Journal of Health and Medical Sciences
Published: 08 August 2023
A Qualitative Study on the Effects of Health Literacy in Population with Hypertension at Blossom Health Care Center, Kabul City, Afghanistan
Ahmad Khan, Melanie M. Tidman, Hasibullah Najib, Ihsanullah Darmal
A T Still Health Sciences University, Blossom Health Care Center, Kandahar University
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Keywords: Hypertension, Health Literacy, Developing Countries, Compliance, Communication
Hypertension is a chronic disease common in developing countries like Afghanistan, and improving patient awareness of the risk factors and the significance of regular treatment decreases the burden of the disease. In Afghanistan, a higher level of health literacy can help patients with hypertension to know the risk factors, the role of lifestyle management, and the significance of regular treatment for hypertension. Also, a higher level of health literacy can provide venues for the patient to comprehend the provided information and actively participate in the care. Alternatively, patients with lower health literacy might need to appropriately understand the information related to diet, treatment, and provider communication during the management of hypertension. A lack of understanding of hypertension-related treatment suggestions might lead to poor compliance with hypertension medication. This qualitative study aimed to assess the health literacy level among patients seeking care for hypertension at Blossom Health Care Center in Kabul, Afghanistan. A total of 198 patients who had hypertension participated in the study, and patients were interviewed using a Likert scale for responses generated by a focus group of 10 Afghan doctors practicing in Kabul, Afghanistan. We found that 68.7% of patients with hypertension scored Strongly Disagree to having adequate hypertension knowledge. Moreover, around 37.3% of participants indicated Always visiting a doctor for this condition, and 38.4 indicated Always taking their medication. Studies have shown that lower health literacy in patients with hypertension might negatively impact their health outcomes. Therefore, increasing awareness and knowledge of hypertension related-treatment among people with hypertension might improve their overall health and well-being.
Aaby, A., Friis, K., Christensen, B., Rowlands, G., & Maindal, H. T. (2017). Health literacy is associated with health behavior and self-reported health: A large population-based study in individuals with cardiovascular disease. European Journal of Preventive Cardiology, 24(17), 1880-1888.
Berkman, N. D., Sheridan, S. L., Donahue, K. E., Halpern, D. J., & Crotty, K. (2011). Low health literacy and health outcomes: An updated systematic review. Annals of Internal Medicine, 155(2), 97-107.
Bruthans, J., Mayer, O., De Bacquer, D., De Smedt, D., Reiner, Z., Kotseva, K., Cífková, R., & IV investigators, T. E. (2016). Educational level and risk profile and risk control in patients with coronary heart disease. European Journal of Preventive Cardiology, 23(8), 881-890.https://doi.org/10.1177/2047487315601078
Castro, E. M., Van Regenmortel, T., Vanhaecht, K., Sermeus, W., & Van Hecke, A. (2016). Patient empowerment, patient participation and patient-centeredness in hospital care: A concept analysis based on a literature review. Patient Education and Counseling, 99(12), 1923-1939.
Cavanaugh, K., Huizinga, M. M., Wallston , K. A., Gebretsadik , T., Shin-tani, A., Davis, D., Gregory, R. P., Fuchs, L., Malone, R., Cherrington, A., Pignone, M., DeWalt, D. A., Elasy, T. A., & Rothman, R. L. (2008). Association of numeracy and diabetes control. Annals of Internal Medicine, 148 ( 10 ), 737 – 746
Coleman, C. (2011). Teaching health care professionals about health literacy: A review of the literature. Nursing Outlook, 59(2), 70-78.
Davis, T. C., Wolf, M. S., Bass III, P. F., Thompson, J. A., Tilson, H. H., Neuberger, M., & Parker, R. M. (2006). Literacy and misunderstanding prescription drug labels. Annals of Internal Medicine, 145(12), 887-894.
DeWalt, D. A., Callahan, L. F., Hawk, V. H., Broucksou, K. A., Hink, A., Rudd, R., & Brach, C. (2010). Health literacy universal precautions toolkit. Rockville, MD: Agency for Healthcare Research and Quality, 1-227.
Du, S., Zhou, Y., Fu, C., Wang, Y., Du, X., & Xie, R.(2018). Health literacy and health outcomes in hypertension: An integrative review. International Journal of Nursing Sciences, 5(3), 301-309. doi.org/10.1016/j.ijnss.2018.06.001
Duong, T. V., Pham, K. M., Do, B. N., Kim, G. B., Dam, H. T., Le, V. T. T., Nguyen, T. T. P., Nguyen, H. T., Nguyen, T. T., Le, T. T., Do, H. T. T., & Yang, S. H. (2020). Digital healthy diet literacy and self-perceived eating behavior change during COVID-19 pandemic among undergraduate nursing and medical students: A rapid online survey. International Journal of Environmental Research and Public Health, 17(19), 7185.
Gaffari-Fam, S., Babazadeh, T., Oliaei, S., Behboodi, L., & Daemi, A. (2020). Adherence to a health literacy and healthy lifestyle with improved blood pressure control in Iran. Patient Preference and Adherence, 499-506.
Gaziano, T. A., Bitton, A., Anand, S., & Weinstein, M. C. (2009). The global cost of nonoptimal blood pressure. Journal of Hypertension, 27(7), 1472-1477.
Global Health Observatory (2022). Noncommunicable diseases: Mortality. https://www.who.int/data/gho/data/themes/topics/topic-details/GHO/ncd-mortality.
Hall, E., Lee, S. Y., Clark, P. C., & Perilla, J. (2016). Social ecology of adherence to hypertension treatment in Latino migrant and seasonal farmworkers. Journal of Transcultural Nursing, 27(1), 33-41.
Harsch, S., Jawid, A., Jawid, E., Saboga-Nunes, L., Sørensen, K., Sahrai, D., & Bittlingmayer, U. H. (2021). Health literacy and health behavior among women in Ghazni, Afghanistan. Frontiers in Public Health, 9, 629334.
Heijmans, M., Waverijn, G., Rademakers, J., van der Vaart, R., & Rijken, M. (2015). Functional, communicative and critical health literacy of chronic disease patients and their importance for self-management. Patient Education and Counseling, 98(1), 41-48.
Hickey, K. T., Creber, R. M. M., Reading, M., Sciacca, R. R., Riga, T. C., Frulla, A. P., & Casida, J. M. (2018). Low health literacy: Implications for managing cardiac patients in practice. The Nurse Practitioner, 43(8), 49
Ibrahim, M. M., & Damasceno, A. (2012). Hypertension in developing countries. The Lancet, 380(9841), 611-619.
Khan, A., Tidman, M. M., Shakir, S., & Darmal, I. (2022). Breast Cancer in Afghanistan: Issues, Barriers, and Incidence. Journal of Medical Research and Health Sciences, 5(8), 2125-2134.
Kutner, M., Greenburg, E., Jin, Y., & Paulsen, C. (2006). The Health Literacy of America's Adults: Results from the 2003 National Assessment of Adult Literacy. NCES 2006-483. National Center for Education statistics.
Levy, H., & Janke, A. (2015). Health Literacy and Access to Care. Journal of Health Communication, 21(Suppl), 43.https://doi.org/10.1080/10810730.2015.1131776
Lindenfeld, J. & Jessup, M. (2017). ‘Drugs don't work in patients who don't take them’(C. Everett Koop, MD, US Surgeon General, 1985). European Journal of Heart Failure, 19(11), 1412-1413
Liu, C., Wang, D., Liu, C., Jiang, J., Wang, X., Chen, H.,Ju, X., & Zhang, X. (2020). What is the meaning of health literacy? A systematic review and qualitative synthesis. Family Medicine and Community Health, 8(2).
Logan, R. A. (2017). Seeking an expanded, multidimensional conceptual approach to health literacy and health disparities research. Information Services & Use, 37(1), 59-83.
Mackey, L. M., Doody, C., Werner, E. L., & Fullen, B. (2016). Self-management skills in chronic disease management: what role does health literacy have? Medical Decision Making, 36(6), 741-759.
Magnani, J. W., Mujahid, M. S., Aronow, H. D., Cené, C. W., Dickson, V. V., Havranek, E., Morgenstern, L. B., Paasche-Orlow, M. K., Pollak, A, & Willey, J. Z. (2018). Health literacy and cardiovascular disease: fundamental relevance to primary and secondary prevention: A scientific statement from the American Heart Association. Circulation, 138(2), e48-e74.
Malloy-Weir, L. J., Charles, C., Gafni, A., & Entwistle, V. (2016). A review of health literacy: Definitions, interpretations, and implications for policy initiatives. Journal of Public Health Policy, 37, 334-352.
McNaughton, C. D., Jacobson, T. A., & Kripalani, S. (2014). Low literacy is associated with uncontrolled blood pressure in primary care patients with hypertension and heart disease. Patient Education and Counseling, 96(2), 165-170.
McQueen, D. V., Kickbusch, I., Potvin, L., Balbo, L., Pelikan, J. M., & Abel, T. (2007). Health and modernity: The role of theory in health promotion. Springer Science & Business Media.
Miller, T. A. (2016). Health literacy and adherence to medical treatment in chronic and acute illness: Ameta-analysis. Patient Education and Counseling, 99(7), 1079-1086.
Mills, K. T., Stefanescu, A., & He, J. (2020). The global epidemiology of hypertension. Nature Reviews Nephrology, 16(4), 223-237.
Mor-Anavy, S., Lev-Ari, S., & Levin-Zamir, D. (2021). Health literacy, primary care health care providers and communication. Health Literacy Research and Practice, 5(3), e194-e200.
Náfrádi, L., Galimberti, E., Nakamoto, K., & Schulz, P. J. (2016). Intentional and unintentional medication non-adherence in hypertension: the role of health literacy, empowerment and medication beliefs. Journal of Public Health Research, 5(3), jphr-2016.
National Institutes of Health (2021). Clear communication: Health literacy. https://www.nih.gov/institutes-nih/nih-office-director/office-communications-public-liaison/clear-communication/health-literacy.
Noncommunicable Disease Risk Factor Collaboration (2017). Worldwide trends in blood pressure from 1975 to 2015: A pooled analysis of 1479 population-based measurement studies with 19.1 million participants. Lancet, 389, 37–55. doi: 10.1016/S0140-6736(16)31919-5.
Nutbeam, D. (2008). The evolving concept of health literacy. Social Science and Medicine, 67(12), 2072-2078.
O’Donnell, M., Mente, A., Alderman, M. H., Brady, A. J., Diaz, R., Gupta, R., Lopez-Jaramillo, P., Luft, F. C., Lucher, T. F., Manica, G., Mann, J. F. E., McCarron, D., McKee, M., Messerli, F. H., Moore, L. L., Narula, J., Oparil, S., Packer, M., Prabhakaran, D., Schutte, A., ... & Yusuf, S. (2020). Salt and cardiovascular disease: Insufficient evidence to recommend low sodium intake. European Heart Journal, 41(35), 3363-3373.
Pandit, A. U., Tang, J. W., Bailey, S. C., Davis, T. C., Bocchini, M. V., Persell, S. D., ... & Wolf, M. S. (2009). Education, literacy, and health: Mediating effects on hypertension knowledge and control. Patient Education and Counseling, 75(3), 381-385.
Parker, R., & Ratzan, S. C. (2010). Health literacy: A second decade of distinction for Americans. Journal of Health Communication, 15(Suppl. 2), S20–S33. 10.1080/10810730.2010.501094 PMID
Patzer, R. E., Serper, M., Reese, P. P., Przytula, K., Koval, R., Ladner, D. P., Levitsky, J. M., Abecassis, M. M., & Wolf, M. S. (2016). Medication understanding, non‐adherence, and clinical outcomes among adult kidney transplant recipients. Clinical Transplantation, 30(10), 1294-1305.
Persell, S. D., Osborn, C. Y., Richard, R., Skripkauskas, S., & Wolf, M. S. (2007). Limited health literacy is a barrier to medication reconciliation in ambulatory care. Journal of General Internal Medicine, 22, 1523-1526.
Pleasant, A., Cabe, J., Patel, K., Cosenza, J., & Carmona, R. (2015). Health literacy research and practice: A needed paradigm shift. Health Communication, 30(12), 1176-1180.
Popkin, B. M., Corvalan, C., & Grummer-Strawn, L. M. (2020). Dynamics of the double burden of malnutrition and the changing nutrition reality. The Lancet, 395(10217), 65-74.
Riegel, B., Moser, D. K., Anker, S. D., Appel, L. J., Dunbar, S. B., Grady, K. L., Gurvitz, M. Z., Havraneck E. P., Lee, C. S., Lindenfeld, J., Peterson, P. N., Pressler, S. J., Schocken, D. D., & Whellan, D. J. (2009). State of the science: promoting self-care in persons with heart failure: A scientific statement from the American Heart Association. Circulation, 120(12), 1141-1163.
Riegel, B., Carlson, B., Moser, D. K., Sebern, M., Hicks, F. D., & Roland, V. (2004). Psychometric testing of the self-care of heart failure index. Journal of Cardiac Failure, 10(4), 350-360.
Rostamzadeh, M., Ezadi, Z., Hosseini, M., & Husseini, A. A. (2022). Maternal health literacy and pregnancy outcomes in Afghanistan. Journal of Education and Health Promotion, 11(1), 421.
Rowlands, G., Protheroe, J., Winkley, J., Richardson, M., Seed, P. T., & Rudd, R. (2015). A mismatch between population health literacy and the complexity of health information: An observational study. British Journal of General Practice, 65(635), e379-e386.
Saeed, K. M. I. (2017). Burden of hypertension in the capital of Afghanistan: A cross-sectional study in Kabul City, 2015. International Journal of Hypertension, 2017.
Samerski, S. (2019). Health literacy as a social practice: Social and empirical dimensions of knowledge on health and healthcare. Social Science and Medicine, 226, 1-8.
Schillinger, D. (2021). Social determinants, health literacy, and disparities: Intersections and controversies. Health Literacy Research and Practice, 5(3), e234-e243.
Schutte, A. E., Srinivasapura Venkateshmurthy, N., Mohan, S., & Prabhakaran, D. (2021). Hypertension in low-and middle-income countries. Circulation Research, 128(7), 808-826.
Sheridan, S. L., Halpern, D. J., Viera, A. J., Berkman, N. D., Donahue, K. E., & Crotty, K. (2011). Interventions for individuals with low health literacy: a systematic review. Journal of Health Communication, 16(sup3), 30-54.
Simonds, S. K. (1974). Health education as social policy. Health Education Monographs, 2(1_suppl), 1-10.
Smith, S. K., Kearney, P., Trevena, L., Barratt, A., Nutbeam, D., & McCaffery, K. J. (2014). Informed choice in bowel cancer screening: a qualitative study to explore how adults with lower education use decision aids. Health Expectations, 17(4), 511-522.
Te Riet, L., van Esch, J. H., Roks, A. J., van den Meiracker, A. H., & Danser, A. J. (2015). Hypertension: Renin–angiotensin–aldosterone system alterations. Circulation Research, 116(6), 960-975.
United Nations Educational, Scientific, and Cultural Organization (2020). Interview: Literacy rate in Afghanistan increased to 43 percent. https://uil.unesco.org/interview-literacy-rate-afghanistan-increased-43-cent.
Wolf, M. S., Davis, T. C., Curtis, L. M., Bailey, S. C., Knox, J. P., Bergeron, A., Abbet, M., Shrank W. H., Parker, R. M., & Wood, A. J. (2016). A patient-centered prescription drug label to promote appropriate medication use and adherence. Journal of General Internal Medicine, 31, 1482-1489.
World Bank (2023). Afghanistan. https://data.worldbank.org/indicator/SE.ADT.LITR.ZS?locations=AF.
World Health Organization (2018). Afghanistan hypertension fact sheet. https://cdn.who.int/media/docs/default-source/country-profiles/hypertension/afg_en.pdf?sfvrsn=979abb87_13&download=true.
World Health Organization. (2017). Shanghai declaration on promoting health in the 2030 Agenda for Sustainable Development (No. WHO/NMH/PND/17.8). https://apps.who.int/iris/bitstream/handle/10665/359526/WHO-NMH-PND-17.8-eng.pdf?sequence=1.
Wu, J. R., Moser, D. K., DeWalt, D. A., Rayens, M. K., & Dracup, K. (2016). Health literacy mediates the relationship between age and health outcomes in patients with heart failure. Circulation: Heart Failure, 9(1), e002250.
Yeung, D. L., Alvarez, K. S., Quinones, M. E., Clark, C. A., Oliver, G. H., Alvarez, C. A., & Jaiyeola, A. O. (2017). Low–health literacy flashcards & mobile video reinforcement to improve medication adherence in patients on oral diabetes, heart failure, and hypertension medications. Journal of the American Pharmacists Association, 57(1), 30-37.
Zhao, D., Qi, Y., Zheng, Z., Wang, Y., Zhang, X. Y., Li, H. J., Liu, H. J., Zhang, X. T., & Liu, J. (2011). Dietary factors associated with hypertension. Nature Reviews Cardiology, 8(8), 456-465.