Research Article: Development of a Hypertension Health Literacy Assessment Tool for use in primary healthcare clinics in South Africa, Gauteng

Date Published: July 27, 2017

Publisher: AOSIS

Author(s): Nokuthula G. Mafutha, Sophie Mogotlane, Hester C. de Swardt.


Hypertension is a universal risk factor for cardiovascular morbidity and mortality in both the ageing and obese populations and patients must be literate in hypertension health issues to participate actively in the management of their disease. Little research has been done to investigate hypertension health literacy levels among South Africans.

To develop a Hypertension Heath Literacy Assessment Tool to establish patients’ comprehension of the health education they receive in primary healthcare (PHC) clinics in Tshwane, Gauteng, South Africa.

PHC clinics in Tshwane, Gauteng, South Africa.

The design was quantitative, descriptive and contextual in nature. The study population comprised health promoters who were experts in the field of health, documents containing hypertension health education content and individuals with hypertension. Participants were conveniently and purposefully selected. A modified Delphi technique was used to develop and validate the Hypertension Health Literacy Assessment Tool (HHLAT). To ensure validity and reliability of the HHLAT, the tool was administered to 195 participants concurrently with the Learning Ability Battery (LAB).

There was a strong positive (F = 76.0, p < 0.0001, R2 = 28.25%) correlation between the LAB and the HHLAT. The HHLAT indicated that only 37 (19%) of the patients with hypertension had poor hypertension health literacy levels. The HHLAT is a valid tool that can be used in busy PHC clinics as it takes less than two minutes to administer. This tool can inform the healthcare worker on the depth of hypertension health education to be given to the patient, empowering the patient and saving time in PHC facilities.

Partial Text

Hypertension is a chronic, preventable non-communicable disease, the causes of which are related to genetics, behaviour and lifestyle.1 Although the pathology of hypertension is mainly located in the cardiovascular and nervous systems, many other factors tend to contribute to its cause.1 These include a diet high in salt and saturated fat, lack of exercise, obesity, excessive consumption of alcohol and cigarette smoking.2

Round 1 of the modified Delphi technique involved the process of generating words, concepts and phrases.

Round 2 of the modified Delphi technique involved identifying the most common hypertension words, phrases and concepts used in PHC to be used in the tool development.

To implement the tool (Table 3), data were collected from 195 patients with hypertension by using the newly developed HHLAT. Field workers who had been trained on how to administer the HHLAT assisted the researcher in this process. The administration and scoring of the tool was similar to the REALM-R tool. The tool consisted of a list of 11 words and phrases. The first three of these items were not counted in the scoring. They were used as icebreakers to relax and calm the participants. The other eight would form the basis for scoring.

From the validation panel, the number of times an HHLAT was selected as being important and valid was recorded in an Excel spreadsheet and the frequency reflected that Tool 1 scored 63.3% (n = 19), Tool 3 scored 23.3% (n = 7) and Tool 2 scored 13.3% (n = 4). Thus, Tool 1 (Box 1) was used as the HHLAT for determining the hypertension health literacy of patients (n = 195) attending selected PHC clinics in Tshwane. Table 3 indicates the age and gender of the participants who took part in the assessment of hypertension health literacy using the newly developed tool.

The Delphi technique has been used by other authors14,15 for examining health promotion and health education where it was found suitable. The modified Delphi technique used in this study comprised a first panel of experts and a second panel of experts (validation panel). The first panel of experts reached a conclusion within one day, as they met in one room. During this meeting, a list of important common words or phrases and concepts used during hypertension health education was created and listed according to those who were voted to be most important to the least. This list can be used by other researchers in health promotion or education. During the process of the tool development, no list similar to the one that has been created in this study existed. The second panel of experts (validation) participated by means of email and they were given 60 days to respond by selecting and validating the most appropriate HHLAT for PHC clinics from the three tools that were developed. This process prevented bias as each participant did not know who was sent an email and their responses were not influenced by other participants.

Using the newly developed HHLAT, the hypertension health literacy levels of patients in PHC clinics can now be determined. This tool can be administered by a healthcare worker in less than two minutes, without disruption of the normal functioning of the clinic. Determining the hypertension health literacy levels of patients will enable the healthcare provider to specifically individualise their health education. When health education is planned and provided to the public, it needs to be simple and easy to comprehend in order for learning to take place. This is because the tool revealed that only 19% of the participants were at risk for poor hypertension health literacy. Further research is required to investigate the compliance to pharmacological and non-pharmacological management related to hypertension as these findings indicate that most (81%) of the participants are hypertension health literate, while the country is experiencing poor control of hypertension. What still needs to be further explored is whether they use this knowledge to live a healthy lifestyle and comply with the management of hypertension.




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