The relationship between patient activation levels and health literacy levels of hypertension patients in a family health centre in Turkey

Abstract

Background

Health literacy has been shown to benefit disease management, with patient activation level being important. This study aimed to assess health literacy and activation levels in hypertensive patients, investigating the relationship between literacy and activation.

Methods

The present descriptive and correlational study was conducted with 425 participants. The study was granted ethical approval by the Health Sciences Ethics Committee of a university, and institutional permission was obtained from the relevant Provincial Health Directorate. The data collection tools employed included the Socio-demographic Data Form, the Patient Activism Measure, and the European Health Literacy Scale short form.The data were collected through in-person interviews conducted in the counselling department of the family health centre.The analysis of the data involved the use of statistical methods, including number, percentage, chi-squared test, and ordinal regression analysis.

Results

The study revealed that 46.4% of the participants exhibited insufficient health literacy, 19.1% demonstrated problematic health literacy, and 34.5% demonstrated adequate literacy. The findings further delineated that 12.4% of the participants were positioned at level 1, 11.8% at level 2, 39.8% at level 3, and 36.0% at level 4 of patient activation. The findings of this study indicate that individuals with a patient activation level 4 exhibit an adequate health literacy level greater (p = .001) in comparison to individuals with a patient activation level 1.

Conclusions

The study found a link between patient activism and health literacy among people with hypertension. It is recommended that efforts be made to improve health literacy to strengthen patient activism in managing the condition.

Background

Hypertension is a cardiovascular disease defined by elevated blood pressure. It affects 30–40% of adults worldwide and significantly increases the risk of cardiovascular disease [1]. Hypertension is the most prevalent cardiovascular disease and mortality risk factor [2, 3]. Since 2003, the World Health Organisation’s Global Burden of Disease Study has identified hypertension as the most significant global risk factor contributing to both morbidity and mortality [4]. Even among individuals presumed to have well-controlled hypertension, less than one-third are protected against subsequent strokes and heart attacks [5]. The WHO World Blood Pressure Report, published in 2023, highlights alarming statistics regarding the prevalence of high blood pressure, estimating that approximately 1.3 billion adults lived with this condition by 2019. The findings of the report indicate that only 54% of adults diagnosed with hypertension receive a diagnosis, only 42% of those receive treatment, and only 21% of those have their blood pressure adequately controlled [6].

Hypertension is common in patients with type 2 diabetes, and can also develop in more than 50% of those with diabetes mellitus. Research shows that the development of these conditions is linked over time, and that insulin resistance is a feature of both prediabetes and prehypertension, and a precursor to the progression of both. Obesity and hypertension are also linked to insulin resistance [7, 8]. The ‘Turkey Diabetes, Hypertension, Obesity and Endocrinological Diseases Prevalence Study’ shows the age-standardised prevalence of hypertension to be 29.6%. Forecasting shows a future rise, with 30.4% by 2023 and 36% by 2045 [9]. Hypertension is a serious problem in Turkey. One in three adults suffer from hypertension, but nearly half are unaware. High salt intake, lack of exercise and obesity are key contributors to the disease burden. Disease awareness has improved, but blood pressure control rates remain low. Patient adherence to treatment varies by region and improves with higher education. Reducing daily salt intake significantly decreases the prevalence of hypertension and, in projection studies, is cost-effective in preventing cardiovascular and cerebrovascular deaths [10, 11]. A Turkish study shows the hypertension (HT) prevalence in the population is 44.0%, but only 41% of individuals diagnosed with hypertension have received a prior diagnosis. Of those, 54.5% use medication, but only 24.3% of those treated have control of their blood pressure, and only 5.43% of all hypertensive individuals do [12].

Health literacy (HL) helps control blood pressure. So improving literacy, especially by giving patients access to health information, should be important in treating hypertension [13, 14]. Health literacy is defined as the ability to obtain, understand, evaluate and use information to make decisions and take actions that affect one’s health [15]. Health literacy raises awareness of patients’ rights, including accessing information about medicines and public health announcements. However, a study of hospitalised patients reveals that only half can comprehend, interpret and use health information, and those with inadequate literacy are more prone to re-admission [16]. Poor health literacy is also a factor in many issues affecting patients with chronic illnesses, as shown by challenges in understanding processes, treatment and communication [17]. Research indicates that those with good health literacy manage hypertension better [18–20].

Numerous studies show a link between health literacy and drug awareness. Also, more activism means better literacy [21, 22]. The literature emphasises that improving health literacy, especially access to health information, is important in managing high blood pressure. This involves educating and counselling HT patients, and providing health literacy resources [9]. Another study emphasised the importance of health institutions and employees implementing patient activation interventions according to the level of activation. These interventions strengthen the role of patients in managing health services to improve health outcomes [23]. In chronic disease management, enhanced activation has been proven to improve self-management and health outcomes [24]. The activation intervention had a significant positive effect on self-management behaviours in patients with Type 2 Diabetes, particularly in relation to physical activity, healthy eating, foot care and blood glucose self-monitoring [25]. One study found that the patient activation intervention significantly improved self-management behaviours in patients with type 2 diabetes, particularly with regard to physical activity, healthy eating, foot care, and blood glucose self-monitoring [26]. It has been suggested that enhancing patient autonomy can decrease healthcare utilisation and expenditures [24].

Health literacy and patient activation are both important. Health literacy affects self-care and decision-making, while patient activation is about an individual’s knowledge, skills and confidence. A high level of activation is linked to better health outcomes and self-care. However, age, social class and education must also be considered [27]. A review of studies indicates that improving patient activation and health literacy slightly enhances physical and mental health, but has no impact on quality of life or use of healthcare. Interventions can increase levels of activation in patients with poor literacy. This shows both literacy and activation are important for self-managing chronic diseases, but more research is needed to see the long-term impact of combining these factors [28].

This study focus on the relationship between health literacy and patient activation in hypertension patients. It will contribute to the literature by revealing the levels of health literacy and patient activation, as well as the factors affecting them, among hypertension patients registered at the family health centre. The objective of this study is to ascertain the health literacy and patient activation levels of hypertension patients and to examine the relationship between health literacy levels and patient activation level.

Research Questions

• Which factors influence the level of patient activation in individuals with hypertension?

• What affects the health literacy levels of hypertensive people?

• What affects patient activation and health literacy among people with hypertension?

Methods

Design, settings and participants

This study was conducted to determine the health literacy levels of individuals with hypertension and to examine the relationship between health literacy levels and patient activism levels. This study was conducted in the Söke district of the Aydın province. There are seven Family Health Centres in total providing services in the district centre of Söke. The study took place in two family medicine units at Family Health Centre No:6 between 1 September 2021 and 1 June 2022. Doctors examined an average of 278 patients per day. The centre has 11,448 registered individuals. The study population consisted of 6041 individuals registered with the two family medicine units and diagnosed with hypertension. The prevalence of hypertension was thus calculated to be 52.76% at the family health centre. Using G-Power Software from the Family Health Centre, it was calculated that 362 participants were needed to reflect 5% sampling error and 80% power at 95% confidence interval. Due to reasons such as leaving the study and not being able to reach the participant, the sample was increased by 20% and a total of 434 individuals were decided to be the study sample. Three individuals who wished to withdraw from the study, as well as six individuals who participated but provided incomplete responses on the data collection form, were excluded. The study was completed with 425 participants. Using stratified sampling, the study included 219 individuals from one family physician with 3055 patients diagnosed with hypertension, and 215 individuals from another family physician with 2986 hypertensive patients. The independent variables of the study were gender, age, occupation, marital status, number of children, and socioeconomic level. The dependent variables were the patient activism and health literacy levels of the participants.

Data collection tools

The study’s data collection tools were the Socio-demographic Data Form, the Patient Activism Level Scale and the European Health Literacy Scale short form.

The socio-demographic data form, prepared by the researchers according to the literature, will be used in the study. It will ask respondents to report their age, gender, marital status, education level, general health status, employment status, economic status, frequency of reading books, general physical status and general mental health status [29].

Patient Activity Measurement: The Patient Activity Measure (PAM) was developed in 2004 by Hibbard, Stockard, Mahoney and Tusler. It contains 22 items and was tested on a sample group of people with chronic diseases [30]. Subsequent to the initial investigation, the researchers developed an abridged version of the scale, comprising 13 questions [30]. PAM evaluates patients’ chronic disease self-management using a 1–5 scale: 1 strongly disagree, 2 disagree, 3 agree, 4 strongly agree or don’t know/can’t evaluate. Scores are calculated using the SPSS programme: ‘don’t know/can’t evaluate’ = 0, ‘strongly disagree’ = 1, ‘disagree’ = 2, ‘agree’ = 3, ‘strongly agree’ = 4. Activity scores range from 0 to 100. Level 1, the lowest with < 47 points, shows belief in the importance of taking an active role. Level 2 (47–55 points) shows knowledge/confidence to act. Level 3 (55–72) shows mobilisation. Level 4 (>72.5 points) shows ability to maintain routines even under stress [30]. The validity and reliability study of the Turkish form of the measurement tool was conducted by Koşar and Besen, and the Cronbach’s alpha value of the scale was 0.83 [31]. In this study, the Cronbach’s alpha value of the Patient Activity Level Measure was determined to be .81.

European Health Literacy Scale Short Form (HLS-EU-Q16): The scale in question was developed by the European Health Literacy Consortium as part of the European Health Literacy Survey [32]. The HLS-EU-Q16 instrument employs a five-point Likert scale, ranging from 0 = ‘No idea’ to 4 = ‘Very easy’, with intermediate options denoting the degree of difficulty experienced. The response to each question ranges from a minimum of 0 points to a maximum of 4 points. Following the application of the scale, the standardisation of the index score is achieved through the calculation process, whereby the total score is determined by the following formula: Index=((mean-1)*(50/3)). The standardised index score varies between 0 and 50. A score of 33 or above on the aforementioned scale would indicate sufficient levels of health literacy [32]. The scale was adapted to Turkish and found to be valid and reliable, with a Cronbach Alpha value of 0.89 for the Turkish form of HLS-EU-Q16-TR [33]. The reliability coefficient of the Turkish European Health Literacy Scale short form was calculated to be 0.96.

Ethical considerations

Ethical approval for this study was obtained from Muğla Sıtkı Koçman University Health Sciences Ethics Committee (179/18.08.2021), and institutional permission was obtained from the Aydın Provincial Health Directorate. The participants were provided with comprehensive information regarding the study, and it was emphasised that their involvement was entirely voluntary. It was assured that the information would be kept confidential and would not be utilised for any other study or application.

Data collection

The researcher used data collection tools in face-to-face interviews with participants. The data collection process took place between 10:00 and 16:00 on weekdays in the counselling department of the family health centre. Participants were registered with the family health centre and data collection forms were used in the family health centre. Participants were only included if they had applied to family physicians, met the study criteria and were diagnosed with hypertension. The safety and health of individuals was considered during the data collection process.

Data analysis

Participants’ patient activation levels were categorised as follows: level 1 = ≤ 47 (not believing activation important); level 2 = 47.1–55.1 (a lack of knowledge and confidence to take action); level 3 = 55.2–67 (beginning to take action); level 4 = ≥ 67.1 (taking action) [30, 31]. The health literacy levels of the participants were categorised as follows: 0–25 points indicated inadequate literacy, 25–33 points indicated problematic-limited literacy, 33–42 points indicated adequate literacy, and 42–50 points indicated excellent health literacy [32]. In the present study, a cut-off point of 33–50 points was utilised to define adequate health literacy.

The data obtained in the study were analysed using SPSS (Statistical Package for Social Sciences) for Windows 25.0 software. The data were analysed using descriptive statistics, including numbers and percentages. The chi-square test was utilised to analyse the factors influencing health literacy levels and patient activation levels. Ordinal regression analysis was utilised to investigate the association between participants’ sociodemographic characteristics and their levels of patient activation. Following the implementation of ordinal regression analysis, the odds ratio, as well as the lowest and highest odds ratio values within the 95% confidence interval, were calculated using Microsoft Excel. Statistical significance was determined at p < .05 in all statistical tests.

Results

The demographic profile of the participants is outlined in Table 1. The sample included 49.9% of individuals below the age of 56, 55.8% of whom were male. A significant proportion of the sample, 38.6%, had received primary education or below, while 85.6% resided with their families. Furthermore, 45.4% of the sample had been diagnosed with HT disease for a period ranging from one to five years. Furthermore, 61.9% of the participants indicated that they had received support from health institutions, while 67.3% stated that they had not received any education about HT. Additionally, 56.3% of the participants had chronic diseases other than HT (Table 1). The results of the study indicate that 61.7% of the participants expressed their physical health as good, while 54% expressed their mental health as good. However, the results also indicate that 65.5% of the participants had inadequate and problematic health literacy levels, and only 36% were at the patient activation level of taking action (level 4). (Table 1).

Table 1.

Distribution of participants according to Socio-Demographic characteristics

Variables	n	%
Age groups
Under 56 years old	216	49.9
56–65 years old	120	28.2
65 years old above	89	20.9
Gender
Women	188	44.2
Man	237	55.8
Education Level
Elementary School	164	38.6
Middle School	69	16.2
High School	52	12.2
University	140	32.9
Cohabitants
Living with family	364	85.6
Living with roommate/living alone	61	14.4
Duration of disease (year)
1–5	193	45.4
6–10	158	37.2
10 above	74	17.4
Receiving support from health institutions
Received	263	61.9
Did not receive	162	38.1
Receiving education about the disease
Received	139	32.7
Did not receive	286	67.3
The presence of another chronic disease
There is	239	56.2
None	186	43.8
Expressing physical health
Perfect	65	15.3
Pretty good	89	20.9
Good	104	24.5
Not bad	167	39.3
Expressing mental health
Perfect	60	14.1
Pretty good	94	22.1
Good	76	17.9
Not bad	195	45.9
Health literacy levels
Inadequate	197	46.4
Problematic	81	19.1
Adequate	147	34.5
Patient activation levels
Level 1	53	12.5
Level 2	50	11.8
Level 3	169	39.8
Level 4	153	36.0

Participants’ patient activation; level 1 = not believing activation important, level 2 = a lack of knowledge and confidence to take action, level 3 = beginning to take action, level 4 = taking action

A comparison of the socio-demographic characteristics of the participants with patient activation and health literacy levels revealed a statistically significant difference between age group, gender, education level, cohabitants, duration of illness, receiving support from health institutions, receiving education about the disease, having other chronic diseases, evaluating physical and mental health and health literacy levels (p < .001) (Tables 2 and 3). The study found female patients, those who received health institution support and education about their illness, and those with no other chronic conditions had higher levels of patient activation and health literacy (p < .01). Younger patients (under 56 years old) had higher levels of patient activation/literacy compared to older patients. University graduates had higher levels of activation than high school or primary school graduates, and high/secondary school graduates had higher levels of activation than primary school graduates (p < .001). Patients with a 1–5 year illness duration had higher levels of activation than those with a 6–10 + year duration or more. Those with 6–10 year durations had higher activation compared to those with > 10 years (p < .001). Individuals with high physical/mental health had higher activation (p < .01). Those with high levels of health literacy and patient activation had higher levels of activation (p < .001).

Table 2.

Comparison of patient activism levels according to Socio-Demographic characteristics and health literacy levels of participants

Variables	Patient Activation Levels								p
	Level 1		Level 2		Level 3		Level 4
	n	%	n	%	n	%	n	%
Age groups
Under 56 years old	11	20.8	10	20.0	72	42.6	123	80.4	< 0.001
56–65 years old	20	37.7	24	48.0	61	36.1	15	9.8
65 years old above	22	41.5	16	32.0	36	21.3	15	9.8
Gender
Women	14	26.4	18	36.0	63	37.3	93	60.8	< 0.001
Man	39	73.6	32	64.0	106	62.7	60	39.2
Education Level
University	0	0	0	0	25	14.8	118	77.1	< 0.001
High School	4	7.5	4	8.0	25	14.8	19	12.4
Middle School	4	7.5	16	32.0	41	24.3	8	5.2
Elementary School	45	84.9	30	60.0	78	46.2	8	5.2
Cohabitants
Living with family	42	79.2	44	88.0	147	87.0	131	85.6	0.525
Living with roommate/living alone	11	20.8	6	12.0	22	13.0	22	14.4
Duration of disease
1–5 years	12	22.6	14	28.0	67	39.6	100	65.4	< 0.001
6–10 years	23	43.4	22	44.0	65	38.5	48	31.4
10 years above	18	34.0	14	28.0	37	21.9	5	3.3
Receiving support from health institutions
Received	27	50.9	34	68.0	83	49.1	119	77.8	< 0.001
Did not receive	26	49.1	16	32.0	86	50.9	34	22.2
Receiving education about the disease
Received	2	3.8	10	20.0	33	19.5	94	61.4	< 0.001
Did not receive	51	96.2	40	80.0	136	80.5	59	38.6
The presence of another chronic disease
None	10	18.9	6	12.0	70	41.4	100	65.4	< 0.001
There is	43	81.1	44	88.0	99	58.6	53	34.6
Expressing physical health
Perfect	2	3.8	2	4.0	8	4.7	53	34.6	< 0.001
Pretty good	2	3.8	6	12.0	23	13.6	58	37.9
Good	8	15.1	18	36.0	56	33.1	22	14.4
Not bad	41	77.4	24	48.0	82	48.5	20	13.1
Expressing mental health
Perfect	0	0	2	4.0	8	4.7	50	32.7	< 0.001
Pretty good	2	3.8	6	12.0	27	16.0	59	38.6
Good	10	18.9	8	16.0	44	26.0	14	9.2
Not bad	41	77.4	34	68.0	90	53.3	30	19.6
Health literacy levels
Inadequate	45	84.9	38	76.0	104	61.5	10	6.5	< 0.001
Problematic	8	15.1	10	20.0	40	23.7	23	15.0
Adequate	0	0	2	4.0	25	14.8	120	78.4

Participants’ patient activation; level 1 = not believing activation important, level 2 = a lack of knowledge and confidence to take action, level 3 = beginning to take action, level 4 = taking action

Table 3.

Comparison of health literacy levels of participants according to Socio-Demographic characteristics and patient activism levels

Variables	Health Literacy Levels						p
	Inadequate		Problematic		Adequate
	n	%	n	%	n	%
Age groups
Under 56 years old	46	23.4	49	60.5	121	82.3	< 0.001
56–65 years old	74	37.6	29	35.8	17	11.6
65 years old above	77	39.1	3	3.7	9	6.1
Gender
Women	57	28.9	38	46.9	93	63.3	< 0.001
Man	140	71.1	43	53.1	54	36.7
Education Level
University	6	3.0	12	14.8	125	85.0	< 0.001
High School	12	6.1	28	34.6	12	8.2
Middle School	45	22.8	18	22.2	6	4.1
Elementary School	134	68.0	23	28.4	4	2.7
Cohabitants
Living with family	174	88.3	67	82.7	123	83.7	0.336
Living with roommate/living alone	23	11.7	14	17.3	24	16.3
Duration of disease
1–5 years	52	26.4	41	50.6	100	68.0	< 0.001
6–10 years	83	42.1	35	43.2	40	27.2
10 years above	62	31.5	5	6.2	7	4.8
Receiving support from health institutions
Received	99	50.3	39	48.1	125	85.0	< 0.001
Did not receive	98	49.7	42	51.9	22	15.0
Receiving education about the disease
Received	14	7.1	20	24.7	105	71.4	< 0.001
Did not receive	183	92.9	61	75.3	42	28.6
The presence of another chronic disease
None	50	25.4	34	42.0	102	69.4	< 0.001
There is	147	74.6	47	58.0	45	30.6
Expressing physical health
Perfect	6	3.0	0	0	59	40.1	< 0.001
Pretty good	4	2.0	24	29.6	61	41.5
Good	62	31.5	30	37.0	12	8.2
Not bad	125	63.5	27	33.3	15	10.2
Expressing mental health
Perfect	6	3.0	0	0	54	36.7	< 0.001
Pretty good	6	3.0	26	32.1	62	42.2
Good	40	20.3	24	29.6	12	8.2
Not bad	145	73.6	31	38.3	19	12.9
Patient activation levels
Level 1	45	22.8	8	9.9	0	0	< 0.001
Level 2	38	19.3	10	12.3	2	1.4
Level 3	104	52.8	40	49.4	25	17.0
Level 4	10	5.1	23	28.4	120	81.6

Participants’ patient activation; level 1 = not believing activation important, level 2 = a lack of knowledge and confidence to take action, level 3 = beginning to take action, level 4 = taking action

The relationship between socio-demographic characteristics and patient activation levels, and health literacy, was examined. The results showed a statistically significant relationship between age group, gender, education level, and patient activation levels (p < .05) (Table 4). The analysis of the coefficients of these relationships revealed that individuals under the age of 56 years (p = .006) exhibited in adequate health literacy compared to those over 65 years of age. Similarly, individuals between the ages of 56 and 65 years (p = .001) demonstrated in adequate health literacy compared to those above 65 years of age. The level of adequate health literacy among women was found higher than that of men (p = .001). Furthermore, the level of adequate health literacy among university graduates was found higher than that of primary school graduates (p < .001). Finally, the level of adequate health literacy among individuals who received education about their disease was higher than that of those who did not receive education (p = .003). The study revealed that the level of adequate health literacy among participants with patient activation level 4 (activated) higher than that of those with patient activation level 1 (not believing that activation is important) (p = .001).

Table 4.

Socio-demographic characteristics of the participants and the relationship between patient activation levels and health literacy levels

Independent Variables	Estimate	SE	OR	%95 CI OR		p
				Lower	Upper
Age groups
Under 56 years old	1.68	0.61	5.344	1.629	17.527	0.006
56–65 years old	1.73	0.54	5.652	1.973	16.192	0.001
65 years old above	0a
Gender
Women	1.06	0.32	2.875	1.547	5.341	0.001
Man	0a
Education Levels
University	2.60	0.54	13.491	4.709	38.649	< 0.001
High School	0.70	0.44	2.008	0.841	4.793	0.117
Middle School	0.82	0.43	2.273	0.986	5.238	0.054
Elementary School	0a
Cohabitants
Living with family	-1.30	0.44	0.271	0.115	0.643	0.003
Living with roommate/living alone	0a
Duration of disease
1–5 years	0.20	0.57	1.218	0.402	3.693	0.728
6–10 years	0.80	0.52	2.232	0.814	6.125	0.119
10 years above	0a
Receiving support from health institutions
Received	-0.79	0.34	0.454	0.233	0.885	0.020
Did not receive	0a
Receiving education about the disease
Received	1.12	0.38	3.062	1.454	6.448	0.003
Did not receive	0a
The presence of another chronic disease
There is	-0.13	0.34	0.875	0.447	1.713	0.695
None	0a
Expressing physical health
Perfect	0.62	1.25	1.857	0.162	21.352	0.620
Pretty good	0.59	0.94	1.804	0.285	11.409	0.531
Good	-0.37	0.44	0.689	0.294	1.617	0.392
Not bad	0a
Expressing mental health
Perfect	1.55	1.31	4.707	0.363	60.991	0.236
Pretty good	0.91	0.94	2.484	0.397	15.527	0.330
Good	0.87	0.45	2.396	0.986	5.823	0.054
Not bad	0a
Patient activation levels
Level 4	2.01	0.60	7.486	2.291	24.455	0.001
Level 3	0.28	0.52	1.318	0.479	3.623	0.593
Level 2	-0.67	0.68	0.512	0.136	1.925	0.322
Level 1	0a

SE = Standard Error. OR = Odds Ratio, X² = 500.75, p < .001, Cox and Snell R² = 0.692. Nagelkerke R² = 0.791. ^aThis parameter is set to zero because it is redundant. Link function: Logit

Participants’ patient activation; level 1 = not believing activation important, level 2 = a lack of knowledge and confidence to take action, level 3 = beginning to take action, level 4 = taking action

Discussion

This study revealed that younger people have higher levels of health literacy than older people, women than men, and university graduates than primary school graduates. Those who received education about the disease have higher levels of health literacy than those who did not, and those who took action at the level of patient activation have higher levels of health literacy than those who did not believe that activation was important.

While some studies within the existing literature appear to demonstrate an absence of relationship between health literacy and patient activity [34, 35], other studies have shown that health literacy has a positive effect on patient activity and that it makes a significant contribution to it [36–38]. The majority of studies that have been conducted on the subject have indicated a significant positive correlation between health literacy and the control of blood pressure [39]. The results of various correlational studies demonstrate a positive relationship between health literacy and hypertension self-management, indicating that hypertensive individuals are able to effectively control and treat their condition [40–42]. The findings of a number of studies have indicated that there is a statistically significant relationship between health literacy and patient activation, as well as health seeking behaviour [28, 43, 44]. The present study found that individuals with a high level of patient activism exhibited a level of adequate health literacy higher than that of individuals with the lowest level. Consequently, the present study posits that hypertensive individuals who possess a high level of health literacy exhibit elevated levels of patient activism. As demonstrated above, there is sufficient evidence to conclude that health literacy is effective in the self-management, treatment and control of hypertension. The present study demonstrates a positive relationship between health literacy and patient activation levels. It can be posited that this relationship provides a satisfactory answer to the research question, “What affects patient activation and health literacy among people with hypertension?” Therefore, it can be posited that a high level of health literacy has a positive effect on the level of patient activation.

The study revealed that younger participants and women exhibited higher levels of adequate health literacy. In a particular study, the health literacy of the participants did not exhibit a significant difference according to gender [43], male patients in another study [45], and in another study, women [46], an elevated level of health literacy was identified. The results of a number of studies suggest that individuals in the younger age group demonstrate higher levels of health literacy [43, 47, 48]. The present study corroborates extant literature by demonstrating that younger patients and female patients have higher levels of adequate health literacy. It is widely acknowledged within the field of health literacy research that an individual’s age is a significant predictor of health literacy levels. Furthermore, the present study posits that women who exhibit superior levels of health literacy in comparison to their male counterparts may be deemed to have attained more sophisticated levels of disease management and treatment adherence. The present study revealed that the level of adequate health literacy among university graduates higher than that of primary school graduates. As indicated by the findings of several studies undertaken with hypertensive patients in the extant literature [43, 48], breast cancer patients [49], patients with Chronic Obstructive Pulmonary Disease [46], and applicants to emergency departments [48], there is a positive correlation between higher levels of education and higher levels of health literacy. The existence of a positive relationship between health literacy and education level has been revealed in a significant number of studies. The present study demonstrates a comparable correlation: an elevated educational attainment is associated with enhanced health literacy.

The present study determined that individuals under the age of 56, women, university graduates, those with shorter illness duration, those receiving support from healthcare institutions, those receiving education about their illness, those without other chronic illnesses, those who rated their physical or mental health as very good or excellent, and those with sufficient health literacy were at the taking action (level 4) patient activity level. A study indicates male patients are more active than female patients, activity decreases with age and education level is positively correlated with activity. The study found that activity decreases with disease duration, the presence of other chronic diseases reduces activity and patients who perceive their general health status as good have the highest activity levels [50]. Another study shows demographic factors such as age, gender, education level, income status, employment status, perception of health, and receipt of support affect patient activity [51]. In the present study, it can be posited that factors such as younger age, higher education attainment, support received from health institutions, shorter disease duration, the absence of co-morbid conditions, positive self-perception of health and adequate health literacy have a favourable impact on patients’ activity levels.

Strengths and limitations

The results of this study reflect only the situation of the community at this family health centre, as they were applied at only one family health centre in a district. However, it should be noted that the findings are subject to limitations, insofar as they reflect only those individuals to whom the data collection tool was applied. Consequently, these findings do not accurately reflect the situation of hypertensive patients in the province or the country as a whole. A further limitation of the study is that the participants’ responses were self-reported.

Conclusions

This study examined the health literacy and patient activism levels of individuals with hypertension. High health literacy positively affected the level of patient activism. It is recommended that healthcare institutions and healthcare professionals contribute to the enhancement of self-management of diseases and adherence to treatment by implementing practices that increase the health literacy level of individuals with hypertension. Researchers are recommended to plan comparative studies on other chronic diseases.

Abbreviations

HL

Health Literacy

HT

Hypertension

PAM

Patient Activation Measure

OR

Odds Ratio

Author contributions

M.T: Conceptualization, Data curation, design of the work, the acquisition, analysis, nterpretation of data, he creation of new software used in the work, drafted the work or substantively revised it. O.A: Conceptualization, Data curation, design of the work, the acquisition, analysis, nterpretation of data, he creation of new software used in the work, drafted the work or substantively revised it.

Funding

The authors received no financial support for the research, authorship, and publication of this article.

Data availability

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics of human subject participation

This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving research study participants were approved by the Ethics Committee of Mugla Sitkı Kocman University (179/18.08.2021). Written informed consent was obtained from all subjects.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.