Health Literacy and Health Outcomes in Diabetes: A Systematic Review

Low health literacy is considered a potential barrier to improving health outcomes in people with diabetes and other chronic conditions, although the evidence has not been previously systematically reviewed. To identify, appraise, and synthesize research evidence on the relationships between health literacy (functional, interactive, and critical) or numeracy and health outcomes (i.e., knowledge, behavioral and clinical) in people with diabetes. English-language articles that addressed the relationship between health literacy or numeracy and at least one health outcome in people with diabetes were identified by two reviewers through searching six scientific databases, and hand-searching journals and reference lists. Seven hundred twenty-three citations were identified and screened, 196 were considered, and 34 publications reporting data from 24 studies met the inclusion criteria and were included in this review. Consistent and sufficient evidence showed a positive association between health literacy and diabetes knowledge (eight studies). There was a lack of consistent evidence on the relationship between health literacy or numeracy and clinical outcomes, e.g., A1C (13 studies), self-reported complications (two studies), and achievement of clinical goals (one study); behavioral outcomes, e.g., self-monitoring of blood glucose (one study), self-efficacy (five studies); or patient-provider interactions (i.e., patient-physician communication, information exchange, decision-making, and trust), and other outcomes. The majority of the studies were from US primary care setting (87.5 %), and there were no randomized or other trials to improve health literacy. Low health literacy is consistently associated with poorer diabetes knowledge. However, there is little sufficient or consistent evidence suggesting that it is independently associated with processes or outcomes of diabetes-related care. Based on these findings, it may be premature to routinely screen for low health literacy as a means for improving diabetes-related health-related outcomes.