The impact of health literacy on health behaviors in individuals with diabetes: findings from a population-based survey in South Korea

doi:10.21203/rs.3.rs-5002904/v1

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Research Article

The impact of health literacy on health behaviors in individuals with diabetes: findings from a population-based survey in South Korea

https://doi.org/10.21203/rs.3.rs-5002904/v1

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Background

Diabetes management requires strict self-care and education, but patients with low health literacy may find it difficult to follow numerous lifestyle recommendations, leading to poor blood sugar control, increased risk of complications, and higher treatment costs. By maintaining a healthy lifestyle, patients with diabetes can prevent or delay adverse health outcomes. Therefore, it is important to identify individuals with low health literacy and seek ways to help them easily understand and use the information they need.

Methods

This study utilized data from the 2021 Korea Community Health Survey, focusing on 23,262 individuals aged ≥ 30 years with diabetes. Health literacy was defined using two variables: "Understanding Health Communication" and "Understanding Written Health Information." Health behaviors were defined meeting three criteria: non-smoking, not engaging in high-risk alcohol consumption, and regular walking. Covariates included sex, age, household income, education level, region, and self-reported health status Multivariate logistic regression analysis was performed to examine the impact of health literacy on health behaviors. Odds ratio (OR) and 95% confidence intervals (CI) were calculated.

Results

After adjusting for all variables, individuals who found it difficult to understand health communication had an OR for engaging health behaviors of 0.91 (95% CI = 0.83–0.99) compared to those who found it easy. Similarly, those who struggled to understand written health information had an OR for health behaviors of 0.87 (95% CI = 0.79–0.96), while individuals who did not pay attention to it had an OR of 0.83 (95% CI = 0.75–0.91).

Conclusions

This study revealed that low health literacy and not paying attention to health information act as obstacles to practicing health behaviors. This emphasizes the need for preventive interventions such as clear communication by healthcare professionals, the use of simple language, maintaining considerate attitudes, and utilizing visual aids in printed materials.

Health literacy

Diabetes mellitus

Health behaviors

Health Communication

Diabetes mellitus is one of the most prevalent non-communicable diseases and a major public health problem [1]. In 2021, there were 536.6 million peoples aged 20–79 with diabetes worldwide, and this number is projected to increase to 783.2 million by 2045 [2]. In 2020, among Korean adults aged 30 years or older, approximately 6.05 million people (16.7%) had diabetes mellitus [3]. People with diabetes mellitus are at risk of various adverse health outcomes, including long-term damage, functional impairment, and failure of organs, such as the eyes, kidneys, nerves, heart, and blood vessels [4, 5, 6].

Health literacy is defined as cognitive and social skills that affect individuals' motivation and ability to access, understand, and use information [7]. Low health literacy negatively impacts health behaviors, health outcomes, quality of life and utilization of health services [8, 9, 10, 11]. This issue becomes even more crucial for patients with chronic diseases, as they need to be aware of and understand the stages of treatment and care, consider and implement recommendations for the sake of their health [12].

Diabetes requires strict self-care, education, and management [13, 14, 15, 16]. Because they rely on printed educational materials and verbal instructions regarding diet and self-care practices [17], patients with low health literacy may find it difficult to follow numerous lifestyle recommendations [18]. Furthermore, this limited health literacy is associated with poor blood sugar control [19, 20] and various diabetic complications [13, 21], leading to higher treatment costs [22]. If patients with diabetes maintain a healthy lifestyle in terms of diet, physical activity, alcohol consumption, and smoking, they can prevent or delay many adverse health outcomes [23]. Therefore, it is important to identify individuals with low health literacy and seek ways to help them understand and use the information they need more easily.

Multiple countries have investigated the association between health literacy and health behaviors in individuals with diabetes using population-based data [18, 24]. However, in Korea, most of the related studies have been conducted on small-scale patient groups [25, 26]. Therefore, this study aimed to examine the impact of health literacy on health behaviors in individuals with diabetes using data from a population-based survey in Korea.

Study Population

We used data from Korea Community Health Survey (KCHS), which was conducted in 2021. The KCHS is a national community-based cross-sectional survey conducted annually by the Korea Centers for Disease Control and Prevention since 2008 and aims to establish and evaluate local health care plans for those aged 19 and older and produce comparable local health statistics. In 2021, a total of 229,242 individuals participated in the survey. After excluding individuals who did not have diabetes (n = 200,887), those who answered 'do not know' to the questions or did not answer all questions included in this study were excluded (n = 5,093). Finally, 23,262 individuals were analyzed in this study.

Assessment of Health Literacy

In the KCHS, health literacy was measured using a modified version of the Brief Health Literacy Screener developed by Chew et al. (2004) and was defined using two variables: "Understanding Health Communication" and "Understanding Written Health Information" [27].

Understanding Health Communication" was assessed by asking participants how difficult it was for them to comprehend verbal explanations provided by healthcare professionals, including doctors, nurses, oriental doctors, and medical staff. Responses were measured on a four-point scale: very easy, easy, difficult, and very difficult. These responses were categorized into two groups: easy (very easy and easy) and difficult (difficult and very difficult).

"Understanding Written Health Information" was evaluated by asking participants how difficult it was for them to comprehend written health information found in sources such as newspapers, the Internet, and informational materials. Responses were measured on a five-point scale: very easy, easy, difficult, very difficult, and not paying attention. These responses were categorized into three groups: easy (very easy and easy), difficult (difficult and very difficult), and not paying attention.

Assessment of Health Behaviors

All the data were self-reported. Health behaviors were defined according to the KCHS, which entails meeting three criteria: non-smoking, not engaging in high-risk alcohol consumption, and regular walking.

Non-smokers were individuals who had never smoked or were currently attempting to quit, regardless of their smoking history. Former smokers were those who had smoked more than five packs (100 cigarettes) in their lifetime but were not smoking at the time of the survey. High-risk alcohol consumption was defined based on KCHS criteria, where consuming more than seven cups (for males) or five cups (for females) per drinking occasion was considered high-risk drinking due to the ethanol content in one standard drink in Korea (7–8 g) [28]. Those who did not meet this criterion were classified as not having a high-risk alcohol consumption. Regular walking was defined as walking for more than 30 min a day for more than five days a week during the previous week. This was assessed using two questions: (1) "How many days did you walk for at least 10 minutes at a time in the last week?" and (2) "How long do you usually walk on one of these days?"

Covariates

Covariates included sex, age, household income, education level, region, and self-reported health status. Age was categorized into 10-year intervals, while household income was classified into categories ranging from less than 1 million won to over 4 million won in increments of 1 million won. Education levels ranged from less than elementary school to college or higher. Residential areas were classified as rural or urban. Self-reported health status was based on responses to the question "How do you perceive your own health?" Responses of "very good" and "good" were categorized as "good," "average" for "moderate," and "poor" and "very poor" for "bad."

Statistical analysis

The statistics were calculated based on a complex sampling design using survey weights, which allowed accurate estimates and ensured national representativeness. To assess the general characteristics of the study population, a chi-squared test was conducted. Multivariate logistic regression analysis was performed to examine the impact of health literacy on health behaviors. We reported adjusted odds ratios (ORs), along with their corresponding 95% confidence intervals (CIs) estimated from the regression models. Data processing and statistical analysis were performed using SAS V.9.4 (SAS Institute, Cary, North Carolina, USA). Statistical significance was determined using a two-tailed p-value of less than 0.05.

Table 1 presents the characteristics of individuals with diabetes based on their engagement in health behaviors. Among 23,262 individuals with diabetes, 67.1% did not engage in health behaviors. Additionally, 70.6% of those who found it difficult to understand health communication did not engage in health behaviors. Similarly, 68.0% of those who had difficulty understanding written health information and 71.2% who did not pay attention to written health information did not engage in health behaviors. Women, urban residents, and those with a better self-reported health status tended to engage in healthier behaviors.

Table 1

Characteristics of individuals with diabetes Based on Engagement in Health Behaviors
Variable	Health Behaviors						P-value
	Total		No		Yes
	N	%	N	%	N	%
Understand Health Communication							< .0001
Easy	16,160	69.5	10,602	65.6	5,558	34.4
Difficult	7,102	30.5	5,011	70.6	2,091	29.4
Understand Written Health information							< .0001
Easy	11,575	49.8	7,478	64.6	4,097	35.4
Difficult	5,880	25.3	4,001	68.0	1,879	32.0
Do not pay attention	5,807	25.0	4,134	71.2	1,673	28.8
Sex
Male	11,394	49.0	8,003	70.2	3,391	29.8
Female	11,868	51.0	7,610	64.1	4,258	35.9
Age							< .0001
30–39	371	1.6	268	72.2	103	27.8
40–49	1,263	5.4	983	77.8	280	22.2
50–59	3,616	15.5	2,609	72.2	1,007	27.9
60–69	7,099	30.5	4,612	65.0	2,487	35.0
70–79	7,329	31.5	4,504	91.5	2,825	38.6
≥ 80	3,584	15.4	2,637	73.6	947	26.4
Household-Income							< .0001
< 100	6,432	27.7	4,514	70.2	1,918	23.8
100–200	5,522	23.7	3,583	64.9	1,939	35.1
200–300	3,551	15.3	2,305	64.9	1,246	35.1
300–400	2,737	11.8	1,789	65.4	948	34.6
> 400	5,020	21.6	3,422	68.2	1,598	31.8
Education							< .0001
Elementary Under	3,837	16.5	2,774	72.3	1,063	27.7
Elementary	5,872	25.2	3,833	65.3	2,039	34.7
Middle school	3,759	16.2	2,418	64.3	1,341	35.7
High school	6,310	27.1	4,286	67.9	2,024	32.1
College or above	3,484	15.0	2,302	66.1	1,182	33.9
Region							< .0001
Urban area	11,905	51.2	7,592	63.8	4,313	36.2
Rural area	11,357	48.8	8,021	70.6	3,336	29.4
Self-reported health condition							< .0001
Good	4,532	19.5	2,745	60.6	1,787	39.4
Moderate	10,114	43.5	6,585	65.1	3,529	34.9
Bad	8,616	37.0	6,283	72.9	2,333	27.1
Total	23,262	100.0	15,613	67.1	7,649	32.9

Table 2 shows the results of the multivariate logistic regression analysis of the impact of health literacy on health behaviors.

Table 2

Multivariate Logistic Regression Analysis of Health Behaviors Influenced by Health Literacy
Variable	Model 1		Model 2		Model 3
Variable	aOR (95% CI)	P-value	aOR (95% CI)	P-value	aOR (95% CI)	P-value
Understand Health Communication
Easy	1.00		-	-	1.00
Difficult	0.85 (0.79–0.92)	< 0.0001	-	-	0.91 (0.83–0.99)	0.0282
Understand Written Health information
Easy	-	-	1.00		1.00
Difficult	-	-	0.83 (0.76–0.91)	0.0657	0.87 (0.79–0.96)	0.3297
Do not pay attention	-	-	0.81 (0.73–0.89)	0.0052	0.83 (0.75–0.91)	0.0070
Model 1 was adjusted for Sex, Age, Household Income, Education, Region, and Self-reported health condition, with “Understand Health Communication”.
Model 2 was adjusted for Sex, Age, Household Income, Education, Region, and Self-reported health condition with “Understand Written Health Communication”.
Model 3 was adjusted for Sex, Age, Household Income, Education, Region, and Self-reported health condition with both “Understand Health Communication” and “Understand Written Health Communication”.
aOR = adjusted Odds Ratio; CI = Confidence Intervals

Model 1 evaluated the impact of understanding health communication on health behaviors, adjusting for sex, age, household income, education, region, and self-reported health condition. Individuals who found it difficult to understand health communication had an OR for engaging health behaviors of 0.85 (95% CI = 0.79–0.92) compared to those who found it easy.

Model 2 assessed the impact of understanding written health information on health behaviors, with the same covariates adjusted as in Model 1. Compared to those who had easy understanding of written health information, those who struggled to understand written health information had an OR for health behaviors of 0.83 (95% CI = 0.76–0.91), while individuals who did not pay attention to it had an OR of 0.81 (95% CI = 0.73–0.89).

Model 3 included both "Understand Health Communication" and "Understand Written Health Information" to evaluate their combined effects, adjusting for the same set of covariates. Individuals who found it difficult to understand health communication had an OR for engaging health behaviors of 0.91 (95% CI = 0.83–0.99) compared to those who found it easy. Similarly, those who struggled to understand written health information had an OR for health behaviors of 0.87 (95% CI = 0.79–0.96), while individuals who did not pay attention to it had an OR of 0.83 (95% CI = 0.75–0.91).

Table 3 shows the results of the subgroup analysis of the impact of health literacy on health behaviors by sex and age. Both men and women who did not pay attention to written health information had the lowest OR for engaging in health behaviors, with men having a lower OR than women (men: OR = 0.71, 95% CI = 0.63–0.81; women: OR = 0.86, 95% CI = 0.77–0.96). In men, there was no significant impact on the other cases. For women, those who found health communication difficult had an OR of 0.91 for engaging in health behaviors (95% CI = 0.82–0.99). For those aged < 65 years, no significant impact was observed. For those 65 years and older, those who found health communication difficult had an OR of 0.85 for engaging in health behaviors (95% CI = 0.78–0.93), and those who did not pay attention to written health information had an OR of 0.78 (95% CI = 0.71–0.86).

Table 3

Subgroup Analysis of Health Behaviors Influenced by Health Literacy
Variable		Male	Female	< 65	≥ 65
Variable		aOR (95% CI)	aOR (95% CI)	aOR (95% CI)	aOR (95% CI)
Understand Health Communication
	Easy	1.00	1.00	1.00	1.00
	Difficult	0.92 (0.82–1.03)	0.91^∗ (0.82–0.99)	0.99 (0.87–1.14)	0.85^∗ (0.78–0.93)
Understand Written Health information
	Easy	1.00	1.00	1.00	1.00
	Difficult	0.91 (0.80–1.02)	0.91 (0.82–1.02)	0.87 (0.75–1.00)	0.91 (0.82–1.00)
	Do not pay attention	0.71^∗ (0.63–0.81)	0.86^∗ (0.77–0.96)	0.81 (0.69–0.95)	0.78^∗ (0.71–0.86)
∗p < 0.05.
Adjusted for Sex, Age, Household Income, Education, Region, and Self-reported health condition with both “Understand Health Communication” and “Understand Written Health Communication”
aOR = adjusted Odds Ratio; CI = Confidence Intervals

Supplementary table1 shows the impact of health literacy on each factor in health behaviors. Individuals who did not pay attention to written health information had ORs of 0.84 (95% CI = 0.73–0.97) for non-smoking, 0.75 (95% CI = 0.63–0.90) for Not high-risk alcohol consumption and 0.83 (95% CI = 0.78–0.89) for regular walking.

Among the 23,262 study participants, 67.1% did not engage in healthy behaviors. Specifically, 70.6% of those who had difficulty understanding health communication, 68% of those who found written health information difficult to understand, and 71.2% of those who did not pay attention to written health information did not practice healthy behaviors. The results of multivariate logistic regression analysis showed that individuals who had difficulty understanding health communication were less likely to engage in healthy behaviors. When analyzed by sex and age, this likelihood was significantly lower among women and those aged ≥ 65 years. Additionally, individuals who had difficulty understanding written health information were less likely to engage in healthy behaviors. Those who did not pay attention to written health information had the lowest likelihood of engaging in healthy behaviors; this trend was observed across both sexes and all age groups, including those under and over 65 years.

In this study, individuals who had difficulty understanding the health communication provided by healthcare professionals were less likely to engage in healthy behaviors, with similar trends observed among women and those aged 65 and above. Previous research has shown that patients with poor health knowledge are less likely to interpret and act on their self-monitoring results [29, 30]. Effective management and treatment of diabetes require mastering and conceptualizing various skills, such as blood sugar self-monitoring, medication management, coordination among multiple providers, foot care, adherence to dietary plans, and physical exercise [13, 14, 15, 16]. These skills need to be communicated proficiently by healthcare professionals and practiced by patients [13, 31]. Any issues in communication and knowledge transfer that affect a patient's self-monitoring and management can lead to inadequate diabetes control [18]. These findings highlight the importance of verbal communication strategies when interacting with patients with low health literacy in diabetes education. To achieve optimal health outcomes in diabetes self-management interventions, it is essential to routinely use verbal communication strategies, such as teach-back methods, clear communication, and follow-up with patients [32].

When it was difficult to understand the written health information in this study, the possibility of practicing health behaviors was low. However, previous studies have shown mixed results regarding the relationship between health literacy and health behaviors in individuals with diabetes. Rafferty et al. (2021), difficulty in understanding written health information was not related to physical activity [33]. Friis et al. (2016) found that the likelihood of physical activity was low when it was difficult to understand written health information; however, smoking and drinking did not show a significant association [18]. Finbråten et al. (2020) also found no association between health information comprehension ability and health behaviors, as measured by physical activity, smoking, and drinking [34]. Owing to differences in health knowledge, consistency in diabetes management measures, statistical adjustments, and approaches, specific comparisons between our results and other findings may be challenging.

In this study, individuals who did not pay attention to written health information had the lowest likelihood of engaging in healthy behaviors. This trend was similar when analyzed according to sex and age. Previous research has shown that young diabetic patients with indifferent mindsets exhibit lower levels of self-care behavior [35]. Additionally, indifference is associated with a significantly higher BMI, lower likelihood of following exercise plans, and less adherence to prescribed insulin administration [36]. These individuals may be perceived as unmotivated because of their low intention to change; however, importantly, the influence of a trusted healthcare provider can support their change [35]. Therefore, healthcare professionals can potentially prevent the development of indifference by supporting these individuals when faced with unexpected negative outcomes. However, since no studies have measured the relationship between indifference to health information and health behaviors or management, it is difficult to directly compare the results of previous studies with those of this study. Consequently, further research is needed to identify the characteristics of individuals who do not pay attention to health information and clarify the results.

The health literacy level of Korean people was relatively higher than that of people in Europe and other Asian countries (Japan, Taiwan) [37]. Despite the high level of literacy, this study revealed that low health literacy and not paying attention to health information act as obstacles to practicing health behaviors. Diabetes is a chronic disease characterized by a high level of complexity that requires extensive self-management, including the application of guidelines in daily life [38]. Therefore, health care professionals need to understand the lack of health literacy in the routine self-management of diabetes. They should use universal precautionary intervention strategies, such as using simple and familiar language, maintaining a considerate tone and attitude, and utilizing printed materials with visuals [39], to help patients with diabetes achieve their self-management goals and improve health outcomes.

Limitations

This study has some limitations. First, as a cross-sectional study, it cannot clearly establish temporality or causality. Second, we did not distinguish between type 1 and type 2 diabetes, and health literacy and health behavior may differ between these groups. Third, there may be inaccuracies and biases inherent in self-report data, with the potential for underestimation of real-world effects due to non-response from some participants. Fourth, although health literacy is a multidimensional construct, the questions in this study are limited to only two aspects. Despite these limitations, this study is significant as it investigates the association between health information comprehension ability and health behavior in diabetic patients using large population-based data in Korea, a relatively rare approach in existing research.

Individuals with diabetes who have difficulty understanding health communication or written health information are less likely to engage in healthy behaviors than those without such difficulties. Additionally, lack of attention to health information can be an obstacle to practicing healthy behaviors. This underscores the importance of clear communication with healthcare professionals for the effective management of diabetes. Therefore, healthcare professionals should use universal precautionary intervention strategies, such as using simple language, maintaining a considerate attitude, and utilizing visual aids in printed materials to help diabetes patients achieve their self-management goals and improve health outcomes.

KCHS

Korea Community Health Survey

ORs

Odds Ratios

CIs

Confidence Intervals

BMI

Body Mass Index

Ethics approval and consent to participate

The requirement for informed consent was waived because the data in this database were de-identified.

Consent for publication

Not applicable

Availability of data and material

The Data are available in a public open-access repository. Korean Community Health Survey provides anonymized data that are disclosed to the public. Data requests and analytical guidelines can be downloaded from the KCHS website (https://chs.kdca.go.kr/chs/rdr/rdrInfoDownMain.do) in Korea.

Competing interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Authors' contributions

JW, BG, TH: Conceptualization, Writing―original, editing

JW, SH, DH: Statistical analysis

JW, BG, SH, DH, TH: Review, Design―theoretical framework, analysis

The authors read and approved the final version of the manuscript.

Acknowledgements

Not applicable.

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No competing interests reported.

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The impact of health literacy on health behaviors in individuals with diabetes: findings from a population-based survey in South Korea

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Abstract

Background

Methods

Results

Conclusions

Introduction

Methods

Study Population

Assessment of Health Literacy

Assessment of Health Behaviors

Covariates

Statistical analysis

Results

Discussion

Limitations

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1