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.