Health Literacy Impacts Diabetes Outcomes

JANUARY 01, 2006
Anna D. Garrett, PharmD, BCPS, CPP

Health literacy is described as a group of skills, including the ability to perform the basic reading and numerical tasks, required to function in the health care environment.1 Patients who have poor health literacy skills may have problems that range from difficulty reading instructions on a medication bottle or interpreting blood glucose readings to an inability to comprehend appointment schedules or informed consent documents. In addition to reading comprehension problems, people with poor health literacy may have difficulty processing oral communication. Limited health literacy can be a significant barrier to chronic disease management, especially in today's environment in which scientific advances place greater technical and self-management demands on patients.

Poor health literacy is more common among patients who have low education levels and among immigrants, older patients, and racial and ethnic minorities.1 People with chronic medical conditions such as type 2 diabetes also tend to have lower levels of health literacy. Little is known about the impact of health literacy on clinical outcomes, but a growing body of evidence suggests that poor health literacy contributes to poor outcomes relative to glycemic control.2,3 The results of these studies are significant from clinical and public health perspectives. Poor health literacy has been identified as an independent predictor of poor glycemic control and is associated with a lower likelihood of tight control (defined as hemoglobin A1C [HbA1C] <7.2%).3 HbA1C is a clinical end point that is linked to health care costs and disabling conditions.4,5 There is a well-described linear relationship between HbA1C and the development of microvascular complications.5 A study by Schillinger et al found that low health literacy is associated with a higher prevalence of retinopathy and other complications of diabetes.3

From a public health perspective, the study findings may have uncovered an important variable that might help explain the prevalence of poor health outcomes among patients with type 2 diabetes. A large portion of this population is more likely to have poor health literacy, and 80% of these patients have completed only a high school education or less.6

Pharmacists and other health care providers often speak in terms that are not understood by patients. Awareness of this tendency is especially important when counseling patients with poor health literacy. Identifying patients with poor literacy can be difficult because the problem can affect anyone, regardless of educational level. Patients often go to great lengths to hide their inability to read or understand medical information.7 Several tools are available that can help providers quickly identify the health literacy level of the patient.8

There are a number of ways to increase the likelihood of providing effective counseling to people who have diabetes and poor health literacy. Suggestions for counseling include the following:

  • Using both oral and written information as part of the education process; using pictures as much as possible; obtaining educational materials that are written at or below a 6th grade reading level
  • Creating a relaxed environment where the patient feels comfortable asking questions. Body language is important—smiling, paying attention, and not crossing the arms (this gesture suggests not being open for questions).
  • Speaking clearly and using short sentences
  • Asking the patient to repeat instructions to ensure that the message intended is what he or she understands
  • Offering adherence aids (eg, pillboxes) to decrease the likelihood of administration errors

Diabetes care requires that a number of concepts and skills be conveyed by the provider and successfully carried out by the patient. Diabetes self-management is challenging for even the most health-literate population. Awareness of the magnitude of the problem among the diabetic population provides an opportunity for pharmacists to impact the outcomes of care for their patients.

Dr. Garrett is a clinical pharmacist practitioner at Cornerstone Health Care in High Point, NC.

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