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Received: 2024/02/20 | Accepted: 2024/05/28 | Published: 2024/06/25
Received: 2024/02/20 | Accepted: 2024/05/28 | Published: 2024/06/25
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Ghorbani A, Kareem Abed E, Ghiyasvandian S, Salami M. Association between Health Literacy and Medication Adherence in Patients with Cirrhosis. J Clinic Care Skill 2024; 5 (2) :63-68
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1- Department of Medical-Surgical Nursing, School of Nursing & Midwifery, Tehran University of Medical Sciences, Tehran, Iran
2- Department of Medical-Surgical Nursing and Basic Sciences, School of Nursing & Midwifery, Tehran University of Medical Sciences, Tehran, Iran
2- Department of Medical-Surgical Nursing and Basic Sciences, School of Nursing & Midwifery, Tehran University of Medical Sciences, Tehran, Iran
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Introduction
Chronic liver disease (CLD) is a prevalent source of chronic issues [1], affecting approximately 5.5 million people worldwide, with as many as 40,000 individuals dying from its natural course or complications [2]. CLDs can have adverse effects on quality of life, causing symptoms such as asthenia, incapacitation, body pain, sleep disorders, lack of appetite, insomnia, and complications related to liver cirrhosis, such as ascites and hepatic encephalopathy. Furthermore, CLDs can lead to job loss, impaired working ability, mood swings, anxiety, low self-esteem, depression, and other emotional issues that significantly impact patients’ quality of life [3]. Providing care for chronic disease patients, such as those with cirrhosis, is crucial for reducing their effects, improving health outcomes, preventing further disabilities, and reducing healthcare costs [4].
Knowledge and awareness among patients play a vital role in reducing complications and enhancing the quality of care. Health literacy is considered an essential component in enabling individuals to take an active role in their health and lifestyle choices [5]. It refers to “the level to which individuals can acquire, process, and comprehend the basic health services and information essential to making informed healthcare decisions” [6, 7]. Patients with chronic diseases require a high level of health literacy, making this group a primary focus for healthcare interventions [8]. Research indicates that 48% of Canadians are projected to have limited knowledge of healthcare [9]. Health literacy research has seen significant growth, particularly among individuals with chronic conditions, as communication-related interventions have the potential to improve clinical outcomes for those with low health literacy [10]. Despite the World Health Organization’s (WHO) emphasis on advancing health literacy as a public health priority, studies in Southeast Asian countries are still in the nascent stage [11, 12]. Well-informed individuals who actively manage their health problems in collaboration with healthcare providers tend to experience a higher quality of life [13]. Conversely, patients with a limited understanding of health issues are more likely to perceive their health as poor and engage in harmful lifestyle behaviors [14].
Health literacy has a significant impact on medication adherence, which the World Health Organization (WHO) defines as “the extent to which a person’s behavior corresponds with agreed upon recommendations from a health care provider” [15]. Research has shown that older adults often do not adhere to their prescribed medication as intended, with reasons including disease-related knowledge, health literacy, drug-related effects, patient-provider relationships, and cognitive function [16]. A study in the United Arab Emirates found that 64.6% of patients were considered non-adherent to their medication, with 26.5% having low adherence and 9.0% displaying medium adherence [17]. Given the complexities of treatment and drug consumption, medication adherence is crucial for the successful management of diseases [18]. Effective clinical management of liver cirrhosis, for example, is complex and demands frequent monitoring and changes to multidisciplinary care plans. Prescribed medications play a pivotal role in cirrhosis management as they have the potential to slow the progression of liver dysfunction, reduce the risk of complications, and decrease the frequency of hospitalization [19]. Nonadherence to medication may lead to a reemergence of symptoms requiring hospitalization, presenting a challenge to subsequent recovery [20]. Therefore, medication adherence plays a specific and critical role in the control of liver diseases, particularly cirrhosis [21]. Zhang et al. conducted a systematic review that found a statistically significant relationship between health literacy and adherence to medication. However, the review noted that this relationship is weak and requires further studies to fully understand its implications [22]. Hyvert et al. concluded that there was an unclear relationship between health literacy and medication adherence in adults with chronic diseases [23].
Health literacy and medication adherence have been the subjects of many studies [24]. However, the researchers did not find any studies about the relationship between health literacy and medication adherence in patients with cirrhosis. Moreover, in other chronic diseases, there were controversy in this matter. Also, in third-world countries, due to educational and cultural weakness, paying attention to health literacy and medication adherence becomes more important. Therefore, this study was conducted to investigate the association between health literacy and medication adherence in cirrhosis patients in Iraq.
Instruments and Methods
This was a descriptive study conducted in Iraq on outpatients and inpatients with cirrhosis from the medical city of Imam AL-Hussein and the teaching hospital of Imam AL-Hassan AL-Mujtaba between December 2022 and April 2023.
Participants and sampling
According to the study of Dore‐Stites et al. [25] the first type error was 0.05, the second type error was 0.1 and the power of the test was 90%. The sample size was estimated to be 141 people.
Convenience sampling was utilized to recruit 141 participants, comprising both outpatients and inpatients. The inclusion criteria were individuals aged 18-65 years and a diagnosis of cirrhosis within the last 6 months or more. The exclusion criteria was the presence of psychological disorders.
Instruments and data gathering
Data were gathered using three self-reported questionnaires covering demographic characteristics, the All Aspects of Health Literacy Scale (AAHLS), and the Adherence to Refills and Medications Scale (ARMS). Each participant completed the questionnaires in the presence of a researcher. The demographic characteristics included age, gender, marital status, economic status, level of education, disease duration, and causes of the disease.
In the current study, health literacy was measured using the All Aspects of Health Literacy Scale (AAHLS), which consists of 13 items loaded onto four factors related to skills in reading or understanding health documents (functional literacy questions or FQ 1-3) with a range of scores from 3 to 9, communicating with health professionals (communicative literacy questions or CommQ 1-3) with a range of scores from 3 to 9, managing health information (critical literacy questions or CritQ 1-4) with a range of scores from 4 to 12, and the capacity to take civic or community action for one’s health (empowerment questions or EmpQ 1-3) with a range of scores from 1 to 3. In this questionnaire, 11 items were scored on a three-point-Likert scale, and two items had yes and no answers and explanatory answers. The range of scores was from 11 to 33 and higher scores indicated lower health literacy [26].
The AAHLS was validated in Arabic-speaking Syrian refugees, with a Cronbach’s alpha of 0.67 for the overall scale and 0.63 for health literacy items. The overall scale had high content validity. The feasibility of this instrument as a self-administered screening tool in clinical or community settings was demonstrated with a high response rate of 0.86 [27]. The overall test was found to have considerable internal reliability (Cronbach's alpha=0.74) [26].
Medication adherence in the current study was measured by the Adherence to Refills and Medications Scale (ARMS), which is a 12-item self-reported medication adherence scale that consists of two subscales (adherence to filling medications and adherence to taking medications). Each item was scored using a 4-point Likert scale (1=None, 2=Some, 3=Most, and 4=All). The ARMS can range from 12 to 48 with higher scores indicating poor adherence. The primary element (adherence with taking medications) included eight items (e.g., item-1, item-2, item-5, item-6, item-7, item-8, item-9, and item-10) with a range of scores from 8 to 32, which accounted for 52.94% of the variance. The next element (adherence with filling medications) included four items (e.g., item-3, item-4, item-11, and item-12) with a range of scores between 4 and 12, which accounted for 47.06% of the variance [28]. In addition, the score of 16 was utilized as a dividing line to classify surveyed patients as noncommitted (e.g., ≥16) or committed (e.g., <16) [29]. Alammari et al. have validated a newly translated Arabic version of the Adherence to Refills and Medications Scale (ARMS) among patients with chronic health conditions. The scale yields good internal consistency (Cronbach's alpha=0.802) and test-retest reliability (Intraclass correlation coefficient=0.97) [28].
The researcher referred to the departments of the target hospitals after approving the project at the School of Nursing and Midwifery of Tehran, Iran, obtaining the code of ethics from the university's ethics committee, and obtaining a recommendation letter from the research vice-chancellor of Tehran Nursing and Midwifery School. First, the objectives of the research were explained to the eligible subjects and after obtaining informed consent, the questionnaires were given to the subjects.
Analysis
Data analysis was done using SPSS software version 16 to collect descriptive statistics, including frequency, mean and standard deviation and inferential statistics i.e., Pearson at the significant level <0.05.
Findings
86 patients out of 141 study people (61%) were male. Approximately 45% of the participants were 60 years old and older, and 61.7% were married. The level of education of 44% of the participants was primary. Economic status was poor for 49.6% of patients. The duration of disease in 52.5% of patients was less than one year. The etiology of the disease was medicine (31.2%), virus (28.4%) and alcohol (27.7%) respectively (Table 1).
Table 1. Frequency of demographic characteristics of patients
The mean medication adherence score was 33.63±7.78 (Table 2). This study revealed that 131 (92.90%) patients had a cut-off point on this scale ≥16 (Table 3). The mean health literacy score was 27.23±3.26 (Table 2). The majority of the studied patients had a low level of health literacy, while only 4.26% of them scored high level in this term (Table 3).
Table 2. Patients’ Adherence to Refills and Medications Scale and Health Literacy Questionnaire
Table 3. Frequency distribution of medication adherence and health literacy
Significantly positive and moderate correlations were observed between the mean scores of health literacy and medication adherence (p<0.001; r=0.358). The correlations between the health literacy domains (functional, communicative, critical and empowerment) and medication adherence domains (adherence to the preparation of medicine and consumption of medicine) is of importance to be assessed (Table 4). Among the domains of health literacy, there was no significant correlation between communicative and empowerment domains, and medication adherence (p>0.05). The correlation between the critical domain and medication adherence was significantly positive and moderate (r=0.436). Also, the correlation between functional domain and medication adherence was significantly positive and slight (r=0.194).
Table 4. Relationship between medication adherence and health literacy by Pearson test
Discussion
The aim of the present study was to investigate the level of medication adherence among cirrhosis patients, the level of their health literacy, and their relationship with each other.
The majority of the patients did not adhere to refills and medications. This can be due to the poor economic status and low education of most of the samples. These results come along with a study done by Mitra et al., which reveals that medication adherence is unacceptable, particularly among patients with serious health conditions [30]. Xu et al. have explored adherence and perceived barriers to oral antiviral therapy for chronic hepatitis B, which shows most patients had low adherence to medication [31]. The findings of Rahmati et al.'s study indicate that 60.7% of people have poor adherence to treatment [32]. Also, Kugler et al. in their study conclude that more than half of the studied patients have many problems following the recommendations related to their diet, which leads to non-adherence to treatment [33], which is consistent with the results of the present study. Kamezaki et al. that most patients presented good medical adherence [34], which is not consistent with the present study. This can be due to cultural and demographic differences.
Regarding patients’ health literacy levels about liver cirrhosis, most of the patients had low to moderate health literacy levels. This can be due to the cultural conditions prevailing in Iraq as well as the low education of most of the samples, which is consistent with the study of Kooshyar et al. [35] and Reisi et al. [36]. In the study of Rahmati et al., the relationship between health literacy and adherence to medication regimens in the elderly with hypertension is investigated. The results show that most of the participants have a low to moderate level of health literacy [32], which is consistent with the present study. Findings of the present study are consistent with Goldsworthy et al.’s study [37], in which patient understanding of liver cirrhosis is poor, and are in line with Burnham et al.’s study finding, which indicates patients do not have general understanding about the causes and hazards of chronic liver disease, screening, disease symptoms, and available treatments [38]. Also, in the study by Majid et al., it is found that only 32% of the studied population have a good understanding of the risk factors of chronic liver diseases, while the majority (68%) have a poor understanding [39].
There was a positive and statistically significant relationship between the total score for medication adherence and the total health literacy score. Patients who had more health literacy, were more aware of the importance of following the treatment regimen in order to control their disease. They knew that any interruption in compliance with the treatment regimen can have irreparable consequences. These results are consistent with the findings of Rahmati et al.'s [32]. Also, it is consistent with Lee et al.’s study that adequate health literacy is associated with higher medication adherence in older people with chronic disease [40]. Lor et al. believe that tailored interventions considering health literacy are needed to support medication adherence in order to improve hypertension outcomes in Hispanics [41]. In the study by Suhail et al. on patients with ischemic heart disease in Pakistan, adequate health literacy is significantly associated with medication adherence [42], which is in line with the present study. Qobadi et al. in their study in Iran on hemodialysis patients, have investigated the relationship between health literacy and medication adherence. They have found out that patients with inadequate health literacy have less medication adherence [43], which is consistent with the present study.
The findings can be used to inform the policymakers with the aim of planning interventions to improve patients’ education and health literacy and consequently to improve medication adherence in patients with cirrhosis.
It is important to acknowledge the limitations of this study, such as the reliance on self-report questionnaires and the use of convenience sampling, which may affect the generalizability of the findings. Future research could focus on implementing interventions to improve health literacy and medication adherence and evaluating their impact on patient outcomes in a more diverse patient population. Due to the insufficient sample size, the association of the parameter subscales of health literacy and medication adherence was not discussed. Therefore, one of the limitations of the present study is the small sample size. It is suggested that the researchers conduct a study with a larger sample size in order to overcome the limitations of the current research.
Conclusion
The majority of the studied patients adhere to medication and have a low health literacy level. Also, there is a positive and statistically significant relationship between the total score for medication adherence and the total health literacy score. The medication adherence increases by increasing knowledge of cirrhosis.
Acknowledgments: The researchers gratefully thank Tehran University of Medical Science (TUMS), the international campus and all cirrhosis patients for their great collaboration during the study.
Ethical Permission: Ethical approval was received from the Institutional Research Ethics Committee of the Faculty of Nursing and Midwifery and Rehabilitation, Tehran University of Medical Science (TUMS), International campus (IR.TUMS.MEDICINE.REC.1401.195). Participants were confident their participation was entirely voluntary and would not be penalized for opting out. In addition, they were also assured that information obtained will be treated with utmost confidentiality.
Conflicts of Interests: There is no conflict of interest in this study.
Authors’ Contribution: Ghorbani A (First Author), Main Researcher (30%); Kareem Abed I (Second Author), Main Researcher/Statistical Analyst (25%); Ghiyasvandian Sh (Third Author), Assistant Researcher/Introduction Writer (15%); Salami M (Fourth Author), Methodologist/Discussion Writer (30%)
Funding/Support: This article is the result of the thesis of the international student of Tehran University of Medical Sciences, Elham Karim Abed from Iraq and funded by the School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran (grant number: 1402-1-100-65783).
Chronic liver disease (CLD) is a prevalent source of chronic issues [1], affecting approximately 5.5 million people worldwide, with as many as 40,000 individuals dying from its natural course or complications [2]. CLDs can have adverse effects on quality of life, causing symptoms such as asthenia, incapacitation, body pain, sleep disorders, lack of appetite, insomnia, and complications related to liver cirrhosis, such as ascites and hepatic encephalopathy. Furthermore, CLDs can lead to job loss, impaired working ability, mood swings, anxiety, low self-esteem, depression, and other emotional issues that significantly impact patients’ quality of life [3]. Providing care for chronic disease patients, such as those with cirrhosis, is crucial for reducing their effects, improving health outcomes, preventing further disabilities, and reducing healthcare costs [4].
Knowledge and awareness among patients play a vital role in reducing complications and enhancing the quality of care. Health literacy is considered an essential component in enabling individuals to take an active role in their health and lifestyle choices [5]. It refers to “the level to which individuals can acquire, process, and comprehend the basic health services and information essential to making informed healthcare decisions” [6, 7]. Patients with chronic diseases require a high level of health literacy, making this group a primary focus for healthcare interventions [8]. Research indicates that 48% of Canadians are projected to have limited knowledge of healthcare [9]. Health literacy research has seen significant growth, particularly among individuals with chronic conditions, as communication-related interventions have the potential to improve clinical outcomes for those with low health literacy [10]. Despite the World Health Organization’s (WHO) emphasis on advancing health literacy as a public health priority, studies in Southeast Asian countries are still in the nascent stage [11, 12]. Well-informed individuals who actively manage their health problems in collaboration with healthcare providers tend to experience a higher quality of life [13]. Conversely, patients with a limited understanding of health issues are more likely to perceive their health as poor and engage in harmful lifestyle behaviors [14].
Health literacy has a significant impact on medication adherence, which the World Health Organization (WHO) defines as “the extent to which a person’s behavior corresponds with agreed upon recommendations from a health care provider” [15]. Research has shown that older adults often do not adhere to their prescribed medication as intended, with reasons including disease-related knowledge, health literacy, drug-related effects, patient-provider relationships, and cognitive function [16]. A study in the United Arab Emirates found that 64.6% of patients were considered non-adherent to their medication, with 26.5% having low adherence and 9.0% displaying medium adherence [17]. Given the complexities of treatment and drug consumption, medication adherence is crucial for the successful management of diseases [18]. Effective clinical management of liver cirrhosis, for example, is complex and demands frequent monitoring and changes to multidisciplinary care plans. Prescribed medications play a pivotal role in cirrhosis management as they have the potential to slow the progression of liver dysfunction, reduce the risk of complications, and decrease the frequency of hospitalization [19]. Nonadherence to medication may lead to a reemergence of symptoms requiring hospitalization, presenting a challenge to subsequent recovery [20]. Therefore, medication adherence plays a specific and critical role in the control of liver diseases, particularly cirrhosis [21]. Zhang et al. conducted a systematic review that found a statistically significant relationship between health literacy and adherence to medication. However, the review noted that this relationship is weak and requires further studies to fully understand its implications [22]. Hyvert et al. concluded that there was an unclear relationship between health literacy and medication adherence in adults with chronic diseases [23].
Health literacy and medication adherence have been the subjects of many studies [24]. However, the researchers did not find any studies about the relationship between health literacy and medication adherence in patients with cirrhosis. Moreover, in other chronic diseases, there were controversy in this matter. Also, in third-world countries, due to educational and cultural weakness, paying attention to health literacy and medication adherence becomes more important. Therefore, this study was conducted to investigate the association between health literacy and medication adherence in cirrhosis patients in Iraq.
Instruments and Methods
This was a descriptive study conducted in Iraq on outpatients and inpatients with cirrhosis from the medical city of Imam AL-Hussein and the teaching hospital of Imam AL-Hassan AL-Mujtaba between December 2022 and April 2023.
Participants and sampling
According to the study of Dore‐Stites et al. [25] the first type error was 0.05, the second type error was 0.1 and the power of the test was 90%. The sample size was estimated to be 141 people.
Convenience sampling was utilized to recruit 141 participants, comprising both outpatients and inpatients. The inclusion criteria were individuals aged 18-65 years and a diagnosis of cirrhosis within the last 6 months or more. The exclusion criteria was the presence of psychological disorders.
Instruments and data gathering
Data were gathered using three self-reported questionnaires covering demographic characteristics, the All Aspects of Health Literacy Scale (AAHLS), and the Adherence to Refills and Medications Scale (ARMS). Each participant completed the questionnaires in the presence of a researcher. The demographic characteristics included age, gender, marital status, economic status, level of education, disease duration, and causes of the disease.
In the current study, health literacy was measured using the All Aspects of Health Literacy Scale (AAHLS), which consists of 13 items loaded onto four factors related to skills in reading or understanding health documents (functional literacy questions or FQ 1-3) with a range of scores from 3 to 9, communicating with health professionals (communicative literacy questions or CommQ 1-3) with a range of scores from 3 to 9, managing health information (critical literacy questions or CritQ 1-4) with a range of scores from 4 to 12, and the capacity to take civic or community action for one’s health (empowerment questions or EmpQ 1-3) with a range of scores from 1 to 3. In this questionnaire, 11 items were scored on a three-point-Likert scale, and two items had yes and no answers and explanatory answers. The range of scores was from 11 to 33 and higher scores indicated lower health literacy [26].
The AAHLS was validated in Arabic-speaking Syrian refugees, with a Cronbach’s alpha of 0.67 for the overall scale and 0.63 for health literacy items. The overall scale had high content validity. The feasibility of this instrument as a self-administered screening tool in clinical or community settings was demonstrated with a high response rate of 0.86 [27]. The overall test was found to have considerable internal reliability (Cronbach's alpha=0.74) [26].
Medication adherence in the current study was measured by the Adherence to Refills and Medications Scale (ARMS), which is a 12-item self-reported medication adherence scale that consists of two subscales (adherence to filling medications and adherence to taking medications). Each item was scored using a 4-point Likert scale (1=None, 2=Some, 3=Most, and 4=All). The ARMS can range from 12 to 48 with higher scores indicating poor adherence. The primary element (adherence with taking medications) included eight items (e.g., item-1, item-2, item-5, item-6, item-7, item-8, item-9, and item-10) with a range of scores from 8 to 32, which accounted for 52.94% of the variance. The next element (adherence with filling medications) included four items (e.g., item-3, item-4, item-11, and item-12) with a range of scores between 4 and 12, which accounted for 47.06% of the variance [28]. In addition, the score of 16 was utilized as a dividing line to classify surveyed patients as noncommitted (e.g., ≥16) or committed (e.g., <16) [29]. Alammari et al. have validated a newly translated Arabic version of the Adherence to Refills and Medications Scale (ARMS) among patients with chronic health conditions. The scale yields good internal consistency (Cronbach's alpha=0.802) and test-retest reliability (Intraclass correlation coefficient=0.97) [28].
The researcher referred to the departments of the target hospitals after approving the project at the School of Nursing and Midwifery of Tehran, Iran, obtaining the code of ethics from the university's ethics committee, and obtaining a recommendation letter from the research vice-chancellor of Tehran Nursing and Midwifery School. First, the objectives of the research were explained to the eligible subjects and after obtaining informed consent, the questionnaires were given to the subjects.
Analysis
Data analysis was done using SPSS software version 16 to collect descriptive statistics, including frequency, mean and standard deviation and inferential statistics i.e., Pearson at the significant level <0.05.
Findings
86 patients out of 141 study people (61%) were male. Approximately 45% of the participants were 60 years old and older, and 61.7% were married. The level of education of 44% of the participants was primary. Economic status was poor for 49.6% of patients. The duration of disease in 52.5% of patients was less than one year. The etiology of the disease was medicine (31.2%), virus (28.4%) and alcohol (27.7%) respectively (Table 1).
Table 1. Frequency of demographic characteristics of patients
The mean medication adherence score was 33.63±7.78 (Table 2). This study revealed that 131 (92.90%) patients had a cut-off point on this scale ≥16 (Table 3). The mean health literacy score was 27.23±3.26 (Table 2). The majority of the studied patients had a low level of health literacy, while only 4.26% of them scored high level in this term (Table 3).
Table 2. Patients’ Adherence to Refills and Medications Scale and Health Literacy Questionnaire
Table 3. Frequency distribution of medication adherence and health literacy
Significantly positive and moderate correlations were observed between the mean scores of health literacy and medication adherence (p<0.001; r=0.358). The correlations between the health literacy domains (functional, communicative, critical and empowerment) and medication adherence domains (adherence to the preparation of medicine and consumption of medicine) is of importance to be assessed (Table 4). Among the domains of health literacy, there was no significant correlation between communicative and empowerment domains, and medication adherence (p>0.05). The correlation between the critical domain and medication adherence was significantly positive and moderate (r=0.436). Also, the correlation between functional domain and medication adherence was significantly positive and slight (r=0.194).
Table 4. Relationship between medication adherence and health literacy by Pearson test
Discussion
The aim of the present study was to investigate the level of medication adherence among cirrhosis patients, the level of their health literacy, and their relationship with each other.
The majority of the patients did not adhere to refills and medications. This can be due to the poor economic status and low education of most of the samples. These results come along with a study done by Mitra et al., which reveals that medication adherence is unacceptable, particularly among patients with serious health conditions [30]. Xu et al. have explored adherence and perceived barriers to oral antiviral therapy for chronic hepatitis B, which shows most patients had low adherence to medication [31]. The findings of Rahmati et al.'s study indicate that 60.7% of people have poor adherence to treatment [32]. Also, Kugler et al. in their study conclude that more than half of the studied patients have many problems following the recommendations related to their diet, which leads to non-adherence to treatment [33], which is consistent with the results of the present study. Kamezaki et al. that most patients presented good medical adherence [34], which is not consistent with the present study. This can be due to cultural and demographic differences.
Regarding patients’ health literacy levels about liver cirrhosis, most of the patients had low to moderate health literacy levels. This can be due to the cultural conditions prevailing in Iraq as well as the low education of most of the samples, which is consistent with the study of Kooshyar et al. [35] and Reisi et al. [36]. In the study of Rahmati et al., the relationship between health literacy and adherence to medication regimens in the elderly with hypertension is investigated. The results show that most of the participants have a low to moderate level of health literacy [32], which is consistent with the present study. Findings of the present study are consistent with Goldsworthy et al.’s study [37], in which patient understanding of liver cirrhosis is poor, and are in line with Burnham et al.’s study finding, which indicates patients do not have general understanding about the causes and hazards of chronic liver disease, screening, disease symptoms, and available treatments [38]. Also, in the study by Majid et al., it is found that only 32% of the studied population have a good understanding of the risk factors of chronic liver diseases, while the majority (68%) have a poor understanding [39].
There was a positive and statistically significant relationship between the total score for medication adherence and the total health literacy score. Patients who had more health literacy, were more aware of the importance of following the treatment regimen in order to control their disease. They knew that any interruption in compliance with the treatment regimen can have irreparable consequences. These results are consistent with the findings of Rahmati et al.'s [32]. Also, it is consistent with Lee et al.’s study that adequate health literacy is associated with higher medication adherence in older people with chronic disease [40]. Lor et al. believe that tailored interventions considering health literacy are needed to support medication adherence in order to improve hypertension outcomes in Hispanics [41]. In the study by Suhail et al. on patients with ischemic heart disease in Pakistan, adequate health literacy is significantly associated with medication adherence [42], which is in line with the present study. Qobadi et al. in their study in Iran on hemodialysis patients, have investigated the relationship between health literacy and medication adherence. They have found out that patients with inadequate health literacy have less medication adherence [43], which is consistent with the present study.
The findings can be used to inform the policymakers with the aim of planning interventions to improve patients’ education and health literacy and consequently to improve medication adherence in patients with cirrhosis.
It is important to acknowledge the limitations of this study, such as the reliance on self-report questionnaires and the use of convenience sampling, which may affect the generalizability of the findings. Future research could focus on implementing interventions to improve health literacy and medication adherence and evaluating their impact on patient outcomes in a more diverse patient population. Due to the insufficient sample size, the association of the parameter subscales of health literacy and medication adherence was not discussed. Therefore, one of the limitations of the present study is the small sample size. It is suggested that the researchers conduct a study with a larger sample size in order to overcome the limitations of the current research.
Conclusion
The majority of the studied patients adhere to medication and have a low health literacy level. Also, there is a positive and statistically significant relationship between the total score for medication adherence and the total health literacy score. The medication adherence increases by increasing knowledge of cirrhosis.
Acknowledgments: The researchers gratefully thank Tehran University of Medical Science (TUMS), the international campus and all cirrhosis patients for their great collaboration during the study.
Ethical Permission: Ethical approval was received from the Institutional Research Ethics Committee of the Faculty of Nursing and Midwifery and Rehabilitation, Tehran University of Medical Science (TUMS), International campus (IR.TUMS.MEDICINE.REC.1401.195). Participants were confident their participation was entirely voluntary and would not be penalized for opting out. In addition, they were also assured that information obtained will be treated with utmost confidentiality.
Conflicts of Interests: There is no conflict of interest in this study.
Authors’ Contribution: Ghorbani A (First Author), Main Researcher (30%); Kareem Abed I (Second Author), Main Researcher/Statistical Analyst (25%); Ghiyasvandian Sh (Third Author), Assistant Researcher/Introduction Writer (15%); Salami M (Fourth Author), Methodologist/Discussion Writer (30%)
Funding/Support: This article is the result of the thesis of the international student of Tehran University of Medical Sciences, Elham Karim Abed from Iraq and funded by the School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran (grant number: 1402-1-100-65783).
Keywords:
References
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