Output Penelitian Kerjasama Luar Negeri

Targeted Indicator
No Output Indicator
Year 1 Year 2 Year 3
International Journal indexed by Scopus Submitted/ Reviewed/
1 Article Accepted
and registered at Scimago Reviewed Accepted
Oral International
2 Presented Presented Presented
Presentation Conference/Symposium/Seminar
Health Education and Health Coaching
Draft/
3 Book with ISBN Porgam for Optimalization on Self-care Draft Submitted
Submitted
Management of Diabetes Type 2 Patient

1. Artikel Penelitian
Sudah di submit ke International Journal Diabetes in Developing Countries
 2. Draft Manuskrip

1. Title Page
Title: Health literacy, self-efficacy and self-care management among people with diabetes type 2
in Indonesia.
Authors:
1. Kusrini S. Kadar, BN. MN. PhD (KK)
Affiliation: Faculty of Nursing, Universitas Hasanuddin, Makassar, Indonesia.
ORCID: https://orcid.org/0000-0002-9208-4859
2. Fitri A. Sabil, BN (FS)
Affiliation: Postgraduate Nursing Program Student, Faculty of Nursing, Universitas
Hasanuddin, Makassar, Indonesia.
3. Dr. Elly L. Sjattar, BN, MH (ES)
Affiliation: Faculty of Nursing, Universitas Hasanuddin, Makassar, Indonesia.
ORCID: https://orcid.org/0000-0002-7376-5771
4. Professor Lisa McKenna (LM)
Affiliation: School of Nursing and Midwifery, La Trobe University, Australia
ORCID: http://orcid.org/0000-0002-0437-6449
5. Saldy Yusuf, BN, MHS, PhD (SY)
Affiliation: Faculty of Nursing, Universitas Hasanuddin, Makassar, Indonesia.
ORCID: https://orcid.org/0000-0002-5993-9325
6. Muh. Zukri Malik, BN, MN (ZM)
Affiliation: School of Nursing, STIKes Panakukang, Makassar, Indonesia
7. Nurul Fadilah Gani, BN, MN (NFG)
Affiliation: School of Nursing, STIK Nani Hasanuddin, Makassar, Indonesia.

Correspondent author:
Kusrini S. Kadar, BN. MN. PhD
Affiliation: Faculty of Nursing, Universitas Hasanuddin, Makassar, Indonesia.
Address: Faculty of Nursing Universitas Hasanuddin
Jl. Perintis Kemerdekaan Km. 10 Kampus UNHAS Tamalanrea
Makassar, Indonesia, Postcode: 90245
E-mail: kusrinikadar@unhas.ac.id; kusrini.kadar@gmail.com
Ph. +62 82291611122
Title: Health literacy, self-efficacy and self-care management among people with diabetes
type 2 in Indonesia

Introduction
Diabetes mellitus is a chronic condition where blood glucose levels are raised due to disturbance of insulin,
either where the body cannot produce any insulin (type 1), or sufficient insulin or the body cannot use
insulin effectively (type 2) [1]. Uncontrolled diabetes is associated with long-term complications such as
cardiovascular disease, eye and kidney disease and nerve damage [1, 2]. In 2015, 415 million adults in the
world reportedly suffered from diabetes, four times higher than in the 1980s. It is predicted that by 2040
the number will rise to 642 million people [3], and among those almost 80% will live in low to middle
income countries. In Western Pacific countries, which includes Indonesia, there are reportedly around 170
million people with diabetes, roughly 1 in 11 adults [1, 3]. Indonesia is one of the 22 countries and
territories of the IDF Western Pacific (WP) region where around 159 million people have diabetes, and
more than half (54%) have not yet been diagnosed and are at higher risk of developing harmful and costly
complications. By 2045, this number is predicted to rise to 183 million [4]. In 2017, there were over
10,276,100 cases of diabetes in Indonesia making Indonesia second ranked after China [5]. Around two
thirds of people with diabetes in Indonesia do not know they have the condition and thus are very late to
access health services, by which time they already have complications [3]. In South Sulawesi Province
Indonesia, there has been a sharp increase in the number of people with diabetes from 1.5% in 2007 to 7.1%
in 2013 [6] putting this province in third position for numbers of people with diabetes in the country. In
2016, the fourth most common cause of death and premature death in Indonesia was diabetes and this
disease has been estimated to cause 100,400 deaths annually, responsible for 6.5% of all deaths [7].
Lack of self-care behaviour is considered among the most important factors affecting mortality for people
with diabetes. [8] Self-care behaviour is defined as the ability that someone has to make decisions and
actions to overcome health problems and/or to improve health status [9]. Lifestyle management is a
fundamental aspect of diabetes care to facilitate knowledge, skills and abilities necessary for optimal
diabetes self-care [10]. Although many factors such as age, gender, and educational level have been proven
to affect self-care behaviour of people with diabetes, all those factors cannot be modified [11]. Several
studies have found that some psychosocial factors, such as health literacy and self-efficacy, also play
important roles in self-care management of people with type 2 diabetes [8, 9, 11, 12]. Health literacy is
described as the degree to which individuals have the ability to obtain, process, and understand basic health
information and services needed to make appropriate health care decisions, and is important for good health
[13-15]. Low levels of health literacy have been associated with poorer health outcomes in many chronic
conditions [12, 16]. Studies have shown that health literacy is correlated with self-efficacy, where
improving self-efficacy can also improve self-care management and promote health literacy [8, 9, 17, 18].
Self-efficacy is the belief one has in their own abilities to meet challenges ahead and complete a task
successfully [8]. As Bandura emphasized, self-efficacy is “the belief in one’s capabilities to organize and
execute the sources of action required to manage prospective situations ”, thus efficacy beliefs influence
how people think, feel and can motivate themselves to act [19]. In order to be able to manage better health
behavior, a person needs to have knowledge and skills related to health, which is known as health literacy,
and self-belief that the person holds about their capabilities of what to do with the knowledge and skills
that they have [20].
Although many studies have been conducted about health literacy, self-efficacy and self-care behaviour or
self-care management, the unique contributions of those variables are not as well understood [9]. Patients
with higher health literacy levels may feel more confident in their ability to perform self-care management
[21]. Although many studies have been conducted related to those variables, there are very limited studies
from Indonesia as there are no statistics and evidence available on the subject. Therefore, this study was
conducted with two aims: to determine health literacy status, self-efficacy level and self-care management
level; and to determine the relationship between health literacy, self-efficacy and self-care management in
people with diabetes type 2 in Makassar District, Indonesia.

Materials and Methods

Design and Sample
This study was conducted using a cross-sectional design from May to July 2018. The subjects were people
with diabetes type 2 residing in their homes. A total of 105 people with diabetes type 2 from three primary
health centres (PHCs, known as Pukesmas) working area in Makassar City, Indonesia were recruited to
participate using purposive sampling technique. Inclusion criteria were: people diagnosed with type 2
diabetes mellitus (T2DM) for a duration of over two years, able to self-care, and communicate and converse
in Bahasa Indonesia. Exclusion criteria included people with dementia and mental health disorders
diagnosed by a physician or hospitalized during the data collection period. Participants underwent face-to-
face interview using structured questionnaires. The research team performed the interviews at the three
Puskemas. Informed written consent was obtained from each participant. The research team consisted of a
nurse educator and postgraduate nursing student.

Data collection procedures

Data were collected by face-to-face interview using four structured questionnaires. Questionnaires used
were the European Health Literacy Questionnaire ([HLS-EU-Q] translated by the Asian Health Literacy
Association [AHLA] Indonesia), Diabetes Management Self Efficacy (DMSE) questionnaire for self-
efficacy and Diabetes Self-care Management Questionnaire (DSMQ) for self-care management that were
translated and back-translated. The HLS-EU was developed by the HSL-EU consortium in 2009 and has
been developed until 2012 to measure the comprehensive concepts around fit of personal competencies to
situational demands for concrete health relevants tasks [22, 23]. Originally, the HLS-EU-Q consisted of 47
items that had been modified into shorter scales with better psychometric properties to 16 scales (HLS-EU-
Q16) and 6 scales (HLS-EU-Q6). This questionnaire has been used widely in European and Asian countries,
including Indonesia. The HLS-EU-Q16 had been translated and validated by the Asian Health Literacy
Association (AHLA) in Indonesia [24]. Health literacy levels were measured by Likert scale. Answers were
scored by choosing answers indicating levels of health literacy (from 1 meaning very difficult to 4 meaning
very easy). The questionnaire of health literacy consisted of 16 questions. This was different from HLS-
EU-47, as in HLS-EU-16 answers are categorized dichotomously, that is, “very difficult” and “moderately
difficult” answers were scored as 0 and “fairly easy” and “very easy” were scored as 1. All scores were
summarised, so the minimum was 0 and the maximum was 16. The scores are categorized as follows:
Inadequate HL (0-8), Problematic HL (9-12), Sufficient HL (13-16). Many previous studies have used this
measurement [24-30], however when creating the categories, highly unequal sample sizes were obtained
for the three groups, with very few individuals in the inadequate HL category. Thus, to obtain more balanced
groups of comparable size, categories of higher or lower HL were created using the median score. The
higher HL score (higher than mean score) is considered good.
Self-efficacy in this study was measured using Diabetes Self-Efficacy Scale (DSES) developed by Lorig
et al. in 2009 [31]. The scale was developed to determine self-efficacy, specifically in people with diabetes.
This questionnaire consists of eight items on a Likert-type scale scored between 1 and 10 (1=not at all
confident, 10=totally confident). The score for the scale is the mean of the eight items thus a higher number
indicates higher self-efficacy [32]. This scale was chosen because the scales had strong and consistent
internal consistency reliability and were associated with a range of health indicators and behaviors. The
scores were sensitive to change and associated with changes in medical outcomes. The scales have been
also associated with six-month changes in health measures and are appropriate for measuring self-efficacy
to manage diabetes, particularly where a brief scale may be desired [32]. The DSMQ was developed at the
Research Institute of the Diabetes Academy Mergentheim. It was the first German instrument targeting
diabetes self-care, and designed to assess behaviours associated with metabolic control within common
treatment regimens for type 1 and type 2 diabetes in adults [33]. Respondents are asked to rate the 16
statements of DSMQ, describing specific self-care behaviours according to their own diabetes self-care
during the last two months. Rating is done using on a four point Likert scale (from 0 – ‘does not apply to
me’ to 3 – ‘applies to me very much’). The tool comprises seven positively-worded statements and nine
negatively-worded statements with regard to what is considered effective self-care. In addition to a ‘Sum
Scale’ scoring (summation of all 16 items score), the tool also enables evaluation of four subscale scores
of diabetes self-care; namely ‘Glucose Management’ (items 1, 4, 6, 10, 12), ‘Dietary Control’ (items 2, 5,
9, 13), ‘Physical Activity’ (items 8, 11, 15), and, ‘Health-Care Use’ (items 3, 7, 14). The last item (item 16)
asks respondents to rate their overall diabetes self-care, hence its score is included only in the ‘Sum Scale’.
The responses were converted to a scale ranging from 0 to 10, where higher scores are indicative of more
effective self-care [33]. Each questionnaire was translated by an accredited translator and nurse educators
expert in this area and was translated back by a native speaker accredited for translating documents from
Bahasa Indonesia to English, except for HLS-EU-Q16 that had been previously translated by AHLA
Indonesia. The questionnaires were evaluated for content validity and reliability. The content validity index
items score for each item was 0.68 for HLS-EU-Q16 and DSES, and 0.5 for DMSQ. Cronbach Alpha for
each scale was as follows: 0.947 (HLS-EU-Q16), 0.852 (DSES), and 0.789 (DSMQ). Based on this data,
all the questionnaires were considered acceptable. Data were analysed by using the Statistical Packages for
Social Sciences (SPSS version 23). Descriptive summaries of demographic, clinical characteristics and
psychological factors were performed using frequencies, and percentages. The level of probability of <0.01
was considered statistically significant. Spearman rank correlation test was used, as the data were not
distributed normally, to examine relationships between health literacy, self-efficacy and self-care
management.

Data editing and statistical analysis

Data editing was carried out by checking and verifying the completed questionnaire at the end of interview
and as well as at the end of the whole survey and before analysis. The data analysis was performed using
Statistical Package for Social Science (SPSS) version 16.0. The respondent’s sociodemographic and clinical
characteristics of participants as well as the level of health literacy, self-efficacy and self-care management
and its subscales were analyzed using descriptive statistics. The data are non-normally distributed;
therefore, Spearman rank correlation was used to determine the correlation between health litearcy, self-
efficacy and self-care management among people with type two diabetes. All associations were considered
significant at the alpha level of 0.01.

Results
Most participants were female (76.2%), just over half had completed senior high school education (51.4%).
Duration of diabetes ranged from 1 to 25 years, with an average years of 7 years. More than half of the
participants had complications from their diabetes (59%). Participants’ ages ranged from 40-70 years, with
the average age being 60 years old. The median scores of health literacy, self-efficacy, and self-care
management were 48.46 ±5.56 (min-max 35-62), 52.24 ±10.96 (min-max 35-78), 45.3 ±7.23 (min-max 31-
64) respectively (Table 1).

Table 1
Demographic and clinical characteristics of participants (n=105)

Characteristics n %
Gender
Male 25 23.8
Female 80 76.2
Education
Primary school and lower 29 27.3
Junior High School 15 14.3
Senior High School 54 51.4
Bachelor and higher 7 6.7
Complication
No 43 41.0
Yes 62 59.0
Min-Max Mean ± SD
Age 40-75 60 7.81
Diabetes duration (year) 1-25 7 3.81
Min-Max Median ± SD

Health Literacy Level 35-62 47.00 5.93

Self-Efficacy Level 35-78 50.00 10.96
Diabetes Self Care Management 31-64 44.00 7.23

Subscales score of self-care management

The diabetes self-care management questionnaire used in this study was DMSQ that has four subscale to
explore self-care activities people with diabetes, namely glucose management, dietary control, physical
activity and health-care use. This study found that the majority of people with diabetes type 2 in this district
had poor self-care management. From all subscales, although majority of people with type 2 diabetes had
used the health care services to control their health (73.3), there were still more people who did not have
good diabetes self-care management (Table 2).
Table 2
Subscale score of self-care management (n=105)
Poor Good
Subscale
n % n %
Glucose management 66 62,9 39 37,1
Dietary control 90 85,7 15 14,3
Physical activity 79 75,2 26 24,8
Health-care use 28 26,7 77 73,3

Correlation between health litearcy, self-efficacy and self-care management

The Spearman rank correlation test showed significant positive correlation between health literacy, self-
efficacy, and self-care management (Table 3). Health literacy and self-efficacy also showed significant
positive correlation (p<0.001, r=.502). In other words, increased health literacy of people with diabetes
could increase their self-efficacy. There was also significant direct correlation between health literacy and
self-care management scores (p<0.001, r=.498). Self-efficacy was also found to have positive correlation
with self-care management (p<0.001, r=.458). From respondents’ characteristics, only age correlated (weak
negative correlation) with self-care management (p<0.05, r=-.194), but was not related to health literacy
and self-efficacy.

Table 3
Correlation matrix of health literacy level, self-efficacy level, and Self-care management (n=105)

Health Self- Self-Care

Literacy Efficacy Management
Health Literacy 1.000
Self-Efficacy .502** 1.000
Self-Care
.498** .458** 1.000
Management
**. Correlation is significant at the 0.01 level (2-tailed).
The data are non-normally distributed; therefore, Spearman rank correlation was used.
Discussion
Correlation between Health Literacy, Self-Efficacy and Self-Care Management
This research was conducted to examine the relations between health literacy, self-efficacy and self-care
management among people with diabetes in Makassar City, Indonesia. Previous studies [8, 9, 12, 34] have
found correlation between health literacy, self-efficacy and self-care behavior. While this study explored
the relation between health literacy, self-efficacy and self-care management using different tools, similar
results were found with those previous studies. This study were consistent with studies by Bohanny et.al
(2013) [9], Masoompour et.al (2017) [8] and Mahnous et.al (2016) [12]. Health literacy has been proven
able to increase level of self-efficacy, where Bandura considered self-efficacy as one of the important inner
sources to empower individuals to perform their personal activities and obtain good self-care behavior [20].
Self-efficacy and self-care behaviours are an integral part of the social-cognitive theory and this is
confirmed with associations with glycaemic control [35].

Indonesian government support

Similar to what was found in previous studies [9], the majority of participants had limited health literacy
and low self-efficacy. This condition was clearly shown in the self-care management subscale. Even though
the majority of respondents had used the health-care facility to control their health, still many of them had
poor glycemic management, dietary control and physical activity. Health literacy people with diabetes can
be improved by the Indonesian government program for elderly people with chronic disease (Prolanis).
This program aims to help the elderly with chronic illnesses, including diabetes, to improve their health
status. The majority of respondents in this study routinely visit the public health centre (Puskesmas),
because they are members of Prolanis, where every Saturday they will go to Puskesmas in their
neighbourhood to obtain health services, such as health assessment and exercise; and every month they will
be provided health education by the doctor [36]. This program is expected to be able to help patients with
chronic disease live in the community, able to manage their health status well , as was shown in one study
conducted in Manado City, Indonesia, that found a correlation between the prolanis program and health
literacy in elderly peoplewith diabetes [37]. However, the Prolanis program cannot be conducted effectively
if it is not supported by skilled health professionals. Health education programs in Prolanis are often not
implemented effectively due to many reasons, such as limited staff numbers and skills of health
professionals who deliver health education [38, 39]. Furthermore, health education that is held once a month
is insufficient to improve health literacy and self efficacy in people with diabetes. It should be followed by
home visit activity to control and help people improve their self-care management. However, home visits
are rarely been performed by community health staff due to many barriers, including budgets and multiple
competing tasks at the health centre [38].

Limitation and recommendation

It is acknowledged that this study has limitations. Firstly, it only explored the correlation between health
literacy, self-efficacy and self-care management. In doing so, it did not explore what other factors might
affect self-care management. Secondly, the study was only conducted in one area of Indonesia and findings
may be different elsewhere. Furthermore, a larger sample and different research approaches are needed to
examine other influencing factors on diabetes self-care management. Nevertheless, the findings provide
important information on which management of people with diabetes can be further enhanced.
Conclusion
Many factors can influence the self-care management ability of people with chronic illness, namely health
literacy and self-efficacy. Higher health literacy has been proven be able to improve self-efficacy, thus
eventually improving self-care management of people with diabetes. Health professionals must facilitate
people with diabetes to improve their health literacy to enhance their ability in better managing their self-
care. The Indonesian government’s program for elderly people with chronic disease (Prolanis) is a good
place for healthcare providers to begin to improve health literacy to improve self-confidence and self-care
management of people with diabetes.

Acknowledgements
The authors acknowledge and thank to the participants, people with type 2 diabetes reside in three working
areas of Puskesmas in Makassar City, Indonesia for their participation, and for the Research and to the
Centre of Research and Community Service Universitas Hasanuddin for funding this research.

Author contributions
All authors conceptualized the project design, analyzed statistical data, interpreted data, drafted the article
and revised it critically for important intellectual content, and finally approved the version to be published;
KK, FS, ES, LM and SY developed the idea, designed the project, interpreted data, and prepared and
submitted the article; ZM, NFG, and FS collected the data, performed statistical analysis, and interpreted
the data; and KK, ES and SY and LM supervised and monitored all aspects of this study. All authors
contributed equally to the final version of the manuscript.

Funding source
The author(s) received financial support from World Diabetes Foundation (WDF Grant no. 05-131) and
Biomedical Research Group (BMRG), BIRDEM.

Compliance with ethical standards

The authors (KK, FS, LM, ES, SY, ZM, NFG)) report no relationship or financial interest with any entity
that would pose a conflict of interest with the subject matter of this article.
This study was approved by the Ethical Committee Board for Health Research, Faculty of Medicine
Universitas Hasanuddin, Indonesia (Ethics No. 460/H4.8.4.5.31/PP36-KOMETIK/2018).
Conflict of Interest
The authors (KK, FS, LM, ES, SY, ZM, NFG)) report no relationship or financial interest with any entity
that would pose a conflict of interest with the subject matter of this article.

References

1. IDF Diabetes ATLAS 8th Edition [Internet]. International Diabetes Federation. 2017 [cited 04
October 2018]. Available from: https://www.idf.org/e-library/epidemiology-research/diabetes-
atlas/134-idf-diabetes-atlas-8th-edition.html.
2. Soewondo P, Ferrario A, Tahapary DL. Challenges in diabetes management in Indonesia: a literature
review. Globalization and Health. 2013;9(1):63.
3. World Health Organization. Diabetes: Facts and Numbers [Diabetes: Fakta dan Angka ] 2016 [1-2].
Available from: http://www.searo.who.int/indonesia/topics/8-whd2016-diabetes-facts-and-
numbers-indonesian.pdf.
4. World Health Organization. Country and regional data on diabetes: Prevalence of diabetes in the
WHO South-East Asia Region: WHO South-East Asia Region; 2018 [Available from:
http://www.who.int/diabetes/facts/world_figures/en/index5.html.
5. International Diabetes Federation. IDF Diabetes ATLAS 8th Edition: WP Regional Fact Sheet:
International Diabetes Federation; 2017 [Available from: http://diabetesatlas.org/resources/2017-
atlas.html.
6. Kementrian Kesehatan RI. Riset Kesehatan Dasar (RISKESDAS) 2013: Badan Penelitian dan
Pengembangan Kesehatan Kemenkes RI; 2013 [Available from:
http://www.depkes.go.id/resources/download/general/Hasil%20Riskesdas%202013.pdf.
7. The Institute for Health Metrics and Evaluation. Health Data: Indonesia 2016 [Available from:
http://www.healthdata.org/indonesia.
8. Masoompour M, Tirgari B, Ghazanfari Z. The Relationship between Health Literacy, Self-Efficacy,
and Self-Care Behaviors in Diabetic Patients. Evidence Based Care. 2017;7(3):17-25.
9. Bohanny W, Wu SFV, Liu CY, Yeh SH, Tsay SL, Wang TJ. Health literacy, self‐efficacy, and self‐
care behaviors in patients with type 2 diabetes mellitus. Journal of the American Association of Nurse
Practitioners. 2013;25(9):495-502.
10. American Diabetes Association. Lifestyle Management. Diabetes Care. 2017;40(Supplement 1):S33-
S43.
11. Lee Y-J, Shin S-J, Wang R-H, Lin K-D, Lee Y-L, Wang Y-H. Pathways of empowerment
perceptions, health literacy, self-efficacy, and self-care behaviors to glycemic control in patients with
type 2 diabetes mellitus. Patient Education and Counseling. 2016;99(2):287-94.
12. Reisi M, Mostafavi F, Javadzade H, Mahaki B, Tavassoli E, Sharifirad G. Impact of Health Literacy,
Self-efficacy, and Outcome Expectations on Adherence to Self-care Behaviors in Iranians with Type
2 Diabetes. Oman Medical Journal. 2016;31(1):52-9.
13. Du S, Zhou Y, Fu C, Wang Y, Du X, Xie R. Health literacy and health outcomes in hypertension:
An integrative review. International Journal of Nursing Sciences. 2018;5(3):301-9.
14. Institute of Medicine. Measures of Health Literacy: Workshop Summary. Washington, DC: The
National Academies Press; 2009. Available from: https://www.nap.edu/catalog/12690/measures-of-
health-literacy-workshop-summary.
15. Nutbeam D. Defining, measuring and improving health literacy. Health Evaluation and Promotion.
2015;42:450-55.
16. Dickson VV, Chyun D, Caridi C, Gregory JK, Katz S. Low literacy self-care management patient
education for a multi-lingual heart failure population: Results of a pilot study. Applied Nursing
Research. 2016;29:122-24.
17. Javadzade SH, Sharifirad G, Radjati F, Mostafavi F, Reisi M, Hasanzade A. Relationship between
health literacy, health status, and healthy behaviors among older adults in Isfahan, Iran. Journal of
Education and Health Promotion. 2012;1(1).
18. Osborn CY, Cavanaugh K, Wallston KA, Rothman RL. Self-Efficacy Links Health Literacy and
Numeracy to Glycemic Control. Journal of Health Communication. 2010;15((Supp 2)):146-58.
19. Bandura A. Self-Efficacy in Changing Societies. In: Ebook L, editor. Cambridge: Cambridge :
Cambridge University Press; 1995.
20. Bandura A. Self-efficacy : the exercise of control. New York: New York : W.H. Freeman; 1997.
21. Chen AM, Yehle KS, Plake KS, Murawski MM, Mason HL. Health literacy and self-care of patients
with heart failure. The Journal of cardiovascular nursing. 2011;26(6):446-51.
22. Sørensen K, Van den Broucke S, Pelikan JM, Fullam J, Doyle G, Slonska Z, et al. Measuring health
literacy in populations: illuminating the design and development process of the European Health
Literacy Survey Questionnaire (HLS-EU-Q). 2013;13(1):948.
23. Pelikan JM, Ganahl K. Measuring Health Literacy in General Populations: Primary Findings from
the HLS-EU Consortium's Health Literacy Assessment Effort. Studies in health technology and
informatics. 2017;240:34-59.
24. Nurjanah N, Rachmani E, M Manglapy Y, editors. Assessing Health Literacy on Student using online
HLS-EU-16. Conference: International Seminar on Public Health and Education 23rd April 2015;
2015.
25. Wångdahl J, Lytsy P, Mårtensson L, Westerling R. Health literacy among refugees in Sweden - a
cross-sectional study. BMC public health. 2014;14(1):1030.
26. Almaleh R, Helmy Y, Farhat E, Hasan H, Abdelhafez A. Assessment of health literacy among
outpatient clinics attendees at Ain Shams University Hospitals, Egypt: a cross-sectional study. Public
Health. 2017;151:137-45.
27. Lorini C, Santomauro F, Grazzini M, Mantwill S, Vettori V, Lastrucci V, et al. Health literacy in
Italy: a cross-sectional study protocol to assess the health literacy level in a population-based sample,
and to validate health literacy measures in the Italian language. BMJ Open 2017;7(11).
28. Storms H, Claes N, Aertgeerts B, Van den Broucke SJBPH. Measuring health literacy among low
literate people: an exploratory feasibility study with the HLS-EU questionnaire. BMC Public Health.
2017;17(1):475.
29. Emiral G, Aygar H, Atalay B, Göktaş S, Dağtekin G, Arslantas D, et al. Health literacy scale-
European union-Q16: a validity and reliability study in Turkey. International Research Journal of
Medical Sciences. 2018;6(1):1-7.
30. Levin-Zamir D, Baron-Epel OB, Cohen V, Elhayany A. The Association of Health Literacy with
Health Behavior, Socioeconomic Indicators, and Self-Assessed Health From a National Adult Survey
in Israel. Journal of Health Communication. 2016;21(sup2):61-8.
31. Lorig K, Ritter PL, Villa FJ, Armas J. Community-Based Peer-Led Diabetes Self-management. The
Diabetes Educator. 2009;35(4):641-51.
32. Ritter PL, Lorig K, Laurent DD. Characteristics of the Spanish- and English-Language Self-Efficacy
to Manage Diabetes Scales. The Diabetes Educator. 2016;42(2):167-77.
33. Schmitt A, Gahr A, Hermanns N, Kulzer B, Huber J, Haak TJH, et al. The Diabetes Self-Management
Questionnaire (DSMQ): development and evaluation of an instrument to assess diabetes self-care
activities associated with glycaemic control. Health and Quality of Life Outcomes. 2013;11(1):138.
34. Shin KS, Lee E-H. Relationships of health literacy to self-care behaviors in people with diabetes
aged 60 and above: Empowerment as a mediator. Journal of advanced nursing. 2018.
35. D'Souza MS, Karkada SN, Parahoo K, Venkatesaperumal R, Achora S, Cayaban ARR. Self-efficacy
and self-care behaviours among adults with type 2 diabetes. Applied Nursing Research. 2017;36:25-
32.
36. Panduan Praktis PROLANIS (Program Pengelolaan Penyakit Kronis) [Internet]. BPJS-Kesehatan
RI. n.d [cited 08 February 2018]. Available from: https://www.bpjs-
kesehatan.go.id/bpjs/dmdocuments/06-PROLANIS.pdf.
37. Toar JM, Kadar K, Sinrang W. PROLANIS: Strategi meningkatkan health literacy pada lanjut usia
dengan diabetes melitus (PROLANIS: A strategy to improve health literacy on Elderly with diabetes
mellitus). Patria Artha Journal Of Nursing Science [Internet]. 2017; 1(2):[95-106 pp.]. Available
from: http://ejournal.patria-artha.ac.id/index.php/jns/issue/view/11/showToc.
38. Kadar KS, McKenna L, Francis K. Scoping the context of programs and services for maintaining
wellness of older people in rural areas of Indonesia. International Nursing Review. 2014;61(3):310-
7.
39. Andrianys I, Kadar K, Massi N. Precede-Proceed Education Model Towards Health Literacy of
Hypertension Patient Within The Working Area of Pattingalloang Health Centre Makassar. ICON
Journal. 2017;1(2).