The association between health literacy and health care utilization in persons with coronary heart disease in Malta

Abstract

Purpose Most international research exploring the relationships between health literacy (HL) and health care utilization were performed outside of Europe. This dissertation aims to explore the relationship between HL and health care utilization in adults with coronary heart disease (CHD) in Malta. Research Design and methods A cross-sectional research design using a probability quota sample stratified by age and sex was used. Persons with CHD were recruited from either cardiology outpatients or cardiology wards. They completed a questionnaire including the 16-item European Health Literacy Survey and agreed to have their responses linked to the public hospital's health service utilization records. The frequency of health centre general practitioner (GP) visits, private GP visits, private specialist visits and dentist visits were self-reported. Results A total of 396 individuals were approached to recruit 384 participants, giving an overall response rate of 97.0%. The respondent population was analysed and found to be representative of the target sample population. The prevalence of limited HL in the Maltese CHD population was 60.1%, with 14.8% and 45.3% of individuals having inadequate and problematic HL respectively. HL was found to have a positive significant relationship with highest educational attainment (p<0.001) and net monthly household income (p<0.001), but not with age, sex, marital status, district of residence, gainful employment or home ownership status. HL was not found to be associated with duration of illness or family history of coronary heart disease, self-report-generated Charlson comorbidity index (SRG-CCI) or a history of depression or anxiety. Univariate analysis found a significant relationship between HL and frequency of self-reported private GP visits (p=0.016), which remained in the multiple linear regression model after adjusting for SRG-CCI and having a history of depression or anxiety (p=O.020). Patients with inadequate HL are less likely to visit a private GP in the previous year when compared to patients with sufficient HL. In contrast, patients with problematic HL are more likely to visit a private GP when compared to patients with sufficient HL. The significant relationships between HL and the frequency of emergency department visits (p=0.010), number of overall hospital admissions (p=0.029) and having had a coronary angiogram (p=0.015) in the 12 months prior to the interview were lost in the multivariate analyses (p=0.146, p=O.389 and p=0.066, respectively). HL was not found to be significantly associated with the frequency of health centre GP visits, outpatient specialist visits (both overall and CHD-related), private specialist visits, hospital admissions (CHD-related), inpatient bed days (both overall and CHD-related), day care admissions, dentist visits, and having had a percutaneous coronary angiogram or coronary artery bypass graft surgery in the 12 months prior to the interview. Conclusions This study found a high prevalence of limited HL in the Maltese CHD population when compared to findings in the literature. HL follows a social gradient supporting the importance of addressing the social determinants of health to reduce health inequalities and improve health outcomes. Furthermore, HL is associated with private GP visits. There is an under- and over-utilization of private GP visits, which may adversely affect health outcomes and ineffective resource utilization.