Intern Emerg Med
DOI 10.1007/s11739-017-1651-7
IM - ORIGINAL
Association between health literacy and hypertension
management in a Chinese community: a retrospective cohort
study
Di Shi1 • Jiangbo Li1 • Yong Wang1 • Si Wang1 • Kai Liu1 • Rufeng Shi1
Qiang Zhang1 • Xiaoping Chen1
Received: 12 January 2017 / Accepted: 8 March 2017
Ó SIMI 2017
Abstract Low health literacy is associated with poor
clinical outcomes. The relationship between literacy and
blood pressure (BP) has been inconsistent. We investigated
the determinants of health literacy and the potential rela-
tionship between health literacy and hypertension man-
agement. We conducted a retrospective cohort trial of 360
hypertensive patients. Scale measurements, physical
examination, and laboratory tests were performed based on
a standard protocol. To determine factors associated with
health literacy, multiple logistic regression analysis was
performed and the discriminatory power of the scale score
for hypertension control was assessed by the area under the
receiver operating curve. After adjusting for potential
confounders, our findings show that the level of education,
home blood pressure measurement, regular medication,
and systolic blood pressure are significantly associated with
health literacy. Moreover, patients with high health literacy
have better hypertension control, a lower risk of ischemic
cardiovascular disease (ICVD), lower brachial an-
kle pulse wave velocity values, and better health-related
quality of life. In addition, our study also demonstrates that
we can identify the health literacy level of hypertensive
patients using the Chinese Health Literacy Scale for
Hypertension. At a cut-off value of 13.5, we predict that
patients will achieve long-term hypertension control.
Adequate health literacy is a contributing factor to better
blood pressure (BP) control and better perceived quality of
D. Shi and J. Li contributed to this work equally.
& Xiaoping Chen
echoshih@163.com
1
Department of Cardiology, West China Hospital, Sichuan
University, Chengdu 610041, China
•
life in hypertensive patients. Low health literacy increases
the 10-year risk of ICVD and incidence of artery stiffness
in hypertensive patients. Improving health literacy should
be considered an important part of the management of
hypertension.
Keywords Health literacy
Hypertension
Home blood
pressure
Blood pressure control
Introduction
Health literacy is currently defined as ‘‘the degree to which
people are able to access, understand, appraise and com-
municate information to engage with the demands of dif-
ferent health contexts in order to promote and maintain
good health across the life-course [1].’’ Low health literacy
is a significant problem in patients with chronic diseases.
An important feature of low health literacy is that people
find it difficult to read the drug labels, and to understand
the registration card of physical examinations and health
education information [1, 2]. Moreover, a higher degree of
education does not necessarily indicate a higher level of
health literacy.
A number of studies demonstrate that the health literacy
level independently predicts patients’ health-related
knowledge, behaviors (such as medication compliance),
and self-reported health status [3–6]. These factors can
make great contributions to important clinical outcomes;
however, the relationship between literacy and blood
pressure (BP) has been inconsistent. Several studies show
that higher health literacy is associated with better BP
control [5, 7], but two studies report that higher health
literacy is associated with worse BP in veterans with
hypertension [8, 9]. The inconsistency of these results may
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be attributed to different models of healthcare delivery
systems.
To better understand determinants of health literacy and
the potential relationship between health literacy and
hypertension management in the healthcare system of
China, we adapted and created a Chinese health literacy
scale for hypertension, which had no cultural differences
and language barriers for a Chinese-speaking population.
We hypothesize that high health literacy is associated with
better BP control in hypertensive patients.
Methods
Related definitions
Hypertension was defined as a systolic blood pressure
(SBP) of at least 140 mmHg, or a diastolic blood pressure
(DBP) of at least 90 mmHg, or currently taking anti-hy-
pertensive medications. Diabetes mellitus was defined as
follows: (1) fasting plasma glucose C7.0 mmol/L; (2) a
positive response to the question, ‘‘Has a doctor ever told
you that you have diabetes;?’’, or (3) current use of insulin
or oral hypoglycemic agents. Smoking was defined as an
average cigarette consumption of at least 1 cigarette per
day. Alcohol intake was defined as an average intake of
alcohol of at least 50 g/day. Physical activity was defined
as performing moderate intensity of 3–6 METs aerobic
physical activity (e.g., Walking briskly, ballroom dancing,
and slow cycling) 3 or more times per week (at least
30 min each time). Participants who previously reported a
diagnosis of hypertension or were taking drugs to lower
their BP were classified as ‘patients on target hypertension’
if the SBP was \140 mmHg or the DBP was \90 mmHg
with respect to treatment goals. Long-term hypertension
control was defined as reaching treatment goals at least
9 months during the year.
Study sample
A retrospective study was conducted involving residents
living in the Jinyang community health center in Chengdu,
China. Patients with hypertension were recruited from
consecutive participants undergoing health check-ups in
the community between September 2014 and May 2015
(n = 523). Three hundred sixty patients who understood
the correct measurement of home blood pressure were
enrolled in the study.
Personal characteristics included physical examinations
(involved assessments of height, weight, and waist cir-
cumference), socio-demographic characteristics (e.g., age,
gender, marital status, education level, work status, and
monthly income), and clinical data (e.g., smoking status,
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Intern Emerg Med
alcohol consumption level, exercise habits, history of dia-
betes mellitus, history of hypertension, and use of anti-
hypertensive drugs). The presence of co-morbidities was
based on self-reported records acknowledged by the study
participants. The body mass index (BMI) was calculated
using the following formula: weight/height2 (kg/m2).
Fasting plasma glucose (FPG), fasting serum total choles-
terol (TC), low-density lipoprotein cholesterol (LDL-C),
high-density lipoprotein cholesterol (HDL-C), and
triglycerides (TG) were included. Blood was drawn from
the antecubital vein in the morning after a 12-h fast and
subsequently analyzed using an automatic biochemical
analyzer (Glamour 1800; MD, Muskegon, MI, USA).
Measures
Home blood pressure measurement (HBPM)
During the visit, all participants were shown how to self-
measure BP. All devices for use at home were evaluated
and validated according to international standardized pro-
tocols [10]. Four BP measures were obtained each day
[twice in the morning (\1 h after awakening and empty-
ing the bladder) and twice in the evening (near bedtime)],
for at least 3–4 days, and preferably for seven consecutive
days as proposed by the European Society of Hypertension
[11]. Instructions were given to have the two measures
performed after at least 5 min of rest in a sitting position
and separated by 2-min intervals. Participants had to record
all BP readings in a logbook that consisted of three pages
(one for each day) with two parts: ‘‘morning measure 1–2’’
and ‘‘evening measure 1–2.’’ As in previous studies,
HBPM was considered successful when at least 12 mea-
sures of 18 were properly performed [12]. We collected
patients’ logbooks containing the BP values during the past
year.
Chinese health literacy scale for hypertension (CHLSH)
We designed the CHLSH to measure the health literacy of
patients with hypertension, which was based on four cog-
nitive levels, according to the revised Bloom’s Taxonomy:
remembering; understanding; applying; and analyzing [13].
The ‘remembering’ subscale measures an individual’s
ability to read aloud commonly used terms frequently seen
in printed educational leaflets or information sheets in
hypertensive management. First, we reviewed some pre-
vious studies, the 2014 Commentary on Chinese Guideli-
nes for the Management of Hypertension in the
Community and the 2010 Chinese Guidelines for the
Management of Hypertension, and collected questionnaires
from five hypertensive patients [14–18]. Then, we selected
Intern Emerg Med
80 items as initial items of ‘remembering.’ Next, the
research team invited two professors of cardiology from
the West China Hospital, three general practitioners from
the community health center, two community nurses, one
community pharmacist, and one clinical laboratory physi-
cian to score each item using the Delphi technique [19].
The scoring criteria were as follows: 5, the most relevant to
hypertension care and 1, the least relevant to hypertension.
Items scoring 4 or 5 were included in the second round of
rating. The experts then rated the items a second and third
time. Finally, ten items that best represent the usual prac-
tice in communication with patients were selected.
The other three subscales (understanding, applying, and
analyzing) were developed based on situations in daily
hypertension management in which patients need to make
decisions. These situations included prescription, patient
education information, and instructions on drug use. These
three subscales included a total of 14 items, as follows: 7
questions for understanding; 3 questions for applying; and
4 questions for analyzing. The experts reviewed and rated
the draft questions. The experts considered whether or not
the chosen labels and questions represented actual situa-
tions encountered by patients with hypertension in a Chi-
nese community, and whether or not the labels and
questions were clearly stated. These items subsequently
became the subscales of understanding, applying, and
analyzing.
Power calculation and participants
In general, a reliable scale requires a Cronbach’s alpha
C0.70. The effect size was estimated to be 0.26 if the
Cronbach’s alpha of our scale was 0.80 [20]. With this
effect size, an alpha level = 0.05, and a power = 0.8, the
calculated sample size was 109 [21]. General practitioners
who work in Jinyang Community Health Center of
Chengdu assisted with subject recruitment. We recruited
140 participants from Jinyang Community Health Center in
Chengdu between March and June 2014.
Pilot study and analysis
Sixty-eight subjects from a total of 140 participants vol-
unteered for the pilot study, which aimed to refine the
questionnaire, assess the time needed to complete the
CHLSH, and assess the clarity of the draft questionnaire.
According to the results of the pilot study, we made
appropriate modifications about the items which were not
clearly stated.
We assessed several psychometric properties of the
CHLSH, including item analysis, construct validity,
discriminative ability, test–retest reliability, and corre-
lation with the other two relevant scales. Items that had
low corrected item-total correlation coefficients were
screened out. We used Cronbach’s alpha to assess the
internal consistency of each subscale and the CHLSH.
Items that all subjects answered correctly were dropped.
Then, we calculated the Cronbach’s alpha for each
subscale again. We compared the alpha of the deleted
item with the Cronbach’s alpha of the subscale. The
alpha of the deleted item represented the overall relia-
bility coefficient for internal consistency of the subscale
if an individual item was removed from the subscale. If
the alpha was greater than the overall alpha of the cor-
responding subscale, we dropped the item and recalcu-
lated the Cronbach’s alpha. We repeated the procedure
until no item could be dropped. Confirmatory factor
analysis was conducted to assess the number of sub-
scales in the CHLSH. Pearson correlations were calcu-
lated to test the relationships between the CHLSH and
the other two scales. Test–retest reliability was calcu-
lated by Pearson correlation to test the reliability of the
scale during a period of 2 weeks.
Demographics of the Respondents
One hundred forty participants completed the CHLSH and
other scales. Then, we received all information again,
including the demographic information, from 132 respon-
dents. The age range of participants was 31–88 years. Of
the participants, 52.3% were female. Approximately 16.7%
of respondents had only completed primary school, 32.6%
had completed secondary school (middle school, 32.6%;
high school, 21.2%), and 29.5% had completed higher
education. The course of hypertension and work status of
respondents was also collected, and is shown in Table 1.
Construct validity assessment
There were 10 items in the remembering subscale, 7 in the
understanding subscale, 3 in the applying subscale, and 4 in
the analyzing subscale (24 items in total) in the originally
designed CHLSH (model 1 in Table 2). After the pilot
study, we eliminated the six items that were answered
correctly by all respondents in the remembering subscale;
the Cronbach’s alpha was 0.882 (model 2 in Table 2). In
the other three subscales (understanding, applying, and
analyzing), no item was dropped and the Cronbach’s alpha
values were 0.686, 0.771, and 0.691, respectively
(Table 2). The Cronbach’s alpha of the final CHLSH scale
with 18 items was 0.878. We carried out confirmatory
factor analysis after item elimination and derived a model
with RMSEA = 0.009 and CFI = 0.982, indicating that
the presence of the four subscales in the CHLSH. The
factor loading of the four subscales of CHLSH is shown in
Table 3.
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 Intern Emerg Med

Table 1 Demographics of study participants (n = 132) Table 3 Factor loading of the CHLSH subscales
Items n % Items Remembering Understanding Applying Analyzing

Sex Male 63 47.7 1 0.605

Female 69 52.3 2 0.853
Age(years) B50 32 24.2 3 0.364
51–60 29 21.9 4 0.703
61–70 37 28.0 5 0.430
C71 34 25.7 6 0.680
Marital status Married 120 90.9 7 0.804
Divorced 11 8.3 8 0.838
Unmarried 1 0.8 9 0.786
Education level Primary school 22 16.7 10 0.767
Middle school 43 32.6 11 0.651
High school 28 21.2 12 0.807
Higher education 39 29.5 13 0.801
Working state On job 47 35.6 14 0.653
Retiring 65 49.2 15 0.782
Jobless 20 15.2 16 0.892
Course of hypertension (years) B1 27 20.4 17 0.835
1–5 32 24.2 18 0.877
6–10 27 20.4 CHLSH Chinese Health Literacy Scale for Hypertension
11–20 31 23.5
C20 15 11.4

Understanding was significantly correlated with applying

(r = 0.77, p \ 0.001) and analyzing (r = 0.56, p \ 0.001),
Table 2 Item analysis of the CHLSH and its subscales
whereas applying was significantly correlated with analyz-
ing (r = 0.48, p \ 0.001). The CHLSH had high internal
Scale Model 1 Model 2 consistency (Cronbach’s alpha = 0.94), and test–retest
Items (n) a Items (n) a reliability during a 3-week period was good (r = 0.82;
p \ 0.001; Table 4).
CHLSH 24 18 0.878
Remembering 10 0.851 4 0.882
Correlation with two relevant scales
Understanding 7 0.686 7 0.686
Applying 3 0.771 3 0.771
We tested the correlations between CHLSH and two other
Analyzing 4 0.691 4 0.691
scales [the Health Literacy Scale for Chronic Care
CHLSH Chinese Health Literacy Scale for Hypertension (HLSCC) and the High Blood Pressure-Health Literacy
Scale (HBP-HLS)] [22, 23]. The first measure is a vali-
dated Chinese scale that assesses knowledge of chronic
We reviewed the CHLSH relationship with age and edu- diseases and ability and self-confidence in chronic disease
cational level to assess discriminative ability. management. The latter measure is used for evaluating
There was a negative correlation between the CHLSH and hypertension management interventions in the community
age (r = -0.28, p \ 0.001). The CHLSH scores were setting. The HLSCC had good internal consistency
compared among participants with different educational (Cronbach’s alpha = 0.91) and good test–retest reliability
levels, as follows: primary school (M = 34.3, SD = 9.7); (r = 0.77, p \ 0.01) during a period of 3 weeks in the
middle school (M = 37.5, SD = 8.3); high school Chinese population of Hong Kong. The HBP-HLS was
(M = 41.6, SD = 4.6); and higher education (M = 44.5, developed and validated among hypertensive Korean
SD = 3.2; F = 20.18, p \ 0.001). We also calculated the Americans, and shown to have good internal consistency
relationship between each of the four subscales. The (Kuder-Richardson-20 coefficient = 0.98).
remembering subscale was significantly correlated with The CHLSH had a significant positive correlation with
understanding (r = 0.82, p \ 0.001), applying (r = -0.53, the HBP-HLS (r = 0.67, p \ 0.001) and the HLSCD
p \ 0.05), and analyzing (r = 0.48, p \ 0.001). (r = 0.45, p \ 0.001). The remembering subscale had a

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Intern Emerg Med

Table 4 Results of validity and reliability of the CHLSH C80%: 18 9 80% = 14.4) and a low health literacy
Discriminant validity M (SD) Coefficient
group [(LLG); the correct answer rate was B80%].
This grouping method was based on the China’s
Age r = -0.28** Ministry of Health used in a previous investigation
Education level F = 20.18** [24].
Primary school 34.3 (9.7)
Middle school 37.5 (8.3) Arterial stiffness measurements
High school 41.6 (4.6)
Higher education 44.5 (3.2) Brachial ankle pulse wave velocity (baPWV) was mea-
Reliability Cronbach’s a sured by an automatic device (VP1000; Colin Co., Ltd.,
Overall scale 0.94 Komaki, Japan) with an appropriate size cuff. For at least
Subscale 5 min before the test, each subject rested in the supine
Remembering 0.90 position in a room at 25 °C. Participants were instructed
Understanding 0.67 to refrain from consuming food, tea, and caffeine or
Applying 0.56 smoking for 3 h before the measurements, and also to
Analyzing 0.51 refrain from consuming alcohol for 24 h before the
Test–retest reliability r measurements. The device simultaneously recorded PWV,
Overall scale 0.82** BP, electrocardiogram records, and heart rate (HR).
Subscale Detailed information for baPWV measurements has been
Remembering 0.92** reported elsewhere [25].
Understanding 0.60**
Applying 0.43* Other tools
Analyzing 0.49**
We used the 10-year risk for ischemic cardiovascular
Pearson’s correlation was used to assess the relationship between
disease (ICVD) to evaluate the risk of cardiovascular
CHLSH and age. Analysis of variance was used to assess the rela-
tionship between CHLSH and education level events. ICVD is a cardiovascular risk prediction model
CHLSH Chinese Health Literacy Scale for Hypertension appropriate for the Chinese population [26]. In addition,
* p \ 0.05, ** p \ 0.001 we used the Medical Outcome Study Short-Form 36-Item
Health Survey (SF-36 scale) to evaluate the association
between health literacy and health-related quality of life
Table 5 Pearson correlations of the CHLSH and its subscales with (HRQOL) [27]. The SF-36 evaluates the following eight
other measures physical and mental health areas: physical functioning
HLSCC HBP-HLS (PF); physical role functioning (RP); bodily pain (BP);
general health (GH); vitality (VT); social role functioning
CHLSH 0.45** 0.67** (SF); emotional role functioning (RE); and mental health
Remembering 0.88** 0.76** (MH). Each of the eight areas was scored on a scale of
Understanding 0.63** 0.58** 0–100, in which a higher score indicated a better per-
Applying 0.32** 0.34** ceived quality of life.
Analyzing 0.27* 0.36**
HLSCC Health Literacy Scale for Chronic Care, HBP-HLS High Statistical analyses
Blood Pressure-Health Literacy Scale
* p \ 0.05, ** p \ 0.001 Continuous variables are expressed as the mean ± stan-
dard deviation (SD). Differences in characteristics
between patients with high and low health literacy were
correlation with HLSCD (r = 0.88, p \ 0.001) and HBP- tested by independent t tests for normally distributed
HLS (r = 0.76, p \ 0.001). The other three subscales variables and by the non-parametric Mann–Whitney or
(understanding, applying, and analyzing) also had a cor- Wilcoxon test for skewed variables. Categorical variables
relation with HLSCD and HBP-HLS (Table 5). are expressed as frequencies and percentages. Differences
Finally, a total of 18 items comprised the CHLSH between two groups were tested by a Chi-square test. To
questionnaire. The scale was self-reported records determine factors associated with health literacy, a mul-
acknowledged by study participants. According to the tiple logistic regression analysis was performed to deter-
CHLSH score, we divided patients into a high health mine the OR and 95% CI values, and the discriminatory
literacy group ([HLG]; the correct answer rate was power of the CHLSH score for hypertension control was

123

assessed by the area under the receiver operating curve
(ROC). Covariates, including age, waist circumference
(WC), BMI, FPG, TG, TC, HDL-C, and LDL-C, were
fitted as continuous variables, and gender, alcohol intake,
smoking, regular physical exercise, work status, monthly
income, diabetes, HBPM, hypertension, and anti-hyper-
tensive drug use, were fitted as categorical variables. The
point representing the largest sum of sensitivity and
specificity on the ROC was calculated. The score of
health literacy was split into four quartiles. A comparison
of BP control was conducted across the four quartiles.
The least significant difference (LSD) test for pairwise
comparisons was used when needed. SPSS 19.0 and
MedCalc 11.0 software were used. Statistical significance
was defined as a p \ 0.05.
Results
Factors associated with health literacy
According to the CHLSH score, we divided patients into
HLG and LLG. Compared with those in the LLG, HLG
subjects had more males, a higher education level, fewer
unemployed, higher income, lower SBP, lower TC, and
lower TG, and were more compliant with regular medica-
tion, HBPM, and regular exercise (all p \ 0.05, Table 6).
Multiple logistic regression analysis
After adjustment for confounders (age, WC, BMI, HR,
alcohol intake, smoking, regular exercise, diabetes, mar-
ital status, FPG, TG, TC, HDL-C, and LDL-C), education
level, work status, HBPM, regular medication, and SBP
were still significantly associated with health literacy
(Table 7). Only a middle school education and retired
from work were significantly associated with health lit-
eracy. Thus, subjects in whom their education level was
middle school, whose work status was retired, who did
HBPM, and who took regular medication had better
health literacy. A higher SBP indicated lower health
literacy.
Association between health literacy and long-term
hypertension control
Fifty-two patients who could not provide complete data
were excluded from this analysis. The average BP values
are shown in Table 8. The SBP of the two groups had
significant differences at 1–3, 4–6, 7–9 months, and the
entire year. The DBP of the two groups had no signifi-
cant differences in any quarters of the year. The SBP
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Intern Emerg Med
and DBP of the HLG had a U-shape with seasonal
changes (Fig. 1a, b), while we only observed a U-shape
with seasonal changes for the DBP of the LLG (Fig. 1b).
A comparison of BP control was made across the four
quartiles of health literacy (Fig. 2). With an increased
CHLSH score, the rate of hypertension control became
higher (p \ 0.001).
ROC curves analyses
The areas under the ROC curves were 0.717 (95% CI
0.649–0.786; p \ 0.001) in predicting the target blood
pressure achieved for the entire year, and 0.703 (95% CI
0.633–0.772; p \ 0.001) in predicting the target blood
pressure achieved in at least three quarters of the year
(Table 9). At a cut-off value of 13.5, the highest sensitiv-
ities and specificities were achieved in both of the afore-
mentioned situations (Fig. 3a, b).
Association between health literacy and ICVD
Compared with the HLG, the LLG had a much higher risk
for ICVD (9.7 vs. 6.6%, p \ 0.001; Fig. 4).
Association between health literacy and baPWV
The average baPWV values of the HLG were lower than
the LLG (1605 ± 337 vs. 1946 ± 471 cm/s; p \ 0.05;
Fig. 5).
Association between health literacy and HRQOL
The total SF-36 score in the HLG was higher than the LLG
(593.6 ± 121.8 vs. 523.5 ± 156.7; p \ 0.05).
Discussion
The goal of our study is to identify factors associated with
health literacy and to investigate the association between
health literacy and hypertension management. After
adjusting for potential confounders, we show that educa-
tion level, HBPM, work status, regular medication use, and
SBP are significantly associated with health literacy.
Moreover, patients with high health literacy have better BP
control, a lower risk of ICVD, lower baPWV values, and
better HRQOL. Our study also demonstrates that we can
identify the health literacy level of hypertensive patients
using the CHLSH. At a cut-off value of 13.5, we can
predict that patients will do well in long-term BP control.
A higher degree of education does not necessarily mean a
higher level of health literacy. Our results show that education
Intern Emerg Med

Table 6 Analysis of factors

HLG (n = 161) LLG (n = 199) p
associated with health literacy
Male (n, %) 82 (51.0) 77 (38.7) \0.05
Age (years) 66.6 ± 6.2 66.6 ± 8.3 NS
Marital status (n, %)
Married 160 (99.4) 196 (98.5) NS
Divorce 1 (0.6) 3 (1.5) NS
Unmarried 0 0
Education level (n, %)
Primary school 16 (9.9) 68 (34.2) \0.001
Middle school 42 (26.1) 66 (33.2) \0.001
High school 42 (26.1) 44 (22.1) \0.001
Higher education 61 (37.9) 21 (10.6) \0.001
Work status (n, %)
Employed 29 (18.0) 28 (14.1) \0.001
Retired 109 (67.7) 120 (60.3) \0.05
Unemployed 25 (15.5) 50 (25.1) \0.001
Monthly income (n, %)
\1000 38 (23.6) 50 (25.1) NS
1000-3000 96 (59.6) 90 (47.1) \0.001
[3000 52 (32.3) 34 (17.8) \0.001
Course of hypertension (years) 8.7 ± 7.3 9.8 ± 10.3 NS
Regular medication (n, %)
Yes 138 (85.7) 94 (47.2) \0.001
No 10 (6.2) 41 (20.6) \0.001
No medication 13 (8.1) 64 (32.2) \0.001
HBPM (n, %) 109 (67.7) 55 (27.6) \0.001
Smoking (n, %) 25 (15.5) 27 (13.6) NS
Alcohol intake (n, %) 19 (11.8) 29 (14.6) NS
Regular exercise (n, %) 89 (55.3) 60 (30.2) \0.001
BMI (kg/m2) 24.3 ± 3.0 24.3 ± 3.2 NS
WC (cm) 84.7 ± 9.9 84.3 ± 10.1 NS
Diabetes (n, %) 37 (23.0) 65 (32.7) NS
SBP (mm Hg) 131.0 ± 12.8 144.6 ± 14.4 \0.001
DBP (mm Hg) 75.0 ± 5.8 75.3 ± 6.2 NS
Heart rate (beats/min) 73.1 ± 9.6 73.7 ± 10.2 NS
TC (mmol/L) 4.9 ± 1.1 5.2 ± 1.0 \0.05
HDL-C (mmol/L) 1.5 ± 3.4 1.5 ± 3.4 NS
LDL-C (mmol/L) 2.5 ± 0.7 2.5 ± 0.7 NS
TG (mmol/L) 1.5 ± 0.6 1.7 ± 0.8 \0.05
FPG (mmol/L) 6.1 ± 2.4 6.6 ± 2.9 NS
HLG high health literacy group, LLG low health literacy group, WC Waist circumference, BMI body mass
index, HBPM home blood pressure measurement, FPG fasting plasma glucose, TG triglyceride, TC total
cholesterol, HDL-C high-density lipoprotein cholesterol, LDL-C low-density lipoprotein cholesterol, NS no
statistical significance

level, work status, HBPM, regular medication use, and SBP are
significantly associated with health literacy, which is in
agreement with another study [16]; however, we do not find a
relationship between age and health literacy. The possi-
ble reason is that most patients we recruited are older. It is
possible that we could not demonstrate a statistically signifi-
cant difference in the relatively narrow range of age. In addi-
tion, only retirement is significantly associated with health
literacy, which suggests that the retired have more time to care
about their own health.

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 Intern Emerg Med

Table 7 Multiple logistic

B SE Wald P OR
regression analysis of factors
associated with health literacy Sex 0.133 0.482 0.082 NS 1.225
Age -0.008 0.047 0.363 NS 0.966
Education level (compared with primary school) 9.705 \0.05
Middle school -1.891 0.687 9.623 \0.05 0.194
High school -1.371 0.457 4.782 NS 0.442
Higher education -0.908 0.544 2.786 NS 0.403
Work status (compared with unemployed) 8.376 \0.05
Employed 1.752 0.562 3.644 NS 0.769
Retired 1.964 0.535 5.773 \0.05 1.064
Monthly income (compared with \1000) 2.696 NS
1000–3000 -1.273 0.813 5.273 NS 1.543
[3000 -0.879 0.668 3.273 NS 1.033
Course of hypertension 0.083 0.231 0.080 NS 1.023
HBPM (yes or no) 1.301 0.379 11.535 \0.05 3.769
Medication (yes or no) 7.473 \0.05
Regular medication 1.497 622 5.443 \0.05 3.618
Irregular medication 0.085 0.956 0.042 NS 1.116
SBP (mm Hg) -0.094 0.053 12.571 \0.05 0.977
Constant 6.877 2.845 6.583 \0.05 1072
B partial regression coefficients, SE standard error, Wald Chi-square value, OR odds ratios, NS no statistical
significance

Table 8 Average BP values of

HLG (n = 170) LLG (n = 138)
the two groups in the past year
SBP (mm Hg) DBP (mm Hg) SBP (mm Hg) DBP (mm Hg)

1– 3 month 136.7 ± 14.5 75.0 ± 7.9 154.7 ± 16.1* 75.8 ± 9.1

4–6 month 127.5 ± 12.3§ 74.5 ± 9.2 140.0 ± 16.8*§ 73.1 ± 9.1
7–9 month 123.1 ± 14.1§ 74.9 ± 10.1 144.0 ± 19.1*§ 75.3 ± 9.6
10–12 month 136.3 ± 18.5 75.7 ± 9.0 139.8 ± 18.4§ 76.6 ± 10.4
The entire year 131.0 ± 12.8 75.0 ± 5.8 144.6 ± 14.4* 75.3 ± 6.2
HLG high health literacy group, LLG Low health literacy group
* Comparison between two groups (p \ 0.05)
§
Compared with 1–3 month in one group (p \ 0.05)

There are no studies that investigate the association
between long-term BP control and health literacy. Our
results demonstrate that patients in the HLG have better
control of SBP than patients in the LLG during three
quarters of the year. In addition, the SBP and DBP of the
HLG have a U-shape with seasonal changes, while only the
DBP of the LLG has a U-shape with seasonal changes. This
phenomenon indicates that blood pressure variability of the
HLG is closer to normal physiologic conditions. Patients
with low health literacy are lacking hypertension knowl-
edge and have poor compliance with medication [28, 29],
which might explain the relationship between health liter-
acy and hypertension control. In addition, the cut-off val-
ues for ROC curves are basically in agreement with the
score that we initially set, which indicates that the CHLSH
is effective for identifying the level of health literacy.

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Fig. 1 Bar Chart of SBP (a) and DBP (b) of two groups in the past
year (*p \ 0.001)
Fig. 2 Hypertension control of health literacy in four quartiles The
BP control rate increased with the improvement of health literacy.
(*p \ 0.001 compared with the former group)
We also find that patients with low health literacy have a
higher risk for ICVD and higher values of baPWV. Martin
et al. [30] assessed the 10-year risk of cardiovascular dis-
ease using the Framingham risk score, and reports similar
results. Because of a lack of hypertension knowledge and
poor compliance with medication, patients with low health
literacy may be accompanied by an unhealthy lifestyle and
more cardiovascular risk factors. Although carotid-
femoral pulse wave velocity (cfPWV) is one of the most
reliable methods for measuring arterial elasticity, baPWV
is closely correlated with cfPWV; the aortic PWV assessed
invasively and the presence of CV risk factors is linked
with an elevated baPWV value [31–33]. Moreover, the
recent AHA recommendation states that baPWV is useful
in cardiovascular outcome predictions in Asian populations
[34]. According to our results, health literacy is a new risk
factor of hypertension for ICVD and arterial stiffness
prediction.
HRQOL evaluations include comprehensive health-re-
lated and disease-specific assessments. Comprehensive
HRQOL evaluations include the SF-36, which was devel-
oped in the United States and is used worldwide. The SF-36
allows patients to quantitatively self-evaluate their physical
and emotional quality of life with relative ease. We exam-
ined the role of health literacy as a predictor of HRQOL that
has not been previously studied in hypertensive patients. In
the current study, the higher levels of health literacy posi-
tively influence HRQOL scores in hypertensive patients. In
addition, given that general health perception is among the
important independent determinants of health service uti-
lization [35], a higher HRQOL is likely to increase individual
health behaviors and self-care management for hypertensive
patients. Thus, high health literacy reflects a better ability for
health service utilization. Ultimately, health literacy might
lead to improved HRQOL among hypertensive patients.
Some studies involving patients with various diseases report
that limited health literacy influences health outcomes, such
as medication cost, knowledge, self-care management,
adherence to medication, and HRQOL [36, 37]. The finding
is consistent with prior studies regarding the impact of health
literacy on HRQOL [37, 38].
Limitations
Our study has several limitations. First, the small sample
size might impact the study’s findings, and the results of a
single-site study may demonstrate atypical outputs. The
findings of this study might not be generalized to other
populations. Second, we could not provide patients with
the same device for use at home. We evaluated and vali-
dated all devices according to international standardized
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 Intern Emerg Med

Table 9 Areas under the ROC

AUC (95% CI) p Cut-off Sensitivity Specificity
curve for different periods of a
year used to predict BP control The whole year 0.717 (0.649–0.786) \0.001 13.5 0.680 0.755
using CHLSH
At least three quarters of the year 0.703 (0.633–0.772) \0.001 13.5 0.700 0.683

Fig. 4 Association between health literacy and ICVD

Fig. 5 Association between health literacy and baPWV

Fig. 3 Receiver operating characteristic curve analysis for predicting

target blood pressure achieved in the entire year (a) and in at least
three quarters of the year (b). Asterisk the cut-off point
protocols. Third, because the average age of our sample is
older, we cannot extend our findings to a general popula-
tion. Finally, there is a potential selection bias to this ret-
rospective study.
risk of ICVD and incidence of artery stiffness in hyper-
tensive patients. Improving health literacy should be con-
sidered as an important part of the management of
hypertension.
Acknowledgements The authors thank Dr. Xiao’s team at Jinyang
Community Health Center in Chengdu, China for their contributions
to this study.

Conclusion Compliance with ethical standards

Conflict of interest The authors declare that they have no competing

Adequate health literacy is a contributing factor to better interests (financial, political, personal, religious, ideological, aca-
BP control and better perceived quality of life in hyper- demic, intellectual, or any other) to declare in relation to this
tensive patients. Low health literacy increases the 10-year manuscript.

123
Intern Emerg Med
Statement of human and animal rights The research protocol was
reviewed by the Medical Ethics committee of West China Hospital,
Sichuan University. The study protocol conforms with the ethical
guidelines of Declaration of Helsinki.
Informed consent Informed written consent was obtained from
patients before enrollment. The Medical Ethics Committee of West
China Hospital Sichuan University approved all procedures.
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