The development of policy recommendation: promoting health literacy for delayed progressive chronic kidney disease (CKD) of diabetes mellitus and hypertensive patients in the 4th public health region research was the research & development by using mixed method design. Health literacy concept of Nutbeam (2000; 2008; 2009), an integrated conceptual model of health literacy of Sorensen & et al. (2012), and health literate organization of Brach et al. (2017) were used as the conceptual framework in this study. Also, literatures review and evidence-base were integrated into the conceptual framework. Data were collected from diabetes and/or hypertensive patients with 3rd CKD, healthcare providers, and community networks or related group to delay progressive CKD in eight provinces of the 4th public health region that were Nakornnayok, Nonthaburi, Pathum Thani, Phra Nakhon Si Ayutthaya Lopburi, Saraburi, Singburi, and Aungthong. The study was divided into three phases within five purposes as follows: Phase 1 was situation analysis (R1) and included 2 purposes that were to: 1) examine the levels of health literacy to delay progressive CKD among diabetes and/or hypertensive patients, and 2) study the situation of health literacy promotion, CKD, and healthcare systems to delay progressive CKD in the 4th public health region.
Phase 2 was the period of the development and testing the model of promoting health literacy to delayed progressive CKD, and developing the prototype model of healthcare service to delayed progressive CKD in the 4th public health region (D1, R2, D2, R3). In phase 2, it covered two study purposes that were to: 3) develop and test the model of promoting health literacy to delayed progressive CKD among diabetes and/or hypertension, and 4) develop the model of health literacy to delayed progressive CKD system among diabetes and/or hypertensive patients in the 4th public health region. Phase 3 was the period of the development of the policy (D3). The study in phase 3 included one purpose that was to: 5) develop policy recommendation to promote health literacy to delayed progressive CKD among diabetes and/or hypertension in the 4th public health region.
The study instruments included both quantitative and qualitative tools. The quantitative instruments were 1) the health literacy to delayed progressive CKD in diabetes and/or hypertensive patient questionnaire, 2) the health literate organization promotion to delayed progressive CKD in diabetes and/or hypertensive patient questionnaire, and 3) the assessment form of self-management to delay progressive CKD in diabetes and/or hypertensive patents. All instruments were tested for validity by five experts and CVI were .97, 1.0, and .97 respectively. Cronbach’s alpha reliability were .94, .96, and .96 respectively. Qualitative instrument included 1) the semi-structure open-end question about health literate organization to delay progressive CKD for healthcare providers, and diabetes and/or hypertensive with stage 3rd CKD patients, and 2) the semi-structure question for related person and stakeholders who related to develop policy recommendation. The experimental instrument was the model of the promoting health literacy to delayed progressive CKD in the 4th public health region. Quantitative data were analyzed by using frequency, percentage, mean, standard deviation, multiple regression procedure, and pair t-test. Qualitative data were analyzed by content analysis which was interpretation, synthetization, and analyzation as reasonable criteria for developing inductive conclusion. Study results revealed as follows: 1. Average score of the health literacy to delayed progressive CKD of diabetes mellitus and/or hypertensive patients with stage 3rd CKD in the 4th public health region was at more levels (mean = 3.59, SD = .81). The most average score was the health decision aspect (mean = 3.85, SD = .81). The lowest average score of health literacy score was media literacy (mean = 3.45, SD = 1.02). Sex, ability of listening, sufficiency of income, receiving information from various sources, participating in health activities, receiving information by group, receiving various information channel, and having social role as a healthcare volunteer were statistically significantly on levels of health literacy to delayed progressive CKD at .00 - .05 (p ≤ .01 - .05). 2. Average score of health literate organization to delayed progressive CKD in diabetes and/or hypertensive patients with stage 3rd CKD was at the more levels (mean = 2.77, SD = 1.02). The most average score was the aspect of the participation in health literate organization to delayed progressive CKD in diabetes and/or hypertensive patients (mean = 2.83, SD = .93). The lowest average score was the organization and leader of organization aspect (mean = 2.73, SD = 1.09). The total scores of health literate organization to delayed progressive CKD in diabetes and/or hypertensive patients with stage 3rd CKD were at neutral level 46.96% (n = 54). The situation of the promotion of health literacy to delayed progressive CKD of healthcare settings in the 4th public health region were found among primary, secondary, and tertiary healthcare settings, however, they did not follow the concept of health literate organization. The major activities were health education. Healthcare providers did not know the meaning of health literate organization and the method to promote health literacy. Nevertheless, they can provide healthcare services to diabetes and/or hypertensive patients to delayed progressive CKD by health education both individual and group for the patient to modify their behaviors. Additionally, healthcare providers screened for CKD and managing the problems of the patients. Few healthcare providers received training of health literate organization. Healthcare providers would like the clear methods and guidelines to develop them to be health literate organization to delayed progressive CKD in the 4th public health region. Healthcare organization leaders and leading style included 4 methods as 1) doing health literacy before they ordered, 2) did not know policy of health literacy and did not doing anything, 3) they order us to do health literacy and I do as my understanding, and 4) they ordered us to do health literacy, and I can do it because they provided us the training of health literacy. Diabetes and/or hypertension with the 3rd stage CKD patients have less knowledge about CKD, and relationship between diabetes/hypertension and CKD because these patients did not experience abnormal symptoms and they cannot access, understand, and analyze reliable data/sources of health data. Patients would like the support to have health literacy to delayed progressive CKD through the specific care, easy to understand, reliability and sufficiency media to develop knowledge, understanding, and deciding for self-management to delayed progressive CKD. 3) The model of promoting health literacy to delayed progressive CKD among diabetes and/or hypertension in the 4th public health region. The program focused on the promotion of health literacy and self-management through the training for cognitive skills, behavior skills, and social skills. The model, also, included comprehensive health education, individual counseling, training for reading skill, communication skill, knowing important number, and media literacy skill. Also, training for self-management that included goal setting, problem solving, monitoring, motivation, and evaluation were conducted to modify health behaviors for controlling diabetes mellitus, hypertension, and delaying CKD. Patients can decide to choose suitable methods that were appropriate to their contexts (tailored made intervention). The use of health information and short message that fit to delay progressive CKD was added into the model. The patients were required to interact in all activities. The program used various media, communication technique, and good relationship between patients and healthcare team both in person, by telephone, and line application. The number of activities were nine times that included five times in healthcare settings, 2 times home visit, and 2 times telephone visit through seven months. After participating in the program, diabetes and/or hypertensive patients had average score of health literacy to delayed progressive CKD (t = 11.407), and average score of self-management to delayed progressive CKD (t = 8.041) to be statistically significantly higher than the score before participating in the program at 0.01 level (p< .01). Clinical outcomes that included body weight (t = 6.951), waist circumstance (t = 6.777), systolic blood pressure (t = 6.100), diastolic blood pressure (t = 8.617), fasting plasma glucose (t = 3.745), HbA1c (t = 3.838), blood urea nitrogen (t = 3.117), and creatinine (t = 5.089) were statistically significantly lower than those clinical outcomes before participating in the program at .01 level (p< .01). Additionally, glomerular infiltration rate (t = -8.216) was statistically significantly increased more than those before participating in the program at 0.01 level. Study sample, 138 patients can delay CKD (88.46%). Patients had average decreased renal function 5% as 1.70 (SD = 0.74), the same and increased renal function 5% as 2.84 (SD = 1.41), and increased renal function over 5% as 13.49 (SD = 10.69) respectively. 4) The prototype model of healthcare system to delayed progressive CKD in primary healthcare settings included ten characteristics as follows: 1) administrators took the concept of health literacy to healthcare system for delayed progressive CKD, 2) development of health literacy skill of delaying CKD for healthcare staff, 3) the use of healthcare service for delaying CKD should be integrated by the health literacy concept, 4) preparation of environment and channel that promote the access of information and service, and sign, 5) providing media and publications related to information to delaying CKD that were simple and easy understanding, 6) opening opportunity for patients and families to participate in healthcare system for delaying CKD, 7) development of health literacy skill of delaying CKD to population in community through home, temple and school, 8) communicate the clear healthcare coverage and out of pocket, 9) preparation the channel of transfer system for continuum of care, and 10) administrators participate in planning for modifying the system to delay CKD with network server continuously. For secondary and tertiary healthcare settings, there are four characteristics out of eleven differently form primary healthcare settings as follows; 1) the use of healthcare system to delayed progressive CKD by integrating health literacy concept in all settings, 2) setting the main team and channel to providing consult to primary client team network, 3) developing the database that support patients who would like to delayed progressive CKD, and 4) providing the chance to the administrator of primary client healthcare settings to participate in planning for improving the system of care to delaying CKD. The research results suggested that the healthcare settings both primary and secondary/tertiary levels that are network should modify the plan of system together for continuous and sustainable of care. 5) The promotion of health literacy to delayed progressive CKD was complex and being necessary to have strategic plan. Also, the progressive action and the cooperation of all related person among healthcare providers, patients, health administrators, communities, society, public health region, and Ministry of Public Health are needed. The various, clear, and continuous actions and specific model for the patient problems that fit the context of the patients are needed at the first diagnosis and suitable for the context, community, and society. Additionally, the adjustment of healthcare system and working culture of healthcare providers that focus on health literacy to delayed progressive CKD, patient center, effective communication, informatics system, and network are needed to be care for the patients systemically and continuously. Furthermore, all parts should cooperate to manage social determinant of health because it is significant basic to promote health literacy, particularly the support of people to have ability of reading, education base, life-long learning, and economic that lead people to have good living and caring for themselves. Also, the preparation of environment that supports health literacy to delayed progressive CKD should be action both in healthcare settings and outside as shown in policy recommendation documents.