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Prevalence of and factors associated with health literacy among people with Noncommunicable diseases (NCDs) in South Asian countries: A systematic review
Corresponding author. National Centre for Epidemiology and Population Health, The Australian National University, Canberra, Australia.
Affiliations
Centre for Research Policy and Implementation (CRPIN), Biratnagar, NepalTorrens University, Sydney, AustraliaCentre for Primary Health Care and Equity, UNSW, Sydney, AustraliaNational Centre for Epidemiology and Population Health, The Australian National University, Canberra, Australia
Health literacy increases the ability of people living with non-communicable diseases (PLWNCDs) to read and understand medical information, access health information and health services, and involvement in shared decision-making required for improving health outcomes and health behaviours. This systematic review aimed to synthesize available evidence on the prevalence and associated factors of adequate and inadequate health literacy among PLWNCDs in South Asian countries.
Methods
Based on PRISMA guidelines, a systematic review of primary studies published between 2010 and 2021 was carried out using four electronic databases and search engines, namely Medline (PubMed and EBSCOhost), CINAHL, Scopus, and Google search engines with various key search terms. Data were extracted, and the findings were narratively synthesized.
Results
A total of thirteen studies were included from four countries, and most of them were from Pakistan. The review found that majority of PLWNCDs had inadequate health literacy. The prevalence of inadequate health literacy was higher among people with diabetes (26.00%–80.88%), cardiovascular disease (51.80%–83.43%), and chronic obstructive pulmonary disease (74.80%–79.00%). No studies were found assessing the level of health literacy among people with chronic kidney diseases. Various factors such as poor disease knowledge, no or less educational attainment, belonging to an indigenous or marginalised community from rural areas, and being female were found to be associated with inadequate health literacy.
Conclusion
Overall, our review found that PLWNCDs had inadequate health literacy. Therefore, it is important to design and implement interventions focusing on improving health literacy among PLWNCDs, which can help promote healthy behaviours and improve the skills to self-manage NCDs in South Asian countries.
Noncommunicable diseases (NCDs) are one of the most emerging public health burdens that have posed significant global challenges to the healthcare system.
A recent study conducted by the World Health Organization (WHO) (2021) found that out of 41 million global NCD deaths, 32 million occur in low- and middle-income countries (LMICs).
A study by Martinez et al. (2020) reports that 83.9% (approximately 34.5 million) of global NCD deaths could be averted through the provision of high-quality health care, addressing common risk factors such as tobacco use, harmful use of alcohol, unhealthy diet and low level of physical activity,
NCDs not only result in adverse health outcomes but also poses an economic burden on the country's health system and society. The study conducted by Global Economic Burden of Non-communicable disease in 2011 predicted that by 2030 world will experience a global financial loss of US $46.7 trillion, out of which the US $30.4 trillion losses will be because of major NCDs, namely diabetes, cardiovascular disease (CVD), chronic respiratory disease and cancer.
PLWNCDs may face multiple consequences such as physical disability, behavioural change, social and emotional turmoil, financial difficulties, lowered self-esteem, and depression.
Regardless of the type of NCDs, the development of a generic set of skills such as patient participation in self-management of disease has been advocated to manage and control illness and improve health outcomes.
Self-management involves a range of skillset and mindset that enables patients to identify their own strengths, and challenges and to design strategies that fit their circumstances required to manage overall health.
Self-management intervention programs were found to be effective among PLWNCDs in improving self-care knowledge, health behaviours, and various physiological parameters (blood pressure, haemoglobin, blood glucose), which in turn result in a significant reduction of hospitalisations, frequent Emergency (ER) visits, economic loss and improvement in quality of life.
Self-management practice, associated factors and its relationship with health literacy and patient activation among multi-morbid COPD patients from rural Nepal.
HL is a set of skills through which an individual can gain access to, understand, evaluate, and utilize health-related information in order to make health-related decisions to improve and enhance the quality of life.
Previous studies from high-income settings documented the effectiveness of HL-sensitive self-management interventions on positive health outcomes. People with an adequate level of health literacy were found to have better healthy lifestyle practices, positive change in SNAPW (smoking, nutrition, alcohol, physical activity, and weight), good self-rated health, self-efficacy, better disease knowledge, self-management of disease, and better health outcomes.
The health literacy management scale (HeLMS): a measure of an individual's capacity to seek, understand and use health information within the healthcare setting.
In addition, health literacy has been recognised as an important foundation that enhances the level of patient understanding and awareness of chronic diseases and hence, facilitates patient engagement in self-management.
South Asia, home to one-quarter of the world's population and more than one-third (approximately 37.00%) of the world's poor people, has been noted to have a surging prevalence of NCDs.
The increasing burden of NCDs in the South Asian region requires increased health care services and crucial participation of people, mainly those with NCDs, in the management of the disease. The Shanghai Declaration from the WHO in 2016 endorsed the importance of HL and identified it as a key for health promotion to achieve Sustainable Development Goals (SDGs) agenda.
This highlights the importance and need to understand the factors associated with inadequate HL, which helps design people-centred HL interventions among people with low levels of HL. Low or inadequate HL is a significant problem among PLWNCDs in LMICs, and primary studies on HL focusing PLWNCDs in South Asian Countries are evolving. To date, there is no comprehensive review that documented HL prevalence and its associated factors among PLWNCDs in South Asia. Therefore, this systematic review was conducted to summarise the prevalence of HL and its associated factors among PLWNCDs.
2. Materials and methods
This systematic review is reported in accordance with the Preferred Reporting Items for Systematic Review (PRISMA) guidelines.
The protocol was registered in the international prospective register of systematic reviews, PROSPERO (CRD 42021230029).
2.1 Literature search strategy
A comprehensive search was done in electronic databases, namely Medline (accessed through EBSCOhost and PubMed), CINAHL, and Scopus. Additionally, Google Scholar was searched to identify potential studies. The journal articles published in English between January 1, 2010 to December 31, 2021 were searched by combining key search terms (both Medical Subject Headings (MeSH) and free-text keywords) using Boolean operators (“AND” & “OR”). The search terms used in this review are presented in BOX 1.
(“Health Literacy” OR “Adequate Health Literacy” OR “Inadequate Health Literacy”) AND (“Non-communicable disease” OR “NCD” OR “Diabetes” OR “Type 2 diabetes” OR “Diabetes Mellitus” OR “Chronic Kidney Disease” OR “CKD” OR “Cardiovascular disease” OR “CVD” OR “Heart Disease” OR “Hypertension” OR “High Blood Pressure” OR “Stroke” OR “Coronary Heart Disease” OR “Chronic obstructive pulmonary disease” OR “COPD”) AND (“South Asia” OR “Nepal” OR “India” OR “Pakistan” OR “Bangladesh” OR “Sri Lanka” OR “Afghanistan” OR “Bhutan” OR “Maldives”).
2.2 Inclusion and exclusion criteria
This systematic review included the studies using quantitative methods (cross-sectional studies, case-control studies, and cohort studies), which have studied HL or domains of HL using a validated tool and the factors associated with HL among PLWNCDs. PLWNCDs in this review were those who were diagnosed or living with cardiovascular diseases, chronic kidney diseases, diabetes, and chronic obstructive pulmonary disease, irrespective of other chronic co-morbidities. This review included studies conducted in South Asian settings. There was no restriction imposed on the age and gender of the participants.
We excluded systematic reviews, randomised control trials, conference papers, opinions, letters to the editors, newspaper articles, theses, and studies with only abstracts. The review also excluded the studies that measure knowledge, awareness, and studies exclusively conducted on cancer, chronic autoimmune disease, and mental illness.
2.3 Study selection process
The search yield was imported to Mendeley, and duplicates were removed. Subsequently, the reviewers (BK and BRB) independently screened the title and abstracts for relevance, and the eligible articles were selected for full-text screening. Thereafter, the full-text articles were retrieved and screened against the preselected inclusion and exclusion criteria. Any discrepancy between reviewers during the screening process regarding inclusion and exclusion was resolved by discussion until consensus was achieved. If consensus was not reached, another reviewer's (UNY) opinion was sought to decide on inclusion.
2.4 Quality assessment and data extraction
The quality assessment of the included studies was performed independently by two reviewers (BK and BRB) using a critical appraisal checklist developed by Joanna Briggs Institute (JBI).
Each item of the critical appraisal checklist was assigned one point with a total maximum score of eight. The total score of each study was calculated as a percentage, and the quality was assigned as good with a score of 80.00%–100%, fair with a score of 50.00%–80.00%, and poor with a score <50.00%.
Data were extracted from all the included studies into an excel spreadsheet. The information extracted from the included studies were study identifiers (authors name and article published year), country, details on NCDs, populations, settings (a place where the study was conducted), literacy tool, study design, factors, and result.
2.5 Data synthesis
Due to heterogeneity in the tools for measuring HL in the included studies, we could not perform a meta-analysis. Instead, we have conducted a narrative synthesis. Firstly, the studies were grouped in accordance with the four NCDs that addressed the prevalence of HL. The associated factors of HL were also categorized on the basis of inadequate and adequate HL among PLWNCDs.
3. Results
The database search yielded 1618 relevant records, of which 1361 unique records were screened after duplicates were removed. The titles and abstracts were screened for relevance, and 1255 articles were removed. In the next step, a total of 18 full-text studies that fit the inclusion criteria were assessed, of which five ineligible articles were excluded, and their reasons for exclusion were documented. Following the PRISMA guidelines, the included articles are presented in Fig. 1.
3.1 Study characteristics and critical appraisal of included studies
A total of thirteen cross-sectional studies met the inclusion criteria. Of them, six were from Pakistan, four were from India, two were from Nepal, and one study was from Bangladesh. Most of the studies (n = 11) were carried out in healthcare settings
Medication adherence and its association with health literacy and performance in activities of daily livings among elderly hypertensive patients in Islamabad, Pakistan.
Association of sociodemographics, technology use and health literacy among type 2 diabetic individuals living in an Indian setting: an exploratory cross-sectional study.
Levels and determinants of health literacy and patient activation among multi-morbid COPD people in rural Nepal: findings from a cross-sectional study.
Health literacy, preventive COVID 19 behaviour and adherence to chronic disease treatment during lockdown among patients registered at primary health facility in urban Jodhpur, Rajasthan.
were carried out in the community settings. The sampling method was outlined in nine studies, of which five studies used the convenience sampling method,
Medication adherence and its association with health literacy and performance in activities of daily livings among elderly hypertensive patients in Islamabad, Pakistan.
Association of sociodemographics, technology use and health literacy among type 2 diabetic individuals living in an Indian setting: an exploratory cross-sectional study.
Levels and determinants of health literacy and patient activation among multi-morbid COPD people in rural Nepal: findings from a cross-sectional study.
Six studies used face-to-face interviews, one used the telephone call method, while others administered questionnaires to patients for data collection. The studies included a broad range of sample size, ranging from 50 to 524 participants. The details of the study characteristics are presented in Table 1. The critical appraisal of included studies are presented as supplementary file.1.
The included studies in this review presented either the prevalence of adequate or inadequate HL or both. One study measured the prevalence of HL based on cut-off value, where a mean score less than the cut-off value on each domain of HL was considered as limited or low HL, while a mean score greater than the cut-off value on HL domains was considered as adequate HL.
This review did not find any national-level HL studies conducted on PLWNCDs in South Asian countries. The prevalence of HL for individual NCDs has been detailed in Table 3.
Table 3Health literacy measurement tools and prevalence of health literacy.
Country
Study ID
Outcome assessment tool/scale
No. of people
Inadequate HL
Problematic/marginal HL
Adequate HL
1
People living with diabetes
Nepal
Shreshta et al., 2018 (37)
Short version of the Europe-Asia-Health Literacy Survey Questionnaire (HLS-EU-ASIA-Q), score 0-16
161
41.00% [inadequate (0–8)]
19.90% [problematic (9–12)]
39.10% [sufficient (13–16)]
India
Sahoo, Kohli & Kishore, 2015 (46)
Health literacy questionnaire
50
26.00% (not understanding information about blood sugar level)
Not Mentioned
74.00% (understanding information about blood sugar level), 84.00% understanding regimen of medications
India
Singh et al., 2018 (38)
Rapid Estimate of Adult Literacy in Medicine (REALM), score 0-66
263
63.00% [low (0-44)]
28.00% [marginal (45–60)]
9.00% [higher (61–66)]
Pakistan
Saeed et al., 2018 (43)
Short Test of Functional Health Literacy (s-TOFHLA), score 0-36
204
67.20% [inadequate (0-16)]
17.60% [marginal (17–22)]
15.20% [adequate (23–36)]
Pakistan
Hussain, Said & Khan, 2020 (45)
Literacy assessment for Diabetes (LAD) and Diabetes Numeracy Test (DNT)
524
40.00% [inadequate (score<85%)]
Not Mentioned
57.20% [adequate (score>86%)]
Bangladesh
Mehzabin et al., 2019 (41)
Short form Test of the Functional Health Literacy in Adults (s-TOFHLA), score 0-36
200
60.50% [inadequate (0-16)]
15.50% [marginal (17–22)]
24.00% [adequate (23–36)]
India
Ramasamy et al., 2016 (47)
Modified version of short test of functional health literacy in adults (STOFHLA) Score always-never
European Health Literacy Survey Questionnaire (HLS-EU-Q47), Score 0-50
181
83.43% [limited (0-33)]
16.57% [adequate (34–50)]
Pakistan
Suhail et al., 2021 (48)
Sixteen Item Questionnaire developed by Chew et al. score 0–64
251
70.11% [inadequate (0-34)]
29.88% [adequate (35–64)]
3
People living with chronic obstructive pulmonary disease
Nepal
Shreshta et al., 2018 (37)
Short version of the Europe-Asia-Health Literacy Survey Questionnaire (HLS-EU-ASIA-Q), score 0-16
101
77.20% [inadequate (0–8)]
12.90% [problematic (9-12)]
9.90% [sufficient (13–16)]
4
People living with co-morbidities
Nepal
Yadav et al., 2020 (39)
five HLQ domains out of nine Health Literacy Questionnaire (HLQ) domains, score lower quartile-upper quartile
238
Low [HPS (79.00%), HIS (76.50%), SS (77.30%), AE (75.20%), and UHI (74.80%)]
Not Mentioned
High [HPS (21.00%), HIS (23.50%), SS (22.70%), AE (24.80%), and UHI (25.20%)]
India
Gautam et al., 2021 (49)
European Health Literacy Survey Questionnaire (HLS-EU-Q47), Score 0-50
95
81.05% [limited (0-33)]
18.95% [adequate (34–50)]
AE: Ability to find the good health information; HIS: Having sufficient information to manage my own health; HPS: Feeling understood and supported by healthcare providers; SS: Social support for health; UHI: understand the health information well enough to know what to do.
Association of sociodemographics, technology use and health literacy among type 2 diabetic individuals living in an Indian setting: an exploratory cross-sectional study.
Health literacy, preventive COVID 19 behaviour and adherence to chronic disease treatment during lockdown among patients registered at primary health facility in urban Jodhpur, Rajasthan.
Health literacy, preventive COVID 19 behaviour and adherence to chronic disease treatment during lockdown among patients registered at primary health facility in urban Jodhpur, Rajasthan.
Association of sociodemographics, technology use and health literacy among type 2 diabetic individuals living in an Indian setting: an exploratory cross-sectional study.
Health literacy, preventive COVID 19 behaviour and adherence to chronic disease treatment during lockdown among patients registered at primary health facility in urban Jodhpur, Rajasthan.
Association of sociodemographics, technology use and health literacy among type 2 diabetic individuals living in an Indian setting: an exploratory cross-sectional study.
Dissimilarity in the prevalence of inadequate HL was also observed in studies from Pakistan. A study published in 2018 found 67.20% prevalence of inadequate HL
Medication adherence and its association with health literacy and performance in activities of daily livings among elderly hypertensive patients in Islamabad, Pakistan.
Health literacy, preventive COVID 19 behaviour and adherence to chronic disease treatment during lockdown among patients registered at primary health facility in urban Jodhpur, Rajasthan.
Medication adherence and its association with health literacy and performance in activities of daily livings among elderly hypertensive patients in Islamabad, Pakistan.
Health literacy, preventive COVID 19 behaviour and adherence to chronic disease treatment during lockdown among patients registered at primary health facility in urban Jodhpur, Rajasthan.
Medication adherence and its association with health literacy and performance in activities of daily livings among elderly hypertensive patients in Islamabad, Pakistan.
Health literacy, preventive COVID 19 behaviour and adherence to chronic disease treatment during lockdown among patients registered at primary health facility in urban Jodhpur, Rajasthan.
Medication adherence and its association with health literacy and performance in activities of daily livings among elderly hypertensive patients in Islamabad, Pakistan.
Health literacy, preventive COVID 19 behaviour and adherence to chronic disease treatment during lockdown among patients registered at primary health facility in urban Jodhpur, Rajasthan.
Medication adherence and its association with health literacy and performance in activities of daily livings among elderly hypertensive patients in Islamabad, Pakistan.
Health literacy, preventive COVID 19 behaviour and adherence to chronic disease treatment during lockdown among patients registered at primary health facility in urban Jodhpur, Rajasthan.
Levels and determinants of health literacy and patient activation among multi-morbid COPD people in rural Nepal: findings from a cross-sectional study.
Levels and determinants of health literacy and patient activation among multi-morbid COPD people in rural Nepal: findings from a cross-sectional study.
Levels and determinants of health literacy and patient activation among multi-morbid COPD people in rural Nepal: findings from a cross-sectional study.
Health literacy, preventive COVID 19 behaviour and adherence to chronic disease treatment during lockdown among patients registered at primary health facility in urban Jodhpur, Rajasthan.
This review identified various factors associated with adequate and limited HL among PLWNCDs. The associates of HL varied according to the characteristics of participants and the nature of NCD conditions.
A study from Nepal found poor knowledge of COPD and its risk factors,
being uneducated on HL domains, feeling understood and supported by healthcare providers (HPS), having sufficient information to manage own health (HIS), ability to find good health information (AE), understand the health information well enough to know what to do (UHI), being female on HIS, AE and UHI, low family income (≤ USD 176 per month) on domain AE, and being low ethnic group (Indigenous or Dalit) on domain social support for health (SS)
Levels and determinants of health literacy and patient activation among multi-morbid COPD people in rural Nepal: findings from a cross-sectional study.
Health literacy, preventive COVID 19 behaviour and adherence to chronic disease treatment during lockdown among patients registered at primary health facility in urban Jodhpur, Rajasthan.
Association of sociodemographics, technology use and health literacy among type 2 diabetic individuals living in an Indian setting: an exploratory cross-sectional study.
Association of sociodemographics, technology use and health literacy among type 2 diabetic individuals living in an Indian setting: an exploratory cross-sectional study.
Association of sociodemographics, technology use and health literacy among type 2 diabetic individuals living in an Indian setting: an exploratory cross-sectional study.
The evolving concept of HL is well recognised in improving health outcomes and quality of life among PLWNCDs. To our knowledge, this is the first review to present a comprehensive summary of the level of HL among PLWNCDs in South Asia.
Our review shows that among people with diabetes, 26.00%-80.88% had inadequate HL and 9.00%–74.00% had adequate HL in the South Asian region. Prior studies from countries such as Malaysia (85.80%),
Diabetic health literacy and its association with glycemic control among adult patients with type 2 diabetes mellitus attending the outpatient clinic of a university hospital in Ethiopia.
have reported a high prevalence of adequate HL among people with diabetes. This could be because the developing countries with better health care system provide quality care that may encourage patients to see their healthcare providers in need.
Prevalence of limited health literacy and its associated factors in patients with type 2 diabetes mellitus in Perak, Malaysia: a cross-sectional study.
where people with CVDs had 49.00% and 48.70% inadequate HL, respectively. Intervention programs like education on disease and its risk factors, healthy diet, medication adherence by health professionals delivered through face-to-face, audiotapes mobile phone interventions (telephone calls, messages, and apps) to register fruits and vegetable consumption and handouts of health education materials were found to be effective in increasing the levels of HL.
Health education interventions to promote health literacy in adults with selected non‐communicable diseases living in low‐to‐middle income countries: a systematic review and meta‐analysis.
This review found two studies that measured HL among people with COPD. Almost three-quarters of the patients with COPD had inadequate HL. This finding aligns with the study conducted in Spain, with 58.78% having inadequate HL.
A structural equation model of relationships of health literacy, illness and medication beliefs with medication adherence among patients with chronic obstructive pulmonary disease.
This review found that various factors were determining HL among PLWNCDs. The common factors associated were educational attainment and knowledge of the disease and its risk factors. Our review found that higher educational attainment was associated with adequate HL, supported by previous studies.
Diabetic health literacy and its association with glycemic control among adult patients with type 2 diabetes mellitus attending the outpatient clinic of a university hospital in Ethiopia.
The plausible explanation could be that people with higher educational attainment have a good cognitive level to understand and interpret the information and can take decisions to seek health services in need.
In addition, good knowledge of disease may increase people's confidence level, allowing them to communicate effectively and efficiently on their health issues with the health care providers.
Furthermore, our review found that lower diabetes medication knowledge was associated with inadequate HL among people with diabetes. One study conducted among people with diabetes in Ethiopia found that inadequate HL leads to difficulty reading drug labels and medication prescriptions.
Diabetic health literacy and its association with glycemic control among adult patients with type 2 diabetes mellitus attending the outpatient clinic of a university hospital in Ethiopia.
Further, unemployment and gender disparity, being female, was also significantly associated with inadequate HL. This result is in accordance with existing literature that found an association between inadequate HL with no or low socioeconomic conditions and being women.
Associations of health literacy with socioeconomic position, health risk behavior, and health status: a large national population-based survey among Danish adults.
Additionally, our review found that having a telephone, computer and internet facility at home and work was associated with adequate HL among people with diabetes, which is consistent with published evidence.
Associations of health literacy with socioeconomic position, health risk behavior, and health status: a large national population-based survey among Danish adults.
The plausible reason could be that people often try to get health-related information through telephone consultation and the internet that might help them self-identify signs and symptoms of chronic disease early and encourage them to seek health care early.
Similarly, our review found that people residing in urban areas had a higher prevalence of adequate HL than those residing in rural areas, which is congruent with the previous study.
Explaining variance in health literacy among people with type 2 diabetes: the association between health literacy and health behaviour and empowerment.
Another factor associated with inadequate HL was medication non-adherence, supported by a study in the U.S.A., where medication adherence was significantly lower among people with lower HL.
This review found other factors associated with HL among people with COPD. Low income was associated with inadequate HL, supported by previous research in the U.S.A., where education and income levels were associated with HL.
In addition to this, our review found that limited health literacy was associated with the female gender. A community-based study on HL found that inadequate HL on some domains of the HL tool was higher among females.
The association of inadequate HL among female and indigenous groups in this study might be because of gender disparity and less women empowerment. Studies from rural plains of Nepal showed that women and minor ethnic groups still fail to access health and education equally because of less autonomy in decision-making.
Distribution of health literacy strengths and weaknesses across socio-demographic groups: a cross-sectional survey using the Health Literacy Questionnaire (HLQ).
consistent with our review where minority or vulnerable groups like Dalit and indigenous people with COPD had inadequate HL.
4.1 Implication of the findings
Our study findings may aid policymakers and researchers in conducting national health literacy research. This may guide the development and implementation of a people-centred comprehensive health literacy program for PLWNCDs to improve their health outcomes. Given that health literacy is an important social determinant of health, it is crucial to develop a contextual health literacy tool that can capture individuals’ capacity to obtain, process, and understand basic health information, skills to navigate the health care system, and ability to communicate with health care providers required to make appropriate health decisions. Moreover, the current review neither found any HL studies focusing on PLWNCDs from Afghanistan, Bhutan, Maldives, and Sri Lanka, which suggests the need for studies in these countries. Additionally, we could not find any studies that measured HL among chronic kidney disease patients in South Asian countries, which warrants future research.
4.2 Limitations
This review restricted the search to the English language and a few databases, because of which we anticipate missing some relevant articles. This review excluded information from grey literature and academic thesis. Besides these, the variation in the tools used in the studies caused a challenge for this review to pool the result statistically. Considering the above limitations, the magnitude of health literacy from our review should be cautiously interpreted as critical appraisal was not used while synthesising the findings.
5. Conclusion
The present review revealed limited HL among people with diabetes, cardiovascular and chronic obstructive pulmonary diseases in South Asia. Considering the findings from this review, we suggest the need for co-designing health promotion programs and strategies to improve HL among PLWNCDs in South Asia. Furthermore, the development of an appropriate contextual health literacy tool that can capture cultural, social and family influences on the health literacy of South Asian people.
Author's contribution
BK conceived the idea and designed the study under the supervision of UNY. BK, BR, and UNY screened eligible articles for full-text screening BK and BR drafted the manuscript. SKM, SP, and UNY contributed significantly to improving the quality of the manuscript. All authors read and approved the final manuscript.
Source of funding
The authors did not receive any funding for conducting this review.
Declaration of competing interest
The authors declare that no conflict of interest exists.
Appendix A. Supplementary data
The following is the Supplementary data to this article:
Self-management practice, associated factors and its relationship with health literacy and patient activation among multi-morbid COPD patients from rural Nepal.
The health literacy management scale (HeLMS): a measure of an individual's capacity to seek, understand and use health information within the healthcare setting.
Levels and determinants of health literacy and patient activation among multi-morbid COPD people in rural Nepal: findings from a cross-sectional study.
Medication adherence and its association with health literacy and performance in activities of daily livings among elderly hypertensive patients in Islamabad, Pakistan.
Association of sociodemographics, technology use and health literacy among type 2 diabetic individuals living in an Indian setting: an exploratory cross-sectional study.
Health literacy, preventive COVID 19 behaviour and adherence to chronic disease treatment during lockdown among patients registered at primary health facility in urban Jodhpur, Rajasthan.
Diabetic health literacy and its association with glycemic control among adult patients with type 2 diabetes mellitus attending the outpatient clinic of a university hospital in Ethiopia.
Prevalence of limited health literacy and its associated factors in patients with type 2 diabetes mellitus in Perak, Malaysia: a cross-sectional study.
Health education interventions to promote health literacy in adults with selected non‐communicable diseases living in low‐to‐middle income countries: a systematic review and meta‐analysis.
A structural equation model of relationships of health literacy, illness and medication beliefs with medication adherence among patients with chronic obstructive pulmonary disease.
Associations of health literacy with socioeconomic position, health risk behavior, and health status: a large national population-based survey among Danish adults.
Explaining variance in health literacy among people with type 2 diabetes: the association between health literacy and health behaviour and empowerment.
Distribution of health literacy strengths and weaknesses across socio-demographic groups: a cross-sectional survey using the Health Literacy Questionnaire (HLQ).
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