Factors Affecting the health literacy Status of Patients with type 2 Diabetes through Demographic Variables: A Case Study from Iran

Health literacy is the ability of a person to acquire the process, understand the necessary health information, and make the health services needed for conscious health decisions. Low levels of health literacy can impair the healthcare and treatment of chronic diseases such as diabetes. Besides, diabetes is the most common metabolic disorder that affects patients' quantity and quality of life. Health literacy means cognitive and social skills, with the motivation and ability to understand and use health information, helping individuals maintain and promote their good health. This study focused on determining the factors that affect the health literacy status of type 2 diabetes patients through the role of the demographic variables. This study selected the using the of a simple sampling and study applied the tools of demographic information and the functional, communicative and critical literacy to collect This used the on including ANOVA, and

The patients of diabetes nd it di cult to face this chronic disease as diabetes self-management involves a complex, lifelong, and poses challenges throughout patients' lives [17]. Diabetes is a lifelong chronic disease, and increasingly it has become a public health problem around the world. The statics showed that over 425 million people were con rmed patients of diabetes by 2017, and according to prediction, there will be over 693 diabetes patients worldwide by 2045 [18]. Another study projected that there would be over 300 million diabetes patients by 2025 [19]. By 2030, almost 366 million individuals' would have diabetes type 2 Mellitus [20]. In Iran, diabetes types 10.8, 5.8, 3.0, and 14.0% prevail in men. Besides, and 14.0, 7.0, 3.0, and 19.4% exist in women with age group 25 to 34, 35 to 44 to 45 to 54 and 55 to 64 years, respectively [21]. According to estimation, Almost 11.40% of adults in Iran have diabetes mellitus. It would increase to 9 million Iranian by 2030, who would face the risk of developing diabetes mellitus [22]. According to statistics, almost 80% of diabetes patients encounter deprived and inadequate healthcare facilities in developing countries [23].
Diabetes is a lifetime chronic disease, and it leads to long-lasting involved complications when blood glucose elevates consistently [24]. Although suffering from diabetes in uences all aspects of the patients' lifecycle. However, with the performance of self-care activities aimed at controlling symptoms and avoiding long-term complications, patients can lead a healthy life. [25]. Achieve the goal of targeted therapy. It is necessary to monitor the level of glucose in the blood regularly, strictly adhere to lifestyle measures and medications dosage, which can help continue to prevent health complications. Achieving treatment goals also requires a high ability to survive social and social challenges related to illness and diabetes support services associated with dynamic consumption [19]. Multiple factors related to diabetes patients can affect glycemic control, helping prevent and treat chronic diabetes diseases [26]. Numerous past studies have shown that the high prevalence of uncontrolled diabetes shows links to multiple health factors associated with poor blood sugar control around the world [27][28][29]. Patients with type 2 diabetes (T2D) have complex needs for their health literacy. They just need to manage their diet and control their blood sugar for the rest of their lives. Lifestyle changes are not easy, so patients with type 2 diabetes must learn self-care management and high drug compliance, including the ability to read, analyze, and interpret nutrition and drug labels [14].
A study indicated that individuals with limited health literacy levels encounter more health management problems in their life [14]. The past literature evidenced that diabetes patients with low health numeracy faced a higher level of BMI and poor glycemic control [10,18]. Such patients cannot smoothly manage their diabetes and face di culties with diseases throughout their life [30]. An earlier study indicated that poor health literacy leads to a higher hospitalization rate among people with diabetes [30]. There is compelling evidence that there is a close association between poor health of diabetics, poorly managed disease, poor self-care, and a low level of health literacy [30]. Adequate health literacy level helps diabetes patients to manage and control the insulin doses [14]. They are likely to prone to interpreting by reading labels of medicines correctly [31]. Other factors that may distress an individual's information, skills and knowledge about health literacy include cultural and social demographics factors, and individuals' lifestyle and environmental impacts. Patients' education level, age, race, and income level can affect an individual's ability to read, understand, and use health information to make correct health decisions.
Patients limited communication skills also jeopardize their health literacy level, which leads to various problems in protecting and managing their diseases. This limitation in uences individuals' ability to navigate the healthcare system that paves the way for the patients to understand health-related matters, communicate with the providers of the health care system, clearly explain symptoms, and accurately ll out personal and health history forms [3].

Study design
This study employed a cross-sectional descriptive-analytical design from January to 30 July 2020. The study included a non-probabilistic sample of 280 patients with diabetes type 2 (T2D) from Diabetes Research Center of Ayatollah Taleghani Hospital in Kermanshah. The survey method consisted of patients of a statistical sample visiting the health centers, and the study applied a simple random sampling method to collect the required data sets. According to the past studies conducted and using Cochran's formula and considering α = 0.5 and d = 0.5, this survey included a sample size of 280 diabetes participants.

Inclusion and Exclusion Criteria
This study set inclusion criteria for the respondents and recruited only those participants diagnosed with diabetes type 2 with the age range of 20 years and more during the last year. The authors included diabetes patients in these patients with su cient language skills by receiving written informed consent. Patients with problems, including mental, cognitive, or physical health issues complications, which might in uence their capability to perform the activities of diabetes self-management, were excluded. These health problems include blindness, end-stage renal disease, and limb amputation, as it could prevent patients' from completing the study questionnaire.
Health Literacy scale (FCCHL) in Persian to measure the health literacy skills among diabetes patients with type 2 disease [32]. There are 14 items on this survey form with sub-scales of cumulative, functional, and critical levels of the disease in patients. The questionnaire shows the 4-points Likert-scale to evaluate the disease condition in patients, such as (4 = often, 3 = sometimes, 2 = rarely, 1 = never). The functional sub-scale has 5, cumulative sub-scale 5, and a critical subscale has 4 questions, respectively. The functional subscale is useful for receiving the patients' feedback, and they rate how often they require help from someone to read medication lea ets or the physician's instructions in the hospitals or pharmacies. The cumulative health literacy subscale helps to ask diabetes patients to rate how often they need information from different sources after diagnosed with diabetes disease. The critical health literacy subscale is useful for diabetes patients to evaluate how often they consider the credibility of the received information or how frequently they check whether the collected data is correct. The functional health literacy scores were reversed, and the higher score levels indicated higher levels of health literacy among diabetes patients.
The past literature sowed that the Japanese diabetes patients used the critical, cumulative, and functional subscales, and the ndings (Cronbach's α = 0.69, 0.81, and 0.85) indicated appropriate consistency of each scale. The higher scores on the scale showed a higher health literacy level [32]. The Persian version translated scale showed the Cronbach's alpha value (α = 0.82) and it indicated an acceptable score for the subscale critical (α = 0.76), cumulative (α = 0.80) and functional (α = 0.91), respectively. The reliability of the test-retest coe cient indicated a satisfactory outcome of 0.85(p < 0.01).
The study evaluated the psychometric properties of the questionnaire. The ndings of this survey a rmed that all the items of the FCCHL scales are a valid and reliable measure of the Iranian diabetes patients' health literacy skills, and these subscales are widely applicable to measure the various skills of health literacy among patients. The internal consistency was satisfactory for all the subscale of health literacy (α = 0.82) and showed a satisfactory degree of scale-items consistency for each subscale (α = 0.76 and 0.91). The past study showed similar results for the original scale of FCCHL [32] and the Dutch version for all the subscale items, respectively [33].
The study of Raisi et al. also con rmed the Persian version translated scale and its validity and reliability [34]. The ndings showed that the Cronbach's alpha was 0.82 and a re-test value 0. 85. Besides, the Cronbach's value (α = 0.81) in the current study was also appropriate to determine the reliability of the questionnaire. The authors received the consent from the study respondents and provided 15-20 minutes session to ll each questionnaire to collect the desired data sets duly.

Data Analyses
The applied descriptive statistics for data analysis to draw the study results from the received data sample of diabetes patients. The study performed various tests and reviews, including frequencies, percentages, mean and standard deviation scores, and t-test, an inferential statistics independent analysis to compare the scores of means of the two independent groups based on the quantitative variable of this model. The investigations covered patients' age, gender, residential location, family history with diabetes disease complications, and abdominal obesity. The study model performed ANOVA test to compare the mean (M) scores based on the three or more groups associated with a quantitative variable. The ANOVA test covered diabetes patients' age, gender, education level, occupation, average monthly income, residential location, type of received treatment, duration of facing diabetes disease, smoking, and eating habits. In further steps, the investigators applied the multiple regression analysis based on the demographic variables to predict the degree of health literacy skills among diabetes patients. The investigators performed all the tests by using the SPSS software version-23 (SPSS Inc. of Chicago, IL, United States of America) at 0.05 level of the signi cance (p < 0.001).

Ethics statement
The principal investigators conducted this study in accordance with the Helsinki Declaration and followed the ethical standards for the scienti c research procedures. The ethical committee from the school of health education and promotion of the Iran University, Tehran approved the protocol of this study to execute the survey for desired data sets of diabetes patients. The investigators informed and educated the study participants and told them about the objectives of this research before the execution of the survey. The authors assured them all the information is strictly con dential. The authors received the signed consent forms from the respondents' and investigators eliminated those participants who did not duly ll the forms. The ethical committee approved to include those participants who could not sign; however, their relatives or the data collectors had the permission to sign at the request of the study participants.

Characteristics of the Study Population
Concerning the characteristics of the participants under study, the proportion of the female diabetes patients was 53.2%, and male patients were 46.8%, respectively. The participants' age ranged from 23 to 88 years old, and the scores of the standard deviation of the research units' age indicated 55.80 ± 13.04 years. Among the age group patients, the highest frequency was in the age group (69 − 60 years), which was 26.1%, and the lowest value was in the age group of (18-29) years. Besides, the married participants made up 76.8% of the population, and the rest were divorced, widowed, or single. Participants' education level indicated that 33.6% are illiterate, 41.8% are undergraduate degree holders, 12.5% have a diploma, and 12.1% have higher than a diploma. Besides, 48.2% of the participants are the homeowners, 17.5% are workers, 8.6% are government employees, 12.9% are self-employed, and 12.9% are retired workers. The highest income level (39.6%) of the respondents was between one 1 to two million Iranian Toman, and 30% of the participants had a minimum income level of less than one million Toman. Regarding the residential status, 95 percent of people live in cities, and 5% live in the villages. In terms of diabetes treatment, 22.1% of the diabetes participants used diet, 18.2% used insulin, 57.1% used contraceptives (pills), and 2.5% used insulin along with tablets to control the diabetes disease. In terms of the diabetes disease duration, 50% of abdominal obesity lasts less than ve years, 29.3% of the patients between 6-10 years old have abdominal obesity, and 168 patients have 60% of abdominal obesity.
Besides, smokers are 16.8% of participants, pre-smokers are 5%, and patients who never smoke are 75.7% of the population. See Table for further details.
The results indicated 2.70 ± 0.44 means (M) and standard deviation scores of diabetes patients' health literacy with type 2, which speci ed the optimal status. Table 2 illustrates the indicators of health literacy related to subscales of cumulative, critical, and functional health literacy among diabetes patients' groups. Independent t-test results show that men's health literacy is higher than that of women (t = 2.76, p = 0.027). Besides, people living in urban areas have higher health literacy than rural areas (t = 2.71, p = 0.023). The one-way analysis of the variance (ANOVA) shows a signi cant relationship between health literacy and education, employment, and income (p = 0.05). Table 3 shows β coe cients results of the multiple regression analysis and the income variable (β = 0.170), age (β = 0.176) and employment variable (β = 0.157), which are the most predictive of the health literacy of diabetic patients. All these effect coe cients are showing statistically signi cant levels.   Note. This table report results from the sequential multiple regression analysis with health literacy as the dependent variable. The independent variables 'Average monthly income', 'age,' and 'Occupation' were entered in the report in three sequential steps. Statistical signi cance was assumed at p < 0.05.

Discussion
The concept of health literacy has gained the attention of the health researcher world. Simonds (1974) introduced this idea to the nursing literature the rst time. The past research documented a few references related to health literacy by 1992. Health literacy originates from the eld of public health, where it advanced in health education, protection, promotion, and primary health prevention [35]. As a result, healthy literacy is a relatively innovative concept for the health staff, including nurses, with few references associated with health literacy, which appear in nursing and health education literature [36,37]. In recent times, patients have to encounter the di culties of complex healthcare systems. Patients have to acquire su cient knowledge to understand the multifaceted information and nd solutions to the complex health care systems. Accordingly, it is vital to evaluate health literacy among diabetes patients and provide them easy-to-understand and required support information associated with health literacy level. Hence, assessing patients' health literacy is critical to provide the necessary support to diabetes patients, as diabetes needs expensive medical treatment and self-care. It is essential that diabetes patients' understand health information, such as symptoms and signs of their diseases. Patients require to know how to control and manage the disease [35]. This study focused on investigating the in uential factors that affect the health literacy status of patients' with type-2 diabetes through demographic variables. Likewise, the results of this study revealed that the eld of health literacy, the subjects performed poor performance. Therefore, the lowest score of health literacy in diabetic patients related to this eld of health literacy and on the other hand the highest average rating in the health literacy eld is related to critical health included numeracy skills (ability to use quantitative information) and using this information to make further decisions. The results of the study Reisi et al. [39], Lai et al. [43] received the lowest score in terms of performance. In the van der Vaart's study [45], patients with rheumatoid arthritis received the highest score in terms of performance. Since the above study was conducted in the Netherlands, where the literacy rate and reading and writing skills are 96.5% [46], thus, compared to the current study, the high level of functional health literacy in the studied people seems reasonable, which was inconsistent with the results of the present study.
Scholars argued that skills related to operational, communicative, and critical health literacy are necessary. The essential factors for improving self-care in diabetic patients are vital because these skills increase patients' self-con dence to communicate e ciently with health service providers and improve the health and abilities of patients to participate and cooperate with the health care system. These capabilities eventually permit patients to receive and evaluate the information they need from different communication channels and nally apply it in practice. Critical health literacy is a prerequisite for achieving a correct understanding of the political and social factors and determinants that provide the environment for health promotion and healthy living. Because of the broader skills range related to functional, communicative, and critical health literacy, their direct association with self-care in diabetic patients is possible. These levels of health literacy, social and cognitive knowledge, provides skills, and necessary understanding is for proper management of the disease by patients [43].
A study reported that diabetes patients with a higher level of critical and communicative health literacy skills actively applied required information to manage the situations, and they achieved accomplishments successfully. Thereby, better health literacy skills are useful in attaining improved selfe cacy [47]. Ishikawa and Yano conducted a study, explained that diabetes patients with a better health literacy level would end to describe a better participation level, and enhanced self-e cacy to control The results revealed that there was a signi cant relationship between gender and health literacy of type 2 diabetic patients; these results are consistent with the study of Yeh et al. [49]. Though, the results were inconsistent with the results of the studies done by Pooryaghob et al. [50], Charoghchian Khorasani et al.
[51] Noroozi et al. [52] and Von et al. [53]. The results of the study done by Maleki et al. [8] and Le et al. [54] Khosravi et al. [55], Tahery et al. [40] disclosed that there was a signi cant relationship between gender and health literacy and men's health literacy was higher than women, which is consistent with the current study. It could be due to men's higher education than women's.
In the current study, there was no signi cant relationship between the average ages of people with health literacy in type 2 diabetic patients; these results are consistent with the review of Charoghchian Khorasani et al. [51] research. But, the results were inconsistent with the results of the studies done by Yeh et al. [49], Noroozi et al. [52], and Tahery et al. [40]. As a result, when reading comprehension is a necessary skill for receiving information, age is a factor that should be considered. Hence, when providing information to diabetic patients, it should not be limited to print media, and other teaching methods such as lecturing and group discussion should be used, as older people may be less literate.
The results of the current study disclosed that there was no signi cant relationship between marital status and health literacy of diabetic patients. These results are consistent with the study of Ansari et al. study, it has been reported that having higher education and functional job status has led to an increase in the level of health literacy [62]. Patients with lower levels of education also have lower levels of health literacy and have di culty understanding and applying health information, application and administration of drugs, and understanding medical prescriptions; so, they require specialized training and attention [63]. However, it is vital to note that during clinical appointments, physicians need to regulate their communication according to the patient's actual health literacy. Some simple techniques for this purpose include the use of simple language, low speed, and the participation of prominent family members in discussions [44]. In a study on a 10-year study of a cohort in the United States it was found that low levels of education were associated with reduced physical activity, and the higher the level of education, the greater the physical activity. Generally, it assumed that the higher the level of literacy of people, the higher their health awareness. Thus, the healthier their lifestyle and the lower the prevalence of type 2 diabetes.
[64] it could result because of the group with higher education, which is more likely to have more senior health-seeking behavior. Critical thinking was leading to them obtaining more information on health and better health literacy.
The results of the current study indicated that there is a signi cant relationship between job and health literacy of diabetic patients. These results are consistent with the studies done by Getaye Tefera et al.
[  [70]. At large, patients with a higher level of education are more aware of the disease complications, self-care, and how to take medication and follow a diet. They have more access to educational resources [71].
The results of the current study disclosed that there was no signi cant relationship between the mean duration of diabetes and the health literacy of diabetic patients. In this regard, studies by Noroozi et al. [52], Maliki et al. [72] and Souza et al. [73] also suggested that health literacy was not associated with the duration of the disease. It expected that as the duration of the disease progresses, the level of the patient's health literacy and their experiences will increase. Therefore, in order to increase the level of health literacy of patients, it is necessary to take steps to promote the provision of educational classes and the use of simple educational tools, understandable and straightforward expressions for patients, especially those with lower education and higher age.
The results of the current study indicated that there was no signi cant relationship between family history and health literacy of diabetic patients. These results are consistent with the study of Teferaet Getaye et al.
[26] and, are not compatible with the research of Tol et al. [74], this may be due to a lack of sensitivity and a lack of attention to the consequences of the illness.
The results of the present study disclosed that there was no signi cant relationship between diabetes complications and the health literacy of diabetic patients. So, it was not possible to compare the ndings with the previous results. Accordingly, it was not possible to compare the ndings with the earlier results.
The results of the current study indicated that there was no signi cant relationship between abdominal obesity and the health literacy of diabetic patients. In the study of Afkhami et al. [75], it was reported that abdominal obesity was widespread in patients with type 2 diabetes, which is similar to the present study.
In this study, no signi cant correlation was observed between health literacy and smoking in patients with

Conclusions
This research study revealed that the highest average showed a link to critical health literacy, and the lowest percentage indicated an association with communicative health literacy in diabetic patients. The impact of communicative and essential health literacy on diabetes management, even for patients whose functional health literacy presented adequate results. Besides, diabetes patients' income level, age, and occupation variables are the most important independent predictors of health literacy. Functional, communicative, and critical health literacy provides patients with social and cognitive knowledge and the skills needed to properly manage the disease. Communicative and critical skills increase patients' selfcon dence; this allows them to communicate effectively with health care providers. Thus, health information specialists are essential in order to recognize diabetes patients' demographic variables. Patients' requirements and capacity are also necessary to achieve health education resources. The study ndings indicated that a higher level of health literacy would increase better health-related behaviors from the patients. Availability of data and materials

Abbreviations
The dataset used and analysed during the current study is available from the corresponding author upon reasonable request.

Competing interests
The authors declare that they have no competing interests.

Funding
This study was drawn from a research project (No. 980789) sponsored by deputy of research and technology of Iran University of Medical Sciences. The cost of the payment is spent on the design and implementation of the study.

Authors' Contributions
MM and AZ conceptualized and designed the study. AZ was responsible for data collection. BM, and AZ performed data analysis, MM and FEFA drafted the manuscript. All authors read and approved the nal draft of the manuscript.