The effect of a health literacy oriented program on physical activity among Chinese patients with type 2 diabetes mellitus

Abstract

Physical inactivity has been widely regarded as a leading cause of non-communicable chronic diseases such as type 2 diabetes mellitus (T2DM) and hypertension. Physical activity (PA) has been shown to be the most effective self-care behaviour in alleviating T2DM, an incurable chronic disease. Previous behavioural modification programs intended to encourage and maintain PA behaviour among middle-aged and older patients with T2DM have had inconsistent results. PA has remained as a recommended diabetes self-care behaviour with the lowest compliance rate in many regions of the world.

This thesis proposes a program focusing on health literacy (HL) as a means to nurture T2DM patients’ ability to navigate, read, understand, process, comprehend and act on health information, and thereby modify PA behaviour. This approach is proposed for three reasons: (1) the flood of available health information of varying quality affects patients’ decision making with regard to self-care behaviour; (2) the high prevalence of low HL in the US, Europe, and Asia affects the comprehension of self-care behaviour programs; (3) because 50% of older T2DM patients are impaired cognitively due to the impact of aging and hence have difficulty in carrying out suitable self-care behaviour without proper guidance. All of these factors can influence the effectiveness of PA behavioural modification programs designed to help middle-aged and older T2DM patients make self-care decisions based on sound health information according to their level of HL.

This thesis reviews existing HL-oriented programs and models and validates the instrument used to examine the effects of a culture-, language-, disease- and age-specific, theory-based, HL-oriented program on PA behaviour among middle-aged and older patients with T2DM. In the study, 324 middle-aged and older Chinese T2DM patients recruited from two hospital diabetes centres in Hong Kong were divided randomly into intervention and control groups. The intervention group participated in an HL-oriented program on PA behaviour. The program significantly improved the mean of PA behaviour of patients in the intervention group from a sedentary level (under 1,000 average Metabolic Equivalents/minutes/week; 4463 mean number of steps per week) to an internationally acceptable standard (over 2,000 average METs-minutes/week; 7459 mean number of steps per week), and this improvement was maintained at three- and six-month follow-ups. The PA behaviour of the control group actually subsided. This study showed that a program addressing and nurturing patients’ ability to explore, understand and manage health information on T2DM and PA was effective in improving the PA behaviour of middle-aged and older adults with T2DM. This thesis is the first study to use objective measurements to evaluate the effect of a culture-, language-, disease- and age-specific, theory-based, HL-oriented program on PA behaviour. It extends the generalizability of culture and language-sensitive HL oriented programming from the United States (where previous HL studies were conducted) to China. The study can serve as a model for future investigations of self-care behaviour among patients with different chronic illnesses in various regions of China.