Mechanisms underlying the relationship between health literacy and glycemic control in American Indians and Alaska Natives

Patient Educ Couns. 2012 Jul;88(1):61-8. doi: 10.1016/j.pec.2012.03.008. Epub 2012 Apr 11.


Objective: Research suggests that health literacy (HL) is associated with clinical outcomes. Few studies, however, have examined the mechanisms accounting for this relationship. To understand why HL is related to outcomes, we tested a theoretical framework proposing that diabetes-related knowledge and behavior mediate (explain) the relationship between HL and glycemic control (i.e., A1c).

Methods: Analyses used baseline data from the Special Diabetes Program for Indians Healthy Heart Project (N=2594), an intervention to reduce cardiovascular risk among American Indians/Alaska Natives (AI/ANs) with diabetes. Three nested structural equation models tested the theoretical framework.

Results: Model 1 demonstrated that participants with stronger HL skills had better glycemic control. Model 2 tested whether diabetes-related behaviors accounted for this relationship. Self-monitoring of blood glucose significantly mediated the HL-A1c relationship. Model 3 examined the role of diabetes knowledge, showing that it mediated the relationship between HL and dietary behavior. When knowledge was included, behavior was no longer a significant mediator, suggesting that knowledge was the main driver of the relationship between HL with A1c.

Conclusion: Interventions to improve knowledge may be particularly important in enhancing outcomes among AI/ANs with diabetes.

Practice implications: Strategies known to enhance patient comprehension may enable low-literate patients to develop needed diabetes knowledge.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Alaska
  • Blood Glucose / analysis*
  • Diabetes Mellitus, Type 2 / ethnology
  • Diabetes Mellitus, Type 2 / therapy*
  • Female
  • Health Behavior*
  • Health Knowledge, Attitudes, Practice
  • Health Literacy*
  • Humans
  • Indians, North American / statistics & numerical data*
  • Male
  • Middle Aged
  • Models, Theoretical
  • Risk Factors
  • Socioeconomic Factors
  • Surveys and Questionnaires


  • Blood Glucose