The Role of Health Literacy in Diabetes Knowledge, Self-Care, and Glycemic Control: a Meta-analysis
Empirical evidence on how health literacy affects diabetes outcomes is inconsistent. The purpose of this meta-analysis was to quantitatively summarize the findings on the associations between health literacy and diabetes knowledge, self-care activities, and glycemic control as disease-related outcomes, with specific focus on the type of health literacy assessment.
Nine databases (MEDLINE, CINAHL, Communication and Mass Media Complete, PsychInfo, PsychArticles, Psychology and Behavioral Sciences Collection, ERIC, Sociology, Embase) were searched for peer-reviewed original research articles published until 31 March 2018.
Studies with type 1 and/or type 2 diabetes patients aged 18 or older, providing a calculable baseline effect size for functional health literacy and diabetes knowledge, self-care activities, or HbA1C were included.
The meta-analysis includes 61 studies with a total of 18,905 patients. The majority were conducted in the USA, on type 2 diabetes patients, and used the S-TOFHLA as a performance-based or the BHLS as a perception-based measure of functional health literacy. Meta-analytic results show that all three outcomes are related to health literacy. Diabetes knowledge was best predicted by performance-based health literacy measures, self-care by self-report measures, and glycemic control equally by both types of health literacy assessment.
Health literacy plays a substantial role in diabetes knowledge. Findings for the role of health literacy in self-care and glycemic control remain heterogeneous, partly due to the type of health literacy assessment (performance- vs. perception-based). This has implications for the use of health literacy measures in clinical settings and original research. This meta-analysis was limited to functional health literacy and, due to the paucity of studies, did not investigate the role of other dimensions including communicative and critical health literacy.
KEY WORDShealth literacy diabetes knowledge self-care glycemic control meta-analysis
L.M., A.L.C., and P.J.S. formulated the research questions and defined the search terms. L.M. carried out the electronic searches. L.M. and A.L.C. carried out the search process, the methodological assessment, and the extraction of studies information. L.M. carried out the meta-analysis. All authors were involved in writing and reviewing the final manuscript.
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they do not have a conflict of interest.
- 4.Ratzan S, Parker R. Introduction. In National Library of Medicine Current Bibliographies in Medicine: Health Literacy. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services, 2000Google Scholar
- 5.Simonds S. Health education as social policy. Health Educ Monogr 1974;21:1–10Google Scholar
- 7.Al Sayah F, Williams B, Johnson JA. Measuring health literacy in individuals with diabetes: a systematic review and evaluation of available measures. Health Educ Behav Off Publ Soc Public Health Educ 2013;40(1):42–55Google Scholar
- 9.Cavanaugh KL. Health literacy in diabetes care: explanation, evidence and equipment. Diabetes Manag Lond Engl 2011;1(2):191–9Google Scholar
- 20.Shamseer L, Moher D, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ 2015;349:g7647Google Scholar
- 21.Lüdecke D. Package “esc”: effect size computation for meta analysis [Internet]. 2018. Available from https://github.com/strengejacke/esc Accessed 18 July 2018
- 22.Schwarzer G, Carpenter JR, Rücker G. Meta-analysis with R (Use R!). Cham, Switzerland, Springer International Publishing, 2015Google Scholar
- 26.Borenstein M, Hedges L, Rothstein H. Meta-analysis: fixed effect vs. random effects. [Online White Paper] Available from https://www.meta-analysis.com/downloads/Meta-analysis%20fixed%20effect%20vs%20random%20effects.pdf. Accessed 11 December 2018
- 28.Higgins JP, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions. Chichester, UK, Wiley, 2008Google Scholar
- 35.Bains S., Osborn C.Y., Egede L.E. Association of health literacy and diabetes self-care utilizing the information-motivationbehavioral skills model. J Investig Med 2010;58(2):481Google Scholar
- 40.Chahardah-Cherik S, Gheibizadeh M, Jahani S, Cheraghian B. The relationship between health literacy and health promoting behaviors in patients with type 2 diabetes. Int J Community Based Nurs Midwifery 2018;6(1):65–75Google Scholar
- 48.Gordilho Souza J, Apolinario D, Magaldi RM, Busse AL, Campora F, Jacob-Filho W. Functional health literacy and glycaemic control in older adults with type 2 diabetes: a cross-sectional study. BMJ Open 2014;4(2):e004180Google Scholar
- 53.Jihye Jeong, Namhee Park, So Young Shin. The influence of health literacy and diabetes knowledge on diabetes self-care activities in Korean low-income elders with diabetes. J Korean Acad Community Health Nurs Jiyeog Sahoe Ganho Hakoeji 2014;25(3):217–24Google Scholar
- 66.Newsome C., Mallawaarachchi I., Garcia J., Ray G. Association between health literacy and diabetes control in a pharmacist-run disease state management clinic. Cogent Med 2016;3: 1269628Google Scholar
- 76.Schillinger D, Barton LR, Karter AJ, Wang F, Adler N. Does literacy mediate the relationship between education and health outcomes? A study of a low-income population with diabetes. Public Health Rep Wash DC 1974 2006;121(3):245–54Google Scholar
- 79.Swavely D, Vorderstrasse A, Maldonado E, Eid S, Etchason J. Implementation and evaluation of a low health literacy and culturally sensitive diabetes education program. J Healthc Qual Promot Excell Healthc 2014;36(6):16–23Google Scholar
- 81.Thabit H, Shah S, Nash M, Brema I, Nolan JJ, Martin G. Globalization, immigration and diabetes self-management: an empirical study amongst immigrants with type 2 diabetes mellitus in Ireland. QJM Mon J Assoc Physicians 2009;102(10):713–20Google Scholar