Hrev_master Healthcare in Low-resource Settings 2024; volume 12:11851 Examining the relationship between health literacy and quality of life in patients with coronary heart disease: a quantitative study at a cardiolo- gy clinic Lita Lita,1 Nadila Khairiyah,1 Agnita Utami,1 Silvia Nora Anggreini,2 Faridah Mohd. Said3 1Nursing Science Study Program, Universitas Hang Tuah Pekanbaru, Pekanbaru, Indonesia; 2Nursing Science Study Program, Institute of Health Science, Pekanbaru Medical Center, Indonesia; 3Nursing Science Study Program, Lincoln University College, Kota Bharu, Malaysia Abstract Coronary Heart Disease (CHD) is the leading cause of death worldwide and is rising, annually. Improved health outcomes require early treatment and self-monitoring, which need health lit- eracy. This study examined how health literacy affects CHD patients’ Quality of Life (QoL) at the Hospital’s Cardiology Clinic. This quantitative, descriptive correlation study was cross- sectional. The sample was 164 respondents, sampled consecutive- ly. Patients must be willing to participate, diagnosed with CHD, and attend cardiology outpatient follow-up appointments. Health literacy was measured with the HLS-EU-SQ10 and QoL with the Seattle Angina Questionnaire. This study used chi-square to ana- lyze the relationship between two ordinal scale variables in a con- tingency table. The average age was 58.07 years, according to research. Of the respondents, 59 (36.0%) had graduated high school. Health literacy was assessed in three QoL domains: phys- ical limitation (P=0.024), angina frequency (P=0.570), and QoL (P=0.338). Service agencies should be able to use pamphlets to improve health literacy and provide rehabilitation to acute coro- nary syndrome patients to improve QoL. Introduction Along with the development of the modern world, non-com- municable diseases are also increasing. This can be seen in the increase in non-communicable disease deaths due to cardiovascu- lar disease which reached 17.9 million in 2016.1 Heart disease is a general term for all diseases involving the heart, cases of heart dis- ease in the world were 550 million people.2 Coronary heart disease (CHD) occurs due to blockage due to the accumulation of fat in the walls of blood vessels which causes stiffness of blood vessels and abnormal blood flow thereby blocking blood flow to the heart.3-5 The incidence of CHD in Indonesia was estimated to be 15 out of 1,000 or 1.5% of the population in Indonesia who have CHD.6 CHD in Indonesia has resulted in the death of approximate- ly 510,840 people.6 The number of CHD patients at the Heart Polyclinic of Arifin Achmad Hospital, Riau Province from January to December 2020 was 1708 cases. Health literacy is the extent to which individuals can access, and process basic health service information by participating in health-related decisions.7-9 Based on research results, functional cardiovascular disease health literacy found that 55.4% of patients understood health information, 53,9% of patients did not under- stand health information, and 50,5% of patients had information enough to manage health.10 The following are some examples of information about behaviors related to CHD: smoking, physical activity, eating habits, response to cardiac symptoms, and medica- tion adherence. Some examples of outcomes related to patients with CHD include morbidity (e.g., rehospitalization), mortality, and quality of life (QoL).11-13 QoL is an assessment of one’s position in life, in the context of cultural and environmental values, in relation to individual Correspondence: Lita Lita, Nursing Science Study Program, Universitas Hang Tuah Pekanbaru, Pekanbaru, Indonesia. E-mail: lita@htp.ac.id Key words: coronary heart disease; health literacy; quality of life. Acknowledgments: we would like to acknowledge the mentoring pro- gram conducted by The Research Centre of Excellence in Advancing Community Health, Surabaya, Indonesia. Contributions: LL, NK, AU, conceptualization, writing – original draft; LL, data curation; LL, AU, SNA, formal analysis; NK, SNA, FMS, investigation; LL, NK, AU, SNA, methodology, validation; LL, SNA, visualization; FMS, resources, supervision; SNA, FMS, resources, writ- ing. All the authors reviewed and edited the manuscript and approved the final version to be published. Conflict of interest: the authors declare no potential conflict of interest. Funding: none. Ethical approval and consent to participate: the research has received eth- ical approval from the Health Research Ethics Commission, Faculty of Nursing, Universitas Airlangga, based on ethical certificate 2742-KEPK. During the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non- maleficence. Availability of data and material: all data generated or analyzed during this study are included in this published article. Informed consent: written informed consent was obtained for anonymized patient information to be published in this article. Received: 20 September 2023. Accepted: 11 June 2024. Early access: 3 July 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12:11851 doi:10.4081/hls.2024.11851 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2024;12:11851] [page 553] Non -co mmerc ial us e o nly goals, expectations, norms, and social aspects. It provides a broad and effective understanding of a person’s physical health status, psychological state and beliefs, social relationships, and relation- ships with the environment.14-17 Based on the results of the previ- ous research, the QoL of coronary heart patients was found good at 52.9% and bad at 47.1%.18 The QoL of coronary heart patients (25.86%) had a good QoL, and 43 people (74.14%) had a poor QoL.19 Low levels of health literacy correlated with heightened levels of anxiety and depression (P<0.0001) and lower assess- ments of health-related QoL (HeartQoL scores P=0.03).20 Statistically significant differences were found in gender, age, smoking history, marital status, education level, household income, and QoL among various health literacy groups. Low levels of education and household income were predictors of poor health literacy.21 One way to improve good QoL is by providing informa- tion in the form of education. This study aimed to look at the rela- tionship between health literacy and QoL in heart patients. Materials and Methods Study design The type of research used a quantitative with a descriptive cor- relational design, utilizing a cross-sectional approach. Cross-sec- tional refers to data collected multiple times at unequal intervals.22 Population, sample, and sampling The study population consisted of 1708 patients, from which a sample of 164 respondents was selected using consecutive sam- pling. The criteria for inclusion were patients willing to participate, those suffering from CHD, and control patients at the heart poly- clinic. Variables and instruments The variables in this study are health literacy and QoL. The instruments used in this study are the Health Literacy Study- European Short Questionnaire-10-Indonesia (HLS-EU-SQ10- IDN), which is the short version of the HLS-EU-47Q question- naire, and the QoL instrument, which is the Seattle Angina Questionnaire-7 (SAQ-7). The validity value of the health literacy questionnaire was standardized with a validity value of 0.89, and the QoL questionnaire with a validity value of 0.64. In the reliabil- ity test of the HLS-EU-SQ10-DN questionnaire, the reliability result was 0.9. Health literacy index values are then categorized as follows: 0-25 = inadequate; >25-33 = problematic; >33-42 = suffi- cient; >42-50 = excellent. The SAQ-7 consists of 7 questions designed to assess the health status of patients with coronary artery disease (CAD). Responses are coded from worst to best status, with scores ranging from 1 to 6 for physical limitation, angina sta- bility, and angina frequency; 1 to 5/6 for treatment satisfaction; and 1 to 5 for QoL. Each domain score is scaled from 0 to 100, with 0 indicating the worst and 100 the best possible status. The SAQ is validated, reproducible, and sensitive to clinical changes. Additionally, patients’ SAQ scores are independently predictive of future mortality, hospitalization, and resource utilization.23 The results of the validity test showed that the questionnaire was valid with a result of 0.80 for physical limitations, 0.78 for angina fre- quency, 0.81 for the QoL, and 0.86 for the summary score.23 Data analysis The data obtained were analyzed using univariate analysis with the central tendency and frequency distribution, then analyzed by bivariate analysis using the chi-square test. The chi-square test evaluates whether there is a difference between the observed fre- quencies in the contingency table and the frequencies we would expect if the two variables were independent. This research passed the ethics test of the Health Research Ethics Commission at Hang Tuah University Pekanbaru with the number: 237/KEPK/STIKes- HTP/IV/2022. Results According to Table 1, it was found that 164 respondents stud- ied were on average 58.07 years old. Table 2 showed the majority of respondents were male which was 117 respondents (71.3%). The majority were married as many as 160 respondents (97.6%). Besides that, many respondents had high school/vocational education levels as many as 59 respondents (36.0%). Many respondents were retirees which was 38 respon- dents (20.1%). There 67.1% of health literacy was in the problem- atic category. Then, the results of the QoL obtained 49.4% with physical limitations which were still classified as good, 38.4% fre- quency of angina every day or week, and 52.5% QoL was excel- lent. The results of the data analysis in Table 3 showed health lit- eracy appears to be significantly associated with physical limita- tion (P=0.024), suggesting that individuals with different levels of health literacy experience varying degrees of physical limitation related to CAD. However, there is no significant association between health literacy and angina frequency (P=0.570) or QoL (P=0.338). This implies that while health literacy may influence physical limitations, it does not have a significant impact on the frequency of angina symptoms or overall QoL among individuals with CAD. Discussion The findings of this study reveal a significant association between health literacy and physical limitation among individuals with CAD. Specifically, the analysis demonstrates that individuals with different levels of health literacy exhibit varying degrees of physical limitation related to their condition. This underscores the importance of health literacy in managing and coping with the physical challenges posed by CAD. These results align with previ- Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions [page 554] [Healthcare in Low-resource Settings 2024;12:11851] Table 1. Respondent’s central tendency by age. Variable N Mean SD Minimum/maximum Range Age 164 58.07 11.983 24-82 58 SD, standard deviation. Non -co mmerc ial us e o nly ous research that has highlighted low health literacy are more like- ly to engage in unhealthy behaviors, such as smoking, insufficient physical activity, and being overweight. Additionally, these indi- viduals tend to report lower levels of physical and mental health, with large clinically significant effect sizes of 0.56 and 0.78 respectively, even after adjusting for confounding factors.24 Furthermore, there exists a negative association between health lit- eracy and QoL among patients with acute coronary syndrome (ACS). Enhanced health literacy among individuals in their eighties, particularly concerning social support for health and the capability to access reliable health information, correlates with better physi- cal and mental well-being following percutaneous coronary inter- vention.25 Health literacy is moderately correlated with QoL, but this finding needs to be supported by more evidence.26 Health lit- eracy is higher compared to the German national survey based on the same outcome measure.27 Individuals with higher levels of health literacy are often better equipped to understand and adhere to treatment regimens, engage in preventive behaviors, and navi- gate the healthcare system effectively, all of which can contribute to improved physical functioning and reduced limitations in daily activities. Contrary to expectations, the study did not find a significant association between health literacy and angina frequency or QoL. This suggests that while health literacy influences physical limita- tions, it does not have a direct impact on the frequency of angina symptoms or overall QoL among individuals with CAD. Other fac- tors, such as disease severity, comorbidities, and social support, may play a more prominent role in determining these outcomes.28 No relationship was found between health literacy and QoL (physical and mental components).29 Low health literacy in patients with ACS is consistently associated with poor QoL. After controlling for demographic and clinical factors in patients with ACS, the physical QoL domain remained a significant result of self-care behavior and health literacy. According to the literature, self-care practices and health literacy should be taken into account when predicting patients with ACS QoL. However, there is no pre- vious evidence about the best process of the relationship between the three variables.30 Health literacy is a determinant of health in cardiovascular dis- ease.31 Low health literacy is associated with the development of cardiovascular disease after adjustment for age and sex.32 Patients with CVD who have low health literacy have higher mortality, higher rates of readmission to the hospital, and lower QoL.33 Low health literacy is common in people with cardiovascular disease.34 This condition can occur due to adherence to treatment, and aware- ness of ACS patients to reduce and maintain activities carried out. Thus, they do not trigger symptoms. The lack of medication during an attack, in addition to the two factors mentioned above, may cause angina to occur more frequently, which will alter how stable angina is. To keep patients motivated to comply with therapy and foster positive family support, nurses can offer emotional support. A very low frequency of angina was reported by almost all respon- dents. This research is consistent with a study that found that elderly hypertensive patients have both positive and negative percep- tions.35 The more serious and severe the patient’s perception, the greater the need for preventive measures.36 Patients change their behavior according to the severity of their disease leading to a pos- itive perception of the disease. Hence, according to one of the rea- sons for positive perceptions as explained by the theory, a good perception will increase a positive subject such as health in healing disease.36 Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions Table 2. Respondents' frequency distribution characteristics, health literacy, and quality of life of patients. Variable N % Sex Male 117 71.3 Female 47 28.7 Marriage status Married 160 97.6 Single 4 2.4 Educational level Uneducated 7 4.3 Primary school 31 18.9 Junior high school 23 14.0 Senior high school 59 36.0 University 41 30.4 Occupation Retired 38 23.2 Housemaid 37 22.6 Teacher/lecturer 5 3.0 Civil servant 13 7.9 Unemployment 33 20.1 Farmer 11 6.7 Entrepreneur 14 8.5 Private staff 5 3.0 Police 5 3.0 Labor 3 1.8 Health literacy Inadequate 30 18.3 Problematic 110 67.1 Sufficiency 24 14.6 Physical limitation Excellent 17 10.4 Good 81 49.4 Poor to fair 66 40.2 Angina frequency Daily to weekly 63 38.4 Monthly 52 31.7 None 49 29.9 Quality of life Excellent 86 52.5 Good 46 28.0 Poor to fair 32 19.5 Total 164 100 Table3. Relationship between health literacy and quality of life of physical activity. Variable Health literacy p Inadequate Problematic Sufficient Physical limitation 0.024 Excellent 3 7 7 Good 14 57 10 Poor to fair 13 46 7 Angina frequency 0.570 Daily to weekly 15 40 8 Monthly 9 36 7 None 6 34 9 Quality of life 0.338 Excellent 15 55 16 Good 8 31 7 Poor to fair 7 24 1 Total 30 110 24 [Healthcare in Low-resource Settings 2024;12:11851] [page 555] Non -co mmerc ial us e o nly Conclusions The findings of this study highlight the nuanced relationship between health literacy and various health outcomes among indi- viduals with CAD. While a significant association was observed between health literacy and physical limitation, indicating that individuals with different levels of health literacy experience vary- ing degrees of physical limitation, no significant associations were found with angina frequency or QoL. These results suggest that while health literacy may play a role in shaping the extent of phys- ical limitations experienced by individuals with CAD, it may not directly influence the frequency of angina symptoms or overall QoL. Other factors, such as disease severity, comorbidities, and access to healthcare resources, may contribute more substantially to these outcomes. References 1. World Health Organization. Global action plan on physical activity 2018-2030: more active people for a healthier world. World Health Organization; 2019. 2. Roth GA, Mensah GA, Johnson CO, et al. Global burden of cardiovascular diseases and risk factors, 1990–2019: update from the GBD 2019 study. J Am Coll Cardiol 2020;76:2982- 3021. 3. Irianto K. Epidemiologi penyakit menular dan tidak menular. kedua. Bandung: Cv. ALFABETA; 2018. 4. Haryuni S, Wahyuni CU, Basuki H, et al. Blood glucose and systolic blood pressure as predictors of hospital length of stay in patients with coronary heart disease. 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Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions [Healthcare in Low-resource Settings 2024;12:11851] [page 557] Non -co mmerc ial us e o nly