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Diabetes Care 27:2980-2982, 2004
© 2004 by the American Diabetes Association, Inc.

Brief Report

Association of Health Literacy With Self-Management Behavior in Patients With Diabetes

Sarang Kim, MD1, Frances Love, MSN, CDE2, D. Alex Quistberg, BA3 and Judy A. Shea, PHD3

1 Division of General Internal Medicine, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey
2 Division of Endocrinology, Diabetes and Metabolism, University of Pennsylvania, Philadelphia, Pennsylvania
3 Division of General Internal Medicine, University of Pennsylvania, Philadelphia, Pennsylvania

Address correspondence and reprint requests to Sarang Kim, MD, Clinical Academic Building, 2nd Floor, 125 Paterson St., New Brunswick, NJ 08901. E-mail: kimsa{at}umdnj.edu

Abbreviations: DKQ, Diabetes Knowledge Questionnaire • SDSCA, Summary of Diabetes Self-Care Activities Measure


   INTRODUCTION
TOP
 INTRODUCTION
RESEARCH DESIGN AND METHODS
 RESULTS
 CONCLUSIONS
 References
 
Limited health literacy, common in patients with diabetes, has been associated with worse diabetes outcomes (1–4). While patients with limited health literacy have worse diabetes knowledge (2–5), knowledge does not necessarily predict outcomes (6–8). Because diabetes requires extensive self-care, differences in self-management behaviors may be a key contributor to the disparity in outcomes. In fact, low health literacy has been associated with poor self-care in other chronic illnesses (9,10). However, no study has examined the relationship between health literacy and self-management behaviors in patients with diabetes. In addition, studies have not assessed whether diabetes education, which is widely recommended, is effective in improving self-management behaviors in patients with limited health literacy. The objectives of our study were to examine the association of health literacy with self-management behaviors in patients with diabetes and to determine whether diabetes education improves self-management behaviors in patients with limited compared with adequate health literacy. Understanding the relationship between health literacy and self-management behaviors should enhance efforts to improve diabetes outcomes.


   RESEARCH DESIGN AND METHODS
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS
RESULTS
 CONCLUSIONS
 References
 
We conducted a prospective observational study of patients enrolled in diabetes education classes at the Hospital of the University of Pennsylvania. The classes consist of an individual meeting with a diabetes educator and three weekly 3-h group classes and are recognized by the American Diabetes Association (11). All patients ≥18 years of age present for a regularly scheduled diabetes class were recruited. Patients who did not speak English were excluded. Participants were compensated with a $10 gift certificate. Written consent was obtained, and the institutional review board approved this study.

At the first class, diabetes educators administered a questionnaire regarding demographic information, social support (12), and diabetes history. Health literacy was measured with the short-form Test of Functional Health Literacy in Adults, a 36-item timed reading comprehension test shown to be a valid measure of functional health literacy (13). Patients scoring <22 on the 36-point scale were considered to have inadequate or marginal health literacy. Self-management behaviors were assessed using the Summary of Diabetes Self-Care Activities Measure (SDSCA), a valid self-report measure that assesses how often self-care activities (diet, exercise, self-glucose monitoring, foot care, and medication adherence) are performed in a given week (14). Other outcome measures included knowledge, using the Diabetes Knowledge Questionnaire (DKQ) (15), and glycemic control, which was assessed by obtaining HbA1c levels from medical records. Follow-up questionnaires (DKQ, SDSCA) were administered by telephone interview. Baseline differences in demographics and DKQ and SDSCA scores between literacy groups were compared with t tests and {chi}2 tests. The DKQ and SDSCA baseline and 3-month values within literacy groups were compared with paired t tests. Nonparametric tests were also performed; there were no differences in results. Effect sizes, which summarize the magnitude of differences between and within groups relative to the pooled SD, were computed. Effect sizes are standardly interpreted as 0.20 = small effect, 0.50 = moderate effect, and 0.80 = large effect. ANCOVA compared 3-month outcomes adjusting for baseline values, age, years of education, and income. A second ANCOVA omitted education as a covariate; the results were nearly identical.


   RESULTS
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS
 RESULTS
CONCLUSIONS
 References
 
Fifty-eight percent (n = 92) of eligible class attendees participated. The primary language for all participants was English. There were no differences between participants and nonparticipants in age, sex, race, education, or HbA1c (P > 0.05). Of the participants, 77% had adequate and 23% had limited (8% marginal, 15% inadequate) health literacy. Lower literacy was associated with being older, having less education, lower annual income, and more self-reported diabetes complications (P < 0.05) (Table 1). There were no differences in years with diabetes or level of social support received from family or friends. At baseline, patients with adequate health literacy had better knowledge of diabetes (P = 0.014), but health literacy was not associated with HbA1c or self-management behaviors.


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  		Table 1— Characteristics of study participants before and after diabetes education

 
Follow-up data were available for 77 patients (84%), of whom 78% had adequate and 22% had limited (8% marginal, 14% inadequate) health literacy. There were no differences between responders and nonresponders in health literacy or other baseline characteristics. At 3 months, paired t tests showed improvement in HbA1c, knowledge, and self-management behaviors for both literacy groups. For the adequate literacy group, effect sizes ranged from 0.53 for HbA1c and diabetes knowledge to 0.13 for exercise. For the limited literacy group, effect sizes ranged from 0.49 for HbA1c to 0.13 for exercise. Adjusted 3-month outcomes showed no significant differences between the groups in HbA1c, but patients with adequate health literacy had higher knowledge scores (Table 1). Patients with adequate health literacy exercised more, but patients with lower literacy reported better adherence to diet, self-glucose monitoring, and foot care.


   CONCLUSIONS
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS
 RESULTS
 CONCLUSIONS
References
 
In this study, diabetes education was effective in improving self-management, diabetes knowledge, and glycemic control for patients with adequate and limited health literacy. These findings are encouraging from a clinical and public health perspective. Expanding educational programs for patients with low literacy may reduce disparities in diabetes outcomes related to literacy status.

An unexpected finding was that at 3 months, the adequate health literacy group performed worse in certain self-management behaviors compared with the limited literacy group. This may be related to baseline diabetes education status, as more patients in the limited literacy group had previously received diabetes education (28.6 vs. 17.6%, P = 0.276). Reinforcement of previously taught behaviors may have led to greater improvement in the limited literacy group.

Our study has several limitations. First, our study participants were a sample of patients already enrolled in diabetes education and may not be representative of all diabetic patients (16,17). Second, our sample was small. Lack of power or chance may explain why patients with adequate health literacy performed worse in certain self-management behaviors. Third, the attrition rate was relatively high (16%) and was higher for patients with limited (24%) compared with adequate (14%) literacy. In addition, the prevalence of low literacy was lower than that observed in other primary care settings (1–5). Finally, given the short duration of follow-up, we cannot ascertain whether the improvements in self-management behaviors are sustainable or whether any differences in behavior over time between literacy groups may explain the association of limited health literacy with worse outcomes, even when adjusting for diabetes education (3). It should also be noted that we used the construct of "health literacy." As recently pointed out by the Institute of Medicine, health literacy, as measured by the short-form Test of Functional Health Literacy in Adults, assesses reading comprehension skills, which is just one component of literacy (18).

In summary, patients with limited health literacy benefit from diabetes education and show similar or better improvement in self-management behaviors compared with those with adequate health literacy. Future efforts should focus on improving educational outreach for patients with low literacy skills.


   Acknowledgments
 
This study was funded in part by the Matthew Slapp Award.


   Footnotes
 
A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.

Received for publication June 24, 2004. Accepted for publication August 28, 2004.


   References
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS
 RESULTS
 CONCLUSIONS
 References
 

  1. Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs: Health Literacy: Report of the Council on Scientific Affairs. JAMA 281:552–557, 1999[Abstract/Free Full Text]
  2. Gazmararian JA, Baker DW, Williams MV, Parker RM, Scott TL, Green DC, Fehrenbach SN, Ren J, Koplan JP: Health literacy among Medicare enrollees in a managed care organization. JAMA 281:545–551, 1999[Abstract/Free Full Text]
  3. Schillinger D, Grumbach K, Piette J, Wang F, Osmond D, Daher C, Palacios J, Sullivan GD, Bindman AB: Association of health literacy with diabetes outcomes. JAMA 288:475–482, 2002[Abstract/Free Full Text]
  4. Williams MV, Baker DW, Parker RM, Nurss JR: Relationship of functional health literacy to patients’ knowledge of their chronic disease: a study of patients with hypertension and diabetes. Arch Intern Med 158:166–172, 1998[Abstract/Free Full Text]
  5. Gazmararian JA, Williams MV, Peel J, Baker DW: Health literacy and knowledge of chronic disease. Patient Educ Couns 51:267–275, 2003[Medline]
  6. Norris SL, Engelgau MM, Narayan KMV: Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials. Diabetes Care 24:561–587, 2001[Abstract/Free Full Text]
  7. Bloomgarden ZT, Karmally W, Metzger MJ, Brothers M, Nechemias C, Bookman J, Faierman D, Ginsberg-Fellner F, Rayfield E, Brown WV: Randomized, controlled trial of diabetic patient education: improved knowledge without improved metabolic status. Diabetes Care 10:263–272, 1987[Abstract]
  8. Coates VE, Boore JRP: Knowledge and diabetes self-management. Patient Educ Couns 29:99–108, 1996[Medline]
  9. Kalichman SC, Ramachandran B, Catz S: Adherence to combination antiretroviral therapies in HIV patients of low health literacy. J Gen Intern Med 14:267–273, 1999[Medline]
  10. Williams MV, Baker DW, Honig EG, Lee TM, Nowlan A: Inadequate literacy is a barrier to asthma knowledge and self-care. Chest 114:1008–1015, 1998[Abstract/Free Full Text]
  11. Mensing C, Boucher J, Cypress M, Weinger K, Mulcahy K, Barta P, Hosey G, Kopher W, Lasichak A, Lamb B, Mangan M, Norman J, Tanja J, Yauk L, Wisdom K, Adams C: National standards for diabetes self-management education. Diabetes Care 27 (Suppl. 1):S143–S150, 2004
  12. Fitzgerald JT, Davis WK, Connell CM, Hess GE, Funnell MM, Hiss RG: Development and validation of the Diabetes Care Profile. Eval Health Prof 19:208–230, 1996[Abstract/Free Full Text]
  13. Baker DW, Williams MV, Parker RM, Gazmararian JA, Nurss J: Development of a brief test to measure functional health literacy. Patient Educ Couns 38:33–42, 1999[Medline]
  14. Toobert DJ, Hampson SE, Glasgow RE: The summary of diabetes self-care activities measure, results from 7 studies and a revised scale. Diabetes Care 23:943–950, 2000[Abstract]
  15. Garcia AA, Villagomez ET, Brown SA, Kouzekanani K, Hanis CL: The Starr County Diabetes Education Study: development of the Spanish-language diabetes knowledge questionnaire. Diabetes Care 24:16–21, 2001[Abstract/Free Full Text]
  16. Coonrod BA, Betschart J, Harris MI: Frequency and determinants of diabetes education among adults in the U.S. population. Diabetes Care 17:852–858, 1994[Abstract]
  17. Glasgow RE, Toobert D, Hampson SE: Participation in outpatient diabetes education programs: how many patients take part and how representative are they? Diabetes Educ 17:376–380, 1991
  18. Institute of Medicine: Health Literacy: A Prescription to End Confusion. Nielsen-Bohlman L, Panzer AM, Kindig DA, Eds. Washington, D.C., The National Academics Press, 2004

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