phone-calls on adherence to a 12-week self-conducted interval walking training (IWT) program, delivered by the InterWalk smartphone among patients with type 2 diabetes (T2D).

METHODS

In a two-arm pilot randomized controlled trial (Denmark, March 2014 to February 2015), patients with T2D (18-80 years with a Body Mass Index of 18 and 40 kg/m2) were randomly allocated to 12 weeks of IWT with (experimental) or without additional support (control). The primary outcome was the difference between groups in accumulated time of interval walking training across 12 weeks. All patients were encouraged to use the InterWalk application to perform IWT for ≥90 minute/week. Patients in the experimental group made individual goals regarding lifestyle change. Once a week inquiries about exercise adherence was made using an ecological momentary assessment (EMA). In case of consistent self-reported non-adherence, the patients would receive a phone-call inquiring about the reason for non-adherence. The control group did not receive additional support. Information about training adherence was assessed objectively. Usability of the EMA was assessed based on response rates and self-reported satisfaction after 12-weeks.

RESULTS

Thirty-seven patients with T2D (66 years, 65% female, hemoglobin 1Ac 50.3 mmol/mol) where included (n = 18 and n = 19 in experimental and control group, respectively). The retention rate was 83%. The experimental group accumulated [95%CI] 345 [-7, 698] minutes of IWT more than the control group. The response rate for the text-messages was 83% (68% for males and 90% for females). Forty-one percent of the experimental and 25% of the control group were very satisfied with their participation.

CONCLUSION

The combination inquiry about adherence using EMA, goal-setting with the possibility of follow-up phone calls are considered feasible interventions to attain training adherence when using the InterWalk app during a 12-week period in patients with T2D. Some uncertainty about the effect size of adherence remains.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02089477.

Health literacy in solid-organ transplantation: a model to improve understanding

Optimizing wellness and health are the most critical goals for patients post solid-organ transplantation. Low health literacy has important implications for wellness and health, increasing patient risk for negative health outcomes. More than 30% of the general US patient population has low health literacy, and solid-organ transplant recipients (SOTRs) may be especially vulnerable to low health literacy and its adverse impact on health outcomes. A comprehensive literature review was conducted and a model was adapted to better depict factors associated with low health literacy. Based on the Paasche-Orlow and Wolf model of health literacy, the Health Literacy Model in Transplantation (HeaL-T) provides a foundation to visually demonstrate the relationships among variables associated with low health literacy and to develop evidence-based strategies to improve care. The model depicts a number of patient and healthcare level factors associated with health literacy, several of which have bi-directional or reciprocal relationships, including access and utilization of healthcare, provider-patient interaction, and self-management/adherence. The impact of these factors and their relationships to SOTR outcomes are reviewed. The HeaL-T represents an important step in developing holistic understanding of the complexity of health literacy in SOTRs and offers clinicians a base from which to design strategies to mitigate adverse health effects including increased hospitalizations, graft failure, and mortality.