development of a hypertension health literacy assessment ......• tool 1 = 19 (63%); tool 3 (23%)...

Development of a Hypertension Health Literacy

Assessment Tool for use in primary health care (PHC)

clinics in South Africa, GautengDR NG MafuthaProf S MogotlaneDr HC de Swardt

INTRODUCTION & BACKGROUND

• Worldwide, hypertension contributes to about 7.6 million premature deaths and 92 million disability-adjusted life years

• In SA, • mortality as a result of hypertension for people ≥30 years as 41.7%;• Stroke - 49.6%• Cardiovascular diseases - 21.6%

• Hypertension is a chronic, preventable non-communicable disease causes are genetics, behaviour and life style


The World Health Organization states that the African region has a high prevalence of hypertension than the American region. Hypertension in South Africa affects about 6.3 million people and about half of them are unaware they have hypertension.

Some people, who know that they suffer from hypertension, and are on medication, might be poorly controlled.


This view is supported by South Africa’s National Department of Health (NDOH) in its policy for strategic planning which reports that 18% of deaths in 2008 were caused by cardiovascular diseases, including hypertension

MANAGEMENT OF HYPERTENSION

PHARMACOLOGICAL MANAGEMENT NON-PHARMACOLOGICAL MANAGEMENT

antihypertensive medication:• diuretic thiazide, • beta-blockers, • ACE inhibitors and the calcium channel

blockers.

• Health education • control weight;• exercise regularly,• take not more than a teaspoon of salt a

day in all the foods combined;• reduce food amounts, fat and sugar

intake; • Reduce alcohol intake • do not smoke or stop smoking.

HEALTH EDUCATION & HEALTH LITERACY

• Health education - fundamental tool for health promotion and disease prevention

• Health education- adversely affected low literacy level

PROBLEM STATEMENT & SIGNIFICANCE

• The National Demographic Health Survey:• only 39% reported hypertension• 29% on medication, only 14% BP well managed

• This can be attributed to:• poor compliance due to lack of comprehension

on hypertension management

ASSESSMENT TOOLS

• These instruments are based on word recognition, experience and knowledge

• Rapid Estimate of Adult Literacy in Medicine Revised (REALM-R)

• Wide Range Achievement Test (WRAT3) • and the Learning Ability Battery (LAB)

• Based on the principles of the REALM-R the HHLAT was developed, to identify those at risk for poor HHL

PURPOSE OF THE STUDY

Based on the principles of the REALM-R develop a HHLAT to identify and determine health literacy specific to hypertension in patients attending primary health care facilities.

OBJECTIVES

Phase 1: Explore the oral and existing printed health education content on prevention, management and control of hypertension; to create a list of common words or phrases used in hypertension health education;

Phase 2: develop a HHLAT to identify and determine the literacy level of hypertensive patients attending primary health care clinics in Tshwane, Gauteng Province, South Africa;

RESEARCH QUESTIONSResearch question 1:

What is the content of oral and existing printed health education materials that is presented to hypertensive patients at PHC, Tshwane, Gauteng Province, South Africa?

Research question 2:

How can the REALM-R be adapted to develop a hypertension health literacy assessment tool?

Research question 3:

Using the adapted REALM-R as the hypertension health literacy assessment tool, what is the hypertension health literacy level of patients at Tshwane primary health care clinics?

FRAMEWORK

METHODS & DESIGN

• Descriptive, • Quantitative • Contextual

POPULATION & SAMPLING STRATEGY

POPULATION SAMPLING METHODS

CONTEXT DATA COLLECTION

DATA ANALYSIS

• Health promoters of Gautengclinics (N=12)

• Pamphlets/posters N=50=11

Purposive and convenience Inclusion criteria:• Willing to

participate• Health

promoter in Gauteng PHC

12 PHC in Tshwane

Audio recording & collection of pamphlets and posters

Quantitativecontent analysis and descriptive statistics

Phase 1




DATA ANALYSIS

• Adaptation

( N=20)• Validation(N=30)

Non-probability Purposive Inclusioncriteria:Expert and willing to participate

Adaptation-TUT building 4Validation-own places

Modified Delphi Technique

Descriptive statistics e.g. frequency distribution

Phase 1

ROUND 1

1. The researcher created a distribution list from the most common hypertension words/phrases used during hypertension health education in PHC and available printed materials e.g. pamphlets.

2. The words were put in according to syllable, ranging from syllable 1 to 6 and more.

ROUND 2

1. The experts were invited in a common room (context).

2. The aim which was to select the most common words or phrases to be used in the adaptation of the realm-r in developing the hypertension health literacy.

3. The researcher provided a list of words according to syllable, ranging from syllable 1 to 6 and more

Starting with syllable 1, the researcher mentioned every word and the experts voted by raising a hand if they though the word or phrase was important in hypertension health education

4. The researcher had 2 assistants, the fist person counted the number of times a word was voted as being important and the second person recorded the process.

5. This round with the experts ended when the last word in syllable 6 and more were voted for and record kept.

6. Using the record kept by the second assistance in an excel spreadsheet starting from syllable one words were ranged according to highest vote to the lowest. Those that were not voted for were automatically removed from the list.

7. The words that scored highest from syllable 1-6 and more were used to adapt the REALM-R and tool 1 of the hypertension health literacy was developed followed by Tool 2 from the words that lower than those used in tool 1. Lastly tool 3 was developed using the least voted words in the list also combining syllable 1 to 6.

ROUND 3

1. Tool 1, 2 and 3 with informed consent was sent out via email to 50 experts (this included first experts who participated in round 2).

2. They were asked to select and validate a tool they considered to be appropriate for assessing hypertension health literacy.

3. Responses were recorded in a excel spreadsheet creating a frequency distribution, each time a tool was selected as being most appropriate, it was given a point. This process was given 60 days to allow time to people who are far and very busy to respond as well. In the end 30 responded, voting tool 1 as most appropriate tool to assess hypertension health literacy.

4. The selected tool was pretested in 5 participants in a PHC that was not to be included in the main study, no adaptations were made.

ROUND 4

The tool 1 of the hypertension health literacy assessment tool was administered to hypertensive patients in 4 primary health care clinics in Gauteng Tshwane.




DATA ANALYSIS

• Hypertensive patients (N=195)

Non-probability purposive and Convenience Inclusioncriteria:• Ability to

read English• Hypertensive

4 PHC Self report –HHLAT & LAB

Descriptive and inferential statistics: chi-squared Spearman’s rho

Phase 2

RESEARCH SETTING

Phase 1: n=24 PHCs however only n=12 were realised due to consent given by only n=12 health promoters in the City of Tshwane, Gauteng South Africa.

The n=20 adaptation panel at the Tshwane University of Technology.

The n=30 validation panel context was in the comfort of their own homes/or offices.

Phase 2: The n=195 patients were from 4 PHCs in the City of Tshwane, Gauteng South Africa.

PHASE 1: DATA COLLECTION & ANALYSIS

Round 1: following a modified Delphi technique :

- Process of generating words, concepts, phrases- N=12 recorded health education provided by health promoters (Translated

and transcribed)- N=50 printed health education materials, 11 remained after duplicates

removed


For data analysis themes were identified guided by literature on content for hypertension health education in terms of: definition of hypertension, risk factors, signs and symptoms, pharmacological management, non-pharmacological management and the complications of poorly-controlled hypertension

Quantitative content analysis was used and frequency distribution e.galcohol 1,2A list of common words, phrases and concepts was developed

Sheet1

One syllableFrqncyTwo syllablesFrqncyThree syllablesFrqncyFour syllablesFrqncyFive syllablesFrqncyMore than six syllablesFrqncy

skiphigh bloodBlood pressureHigh blood pressuremenopause womenphysical activity

pillHeadachestirednesshypertensionavoid processed fooddon't run out on of medication

takedizzymargarinevegetablesstressful emotionsone teaspoon of salt a day

drinkreduceregularkeep appointmentscomply with treatmentavoid restaurant food

keepChronic everydayincurableeat avocadoexercise for 30 minutes

stickchest painno muffinssilent killerhigh cholesterolpoor eyesight (retinopathy)

timetreatmentno vetkoekshortness of breathNormal blood pressure blocked arteries (coronary artery disease)

legsbettergeneticunhealthy dietPre-hypertension damaged internal organs

eatfeelingNo symptomscheck blood pressure reduce alcoholdon't borrow medication

foodlittlecanolano cigarettestake medication correctly

weightno salt tobaccono aromatcan damaged internal organs

salttennishistoryobesitymore common in African

spicechange dietcalorieread ingredients

addless starchless sugaravoid fast-food

eatno salt heart failure lead to blindness

oilswelling poor eye sightno bunny chow

addless sweetslifestyle changeknow blood pressure

fastless beefread labelsbrick margrine

boilless cheeseoverweightcheck blood pressure

grillless spicediabetes

frydietno fat cakes

diedo not no stock cubes

eyechickenstop smoking

poorsodiumheart failure

agewalking

strokerunning

deathcleaning

groupscooking

herbslevel

beanssupport

limit

healthy

spinach

peanuts

control

intake

ageing

biltong

tinned

women

drinking

adding

steam food

avoid stress

heart attack

check-ups


• Round 2: following the modified Delphi technique common words/concepts/phrases were identified to develop the HHLAT

• a panel of experts voted for the commonly used words/phrases/concepts to be used in the development of hypertension

• Two research assistance counted and recorded the votes per word/phrase/concept

Health promoters Data

TRANSCRIPTS FROM HEALTH PROMOTERS RECORDINGSFrequencyCOMBINED THEMESfrequencyCategoriesFrequency

TERM USED:Frequency TERMS USED:frequencyTERMS USEDFrequency

Normal blood pressure 120/801,3,123Normal blood pressure 120/801,3,121,2,3=3Highbloodpressure1,3,4,5,6,86

140/90 prehypertensive121Pre-hypertension 140/90 1212=1hypertension2,4,6,7,85

high blood1,4,83High blood pressure1,3,4,5,6,81,3,4,5,6,8=6high blood1,4,83

hypertension2,4,6,7,85high blood1,4,81,4,8=3Normal blood pressure 120/801,3,123

Blood pressure2,42hypertension2,4,6,7,82,4,6=3Bloodpressure2,42

High blood pressure3,5,6,84Blood pressure2,42,4=2Pre-hypertension 140/90 121

normal blood pressure 120/805,72

120/9081

high high61

SIGNS AND SYMPTOMS:SIGNS AND SYMPTOMS:Signs and symptomsfrequency

Headaches1,4,5,6,75Headaches1,4,5,6,71,4,5,6,7=5Headaches1,4,5,6,75

feel dizzy1,4,5,74 feel dizzy1,4,5,7,81,4,5,7,8=5dizzy1,4,5,7,85

inactive11tiredness and weakness4,6,74,6,7=3cannot be cured6,7,8,9 not uncurable4

sweating4,5,6,74swelling6,116,11=2tiredness and weakness4,6,73

fever41loss of memory77=1swelling6,112

tiredness4,6,73has no sign1212=1loss of memory71

weakness41chronic illness77=1has no sign121

blurred vision5,6,7,84cannot be cured6,7,8,96,7,8,9=4Chronic disease1

swelling6,112

feeling hot61

loss of memory71

has no sign121

chronic illness71

cannot be cured6,7,8,94

PHARMACOLOGICAL MANAGEMENT PHARMACOLOGICAL MANAGEMENTPHARMACOLOGICAL MANAGEMENTFrequency

Take medication correctly1,7,8,10,5,6,3,9,4=9

Medication11Medication1Take medication correctly1,7,8,10,5,6,3,9,49

Pills11Pills everyday for the rest of your life1,7,8,10Can be controlled but not cured6,7,8,104

Pills everyday for the rest of your life1,7,8,104Do not skip medication1,5,6do not borrow each other treatment4,82

Do not skip medication1,5,63Take treatment3,8,10

Take treatment3,8,103take treatment correctly4,5, 6,9,10

take treatment correctly4,6,9,104do not borrow each other treatment4,84,8=2

do not borrow each other treatment4,82Can be controlled but not cured6,7,8,106,7,8,10=4

Take treatment at the right time51

Can be controlled but not cured6,7,8,104

NON PHARMACOLOGICAL MANAGEMENTFrequencyNON PHARMACOLOGICAL MANAGEMENTFrequencyNON PHARMACOLOGICAL MANAGEMENTFrequency

check food labels121DIETDIET

do not add salt before tasting121SALT:SALT:

check ingredience for sodium121Aromat, Spice, chicken spice, all of this have salt do not eat1,2,3,4,8,11,107Aromat, Spice, chicken spice, all of this have salt do not eat1,2,3,4,8,11,107

Aromat, Spice, chicken spice, all of this have salt do not eat1,2,3,4,8,116do not eat salt1, 2,4,5=4do not eat salt= 1,2,4,54

eat meat without salt without oil or sugar nothing11use salt or aromat sparingly or little1, 2,5=3use salt or aromat sparingly or little3

start using Aromat sparingly or salt a little1,2,53reduce salt4,5,11=3reduce salt3

when they say stop taking salt, stop it1,2,43OILOIL

reduce salt4,5,113Do not add cooking oil3,4=2reduce oil4

exercise1, 2,4,5,6,7,8,10,11,1210reduce oil5,7,8,11=4Do not add cooking oil2

exercise for 30 minutes5,6,83avoid oily food10=1avoid oily food1

join support groups1,3,63Fruits and vegetablesFruits and vegetables

share your problems11Fruits2,3,11,12=4Vegetable9

exercise it is not only running11Vegetable2,3,5,6,7,8,10,11,12=9Fruits4

FOOD LABELS

check ingredience for sodium1212=1Check ingredience for sodium1

as long as your heart starts pumping faster and pumping lot of blood11PHYSICAL ACTIVITYPHYSICAL ACTIVITY

Walking and visiting friends1,3,6,7,105exercise1, 2,4,5,6,7,8,10,11,1210walking, running, playing tennis, walking fast, cleaning and cooking10

walk fast effectively7,122walking, running, playing tennis, walking fast, cleaning and cooking7,12,1,3,6,10=6walking, running, playing tennis, walking fast, cleaning and cooking6

playing tennis121excercize for 30 minutes5,6,8=3excercize for 30 minutes3

drinking a lot of water, X2 litre of water1,2,3,5,7,8,107EmotionsEmotions

healthy lifestlye2,4,5,10,115join support groups1,3,61,3,6=3reduce stress level2,4,9,10,12,5,7,118

boil food2,3,4,74reduce stress level2,4,9,5,7,10,122,4,9,10,12,5,7,11=8join support groups1,3,63

vegetables2,3,5,6,7,8,10,11,129LIFESTYLELIFESTYLE

knorox have lot of salt avoid them2,42healthy lifestlye e.g change lifestle 82,4,5,10,11,8=6Boil food, grill do not fry8

soups have got lot of salt do not use them21Boil food, grill do not fry2,3,4,7,8=5healthy lifestlye e.g change lifestle 86

eat breakfast2,32control your diet2,3,5=3Eat healthy5,6,7,8,10,11 spinach, peanuts, herbs,less starch, proteins,beans6

fruit2,3,11,124Eat healthy5,6,7,8,10,11 spinach, peanuts, herbs,less starch, proteins,beans5,6,7,8,10,11=6Boil food, grill do not fry5

control your diet for treatment to be effective2,3,53stop smoking ciagarrates6,7,8,106,7,8,10=4stop smoking ciagarrates6,7,8,104

check your blood pressure2,3,53stop alcohol88=1control your diet3

reduce stress level2,4,9,10,125know your blood pressure1212=1stop alcohol81

do not add cooking oil3,4,2know your blood pressure121

reduce oil5,7,8,114

vegetable gardens31

support groups31

cleaning is exercise31

cooking is part of exercise31

doing your vegetable garden is part of excercise31

avoid thinking a lot4,5,73

no salt even a little4,7,8,10,115

grill your meat4,82

do not fry food41

do not add raw salt in your cooked food5,82

eat healthy5,6,7,8,10,116

change lifestyle81

remove unnecessary fat in your meat5,62

eat peanuts61

eat beans61

spinach61

eat 3 times a day61

stop smoking ciagarrates6,7,8,104

stop alcohol81

use herbs instead of salt101

avoid oily food101

avoid salty food101

eat less starch10,112

eat proteins101

reduce stress 9,10,113

know your blood pressure121

COMPLICATIONS OF UNCONTROLLED HYPERTENSION:COMPLICATIONS OF UNCONTROLLED HYPERTENSION:COMPLICATIONS OF UNCONTROLLED HYPERTENSION:

can avoid stroke or the headaches that comes with high blood pressure even while you’re taking medication11Stroke1,2,4,5,6,7,10,11=8Stroke8

stroke1,2,4,5,6,7,10,118Silent killer2,4,6=3Silent killer3

silent killer2,4,63Die/Death1 ,2,11=3Die/Death3

die1 ,2,113swelling6,116,11=2swelling6,112

swelling4,52Poor eye sight4,7=2Poor eye sight2

poor eye sight4,72blocked arteries5,6=2blocked arteries2

blocked arteries5,62heart attack6=1heart attack1

heart attack61damaged internal organs7=1damaged internal organs1

damaged internal organs71

unable to talk111

RISK FACTORS TO HYPERTESNION:FREQUENCYRISK FACTORS TO HYPERTESNION:FREQUENCYRISK FACTORS TO HYPERTESNION:FREQUENCY

stress1,2,3,4,5,7,97Stress1,2,3,4,5,7,9=7Stress7

genetic2,4,6,7,85genetic2,4,6,7,82,4,6,7,8=5genetic5

arteries when you smoke they become blocked and blood cannot pass anymore21Blocked arteries22=1lot of salt and spice5

Even if you do not have high blood as long as you eat lot of salt and spice you can end up with it11lot of salt and spice1,6,7,8,9=5overweight3

overweight4,7,93overweight4,7,9=3blocked arteries1

diabetes91Daibetes9=1diabetes1

lot of oil4,92unhealthy eating:unhealthy eating:

smoking cigarrates2,4,6,7,9,126lot of oil4,94,9=2oily foods=4,9,6,7,85

unhealthy eating61lot of fat in blood 66=1red meat1

Lifestyle81fat cakes6=1

lack of exercise61bunny chow6,7,8=3

drinking a lot of alcohol6,92red meat6=1

lot of fat in blood61adding oil in meat6=1

Fat cakes61smoking cigarrates2,4,6,7,9,122,4,6,7,9,12=6

lot of salt7,82lack of exercise6=1

Bunny chow6,7,83

red meat61

adding salt before tasting the food6,92

adding oil in meat61

Pamphlets

Data analysed from pamphletsFrequencyCombined words from pamphletsFrequencyCategoriesFrequency

TERM USED:TERM USED:FrequencyCategoriesFrequency

Blood pressure1,22Blood pressure1,2=2High blood pressure4

High blood pressure7,102High blood pressure7,10,2,4=4High blood pressure 140/903

Normal blood pressure 120/802,72Normal blood pressure 120/802,7=2Hypertension2

High blood pressure 140/902,4,103High blood pressure 140/902,4,10=3Blood pressure2

high blood pressure cannot be permanently cured21Hypertension8,11=2Normal blood pressure 120/802

high blood pressure can be controlled21

Hypertension8,112

SIGNS AND SYMPTOMS:SIGNS AND SYMPTOMS:

Headaches4,112Headaches4,112Headaches4,112

Dizziness4,12Dizziness4,12Dizziness4,12

Blurred vision41Blurred vision41Blurred vision41

Chest Pain41Chest Pain41Chest Pain41

Shortness of breath4Shortness of breath41Shortness of breath41

PHARMACOLOGICAL MANAGEMENT PHARMACOLOGICAL MANAGEMENT FrequencyCategoriesFrequency

Keep appointments11Keep appointments1,82Take medication as prescibed/compliance 1,2,5,7,8,46

Take medication as prescibed1,2,5,7,8,5Take medication as prescibed1,2,5,7,8,46take treatment even when feeling better/ always take medication1,2,83

Dosage21don’t run out of pills1,82Keep appointments1,82

Intervals21take treatment even when feeling better1,2,83don’t run out of pills1,82

same time each day21Find convenient time to take your treatment21Find convenient time to take your treatment/right time21

don’t run out of pills1,82Do not borrow other people medication111Do not borrow other people medication/not borrow medication111

take treatment even when feeling better11

Do not stop medication2,1

Find convenient time to take your treatment21

Antihypertensives41

Treatment can only be stopped by your doctor81

Keep your appointments with your doctor81

Do not borrow other people medication111

NON PHARMACOLOGICAL MANAGEMENTNON PHARMACOLOGICAL MANAGEMENTFrequencyCategoriesFrequency

Use soft margarine, avocado and canola oil101Use soft margarine, avocado and canola oil101Cut out smoking1,3,4,5,9, 2,6,88

Avoid muffins, vetkoek, cake and brick margarine101Avoid muffins, vetkoek, cake and brick margarine101moderate alcohol intake1,3,4,5,6,8,107

Use 1 teaspoon of salt per day101Use 1 teaspoon of salt per day101regular exercise1,3,4,5,8,106

Check labels for sodium101Check labels for sodium101regular check ups1,,8,2,7,9,5

Choose low fat dairy products101Grill, bake or steam your food101reduce salt intake1,2,9,104

Choose whole grains101Limit sweet and added sugars101Eat fresh fruits2,6,9,104

Eat lean meats, fish and poultry101Cut out smoking1,3,4,5,9, 2,6,88Eat vegetables2,6,9,104

Choose nuts, seeds and legumes101reduce weight1,4,83limit fat intake2,9,103

Grill, bake or steam your food101reduce stress1,5,8,104Exercise for 30 minutes2,62

Limit sweet and added sugars10moderate alcohol intake1,4,5,6,8,106Use soft margarine, avocado and canola oil101

Cut out smoking1,3,5,94regular exercise1,3,4,5,8,106Avoid muffins, vetkoek, cake and brick margarine101

reduce weight1,4,83regular check ups1,,8,2,7,9,5Use 1 teaspoon of salt per day101

reduce stress1,5,8,104reduce salt intake1,2,9,104Check labels for sodium101

moderate alcohol intake1,4,5,6,8,106limit fat intake2,9,103Grill, bake or steam your food101

regular exercise1,3,4,5,8,106Eat fresh fruits2,6,9,104Limit sweet and added sugars101

have your family checked1,82Eat vegetables2,6,9,104Drink water91

regular check ups1,2,7,9,4Exercise for 30 minutes2,62Do not eat lot of red meat91

reduce salt intake11Drink water91Regular check up21

stop smoking2,6,83Do not eat lot of red meat91Join a support group21

limit fat intake2,9,103Regular check up21Eat healthy51

limit salt intake2,9,103Join a support group21Avoid salty foods (biltong; chips; take aways; stock cubes; sauces and cheese)101

Eat fresh fruits2,6,9,104Eat healthy51

Eat vegetables2,6,9,104Avoid salty foods (biltong; chips; take aways; stock cubes; sauces and cheese)101

Exercise for 30 minutes2,62

Join gym21

Walk21

Run21

Keep the benefits of treatment in mind daily21

Drink water91

Do not eat lot of red meat91

Meet with your doctor or caregiver regularly21

Join a support group21

Stop drinking31

Tobacco control41

Eat healthy51

limit alcohol intake101

Avoid salty foods101

Tinned, processed and preserved food are high in sodium101

Avoid salty foods (biltong; chips; take aways; stock cubes; sauces and cheese)101

Do not add salt to food101

Avoid salty foods (biltong; chips; take aways; stock cubes; sauces and cheese)101

COMPLICATIONS OF UNCONTROLLED HYPERTENSION:COMPLICATIONS OF UNCONTROLLED HYPERTENSION:FrequencyCategoriesFrequency

Heart attack1,102Stroke6

Heart failure1,102Heart failure1,102Kidney disease4

Stroke1,2,4,7,9,106Stroke1,2,4,7,9,106Heart attack4

Kidney disease1,192Kidney disease1,2,4,94Blindness3

Silent Killer1,72Silent Killer1,72Heart failure2

Blindness2,102Blindness2,10,43Silent killer2

Arteriosclerosis21Death2,102Death2

Atherosclerosis21Heart attack2,4,7,104difficulty in breathing21

Aorta Aneurism21difficulty in breathing21Swollen legs21

Death2,102Swollen legs21

Heart attack2,4,7,104

Lungs fill up with fluid leading to difficulty in breathing21

Fluid retension21

Swollen legs21

Kidney Failure2,42

Eye damage41

RISK FACTORS TO HYPERTESNION:RISK FACTORS TO HYPERTESNION:FrequencyCategoriesFrequency

High salt intake1,3,2High salt intake1,3,2Overweight1,2,4,11,125

High calorie intake11High calorie intake11smoking1,2,3,4,4

weight11Diabetes (insulin resistant)11Stress1,2,3,3

Diabetes (insulin resistant)11smoking1,2,3,4,4Lack of excersise2,3,43

smoking1,2,3,4,4Alcohol1,22African3,42

Alcohol1,22Stress1,2,3,3Family history3,42

Stress1,3,2Obesity3,42

Poor eating habits21Overweight1,2,4,11,125Unhealthy diet 2,32

Overweight2,4,11,124Aged between 35 and 55 men2,32Excessive drinking3,42

High stress level21menopause women21Aged between 35 and 55 men2,32

Do not excersize21woman above 4521Alcohol1,22

Aged between 35 and 55 men2,32Excessive drinking3,42High salt intake1,3,2

menopause women21Unhealthy diet 2,32High calorie intake11

woman above 4521Obesity3,42Diabetes (insulin resistant)11

Excessive drinking3,42High cholesterol31menopause women21

Unhealthy diet31Lack of excersise2,3,43woman above 4521

Obesity3,42African3,42High cholesterol31

High cholesterol31Old age31Old age31

Lack of excersise3,42Family history3,42

African3,42

Old age31

Family history3,42

words per syllable

One syllableTwo syllablesThree syllablesFour syllablesFive syllablesMore than six syllables

skip0high blood13Blood pressure13High blood pressure11menopause women5physical activity18

pill10Headaches12tiredness3hypertension7avoid processed food10don't run out on of medication18

take0dizzy7margarine0vegetables6stressful emotions15one teaspoon of salt a day 1

drink7reduce4regular3keep appointments10comply with treatment20avoid restaurant food4

keep1Chronic 5everyday5incurable4eat avocado0exercise for 30 minutes18

stick1chest pain0no muffins0silent killer13high cholesterol15poor eyesight (retinopathy)3

time3treatment8no vetkoek1shortness of breath3Normal blood pressure 14blocked arteries (coronary artery disease)6

legs0better0genetic3unhealthy diet7Pre-hypertension 2damaged internal organs3

eat5feeling1No symptoms4check blood pressure 16reduce alcohol20don't borrow medication10

food8little0canola1no cigarettes5take medication correctly18

weight11no salt 5tobacco11no aromat2can damaged internal organsDupl

salt17tennis0history4obesity7more common in African4

spice1change diet6calorie1read ingredients1

add0less starch1less sugar0avoid fast-food7

eat3no salt Duplheart failure 8lead to blindness0

oil6swelling0 poor eye sight3no bunny chow0

add0less sweets0lifestyle change12know blood pressure 6

fast0less beef0read labels2brick margrine0

boil2less cheese0overweight9check blood pressureDupl

grill3less spice0diabetes6

fry2diet5no fat cakes0

die0do not no stock cubes0

eye0chicken3stop smoking12

poor0sodium2heart failureDupl

age2walking7

stroke13running2

death5cleaning1

groups1cooking2

herbs0level0

beans0support2

limit0

healthy1

spinach0

peanuts0

control0

intake0

ageing1

biltong0

tinned0

women0

drinking0

adding0

steam food0

avoid stress3

heart attack2

check-ups2

frequency of words selected

SYLLABLE 1FREQUENCYSYLLABLE 2FREQUENCYSYLLABLE 3FREQUENCYSYLLABLE 4FREQUENCYSYLLABLE 5FREQUENCYSYLLABLE 6 & MoreFREQUENCY

salt17high blood13Blood pressure13check blood pressure 16comply with treatment20physical activity18

stroke13Headaches12stop smoking12silent killer13reduce alcohol20don't run out on of medication18

weight11dizzy7lifestyle change12keep appointments10stressful emotions15take medication correctly18

pill10walking7tobacco11hypertension7high cholesterol15exercise for 30 minutes18

food8change diet6overweight9unhealthy diet7Normal blood pressure 14don't borrow medication10

drink7Chronic 5heart failure 8obesity7avoid processed food10blocked arteries (coronary artery disease)6

oil6no salt 5diabetes6avoid fast-food7menopause women5avoid restaurant food4

eat5diet5everyday5vegetables6Pre-hypertension 2more common in African4

death5reduce4No symptoms4know blood pressure 6poor eyesight (retinopathy)3

time3chicken3history4no cigarettes5damaged internal organs3

eat3avoid stress3tiredness3incurable4one teaspoon of salt a day 1

grill3sodium2regular3shortness of breath3

age2running2genetic3no aromat2

boil2cooking2 poor eye sight3read ingredients1

keep1support2read labels2

stick1heart attack2no vetkoek1

spice1check-ups2canola1

groups1feeling1calorie1

less starch1

cleaning1

healthy1

ageing1

TOOLS

sylable 1 sylable 4ADMINISTERING

sylable 2sylabl 51. Print the list in 18-point font or greater

sylable 3sylable 6 more2. Introduce the hypertension literacy assessment tool to the person. The words read and test should be avoided when introducing and administering the literacy assessment tool. The following statement can be used to introduce the tool:

"sometimes in the health care system, medical words are used for hypertension, that many people arre nto familiar with." "I would like to get an idea of what hypertension medical words you are familiar with."

Name:Grade completed:3. Give the person the list of the hypertension literacy assessment tool words. Point to the first word and ask the person to read the 11 words out loud. Be sensitive to dialect, accent and articulation problems.

Date of Birth:4. If the person takes more than five seconds on a word, they should be encouaged to move on to the next word (e.g. Say "Lets try the next word". ) if the person begins to miss every word or appears to be struggling or frustrated, tell them, "Just look down the list and say the words you know."

Date: Examiner:

Reading level:Clinic:SCORING

lifestyle changeUse the hypertension literacy examiner to record the outcome of the test. The first 3 Words of the test are not scored. Count as an error any word that is not attempted or is mispronounced. Place a check mark ("√") next to each word a person pronounces correctly ,and an "X" next to each word a person dooes not attempt or mispronounces. Those with a score of 6 or less should be considered to be at risk for hypertension health literacy.

saltsilent killerpronounced incorrectly

strokecomply with treatment

weightreduce alcohol

Headachesphysical activity

Blood pressure

stop smoking

Salt, Stroke, Weight are not scored. A score of 6 or less is used to identify patients with poor literacy

SCORE

Name Grade completed:ADMINISTERING

Date of Birth:1. Print the list in 18-point font or greater

Date: Examiner:2. Introduce the hypertension literacy assessment tool to the person. The words read and test should be avoided when introducing and administering the literacy assessment tool. The following statement can be used to introduce the tool:

Reading level:Clinic:"sometimes in the health care system, medical words are used for hypertension, that many people arre nto familiar with." "I would like to get an idea of what hypertension medical words you are familiar with."

3. Give the person the list of the hypertension literacy assessment tool words. Point to the first word and ask the person to read the 11 words out loud. Be sensitive to dialect, accent and articulation problems.

pillheart failure 4. If the person takes more than five seconds on a word, they should be encouaged to move on to the next word (e.g. Say "Lets try the next word". ) if the person begins to miss every word or appears to be struggling or frustrated, tell them, "Just look down the list and say the words you know."

foodkeep appointments

drinkhypertensionSCORING

dizzystressful emotionsUse the hypertension literacy examiner to record the outcome of the test. The first 3 Words of the test are not scored. Count as an error any word that is not attempted or is mispronounced. Place a check mark ("√") next to each word a person pronounces correctly ,and an "X" next to each word a person dooes not attempt or mispronounces. Those with a score of 6 or less should be considered to be at risk for hypertension health literacy.

tobaccodon't run out on of medicationpronounced incorrectly

overweight


SCORE

Name:Grade completed:ADMINISTERING

Date of Birth:1. Print the list in 18-point font or greater

Date: Examiner:2. Introduce the hypertension literacy assessment tool to the person. The words read and test should be avoided when introducing and administering the literacy assessment tool. The following statement can be used to introduce the tool:

Reading level:Clinic:"sometimes in the health care system, medical words are used for hypertension, that many people arre nto familiar with." "I would like to get an idea of what hypertension medical words you are familiar with."

oilavoid fast-food3. Give the person the list of the hypertension literacy assessment tool words. Point to the first word and ask the person to read the 11 words out loud. Be sensitive to dialect, accent and articulation problems.

eatknow blood pressure 4. If the person takes more than five seconds on a word, they should be encouaged to move on to the next word (e.g. Say "Lets try the next word". ) if the person begins to miss every word or appears to be struggling or frustrated, tell them, "Just look down the list and say the words you know."

change dietavoid processed food

no salt take medication correctlySCORING

No symptomsdon't borrow medicationUse the hypertension literacy examiner to record the outcome of the test. The first 3 Words of the test are not scored. Count as an error any word that is not attempted or is mispronounced. Place a check mark ("√") next to each word a person pronounces correctly ,and an "X" next to each word a person dooes not attempt or mispronounces. Those with a score of 6 or less should be considered to be at risk for hypertension health literacy.

read labelspronounced incorrectly


SCORE

validation panel

TOOL 1FREQUENCYTOOL 2FREQUENCYTOOL 3FREQUENCYColumn1Column2Column3Column4Column5Column6Column7Column8Column9

Prof Nurse,Univeristy educator, community nurseOslinah1Prof Nurse, DialisisLawrah1Prof Nurse, cardio ICUThabiso Bale1TOOL 1FRQ

Prof Nurse,Univeristy educator, community nurseEvelyn2Prof Nurse,Univeristy educator, community nurse, Gayle2Prof Nurse, community nurse,University educatorGeorge Senyolo2Prof Nurse,Univeristy educator, community nurse1

Prof Nurse,Univeristy educator, community nurse, chronic diseasesGert Matshoge3Prof Nurse, Community nurse, PHCDineo Mokoena3Hypertension specialistDr Vicki3Prof Nurse,Univeristy educator, community nurse2

Prof Nurse,BotswanaMosiiwa O4Health PromoterGrita4Health Promotion specialistKhensani Lebese4Prof Nurse,Univeristy educator, community nurse, chronic diseases3

Prof Nurse,hypertension specialistAgnes Maseko5Prof Nurse, Community nurse, PHCKhumalo Mosa5Prof Nurse,Botswana4

PharmacistMagareth6Health PromoterJoyce6Prof Nurse,hypertension specialist5

Prof Nurse,Univeristy educator, community nurseSana Mataboge7Health PromoterThndi7Pharmacist6

Prof Nurse,Univeristy educator, community nurse, developer of REALMR SAZelda 8Prof Nurse,Univeristy educator, community nurse7

Prof Nurse, Community nurse, PHCThenjiwe Lebese9Prof Nurse,Univeristy educator, community nurse, developer of REALMR SA8

Prof Nurse, Community nurse, PHCTshiamo Ramalepa10Prof Nurse, Community nurse, PHC9

Dr Mpe, cardiologistDr Martin Mpe11Prof Nurse, Community nurse, PHC10

Prof Nurse, Community nurse, PHCSr Zuma12Dr Mpe, cardiologist11

Health PromotionMr Mncube13Prof Nurse, Community nurse, PHC12

Health PromoterBen 14Health Promotion13

Health PromoterSalaminah15Health Promoter14

Prof Nurse Cardio ThoracicRudzani Ramaru16Health Promoter15

Nutritionist,Health promotion expext, heart stroke foundation SAJessica Byrne17Prof Nurse Cardio Thoracic16

Prof Nurse, Critical care, didaticsDr van Belkum18Nutritionist,Health promotion expext, heart stroke foundation SA17

Prof Nurse,Univeristy educator, community nurse, chronic diseasesMartjie Devilliers19Prof Nurse, Critical care, didatics18

Prof Nurse,Univeristy educator, community nurse, chronic diseases19

Column4Column5Column6TOOL 3FRQ

TOOL 2FRQProf Nurse, cardio ICU1

Prof Nurse, 1Prof Nurse, community nurse,University educator2

Prof Nurse,Univeristy educator, community nurse, 2Hypertension specialist3

Prof Nurse, Community nurse, PHC3Health Promotion specialist4

Health Promoter4Prof Nurse, Community nurse, PHC5

Health Promoter6

Health Promoter7


• Phase 3: of the modified Delphi technique involved development of the HHLAT

• REALM-R, the tool has 11 words. Three of these always have one syllable and the other eight have between two and six syllables.

• To decide on the 11 words, phrases and concepts, the words, phrases and concepts with the highest scores (5 and above) were considered.

• Words, phrases and concepts with scores below 5 were not considered. • For example, the highest scores of words, phrases and concepts with

between one and six syllables were considered for the development of tool 1.

• 3 tools were developed

SYLLABLE 1

FREQ1

SYLLABLE 2

FREQ2

SYLLABLE 3

FREQ3

SYLLABLE 4

FREQ4

SYLLABLE 5

FREQ5

SYLLABLE 6 & More

FREQ6

salt

17

high blood

13

Blood pressure

13

Check blood pressure

16

comply with treatment

20

physical activity

18

stroke

13

Headaches

12

stop smoking

12

silent killer

13

reduce alcohol

20

don't run out on of medication

18

weight

11

dizzy

7

lifestyle change

12

keep appointments

10

stressful emotions

15

take medication correctly

18

pill

10

walking

7

tobacco

11

hypertension

7

high cholesterol

15

exercise for 30 minutes

18

food

8

change diet

6

overweight

9

unhealthy diet

7

Normal blood pressure

14

don't borrow medication

10

drink

7

heart failure

8

obesity

7

avoid processed food

10

blocked arteries (coronary artery disease)

6

oil

6

diabetes

6

avoid fast-food

7

vegetables

6

know blood pressure

6

Patient file number: ____________ School grade completed: ______________

Date of birth: _______/______/____Name of the clinic: _________________

LAB reading level: _________________

Examiner: _________________________

Date of assessment: _______/______/_______

Salt

Stroke

Weight

Headaches________

Blood pressure_____

Stop smoking______

Lifestyle change____

Silent killer_________

Physical activity_____

Comply with treatment___

Reduce alcohol intake____

Salt, stroke, and weight are not scored. A score of 6 or less is used to identify patient at risk for poor hypertension health literacy.

Score: /8


Round 4: face validation of the HHLAT, 2nd group of experts

The 3 tools along with informed consent via- email was sent to 50 prospective participants, 60 days to respond

Responses recorded in a frequency distribution, only 30 responded.

The selected tool was then pretested in 5 patients in a PHC

DATA COLLECTION AND ANALYSIS PHASE 3

• 195 patients in 4 PHC conveniently selected with hypertension using the newly developed HHLAT & the LAB

• Secured a private room, asked to pronounce out loud words/phrases/concept as they appear on the tool

• Taking more than 5 sec they were asked to “pass”• A scoring sheet, (√) and (X) incorrect and (-) not attempted• All ticks (√) were added up for final score /8 determining the HHL of the

patient

• Score of 6 or lower considered at risk for poor HHL

VALIDITY AND RELIABILITY

• The REALM-R a validated shortened version of the REALM for PHC settings to identify patients with low health literacy levels at the General Internal Medicine Clinic at the University of Kentucky in the year 2000. The REALM-R has been shown to correlate with a number of other tests used in health to determine health literacy, such as WRAT-R, TOFHLA, PIAT-R and SORT-R.12 The test–retest reliability of the REALM-R was 0.99. 13

• In round 4 of the tool development, the validation panel evaluated the tool to ensure face validity by expressing their opinion on whether they thought the tool would measure what is supposed to measure.

• For concurrent validity, the HHLAT was administered simultaneously with LAB.

ETHICAL CONSIDERATION

• The research was given ethical clearance by the Tshwane University of Technology (REF: 2013/06/001 (2) (SCI)

• Gauteng Department of Health (REF: PROJ: 43/2013). • All participants in the study were provided with information leaflet, and they

gave consent prior to participation.

RESULTS

• Tool 1 = 19 (63%); Tool 3 (23%) Tool 2 ( 13%) selected by validation experts• From the 195 (n=123 females; 72 males)• Age 18 to 85• HHLAT indicated 37% of the 195 were at risl for poor hypertension health

literacy

17.7% (f) v 22.2 (m)

• Time to administer less than 2 min• Concurrent validity HHLAT & lab

0

3

6

9

12

LAB

02468

Hypertension Health Literacy Assessment Tool

LABFitted values

Regression of LAB on HHLAT

DISCUSSION

• The Delphi technique has been found to be suitable for examining health promotion and health education

• Considering that men (72) representing quarter of the total sample posed a higher risk (22.2%) of being at risk for poor hypertension health literacy.

• Poor health literacy is associated with poor health status those with poor health literacy are at risk for frequently using emergency rooms, missing hospital appointments and having a record of poor compliance.

• The association between the HHLAT and the LAB was confirmed by fitting a linear regression model of LAB on the HHLAT.

CONCLUSION

• Determining the hypertension health literacy levels of patients will enable the health care provider to specifically individualise their health education.

• Further research is required to investigate the compliance to pharmacological and non-pharmacological management related to hypertension as this findings indicate that most (81%) of the participants are hypertension health literate while the country is experiencing poor control of hypertension.

• What still need to be further explored is whether they use this knowledge to live a healthy lifestyle and comply with the management of hypertension.

Development of a Hypertension Health Literacy Assessment Tool for use in primary health care (PHC) clinics in South Africa, GautengINTRODUCTION & BACKGROUNDINTRODUCTION & BACKGROUNDINTRODUCTION & BACKGROUNDMANAGEMENT OF HYPERTENSIONHEALTH EDUCATION & HEALTH LITERACYPROBLEM STATEMENT & SIGNIFICANCEASSESSMENT TOOLS PURPOSE OF THE STUDY OBJECTIVESRESEARCH QUESTIONSFRAMEWORKMETHODS & DESIGNPOPULATION & SAMPLING STRATEGYPOPULATION & SAMPLING STRATEGYPOPULATION & SAMPLING STRATEGYRESEARCH SETTINGPHASE 1: DATA COLLECTION & ANALYSISPHASE 1: DATA COLLECTION & ANALYSISPHASE 2: DATA COLLECTION & ANALYSISPHASE 2: DATA COLLECTION & ANALYSISPHASE 2: DATA COLLECTION & ANALYSISDATA COLLECTION AND ANALYSIS PHASE 3VALIDITY AND RELIABILITYETHICAL CONSIDERATIONRESULTSDISCUSSIONCONCLUSION

development of a hypertension health literacy assessment ......• tool 1 = 19 (63%); tool 3 (23%)...

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