Abstract
BACKGROUND:
Considering the limited number of studies on health literacy among the rural population, the necessity of measuring the level of health literacy, and the increasing number of patients with hypertension, the present study aimed to determine the relationship between health literacy and the adoption of preventive behaviors in high blood pressure among the villagers.
MATERIALS AND METHODS:
In a descriptive-analytical cross-sectional study, 300 villagers living in Qayenat were selected by multi-stage random sampling in 2024. The data were obtained by demographic and background characteristics and the health literacy assessment questionnaire (HELIA) as well as a valid and reliable questionnaire to measure the adoption of preventive behaviors against hypertension. The data were analyzed using SPSS ver 22. (IBM Coporation, Armonk, NY) and descriptive statistics and logistic regression.
RESULTS:
The mean and standard deviation of adoption of preventive behaviors against hypertension and health literacy were 15.188 ± 1.215 and 61.07 ± 18.206, respectively, and both were at an unfavorable level. Health literacy, the number of children, the amount of physical activity per week, and the history of having high blood pressure were effective factors in adopting preventive behaviors against high blood pressure.
CONCLUSION:
The adoption of preventive behaviors against hypertension was lower among villagers with lower health literacy, having more children, less physical activity per week, and those who had no history of hypertension. Therefore, community health policymakers must design educational interventions in health literacy and hypertension prevention to help improve these patients’ health.
Keywords: Health literacy, high blood pressure, preventive behaviors, villagers
Background
High blood pressure is one of the major health problems in the world, and since the control of communicable diseases has improved significantly, the control and treatment of non-communicable diseases have received more attention today.[1] Hypertension is one of the most important risk factors for cardiovascular diseases. The most important characteristic of hypertension is its asymptomatic nature, which is called the silent killer. However, there is no need for advanced equipment to diagnose it, and it can be easily controlled with changes in lifestyle and medications.[2] People with high blood pressure have several symptoms such as headache, blurred vision, nausea, vomiting, seizures, heart failure, and oliguria (decrease in urination).[3] If untreated, 50% of patients with hypertension die due to coronary artery disease and congestive heart failure, 33% due to stroke, and 10-15% due to kidney complications. Also, other organs such as eyes and large arteries can be affected.[4] It also causes disability, death, and imposes huge costs on health services in every society.[5]
It seems that the changes in lifestyle and urbanization, decrease in physical activity, obesity, diet rich in salt and sugar, alcohol intake, and smoking are associated with hypertension. However, the prevalence of high blood pressure is influenced by demographic characteristics such as age, gender, race, and socio-economic conditions.[6] The high prevalence of this disease in the world has caused more than 7 million people to die due to the complications of hypertension. Therefore, the growing increase in the number of patients with hypertension in the world is a serious warning that needs urgent attention. Evidence shows that in recent years, among non-communicable diseases, high blood pressure is the leading cause of death in the world, so that approximately 1.5 billion people in the world will be affected by this disease by 2025.[4]
Studies in Iran showed that the prevalence of high blood pressure was 20.88% in Gonabad, 14% in Kermanshah, 20.82% in Tabriz, and 22% in Tehran.[5] According to the national survey on risk factors of non-communicable diseases in 2016, about 30% of Iranians over 30 years underwent hypertension, more than 15 million people. Only 60% of these patients were aware of their disease, half of the patients received medication, and only 19% of the patients’ hypertension was controlled.[7] Some studies suggested a lower prevalence and awareness of hypertension in rural communities compared to urban areas; in some studies, the prevalence of hypertension in rural communities was higher than in urban ones. A study in Isfahan showed that the prevalence of hypertension in the urban community was higher than that in the rural areas.[8]
Low levels of health literacy were more common in people with chronic diseases such as hypertension, and these people were at risk of undesirable effects of low levels of health literacy.[9] However, promoting health literacy was effective in preventing and controlling hypertension.[10] Health literacy was the degree to which people had the appropriate capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.[11] Health literacy was a multidimensional concept that ultimately led to increasing health behaviors and improving access to health care.[12] People with low levels of health literacy tended to have poorer health and a higher prevalence of chronic diseases. In addition, they tended to use less preventive and screening services and pay more for medical services.[13]
It is necessary to measure the level of health literacy to avoid the possibility of risks caused by low health literacy.[14] A study on health literacy in eight European countries, Austria, Bulgaria, Germany, Greece, Ireland, the Netherlands, Poland, and Spain, showed that almost 47% had limited (insufficient or problematic) health literacy.[7] The level of health literacy in Iran, based on a national survey, was 44%; That is, almost one out of every two Iranians had limited health literacy.[15] Also, the results of Nejad Hossein et al.’s[16] study showed that the villagers of Behbahani had an average level of health literacy, and their health literacy was slightly lower than that of the urban residents of Behbahani. In the study of Tehrani Bani Hashemi et al.,[17] health literacy among villagers was lower than among urban residents. Also, the results of Vafai Najjar et al.[18] showed that the level of health literacy in rural communities of Iran was insufficient. In the study of Shayakhmetov et al.,[19] the health literacy level of the rural dwellers of Kazakhstan was 8.09%, which was significantly different from that of the urban residents.
Considering the limited number of studies on health literacy among the rural population (16-19) the necessity of measuring the level of health literacy[14] and the increasing number of patients with hypertension and the adverse effects of this disease on the quality of life of people as well as the role of desirable health literacy in promoting people’s responsibility in maintaining people’s health,[20] and lack of information on the relationship between health literacy and hypertension prevention, this study aimed to determine the relationship between health literacy and the adoption of hypertension prevention behaviors among villagers.
Materials and Methods
Study design and setting
This was a descriptive-analytical cross-sectional study on 300 villagers living in Qayenat in 2024.
Study participants and sampling
A multi-stage random sampling method was used for sampling. First, a list of the number of villages and health centers was prepared. Then, three villages were randomly selected, and within each village, several families were randomly selected; then, one person, 18–65 years old, from each family was randomly included in the study.
According to the results of a pilot study among 30 villagers, considering r = 0.15 for the correlation between health literacy and hypertension prevention, and also using the sample size table for correlation studies, the minimum required sample size was 175 participants [21]. Next, considering the Design Effect = 1.4, the sample size was estimated to be 245. Finally, considering the possibility of 20% of samples dropping, 300 participants were included in the study.
The inclusion criteria included willingness to participate in the study, living in a village, being registered in the Sib system, being in the age range of 18-65 years, having Iranian citizenship, and being able to read and write. Also, not willing to continue the study at any stage, and incomplete questionnaires were the exclusion criteria.
Data collection tool and technique
The data were gathered by a three-part questionnaire, as follows:
(A) The first part included demographic and background information with items about age, sex, marital status, number of children, occupation, spouse’s occupation, education level, spouse’s education level, economic status, body mass index, amount of physical activity per week, smoking and hookah, history of other diseases, history of hypertension in the family, duration of hypertension, history of taking hypertension medications and history of hypertension among first-degree relatives.
(B) To measure health literacy, the Health Literacy Assessment Questionnaire of Iranian Adults (HELIA) was used.[22] This questionnaire had five main skills (reading, access, comprehension, evaluation, decision-making, and use of health information) and 33 items. The scoring was based on a 5-option Likert scale, so in the items related to reading skills; A score of 5 was assigned to the completely easy option, 4 to the easy option, 3 to the neither easy nor difficult option, 2 to the difficult option, and a score of 1 to the completely difficult option, regarding the other four health literacy skills. A score of 5 was assigned to always, 4 to most of the time, 3 to sometimes, 2 to rarely, and 1 to never (or never). First, the raw score of each participant in each of the skills was obtained from the algebraic sum of the scores. Then, to convert this score into a range of 0 to 100, the formula of the raw score difference obtained from the minimum possible raw score divided by the difference between the maximum possible score and the minimum possible score was used. Finally, to calculate the total score, the scores of all skills (based on the range of zero to 100) were added and divided by the number of skills (number 5). Then, different levels of health literacy were considered as follows: Scores 0 to 50 as insufficient health literacy, 1.50 to 66 as insufficient health literacy, 1.66 to 84 as sufficient health literacy, and scores 1.84 to 100 as excellent health literacy. The design and psychometrics of this questionnaire were conducted by Montazeri et al.[22] and it had good validity and acceptable reliability (Cronbach’s alpha scale of the items was 72% to 89%. In the present study, the questionnaire was first given to 30 villagers, and its Cronbach’s alpha coefficient was reported to be 0.85.
(C) To measure the adoption of preventive behaviors in hypertension, the questionnaire developed by Ramzankhani and colleagues was used.[10] This questionnaire had 8 items. In the behavior section, the score ranged from 1 to 4 and the final scores were calculated from 8 to 32. The validity of the questionnaire was established using two methods: Face validity and content validity. First, it was prepared by expert professors (5 health education and health promotion experts, one epidemiologist, one cardiologist, and two researchers who have worked in connection with the subject) based on reliable sources and books, and then, after solving the ambiguities and problems, its validity was confirmed. The reliability of the questionnaire was also tested using test-retest and internal consistency (Cronbach’s alpha) methods and was confirmed.[10] In this study, at first, this questionnaire was given to 30 participants, and Cronbach’s alpha coefficient was calculated for the whole questionnaire to be 0.93.
Ethical consideration
The ethics code was received from the Deputy of Research and Technology of Birjand University of Medical Sciences (with ethics code IR.BUMS.REC.1402.537). Also, the purpose of this research was explained to the participants, and their written consent was obtained. The questionnaires were completed as self–reported. They were also assured that all the information requested in the questionnaire would be kept confidential.
Statistical analysis method
The data was analyzed by SPSS ver 22. (IBM Coporation, Armonk, NY) and descriptive statistics and logistic regression tests. In addition, the significance level was considered less than 0.05.
Results
Three hundred villagers were studied (response rate: 100%). Meanwhile, 61.3% (184 participants) were women, 86% (258) were married, and 10.7% (32) had a history of high blood pressure in the past [Table 1]. The mean and standard deviation of the age and body mass index of the participants were 37.671 ± 14.333 years and 23.287 ± 3.145 kg/m2, respectively. Also, the average and standard deviation of the scores of the adopting preventive behaviors were 15.188 ± 1.215 out of 32, which was at an undesirable level. The mean and standard deviation of the health literacy scores were 61.07 ± 18.206 out of 100 and were undesirable. Also, 23.3% (70 participants) had insufficient health literacy, 31.3% (94) had insufficient health literacy, 39.3% (118) had sufficient health literacy, and 6%[18] had excellent health literacy.
Table 1.
Demographic and background characteristics of the studied villagers
| Variable | Level | Frequency | Percent | |||
|---|---|---|---|---|---|---|
| Sex | Female | 184 | 61.3 | |||
| Male | 116 | 38.7 | ||||
| Marital status | Married | 258 | 86 | |||
| Single | 42 | 14 | ||||
| Number of children | a child | 46 | 15.3 | |||
| two children | 98 | 32.7 | ||||
| Three children and more | 156 | 52 | ||||
| Job | Housewife | 142 | 47.3 | |||
| Employee | 42 | 14 | ||||
| Farmer | 28 | 9.3 | ||||
| Other | 88 | 29.4 | ||||
| Wife’s job | Housewife | 82 | 27.3 | |||
| Employee | 40 | 13.3 | ||||
| Farmer | 58 | 19.4 | ||||
| Other | 120 | 40 | ||||
| Level of Education | Elementary School | 86 | 28.7 | |||
| Junior high school | 54 | 18 | ||||
| Senior high school and diploma | 94 | 31.3 | ||||
| Associate and bachelor’s degrees | 52 | 17.3 | ||||
| Master’s degree and higher | 14 | 4.7 | ||||
| Spouse’s education level | Elementary School | 82 | 27.3 | |||
| Junior high school | 58 | 19.3 | ||||
| Senior high school and diploma | 96 | 32 | ||||
| Associate and bachelor degrees | 52 | 17.3 | ||||
| Master’s degree and higher | 12 | 4 | ||||
| Economic status of the family | Undesirable | 34 | 11.3 | |||
| Medium | 184 | 61.3 | ||||
| Optimal | 82 | 27.4 | ||||
| Physical activity per week | Everyday | 30 | 10 | |||
| Most days | 42 | 14 | ||||
| Some days | 132 | 44 | ||||
| Rarely | 74 | 24.7 | ||||
| Never | 22 | 7.3 | ||||
| Smoking | Yes | 30 | 10 | |||
| No | 270 | 90 | ||||
| Hookah use | Yes | 36 | 12 | |||
| No | 264 | 88 | ||||
| History of other diseases | Yes | 266 | 11.3 | |||
| No | 34 | 88.7 | ||||
| History of high blood pressure in the past | Yes | 32 | 10.7 | |||
| No | 268 | 89.3 | ||||
| Duration of hypertension | Less than 6 months | 84 | 28 | |||
| 6 months and more | 216 | 72 | ||||
| History of using blood pressure medication | Yes | 28 | 9.3 | |||
| No | 272 | 90.7 | ||||
| Blood pressure | Yes | 60 | 20 | |||
| No | 240 | 80 |
Table 2 shows the results of logistic regression to determine the factors affecting the adoption of preventive behaviors in hypertension. As the results show, the number of children, the amount of physical activity per week, the history of having hypertension in the past, and health literacy were effective factors in adopting preventive behaviors for high blood pressure.
Table 2.
Factors affecting the adoption of preventive behaviors from high blood pressure in logistic regression*
| Variables | P | OR | CI |
|||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Lower | Upper | |||||||||
| Age | 0.222 | 0.948 | 0.871 | 1.033 | ||||||
| Sex | 0.182 | 0.198 | 0.018 | 2.137 | ||||||
| Marital status | 0.632 | 0.176 | 0.000 | 217.485 | ||||||
| BMI | 0.215 | 1.039 | 0.978 | 1.103 | ||||||
| Number of children | One | 0.007 | ||||||||
| Two | 0.006 | 0.038 | 0.004 | 0.390 | ||||||
| Three and more | 0.006 | 0.066 | 0.010 | 0.453 | ||||||
| Wife’s Job | Housewife | 0.575 | ||||||||
| Employee | 0.103 | 0.087 | 0.005 | 1.640 | ||||||
| Farmer | 0.376 | 0.299 | 0.021 | 4.322 | ||||||
| Other | 0.308 | 0.213 | 0.011 | 4.161 | ||||||
| Spouse Job | Housewife | 0.165 | ||||||||
| Employee | 0.194 | 9.055 | 0.325 | 252.454 | ||||||
| Farmer | 0.116 | 8.652 | 0.586 | 127.812 | ||||||
| Other | 0.573 | 0.412 | 0.019 | 8.987 | ||||||
| Education | Elementary school | 0.159 | ||||||||
| Junior high school | 0.369 | 12.667 | 0.050 | 3208.46 | ||||||
| Senior high school and diploma | 0.731 | 2.431 | 0.015 | 388.349 | ||||||
| Associate and bachelor degrees | 0.802 | 0.542 | 0.005 | 64.859 | ||||||
| Master’s degree and higher | 0.708 | 0.461 | 0.008 | 26.415 | ||||||
| Spouse Education | Elementary School | 0.786 | ||||||||
| Junior high school | 0.745 | 0.511 | 0.009 | 29.064 | ||||||
| Senior high school and diploma | 0.445 | 0.207 | 0.004 | 11.741 | ||||||
| Associate and bachelor’s degrees | 0.804 | 0.638 | 0.018 | 22.064 | ||||||
| Master’s degree and higher | 0.901 | 0.803 | 0.026 | 25.217 | ||||||
| Family Economic Status | Undesirable | 0.432 | ||||||||
| Moderate | 0.904 | 0.788 | 0.016 | 38.385 | ||||||
| Desirable | 0.663 | 0.396 | 0.006 | 25.526 | ||||||
| Daily physical activity | Every day | 0.046 | ||||||||
| Most of the days | 0.041 | 0.040 | 0.002 | 1.015 | ||||||
| Some days | 0.017 | 0.022 | 0.001 | 0.499 | ||||||
| Rarely | 0.102 | 0.143 | 0.014 | 1.470 | ||||||
| Never | 0.750 | 0.699 | 0.077 | 6.348 | ||||||
| Smoking | 0.069 | 0.028 | 0.001 | 1.321 | ||||||
| Hookah | 0.674 | 0.647 | 0.085 | 4.933 | ||||||
| History of hypertension | 0.044 | 0.021 | 0.001 | 0.906 | ||||||
| Duration of hypertension | 0.055 | 0.237 | 0.055 | 1.029 | ||||||
| Hypertension medications | 0.485 | 3.795 | 0.090 | 160.621 | ||||||
| History of other diseases | 0.445 | 2.168 | 0.297 | 15.829 | ||||||
| History of hypertension in first-degree relatives | 0.337 | 0.525 | 0.141 | 1.956 | ||||||
| Health literacy Level | Insufficient | 0.015 | ||||||||
| Not sufficient | 0.018 | 1.012 | 0.278 | 9.103 | ||||||
| Sufficient | 0.011 | 2.217 | 0.297 | 15.829 | ||||||
| Excellent | 0.008 | 2.457 | 0.312 | 17.114 | ||||||
*Data entered step by step. BMI=Body Mass Index, OR=Odd Ratio, CI=Confidence Interval
The number of children was one of the factors influencing the adoption of preventive behaviors in high blood pressure, so the chance of adopting preventive behaviors with two children and three children and above was 0.038 and 0.066 times less than those with one child, respectively.
The amount of physical activity per week was one of the factors influencing the adoption of preventive behaviors in high blood pressure, so the chance of adopting preventive behaviors with physical activity on most days and some days of physical activity was 0.040 and 0.022 respectively.
Having high blood pressure in the past was another factor influencing the adoption of preventive behaviors for high blood pressure, so the chance of adopting preventive behaviors among those who did not have a history of high blood pressure in the past was 0.021 times more than those with a history of high blood pressure in the past.
Also, health literacy was one of the factors influencing the adoption of preventive behaviors in hypertension, so the chances of adopting preventive behaviors with insufficient, adequate, and excellent health literacy were 1.012, 2.217, and respectively for those with insufficient health literacy. Besides, other demographic and background variables did not have a significant effect on the adoption of preventive behaviors in hypertension (P > 0.05).
Discussion
This study aimed to determine the relationship between health literacy and the adoption of high hypertension behaviors among villagers. The results showed that the health literacy of villagers was at an undesirable level. Considering the effect of education level on health literacy level[16,23] and that almost 78% of the villagers in the study had diplomas and lower than diploma education, these results could be justified. Meanwhile, difficult access to health centers or more specialized hospitals could be another reason. This finding was consistent with the results of studies by Shayakhmetov et al.[19] and Vafai Najar et al.[18] The results were also inconsistent with Nezhad Hosain et al.[16] in which the villagers’ health literacy was moderate. The possible reasons for this discrepancy could be the differences between the things such as the instrument used to measure health literacy and the level of education of the participants (more participants with elementary education in the present study). In the study by Darabi et al.,[24] health literacy was also moderate. Possible reasons for this discrepancy include the fact that in that study, 83% of the subjects were urban residents and a smaller percentage of them had a sub-diploma education compared to the present study.
Also, the adoption of preventive behaviors in high blood pressure was at an undesirable level here. This could probably be due to their low awareness and unfavorable attitude toward hypertension. Also, their low level of health literacy could be another reason for this finding. This finding was contrary to the results of Ramzankhani et al.’s[10] study, in which mothers aged 20 to 49 had an average level of adoption of preventive behaviors in high blood pressure. Among the possible reasons for this discrepancy, we could point to the differences in age, sex, and education level of the participants in the two studies. Besides, another important reason could be the difference in the urban and rural populations’ access to health and treatment centers.
The results showed that health literacy was one of the factors influencing the adoption of preventive behaviors in high blood pressure. It can be concluded that due to the existence of unfavorable levels of health literacy and the adoption of preventive behaviors in hypertension, and considering the role of health literacy in the adoption of preventive behaviors,[25,26,27,28,29,30,31] the significant relationship between these two variables seems reasonable. This could be because health literacy is a collection of skills, abilities, and capacities in various dimensions. These skills and capacities could be sometimes updated in acquiring and obtaining new medical and health information, sometimes in reading them, sometimes in understanding and comprehending them, sometimes in processing and interpreting them, and sometimes in decision-making and applying this information; therefore, it could have influenced the adoption of preventive behaviors in this way.[31] These results were in agreement with the results of the study of Sumloram and THI[32] and Darwish pour et al.[33]
The results also showed that the number of children was one of the factors influencing the adoption of preventive behaviors in high blood pressure. It can be argued that probably the villagers who had more children, spent more time on daily family activities and providing the facilities for their children, and this could be the reason that they did not spend enough time on their health and adopting preventive behaviors to avoid high blood pressure.
Moreover, the results showed that the amount of physical activity per week was one of the factors influencing the adoption of preventive behaviors in high blood pressure. Doing physical activity, like adopting preventive behaviors against high blood pressure, was itself a type of preventive behavior. Therefore, doing physical activity affected this variable. Similar to this result, the results of a review by Rego et al.[34] showed that physical activity was an efficient and complementary tool for the management of hypertension. In the study of Babaei-Sis et al.[35] and Vahedian-Shahroodi et al.,[36] it also increases physical activity, which increases blood pressure among patients with hypertension.
The results also showed that a history of having high blood pressure in the past was one of the factors influencing the adoption of preventive behaviors for high blood pressure. The villagers with a history of high blood pressure in the past probably had more experience, skills, and knowledge to adopt preventive behaviors of high blood pressure. Consistent with this finding, in the Sumloram and THI study, a family history of high blood pressure was also significantly associated with having high blood pressure.[32] Also, in the study by Khanlarzadeh et al.,[37] a history of hypertension was significantly associated with the lifestyle of patients with hypertension.
To our knowledge, the present study was the first study to examined the relationship between the adoption of preventive behaviors in hypertension and health literacy among villagers. Therefore, this was an innovation. One of the limitations of this study was the self-report when completing the questionnaire by the villagers, which might not have provided accurate information to the research team. Also, the small number of samples, the limited number of studies, especially among the villagers, and the lack of access to the villagers who had traveled to the city were other limitations of the present study. Also, the results obtained might not be generalized to the villagers of other parts of Iran. Therefore, it is recommended to study larger scales of villagers in other parts of the country (and even in urban areas). Moreover, ignoring other dimensions related to health literacy, such as communication, self-efficacy, and calculation, is the last but not the least limitation of this study. It is recommended to do a wider and more comprehensive study on the relationship between the dimensions of health literacy and the adoption of preventive behaviors.
Conclusion
The results of the present study indicated that the adoption of preventive behaviors in hypertension and health literacy among the villagers was at an undesirable level. Also, health literacy, the number of children, the amount of physical activity per week, and a history of high blood pressure in the past were effective factors in adopting preventive behaviors for high blood pressure. The adoption of preventive behaviors was also less among villagers with lower health literacy, with more children, less physical activity per week, and those who had no history of hypertension. Therefore, it is essential that community health policymakers design educational interventions in the areas of health literacy and hypertension prevention to help improve the health of these patients.
Abbreviations
HELIA: Health Literacy Assessment Questionnaire of Iranian Adults.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest
There are no conflicts of interest.
Acknowledgments
This study was carried out with the support of the Vice-Chancellor of Research and Technology of Birjand University of Medical Sciences and the cooperation of villagers living around Qaynat (ethical approval code: IR.BUMS.REC.1402.537). The authors express their thanks and appreciation to all the villagers and officials who helped the researchers with this study.
Funding Statement
This study had no funding.
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