The relationship between health literacy and knowledge improvement after a multimedia type 2 diabetes education program
Introduction
Type 2 diabetes mellitus (DM) is a significant public health problem, affecting over 20 million Americans [1]. Effective diabetes education has been shown to improve self-management skills and glycemic control [2], [3], [4]. However, there is evidence that patients with low health literacy and diabetes may not be fully benefiting from diabetes education [5], [6], [7]. Health literacy is the degree to which individuals have the capacity to obtain, process, and understand the health information and services they need to make appropriate decisions about their health [8]. Low health literacy has been linked to a higher prevalence of diabetes, as well as poor disease and treatment knowledge and sub-optimal self-management and glycemic control [9], [10], [11], [12]. The Institute of Medicine highlights diabetes as an area in which there is a great need for health communication tools targeting diverse audiences [13].
While many tools for diabetes education currently exist, few of them target low literacy populations [3], [5], [14]. Most diabetes education materials introduce too much information, present concepts in an overly complex manner, and use language that is for individuals with higher literacy [15]. Print materials are often limited in their ability to reach patients with varying literacy levels and to communicate complex concepts. Multimedia programs combine text, sound, graphics, and video, which serve to reinforce and complement one another to facilitate learning and maintain audience interest [16]. To address this gap in diabetes education materials, we developed and tested a multimedia diabetes education program (MDEP) targeted to patients with low literacy. MDEPs have the potential to improve communication and education of those with low health literacy, but few studies have examined the relationship between health literacy and the amount of new information learned after viewing a MDEP [3]. While it is recognized that knowledge does not always predict behavior change or glycemic control [17], health behavior theories generally include basic knowledge as a necessary element of health behavior change and outcomes [18]. In this study, we examined the effect of a MDEP targeted to patients with low literacy on knowledge improvement and assessed the association between literacy and knowledge improvement. Because literacy has been shown to affect oral and visual comprehension (in addition to reading comprehension), we hypothesized that lower literacy would be associated with less knowledge improvement, independent of baseline knowledge.
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Methods
This study protocol was approved by the Institutional Review Board of Northwestern University.
Results
A total of 190 patients participated in the study. The mean age was 56 (standard deviation (SD) ± 9.3) years old, 73% were women, 68% self-identified as African-American, and 45% had self-reported type 2 diabetes (Table 1). Overall, the mean number of years of education was 13.5 years, and 18% of participants had less than a high school education. The mean TOFHLA score was 28.8 (SD ± 8.8, range 0–36). Seventy-nine percent of the patients had adequate literacy, 13% had marginal, and 8% had
Discussion
Multimedia education programs have the potential to improve communication and education of those with low health literacy by reducing reading demands and presenting information through the spoken work and images that convey meaning. However, the methods for developing these communication tools for low literate populations are not well defined [22], and there are significant obstacles to achieving this goal [13], [22], [23]. During the course of our MDEP development, some of the challenges
Conflict of interest
This research was supported by a research grant from the Northwestern Memorial Hospital Foundation. No other potential conflict of interest is involved in this research.
Acknowledgements
The authors thank Dr. Daniel Derman, Lisa Azu-Popow, and Posh Charles, from Northwestern Memorial Hospital, who were instrumental in developing and conducting this project. The authors thank Dr. Timothy Long, Deidre Johnson, and staff at Near North Health Services Corporation for their feedback on the MDEP and assistance in subject recruitment. We also thank Jason Thompson for his help with data management and analysis.
Funding: This work was supported by a grant from the Northwestern Memorial
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