Health Delivery

The impact of low health literacy

on diabetes outcomes
[

Lisa D Chew

According to the 1993 US National Adult Literacy Survey,

approximately 90 million people in the USA have deficiencies
in reading or computational skills that prevent them from
fully participating in normal daily activities such as reading
a bus schedule or entering background information on an
application form. Although the Survey did not evaluate the
ability to read and comprehend health-related materials,
results from this survey raised concern about whether peoples
reading abilities were adequate to function in a healthcare environment. In this article which makes particular
reference to the status of care in the USA Lisa Chew reports
on the impact of poor health literacy on diabetes care, and
makes suggestions for improving communication between
health providers and people with diabetes.

>>
Health literacy has been defined as
the degree to which individuals
have the capacity to obtain, process,
and understand the basic health
information and services needed to
make appropriate health decisions.1
Approximately a third of the people in
the USA cannot read and understand
basic health-related materials and
therefore have low health literacy.
Among people with diabetes receiving

care at one public hospital in the

USA, it was reported that up to
38% have low health literacy.2
Low health literacy is especially
common among people who have
low educational attainment, older
people, and ethnic minorities.
Despite the high prevalence of this
disability, health-related materials
are often written at levels that

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Issue 3

far exceed many peoples reading

abilities. Compared to people
with adequate levels of literacy,
those with low health literacy have
been shown to have significantly
worse health outcomes; poorer
knowledge about their health
conditions; lower use of preventative
services; higher rates of nonadherence to medication regimens;
increased risk of hospitalization;
and lower health status.

( )
Approximately a
third of the people
in the USA cannot
read and understand
basic healthrelated materials.

Health literacy and

diabetes outcomes
Diabetes is a leading cause of
death and disability in the USA.
Preventative care practices such
as self-monitoring of blood sugar
(glucose), routine foot care, and
eye examinations can help to
improve health status, prevent
diabetes complications, and reduce
mortality among people with the
condition. Although the majority of
people with diabetes in the USA
are followed closely by health-care

Health Delivery

People with diabetes with

low health literacy may not
develop the necessary skills
and knowledge to manage
their condition.

professionals, they are often asked to

perform complex self-management
activities, such as following a
complicated medication regimen and
monitoring their blood sugar levels.
Effective communication between
people with diabetes and health
professionals has been linked to
improvements in self-care and clinical
outcomes. However, low health
literacy may impair communication
between those with the condition
and their health-care providers.
Confusing communication can arise
from a combination of the terminology
often used by health-care providers,
insufficient comprehension of health
vocabulary among people with low
health literacy, their limited health
knowledge, and an impaired ability to
integrate new information. As a result,
people with diabetes with low health
literacy may feel overwhelmed by the
information about their illness and may
not develop the necessary skills and
knowledge to manage their condition.
Recent studies
Low health literacy has been
associated with poor diabetes
knowledge, poor glucose control,
and an elevated risk of diabetes

eye damage (retinopathy). In a study

of 408 adults with Type 2 diabetes,
those with low health literacy were
less likely to achieve optimal glucose
control and more likely to report
having retinopathy than a group of
more health-literate people.2
Moreover, studies have demonstrated
that among people with diabetes,
those with low health literacy scored
lower on diabetes knowledge tests.
For example, only 38% of people
with low health literacy knew the
signs and symptoms of low blood
sugar, compared to 73% of people
with adequate health literacy.3
Some similar results are reported from
India see article by Anil Kapur and
colleagues in this issue of Diabetes Voice.
Another study attempted to look at
the communication problems faced by

people with diabetes when interacting

with their health-care provider. People
with diabetes who had low health
literacy were more likely to report that
their physician did not clearly explain
the implications of their condition or
adequately describe the necessary
steps for the successful management of
their diabetes. This study implies that
people with low health literacy may
have limitations not only in reading
but also with oral communication.4
Identifying people with
low health literacy
It is difficulty to identify people
with low health literacy; often,
physical appearance offers no clues.
In addition, because of the shame
associated with low literacy, many
people with low health literacy
are often able to successfully hide
this limitation from others.

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September 2004 Volume 49

Issue 3

Health Delivery
Figure 1: Strategies for health-care providers to communicate clearly with people
with low health literacy.

literacy. However, additional research

is needed to further understand the
impact of this disability on health
outcomes; identify optimal methods
for communicating with people who
have low health literacy; and develop
effective interventions to improve the
health and health care of people with
diabetes who have low health literacy.

[ Lisa D Chew
Lisa Chew is a member of faculty in the

Although health carers often attempt

to assess a persons health literacy
by asking about the level of schooling
completed, the association between
educational attainment and health
literacy skills is poor. Therefore, it
is not possible to predict a persons
health literacy level by asking
about their educational level.
In the USA, instruments to assess
health literacy such as the Rapid
Estimate of Adult Literacy in Medicine
(REALM) and the Short Test of
Functional Health Literacy in Adults
(STOFHLA) can be used to identify
people with low health literacy.
However, the literature does not
support the use of these instruments
unless health-care providers are
willing to tailor communication and
health education to the needs of
people with low health literacy who
are identified through testing.5
Recommendations and
future actions
So far, most of the solutions to the
problem of health literacy have
focussed on improving the readability
of written documents or replacing

printed materials with other types of

health communication. Using visual
aids and computer-based multimedia
as alternatives to printed materials
may improve communication with
people with low health literacy.

The value of health

literacy assessment
tools is limited unless
health-care providers
are willing to tailor
communication to
people identified with
low health literacy.

In addition, various sources offer

advice about how physicians and
other health-care providers can
communicate more clearly with
people with low health literacy
such as Lessons and Tips for
Addressing Health Literacy Issues
in a Medical Setting, which is
available at the website of the
Harvard School of Public Health
(Figure 1).6
These efforts will lead to helpful
changes in the health-care
experience of people with low health

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Issue 3

Health Services Research and Development

Center of Excellence at the VA Puget Sound
Health Care System, Seattle, USA and
in the Department of Medicine, Division
of General Internal Medicine at the
University of Washington, Seattle, USA.

References
1

Healthy People 2010: Understanding and

Improving Health. 2nd ed. Washington DC. US
Government Printing Office: US Department of
Health and Human Services; 2000. (Available
online at: www.healthypeople.gov/Publications)
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 2002; 288:
475-82.
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 1998; 158: 166-72.
Schillinger D, Bindman A, Wang F, Stewart A,
Piette J. Functional health literacy and the
quality of physician-patient communication
among diabetes patients. Patient Educ Couns
2004; 52: 315-23.
Davis TC, Michielutte R, Askov EN, Williams MV,
Weiss BD. Practical assessment of adult literacy
in health care. Health Educ Behav 1998; 25:
613-24.
Ebeling S. Lessons and Tips for Addressing
Health Literacy Issues in a Medical Setting.
Harvard School of Public Health: Health
Literacy Website. 2003. (Available online at:
www.hsph.harvard.edu/healthliteracy/insights.
html)