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Health literacy is independently associated with self-care behavior in patients with heart failure
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Health literacy is independently associated with self-care behavior in patients with heart failure Shiho Matsuokaa,* , Miyuki Tsuchihashi-Makayab , Takahiro Kayanec , Michiyo Yamadad, Rumi Wakabayashie , Naoko P. Katof , Miyuki Yazawag a Section of Liaison Psychiatry & Palliative Medicine, Graduate School of Medical & Dental Sciences, Tokyo Medical & Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan b School of Nursing, Kitasato University, 2-1-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0329, Japan cDepartment of Nursing, Edogawa Hospital, 2-24-18 Higashikoiwa, Edogawa-ku, Tokyo 133-0052, Japan dDepartment of Nursing, Edogawa Hospital, 2-24-18 Higashikoiwa, Edogawa-ku, Tokyo 133-0052, Japan eDepartment of Nursing, Tokyo Women's Medical University Hospital, 8-1 Kawada-cho, Shinjyuku-ku, Tokyo 162-8666, Japan fDepartment of Social and Welfare Studies, Faculty of Health Sciences, Linköping University, 581 83 Linköping, Sweden gDepartment of Cardiology, Saiseikai Karatsu Hospital, 817 Motohatamachi, Karatsu-shi, Saga 847-0852, Japan
A R T I C L E I N F O
A B S T R A C T
Article history: Received 17 July 2015 Received in revised form 5 January 2016 Accepted 8 January 2016
Objective: Health literacy (HL) has been recognized as an important concept in patient education and disease management for heart failure (HF). However, previous studies on HL have focused predominantly on the relationships between functional HL (the ability to read and write), comprehensive HL including the ability to access information (communicative HL), and the ability to critically evaluate information (critical HL). Self-care behavior has not been evaluated. This study determined the relationship between functional, communicative, and critical HL and self-care behavior in HF patients. Methods: Cross-sectional analysis of the data was completed for HL, HF-related knowledge, and HFrelated self-care behaviors. Sociodemographic and clinical characteristics were also assessed. Multivariate linear regression analysis was used to estimate the associations between literacy and self-care behavior. Results: 249 patients with HF were assessed (mean age, 67.7 13.9 years). Patients with low HL had poorer knowledge and self-care behavior than those with high HL. Critical HL was an independent determinant of self-care behavior (sb = 0.154, P = 0.027). Conclusions: Critical HL was independently associated with self-care behavior in HF patients. Practice implications: Effective intervention should be developed to improve patient skills for critically analyzing information and making decisions. ã 2016 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Heart failure (HF) is a common and complex chronic disease with high morbidity and mortality. Despite substantial advances in treatment, the prognosis remains poor in patients with HF. Patients with HF are frequently readmitted to hospital because of exacerbation of their symptoms. In Japan, 35% of patients with HF were readmitted within 1 year of discharge [1]. The main reason
* Corresponding author. Fax: +81 3 5803 0217. E-mail addresses: [email protected] (S. Matsuoka), [email protected] (M. Tsuchihashi-Makaya), [email protected] (T. Kayane), [email protected] (M. Yamada), [email protected] (R. Wakabayashi), [email protected] (N.P. Kato), [email protected] (M. Yazawa).
for HF exacerbations and re-hospitalizations is a lack of self-care behavior, also known as “self-care maintenance” and “self-care management. ‘Self-care maintenance’ is necessary to maintain the patient's physiological stability, and may consist of basic mandates such as adherence to medication and fluid restriction [2,3] “Selfcare management is a measure of a patient's ability to respond to symptoms when they occur [4]. Self-care management includes an evaluation of symptom changes and treatment-seeking behavior, as well as the ability to independently contact medical staff in cases of questions or emergencies, that is to say ‘consulting behavior’. Self-care involves acquiring knowledge about one's current disease status and applying this knowledge appropriately for selfmanagement [5,6]. Self-care is also a decision-making process in which the patient chooses appropriate actions to prevent
http://dx.doi.org/10.1016/j.pec.2016.01.003 0738-3991/ ã 2016 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: S. Matsuoka, et al., Health literacy is independently associated with self-care behavior in patients with heart failure, Patient Educ Couns (2016), http://dx.doi.org/10.1016/j.pec.2016.01.003
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exacerbation, including undergoing clinical examinations and interventions [7]. To improve self-care, it is important to discern how best to support patients in acquiring and applying the appropriate knowledge. While patients previously acquired most of this knowledge from health professionals, it is now possible to gather health-related information rapidly via the media and internet. However, such information, particularly when gathered from the internet, is of highly variable quality [8]. It is therefore more important that patients are able to gather and critically evaluate information properly and use this information to make appropriate healthcare and lifestyle choices. This ability is defined as health literacy (HL). As defined by the Institute of Medicine, HL is “the degree to which individuals can obtain, process and understand basic health information and services needed to make appropriate health decisions” [9]. Using this definition as a basis, Nutbeam proposed a more comprehensive definition of HL combining three levels: functional literacy, the basic level of reading and writing skills that let someone function effectively in everyday situations; communicative literacy, advanced skills that allow a person to extract information, derive meaning from different forms of communication, and apply new information to changing circumstances; and critical literacy, more advanced skills for critically analyzing information and using information to exert greater control over life events and situations [10]. People with low HL may have trouble processing information on disease management, such as reading appointment slips and medication labels, comprehending verbal information from their healthcare providers, and understanding educational materials [11,12]. Studies have also shown that low HL is associated with poorer healthcare knowledge [13,14], decreased medication adherence [15,16], and increased hospitalizations and mortality [17–19]. Previous studies on HL have focused on functional HL—the ability to read health-related information—and have investigated the relationship between functional HL and health outcomes in a number of patient groups with HF. The ability to gather information, select pertinent items, convey these to others, and analyze them critically is also vital for the optimal utilization of health information to guide health-related behaviors. In addition to functional HL, assessments of social interaction skills and problem-solving skills related to HL have been conducted [20], but the relationship between these higher levels of HL and self-care behavior has not been demonstrated yet. The aim of this study was to investigate the relationship between comprehensive HL, including functional, communicative, and critical HL, and self-care behavior in HF patients. 2. Methods 2.1. Study design and setting This was a cross-sectional, observational study conducted from August 2012 to March 2013. We enrolled patients from departments of cardiovascular medicine at a university hospital and two general hospitals in rural and urban areas, and asked them to complete a survey approved by the ethical review boards of each participating hospital. The investigator explained the study protocol to each patient and written informed consent was obtained from them. Patients were given a self-administered questionnaire immediately, which they completed in a private room.
voluntary written informed consent given following an explanation of the study purpose; and (5) full understanding of the participation details. Exclusion criteria were as follows: (1) NYHA class IV; and (2) difficulty in participating in the study because of physical or mental conditions or problems with cognitive abilities. Power calculations were carried out to identify the required sample size; we needed 104 participants (52 case–control sets) with 80% power, 5% significance and an effect size (Cohen's d) of 0.56, which was detected from the prior literature [21,22]. 2.3. Measures 2.3.1. Health literacy The Heart Failure-Specific Health Literacy Scale consisted of 14 items with four response options: (1) inapplicable; (2) rarely applicable; (3) sometimes applicable; and (4) strongly applicable. A higher score indicated a higher level of HL except for items 1–4, where a lower score indicated a higher level of HL. The validity and reliability of the HF-specific HL scale have been tested and confirmed [23]. The reliability was reported with Cronbach's alpha ranging from 0.68 to 0.73. To identify patients with lower HL in each HL level, we calculated inter-quartile ranges (IQR) and designated patients with less than the IQR as lower HL patients. 2.3.2. Heart failure self-care behaviors Self-care behavior was assessed using the Japanese version of the European Heart Failure Self-Care Behavior Scale (EHFScBS), which tested and confirmed validity and reliability [24,25]. This is a 12-item, self-administered questionnaire that covers information on the self-care behavior of patients with HF, such as daily weighing, fluid restriction, medication, and contacting health care providers when they experience increased weight gain. For each item, patients rate their self-care behavior on a 5-point scale from 1 (“I completely agree”) to 5 (“I do not agree at all”). The total score ranges from 12 to 60 and is calculated by summing the scores for each item. A higher score indicates poorer self-care behavior. Cronbach's alpha of this measure was 0.71 in the Japanese version [25]. Consulting behaviors (the likelihood of contacting a healthcare provider when symptoms occur) were assessed using the Japanese version of the European Heart Failure Self-Care Behavior Scale (EHFScBS), which has 4 items (item 3 “If my shortness of breath increase, I contact a hospital, my doctor, or nurse”, item 4 “If my feet/legs become more swollen than usual, I contact a hospital, my doctor, or nurse”, item 5 “If I gain 2 kg in 1 week, I contact a hospital, my doctor, or nurse”, item 8 “If I experience increased fatigue, I contact a hospital, my doctor, or nurse”) [24,26]. The consulting behaviors subscale scores range from 4 to 20, with lower scores indicating an increased likelihood to pursue medical treatment in response to symptoms. Cronbach's alpha was 0.85 on the consulting behaviors subscale [26].
2.2. Study patients
2.3.3. Knowledge of heart failure We used the Japanese heart failure knowledge scale to assess knowledge of HF [27]. This questionnaire consists of 15 items to which patients could respond with “yes”, “no”, or “I don't know”. One point was given for each correct answer; an incorrect answer or “I don't know” received no points. The total score was determined by the sum of these points; higher scores indicated greater knowledge of HF. The reliability and validity of this scale have been demonstrated in Japanese HF patients. Cronbach's alpha was 0.79, and item-total correlation was 0.22–0.51.
Outpatients who met the following criteria were enrolled: (1) confirmed diagnosis of HF; (2) aged 18 years or older on enrollment; (3) New York Heart Association (NYHA) functional class I, II, or III; (4)
2.3.4. Demographic and psychosocial characteristics Patients were asked to complete a self-administered questionnaire on employment status, living arrangements, level of education,
Please cite this article in press as: S. Matsuoka, et al., Health literacy is independently associated with self-care behavior in patients with heart failure, Patient Educ Couns (2016), http://dx.doi.org/10.1016/j.pec.2016.01.003
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and annual income. Level of education comprised seven categories: elementary school; middle school; high school; university; graduate school; other; and no response. Annual income comprised 10 categories: under US$10,000 (under 1 million yen); $10,100 $30,000 (1,000,010–3,000,000 yen), $30,100–$50,000 (3,000,010–5,000,000 yen), $50,100–$70,000 (5,000,010– 7,000,000 yen), $70,100–$90,000 (7,000,010–9,000,000 yen), $90,100–$100,000 (9,000,010–10,000,000 yen), over $100,000 (over 10 million yen); only pension; social welfare; and no response. In the analysis, we divided annual income into two groups—above or below $36,000 (3,000,000 yen)—using the average annual income of households with elderly persons from a national survey (2011) conducted by the Ministry of Health, Labour and Welfare. Information on age and sex was obtained from medical records. 2.3.5. Clinical characteristics The following variables were assessed from the medical records: etiology of HF, comorbidities, NYHA functional class, duration of HF, previous hospitalization for HF, echocardiography findings, blood test data, hospitalization, medication, device therapy, level of brain natriuretic peptide (BNP), estimated glomerular filtration rate (GFR), smoking history, and drinking history. 2.4. Data analysis Categorical data were presented as frequencies and percentages. For continuous variables with a normal distribution, the mean and standard deviations were reported. Characteristics of patients were compared using the unpaired t-test or Mann– Whitney U-test for continuous variables, and the chi-square test or Fisher exact test for categorical variables, as appropriate. We used Student's t-test to compare self-care behavior, consulting behaviors, and knowledge with the groups classified by lower or higher HL. Subsequently, univariate analysis was performed to identify related factors. To identify factors influencing self-care and consulting behaviors, logistic regression analyses were performed. In the multivariate analysis, the variables that were related to selfcare at P < 0.10 in the univariate analysis were entered into the multivariate model. Finally, to determine differences between the mean scores of patients with lower and higher HL, the response to each EHFScBS item was calculated by Student's t-test. All statistical tests were two-tailed, and statistical significance was defined as P < 0.05. Statistical analysis was performed with SPSS software (SPSS Version 20.0J). 3. Results 3.1. Characteristics of study patients In all, 249 patients met the study's eligibility criteria. We excluded 12 patients because of physical problems, and three patients did not give their consent to participate; thus, 234 patients took part in the study. Seven patients had missing responses and were also excluded. Accordingly, 227 patients were included in the final analysis. The effective response rate was 91.2%. The participants' sociodemographic and clinical characteristics appear in Table 1. The mean age of the patients was 67.7 13.9 years; 17.2% were living alone; 95.1% were NYHA functional class I or II. Patients with lower HL were older and had lower education levels than patients with higher HL (Table 2). 3.2. Relationship between HL and self-care behavior, consulting behavior and HF knowledge Table 3 presents the scores for self-care behavior, consulting behavior and HF knowledge by HL level. The mean self-care
3
behavior scores for total HL, communicative HL, and critical HL for patients with lower HL were significantly higher than those for patients with higher HL (36.00 vs 32.72, P = 0.03; 36.57 vs 32.60, P < 0.01; 36.73 vs 32.65, P < 0.01, respectively), but there were no significant differences between lower and higher functional HL patients. Moreover the mean consulting behavior scores for critical HL for patients with lower HL were significantly higher than those for patients with higher HL (15.39 vs 13.56, P = 0.02), there were no significant differences between lower and higher total HL, functional HL and communicative HL patients. HF knowledge scores for all HL levels (total HL, functional HL, communicative HL, and critical HL) were lower in patients with lower HL than in patients with higher HL (7.02 vs 10.28, P < 0.01; 8.33 vs 9.84, P < 0.01; 7.53 vs 10.07, P < 0.01, and 8.39 vs 9.78, P < 0.01, respectively). 3.3. Health literacy and each EHFScBS item Table 4 shows the mean scores for self-care behavior, according to our operational definition, in higher and lower HL patients. There was no significant difference in functional HL between lower and higher HL patients. In communicative and critical HL, patients with lower HL had poorer adherence to daily weighing than patients with higher HL (3.00 vs 2.60, P = 0.09; 3.10 vs 2.58, P = 0.03, Table 1 Patient characteristics. Characteristic
All N = 227
Male Age in years (mean SD) Living alone
142 (62.6) 67.7 (13.9) 39 (17.2)
Level of education Junior high school High school College Non-respondent
55 (24.2) 92 (40.5) 73 (32.2) 7 (3.1)
Employment Employed Unemployed
88 (38.8) 139 (61.2)
Yearly income $3.6 million > $3.6 million Non-respondent
57 (25.1) 134 (59.0) 36 (15.9)
Etiology of heart failure Ischemic heart disease
55 (24.2)
Comorbidity Hypertension Chronic kidney disease Atrial fibrillation Diabetes mellitus
128 (56.4) 106 (46.7) 95 (41.9) 68 (30.0)
NYHA functional class I II III BNP, pg/mL (meanSD) Estimated GFR, mL/min/1.73 m2 (mean SD)
109 (48.0) 107 (47.1) 11 (4.8) 309.6 (706.6) 61.1 (34.3)
Echocardiogram LVEF, % (mean SD) LVEF > 40% Duration of HF in years (mean SD) Previous hospitalization for HF Implanted pacing devices
46.5 (15.0) 154 (67.8) 8.25 9.00 172 (75.8) 57 (25.1)
HL: health literacy, SD: standard deviation, NYHA: New York Heart Association, BNP: brain natriuretic peptide, GFR: glomerular filtration rate, LVEF: left ventricular ejection fraction, HF: heart failure.
Please cite this article in press as: S. Matsuoka, et al., Health literacy is independently associated with self-care behavior in patients with heart failure, Patient Educ Couns (2016), http://dx.doi.org/10.1016/j.pec.2016.01.003
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Table 2 Patient characteristics according to level of HL. Characteristic
HL total Lower n = 56
Male 37 (66.1) Age in years 74.3 10.0 (mean SD) 10 (17.9) Living alone Level of education Junior high 23 (41.0) school 15 (26.8) High school College 17 (30.4) Employed 22 (39.3) Yearly income 12 (21.4) ($3.6 million) Etiology of heart failure Ischemic 18 (32.1) heart disease Comorbidity Hypertension Chronic kidney disease Atrial fibrillation Diabetes mellitus NYHA functional I II III BNP, pg/mL (mean SD) Estimated GFR, mL/min/1.73m2 (mean SD) LVEF, % (mean SD) Duration of HF in years (mean SD) Previous hospitalization for HF Implanted pacing devices
Functional HL
Communicative HL
Critical HL
Higher n = 171
P value
Lower n = 55
Higher n = 172
P value
Lower n = 53
Higher n = 174
P value
Lower n = 49
Higher n = 178
105 (61.4) 65.5 14.3
0.63 <0.01
37(67.3) 71.3 11.0
105 (61.0) 66.514.6
0.43 0.03
41 (77.4) 71.9 11.8
101 (58.0) 66.414.3
0.02 0.01
29 (59.2) 70.7 12.8
113 (63.5) 66.9 14.1
0.62 0.09
29 (17.0)
0.84 0.04
10 (18.2)
29 (16.9)
0.84 0.30
10 (18.9)
29 (16.7)
0.68 0.02
11 (22.4)
28 (15.7)
0.29 0.51
14 (25.5)
40 (23.3)
22 (41.5)
33 (19.0)
16 (32.7)
39 (21.9)
68 (39.5) 59 (34.3) 68 (39.5) 41 (23.8)
0.75 0.59
13 16 21 13
(24.5) (30.2) (39.6) (24.5)
79 (45.4) 57 (32.8) 67 (38.5) 44 (28.1)
0.87 0.86
19 (38.3) 14 (28.6) 17 (34.7) 10 (27.7)
73 (41.0) 59 (33.1) 71 (39.9) 47 (29.9)
0.62 0.69
32 (18.7) 77 56 66 45
P value
(45.0) (32.7) (38.6) (26.3)
1.00 0.37
24 (43.5) 14 (25.5) 20 (36.4) 16 (29.1)
37 (21.6)
0.15
15 (23.8)
40 (26.7)
0.59
18 (38.3)
37 (22.8)
0.07
16 (34.0)
39 (24.0)
0.13
41 (73.2) 26 (46.4)
87 (50.9) 80 (46.8)
<0.01 1.00
39 (61.9) 28 (40.5)
89 (55.8) 78 (46.5)
0.01 0.54
36 (68.1) 26 (46.8)
92 (53.9) 80 (44.9)
0.06 0.75
30 (61.7) 20 (40.4)
98 (55.7) 86 (46.7)
0.52 0.42
18 (32.1)
77 (45.0)
0.12
25 (40.5)
70 (41.9)
0.54
16 (31.9)
79 (44.3)
0.06
16 (31.9)
79 (44.3)
0.19
25 (44.6)
43 (25.1)
<0.01
22 (23.8)
46 (30.8)
0.07
24 (44.7)
44 (25.1)
0.01
18 (36.2)
50 (27.5)
0.29
class 30 (53.6) 79 (46.2) 23 (41.1) 84 (49.1) 3 (5.4) 8 (4.7) 371.7 547.8 289.7 751.0
0.58
0.46
0.76 25 (54.8) 84 (48.3) 28 (35.7) 79 (47.1) 2 (7.1) 9 (4.7) 469.7 118.9 258.2 448.0
0.05
0.22 31 (59.6) 78 (46.7) 20 (36.2) 87 (47.3) 2 (4.3) 9 (5.4) 329.7 516.2 303.7 755.5
0.82
0.27 28 (57.4) 81 (47.3) 20 (40.4) 87 (46.1) 1 (2.1) 10 (6.0) 246.5 417.8 327.1 67.7
0.48
57.5 24.1
62.3 37.0
0.37
57.9 22.8
62.1 37.2
0.43
57.0 23.4
62.3 37.0
0.32
61.8 23.3
60.9 36.8
0.88
48.1 15.9
46.0 14.7
0.35
49.1 16.8
45.7 14.3
0.14
48.9 14.3
45.8 15.1
0.19
48.3 12.6
46.3 15.7
0.39
8.2 9.0
8.2 7.3
0.97
8.7 10.0
8.1 6.9
0.62
8.8 9.6
8.1 7.1
0.56
6.35.4
8.7 8.2
0.06
47 (83.9)
125 (73.1)
0.11
38 (73.8)
134 (76.2)
0.21
46 (85.1)
126 (73.1)
0.04
39 (80.9)
113 (74.3)
0.57
15 (26.8)
42 (24.6)
1.00
14 (31.0)
43 (29.7)
1.00
11 (34.0)
46 (28.7)
0.45
14 (29.8)
43 (29.9)
0.70
HL: health literacy, SD: standard deviation, NYHA: New York Heart Association, BNP: brain natriuretic peptide, GFR: glomerular filtration rate, LVEF: left ventricular ejection fraction, HF: heart failure.
respectively) and fluid restriction (4.06 vs 3.38, P < 0.01; 4.00 vs 3.41, P = 0.03, respectively). Additionally, patients with lower critical HL scored higher than those with higher critical HL in the following items: “If I gain 2 kg in 1 week, I contact a hospital, my doctor, or nurse” and “If I experience increased fatigue, I contact a hospital, my doctor, or nurse”. 3.4. Factors associated with self-care behavior Table 4 compares self-care behavior scores between the two populations stratified by all HL levels and various patients' characteristics. Patients with higher communicative and critical HL had lower scores for self-care behavior, indicating fewer selfcare behavior (sb = 0.837, P < 0.01; sb = 0.631, P < 0.01, respectively). Increased age was correlated with fewer self-care behavior (sb = 0.122, P < 0.01). The scores for cardiac parameters showed that prior hospitalization for HF and NYHA functional class were associated with fewer self-care behavior (sb = 4.029, P < 0.01; and sb = 3.735, P < 0.01; respectively), but LV ejection fraction (LVEF) was not. The scores for comorbidity revealed that chronic
kidney disease was associated with fewer self-care behaviors. Additionally, a lower HF knowledge score was significantly associated with lack of self-care behavior (sb = 0.530, P < 0.01). Multiple regression analysis revealed that independent determinants of fewer self-care behavior were critical HL (sb = 0.154, P = 0.027), age (sb = 0.247, P < 0.01), prior hospitalization for HF (sb = 0.167, P < 0.01), NYHA functional class (sb = 0.147, P = 0.021) and HF knowledge (sb = 0.214, P < 0.01). In addition, the independent determinants of fewer consulting behavior were critical HL (sb = 0.266, P = 0.048), prior hospitalization for HF (sb = 1.811, P = 0.022) (Table 5). 4. Discussion and conclusion 4.1. Discussion The present study demonstrated that fewer self-care behavior and lack of HF knowledge correlated with patients with lower HL. In particular, patients with a lower critical HL do not perform consulting behaviors as often as those with a high critical HL. With
Please cite this article in press as: S. Matsuoka, et al., Health literacy is independently associated with self-care behavior in patients with heart failure, Patient Educ Couns (2016), http://dx.doi.org/10.1016/j.pec.2016.01.003
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S. Matsuoka et al. / Patient Education and Counseling xxx (2015) xxx–xxx Table 3 Health literacy level in relation to HF knowledge and self-care behavior HL: health literacy, SD: standard deviation, 95%CI: confidence interval.
lower critical HL scored lower for the items about contacting the hospital and medical staff when their body weight and fatigue increased. The key finding of this study was that critical HL was an independent determinant of fewer self-care behavior and consulting behavior, controlling for the effects of other variables. A notable point in this study was that we determined the relationship between three levels of HL (functional, communicative, and critical HL) and self-care behavior. The results of previous research into the association between HL and self-care behavior have not been consistent. Some studies have indicated an association between HL and self-care behavior [17,28], while others found no significant association [29–31]. Most previous measurements of HL in HF patients used scales such as the Test of Functional Health Literacy in Adults (TOFHLA) and the Rapid Estimate of Adult Literacy in Medicine (REALM) [32], which apply only to the functional domain of HL. However, for HF patients to modify their daily lives and assess their own symptoms and signs, it is necessary to acquire appropriate information and make effective use of it in self-care behavior. Because assessment of functional HL alone is thus insufficient, the results of the relationship between HL and self-care behavior could be different in each study. An important finding of this study was that critical HL was an independent predictor of self-care behavior and consulting behavior in patients with HF, in addition to the factors identified in previous studies (older age, experience of previous HF hospitalization, higher NYHA functional class, chronic renal failure, and lack of knowledge of HF) [6,31,32]. This finding is consistent with previous studies showing that adherence to self-care behavior in patients with HF is poor if patients do not understand, absorb and retain health information [33]. HF patients require selfcare behaviors to maintain their physiological stability (self-care maintenance) and to respond to symptoms when they occur (selfcare management) [4]. HF self-care maintenance behavior includes taking medications, eating a low-sodium diet, and performing routine exercise and symptom monitoring. Self-care management in HF requires that patients recognize a change, evaluate the change, decide to take action, implement a treatment strategy, and evaluate the response to the treatment implemented [6]. Riegel
Total HL
HF knowledge Self-care behavior Consulting behavior
Lower (n = 56) Mean SD
Higher (n = 171) Mean SD
P value
95% CI
7.02 36.00 15.02
10.28 32.72 13.61
<0.01 0.03 0.07
2.40 to 4.13 6.26 to 0.39 0.094 to 2.913
3.30 9.83 4.84
2.68 9.45 5.15
Functional HL Lower (n = 55) Mean SD 8.33 HF knowledge Self-care behavior 34.89 Consulting behavior 14.51
3.20 8.66 4.74
Higher (n = 172) Mean SD
P value 95% CI
9.84 33.09 13.78
<0.01 0.23 0.33
3.08 9.90 5.21
0.57 to 2.46 4.73 to 1.14 0.763 to 2.22
Communicative HL Lower (n = 53) Mean SD 7.53 HF knowledge Self-care behavior 36.57 Consulting behavior 15.02
3.42 10.37 4.91
Higher (n = 174) Mean SD
P value 95% CI
10.07 32.60 13.63
<0.01 <0.01 0.08
2.84 9.22 5.13
1.62 to 3.46 6.90 to 1.03 0.16 to 2.93
Critical HL Lower (n = 49) Mean SD 8.39 HF knowledge Self-care behavior 36.73 Consulting behavior 15.39
3.29 9.11 4.38
Higher (n = 178) Mean SD
P value 95% CI
9.78 32.65 13.56
<0.01 <0.01 0.02
3.07 9.60 5.23
5
0.40 to 2.38 7.11 to 1.07 0.36 to 3.29
respect to individual items of the EHFScBS, there were no significant differences between patients with lower and higher functional HL, but patients with lower critical and communicative HL had poorer adherence to daily weighing, fluid restriction, and to taking it easy when short of breath than those with higher critical and communicative HL. In addition to these items, patients with Table 4 Health literacy level in relation to EHFScBS items. Total HL Lower (n = 56) (1) I weigh myself everyday (2) If I am short of breath, I take it easy (3) If my shortness of breath increase, I contact a hospital, my doctor, or nurse (4) If my feet/legs become more swollen than usual, I contact a hospital, my doctor, or nurse (5) If I gain 2 kg in 1 week, I contact a hospital, my doctor, or nurse (6) I limit the amount of fluids I drink (not more than 1–1.5 l/ day) (7) I take a rest during the day (8) If I experience increased fatigue, I contact a hospital, my doctor, or nurse (9) I eat a low salt diet (10) I take my medication as prescribed (11) I get a flu shot every year (12) I exercise regularly
Functional HL Higher (n = 171)
P value
Lower (n = 55)
3.04 (1.60) 2.58 (1.43) 0.05 2.87 (1.41) 2.41 (1.55) 1.71 (1.06) <0.01 2.13 (1.39)
Higher (n = 172)
Communicative HL P Lower value (n = 53)
2.64 (1.50) 0.31 1.80 (1.17) 0.09
3.29 (1.78) 2.91 (1.63)
0.14
3.68 (1.66) 3.38 (1.59)
0.23 3.42 (1.63) 3.47 (1.61)
4.18 (1.39)
3.71 (1.60)
3.20 (1.70) 2.94 (1.66) 0.31
Higher (n = 174)
Critical HL P value
Lower (n = 49)
3.00 (1.57) 2.60 (1.45) 0.09 3.10 (1.57) 2.51 (1.64) 1.69 (1.01) <0.01 1.98 (1.39)
Higher (n = 178)
P value
2.58 (1.44) 0.03 1.85 (1.12) 0.53
3.34 (1.76) 2.90 (1.63)
0.09 3.33 (1.75) 2.91 (1.64) 0.12
3.70 (1.70) 3.38 (1.59)
0.21 3.71 (1.63) 3.38 (1.60) 0.20
0.05 3.95 (1.43) 3.78 (1.60) 0.51
4.15 (1.42)
0.08 4.29 (1.37) 3.70 (1.59) 0.02
3.86 (1.50) 3.43 (1.67)
0.09 3.84 (1.44) 3.44 (1.69) 0.21
4.06 (1.43) 3.38 (1.66) <0.01 4.00 (1.51) 3.41 (1.65)
2.46 (1.63) 2.47 (1.39) 3.88 (1.49) 3.61 (1.47)
0.99 2.47 (1.53) 2.47 (1.42) 0.25 3.95 (1.33) 3.59 (1.51)
2.62 (1.60) 2.42 (1.40) 3.83 (1.47) 3.63 (1.49)
0.37 2.63 (1.56) 2.42 (1.41) 0.37 0.39 4.06 (1.44) 3.57 (1.48) 0.04
2.70 (1.55) 2.37 (1.33) 1.13 (0.51) 1.20 (0.71)
0.13 2.60 (1.54) 2.40 (1.34) 0.36 0.47 1.15 (0.62) 1.19 (0.68) 0.65
2.53 (1.51) 1.21 (0.74)
0.64 2.65 (1.52) 2.39 (1.35) 0.25 0.74 1.14 (0.50) 1.19 (0.70) 0.65
3.07 (1.84) 2.80 (1.87) 2.32 (1.32) 2.55 (1.38)
0.35 2.76 (1.81) 2.90 (1.89) 0.64 0.28 2.56 (1.27) 2.47 (1.40) 0.66
3.15 (1.81) 2.78 (1.88) 2.47 (1.35) 2.47 (1.35)
0.85
0.97 0.12
3.72 (1.59)
2.43 (1.35) 1.17 (0.64)
0.21 3.27 (1.95) 2.76 (1.83) 0.89 2.57 (1.51) 2.47 (1.33)
0.03
0.09 0.65
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Table 5 Multiple linear regression analysis between HL level and self-care behavior. Self-care behavior total Univariate analysis sb
Multivariate analysis
SE
P value
0.275 0.837 0.631
0.238 0.236 0.229
0.249 <0.01 <0.01
Demographic characteristics Gender (male) Age Living alone Employed Junior high school
2.801 0.122 0.476 4.611 0.314
1.310 0.045 1.697 1.278 1.494
0.034 <0.01 0.779 <0.01 0.210
Cardiac parameters Ischemic etiology of HF Prior hospitalization for HF Log BNP (pg/mL) LVEF40% NYHA functional class
2.641 4.029 0.001 1.607 3.735
1.484 1.470 0.001 1.367 1.066
0.076 <0.01 0.126 0.241 0.001
0.583 0.209 0.713 4.000
1.297 1.291 1.397 1.255
0.653 0.876 0.610 <0.01
2.069 0.530
1.546 0.200
0.183 <0.01
Health literacy Functional HL Communicative HL Critical HL
Comorbidity Atrial fibrillation Hypertension Diabetes mellitus Chronic kidney disease Treatment Implanted pacing devices HF Knowledge R2 (adjusted R2)
Consulting behavior
sb
Multivariate analysis sb
SE
P value
0.069 0.154
0.262 0.242
0.337 0.027
0.116 0.266
0.152 0.141
0.446 0.048
0.124 0.247
1.261 0.052
0.052 <0.01
1.361 0.017
0.732 0.030
0.064 0.567
1.324
0.164
0.010
0.768
0.989
0.119 0.167
1.409 1.353
0.061 <0.01
1.429 1.811
0.818 0.785
0.082 0.022
0.147
1.011
0.021
0.492
0.587
0.403
0.109
1.198
0.080
1.344
0.695
0.055
0.214 0.264
0.231 (0.230)
<0.01
0.111 0.144
0.134 (0.118)
0.409
0.092
SE
P value
SE: standard error, BNP: brain natriuretic peptide, NYHA functional class: NYHA: New York Heart Association
et al. indicated that patient evaluation and response to symptoms after perception of symptoms as well as treatment adherence are importance to prevent re-hospitalization due to HF [33]. This is particularly important with respect to the likelihood of patients to seek treatment when HF symptoms are severe, which has been correlated with repeat admissions [34,35]. In the present study, critical HL was associated with an evaluation of changes in symptoms and seeking-treatment behavior, which is consulting behavior. HF patients with high critical HL can recognize worsening symptoms, determine if it is a condition that needs treatment, and implement treatment-seeking behaviors. Functional HL and communicative HL were not directly related to self-care and consulting behavior, while a lack of knowledge of HF was greater in low HL patients. In addition, we found that knowledge of HF is an independent determinant of self-care behavior. HF patients may have several misunderstandings regarding HF, which can lead to poor adherence to self-care and to the deterioration of HF [36,37]. It is necessary to increase the overall HL level of HF patients if we seek to reinforce appropriate self-care behavior. If we evaluate not only functional HL but multifaceted HL as well, we are able to help compensate for the lack of HL skills and introduce more specific and effective interventions to connect obtained knowledge with the practice of self-care behaviors in the context of daily life. This study defined patients whose total score on the HF-specific HL scale was less than the IQR as lower HL patients, and the prevalence of lower HL patients was 16.3%. A systematic review of HL and HF patients published in 2015 reported values ranging from 17.5% to 97% (average 39%) for HF patients with low HL [22]. One study using S-TOFLA reported that 19.2% of HF patients had low HL
[38], and another study using SHLS reported 17.5% of HF subjects with low HL [19]. The prevalence of low HL in HF patients is affected by the method of assessment, the definition, and the classification of low HL. Our study reported a somewhat lower percentage compared with the results of previous studies; however, since our study focused on patients with low HL and the relationship between low HL and HF self-care behavior, the definition of low HL using quartiles was appropriate. The present study has a number of limitations. First, HF-specific HL, self-care behaviors and HF knowledge were assessed using self-reporting measures delivered orally. Hence, the items could be subject to a social desirability bias. Second, in this explorative study we did not test the “goodness of fit” of the model. In the health literacy model of Westlake et al. [39], “self-care” consisted of “patient factors” (such as motivation, problem solving, and selfefficacy) and “extrinsic factors” (such as support technologies, mass media, and health education resources). In our study, several of these factors were missing. Third, in this study, all findings should be clearly noted as self-reporting measures. A longitudinal follow-up is needed to define the association between HL and other objective evaluations, such as hospitalizations and death. Finally, because of the cross-sectional nature of our survey we could not test for a cause–effect relationship. Despite these limitations, the significant association between HL and self-care behavior is considered to be valid. 4.2. Conclusions In conclusion, health literacy is strongly correlated with selfcare behavior for patients with HF. Critical HL in particular was
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found to be an independent determinant of self-care behavior. With more effective support, we can help patients to critically assess the large amount of information they have obtained and effectively use it in their decision-making. 4.3. Implications for practice We believe that the results of this study could change the methodology of patient education for patients with HF. Recently, the use of teach-back methods, in which patients are asked openended questions requiring them to respond to healthcare educators, enabling nonthreatening assessment of the patient's understanding of content, has been associated with improved learning outcomes for knowledge retention, and reduced hospital readmission [40]. It is important for patients not only to read educational materials, but also to obtain the information relevant to them, to understand this information, and to communicate it to others including their family and healthcare providers. In other words, a high level of HL is essential for patients with HF. Conflicts of interest The authors have no conflicts of interest to declare. Acknowledgments This study was supported by a Grant-in-Aid for Scientific Research (Research Activity Start-up) from the Japan Society for the Promotion of Science (Grant number 23890214). References [1] M. Tsuchihashi, H. Tsutsui, K. Kodama, F. Kasagi, S. Setoguchi, M. Mohr, et al., Medical and socioenvironmental predictors of hospital readmission in patients with congestive heart failure, Am. Heart J. 142 (2001) E7. [2] A. Michalsen, G. Konig, W. Thimme, Preventable causative factors leading to hospital admission with decompensated heart failure, Heart 80 (1998) 437– 441. [3] M.H. van der Wal, T. Jaarsma, D.J. van Veldhuisen, Non-compliance in patients with heart failure; how can we manage it? Eur. J. Heart Fail. 7 (2005) 5–17. [4] D.K. Moser, V. Dickson, T. Jaarsma, C. Lee, A. Stromberg, B. Riegel, Role of selfcare in the patient with heart failure, Curr. Cardiol. Rep. 14 (2012) 265–275. [5] M.H. van der Wal, T. Jaarsma, D.K. Moser, N.J. Veeger, W.H. van Gilst, D.J. van Veldhuisen, Compliance in heart failure patients: the importance of knowledge and beliefs, Eur. Heart J. 27 (2006) 434–440. [6] M.H. van der Wal, T. Jaarsma, D.K. Moser, W.H. van Gilst, D.J. van Veldhuisen, Qualitative examination of compliance in heart failure patients in The Netherlands, Heart Lung 39 (2010) 121–130. [7] B. Riegel, D.K. Moser, S.D. Anker, L.J. Appel, S.B. Dunbar, K.L. Grady, et al., State of the science: promoting self-care in persons with heart failure: a scientific statement from the American Heart Association, Circulation 120 (2009) 1141– 1163. [8] B.W. Hesse, D.E. Nelson, G.L. Kreps, R.T. Croyle, N.K. Arora, B.K. Rimer, et al., Trust and sources of health information: the impact of the Internet and its implications for health care providers: findings from the first Health Information National Trends Survey, Arch. Int. Med. 165 (2005) 2618–2624. [9] C.R. Selden, M. Zorn, S. Ratzan, R.M. Parker, no, Health Literacy: Current Bibliographies in Medicine, National Library of Medicine, Bethesda, MD, 2000 [article online] 2000-1. [10] D. Nutbeam, Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century, Health Promot. Int. 15 (2000) 259–267. [11] D. Schillinger, K. Grumbach, J. Piette, F. Wang, D. Osmond, C. Daher, et al., Association of health literacy with diabetes outcomes, JAMA 288 (2002) 475– 482. [12] E.J. Mayeaux Jr., P.W. Murphy, C. Arnold, T.C. Davis, R.H. Jackson, T. Sentell, Improving patient education for patients with low literacy skills, Am. Fam. Physician 53 (1996) 205–211. [13] M.V. Williams, D.W. Baker, R.M. Parker, J.R. Nurss, Relationship of functional health literacy to patients' knowledge of their chronic disease: a study of patients with hypertension and diabetes, Arch. Int. Med. 158 (1998) 166–172.
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Health literacy is independently associated with self-care behavior in patients with heart failure Shiho Matsuokaa,* , Miyuki Tsuchihashi-Makayab , Takahiro Kayanec , Michiyo Yamadad, Rumi Wakabayashie , Naoko P. Katof , Miyuki Yazawag a Section of Liaison Psychiatry & Palliative Medicine, Graduate School of Medical & Dental Sciences, Tokyo Medical & Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan b School of Nursing, Kitasato University, 2-1-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0329, Japan cDepartment of Nursing, Edogawa Hospital, 2-24-18 Higashikoiwa, Edogawa-ku, Tokyo 133-0052, Japan dDepartment of Nursing, Edogawa Hospital, 2-24-18 Higashikoiwa, Edogawa-ku, Tokyo 133-0052, Japan eDepartment of Nursing, Tokyo Women's Medical University Hospital, 8-1 Kawada-cho, Shinjyuku-ku, Tokyo 162-8666, Japan fDepartment of Social and Welfare Studies, Faculty of Health Sciences, Linköping University, 581 83 Linköping, Sweden gDepartment of Cardiology, Saiseikai Karatsu Hospital, 817 Motohatamachi, Karatsu-shi, Saga 847-0852, Japan
A R T I C L E I N F O
A B S T R A C T
Article history: Received 17 July 2015 Received in revised form 5 January 2016 Accepted 8 January 2016
Objective: Health literacy (HL) has been recognized as an important concept in patient education and disease management for heart failure (HF). However, previous studies on HL have focused predominantly on the relationships between functional HL (the ability to read and write), comprehensive HL including the ability to access information (communicative HL), and the ability to critically evaluate information (critical HL). Self-care behavior has not been evaluated. This study determined the relationship between functional, communicative, and critical HL and self-care behavior in HF patients. Methods: Cross-sectional analysis of the data was completed for HL, HF-related knowledge, and HFrelated self-care behaviors. Sociodemographic and clinical characteristics were also assessed. Multivariate linear regression analysis was used to estimate the associations between literacy and self-care behavior. Results: 249 patients with HF were assessed (mean age, 67.7 13.9 years). Patients with low HL had poorer knowledge and self-care behavior than those with high HL. Critical HL was an independent determinant of self-care behavior (sb = 0.154, P = 0.027). Conclusions: Critical HL was independently associated with self-care behavior in HF patients. Practice implications: Effective intervention should be developed to improve patient skills for critically analyzing information and making decisions. ã 2016 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Heart failure (HF) is a common and complex chronic disease with high morbidity and mortality. Despite substantial advances in treatment, the prognosis remains poor in patients with HF. Patients with HF are frequently readmitted to hospital because of exacerbation of their symptoms. In Japan, 35% of patients with HF were readmitted within 1 year of discharge [1]. The main reason
* Corresponding author. Fax: +81 3 5803 0217. E-mail addresses: [email protected] (S. Matsuoka), [email protected] (M. Tsuchihashi-Makaya), [email protected] (T. Kayane), [email protected] (M. Yamada), [email protected] (R. Wakabayashi), [email protected] (N.P. Kato), [email protected] (M. Yazawa).
for HF exacerbations and re-hospitalizations is a lack of self-care behavior, also known as “self-care maintenance” and “self-care management. ‘Self-care maintenance’ is necessary to maintain the patient's physiological stability, and may consist of basic mandates such as adherence to medication and fluid restriction [2,3] “Selfcare management is a measure of a patient's ability to respond to symptoms when they occur [4]. Self-care management includes an evaluation of symptom changes and treatment-seeking behavior, as well as the ability to independently contact medical staff in cases of questions or emergencies, that is to say ‘consulting behavior’. Self-care involves acquiring knowledge about one's current disease status and applying this knowledge appropriately for selfmanagement [5,6]. Self-care is also a decision-making process in which the patient chooses appropriate actions to prevent
http://dx.doi.org/10.1016/j.pec.2016.01.003 0738-3991/ ã 2016 Elsevier Ireland Ltd. All rights reserved.
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exacerbation, including undergoing clinical examinations and interventions [7]. To improve self-care, it is important to discern how best to support patients in acquiring and applying the appropriate knowledge. While patients previously acquired most of this knowledge from health professionals, it is now possible to gather health-related information rapidly via the media and internet. However, such information, particularly when gathered from the internet, is of highly variable quality [8]. It is therefore more important that patients are able to gather and critically evaluate information properly and use this information to make appropriate healthcare and lifestyle choices. This ability is defined as health literacy (HL). As defined by the Institute of Medicine, HL is “the degree to which individuals can obtain, process and understand basic health information and services needed to make appropriate health decisions” [9]. Using this definition as a basis, Nutbeam proposed a more comprehensive definition of HL combining three levels: functional literacy, the basic level of reading and writing skills that let someone function effectively in everyday situations; communicative literacy, advanced skills that allow a person to extract information, derive meaning from different forms of communication, and apply new information to changing circumstances; and critical literacy, more advanced skills for critically analyzing information and using information to exert greater control over life events and situations [10]. People with low HL may have trouble processing information on disease management, such as reading appointment slips and medication labels, comprehending verbal information from their healthcare providers, and understanding educational materials [11,12]. Studies have also shown that low HL is associated with poorer healthcare knowledge [13,14], decreased medication adherence [15,16], and increased hospitalizations and mortality [17–19]. Previous studies on HL have focused on functional HL—the ability to read health-related information—and have investigated the relationship between functional HL and health outcomes in a number of patient groups with HF. The ability to gather information, select pertinent items, convey these to others, and analyze them critically is also vital for the optimal utilization of health information to guide health-related behaviors. In addition to functional HL, assessments of social interaction skills and problem-solving skills related to HL have been conducted [20], but the relationship between these higher levels of HL and self-care behavior has not been demonstrated yet. The aim of this study was to investigate the relationship between comprehensive HL, including functional, communicative, and critical HL, and self-care behavior in HF patients. 2. Methods 2.1. Study design and setting This was a cross-sectional, observational study conducted from August 2012 to March 2013. We enrolled patients from departments of cardiovascular medicine at a university hospital and two general hospitals in rural and urban areas, and asked them to complete a survey approved by the ethical review boards of each participating hospital. The investigator explained the study protocol to each patient and written informed consent was obtained from them. Patients were given a self-administered questionnaire immediately, which they completed in a private room.
voluntary written informed consent given following an explanation of the study purpose; and (5) full understanding of the participation details. Exclusion criteria were as follows: (1) NYHA class IV; and (2) difficulty in participating in the study because of physical or mental conditions or problems with cognitive abilities. Power calculations were carried out to identify the required sample size; we needed 104 participants (52 case–control sets) with 80% power, 5% significance and an effect size (Cohen's d) of 0.56, which was detected from the prior literature [21,22]. 2.3. Measures 2.3.1. Health literacy The Heart Failure-Specific Health Literacy Scale consisted of 14 items with four response options: (1) inapplicable; (2) rarely applicable; (3) sometimes applicable; and (4) strongly applicable. A higher score indicated a higher level of HL except for items 1–4, where a lower score indicated a higher level of HL. The validity and reliability of the HF-specific HL scale have been tested and confirmed [23]. The reliability was reported with Cronbach's alpha ranging from 0.68 to 0.73. To identify patients with lower HL in each HL level, we calculated inter-quartile ranges (IQR) and designated patients with less than the IQR as lower HL patients. 2.3.2. Heart failure self-care behaviors Self-care behavior was assessed using the Japanese version of the European Heart Failure Self-Care Behavior Scale (EHFScBS), which tested and confirmed validity and reliability [24,25]. This is a 12-item, self-administered questionnaire that covers information on the self-care behavior of patients with HF, such as daily weighing, fluid restriction, medication, and contacting health care providers when they experience increased weight gain. For each item, patients rate their self-care behavior on a 5-point scale from 1 (“I completely agree”) to 5 (“I do not agree at all”). The total score ranges from 12 to 60 and is calculated by summing the scores for each item. A higher score indicates poorer self-care behavior. Cronbach's alpha of this measure was 0.71 in the Japanese version [25]. Consulting behaviors (the likelihood of contacting a healthcare provider when symptoms occur) were assessed using the Japanese version of the European Heart Failure Self-Care Behavior Scale (EHFScBS), which has 4 items (item 3 “If my shortness of breath increase, I contact a hospital, my doctor, or nurse”, item 4 “If my feet/legs become more swollen than usual, I contact a hospital, my doctor, or nurse”, item 5 “If I gain 2 kg in 1 week, I contact a hospital, my doctor, or nurse”, item 8 “If I experience increased fatigue, I contact a hospital, my doctor, or nurse”) [24,26]. The consulting behaviors subscale scores range from 4 to 20, with lower scores indicating an increased likelihood to pursue medical treatment in response to symptoms. Cronbach's alpha was 0.85 on the consulting behaviors subscale [26].
2.2. Study patients
2.3.3. Knowledge of heart failure We used the Japanese heart failure knowledge scale to assess knowledge of HF [27]. This questionnaire consists of 15 items to which patients could respond with “yes”, “no”, or “I don't know”. One point was given for each correct answer; an incorrect answer or “I don't know” received no points. The total score was determined by the sum of these points; higher scores indicated greater knowledge of HF. The reliability and validity of this scale have been demonstrated in Japanese HF patients. Cronbach's alpha was 0.79, and item-total correlation was 0.22–0.51.
Outpatients who met the following criteria were enrolled: (1) confirmed diagnosis of HF; (2) aged 18 years or older on enrollment; (3) New York Heart Association (NYHA) functional class I, II, or III; (4)
2.3.4. Demographic and psychosocial characteristics Patients were asked to complete a self-administered questionnaire on employment status, living arrangements, level of education,
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and annual income. Level of education comprised seven categories: elementary school; middle school; high school; university; graduate school; other; and no response. Annual income comprised 10 categories: under US$10,000 (under 1 million yen); $10,100 $30,000 (1,000,010–3,000,000 yen), $30,100–$50,000 (3,000,010–5,000,000 yen), $50,100–$70,000 (5,000,010– 7,000,000 yen), $70,100–$90,000 (7,000,010–9,000,000 yen), $90,100–$100,000 (9,000,010–10,000,000 yen), over $100,000 (over 10 million yen); only pension; social welfare; and no response. In the analysis, we divided annual income into two groups—above or below $36,000 (3,000,000 yen)—using the average annual income of households with elderly persons from a national survey (2011) conducted by the Ministry of Health, Labour and Welfare. Information on age and sex was obtained from medical records. 2.3.5. Clinical characteristics The following variables were assessed from the medical records: etiology of HF, comorbidities, NYHA functional class, duration of HF, previous hospitalization for HF, echocardiography findings, blood test data, hospitalization, medication, device therapy, level of brain natriuretic peptide (BNP), estimated glomerular filtration rate (GFR), smoking history, and drinking history. 2.4. Data analysis Categorical data were presented as frequencies and percentages. For continuous variables with a normal distribution, the mean and standard deviations were reported. Characteristics of patients were compared using the unpaired t-test or Mann– Whitney U-test for continuous variables, and the chi-square test or Fisher exact test for categorical variables, as appropriate. We used Student's t-test to compare self-care behavior, consulting behaviors, and knowledge with the groups classified by lower or higher HL. Subsequently, univariate analysis was performed to identify related factors. To identify factors influencing self-care and consulting behaviors, logistic regression analyses were performed. In the multivariate analysis, the variables that were related to selfcare at P < 0.10 in the univariate analysis were entered into the multivariate model. Finally, to determine differences between the mean scores of patients with lower and higher HL, the response to each EHFScBS item was calculated by Student's t-test. All statistical tests were two-tailed, and statistical significance was defined as P < 0.05. Statistical analysis was performed with SPSS software (SPSS Version 20.0J). 3. Results 3.1. Characteristics of study patients In all, 249 patients met the study's eligibility criteria. We excluded 12 patients because of physical problems, and three patients did not give their consent to participate; thus, 234 patients took part in the study. Seven patients had missing responses and were also excluded. Accordingly, 227 patients were included in the final analysis. The effective response rate was 91.2%. The participants' sociodemographic and clinical characteristics appear in Table 1. The mean age of the patients was 67.7 13.9 years; 17.2% were living alone; 95.1% were NYHA functional class I or II. Patients with lower HL were older and had lower education levels than patients with higher HL (Table 2). 3.2. Relationship between HL and self-care behavior, consulting behavior and HF knowledge Table 3 presents the scores for self-care behavior, consulting behavior and HF knowledge by HL level. The mean self-care
3
behavior scores for total HL, communicative HL, and critical HL for patients with lower HL were significantly higher than those for patients with higher HL (36.00 vs 32.72, P = 0.03; 36.57 vs 32.60, P < 0.01; 36.73 vs 32.65, P < 0.01, respectively), but there were no significant differences between lower and higher functional HL patients. Moreover the mean consulting behavior scores for critical HL for patients with lower HL were significantly higher than those for patients with higher HL (15.39 vs 13.56, P = 0.02), there were no significant differences between lower and higher total HL, functional HL and communicative HL patients. HF knowledge scores for all HL levels (total HL, functional HL, communicative HL, and critical HL) were lower in patients with lower HL than in patients with higher HL (7.02 vs 10.28, P < 0.01; 8.33 vs 9.84, P < 0.01; 7.53 vs 10.07, P < 0.01, and 8.39 vs 9.78, P < 0.01, respectively). 3.3. Health literacy and each EHFScBS item Table 4 shows the mean scores for self-care behavior, according to our operational definition, in higher and lower HL patients. There was no significant difference in functional HL between lower and higher HL patients. In communicative and critical HL, patients with lower HL had poorer adherence to daily weighing than patients with higher HL (3.00 vs 2.60, P = 0.09; 3.10 vs 2.58, P = 0.03, Table 1 Patient characteristics. Characteristic
All N = 227
Male Age in years (mean SD) Living alone
142 (62.6) 67.7 (13.9) 39 (17.2)
Level of education Junior high school High school College Non-respondent
55 (24.2) 92 (40.5) 73 (32.2) 7 (3.1)
Employment Employed Unemployed
88 (38.8) 139 (61.2)
Yearly income $3.6 million > $3.6 million Non-respondent
57 (25.1) 134 (59.0) 36 (15.9)
Etiology of heart failure Ischemic heart disease
55 (24.2)
Comorbidity Hypertension Chronic kidney disease Atrial fibrillation Diabetes mellitus
128 (56.4) 106 (46.7) 95 (41.9) 68 (30.0)
NYHA functional class I II III BNP, pg/mL (meanSD) Estimated GFR, mL/min/1.73 m2 (mean SD)
109 (48.0) 107 (47.1) 11 (4.8) 309.6 (706.6) 61.1 (34.3)
Echocardiogram LVEF, % (mean SD) LVEF > 40% Duration of HF in years (mean SD) Previous hospitalization for HF Implanted pacing devices
46.5 (15.0) 154 (67.8) 8.25 9.00 172 (75.8) 57 (25.1)
HL: health literacy, SD: standard deviation, NYHA: New York Heart Association, BNP: brain natriuretic peptide, GFR: glomerular filtration rate, LVEF: left ventricular ejection fraction, HF: heart failure.
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Table 2 Patient characteristics according to level of HL. Characteristic
HL total Lower n = 56
Male 37 (66.1) Age in years 74.3 10.0 (mean SD) 10 (17.9) Living alone Level of education Junior high 23 (41.0) school 15 (26.8) High school College 17 (30.4) Employed 22 (39.3) Yearly income 12 (21.4) ($3.6 million) Etiology of heart failure Ischemic 18 (32.1) heart disease Comorbidity Hypertension Chronic kidney disease Atrial fibrillation Diabetes mellitus NYHA functional I II III BNP, pg/mL (mean SD) Estimated GFR, mL/min/1.73m2 (mean SD) LVEF, % (mean SD) Duration of HF in years (mean SD) Previous hospitalization for HF Implanted pacing devices
Functional HL
Communicative HL
Critical HL
Higher n = 171
P value
Lower n = 55
Higher n = 172
P value
Lower n = 53
Higher n = 174
P value
Lower n = 49
Higher n = 178
105 (61.4) 65.5 14.3
0.63 <0.01
37(67.3) 71.3 11.0
105 (61.0) 66.514.6
0.43 0.03
41 (77.4) 71.9 11.8
101 (58.0) 66.414.3
0.02 0.01
29 (59.2) 70.7 12.8
113 (63.5) 66.9 14.1
0.62 0.09
29 (17.0)
0.84 0.04
10 (18.2)
29 (16.9)
0.84 0.30
10 (18.9)
29 (16.7)
0.68 0.02
11 (22.4)
28 (15.7)
0.29 0.51
14 (25.5)
40 (23.3)
22 (41.5)
33 (19.0)
16 (32.7)
39 (21.9)
68 (39.5) 59 (34.3) 68 (39.5) 41 (23.8)
0.75 0.59
13 16 21 13
(24.5) (30.2) (39.6) (24.5)
79 (45.4) 57 (32.8) 67 (38.5) 44 (28.1)
0.87 0.86
19 (38.3) 14 (28.6) 17 (34.7) 10 (27.7)
73 (41.0) 59 (33.1) 71 (39.9) 47 (29.9)
0.62 0.69
32 (18.7) 77 56 66 45
P value
(45.0) (32.7) (38.6) (26.3)
1.00 0.37
24 (43.5) 14 (25.5) 20 (36.4) 16 (29.1)
37 (21.6)
0.15
15 (23.8)
40 (26.7)
0.59
18 (38.3)
37 (22.8)
0.07
16 (34.0)
39 (24.0)
0.13
41 (73.2) 26 (46.4)
87 (50.9) 80 (46.8)
<0.01 1.00
39 (61.9) 28 (40.5)
89 (55.8) 78 (46.5)
0.01 0.54
36 (68.1) 26 (46.8)
92 (53.9) 80 (44.9)
0.06 0.75
30 (61.7) 20 (40.4)
98 (55.7) 86 (46.7)
0.52 0.42
18 (32.1)
77 (45.0)
0.12
25 (40.5)
70 (41.9)
0.54
16 (31.9)
79 (44.3)
0.06
16 (31.9)
79 (44.3)
0.19
25 (44.6)
43 (25.1)
<0.01
22 (23.8)
46 (30.8)
0.07
24 (44.7)
44 (25.1)
0.01
18 (36.2)
50 (27.5)
0.29
class 30 (53.6) 79 (46.2) 23 (41.1) 84 (49.1) 3 (5.4) 8 (4.7) 371.7 547.8 289.7 751.0
0.58
0.46
0.76 25 (54.8) 84 (48.3) 28 (35.7) 79 (47.1) 2 (7.1) 9 (4.7) 469.7 118.9 258.2 448.0
0.05
0.22 31 (59.6) 78 (46.7) 20 (36.2) 87 (47.3) 2 (4.3) 9 (5.4) 329.7 516.2 303.7 755.5
0.82
0.27 28 (57.4) 81 (47.3) 20 (40.4) 87 (46.1) 1 (2.1) 10 (6.0) 246.5 417.8 327.1 67.7
0.48
57.5 24.1
62.3 37.0
0.37
57.9 22.8
62.1 37.2
0.43
57.0 23.4
62.3 37.0
0.32
61.8 23.3
60.9 36.8
0.88
48.1 15.9
46.0 14.7
0.35
49.1 16.8
45.7 14.3
0.14
48.9 14.3
45.8 15.1
0.19
48.3 12.6
46.3 15.7
0.39
8.2 9.0
8.2 7.3
0.97
8.7 10.0
8.1 6.9
0.62
8.8 9.6
8.1 7.1
0.56
6.35.4
8.7 8.2
0.06
47 (83.9)
125 (73.1)
0.11
38 (73.8)
134 (76.2)
0.21
46 (85.1)
126 (73.1)
0.04
39 (80.9)
113 (74.3)
0.57
15 (26.8)
42 (24.6)
1.00
14 (31.0)
43 (29.7)
1.00
11 (34.0)
46 (28.7)
0.45
14 (29.8)
43 (29.9)
0.70
HL: health literacy, SD: standard deviation, NYHA: New York Heart Association, BNP: brain natriuretic peptide, GFR: glomerular filtration rate, LVEF: left ventricular ejection fraction, HF: heart failure.
respectively) and fluid restriction (4.06 vs 3.38, P < 0.01; 4.00 vs 3.41, P = 0.03, respectively). Additionally, patients with lower critical HL scored higher than those with higher critical HL in the following items: “If I gain 2 kg in 1 week, I contact a hospital, my doctor, or nurse” and “If I experience increased fatigue, I contact a hospital, my doctor, or nurse”. 3.4. Factors associated with self-care behavior Table 4 compares self-care behavior scores between the two populations stratified by all HL levels and various patients' characteristics. Patients with higher communicative and critical HL had lower scores for self-care behavior, indicating fewer selfcare behavior (sb = 0.837, P < 0.01; sb = 0.631, P < 0.01, respectively). Increased age was correlated with fewer self-care behavior (sb = 0.122, P < 0.01). The scores for cardiac parameters showed that prior hospitalization for HF and NYHA functional class were associated with fewer self-care behavior (sb = 4.029, P < 0.01; and sb = 3.735, P < 0.01; respectively), but LV ejection fraction (LVEF) was not. The scores for comorbidity revealed that chronic
kidney disease was associated with fewer self-care behaviors. Additionally, a lower HF knowledge score was significantly associated with lack of self-care behavior (sb = 0.530, P < 0.01). Multiple regression analysis revealed that independent determinants of fewer self-care behavior were critical HL (sb = 0.154, P = 0.027), age (sb = 0.247, P < 0.01), prior hospitalization for HF (sb = 0.167, P < 0.01), NYHA functional class (sb = 0.147, P = 0.021) and HF knowledge (sb = 0.214, P < 0.01). In addition, the independent determinants of fewer consulting behavior were critical HL (sb = 0.266, P = 0.048), prior hospitalization for HF (sb = 1.811, P = 0.022) (Table 5). 4. Discussion and conclusion 4.1. Discussion The present study demonstrated that fewer self-care behavior and lack of HF knowledge correlated with patients with lower HL. In particular, patients with a lower critical HL do not perform consulting behaviors as often as those with a high critical HL. With
Please cite this article in press as: S. Matsuoka, et al., Health literacy is independently associated with self-care behavior in patients with heart failure, Patient Educ Couns (2016), http://dx.doi.org/10.1016/j.pec.2016.01.003
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S. Matsuoka et al. / Patient Education and Counseling xxx (2015) xxx–xxx Table 3 Health literacy level in relation to HF knowledge and self-care behavior HL: health literacy, SD: standard deviation, 95%CI: confidence interval.
lower critical HL scored lower for the items about contacting the hospital and medical staff when their body weight and fatigue increased. The key finding of this study was that critical HL was an independent determinant of fewer self-care behavior and consulting behavior, controlling for the effects of other variables. A notable point in this study was that we determined the relationship between three levels of HL (functional, communicative, and critical HL) and self-care behavior. The results of previous research into the association between HL and self-care behavior have not been consistent. Some studies have indicated an association between HL and self-care behavior [17,28], while others found no significant association [29–31]. Most previous measurements of HL in HF patients used scales such as the Test of Functional Health Literacy in Adults (TOFHLA) and the Rapid Estimate of Adult Literacy in Medicine (REALM) [32], which apply only to the functional domain of HL. However, for HF patients to modify their daily lives and assess their own symptoms and signs, it is necessary to acquire appropriate information and make effective use of it in self-care behavior. Because assessment of functional HL alone is thus insufficient, the results of the relationship between HL and self-care behavior could be different in each study. An important finding of this study was that critical HL was an independent predictor of self-care behavior and consulting behavior in patients with HF, in addition to the factors identified in previous studies (older age, experience of previous HF hospitalization, higher NYHA functional class, chronic renal failure, and lack of knowledge of HF) [6,31,32]. This finding is consistent with previous studies showing that adherence to self-care behavior in patients with HF is poor if patients do not understand, absorb and retain health information [33]. HF patients require selfcare behaviors to maintain their physiological stability (self-care maintenance) and to respond to symptoms when they occur (selfcare management) [4]. HF self-care maintenance behavior includes taking medications, eating a low-sodium diet, and performing routine exercise and symptom monitoring. Self-care management in HF requires that patients recognize a change, evaluate the change, decide to take action, implement a treatment strategy, and evaluate the response to the treatment implemented [6]. Riegel
Total HL
HF knowledge Self-care behavior Consulting behavior
Lower (n = 56) Mean SD
Higher (n = 171) Mean SD
P value
95% CI
7.02 36.00 15.02
10.28 32.72 13.61
<0.01 0.03 0.07
2.40 to 4.13 6.26 to 0.39 0.094 to 2.913
3.30 9.83 4.84
2.68 9.45 5.15
Functional HL Lower (n = 55) Mean SD 8.33 HF knowledge Self-care behavior 34.89 Consulting behavior 14.51
3.20 8.66 4.74
Higher (n = 172) Mean SD
P value 95% CI
9.84 33.09 13.78
<0.01 0.23 0.33
3.08 9.90 5.21
0.57 to 2.46 4.73 to 1.14 0.763 to 2.22
Communicative HL Lower (n = 53) Mean SD 7.53 HF knowledge Self-care behavior 36.57 Consulting behavior 15.02
3.42 10.37 4.91
Higher (n = 174) Mean SD
P value 95% CI
10.07 32.60 13.63
<0.01 <0.01 0.08
2.84 9.22 5.13
1.62 to 3.46 6.90 to 1.03 0.16 to 2.93
Critical HL Lower (n = 49) Mean SD 8.39 HF knowledge Self-care behavior 36.73 Consulting behavior 15.39
3.29 9.11 4.38
Higher (n = 178) Mean SD
P value 95% CI
9.78 32.65 13.56
<0.01 <0.01 0.02
3.07 9.60 5.23
5
0.40 to 2.38 7.11 to 1.07 0.36 to 3.29
respect to individual items of the EHFScBS, there were no significant differences between patients with lower and higher functional HL, but patients with lower critical and communicative HL had poorer adherence to daily weighing, fluid restriction, and to taking it easy when short of breath than those with higher critical and communicative HL. In addition to these items, patients with Table 4 Health literacy level in relation to EHFScBS items. Total HL Lower (n = 56) (1) I weigh myself everyday (2) If I am short of breath, I take it easy (3) If my shortness of breath increase, I contact a hospital, my doctor, or nurse (4) If my feet/legs become more swollen than usual, I contact a hospital, my doctor, or nurse (5) If I gain 2 kg in 1 week, I contact a hospital, my doctor, or nurse (6) I limit the amount of fluids I drink (not more than 1–1.5 l/ day) (7) I take a rest during the day (8) If I experience increased fatigue, I contact a hospital, my doctor, or nurse (9) I eat a low salt diet (10) I take my medication as prescribed (11) I get a flu shot every year (12) I exercise regularly
Functional HL Higher (n = 171)
P value
Lower (n = 55)
3.04 (1.60) 2.58 (1.43) 0.05 2.87 (1.41) 2.41 (1.55) 1.71 (1.06) <0.01 2.13 (1.39)
Higher (n = 172)
Communicative HL P Lower value (n = 53)
2.64 (1.50) 0.31 1.80 (1.17) 0.09
3.29 (1.78) 2.91 (1.63)
0.14
3.68 (1.66) 3.38 (1.59)
0.23 3.42 (1.63) 3.47 (1.61)
4.18 (1.39)
3.71 (1.60)
3.20 (1.70) 2.94 (1.66) 0.31
Higher (n = 174)
Critical HL P value
Lower (n = 49)
3.00 (1.57) 2.60 (1.45) 0.09 3.10 (1.57) 2.51 (1.64) 1.69 (1.01) <0.01 1.98 (1.39)
Higher (n = 178)
P value
2.58 (1.44) 0.03 1.85 (1.12) 0.53
3.34 (1.76) 2.90 (1.63)
0.09 3.33 (1.75) 2.91 (1.64) 0.12
3.70 (1.70) 3.38 (1.59)
0.21 3.71 (1.63) 3.38 (1.60) 0.20
0.05 3.95 (1.43) 3.78 (1.60) 0.51
4.15 (1.42)
0.08 4.29 (1.37) 3.70 (1.59) 0.02
3.86 (1.50) 3.43 (1.67)
0.09 3.84 (1.44) 3.44 (1.69) 0.21
4.06 (1.43) 3.38 (1.66) <0.01 4.00 (1.51) 3.41 (1.65)
2.46 (1.63) 2.47 (1.39) 3.88 (1.49) 3.61 (1.47)
0.99 2.47 (1.53) 2.47 (1.42) 0.25 3.95 (1.33) 3.59 (1.51)
2.62 (1.60) 2.42 (1.40) 3.83 (1.47) 3.63 (1.49)
0.37 2.63 (1.56) 2.42 (1.41) 0.37 0.39 4.06 (1.44) 3.57 (1.48) 0.04
2.70 (1.55) 2.37 (1.33) 1.13 (0.51) 1.20 (0.71)
0.13 2.60 (1.54) 2.40 (1.34) 0.36 0.47 1.15 (0.62) 1.19 (0.68) 0.65
2.53 (1.51) 1.21 (0.74)
0.64 2.65 (1.52) 2.39 (1.35) 0.25 0.74 1.14 (0.50) 1.19 (0.70) 0.65
3.07 (1.84) 2.80 (1.87) 2.32 (1.32) 2.55 (1.38)
0.35 2.76 (1.81) 2.90 (1.89) 0.64 0.28 2.56 (1.27) 2.47 (1.40) 0.66
3.15 (1.81) 2.78 (1.88) 2.47 (1.35) 2.47 (1.35)
0.85
0.97 0.12
3.72 (1.59)
2.43 (1.35) 1.17 (0.64)
0.21 3.27 (1.95) 2.76 (1.83) 0.89 2.57 (1.51) 2.47 (1.33)
0.03
0.09 0.65
Please cite this article in press as: S. Matsuoka, et al., Health literacy is independently associated with self-care behavior in patients with heart failure, Patient Educ Couns (2016), http://dx.doi.org/10.1016/j.pec.2016.01.003
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Table 5 Multiple linear regression analysis between HL level and self-care behavior. Self-care behavior total Univariate analysis sb
Multivariate analysis
SE
P value
0.275 0.837 0.631
0.238 0.236 0.229
0.249 <0.01 <0.01
Demographic characteristics Gender (male) Age Living alone Employed Junior high school
2.801 0.122 0.476 4.611 0.314
1.310 0.045 1.697 1.278 1.494
0.034 <0.01 0.779 <0.01 0.210
Cardiac parameters Ischemic etiology of HF Prior hospitalization for HF Log BNP (pg/mL) LVEF40% NYHA functional class
2.641 4.029 0.001 1.607 3.735
1.484 1.470 0.001 1.367 1.066
0.076 <0.01 0.126 0.241 0.001
0.583 0.209 0.713 4.000
1.297 1.291 1.397 1.255
0.653 0.876 0.610 <0.01
2.069 0.530
1.546 0.200
0.183 <0.01
Health literacy Functional HL Communicative HL Critical HL
Comorbidity Atrial fibrillation Hypertension Diabetes mellitus Chronic kidney disease Treatment Implanted pacing devices HF Knowledge R2 (adjusted R2)
Consulting behavior
sb
Multivariate analysis sb
SE
P value
0.069 0.154
0.262 0.242
0.337 0.027
0.116 0.266
0.152 0.141
0.446 0.048
0.124 0.247
1.261 0.052
0.052 <0.01
1.361 0.017
0.732 0.030
0.064 0.567
1.324
0.164
0.010
0.768
0.989
0.119 0.167
1.409 1.353
0.061 <0.01
1.429 1.811
0.818 0.785
0.082 0.022
0.147
1.011
0.021
0.492
0.587
0.403
0.109
1.198
0.080
1.344
0.695
0.055
0.214 0.264
0.231 (0.230)
<0.01
0.111 0.144
0.134 (0.118)
0.409
0.092
SE
P value
SE: standard error, BNP: brain natriuretic peptide, NYHA functional class: NYHA: New York Heart Association
et al. indicated that patient evaluation and response to symptoms after perception of symptoms as well as treatment adherence are importance to prevent re-hospitalization due to HF [33]. This is particularly important with respect to the likelihood of patients to seek treatment when HF symptoms are severe, which has been correlated with repeat admissions [34,35]. In the present study, critical HL was associated with an evaluation of changes in symptoms and seeking-treatment behavior, which is consulting behavior. HF patients with high critical HL can recognize worsening symptoms, determine if it is a condition that needs treatment, and implement treatment-seeking behaviors. Functional HL and communicative HL were not directly related to self-care and consulting behavior, while a lack of knowledge of HF was greater in low HL patients. In addition, we found that knowledge of HF is an independent determinant of self-care behavior. HF patients may have several misunderstandings regarding HF, which can lead to poor adherence to self-care and to the deterioration of HF [36,37]. It is necessary to increase the overall HL level of HF patients if we seek to reinforce appropriate self-care behavior. If we evaluate not only functional HL but multifaceted HL as well, we are able to help compensate for the lack of HL skills and introduce more specific and effective interventions to connect obtained knowledge with the practice of self-care behaviors in the context of daily life. This study defined patients whose total score on the HF-specific HL scale was less than the IQR as lower HL patients, and the prevalence of lower HL patients was 16.3%. A systematic review of HL and HF patients published in 2015 reported values ranging from 17.5% to 97% (average 39%) for HF patients with low HL [22]. One study using S-TOFLA reported that 19.2% of HF patients had low HL
[38], and another study using SHLS reported 17.5% of HF subjects with low HL [19]. The prevalence of low HL in HF patients is affected by the method of assessment, the definition, and the classification of low HL. Our study reported a somewhat lower percentage compared with the results of previous studies; however, since our study focused on patients with low HL and the relationship between low HL and HF self-care behavior, the definition of low HL using quartiles was appropriate. The present study has a number of limitations. First, HF-specific HL, self-care behaviors and HF knowledge were assessed using self-reporting measures delivered orally. Hence, the items could be subject to a social desirability bias. Second, in this explorative study we did not test the “goodness of fit” of the model. In the health literacy model of Westlake et al. [39], “self-care” consisted of “patient factors” (such as motivation, problem solving, and selfefficacy) and “extrinsic factors” (such as support technologies, mass media, and health education resources). In our study, several of these factors were missing. Third, in this study, all findings should be clearly noted as self-reporting measures. A longitudinal follow-up is needed to define the association between HL and other objective evaluations, such as hospitalizations and death. Finally, because of the cross-sectional nature of our survey we could not test for a cause–effect relationship. Despite these limitations, the significant association between HL and self-care behavior is considered to be valid. 4.2. Conclusions In conclusion, health literacy is strongly correlated with selfcare behavior for patients with HF. Critical HL in particular was
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found to be an independent determinant of self-care behavior. With more effective support, we can help patients to critically assess the large amount of information they have obtained and effectively use it in their decision-making. 4.3. Implications for practice We believe that the results of this study could change the methodology of patient education for patients with HF. Recently, the use of teach-back methods, in which patients are asked openended questions requiring them to respond to healthcare educators, enabling nonthreatening assessment of the patient's understanding of content, has been associated with improved learning outcomes for knowledge retention, and reduced hospital readmission [40]. It is important for patients not only to read educational materials, but also to obtain the information relevant to them, to understand this information, and to communicate it to others including their family and healthcare providers. In other words, a high level of HL is essential for patients with HF. Conflicts of interest The authors have no conflicts of interest to declare. Acknowledgments This study was supported by a Grant-in-Aid for Scientific Research (Research Activity Start-up) from the Japan Society for the Promotion of Science (Grant number 23890214). References [1] M. Tsuchihashi, H. Tsutsui, K. Kodama, F. Kasagi, S. Setoguchi, M. Mohr, et al., Medical and socioenvironmental predictors of hospital readmission in patients with congestive heart failure, Am. Heart J. 142 (2001) E7. [2] A. Michalsen, G. Konig, W. Thimme, Preventable causative factors leading to hospital admission with decompensated heart failure, Heart 80 (1998) 437– 441. [3] M.H. van der Wal, T. Jaarsma, D.J. van Veldhuisen, Non-compliance in patients with heart failure; how can we manage it? Eur. J. Heart Fail. 7 (2005) 5–17. [4] D.K. Moser, V. Dickson, T. Jaarsma, C. Lee, A. Stromberg, B. Riegel, Role of selfcare in the patient with heart failure, Curr. Cardiol. Rep. 14 (2012) 265–275. [5] M.H. van der Wal, T. Jaarsma, D.K. Moser, N.J. Veeger, W.H. van Gilst, D.J. van Veldhuisen, Compliance in heart failure patients: the importance of knowledge and beliefs, Eur. Heart J. 27 (2006) 434–440. [6] M.H. van der Wal, T. Jaarsma, D.K. Moser, W.H. van Gilst, D.J. van Veldhuisen, Qualitative examination of compliance in heart failure patients in The Netherlands, Heart Lung 39 (2010) 121–130. [7] B. Riegel, D.K. Moser, S.D. Anker, L.J. Appel, S.B. Dunbar, K.L. Grady, et al., State of the science: promoting self-care in persons with heart failure: a scientific statement from the American Heart Association, Circulation 120 (2009) 1141– 1163. [8] B.W. Hesse, D.E. Nelson, G.L. Kreps, R.T. Croyle, N.K. Arora, B.K. Rimer, et al., Trust and sources of health information: the impact of the Internet and its implications for health care providers: findings from the first Health Information National Trends Survey, Arch. Int. Med. 165 (2005) 2618–2624. [9] C.R. Selden, M. Zorn, S. Ratzan, R.M. Parker, no, Health Literacy: Current Bibliographies in Medicine, National Library of Medicine, Bethesda, MD, 2000 [article online] 2000-1. [10] D. Nutbeam, Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century, Health Promot. Int. 15 (2000) 259–267. [11] D. Schillinger, K. Grumbach, J. Piette, F. Wang, D. Osmond, C. Daher, et al., Association of health literacy with diabetes outcomes, JAMA 288 (2002) 475– 482. [12] E.J. Mayeaux Jr., P.W. Murphy, C. Arnold, T.C. Davis, R.H. Jackson, T. Sentell, Improving patient education for patients with low literacy skills, Am. Fam. Physician 53 (1996) 205–211. [13] M.V. Williams, D.W. Baker, R.M. Parker, J.R. Nurss, Relationship of functional health literacy to patients' knowledge of their chronic disease: a study of patients with hypertension and diabetes, Arch. Int. Med. 158 (1998) 166–172.
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Please cite this article in press as: S. Matsuoka, et al., Health literacy is independently associated with self-care behavior in patients with heart failure, Patient Educ Couns (2016), http://dx.doi.org/10.1016/j.pec.2016.01.003