Quality of Life Research

, Volume 25, Issue 6, pp 1487–1494 | Cite as

Health literacy and health-related quality of life in adults with type 2 diabetes: a longitudinal study




To examine the association of health literacy (HL) with changes in health-related quality of life (HRQL) among patients with type 2 diabetes.


Data from a cohort study of type 2 diabetes patients were used. HL was assessed using 3 previously validated screening questions and HRQL using the EQ-5D-5L and SF-12 [physical and mental composite summary scores (PCS, MCS)]. The associations of baseline HL with changes in EQ-5D, PCS, and MCS scores over 1 year and with directions of changes (no change; declined; improved) were examined. Missing data were handled with multiple imputation and sensitivity analyses.


Average age of participants (N = 1948) was 64.6 ± 10.9 years, 45 % were female, and 12.6 % had inadequate HL. Participants had mean decrements of 0.01 in EQ-5D, 1.0 in PCS, and 1.2 in MCS over 1 year. In adjusted analysis, HL was not associated with changes in EQ-5D over 1 year (β = 0.01, P = 0.146); however, patients with adequate HL had 2.1 points greater increase in PCS (P < 0.001) and 3.1 points in MCS (P < 0.001) compared to those with inadequate HL. Patients with adequate HL were less likely to have a decline in EQ-5D (RR 0.66; 95 % CI 0.44, 0.98), PCS (RR 0.51; 95 % CI 0.34, 0.76), and MCS (RR 0.49; 95 % CI 0.33, 0.72) compared to those with inadequate HL. Patients with adequate HL were more likely to have an improvement in MCS compared to those with inadequate HL (RR 1.78; 95 % CI 1.04, 3.04); such associations were not observed for PCS or EQ-5D. All results were robust in sensitivity analyses.


Inadequate HL was independently associated with worsening HRQL in adults with type 2 diabetes, particularly in the mental health domain.


Health literacy Quality of life Type 2 diabetes Longitudinal 



Author’s contribution

F.A.S. and J.A.J. conceived this study. F.A.S. and W.Q. conducted the analysis. F.A.S. wrote the first draft of this manuscript, and all authors provided feedback and approved the submitted version. Fatima Al Sayah is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.


This work was supported by grant from Alberta Health and a CIHR Team Grant to the Alliance for Canadian Health Outcomes Research in Diabetes (Reference No.: OTG-88588), sponsored by the CIHR Institute of Nutrition, Metabolism and Diabetes (INMD).

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

Ethical approval for the study was granted by the Health Research Ethics Board at the University of Alberta.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material

11136_2015_1184_MOESM1_ESM.doc (40 kb)
Supplementary material 1 (DOC 39 kb)


  1. 1.
    Guyatt, G. H., Feeny, D. H., & Patrick, D. L. (1993). Measuring health-related quality of life. Annals of Internal Medicine, 118(8), 622–629.CrossRefPubMedGoogle Scholar
  2. 2.
    Maddigan, S. L., Feeny, D. H., Majumdar, S. R., Farris, K. B., & Johnson, J. A. (2006). Understanding the determinants of health for people with type 2 diabetes. American Journal of Public Health, 96(9), 1649–1655.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Walker, R. J., Gebregziabher, M., Martin-Harris, B., & Egede, L. E. (2014). Relationship between social determinants of health and processes and outcomes in adults with type 2 diabetes: validation of a conceptual framework. BMC endocrine disorders, 14, 82.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Berkman, N., Terry, D., & McCormack, L. (2010). Health literacy: What is it? Journal of Health Communication, 15, 9–19.CrossRefPubMedGoogle Scholar
  5. 5.
    Schillinger, D., Grumbach, K., Piette, J., Wang, F., Osmond, D., Daher, C., et al. (2002). Association of health literacy with diabetes outcomes. JAMA, 288, 475–482.CrossRefPubMedGoogle Scholar
  6. 6.
    Sarkar, U., Karter, A., Liu, J., Moffet, H. H., Adler, N. E., & Schillinger, D. (2010). Hypoglycemia is more common among type 2 diabetes patients with limited health literacy: The diabetes Study of Northern California (DISTANCE). Journal of General Internal Medicine, 25, 962–967.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Powell, C. K., Hill, E. G., & Clancy, D. E. (2007). The relationship between health literacy and diabetes knowledge and readiness to take health actions. The Diabetes Educator, 33, 144–151.CrossRefPubMedGoogle Scholar
  8. 8.
    Berkman, N. D., Sheridan, S. L., Donahue, K. E., Halpern, D. J., Viera, A. & Crotty, K., et al. (2011). Health literacy interventions and outcomes: An update of the literacy and health outcomes systematic review of the literature. In Evidence report/technology, Assessment No. 199. Rockville, MD: Agency for Healcare Research and Quality.Google Scholar
  9. 9.
    Al Sayah, F., Majumdar, S. R., Williams, B., Robertson, S., & Johnson, J. A. (2013). Health literacy and health outcomes in diabetes: A systematic review. Journal of General Internal Medicine, 28(3), 444–452.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Al Sayah, F., Majumdar, S. R., & Johnson, J. A. (2015). Association of inadequate health literacy with health outcomes in patients with type 2 diabetes and depression: Secondary analysis of a controlled trial. Canadian Journal of Diabetes, 39(4), 259–265.CrossRefPubMedGoogle Scholar
  11. 11.
    DeWalt, D. A., Boone, R. S., & Pignone, M. P. (2007). Literacy and Its relationship with self-efficacy, trust, and participation in medical decision making. American Journal of Health Behavior, 31(Suppl 1), S27–S35.CrossRefPubMedGoogle Scholar
  12. 12.
    Robinson, R. (1993). Cost-utility analysis. British Medical Journal, 307(6908), 859–862.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Zhang, X. H., Li, S. C., Fong, K. Y., & Thumboo, J. (2009). The impact of health literacy on health-related quality of life (HRQoL) and utility assessment among patients with rheumatic diseases. Value in Health, 12(Suppl 3), S106–S109.CrossRefPubMedGoogle Scholar
  14. 14.
    Al Sayah, F., Majumdar, S. R., Qiu, W., Soprovich, A., Wozniak, L., Rees, S., et al. (2015). The Alberta’s caring for diabetes (ABCD) study: Rationale, design and baseline characteristics of a prospective cohort of adults with type-2 diabetes. Canadian Journal of Diabetes, 39(Suppl 3), S113–S119.CrossRefPubMedGoogle Scholar
  15. 15.
    Chew, L. D., Griffin, J. M., Partin, M. R., Noorbaloochi, S., Grill, J. P., Snyder, A., et al. (2008). Validation of screening questions for limited health literacy in a large VA outpatient population. Journal of General Internal Medicine, 23(5), 561–566.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Herdman, M., Gudex, C., Lloyd, A., Janssen, M., Kind, P., Parkin, D., et al. (2011). Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L). Quality of Life Research, 20(10), 1727–1736.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Fleishman, J. A., Selim, A. J., & Kazis, L. E. (2010). Deriving SF-12v2 physical and mental health summary scores: A comparison of different scoring algorithms. Quality of Life Research, 19(2), 231–241.CrossRefPubMedGoogle Scholar
  18. 18.
    Luo, N., Johnson, J. A., & Coons, S. J. (2010). Using instrument-defined health state transitions to estimate minimally important differences for four preference-based health-related quality of life instruments. Medical Care, 48(4), 365–371.CrossRefPubMedGoogle Scholar
  19. 19.
    Stewart, A. L., Greenfield, S., Hays, R. D., Wells, K., Rogers, W. H., Berry, S. D., et al. (1989). Functional status and well-being of patients with chronic conditions. Results from the medical outcomes study. JAMA, 262(7), 907–913.CrossRefPubMedGoogle Scholar
  20. 20.
    Lorig, K. R., Sobel, D., Ritter, P. L., Laurent, D., & Hobbs, M. (2001). Effect of a self-management program for patients with chronic disease. Effective Clinical Practice, 4, 256–262.PubMedGoogle Scholar
  21. 21.
    Kroenke, K., Strine, T. W., Spitzer, R. L., Williams, J. B., Berry, J. T., & Mokdad, A. H. (2009). The PHQ-8 as a measure of current depression in the general population. Journal of Affective Disorders, 114(1–3), 163–173.CrossRefPubMedGoogle Scholar
  22. 22.
    Biering, K., Hjollund, N. H., & Frydenberg, M. (2015). Using multiple imputation to deal with missing data and attrition in longitudinal studies with repeated measures of patient-reported outcomes. Clinical Epidemiology, 16(7), 91–106.CrossRefGoogle Scholar
  23. 23.
    Royston, P., & White, I. R. (2011). Multiple imputation by chained equations (MICE): Implementation in Stata. Journal of Statistical Software, 45(4), 1–20.CrossRefGoogle Scholar
  24. 24.
    Paasche-Orlow, M., & Wolf, M. (2007). The causal pathway linking health literacy to health outcomes. American Journal of Health Behavior, 31, S19–S26.CrossRefPubMedGoogle Scholar
  25. 25.
    Al Sayah, F., & Williams, B. (2012). An integrated model of health literacy using diabetes as an exemplar. Canadian Journal of Diabetes, 36, 27–31. doi: 10.1016/j.jcjd.2011.08.001.CrossRefGoogle Scholar
  26. 26.
    McCarthy, D. M., Waite, K. R., Curtis, L. M., Engel, K. G., Baker, D. W., & Wolf, M. S. (2012). What did the doctor say? Health literacy and recall of medical instructions. Medical Care, 50(4), 277–282.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Sheridan, S. L., Halpern, D. J., Viera, A. J., Berkman, N. D., Donahue, K. E., & Crotty, K. (2011). Interventions for individuals with low health literacy: A systematic review. Journal of Health Communication, 16(Suppl 3), 30–54.CrossRefPubMedGoogle Scholar
  28. 28.
    Kivelä, K., Elo, S., Kyngäs, H., & Kääriäinen, M. (2014). The effects of health coaching on adult patients with chronic diseases: A systematic review. Patient Education and Counseling, 97(2), 147–157.CrossRefPubMedGoogle Scholar
  29. 29.
    Sarkar, U., Schillinger, D., López, A., & Sudore, R. (2011). Validation of self-reported health literacy questions among diverse English and Spanish-speaking populations. Journal of General Internal Medicine, 26(3), 265–271.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Al Sayah, F., Williams, B., & Johnson, J. A. (2012). Measuring health literacy in individuals with diabetes: A systematic review and evaluation of available measures. Health Education and Behavior,. doi: 10.1177/1090198111436341.PubMedGoogle Scholar
  31. 31.
    Stagliano, V., & Wallace, L. S. (2013). Brief health literacy screening items predict newest vital sign scores. The Journal of the American Board of Family Medicine, 26(5), 558–565.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2015

Authors and Affiliations

  • Fatima Al Sayah
    • 1
  • Weiyu Qiu
    • 1
  • Jeffrey A. Johnson
    • 2
  1. 1.Alliance for Canadian Health Outcomes Research in DiabetesUniversity of AlbertaEdmontonCanada
  2. 2.2-040 Li Ka Shing Centre for Health Research Innovation, Alliance for Canadian Health Outcomes Research in Diabetes, School of Public HealthUniversity of AlbertaEdmontonCanada

Personalised recommendations