Addressing Literacy and Numeracy to Improve Diabetes Care

Two randomized controlled trials

  1. Kerri Cavanaugh, MD, MHS1,2,
  2. Kenneth A. Wallston, PHD3,
  3. Tebeb Gebretsadik, MPH4,
  4. Ayumi Shintani, PHD, MPH4,
  5. Mary Margaret Huizinga, MD, MPH5,
  6. Dianne Davis, RD, CDE2,
  7. Rebecca Pratt Gregory, RD, CDE2,
  8. Robb Malone, PHARMD, CDE6,7,
  9. Michael Pignone, MD, MPH6,
  10. Darren DeWalt, MD, MPH6,
  11. Tom A. Elasy, MD, MPH2,8 and
  12. Russell L. Rothman, MD, MPP2,8,9
  1. 1Division of Nephrology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee;
  2. 2Vanderbilt Eskind Diabetes Center, Diabetes Research and Training Center, Vanderbilt University, School of Medicine, Nashville, Tennessee;
  3. 3School of Nursing, Vanderbilt University Medical Center, Nashville, Tennessee;
  4. 4Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee;
  5. 5Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland;
  6. 6Department of Medicine, University of North Carolina, Chapel Hill, North Carolina;
  7. 7Division of Pharmacy Practice and Experiential Education, UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina;
  8. 8VA Tennessee Valley Healthcare System, VA Quality Scholars Program, Nashville, Tennessee;
  9. 9Division of General Medicine and Public Health, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee.
  1. Corresponding author: Russell L. Rothman, russell.rothman{at}


OBJECTIVE Diabetic patients with lower literacy or numeracy skills are at greater risk for poor diabetes outcomes. This study evaluated the impact of providing literacy- and numeracy-sensitive diabetes care within an enhanced diabetes care program on A1C and other diabetes outcomes.

RESEARCH DESIGN AND METHODS In two randomized controlled trials, we enrolled 198 adult diabetic patients with most recent A1C ≥7.0%, referred for participation in an enhanced diabetes care program. For 3 months, control patients received care from existing enhanced diabetes care programs, whereas intervention patients received enhanced programs that also addressed literacy and numeracy at each institution. Intervention providers received health communication training and used the interactive Diabetes Literacy and Numeracy Education Toolkit with patients. A1C was measured at 3 and 6 months follow-up. Secondary outcomes included self-efficacy, self-management behaviors, and treatment satisfaction.

RESULTS At 3 months, both intervention and control patients had significant improvements in A1C from baseline (intervention −1.50 [95% CI −1.80 to −1.02]; control −0.80 [−1.10 to −0.30]). In adjusted analysis, there was greater improvement in A1C in the intervention group than in the control group (P = 0.03). At 6 months, there were no differences in A1C between intervention and control groups. Self-efficacy improved from baseline for both groups. No significant differences were found for self-management behaviors or satisfaction.

CONCLUSIONS A literacy- and numeracy-focused diabetes care program modestly improved self-efficacy and glycemic control compared with standard enhanced diabetes care, but the difference attenuated after conclusion of the intervention.


  • Clinical trial registry nos. NCT00311922 and NCT00469105,

  • The funding sources did not have any involvement in the design and conduct of the study, collection, management analysis, and interpretation of the data or preparation, review, or approval of the manuscript.

  • The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.

    • Received March 23, 2009.
    • Accepted August 31, 2009.
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  1. Diabetes Care vol. 32 no. 12 2149-2155
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