Interventions to Improve Diabetes Outcomes for People With Low Literacy and Numeracy: A Systematic Literature Review

Diabetes is complicated. Living with diabetes is more complicated. People with diabetes are tasked with learning to manipulate their own physiology in an effort to mimic normal physiology. It took evolution millions of years to sort this out, so it is not difficult to imagine why it would be hard for patients with diabetes. That diabetes is complicated is not news. To help patients manage diabetes, we have created systems to help them understand their illness. The entire field of diabetes education has emerged, and we have shown remarkable progress and success. However, research during the past 10–15 years has shown that we are still struggling with the most vulnerable of our patients. One marker of vulnerability is low literacy.1 Educators know that patients with low literacy struggle more to learn many diabetes concepts, and at least one study has suggested that patients with low literacy are less likely to have good control of their blood glucose.2 Subsequent studies have tried to untangle the relationship between low literacy and poor diabetes control. The primary hypothesis behind this research is that people with low literacy are less likely to understand self-management tasks. If one does not understand a task, he or she is unable to implement the correct self-management behavior. This theory is supported by research documenting the relationship between literacy and knowledge about health topics.1 One problem in this area of research is that knowledge, as we measure it in most studies, is not always related to health outcomes. This does not fit the paradigm of literacy and health research and raises questions about how best to help our patients if improving knowledge does not improve health outcomes. One possibility is that we are measuring the wrong knowledge. If we are asking about knowledge of pathophysiology or …