Health literacy, medication adherence, and diabetes complications in Morocco: A cross-sectional study

Abstract

<h2>Abstract</h2><h3>Background</h3> Diabetes is a major public health challenge in Morocco. Health literacy (HL) and medication adherence are central to self-management and complication prevention, yet evidence from primary care is limited. <h3>Objective</h3> To assess functional, communicative, and critical HL among adults with diabetes in Marrakech primary care, and examine their associations with medication adherence and self-reported complications. <h3>Methods</h3> A cross-sectional survey was conducted among 333 adults with type 1 or type 2 diabetes attending urban and rural primary healthcare facilities. HL was assessed using the French Functional, Communicative, and Critical Health Literacy (FCCHL) scale, and adherence using the 8-item Morisky Medication Adherence Scale (MMAS-8). Sociodemographic and clinical data were collected through interviewer-administered questionnaires. Non-parametric tests, Spearman correlations, and multivariable linear regression examined factors associated with HL, adherence, and complications. <h3>Results</h3> Overall HL was moderate (median FCCHL 49, IQR 45–54), with critical literacy the least developed. HL did not differ by age or diabetes type but varied by education, occupation, and insurance. Three-quarters of participants had low or moderate adherence, which correlated positively with functional and critical literacy and negatively with communicative literacy. Diabetes complications were frequent (43.5%) but showed only weak links with HL. <h3>Conclusion</h3> HL domains were differentially associated with adherence, with critical literacy showing the strongest relationship. Education and social position were key predictors of HL, whereas clinical characteristics contributed little. Primary care interventions should target functional and critical HL and adapt communication to patients' sociodemographic profiles, while longitudinal studies clarify causal pathways linking HL, adherence, and complications.