Abstract
Aim
This study aimed to investigate the relationship between health literacy and self-efficacy in the elderly with diabetes.
Method
This cross-sectional study was conducted on 375 diabetic elderly members from a diabetes association, in Iran. Self-efficacy and health literacy questionnaires were used. The Pearson test was used to determine the relationship between self-efficacy and health literacy and linear regression was used to predict self-efficacy by health literacy.
Results
Elderly men and women with diabetes showed a significant difference in terms of health literacy (P = 0.003). People over the age of 70 had a lower level of literacy (P < 0.05). The highest and lowest self-efficacy in the elderly patients were related to taking medications (89.75 ± 17.56) and physical activity (71.38 ± 24.40), respectively. The results of stepwise linear regression showed that health literacy is a predictor of self-efficacy in the diabetic elderly (r2 = 0.55, P < 0.001).
Conclusion
Health literacy is directly related to self-efficacy in older people with diabetes.
Supplementary Information
The online version contains supplementary material available at 10.1007/s40200-023-01181-w.
Keywords: Health literacy, Elderly, Self-efficacy, Diabetes
Introduction
The dramatic increase in the elderly around the world has become one of the most important challenges of the century [1, 2]. According to the results of the 2016 census, 9.27% of the total population of Iran is elderly [3]. It is estimated that by 2051, between 21 and 25% of the country’s population will be elderly [4]. Chronic diseases are one of the most challenges in the elderly that cause functional and physical disorders [5]. Among the chronic diseases in the elderly, diabetes is a chronic disease with complex etiology, unpredictable recovery, and a long course of treatment [6]. Diabetes is the most important cause of mortality and disability in the elderly [7]. Therefore, the diagnosis of diabetes in the elderly as the main goal of health care is important [8] for prevention of heart disease, stroke, high blood pressure, kidney disease blindness, amputation, and mental health problems [9]. Therefore, empowering self-care behaviour is crucial in diabetes management [10]. Promoting health literacy is one of the mechanisms to achieve this goal [11]. Health literacy is the capacity to interpret and understand basic health information to make appropriate decisions in health-related challenges [12]. Inadequate health literacy makes people less likely to report problems related to their illnesses [13, 14]. Regarding the health literacy of diabetic elderly, diabetes literacy is a factor that affects how the elderly go about their diabetes self-management routines [15]. Self-management in chronic diseases increases self-efficacy and health-related outcomes [16]. In reviewing of the relationship between self-efficacy and diabetes self-management in diabetic older adults in the United States, higher self-efficacy predicted better self-management behaviors [17].
Self-efficacy can be defined as a person’s belief in his or her ability to perform activities that affect human life. In chronic diseases such as type 2 diabetes, these activities are related to self-care behaviours [18]. Studies show that self-efficacy is highest in middle age but decreases after the age of sixty [19, 20]. Self-efficacy is very important in the elderly. For example, a study shows that older people, who underwent self-efficacy intervention, reported better life satisfaction, and physical function [21]. Current studies address the issue of self-efficacy in the elderly with diabetes. For example, Sousa et al. (2020) in a study on 256 Brazilian elderly people with type 2 diabetes mellitus showed negative knowledge and attitude in most of these elderly, and the self-efficacy of the elderly was related to their attitude and knowledge in some areas such as general and specific diet, physical exercise and blood glucose [22]. In a concept analysis of self-efficacy in elderly with diabetes in China Self-efficacy has been identified as an important determinant in self-management among the elderly with diabetes [23]. Masoompur et al. (2017) investigate the relationship between health literacy, self-efficacy, and self-care behaviours in diabetic patients [24]. Rachmawati et al. (2019) describes the relationship of diabetes literacy with self-management among older people with type 2 diabetes mellitus [15]. In such studies, health literacy has been studied with self-management and not necessarily self-efficacy. But what seems important here is that self-management is a mediator for the self-efficacy of diabetic patients to achieve the ability to manage treatment regimens and return to normal life. On the other hand, these studies have focused on health literacy in specific areas such as functional health literacy, which evaluates pronunciation and comprehension of commonly used medical terms in older adults [25]. Accordingly, the authors of these articles examined the general aspects of health literacy in the diabetic elderly. Given the importance of self-efficacy in the diabetic elderly and that the evidence does not clearly show how the health literacy of the elderly with diabetes can be related to their self-efficacy. Therefore, the researchers of this study investigate the relationship between health literacy and self-efficacy of the elderly with type 2 diabetes.
Methods
This is a cross-sectional study which examines the relationship between health literacy in the diabetic elderly with self-efficacy. The population was diabetic elderly members of the non-profit Diabetes Association of…. Elderly were eligible if they were: ≥60 years, history of type 2 diabetes (had type 2 diabetes, controlled or uncontrolled, with or without complications). Exclusion criteria were lack of cognitive impairment such as dementia, because these conditions could interfere with accurate completion of the questionnaires. Simple random sampling was used to select participant. According to Cochran’s formula, 341 elderly people were calculated (d = 0.5, Z = 1.96, p = 0.5, q = 0.5, and α = 0.05). The number of 375 elders was considered by 10% probability of attrition.
 |
Data collection tools included demographic data sheet (age, sex, education, occupation, marital status and duration of type 2 diabetes), abbreviated mental test score (AMTS), a questionnaire for health literacy for Iranian adults (HELIA), and diabetes management self efficacy scale (DMSES). AMTS consisting of 10 simple and short questions that measures orientation, concentration and attention of short and long term memory and is useful for screening cognitive disorders including dementia and delirium in the elderly. The short form consists of 10 questions with 10 points, which takes 3 min to complete. In some studies, the clinical cut-off point has been introduced as less than 8 to differentiate people with normal cognitive status from people with mild cognitive impairment [26]. In the present study, according to the DSM-IV criteria, the cut-off point = 7 was considered. The Health Literacy for Iranian Adults questionnaire has five domains: access, reading skills (4 items), comprehension (6 items), appraisal (7 items), evaluation (4 items), and decision-making and behaviour (12 items). Internal consistency of HELIA showed satisfactory results with cronbach’s alpha coefficients ranging from 0.72 to 0.89 [27]. The raw score of each individual in the subscales is obtained from the sum of the scores, and then this score was converted into a range of 0 to 100 based on this formula: (obtained raw score - minimum possible raw score)/ (maximum possible score - minimum possible score).To calculate the total score, the scores of the items are added and divided by 5. The ranking of the level of health literacy of the elderly was inadequate(0–50), not very adequate(50.1–66), adequate(66.1–84), and excellent(84.1–100) [28].The self-efficacy scale consists of 19 items that measure a person’s ability to self care. The findings of the factor analysis have divided the questions into four factors: nutrition, physical activity, taking medications, and blood glucose measurement. The results of the reliability analysis have shown that all four factors have acceptable and significant internal and retest coefficients. The Iranian version of DMSES has good reliability and validity, and there is consistency between the research findings and other psychometric versions of the instrument in other languages [29]. In this study, the researcher (the first author of this article) referred to the diabetes association or to a home or any place agreed upon by the elderly. Adequate explanations on how to complete the questionnaires were provided to the participants. It was emphasized to the participants to complete the questionnaires carefully and patiently and to postpone the completing the questionnaires to another time if they were tired. If the elderly person was illiterate, the items of the questionnaire were asked by a researcher and the answers were entered in the questionnaire. Pearson test was used to determine the relationship between self-efficacy and health literacy. Stepwise linear regression was used to predict self-efficacy by health literacy dimensions. Data analysis was performed using SPSS software version 22.
Results
In this study, the mean age of the elderly was 65.42 ± 4.88 years. 129 elderly (34.4%) were male and 336 elderly people (89.6%) were married. Of the participants, 262 elderly people (69.9%) had undergraduate education. Also, 220 of the elderly (58.7%) were housewives. The average number of years of diabetes in the elderly was 13.62 (SD = 8.20) years (Range = 1–42). The ATMS scores in the elderly were: 77 participants (20.5%) = 7, 72 (19.2%) = 8, 113 (30.1%) = 9 and 113 participants (30.1%) reported a score of 10 on the scale. The most ways to obtain health information were asking physicians and health care providers (n = 316, 84.3%), radio and television (n = 222, 59.2%) and the lowest frequency was related to telephone messengers (n = 4, 1.1%) (Table 1). In the study of health literacy of the elderly with diabetes, the highest mean score was related to the decision-making and behavior (77.95 ± 84 19.84) and the least mean was related to reading skills (51.51 ± 35 35.88). Most of the elderly had an insufficient level of health literacy in access (38.1%), reading skills (58.7%), understanding (38.7%) and evaluation (47.5%). In decision making, 48.3% of the elderly had excellent health literacy (Table 2). There was a significant relationship between health literacy and gender. So that men had a higher level of health literacy. Elderly people with higher education had higher levels of health literacy. Employed and retired elderly showed a higher level of literacy than others. Elderly people over 70 years had lower health literacy (p < 0.05). But marital status (P = 0.14) and duration of illness (P = 0.19) did not show a significant relationship with health literacy (Table 1). In the study of self-efficacy of elderly patients with diabetes, the lowest mean was related to physical activity (71.38 ± 24.40) and the highest mean was related to taking medications (89.75 ± 17.56) (Table 3). To determine the degree of self-efficacy prediction by health literacy, the results of stepwise linear regression showed decision-making (β = 0.57, P < 0.001), access (r2 = 0.11, P = 0.006) and understanding (r2 = 0.08, p = 0.01) predict 55% of the variance; with increasing each of the above variables, the level of self-efficacy increases. Also, total health literacy predicted 38% of the variance (r2 = 0.55, p < 0.001) (Table 4). In investigating the relationship between health literacy of the elderly with diabetes and self-efficacy, the results of pearson correlation analysis showed that decision making and use of health information had the highest correlation with self-efficacy (P < 0.001, r = 0.72). The lowest correlation was between nutrition and reading skills (P < 0.001, r = 0.22). Also, a strong correlation was observed between self-efficacy and health literacy (P < 0.001, r = 0.62) (Table 5).
Table 1.
Health literacy according to demographic characteristics of the elderly
| Variable | Insufficient N (%) |
Not enough N (%) |
Enough N (%) |
Excellent N (%) |
P | |
|---|---|---|---|---|---|---|
| Gender | Male | 29(22.5) | 29(22.5) | 42(32.6) | 29(22.5) | 0.003 |
| Female | 91(37) | 67(27.2) | 47(19.1) | 41(16.7) | ||
| Education | High school | 115(43.9) | 85(32.4) | 44(16.8) | 18(6.9) | < 0.001 |
| Diploma | 4(6.7) | 5(8.3) | 27(45) | 24(40) | ||
| Higher education | 1(1.9) | 6(11.3) | 89(34) | 28(52.8) | ||
| Job | Housekeeper | 95(43.2) | 65(29.5) | 36(16.4) | 24(10.9) | 0.003 |
| Self-employment | 11(27.5) | 9(22.5) | 9(22.5) | 11(27.5) | ||
| Employee | 1(3.8) | 6(23.1) | 13(50) | 6(23.1) | ||
| Retired | 4(6) | 8(11.9) | 26(38.8) | 29(43.3) | ||
| Farm worker | 5(35.7) | 7(50) | 2(14.3) | - | ||
| Marital status | Single | 6(75) | 1(12.5) | 1(12.5) | - | 0.14 |
| Married | 107(31.8) | 84(25) | 81(24.1) | 64(19) | ||
| Widow | 7(23.3) | 11(36.7) | 6(20) | 6(20) | ||
| Age | 60–65 | 63(28) | 56(24.9) | 56(24.9) | 50(22.2) | 0.004 |
| 66–70 | 33(30.3) | 33(30.3) | 25(22.9) | 18(16.5) | ||
| > 70 | 24(58.5) | 7(17.1) | 8(19.5) | 2(4.9) | ||
|
Duration of illness (years) |
0–5 | 26(39.4) | 14(21.2) | 18(27.3) | 8(12.1) | 0.19 |
| 6–10 | 30(28.6) | 26(24.8) | 24(22.9) | 25(23.8) | ||
| 10–20 | 46(34.6) | 37(27.8) | 31(23.3) | 19(14.3) | ||
| > 20 | 14(26.9) | 13(25) | 9(17.3) | 19(30.8) | ||
Table 2.
Domains of health literacy in the elderly with diabetes
| Domain | X ± SD | Inadequate health literacy N (%) |
Not enough N (%) |
Adequate health literacy N (%) |
High health literacy N (%) |
|---|---|---|---|---|---|
| Access | 59.01 ± 22,073 | 143(38.1) | 94(25.1) | 73(19.5) | 65(17.3) |
| Reading skills | 51.51 ± 35.88 | 220(58.7) | 10(2.7) | 42(11.2) | 103(27.5) |
| Understanding | 63.99 ± 27.9 | 145(38.7) | 47(12.5) | 62(16.5) | 121(32.3) |
| Appraisal | 52.25 ± 25.3 | 178(47.5) | 76(20.3) | 87(23.2) | 34(9.1) |
| Decision making and behavior | 77.95 ± 19.84 | 40(10.7) | 39(10.4) | 115(30.7) | 181(48.3) |
| Total health literacy | 60.94 ± 21.27 | 120(32) | 96(25.6) | 89(23.7) | 70(18.7) |
Table 3.
Self-efficacy and its domains in the elderly with diabetes
| Self-efficacy domains | Mean ± SD |
|---|---|
| Blood glucose measurement | 77.84 ± 25/68 |
| Nutrition | 75.71 ± 24/44 |
| physical activity | 71.38 ± 24/40 |
| Taking medications | 89.75 ± 17/56 |
| Self-efficacy (total) | 78.67 ± 19/13 |
Table 4.
Regression analysis to predict self-efficacy by health literacy
| Variable | Coefficiencies | t | P-value | R | r2 | ||
|---|---|---|---|---|---|---|---|
| Non-standardized | standardized | ||||||
| Β | The standard deviation | Β | |||||
| Decision making | 0.57 | 0.04 | 0.59 | 13.75 | 0.001 | 0.75 | 0.55 |
| Access | 0.11 | 0.04 | 0.13 | 2.74 | 0.006 | ||
| Conception | 0.08 | 0.03 | 0.11 | 2.51 | 0.01 | ||
| Health literacy | 0.55 | 0.04 | 0.62 | 15.08 | 0.001 | 0.62 | 0.38 |
Table 5.
Correlation between health literacy and self-efficacy components in the elderly with diabetes
| Subscales | access | Reading skills | conception | Assessment | Decision making and application of health information | Total health literacy |
|---|---|---|---|---|---|---|
| Blood sugar measurement |
0.47 p < 0.001 |
0.35 p < 0/001 |
0.49 p < 0.001 |
0.47 p < 0.001 |
0.60 p < 0/001 |
0.57 p < 0.001 |
| Nutrition |
0.43 p < 0.001 |
0.22 p < 0/001 |
0.36 p < 0.001 |
0.37 p < 0.001 |
0/66 p < 0.001 |
0.47 p < 0.001 |
| Physical activity |
0.42 p < 0.001 |
0.35 p < 0/001 |
0/44 p < 0.001 |
0.43 p < 0.001 |
0.57 p < 0.001 |
0.53 p < 0/001 |
| Taking medications |
0.41 p = 0.03 |
0.25 p = 0/01 |
0.34 p = 0/007 |
0.38 p < 0.001 |
0.57 p < 0.001 |
0.46 p < 0/001 |
| Self-efficacy (total) |
0.52 p = 0.03 |
0.36 p < 0.001 |
0.50 p < 0.001 |
0.50 p < 0.001 |
0.72 p < 0.001 |
0.62 p < 0.001 |
Discussion
This study investigates health literacy and self-efficacy of the elderly with diabetes. As studies show, inadequate health literacy is associated with difficulty in understanding health information, limited knowledge of disease, reduced adherence to treatment, poor health, increased costs, and mortality [30]. A study show that low health literacy is linked to the decrease health status of the elderly and results in low compliance to disease prevention [15]. A finding of this study is that health literacy in elderly is related to their education level; elderly with higher levels of education have higher levels of health literacy. Similarly, Forghani et al. (2016) show in type 2 diabetic elderly, low-educated elderly women have poor health literacy [31] In the present study, elderly men report a higher level of health literacy. People over the age of 70 had a lower level of literacy. Also, Mohamadloo et al. (2020) show the score of health literacy in older men, and elderly with higher education is higher than other elderly. Similar to our finding, this study reveal that retired and employed elderly people have a higher level of literacy [32]. On the subject of occupation and literacy, Chesser et al. (2016) in a systematic analysis of articles published in the United States on elderly, highlight the importance of working to improve health care strategies in the elderly with low health literacy [33]. Our finding shows that the elderly who continue their daily and social activities have a higher level of health literacy. This may be due to the fact that more elderly people with diabetes feel the need to receive more health information to maintain a life of independence and self-efficacy. In the present study, the self-efficacy of elderly patients with diabetes is higher than average. In this regard, in the research of Taheri et al. (2015) in explaining the relationship between health literacy and self-efficacy and self-care in patients with type 2 Diabetes show that designing a codified and continuous educational program to improve the level of literacy, self-efficacy of patients with diabetes is a very important matter [34]. In the present study, taking medications in the elderly is identified as the component with the highest score. One of the reasons for this is the favorable cognitive status of the elderly. On the other hand, the increase in the years of diabetes in the elderly makes them aware to prevent complications or recurrence of the disease, so that they promote self-efficacy in managing their disease. As finding show, taking medication is significantly related to all self-efficacy subscales. This result indicates that a better understanding and adherence to the medication regimen is associated with greater self-efficacy in the elderly. similarly, Rosli et al(2022) in an investigation in Malaysia show higher medication understanding in elderly with type 2 diabetes mellitus is correlated with high quality of life and emphasizing self-efficacy in medication understanding in the management of elderly with diabetes[35]. Another result of the study is lower score of physical activity among diabetic elderly. In consistent with this finding, Mahmudiono et al. (2021) in assessing the relationship between self-efficacy in physical activity in older adults’ with diabetes mellitus in Indonesia show only 32.7% of the participants was categorized as being physically active and self-efficacy in performing the physical activity was significantly related to the duration of physical activity [36].
Regarding the importance of self-efficacy in diabetes mellitus, Masoompour et al. (2017) show that health literacy and self-efficacy can affect self-care behaviors in diabetics [24]. Consistent with the findings of this study, a study shows that diabetes self-management in older people with type 2 diabetes is associated with health literacy [15]. The correlation between health literacy and self-efficacy of diabetic elderly in this study suggests that health policy makers should pay more attention to the issue of health literacy in health planning in the elderly with chronic diseases. Similarly, increasing the health literacy and self-efficacy of diabetic elderly has been emphasized in other studies [37]. The results of the study show that all components of health literacy are above average and the self-efficacy of the elderly has a good score in all subsets. Contrary to this finding, tamizkar et al. (2019) suggests the level of health literacy in the elderly is moderate to high, and many older people report insufficient self-care ability. [38]. In the present study, the results show that there is a high correlation between self-efficacy and health literacy. In the previous researches, the term “self-care” is used instead. In any case, self-efficacy is correlated with self-care and its dimensions are analyzed in relation to the health literacy of the elderly. In this regard, a study on diabetic adolescents determined self-efficacy is important factor for successful self-care behavior and promotion of self-efficacy improve self-care [39]. In another study, in investigating association of self-efficacy and self-care behaviors on glycemic control, there were no significant relationships between self-efficacy and self-care, and A1C levels. Those whose diabetes was well controlled were confident in appropriate nutrition and exercise [40].
From the findings of this study, the correlation of health literacy has a strong relationship with the self-efficacy of diabetic elderly. Health literacy affects decision-making in the elderly patients with diabetes. More research is needed on how factors may influence decision-making preferences, particularly for those with limited health literacy. As the findings of this study show, decision-making can predict 57% of self-efficacy in the studied elderly, this is relatively significant. In other words, it is concluded that the elderly with higher decision-making ability have better self-efficacy for diabetes management. In line with this finding, Seo et al. (2026) in examining the relationship between health literacy and decision-making suggest that adequate health literacy is significantly associated with preferring patient-involved decision-making [41]. Regarding to correlation between decision-making and self efficacy, authors of this article believe that improving self-efficacy would be accomplished with sound judgment and valid decision making in the elderly with diabetes. In other words, considering improving the ability to make appropriate decisions in the elderly, it will most likely be associated with improving self-efficacy and its positive results, such as compliance with diabetes treatment. This study shows that the health literacy of the elderly with type 2 diabetes is directly related to self-efficacy. Researchers believe that improving health literacy in the elderly with diabetes will improve their performance in treatment management through appropriate self-efficacy. The results of this study can be considered for nursing care approaches in inpatient and outpatient units such as nursing homes in several ways. It is expected that the results of this research will able to provide an educational materials to overcome the problems of older people diabetes by considering the aspect of diabetes literacy in nursing process when assessing and addressing diabetes-specific health education needs. According to the findings, nurses can promote health literacy with creative educational methods such as peer group training or focused groups to improve the self-efficacy of diabetic elderly in physical activities and in other health-related behaviors. Also, in the cases of hospitalization, pre-discharge planning becomes especially important for increasing the effects of health literacy education on the elderly patients. Techniques such as teach-back method can bring better self-efficacy for the management of diabetes. According to finding, the use of such methods could improve the durability of health literacy in people over 70 years old.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Acknowledgements
This study is the result of a research that was carried out in the Babol Diabetes Association with the approval of the ethics (ID IR.SHAHED.REC.1399.096) of Shahed University. The researchers appreciate the president and all the staff of Babol diabetes association who had a sincere cooperation.
Funding
The authors declare they have no financial interests.
Declarations
Conflict of interest
There is no conflict of interest in this study.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Abdollah Goli Roshan, Email: abdollahgoli@yahoo.com.
Seyedeh Navabeh Hosseinkhani, Email: navabehhosseinkhani@yahoo.com.
Reza Norouzadeh, Email: norouzadeh@shahed.ac.ir.
References
- 1.Sabooteh S, Shahnazi H, Mostafavi F. Health literacy status and its related factors in the Elderlies in Dorood, Iran. J Educ Community Health. 2019;6(1):41–7. doi: 10.29252/jech.6.1.41. [DOI] [Google Scholar]
- 2.Barghi Irani Z, Aliakbari M, Bagian Kulehmarz MJ. The effectiveness of cognitive-behavioral therapy on Sleep and Memory State in the Elderly. Aging Psychol. 2015;1(1):19–30. [Google Scholar]
- 3.Rahmati M, Rejeh N, Heravi Karimooi M, Tadrisi SD. Investigating the relationship between health literacy and adherence with treatment regimen in the elderly with hypertension. Iran J Nurs Res. 2019;13(5):15–22. [Google Scholar]
- 4.Tajvar M, Arab M, Montazeri A. Determinants of health-related quality of life in elderly in Tehran, Iran. BMC Public Health. 2008;8(1):1–8. doi: 10.1186/1471-2458-8-323. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Behrouz S, Peyman N, Kooshiar H. Relationship between medical literacy and mortality in older adults: Narrative Review. J North Khorasan Univ Med Sci. 2018;10(2):122–9. doi: 10.52547/nkums.10.2.122. [DOI] [Google Scholar]
- 6.vel Szic KS, Declerck K, Vidaković M, Berghe WV. From inflammaging to healthy aging by dietary lifestyle choices: is epigenetics the key to personalized nutrition? Clin epigenetics. 2015;7(1):1–18. doi: 10.1186/s13148-015-0068-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Maresova P, Javanmardi E, Barakovic S, Husic JB, Tomsone S, Krejcar O, et al. Consequences of chronic diseases and other limitations associated with old age–a scoping review. BMC Public Health. 2019;19(1):1–17. doi: 10.1186/s12889-019-7762-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Noohi E, Khandan M, Mirzazadeh A. Effective of electronic education on knowledge attitude and self-care in patient’s diabetic type 2 refer to diabetic. center of Kerman University of medical science; 2011.
- 9.Ellis SE, Speroff T, Dittus RS, Brown A, Pichert JW, Elasy TA. Diabetes patient education: a meta-analysis and meta-regression. Patient Educ Couns. 2004;52(1):97–105. doi: 10.1016/S0738-3991(03)00016-8. [DOI] [PubMed] [Google Scholar]
- 10.Schiøtz M, Bøgelund M, Almdal T, Willaing I. Discrete choice as a method for exploring education preferences in a danish population of patients with type 2 diabetes. Patient Educ Couns. 2012;87(2):217–25. doi: 10.1016/j.pec.2011.09.003. [DOI] [PubMed] [Google Scholar]
- 11.Heidari S, Nouri Tajer M, Hosseini F, Inanlou M, Golgiri F, Shirazi F. Geriatric family support and diabetic type-2 glycemic control. Iran J Ageing. 2008;3(2):573–80. [Google Scholar]
- 12.Vares Z, Asayesh H, Sharififard F. Related factors in the quality of life of Diabetic Elderlies. Iran J Diabetes Metabolism. 2017;16(5):261–8. [Google Scholar]
- 13.Abazari P, Vanaki Z, Mohammadi E, Amini M. Inadequate investment on management of diabetes education. J Res Med sciences: official J Isfahan Univ Med Sci. 2012;17(8):792. [PMC free article] [PubMed] [Google Scholar]
- 14.Baraz S, Rostami M, Farzianpor F, Rasekh A. Effect of Orem Self Care Model on ederies’ quality of life in health care centers of Masjed Solaiman in 2007–2008. J Arak Univ Med Sci. 2009;12(2):51–9. [Google Scholar]
- 15.Rachmawati U, Sahar J, Wati DNK. The association of diabetes literacy with self-management among older people with type 2 diabetes mellitus: a cross-sectional study. BMC Nurs. 2019;18(1):1–8. doi: 10.1186/s12912-019-0354-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.THE IMPACT OF SELF-MANAGEMENT PROGRAM ON SELF-EFFICACY OF ELDERLY PATIENTS WITH HEART FAILURE Aghamohamadi said ba bagher maddah s, mohammadi shahbolaghi sf, dalvandi a, Khaleghipour m. Nurs Midwifery J. 2017;14(12):1013–23. [Google Scholar]
- 17.Qin W, Blanchette JE, Yoon M. Self-efficacy and diabetes self-management in middle-aged and older adults in the United States: a systematic review. Diabetes Spectr. 2020;33(4):315–23. doi: 10.2337/ds19-0051. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.La Vonne AD, Zun LS. Assessing adult health literacy in urban healthcare settings. J Natl Med Assoc. 2008;100(11):1304–8. doi: 10.1016/s0027-9684(15)31509-1. [DOI] [PubMed] [Google Scholar]
- 19.Cooper J, Davenport M, Gaillard K, Kompier A. Health Literacy in Practice Program Evaluation. Michigan: Western Michigan University School of Social Work. 2011;13:111-7.
- 20.Tehrani Banihashemi S-A, Haghdoost AA, Amirkhani MA, Alavian S-M, Asgharifard H, Baradaran H, et al. Health literacy and the influencing factors: a study in five provinces of Iran. Strides in development of medical education. 2007;4(1):1–9. [Google Scholar]
- 21.Reisi M, Javadzade SH, Mostafavi F, Sharifirad G, Radjati F, Hasanzade A. Relationship between health literacy, health status, and healthy behaviors among older adults in Isfahan, Iran. J Educ health promotion. 2012;1(1):31. doi: 10.4103/2277-9531.100160. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Sousa MCd, Malaquias BSS, Chavaglia SRR, Ohl RIB, Paula FFSd S, KSd et al. Self-efficacy in elderly with type 2 Diabetes Mellitus.Revista Brasileira de Enfermagem. 2020;73. [DOI] [PubMed]
- 23.Liu T, editor. Nursing forum. Wiley Online Library; 2012. Editor A Concept Analysis of Self-Efficacy among C hinese Elderly with Diabetes Mellitus. [DOI] [PubMed]
- 24.Masoompour M, Tirgari B, Ghazanfari Z. The relationship between health literacy, self-efficacy, and self-care behaviors in diabetic patients. Evid Based Care. 2017;7(3):17–25. [Google Scholar]
- 25.Souza JG, Apolinario D, Magaldi RM, Busse AL, Campora F, Jacob-Filho W. Functional health literacy and glycaemic control in older adults with type 2 diabetes: a cross-sectional study.BMJ open. 2014;4(2). [DOI] [PMC free article] [PubMed]
- 26.Bakhtiyari F, Foroughan M, Fakhrzadeh H, Nazari N, Najafi B, Alizadeh M, et al. Validation of the persian version of abbreviated Mental Test (AMT) in elderly residents of Kahrizak charity foundation. Iran J Diabetes Metabolism. 2014;13(6):487–94. [Google Scholar]
- 27.Montazeri A, Tavousi M, Rakhshani F, Azin SA, Jahangiri K, Ebadi M, et al. Health literacy for iranian adults (HELIA): development and psychometric properties. Payesh (Health Monitor) 2014;13(5):589–99. [Google Scholar]
- 28.Montazeri A, Tavousi M, Rakhshani F, Azin SA, Jahangiri K, Ebadi M, et al. Health literacy for iranian adults (HELIA): development and psychometric properties. Health Monit J Iran Inst Health Sci Res. 2014;13(5):589–99. [Google Scholar]
- 29.Ghodrati Mirkohi M, Rahimian Boogar I. Predicting diabetes management self-efficacy base on hardiness and coping strategies in patients with type 2 diabetes mellitus. J Qazvin Univ Med Sci. 2016;20(4):43–51. [Google Scholar]
- 30.Liu C, Wang D, Liu C, Jiang J, Wang X, Chen H et al. What is the meaning of health literacy? A systematic review and qualitative synthesis.Family medicine and community health. 2020;8(2). [DOI] [PMC free article] [PubMed]
- 31.Forghani T, Hasanzadeh T, Ghahhar M-R, Panahi S, Alizadeh M. The relationship between health literacy and self-care Behaviors in Diabetic Type 2 Elderly People. J Health Lit. 2020;5(2):46–53. [Google Scholar]
- 32.mohamadlo a Batooli z, ramezankhani a. The analysis and review of the literatures in the field of health literacy. J Mod Med Inform Sci. 2020;6(2):58–72. [Google Scholar]
- 33.Chesser AK, Keene Woods N, Smothers K, Rogers N. Health literacy and older adults: a systematic review. Gerontol geriatric Med. 2016;2:2333721416630492. doi: 10.1177/2333721416630492. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Tahery N. The association of health literacy with self-efficacy and self-care, in type 2 diabetes patients. Iran J Endocrinol Metabolism. 2018;20(3):135–41. [Google Scholar]
- 35.Rosli NA, Mazapuspavina MY, Ismail Z, Elkudssiah Ismail N. Relationship of Self Efficacy in Medication understanding with Quality of Life among Elderly with type 2 diabetes Mellitus on Polypharmacy in Malaysia. Int J Environ Res Public Health. 2022;19(5):3031. doi: 10.3390/ijerph19053031. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Mahmudiono T, Setyaningtyas SW, Rachmah Q, Nindya TS, Megatsari H, Indriani D, et al. Self-efficacy in physical activity and glycemic control among older adults with diabetes in Jagir Subdistrict, Surabaya, Indonesia. Heliyon. 2021;7(7):e07578. doi: 10.1016/j.heliyon.2021.e07578. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Azimian J, Mohammadi F, Javadi A, Asgarian N. Correlation between health literacy and self-efficacy of the Elderly. J Inflamm Disease. 2020;24(3):224–33. [Google Scholar]
- 38.tamizkar mohammadi. Fathnezhad-kazemi a, marami s. The relationship between health literacy level and self-care ability in the elderly. J Gerontol. 2019;4(3):54–62. [Google Scholar]
- 39.Rezasefat Balesbaneh A, Mirhaghjou N, Jafsri Asl M, Kohmanaee S, Kazemnejad Leili E, Monfared A. Correlation between self-care and self-efficacy in adolescents with type 1 diabetes. J Holist Nurs Midwifery. 2014;24(2):18–24. [Google Scholar]
- 40.Beckerle CM, Lavin MA. Association of self-efficacy and self-care with glycemic control in diabetes. Diabetes Spectr. 2013;26(3):172–8. doi: 10.2337/diaspect.26.3.172. [DOI] [Google Scholar]
- 41.Seo J, Goodman MS, Politi M, Blanchard M, Kaphingst KA. Effect of health literacy on decision-making preferences among medically underserved patients. Med Decis Making. 2016;36(4):550–6. doi: 10.1177/0272989X16632197. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.