Patient Education and Counseling 84 (2011) 393–397

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Patient Education and Counseling

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The relationship of patient participation and diabetes outcomes for patients with
high vs. low health literacy
Hirono Ishikawa a,*, Eiji Yano b
a
Department of Health Communication, School of Public Health, The University of Tokyo, Japan
b
Department of Hygiene & Public Health, Teikyo University School of Medicine, Japan

A R T I C L E I N F O A B S T R A C T

Article history: Objective: To examine whether patient participation in medical consultations have differing effects on
Received 20 October 2010 self-efficacy and diabetes control by the level of patient communicative health literacy (CHL).
Received in revised form 20 January 2011 Methods: Participants were 143 outpatients with type 2 diabetes at a university-affiliated hospital.
Accepted 23 January 2011
Patient CHL was measured using a newly developed self-rated scale of health literacy. Patient perceived
participation in medical consultations and self-efficacy of diabetes self-care were assessed using the self-
Keywords: reported questionnaire. Patient clinical characteristics were obtained from electronic medical records.
Health literacy
Results: Both patient CHL and perceived participation were related to greater self-efficacy and decreased
Patient participation
HbA1c at the 3-month follow-up. Patient CHL had a moderating effect on the relationship between
Self-efficacy
Diabetes perceived participation and self-efficacy. Patients with lower CHL reported greater self-efficacy when
they actively participated in patient–physician communication, whereas this relationship was less
evident among patients with higher CHL.
Conclusions: The examination of patient CHL levels may provide a better understanding of the potential
barriers to patients’ self-management of disease.
Practice implications: The benefit of active participation may be greater among patients with lower CHL
who are likely to have greater difficulties in communicating with the physician, yet tend to rely on the
physician as the sole source of health information.
ß 2011 Elsevier Ireland Ltd. All rights reserved.

1. Introduction the capacity of individuals to access, understand, and use health

Patient participation in the health care process is central to
achieving patient-centered care and successful disease manage-
ment. This is particularly true in the case of chronic diseases, such
as diabetes, which require long-term patient–physician relation-
ships and on-going patient self-care. Several diabetes studies have
reported that patient’s active involvement in provider–patient
communication during the medical visit is related to a decrease
in functional limitations and improvement in metabolic control
[1–4].
In order to actively engage in the management of a health
condition, patients need comprehensible health information that is
accessible and appropriate to their individual needs [5]. Patients
with chronic diseases receive health information from a variety of
sources including the mass media, World Wide Web, health care
providers, family members, and friends. Thus, health literacy (HL),
* Corresponding author at: Department of Health Communication, School of
Public Health, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655,
Japan. Tel.: +81 3 5800 8781; fax: +81 3 5689 0726.
E-mail address: hirono-tky@umin.ac.jp (H. Ishikawa).
information to make informed and appropriate health-related
decisions, is recognized as an important factor affecting patient’s
health behaviors and outcomes. Increased HL may help patients
understand their health problems, seek information from health
care providers and other sources, and make informed and shared
decisions, leading to better treatment adherence and subsequent
self-management [6].
Additionally, limited HL may impede patient–physician com-
munication. Several studies have reported that limited HL is
associated not only with a poor understanding of the health care
information provided by a physician [7,8], but also with less active
participation in the communication process during the medical
visit (e.g., asking fewer questions) [9,10].
HL can be divided into three major constructs: functional
literacy, the basic level of reading and writing skills that let
someone function effectively in everyday situations; communica-
tive literacy, advanced skills that allow a person to extract
information, derive meaning from different forms of communica-
tion, and apply new information to changing circumstances; and
critical literacy, more advanced skills for critically analyzing
information and using information to exert greater control over
life events and situations [11]. Previous studies on HL have

0738-3991/$ – see front matter ß 2011 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.pec.2011.01.029
394 H. Ishikawa, E. Yano / Patient Education and Counseling 84 (2011) 393–397
predominantly focused on functional HL. In many of these studies,
the Short Test of Functional Health Literacy in Adults (S-TOFHLA)
[12] and the Rapid Estimate of Adult Literacy in Medicine (REALM)
[13] have been used. Previous studies exploring the relationship of
such functional HL measures with self-efficacy and diabetes
control have demonstrated somewhat mixed results [14–17].
Recent studies have indicated that other forms of HL, such as
communicative and critical HL [18] and numeracy skills [19,20]
might be more important to diabetes management.
Further, our previous study suggested that communicative HL
might be especially important to the patient–physician exchange
of information during the medical consultation [10]. Although
limited HL may decrease the quality of patient–physician
communication during the medical visit, previous research has
focused on HL and patient–physician communication in isolation.
Importantly, patients with limited HL are more likely to use their
physician as the sole source of medical information and are less
likely to seek information from other sources [18,21]. Consequent-
ly, face-to-face communication with a health care provider may be
an important opportunity for patients with limited HL to obtain
and understand information regarding their illness and its
management.
This study sought to examine whether patient participation in
medical consultations have differing effects on self-efficacy and
diabetes control by the level of patient communicative health
literacy (CHL).
2. Methods
2.1. Study population and setting
The study participants were patients with type 2 diabetes who
visited the outpatient department of internal medicine at a
university-affiliated hospital in Tokyo, Japan. Patients who had
type 2 diabetes and who were under continuous care by one of four
attending physicians in the department of metabolic diseases met
the study inclusion criteria. During the study period from October
to December 2006, we aimed to recruit approximately 150 patients
for the study and randomly selected eligible patients from the
physician’s appointment logs. The selected patients were
approached in the waiting room and provided an explanation of
the study purpose and procedure.
Of the 169 eligible patients identified, 157 patients provided
written consent to participate in the study and completed the
baseline questionnaire. A total of 12 patients refused to
participate in the study (7.1% refusal rate). The most common
reasons for refusal were lack of time and poor physical condition
on the day of the questionnaire. At the subsequent visit, typically 4
weeks later, the physician consultation was recorded and the
participants were asked to complete the second questionnaire
following the consultation. Each questionnaire took about 5–
10 min to administer. Fourteen patients did not return the second
questionnaire, resulting in a final sample of 143 patients. Patient
clinical characteristics and hemoglobin A1c (HbA1c) levels at the
baseline and 3-month later were obtained from electronic
medical records. The study was conducted with the approval of
the Ethical Review Committee at Teikyo University School of
Medicine.
2.2. Measures
Patient communicative health literacy (CHL) was measured in the
baseline questionnaire using a newly developed self-rated HL
scale. The scale development and validation are described
elsewhere [18]. Selected from the three HL scale constructs, the
CHL scale was used in this study. This scale assesses the ability to
extract information, derive meaning from different forms of
communication, and apply new information to changing circum-
stances [11]. The scale consists of 5 items asking since being
diagnosed with diabetes, whether the patient (1) collected
information from various sources, (2) extracted the information
he/she wanted, (3) understood the obtained information, (4)
communicated his/her thoughts about his/her illness to someone,
and (5) applied the obtained information to his/her daily life. Each
item was rated on a 4-point scale, with responses ranging from 1
(never) to 4 (often). The scores for each item were summed and
divided by the number of items in the scale to generate a total scale
score (Cronbach’s a = 0.77, theoretical range: 1–4). In the analyses,
negative responses (scores 2 on average) on each 4-point scale
were classified as low CHL and used as a dichotomous variable.
Patients’ perceived participation in medical consultations was
measured in the second questionnaire using a 5-item scale
obtained from the patients’ perceived participation measure
[22]. Patients were asked whether they (1) talked about physical
conditions and symptoms, (2) talked about worries and concerns,
(3) expressed preferences for the treatments and tests, (4) asked
what they wanted to ask, and (5) asked for a detailed explanation
of their condition and test results. Each item was rated on a 4-point
scale and summed to obtain a final scale score (Cronbach’s a = 0.84,
theoretical range: 4–16).
Self-efficacy in diabetes self-care was assessed in the second
questionnaire using a 4-item scale obtained from the self-care
ability measure in the Diabetes Care Profile [23]. The reliability of
this scale in our study was similar to the previously reported value
(Cronbach’s a = 0.83). Higher scores on this scale indicate greater
self-efficacy (theoretical range: 4–16), and used as a continuous
variable.
Diabetes control was operationalized as the change in HbA1c
level from baseline to the 3-month follow-up. We categorized
those with a higher HbA1c level at the 3-month follow-up
compared to baseline as poor management (coded as 1), and
treated as a dichotomous variable in the analyses.
2.2.1. Sociodemographic and clinical characteristics
Information on educational attainment and duration of
diabetes was collected for each patient using the self-report
questionnaire. Age, gender, and HbA1c levels at baseline and 3-
month later were collected by review of electronic medical records.
The visit length was determined from the audio file.
2.3. Statistical analysis
First, we used Pearson correlation to explore bivariate
relationships among patient CHL, perceived participation, self-
efficacy, and baseline and follow-up HbA1c levels. Then, the
relationship of patient CHL and perceived participation to self-
efficacy was examined, controlling for patient and clinical
characteristics (i.e., age, gender, educational attainment, duration
of diabetes, baseline HbA1c level, and consultation length) using
regression analysis. Similarly, the relationship of patient CHL and
perceived participation to diabetes control was examined using
logistic regression analysis. Because the patient–provider data
included four different physicians, regression analysis and logistic
regression analysis with robust variance estimates were used to
compensate for within-group correlations among patients seeing
the same physician. Furthermore, interaction terms for patient
CHL and perceived participation were added to the models to
investigate whether CHL has a moderating effect on the
relationship between perceived participation, and self-efficacy
and diabetes control. The p-value of <0.05 was used as level of
significance. The analyses were conducted using Stata 11.0
software (Stata Corporation, TX).
 H. Ishikawa, E. Yano / Patient Education and Counseling 84 (2011) 393–397 395

Table 1 14
Low HL
Patient and clinical characteristics.
High HL
N % 13

Patient self-efficacy
Gender
Male 82 57.3
12
Female 61 42.7
Educational attainment 11
Middle school 34 23.8
High school 70 48.9
10
Vocational school/2-year college 19 13.3
University or higher 20 14.0
Mean SD Range 9
Age (year) 65.0 9.1 [39–85]
Duration of diabetes (years) 11.1 9.6 [0–54]
8
HbA1c at baseline (%) 7.3 1.4 [5.0–12.6]
Low High
HbA1c at 3-month follow-up (%) 7.2 1.4 [4.9–13.2]
Visit length (min) 5.0 2.2 [2.0–15.1] Patiet participation

Fig. 1. Estimated relationship between patient perceived participation and self-

3. Results efficacy by the level of patient CHL. The slopes were estimated based on the second
model of Table 3 when patient CHL was low and high, with all other variables were
3.1. Patient and clinical characteristics set at the mean.

The sociodemographic and clinical characteristics of the partici-

pants are shown in Table 1. The mean age of the patients was 65 years,
and the mean duration since the diagnosis of diabetes was 11.1 years.
More than 75% of the patients had at least a high school education. The
participants had been patients at this outpatient service for an average
of 6.8 years (SD = 5.8) prior to inclusion in the study.
Table 2 shows the mean scores and correlations for the main
study variables. The mean scale score for patient CHL was 2.53
(SD = 0.71). Thirty-seven patients (25.9%) were categorized as
having low CHL. Patient CHL and perceived participation were
positively associated with self-efficacy in diabetes self-care;
however, no significant association was found for either baseline
or follow-up HbA1c level. On the other hand, self-efficacy in
diabetes self-care was significantly correlated with both baseline
and follow-up HbA1c levels.
3.2. Influence of patient CHL and perceived participation on self-
efficacy and diabetes control
As shown in Table 3, patient CHL and perceived participation in
medical consultations were positively associated with self-efficacy
in diabetes self-care while controlling for patient and clinical
characteristics. When the interaction term for patient CHL and
perceived participation was included in the model, the main effects
of CHL and perceived participation became more evident because
the interaction term was significant. Patients with lower CHL
reported greater self-efficacy in diabetes self-care when they
actively participated in the patient–physician communication.
This finding was not observed in participants with higher CHL
(Fig. 1).
Similarly, the relationship of patient CHL and perceived
participation to diabetes control was examine (Table 4). Patients
with higher CHL and greater perceived participation were less
likely to be categorized as poor diabetes control (i.e. they were
more likely to have decreased HbA1c at 3-month follow up as
compared to their baseline levels). On the other hand, the
interaction term for patient CHL and perceived participation
was not statistically significant, suggesting that the relationship of
patient participation to diabetes control was not different for
patients with high vs. low CHL.

Table 2
The mean scores and correlations of the major study variables.

CHL Patient participation Self-efficacy

Mean (SD) 2.53 (0.71) 11.56 (3.91) 11.46 (2.62)
r p-value r p-value r p-value

Patient participation 0.289 0.001

Self-efficacy 0.251 0.003 0.164 0.052
Baseline HbA1c 0.104 0.221 0.062 0.465 0.218 0.010
Follow-up HbA1c 0.120 0.158 0.077 0.365 0.233 0.006

Table 3
Relationship of patient CHL and perceived participation to self-efficacy in diabetes self-care.

Model 1 Model 2

B s.e. p-value B s.e. p-value

Age 0.072 0.012 0.010 0.077 0.012 0.008

Gender (1: female) 0.073 0.540 0.901 0.097 0.568 0.875
Education 0.167 0.201 0.466 0.160 0.202 0.486
Duration of diabetes 0.015 0.015 0.372 0.022 0.013 0.180
Baseline HbA1c 0.170 0.219 0.494 0.167 0.229 0.520
Consultation length 0.109 0.095 0.337 0.116 0.101 0.333
CHL 1.126 0.391 0.063 3.013 0.503 0.009
Patient participation 0.092 0.033 0.070 0.230 0.062 0.034
CHL  participation 0.182 0.044 0.026
396 H. Ishikawa, E. Yano / Patient Education and Counseling 84 (2011) 393–397
Table 4
Relationship of patient CHL and perceived participation to diabetes control.
Odds ratio [95% CI]
Age 1.004 [0.970,
Gender (1: female) 0.907 [0.278,
Education 1.245 [0.680,
Duration of diabetes 1.007 [0.965,
Baseline HbA1c 0.664 [0.574,
Visit length 0.941 [0.764,
CHL 0.680 [0.555,
Patient participation 0.934 [0.875,
4. Discussion and conclusions
4.1. Discussion
This study explored the relationship of patient CHL and
perceived participation in medical consultations with diabetes
control, and examined how patient participation and diabetes
control vary by patient CHL. Study results indicate that patient CHL
and perceived participation in patient–physician communication
are related to higher self-efficacy in diabetes self-care and better
diabetes control. These findings are consistent with previous
studies indicating that poor numeracy skills and functional HL are
associated with worse self-efficacy, fewer self-management
behaviors, and worse glycemic control [17,19,20], and active
patient participation in medical consultations is associated with
improved diabetes health outcomes [2,3]. Although patients with
higher HL were more likely to be active participants in the visit
communication [9,10], our study suggests that patient CHL and
perceived participation have independent effects on diabetes
health outcomes.
Further, our findings suggest that the benefit of active
participation is greater among patients with lower CHL. Patients
with lower CHL reported greater self-efficacy in diabetes self-care
when they actively participated in the communication, whereas
this relationship was less evident among patients with higher CHL.
Previous reports suggested that patients with limited HL are more
likely to use their physician as the sole source of medical
information and are less likely to seek information from other
sources [18,21]. Face-to-face communication with a health care
provider may be more critical for patients with limited CHL who
have a limited ability and lack of motivation to extract, understand,
and apply health care information regarding their disease and its
management from other sources. Failure to tailor the communica-
tion of health care providers to patient HL levels may explain why
provider attempts to educate patients are often unsuccessful [24].
The examination of patient HL levels may provide a better
understanding of the potential barriers to patient–physician
communication during the consultation and to patients’ self-
management of disease. In recent studies, literacy-appropriate
patient education programs have been developed and have been
shown to be effective in increasing the skills necessary for diabetes
self-management [25–27].
Several limitations should be noted in interpreting our study
findings. First, the study was conducted at a single university
hospital in a metropolitan area using a sample of patients with
established patient–physician relationships. It is possible that the
patients were better educated and less likely to be illiterate than
those who attend local clinics or live in rural areas. In addition,
sociocultural context and practice style may differ between
Japanese and Western cultures, and our findings might be specific
to the Japanese sociocultural context. For instance, compared to
the US, the typical visit length is shorter in Japan, and the high-
context communication where the message is less explicitly
verbalized but communicated implicitly tends to be preferred [28].
However, many similarities in patient–physician communication
between Japan and Western countries are also reported [28–30].
Indeed, our previous study has suggested that the relationship
1.038] between HL and patient and clinical characteristics is similar to
2.960] those reported in Western studies [18]. Another limitation was
2.279] that we were unable to include a standard measure of functional
1.051] HL (e.g., S-TOFHLA and REALM) because these measures were not
0.768]
available in the Japanese language at the time of this study.
1.160]
0.833]
0.998] 4.2. Conclusion
Despite these limitations, our results suggest that both patient
participation and CHL are related to clinical health outcomes
among diabetes patients, and active patient participation in
medical consultations may be particularly important for patients
with limited CHL. Further study with an English-speaking
population is needed to revise and validate our HL measure. Also,
research is needed to identify ways to effectively communicate
health information to patients with limited HL in everyday health
care practice and within the current health care system.
4.3. Practice implications
Participation in medical consultations may be particularly
important for patients with limited CHL who are likely to have
greater difficulties in communicating with the physician, yet tend
to rely on the physician as the sole source of medical information.
Previous studies reported that patients who actively participate in
medical consultations influence their physicians to practice a more
patient-centered, interactive style of communication [31]. Physi-
cians can improve patient participation and diabetes control with
the use of patient-centered, interactive communication, such as
soliciting the patient’s opinions and questions, offering support,
allowing the patient to be involved in the decision making, and
assessing the patient’s comprehension [4,32]. However, it is
speculated that physicians may be less likely to adopt this style
of communication for patients with limited CHL who are less likely
to actively participate in the communication. Therefore, physicians
need to make additional efforts to facilitate the involvement of
patients with limited CHL by using communication skills that
improve patient comprehension of health information and self-
management behavior.
Conflicts of interest
No potential conflicts of interest relevant to this article were
reported.
Role of the funding source
This study was supported by a Grant-in-Aid for Young Scientists
(B) from the Japanese Ministry of Education, Culture, Sports,
Science, and Technology.
Acknowledgments
We acknowledge the contributions of Drs. Tamio Teramoto,
Shin Fujimori, Makoto Kinoshita, and Toshikazu Yamanouchi at
Teikyo University School of Medicine, and participating patients at
the Teikyo University Hospital.
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