Factors Related to the Level of Health Literacy in Patients with Hypertension: Literature Review

Introduction: Hypertension is the leading cause of death worldwide. People with hypertension often receive health education about their health but cannot implement it. Patients with hypertension must be responsible for self-management related to the level of a person's health literacy, such as efforts that should they take so that the illness they suffer from is not getting worse. The aim of this study is to determine the factors related to the level of health literacy in hypertensive patients.


INTRODUCTION
Hypertension or high blood pressure is the leading cause of premature death worldwide. Hypertension is a condition in which a person's systolic blood pressure is above 140 mmHg and diastolic blood pressure is above 90 mmHg. People with hypertension often receive health education regarding its health but can not apply it where precisely worsening the situation even though as it is known that hypertension is a chronic disease, therefore sufferers must be responsible for selfmanagement behavior both to reduce symptoms and reduce the risk of complications where it is related to a person's health literacy level.
Health literacy is a person's ability to access, understand, and the ability to be able to apply the information and health services needed in making the right decisions about health (World Health Organization, 1998). However, there are factors related to the level of health literacy that cause the level of health literacy for each individual to be different. Research that has been conducted by Wang et al. (2017) proved that the low health literacy possessed by hypertensive patients is related to unwillingness to receive regular treatment, the importance of self-management, and non-compliance with medication. Soemitro (2014) reports that the level of health literacy or the level of health literacy in hypertensive patients at the Malang District Health Center mostly has a poor literacy level that is, 65.35%. Patients with low levels of health literacy will be worse off in managing a chronic disease. This makes health literacy a predictor for one's health. The factors related to the level of health literacy in sufferers of each disease are likely to be different. This is because the condition of a person's disease also affects. Research conducted by Santosa (2012) where age, education level, access to health information, and income affect a person's health literacy level.
Another study conducted by Nazmi et al (2015) states that ethnicity / race, socioeconomic status, home status, received empathy, happiness and acculturation have significant results to influence health literacy. Broadly speaking, the factors related to the level of health literacy are the level of knowledge, the ability to access health information, the level of education, age, gender, occupation, income, and the ability to access health services.

METHOD
The literature search was carried out in May-June 2020 using secondary data. The formulation of research questions using PICOT where the population is hypertension sufferers; Interest is a factor related to the level of health literacy, namely knowledge, age, education, occupation, income, access to health information, and access to health services for patients

RESULT
It was found 1,173 articles or research journals, then screened 926 articles or journals that were not relevant. Then, as many as 247 articles were evaluated based on their titles and abstracts.
Elimination was carried out on articles that did not meet the inclusion criteria where the population was not patients with hypertension as many as 183 articles, 28 articles that were not full text, and 7 articles that used languages other than Indonesian and English so that the number of articles used in this literature review was as many as 7 articles. 10 articles with conditions, namely English articles translated into Indonesian. Factors related to the level of health literacy in hypertensive patients are grouped based on the stage of health literacy.

Access Stage
At the access stage, factors related to the level of health literacy in hypertensive patients include access to health information and access to health services.
The more affordable access to health services will increase the level of health literacy of hypertensive patients (Andrianys et al., 2016). In addition, Andrianys et al. (2016) also stated that easy access to health information will increase the level of health literacy of hypertensive patients.

Understanding Stage
At the understanding stage, factors related to the level of health literacy in hypertensive patients include age, education, occupation, income, knowledge, selfmanagement efficacy, acculturation, and social support. According to Borges et al. (2019) age is a factor related to inadequate levels of health literacy in adults with hypertension. Sahroni et al. (2019) in their research stated that age is one of the demographic factors related to social health determinants related to health literacy scores.
Another study conducted by Andrianys et al. (2016) stated that the older a person is, the lower his health literacy is.
Research which states that education is one of the factors related to the level of health literacy in hypertensive patients is a study conducted by Andrianys et al. (2016) where the higher a person's education level, the higher the level of health literacy they have. Apart from that, another study conducted by Borges et al. (2019) and Ingram and Ivanov (2013) also show the same results where the length of schooling is a factor related to inadequate levels of health literacy in adults with hypertension and someone who is more educated is more literate about health literacy. person with a minimum income equivalent to the UMR or more has a good level of health literacy (Andrianys et al., 2016). The results of research conducted by Sahroni et al. (2019) show that income is one of the demographic factors related to social health determinants related to health literacy scores.
Another study that also stated the same result was a study conducted by Wang et al. (2017) where income is one of the demographic characteristics that affect health literacy.  Andrianys et al. (2016) stated that the more affordable access to health services, the better the level of health literacy. Research conducted by Forsyth et al. (2008) stated that access to health services depends on the location of health services, doctor's offices, and hospitals that are close to public transportation stops. Access to health services that is easily accessible will make it easier for someone to get information for their health so that their level of health literacy can increase. Andrianys et al. (2016) also stated that the easier health information is to be accessed, the better the level of health literacy. Research conducted by Lintang Kristi Purwadi and Ika Krismayani (2016) states that the sources of information accessed by pregnant women in Wonosobo District are obtained through asking the closest people, asking health workers, magazines, books, internet, smart phone applications, joining in the forum for discussion and sharing. Health information that is easily accessible will increase a person's knowledge and selfmanagement efficacy where the information will be obtained can be applied in everyday life so that the level of health literacy a person has will increase.

Age with Health Literacy
Research conducted by Andrianys et al. (2016), Borges et al. (2019), and Sahroni et al. (2019) stated that a person's age has a significant relationship with that person's level of health literacy. This is consistent with research conducted by Ownby et al. (2012) which states that older age is closely related to inadequate levels of health literacy in studies assessing math skills, understanding, reasoning, and abilities.
The older a person is, the more vulnerable he is to inadequate levels of health literacy because it is related to his cognitive abilities where there is a decrease in thinking skills so that it will affect behavior to manage external resources such as a person's understanding of information.

Education with Health Literacy
The results of research conducted by Andrianys et al. Education is needed in getting the information that can be support one's health. The higher a person's education level, the easier it is to receive information, in this case related to health so that later it can improve the quality of life.

Work with Health Literacy
A study conducted by Andrianys et al. (2016) andShi et al. (2017) stated that work has a positive relationship with a person's health literacy level.
These results are consistent with other research conducted by Pawlak (2005) where a person's employment status can affect the economic capacity that determines a person in getting health services and obtaining health information sources.
In a work bond, there is generally health insurance that will be provided for workers from the workplace. This will increase a person's chance to get health information and services so that the greater the chance for that person to achieve an adequate level of health literacy.

Income with Health Literacy
Income has a relationship with a person's health literacy level (Andrianys et al., 2016;Sahroni et al., 2019;Wang et al., 2017). This is in accordance with research conducted by Ng and Omariba (2014) which states that household income is related to the possibility of a person having an adequate level of health literacy. Income is related to a person's education level because education is related to one's job which has an impact on the economic level and financial ability to deal with unexpected problems such as health problems.

Knowledge with Health Literacy
In a study conducted by Chajaee et al. (2018) stated that knowledge about blood pressure has a relationship with the level of health literacysomeone. In another study, the level of knowledge did not have a significant difference so that this result may be related to the level of education. A person's level of knowledge will affect his efforts in making prevention against a disease, treatment of a disease, and also in his own care. Wang et al. (2017)  Self-management efficacy focuses on selfconfidence in the ability to perform self-management activities. Self-management activities can be carried out by finding, understanding and applying information about health so that they can make the right decisions for health. This effort is called health literacy, so a person's high self-management efficacy score indicates that the person has confidence in carrying out self-management activites related to health literacy.

Acculturation with Health Literacy
A study conducted by Perez (2015) shows that acculturation has a relationship with a person's health literacy. These results are consistent with other studies conducted by Koskan et al. (2010) where he stated in his research that when a person's acculturation increases, the person's health literacy level will also increase. Acculturation is meant here regarding language use and social preferences. The increased level of acculturation will increase health literacy so that a person's perception of the disease regarding control and understanding of hypertension will also increase.

Social Support with Health Literacy
In addition, Andrianys et al. (2016) also stated that social support is positively related to health literacy.
People who suffer from a disease tend to feel neglected and often think about their illness in a negative light. This is where the role of social support is needed. In general, people who feel comforted, get the attention, and help they need are more likely to receive and apply the recommended medical advice.
Social support has a very big role in a person's psychological well-being. A person with good social support will be able to accept and try to implement the recommendations given so that the level of health literacy of that person will increase.

Pressure with Health Literacy
Research conducted by Shi et al. (2017)