The Instruments Used to Assess Health Literacy and Pharmacotherapy Literacy of Diabetes Mellitus Type 2 Patients: A Scoping Review

Background: Patients with chronic diseases, like diabetes need to continuously perform tasks associated with self-management especially with medications they use. It is shown that the patients with diabetes with limited HL and PTHL cannot read medication labels correctly, may misuse their medications, spend much more on therapy and generally have difficulties in understanding printed care instructions and perceiving health advice and warnings. There has been an increasing demand for valid and reliable instruments for HL and PTHL assessment in this population. This review aims to search and critically discuss instruments used to assess HL and PTHL in people with type 2 diabetes and propose their use in different settings. Methods: Authors conducted a comprehensive, electronic search of original studies using a structured approach of the Scopus and PubMed databases, during November and the first 2 weeks of December 2020 to find relevant papers. The review was conducted in accordance with the Cochrane guidelines and the reporting was based on the PRISMA-ScR. The comparison of instruments was made by utilizing a comparison model related to their structure, measurement scope, range, psychometric properties, validation, strengths, and limitations. Results: The final number of included studies was 24, extracting the following identified instruments: Korean Functional Test HL, NVS, FCCHL, HLS-EU-47, TOFLHA, S-TOFHLA, REALM-R, 3-brief SQ, REALM, HLQ and DNT-15. In all, FCCHL and 3-brief SQ are shown with the broadest measurement scopes. They are quick, easy, and inexpensive for administration. FCCHL can be considered the most useful and comprehensive instrument to screen for inadequate HL. The limitation is that the English version is not validated. Three-brief SQ has many advantages in comparison to other instruments, including that it is less likely to cause anxiety and shame. These instruments can be considered the best for measuring functional HL in patients with diabetes mellitus type 2 and other chronic diseases. PTHL instruments (REALM and DNT-15) did not find the best application in this population. Conclusions: The future research should be directed in validation of the FCCHL in English and establishing of the structural validity of this questionnaire. Developing a specific PTHL questionnaire for this population will be of great help in management of their disease.


INTRODUCTION
The main goal of today's healthcare system is to promote and maintain good health and at the same time enable people to take care of their health. People are also expected to be more responsible for their health and participate more in decision-making related to their health (1)(2)(3). When we talk about responsibility for our health, we must consider different assumptions. Efforts should be focused on a person's ability to cope and take responsibility for their health (3). The Patients' Rights Act from 1999 states that the manner of participation in healthcare decisions should be adapted to each person's ability to give and receive health information. These abilities are related to health literacy (HL) (4).
To understand and use health information to make health decisions, adequate HL is needed (4). In a report by the World

Health Literacy
Adequate health literacy is crucial for patients to make optimal choices for their health and medications management.
Additionally, successful health communication presupposes certain levels of competence of both the healthcare professional and the patients and is adapted to the HL of the individuals (5).
"HL" as a recognized term came into use around 1974, but only became a [Medical Subject Headings (MeSH)] term in MEDLINE in 2006. A systematic review of Sørensen et al. (17) discovered 17 definitions and 12 conceptual models of HL. Based on all the offered, one overall definition was obtained, which reads: "HL is linked to literacy and entails people's knowledge, motivation and competencies to access, understand, appraise, and apply health information in order to make judgments and take decisions in everyday life concerning healthcare, disease prevention and health promotion to maintain or improve quality of life during the life course." There is currently no consensus on defining HL, which means that different approaches to this term are used in various research environments (17)(18)(19)(20). An additional concept of understanding becomes a problem when it comes to assessing and measuring HL and then comparing these results between different studies (16). The presence of different definitions is probably due to the fact that the concept has been developed in different parts of the world, with varying abilities and skills considered necessary to deal with health information in each specific context (21).
In the twentieth century, reading and writing were sufficient to use information obtained from health professionals. However, with increasing expectations of active participation in health decisions, increasing responsibility for one's health, and digital development in health information, additional skills are needed to handle health information. First, the need for reading has increased, and the skills to apply and critically evaluate health information from various sources are essential. HL combines a set of skills or abilities, while on the other hand it depends on the requirements to which the individual is exposed. The impact of technological development has also increased, which will affect the definition and understanding of HL in the future (22).

Pharmacotherapy Literacy (PTHL)
Patients with chronic diseases need to continuously perform tasks associated with self-care and self-management of their medications. When taking medicines, they constantly need abilities related to various domains of HL, so HL brings together many concepts that are associated with patient's pharmacotherapy. Whether they rely on information in printed materials or verbal instruction patients with chronic conditions need to have adequate HL related to medications as critical for managing their conditions. Due to the complexity of the various procedures required for the adequate use of medications, the concept of PTHL was introduced.
King and colleagues, in consultation with the academy and pharmacists, formulated PTHL as: "An individual's capacity to obtain, evaluate, calculate, and comprehend basic information about pharmacotherapy and pharmacy related services necessary to make appropriate medication-related decisions, regardless of the mode of content delivery (e.g., written, oral, visual images and symbols)" (23). This definition was updated by adding to reduce thereby the risk of poor pharmacotherapy outcomes (24).

HL and PTHL in Persons With Type 2 Diabetes Mellitus
Diabetes is one of the most common chronic non-communicable diseases and is a major public health problem. In 2019, the International Diabetes Federation estimated that 463 million adults worldwide have diabetes and that this number is expected to increase to 700 million by 2,045. The cause of this disease is multifactorial, but it is associated with unhealthy lifestyles such as physical inactivity and poor diet. It is assumed that between 30 and 80% of people with type 2 diabetes are still undiagnosed. Complications such as diabetic nephropathy and neuropathy may occur at a later diagnosis of disease (25). Despite advances in therapy and the availability of clinical practice guides, only 30% of patients manage to achieve the target values of glycemia, cholesterol and blood pressure. The fact is that patients perform 95% of diabetes care on their own (26).
Type 2 diabetes is more common than type 1, so 90% of all diabetes is type 2 diabetes. It most often occurs in middle age and in the elderly. It is closely related to lifestyle and health habits, with being overweight and obese being risk factors. Hereditary factors can also influence the risk of developing this disease. Therapy includes weight loss, diet and therapy with drugs that lower blood glucose levels. Affected people are advised to give up cigarettes and reduce alcohol intake to prevent the appearance of cardiovascular diseases. Living with this disease requires changes in health behavior, self-control, and a lot of care (27)(28)(29). Since living with type 2 diabetes requires a lot from people with the disease, these persons must be informed about therapy, diet and other health behaviours, which require adequate HL and PTHL. Several international studies have shown that reading and understanding the guidelines for modern diabetes medications, applying appropriate dietary restrictions, and gaining insight into the physiological processes involved in the disease can be a major challenge for an individual (30,31). The performing of diabetes self-management tasks frequently involves abilities, such as taking medications at the right time, interpreting blood glucose levels and calculating insulin doses.
A recent review of HL and health outcomes in patients with type 2 diabetes concludes that there is strong evidence to suggest a positive correlation between HL and diabetes knowledge (32). It is also considered that there is sufficient evidence to support a link between HL and self-care (33). On the other hand, the evidence of a link between HL and clinical indicators was inconsistent (34).
Some primary studies that looked at the level of HL in patients with type 2 diabetes found that a small number of these patients had adequate levels of HL (35)(36)(37)(38)(39).
Patients with diabetes and limited HL and PTHL often cannot read drug medication labels correctly, may misuse their medication, do not understand the meaning of consent forms, and generally have difficulty understanding printed care instructions and reading health advice and warnings (40)(41)(42)(43). For this reason, is very important to assess their PTHL and in case of needs perform adequate training in order to improve control of their disease and pharmacotherapy management.
These patients also have poorer communication with doctors and participate less in making health decisions (4). Patients who are diagnosed have to make health decisions daily and must also perform complex self-care activities to keep the disease under control. Interventions in upgrading HL education and intensive diabetes-related education have shown good results in patients with limited HL to improve diabetes outcomes (44,45). People with type 2 diabetes should undergo diabetes education programs at the time of diagnosis and then once a year. This education aims to enable individuals to participate in informed decision-making and disease control, all with the aim of better outcomes in treatment of this disease, improvement of glycemic control, prevention of complications and comorbidities, and improvement of quality of life (46). Education for diabetics should be evidence-based, have specific goals, and be tailored to the needs of individuals. However, the effectiveness of this education depends on individuals, i.e., characteristics such as age, gender, ethnicity, level of HL, ability to take care of themselves, all of which should be taken into account when planning and implementing this type of education (27,47). In this way, they will be able to understand and use the information they receive to maintain health and control diabetes in everyday life (47).

Instrument Development
In the past 25 years, numerous instruments have been developed to measure HL and PTHL in various contexts (14,24,48). These instruments significantly differ in structure, measurement, range, and psychometric properties. The diversity of instruments has led to inconsistencies in measurement with the complexity of interpreting the results and choosing suitable instruments for new studies. Several studies have examined the variation through the range of the most used HL instruments (49,50). Such variations can come from the fact that the instruments measure different conceptual dimensions of HL. However, it may be difficult for health professionals or researchers to choose the best instrument when they are unfamiliar with measurement properties. Another very important consideration in selecting a HL instrument is its mode of administration. In a subjective instrument, individuals self-report their perceived levels of literacy skills, such as using Likert scales. In contrast, an objective instrument is the interviewer-administrated instrument and assesses the ability to process information by asking respondents to answer specific questions, such as about the time to take the next medication. A subjective instrument requires less cognitive effort in responding to questions, whereas an objective instrument assesses health numeracy more accurately. A self-administrated instrument can be more practical in a very busy clinical settings, than interviewer-administered instrument.
Sometimes, the interviewer-administrated instrument may result in discomfort or embarrassment for patients who have a low HL.
Although the instruments were used in several populations, due to the complexity of the tasks and skills that people with type 2 diabetes require, their usefulness and applicability for this population remain challenging. With the growing interest in this construct, there has been an increasing demand for valid and reliable instruments for estimating HL and PTHL.
A systematic review of measurement properties has been designed for providing a comprehensive overview of the available instruments and identifying the best currently available instrument for general population (51). In the previous reviews of HL instruments methodological limitations were identified, such as being descriptive rather than systematic reviews, or lacking quality assessment or data synthesis (14,52,53). To address these limitations, a scoping review was conducted to systematically collect the literacy instruments used in people with type 2 diabetes and meet needs for understanding the characteristics, scope of measurements, and their applicability in this population.

METHODOLOGICAL STUDY DESIGN Aim
This study aims to analyze instruments used in patients with type 2 diabetes mellites for measuring HL and PTHL, in relation to their characteristics (measurement scope, structure, domains, method of scoring), validation, strengths, limitations and accordingly to propose applicability of these instruments in clinical and research settings. This work can be useful as an inventory for researchers and practitioners who are seeking to identify validated measurement instruments in patients with type 2 diabetes mellitus and other chronic diseases that are fitting the best for their research and practice.

Materials and Methods
Authors built a search strategy by using the PICOS questionnaire. During November and the first 2 weeks of December 2020, a systematic search of the Scopus and PubMed databases was performed in search of peer-reviewed literature of patients with type 2 diabetes mellitus. The protocol of this systematic review (including the article identification strategy and data collection form, etc.) mainly referred to the Cochrane Handbook for Systematic Reviews of Interventions (54) and the reporting of this systematic review was based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement (55).

Search Strategy
The keywords used were: "medication literacy, " "measurement tool, " "assessment, " "patient, " "chronic diseases" and "healthcare system." A search of the terms above found that the number of articles specifically mentioning PTHL was limited, so the search was extended to articles mentioning "health literacy" combined with patients with type 2 diabetes.
In the articles obtained by this search, the references were manually checked to identify additional articles of importance for the work.

Study Screening and Selection
All original articles in English are taken into consideration, which meet the below criteria. Duplicates have been excluded. The evaluation of studies regarding the inclusion and exclusion criteria was performed by a pair of independent reviewers (ML and DK): (1) review of titles and abstracts of articles related to the topic (2) review of complete articles was done which examined the HL and PTHL of patients with type 2 diabetes and had the original results of the health and pharmacotherapeutic literacy of patients with type 2 diabetes mellitus conducted through appropriate questionnaires. After cross-checking, a third reviewer (NBS) resolved cases of disagreement.

Inclusion and Exclusion Criteria
Peer-reviewed papers with cross-sectional studies, longitudinal studies and cohorts were included if they were: published between the period 2006-2021, written in English, involved patients with type 2 diabetes and papers in which HL and PTHL were examined in patients with type 2 diabetes.
The exclusion criteria were: reviews, case reports, book chapters, letters, editorials, studies that did not address HL and PTHL among patients with type 2 diabetes, studies that did not use the questionnaire for assessing literacy, studies not available or not published in English.
The inclusion and exclusion criteria are presented in Table 1.

Data Extraction and Synthesis of Results
Data extraction was performed independently by the authors. They extracted different characteristics from each publication, such as (i) publication information: author and year; (ii) study characteristics: country, setting, population, number of participants and results in terms of HL and PTHL (iii) HL and PTHL instruments: name, dimensions, number of items, purpose, target population, administration mode, validation process, scoring, cut-off points, strengths and limitations. The studies were grouped according to instruments used for the measurement of literacy: HL and PTHL. A descriptive synthesis of the identified studies was performed, and variables described in the synthesis include number of participants, setting,

Critical Appraisal
At the time of our research, there were no accepted quality assessment instruments for cross-sectional studies (56), authors decided to choose a relatively widely used scale, the Agency for Healthcare Research and Quality scale (AHRQ scale) with 11 items, each of which was answered with "yes, " "no" and "unclear." Two researchers (DK and ML) independently evaluated the quality of the included articles using the AHRQ scale. Any disagreements after cross-checking were resolved by discussions between the two researchers with the final decisions of the third researcher (NBS). If the answer was "no, " "unclear" or "not applicable, " the item was given a score of "0"; if the answer was "yes, " the item was scored as "1." The quality assessments of the articles were classified as follows: low quality = 0-3, medium quality = 4-7, high quality = 8-11 (57). The quality assessment of the identified studies is presented in Table 2. The majority of them were classified with medium quality and one fulfilled the criteria for high.

Study Screening and Selection
The PRISMA flow chart in Figure 1 summarises the results of the search process. 1. A search obtained 5,874 potentially relevant studies, while 8 were found by reference review. A cursory review of the content of the papers left 356 papers for further evaluation. Further exclusion (after reading the abstracts and methodology) was based on the principle of excluding papers that mentioned the instrument for assessing HL and PTHL, but without analyzing its structure, and excluding papers that are duplicates (same author, same instrument) left 111 articles for full reading, of which the final number of included studies was 24.
The comparison method was used to compare the instrument in terms of their structure (number and type of questions), the way of reporting, version, purpose, place where they were developed, target population, the person who developed it, year of publication, scoring, heath literacy domains, time and way for administration, measurement scope, validation, strengths, and limitations.
A thorough analysis has been presented in the Tables 3-5.  Tables 3, 4 present the instruments used in the studies to assess HL and PHTL, their basic characteristics: domains, methods of assignment, structure and method of scoring. Table 5 shows the psychometric characteristics of the instruments, strengths and limitations.

Instrument Characteristics
The identified instruments used for assessing the level of HL and PTHL in extracted works are the following: Korean Functional Test HL (1 study (37,. There are considerable differences found in their structure, number of items, administration time, available languages, type of administration, scoring system, measurement scope and properties, implicating their use in different settings. The

Validation, Strengths, and Limitations
NVS -Good reliability and convergent validity with wellvalidated and commonly used measures of HL such as the TOFHLA. Strengths are related to its suitability for rapid assessment of low HL. Test format might intimidate respondents.
FCCHL -Strong positive evidence for its content and structural validity and moderate positive evidence for internal consistency. This scale includes three levels of HL, each of which might have different effects on patient outcomes. It is proved to be easy to administer in a clinical setting. The scale is not validated in English.
Three-brief SQ -Positive evidence for the criterion validity of the 3-SQ with the S-TOFHLA (36 items) and limited negative evidence for its hypothesis testing validity and internal consistency. Instrument is validated in several diverse sample populations. It is quick, easy, and inexpensive for administration. Limitation is related to self-assessment and potential for selfreport bias.
HLS-EU-47 -High levels of internal consistency reliability. It is available in many languages, length of assessment increases response burden.
S-TOFHLA -Demonstrated evidence for the internal consistency due to there being no evidence of structural validity. It has been validated in several diverse populations. Lack of this instrument is that it may not capture an individuals' HL in the dimension of numeracy.    REALM -Found to have a high test-retest reliability of 0.99. It is assessed by healthcare professionals and was found to have good face validity; however, it lacks in construct validity. It is quick and easy for administration, limited to the ability to pronounce words without being able to measure the patient's ability to understand the instructions on labelling of prescribed drug.
HLQ -Positive moderate evidence for its content validity and internal consistency and unknown evidence for structural validity. Strength is that measures multiple domains of HL, but due to self-assessment has a potential for self-report bias.

Health Literacy and Pharmacotherapy Literacy
Preliminary data in relation to HL and PTHL were extracted from the studies included in the qualitative synthesis and summarized in Table 6 (for HL) and Table 7 (for PTHL).
In the research period most of the studies were published in the period from 2006 to 2021 (37,. The largest number of studies was conducted in the United States (11 studies) and Canada (2 studies). In contrast, in South Korea, Japan, Switzerland, Taiwan, Spain, Norway, Brazil, Denmark, Iraq, Netherlands and Hungary, one study was performed. Crosssectional studies make up the majority (20 studies), while three are longitudinal and one is a cohort study. The sample size ranged from at least 50 to 46,354 subjects and are adults over the age of (37,.
In six studies, limited HL was observed in <50% of subjects, and in five studies, more than 50% of subjects had limited HL. HL levels have been linked to diabetes knowledge and treatment efficacy, while HbA1C concentrations, Internet use, glycemic control, and health consequences have not been linked to HL Methods typically relied on convenience samples. Self-assessment has potential for self-report bias.

KHLS
The overall fit of the two-factor model of the scale was assessed by root mean square error of approximation (0.039), indicating a good fit (criterion 0.05 or less) with an internal consistency of 0.89.
Measure uses questionnaire format containing short passages, pictures, and graphs with multiple-choice answer format, providing a skills-based approach to measurement. Authors used factor analysis methods for development.
No concurrent validity assessed due to lack of a comparative instrument. 10% of study participants needed assistance from interviewers. This scale includes three levels of HL, each of which might have different effects on patient outcomes. It is proved to be easy to administer in a clinical setting.
HL was measured based on a self-reported questionnaire. Individuals with reading problems are often ashamed and hide their inability to read, which might have led to an overestimation of the HL levels. Not validated in English.

HLS-EU-Q47
Correlated with NVS (0.25). A multivariate linear regression model with the total sample measured the relation between social variables and health literacy yielding an adjusted R2L17.4%, pL.00. Financial deprivation was the strongest predictor of health literacy.
Available in many languages. Comprehensive, conceptual based measure of most dimensions of health literacy.
Self-assessment has potential for self-report bias. Length of assessment increases response burden. The NVS test is suitable for rapid assessment of low HL.
Validation sample did not fully represent a demographically diverse population. Test format might intimidate respondents. It is quick and easy for administration. It is short, can be easily administered with minimal training, and it's strongly correlated with standardized literacy assessments.
Only measures one dimension of HL. Limited to the ability to pronounce words without being able to measure the patient's ability to understand the instructions on labeling of prescribed drug. A promising tool for the rapid assessment of HL in a busy clinical practice to screen for potential literacy problems.

REALM-R
Only measures one dimension of HL. Presence of a ceiling effect. Does not measure the patient's understanding of the words.

HLQ
A nine-factor model was fit using 44 final items with no cross-loadings or correlated residuals. The fit was satisfactory CFI = 0.936 = 0.930, RMSEA = 0.076, and WRMR = 1.698. Correlations between factors showed a clear distinction between the agree/disagree scales, but less distinction for cannot do/very easy scales.
It measures multiple domains of HL. Self-assessment that has a potential for self-report bias.
DNT Tests numeracy is associated with diabetes management.
Validated in highly educated sample and resulted in mean score correct of 61%-may be difficult or require high numeracy skills. Most subjects had limited HL and poor glycemic control (59) levels (37,. One study found an increased prevalence of people with limited HL who were diagnosed with depression (67), while another study found that people with limited HL were more likely to eat unhealthily and had reduced physical activity compared to people with high HL (62).

DISCUSSION
This work presents the most comprehensive inventory of HL and PTHL measures in patients with type 2 diabetes mellites to date. There are limited number of works assessed the instruments that measure HL in patients with type 2 diabetes and they were focused only on available self-administered instruments in regards of validation aspects (90), however this work presents the broader perspective including the more comprehensive report on their structure, measurement scope, scoring etc. allowing possibilities for clinicians, health professionals and researchers to evaluate available HL and PTHL instruments and match them with the goals of their work. HL has been presented as a measurable and important concept in considering education for patients with chronic diseases such as diabetes. It has been shown that in comparation to the other scales that focus exclusively on functional HL, FCCHL covers all three levels of HL, each of which can have different effects on patient outcomes. Also, the scale is easy to apply in clinical conditions (61).
The identified instruments have inherent strengths and weaknesses as a result of their structure, properties and measurement scope. The REALM, NVS, TOFHLA/ s-TOFHLA, DNT, KHLS, FCCHL and NVS are designed to directly measure specific skills and have some limitations in administration, especially in clinical settings where they are more likely to cause anxiety and shame among patients with inadequate HL and PTHL skills. Self-administrated instruments such as 3brief SQ, HLS-EU-47 and HLQ non-directly measure certain skills and they are less likely to cause the anxiety and shame which makes them more suitable to be used in clinical settings and research applications. Many self-reported measures are designed as screening tests that may be differentially sensitive and specific than measures developed to more fully describe HL for research or clinical purposes. This is also seen in other articles (21,91,92). The NVS had good sensitivity and may be more sensitive than the TOFHLA for marginal HL (83). Using the test can alert physicians and pharmacists to focus on the patients who require more attention and help them communicate with those patients by using recommended techniques.
The REALM and the TOFLHA focus primarily on readingrelated skills and therefore do not present comprehensive measures for the skills needed by individuals in the healthcare system (21).
Time of administration plays a significant role in clinical settings. In this regard 3-brief SQ, NVS, FCCHL, REALM, REALM-R, S-TOFHLA and HLQ are relatively quick and easy for an administration and can be considered in different clinical settings and survey researches.
The type of administration must also be considered for practicality in clinical settings. REALM, REALM-R, KHLS and DNT-15 require involvement of the researcher and could cause shame and discomfort. Since self-administered instruments TOFHLA, S-TOFHLA, NVS, HLS-EU-47 and HLQ are very unlikely to cause discomfort, they require good visual abilities, full concentration, and good writing skills. Three-brief SQ and FCCHL can be administered in both ways and are more flexible and convenient for use.
A lack of researches with PTHL questionnaires in patients with type 2 diabetes mellitus is a very limiting factor for this population since the use of multiple drugs/insulins is very common. REALM only measures one dimension of HL and does not assess the patient's understanding of the words. DNT-15 is the test for numeracy.
The findings of this review can be used for other chronic conditions with similar HL and PTHL demands on individuals. This review did not only address the usefulness and applicability of the instruments in individuals with diabetes but also provided an evaluation of these instruments and their strengths and weaknesses, which are transferable for evaluating their applicability in other health conditions and situations.

Practice Implications
As instruments for measuring HL and PTHL continue to be published, authors advise clinicians, health professionals and researchers to evaluate available HL and PTHL measurements for a conceptual and practical match with the goals of their work.
When choosing a practical match, style of administration, purpose for measurement, their basic characteristics: domains, methods of assignment, structure, method of scoring, validation, strengths and limitations should be considered. It is important to align with the topic or task under consideration and choose the one that has been validated in a similar target population in order to have an accurate measure of the domain being assessed. Predictive qualities and appropriateness for assessment of changes in HL and outcomes over time have to be taken under consideration.
FCCHL was evaluated as the most appropriate instrument to apply to people with diabetes since a diabetes-specific type of instrument and the contents of its items may be more sensitive in a diabetes clinical setting targeted at diabetes, it is a modelbased and comprehensive measure which covers all 3 levels of HL and the evidence for the measurement properties are better than those for the other instruments. However, his structural validity needs to be further established, and therefore adding DNT-15 questionnaire can be one of the options for considering application of FCCHL in this population (90).
Based on the previous considerations FCCHL and 3brief SQ have the broadest measurement scopes. They are quick, easy, and inexpensive for administration. Three-level HL can be considered as the most useful and comprehensive instrument to screen for inadequate HL. The limitation is that the English version is not validated. Three-brief SQ has many advantages in comparison to other instruments, including that it is less likely to cause anxiety and shame. This instrument can be considered the best for measuring functional HL in patients with diabetes mellitus type 2 and other chronic diseases.

Limitations
This review was subject to some limitations. The use of noninterventional studies, the heterogeneity of studies in terms of samples represent important limitations for this scoping review. Only works written in English have been considered. Assessments of the instruments' dimensions, strengths, and limitations were made on the basis of our own experience and judgment; and as such, this was a subjective review. In order to minimize the effect of the issue of subjectivity, each measure was analyzed by multiple authors, and any discrepancy was addressed by all the authors and resolved through fruitful discussion.

CONCLUSION
The ongoing development of instruments suggests that there is still a need for comprehensive measurement across diverse populations. Three-brief SQ has been found convenient for use in populations with diabetes mellitus type 2 taking into consideration the broadest measurement scope, demonstrated good measurement properties, that has many advantages over other instruments, and could be considered the best available instrument to measure functional HL. FCCHL scale measures the broader concept of HL, including the ability to retrieve, understand, and use health-related information and could be one of the most appropriate and comprehensive instrument for measuring HL in people with diabetes. However, it has not been validated in English and the future research must be directed in this way, as well as establishing of the structural validity of the questionnaire.
The results of the studies show that HL may be directly related to the clinical outcome in patients with diabetes and that each individual level of HL could act differently. The ways in which each level of HL influences patient behaviour about care and health outcomes should be further explored.
So far, PTHL questionnaires (REALM/R and DNT-15) have not found their best application in people with type 2 diabetes mellitus and further research should certainly be aimed at developing a specific PTHL questionnaire for people with type 2 diabetes mellitus, due to the nature of the disease itself and the frequent use of multiple drugs in its therapy.
This works provides information to enable practitioners, health professionals and researches to select the most appropriate instrument available for measuring HL and PTHL in patients with type 2 diabetes mellitus.

DATA AVAILABILITY STATEMENT
The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.

AUTHOR CONTRIBUTIONS
DK and ML contributed substantially to the conception, design of the study, screening, and selection of the studies. ML produced the first draft of the paper, which was extensively redrafted by DK, with significant input from NB-S. All authors contributed to the interpretation of data and read and approved the final manuscript.