Health Science

Communication

Biosci. Biotech. Res. Comm. 10(1): 114-120 (2017)

Relationship between health literacy and health

promoting behavior in patients with heart failure

referred to clinics of Shahid Beheshti University of

Medical Sciences

Mahrokh Imanian

, Meimanat Hosseini

*, Tahereh Ashk Torab

, Nezhat Shakeri

and

Mahsa Matbouei

Department of Medical Surgical Nursing, Student’s Research Of ce, Shahid Beheshti University of Medical

Sciences, Tehran, Iran

PhD in Nursing, Assistant Professor of Community Health Nursing Department, School of Nursing and

Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran

PhD in Nursing, Assistant Professor of Nursing Department, School of Nursing and Midwifery, Shahid

Beheshti University of Medical Sciences, Tehran, Iran

PhD in Biostatistics, Department of Biostatistics, Faculty of Paramedical Sciences, Shahid Beheshti

University of Medical Sciences, Tehran, Iran

Instructor of Nursing (MSc), Dept.of Community Health Nursing, School of Nursing & Midwifery Shahid

Beheshti University of Medical Sciences, Tehran, Iran

ABSTRACT

Patients with heart failure are considered one of the most important groups exposed to the danger of low health

literacy that may affect their health-promotion behaviors and quality of life and increase the load of health-related

costs. Therefore, the present study aimed to determine the relationship between health literacy and health-promoting

behaviors in patients with heart failurewho referred to heart clinics of Shahid Beheshti University of Medical Sci-

ences.This correlational study was conducted on 300 heart failure patients, selected byrandom cluster sampling

method with proportional allocation. Data collection tool was demographic information questionnaire,Health literacy

measurement and Health promoting Lifestyle Pro le 2 (HPLP2). Data analysis was performed using SPSS software

version 19 though statistical tests, includingindependent t-test, Pearson and Spearman correlation coef cient, Mann-

114

ARTICLE INFORMATION:

*Corresponding Author: m_hoseini@sbm

Received 27

Nov, 2016

Accepted after revision 12

March, 2017

BBRC Print ISSN: 0974-6455

Online ISSN: 2321-4007 CODEN: USA BBRCBA

Thomson Reuters ISI ESC and Crossref Indexed Journal

NAAS Journal Score 2017: 4.31 Cosmos IF : 4.006

reserved.

Online Contents Available at: http//www.bbrc.in/

Mahrokh Imanian et al.

Whitney-U test and Kruskal-Wallis. The results showed that mean and standard deviation (SD) score ofhealth literacy

of participants was 3.29±0.6 and meanand SD score of health-promoting behaviors was 2.42±0.29. The Pearson

correlation coef cientshoweddirect and signi cant relationship between health literacy andhealth-promoting behav-

iors (r=0.66, P<0.001). The results of this research showed the statistically signi cant relationship between health

literacy level and health-promoting behavior. Therefore, health literacy should be paid special attention, as a factor

affectinghealth-promoting behaviors,healthy life style and quality of life. According to the results of this study, pro-

grammingeducation and development of health-promoting behaviorsin patients with heart failure suggest that the

health literacy needsmore attention inhealth-promotion plans.

KEY WORDS: HEALTH LITERACY, HEALTH-PROMOTING BEHAVIOR, PATIENT, HEART FAILURE

INTRODUCTION

The prevalence ofchronic diseases is a challenge in the

present century in health and treatment sector (Kar-

baschi et al. 2012). Among chronic diseases, the preva-

lence of congestive heart failure is increasing(Rahnavard

et al, 2006). As in the whole world, 23 million people

are suffering fromheart failure and annually two mil-

lion new casesof heart failureare diagnosed(Shiba and

Shimokawa, 2011). However, inIran,no detailed data

exists from people withheart failure(Rezaee loye et al,

2009). At the same time, with increase in number of

patients suffering from chronic diseases, likeheart fail-

ure, systems presenting health services face numerous

dif culties in long runtoprovide services to these peo-

ple. In other words, chronic diseases need chronic care.

Therefore, many believe that self-care should be per-

formed by patients, in order toorganize these patients

and facilitate their affairs(Mellen, 2002). Based on the

 ndings of previous studies, high mortality rate, inap-

propriate use of preventive services, and deterioration

ofheart failureare associated with inadequate health lit-

eracy (Dennison et al, 2011).

Inadequate health literacy is de ned asthe limited

ability of people for acquiring, interpreting, and under-

standing primary information and health services that

are necessary for appropriate decision-making inhealth

areas (Raisi et al, 2013). Among patients with heart fail-

ure, as well,low health literacy is associated with mortal-

ity (Eckman et al, 2015).

According to studies by American Center for Health

Care Strategies,people withlow health literacy are

unlikely tounderstand and practice the written and

oralinformation presented by the specialists(Raisi et al,

2011). Recent reviews have reported poor health literacy

in 33 to 51% of adults discharged from hospitals and

more than60% of referrals to cardiac clinics (Fernan-

dez, 2014); while,heart failuredisease can affect routine

life activities, due to its natural capability. As a result,

these patients become dependent to others for self-

care (Abbasi et al, 2010). Today, health literacy is also

an important concept inwidespread aspects of health

promotion (Kanj and Mitic, 2010).Epidemiologicalstud-

ies have shown that the development of risk factors for

coronary artery disease can be controlled by having a

healthy lifestyle and people can improve their health

through health-promoting behaviors (Mohseni Pouya

et al, 2016).

Pender have suggestedthat health-promoting behav-

iors including exercise, nutrition, stress management,

interpersonal relationship, spiritual growth, and health

responsibilities reduce the risk of disease (Hosseini

et al, 2015). These behaviorsare one of themajor meas-

ures exterminating health that is known as abackground

factor in preventing many diseases (Raisi et al, 2011).

With regard to the importance of two issues ofhealth

literacy and health-promoting behaviorsin patients with

heart failure and regarding the report ofAgency for

Health Care Research and Quality on need for further

researches more on health literacy and the way itaffects

people’s health (Raisi et al., 2013) and consideringthe

fact that until now the relationship between health lit-

eracy andhealthy behaviorsin cardiac patients has not

been studied inIran, the present research evaluated the

relationship between health literacy level and health-

promoting behaviorsin patients with heart failure as one

of the most important vulnerable groups.

MATERIALS AND METHODS

Inthis correlational study, a total of 300 of patients suf-

fering from heart failure referred to cardiac clinics of

hospitals af liated to Shahid Beheshti University of Med-

ical Sciences were selected by random cluster sampling

according to the following inclusion criteria: diagnosis

of heart failure grade 2 and 3 in medical records accord-

ing to doctor’s diagnosis, minimum age of 25 years and

maximum of 65 years, ability to read and write Farsi

texts, passing at least six monthsafter  naldiagnosis of

the disease, receivingpharmaceutical treatment for heart

failure (pills and medicinal regimen). Datawas collected

through two questionnaires and a scale that included the

following tools:

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS THE RELATIONSHIP BETWEEN HEALTH LITERACY AND HEALTH PROMOTING BEHAVIOR 115

Mahrokh Imanian et al.

1. Demographic information questionnaire (includ-

ing a total of 7 questions, 5 questions related to

personal information and 2 questions related to

the disease).

2. Health literacy measurement: This tool was de-

signed by Montazeri et al.,in 2014that includes

33 items in 5 domains; 4 of theminclude access,

understanding, assessment, decision-making, and

employing the information, each containing 6, 7,

4, and 12 items, respectively, and the reading skill

contains 4 items with 5-item Likert scale.

3. HPLP2: This scale is used toassesshealth-promoting

behavior, which includes spiritual growth, respon-

sibility, physical activity, nutrition, interpersonal

relationship, and stress management, designed by

Walker et al (1987), containing 52 items and 4-op-

tionLikert scale that wastranslated by Hosseini

et al., in 2010 (Hosseini, 2013).

In the present research, validity of the demographic

questionnaire was determined through qualitativem-

ethod. Also, todetermine the validity, other qualitative

method was used to determinefacevalidity and qualita-

tive and quantitative methods were used for determine

content validity. Content validity index (CVI)was deter-

mined using quantitative methods. For this purpose,

opinion of 10 experts in thenursing  eld was used. CVI

of the Health literacy measurement and HPLP2 was

0.92, and 0.94, respectively. To determine the reliabil-

ity of the tools in the present study, internalconsistency

(Cronbach’s alpha) and stability (Interclass Correlation

Coef cient (ICC)) were used. Cronbach’s alpha coef -

cient of the total health literacy tool and HPLP2 was

 = 0.78, and 0.87, respectively. Also, total ICC of this

tools was calculated  = 0.82, and 0.79, respectively. To

gather data, aftercon rming the proposal of the research

and getting introduction letter and receivingsampling

license, 7 hospitals were purposively selected based on

the list of hospitals with cardiac clinic af liated toSha-

hid Beheshti University of Medical Sciences, Tehran.

Then, one of the researchersselected hospitals randomly

and referred to each clinic (which was assessed by the

researcher before) during working hours. Then, samples

were selected randomly among patients with quali ed

conditions of sampling in the research. Then, while pro-

viding necessary explanation about the research objec-

tives and emphasis on con dentiality of data, written

informed consent letter was obtained from patients and

the research tools were completed orally and by asking

participants.

To analyze data, SPSS software version 19 was used.

To report descriptive data,mean and SD, frequency-

and percentage were used. To analyze data in infer-

ential statistics, Kolmogorov-Smirnov test was used

and when the data distribution was normal,parametric

tests(independent t-test, Pearson correlation coef cient)

and when the data distribution was not normal, non-

parametric tests (Mann-Whitney-U, Kruskal-Wallis and

Spearman correlation coef cient) were used. Finally,

after univariate analysis, to assess the impact of vari-

ables beside each other on the outcome variable (health

promotion behaviors), all variables witha possibility

greater than 0.2 enteredmultiple regression model.

RESULTS AND DISCUSSION

The results showed that men included 51.7% of patients

with heart failure and 86% were married. Mean and

SDof age of participants was 54.83±8.21 and they were

mostly at age range 60 to 65 years. 39.3% of partici-

pants had secondary school education and 98%had no

history of employment inarea of medical sciences. Most

of participants (57.7%) had a monthly income of less

than 250,000 Tomans per family member. Also, 90% of

participants stated a history of hospitalization due to

heart reasons. At the same time, 84% of the participants

claimed no history of education in the form of lea ets,

pamphlets or oral training (Table 1).

Based on the results of the current study,mean and

SD score of health literacy in patients with heart failure

was 3.29±0.6 and 87.7% of participant showed moder-

atehealth literacy. Also, mean and SD of health-promot-

ing behaviors of participant in the study was 2.42±0.29

and 57% of participant had moderate level. Resultsof

Pearson statistical test showeda signi cant positive cor-

relation betweenhealth literacy and health-promoting

behaviors(P<0.001). Therefore, higher level of health lit-

eracy increased the health-promoting behaviors score in

patients with heart failure.

Amongthe subscales of health literacy,mean and SD

scores of total participants in thereading skill was higher

than other skills (3.8±0.87), and in the aspect of evalu-

ation and decision-making,the mean and SD scores of

people was less than other factors (3±0.83). The results

of independent t-test showed no signi cant difference

in scores of overall health literacy between women and

men (P>0.05). Among other demographic variables of

health literacy, marital status and monthly income had

a signi cant relationship (P>0.05). Pearson correlation

test showed signi cantdifference intotal health liter-

acy at different age groups with education (P<0.001).

Table 2 shows the correlation of health literacy with age

and educational status of participants in the research.

Inthe  elds of health-promoting behaviors, mean and

SD scores of participantswas higher in interpersonal

relationship thanother subscales (2.8±0.34) and was the

leastin the stress management with a mean and SD of

116 THE RELATIONSHIP BETWEEN HEALTH LITERACY AND HEALTH PROMOTING BEHAVIOR BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

Mahrokh Imanian et al.

Table 1. Frequency of distribution of demographic characteristics of patients

variable number %

Sex

male 155 51.7

female 144 48.3

Education

primary 81 27

Middle (guidance level) 118 39.3

Secondary 14 4.7

College 43 43

Employment status

Working in medical sciences 4 1.3

Not employed in medical sciences 296 98.7

Marital status

Single 15 5

Married 258 86

Divorced 1 0.3

Widow(er) 26 8.7

Age

25-29 4 1.3

30-34 5 1.7

35-39 6 2

40-44 20 6.7

45-49 20 6.7

50-54 75 25

55-59 51 17

60-65 119 39.7

Monthlyincome

Morethan 250,000 Tomans per family member 32 32

Lessthan 250,000 Tomans per family member 36 36

History of hospitalization

Yes 270 90

No 30 10

Historyof education

Yes 48 16

No 252 84

Table 2. correlation between health literacy and health-

promoting behavior with age and educational level

Scale

Age Educationalstatus

r p-value r p-value

Health literacy ** -0.41 <0.001 0.82 <0.001

Health-promoting

behavior**

-0.18 0.002 0.6 <0.001

**Correlationis signi cant at 0.05.

2.21±0.32, had the lowest score. The results of independ-

ent t-test showed signi cant differences in health-pro-

moting behaviors betweenthe studied women and men

(P=0.02) andstudied men were in better condition. Total

health-promoting behaviorswere signi cantly asso-

ciated only with monthly income (P<0.001). Pearson

correlation coef cient showed signi cant differences

in health-promoting behaviors in different age groups

and educational status (P<0.001). The correlation test of

health-promoting behaviors with education level and

age are expressed in table 2. Also, table 3 shows the cor-

relation between health literacy and health-promoting

behaviors subscales in the study subjects.

Table 3. Correlation between health literacy and

subscales of health-promoting behaviorsin study

subjects

Subscale of health-promoting

behaviors

Health literacy

r p-value

Nutrition** 0.516 <0.001

Physical activity ** 0.520 <0.001

Interpersonal relationship ** 0.457 <0.001

Health responsibility** 0.547 <0.001

Spiritual growth** 0.607 <0.001

Stress management** 0.544 <0.001

Total health-promotingbehavior 0.66 <0.001

**Correlation is signi cant at 0.05.

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS THE RELATIONSHIP BETWEEN HEALTH LITERACY AND HEALTH PROMOTING BEHAVIOR 117

Mahrokh Imanian et al.

The results of multiple regression models showed that

health literacy, education, age and income status were

effective factors onhealth-promoting behaviors(P>0.05).

Health-promoting behaviors in people with secondary

schooleducation had a0.13 less mean value than people

with college education and each unit increase in age,

increasedmeanHealth-promoting behaviors at 0.005

units.Health-promoting behaviors in people with an

income more than 250,000 Tomans per person had a

mean 0.1 unit increased than people with income less

than 250,000 Tomans per person. Each unit increase

inhealth literacy increased the meanHealth-promot-

ing behaviors0.29 units. Among theabove-mentioned

variables,health literacy had the greatest impact on

health-promoting behavior. The results ofmultiple

regression models are demonstrated in table 4.

DISCUSSION

The results showed that more than two-thirds of heart

failure patients have moderate health literacy. This  nd-

ing is consistent with the results of studies byTehrani-

Banihashemiet al., 2007; Raisi et al., 2013; Mollakhalili

et al., 2014; Mo’tamedi et al., 2016; Raisi et al., 2011

inside our country, and abroad researchesby Tung et al.,

2014; Moseret al., 2015; and Jovis_veranes et al., 2011.

Regarding the  ndings of the above-mentioned studies,

it should be noted that patients withchronic conditions,

like heart failureare at greater risk o nadequate care and

weak consequences, such as lack of knowledge ofdisease,

poor care, increasednumber of hospitalization and mor-

tality caused by the disease.So, patients need adequate

health literacy to participate in health care systems and

appropriate health decisions (Mollakhalili et al., 2014).

Theresults of the current study showed that health lit-

eracy is an important factor affecting health-promoting

behaviors in heart failure patients. Tsai et al (2014) and

Raisi et al (2013) also found similar results in their study.

In the present study, patients with higher health literacy

had a better condition in all aspects of health promot-

ing behaviors. As increase in patients’health literacy

increased the physical activity levels. Also, these people

had a better nutritional status and sense of responsibil-

ity to their health. In this regard,Mollakhalili et al (2014)

have pointed out that health literacy led to empower-

ment of people to apply information and health-related

commands. Considering the effect of health-promoting

behaviorsin patients with heart failure on advancing

health and quality of life,it decrease health-related costs

to the same proportion, so health literacy should be con-

sideredas a factor that promotes healthbehaviors, cre-

ate healthy life style and  nally improves the quality

of life. Meanwhile, the weaker health literacy was more

prevalent among older patients. Higherhealth literacy

in younger patients can be attributed to the fact that

inthe present study,this group with higher level educa-

tion and more information on application of commu-

nicational media, like internet, has fewer problems and

higher mean scores compared to older patients. Also,

the higher physical power and probably lower inci-

dence of comorbidities of heart failure, such as diabe-

tes and hypertension,and lessinvolvement of the joints

cause higher physical activity were observed in younger

patients. Based on the  ndings of the present research,

health literacy had no signi cant relationship with

gender of patients (P>0.05). Therefore, the amount and

method of understanding and interpretation of health

information were not different betweenwomen and men

and both groups need attention of the authorities con-

cerned in this regard. But independent t-test showed sig-

ni cant difference between gender andhealth-promoting

life style(P<0.05). According to the results of the current

study, generally, men were more likely to take care of

their health than women. In the study by Tallet al (2014)

and Nuthwer and Stump (2000), there was also a sig-

ni cant relationship betweenhealth-promoting life style

and sex (P<0.001). In the present study, all sub-scales

ofhealth literacy and health-promoting behaviorshad

higher scores among college-educated individuals than

those with lower educational level. Tsai’s study (2014), as

well,showed a signi cant association between education

and health literacy and these people were more likely to

have aneducational level above high school (P<0.001).

Notably,in thepresent study, allparticipants were literate,

who were placed in that 4 educational groupsandhigher

Table 4. The results of multiple regression model  tto assess effective factors on health-promoting behaviors

Variable

Non-standardized

regression coef cients

Standard deviation of

regression coef cients

Standardized

regression coef cients

p-value

Intercept 0.53 0.24 0.03

Health literacy 0.29 0.03 0.59 <0.001

Secondary school education -0.15 0.07 -0.26 0.03

Age 0.005 0.002 0.1 0.005

Income status 0.1 029/0 0.17 <0.001

118 THE RELATIONSHIP BETWEEN HEALTH LITERACY AND HEALTH PROMOTING BEHAVIOR BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

Mahrokh Imanian et al.

level of education will possibly improve theirhealth

literacy. But in other studies in this regard, people’s

educational levelwere categorized as literate and illit-

erate that could have animpact on the results of the

study.

Lev and Owen (2000) writesin this regard that knowl-

edge and education increases thepotential ability of the

person against confusion and tension-causing factors

and cause success in self-care behavior. As academic

history of people is directly and meaningfully associated

with health literacy,it is necessary to pay more atten-

tion to education and societyhealth literacy, especially

on health information. Developing appropriate health

programs, providingsimple and understandable training

materials, spendingmore time with patients andslower

interviews by doctors and medical staff are the solu-

tions to help patients with lowhealth literacy to improve

theirliteracy. Inthe present study, the difference between

people with and without a history of work experience

in medical areaswas not signi cant inhealth literacy

(P=0.3) and health-promoting behaviors (P=0.9). This

lack of difference is probably due to the small number

of people employed in medical sciencesparticipating in

the present study that accounted for only 1.3% of them.

Regarding the fact that the majority of participants in

the present study had secondary school education, lack

of high level health and treatment activity seems logi-

cal at this level of education. Another result of the pre-

sent study indicated that except interpersonal relation-

ship (P=0.13) and health responsibility (P=0.9), other

dimensions ofhealth-promoting behaviorshad a signi -

cant relationship with income status (P<0.05), which

can guide us to the fact that higher income does not

necessarily lead to higherhealth responsibility and vice

versa, people fromlow level of society do not take less

care of their health; thus, training programs should be

performed for all classesof the society. But higher mean

scores of people inother dimensions, like nutrition, was

due to higher income and can be justi ed due to better

access to nutrition.

Inthe present study, the mean score of total health

literacy and health-promoting behaviors was higher in

trained people than untrained, but this difference was

only signi cant in health literacy (P<0.001). Health lit-

eracy (P=0.2) and health-promoting behaviors(P=0.6)

had no signi cant relationship with history of hospi-

talization, so that people withno history of hospitaliza-

tion had highermean scores in both variables. It seems

that when the patient has no history of hospitalization

after 6 months from de nite diagnosis of heart failure,

it con rmshigher health literacy and more adherences

tohealth-promoting behaviorsin the patient. Thus, the

results of this research emphasize the importance of

health literacy in the society, especially in hospitalized

patients.

STUDY LIMITATIONS

In general, in this study, high number of questions of

the tools used was one of the limitations, which was

tried to be confronted by the following measurements:

dedicateenough time to samples,answer their questions,

consider a short break during interviews, and change the

order of the research tools to be completed. In addition,

the present study was performed in a cross-sectional

basis, so future research with longer follow-ups can

providea better understanding of the causality relation-

ships between variables.

CONCLUSION

The results of the current research showed that most

of patients had moderate (borderline)health literacy.

Therefore, these patients require more explanations by

medical staff to understand and implement thedoctors’

instruction and other information and it is necessary to

provide more time for relationships with their physicians

and nurse and receivea simpler and more understand-

able information. Also, health managers and caregivers

should pay attention to this issue and spend more time

and give health instructions to this category ofpatients.

In the end, assessinghealth-promoting behaviorsand

understanding the factors affecting it is of great impor-

tance that could improve the quality of life of patients

with heart failure, but it needs policy-making and plan-

ning in this area. Theimportance of health-promoting

behaviorsshould be considered more than before and

be included inhealth care policy-making and programs.

Regarding the vulnerability of heart failure patients and

increasing prevalence in near future and the resulting

associated challenge, planning is essential to face this

challenge and lack of programing and policy-making

in this regard will cause serious social, economic and

health problems for society.

ACKNOWLEDGEMENTS

The present article is the result of master’s thesis and

research project with the Ethics code sbmu2.rec.1394.138

in Shahid Beheshti School of nursing and midwifery.

The researchers express their sincere thanks to all who

helped us in different phases of the study, the respected

of cials of Shahid Beheshti School of nursing and mid-

wifery, patients with heart failure, managers of heart

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS THE RELATIONSHIP BETWEEN HEALTH LITERACY AND HEALTH PROMOTING BEHAVIOR 119

Mahrokh Imanian et al.

clinics in teaching hospitals af liated to Shahid Behesh-

tiUniversity of Medical Sciences.

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120 THE RELATIONSHIP BETWEEN HEALTH LITERACY AND HEALTH PROMOTING BEHAVIOR BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS