EVALUATING THE RELATIONSHIP BETWEEN HEALTH LITERACY
AND SELF-EFFICACY ON DIABETES SELF-MANAGEMENT AFTER
PARTICIPATION IN A WEB-BASED EDUCATIONAL PROGRAM FOR
PATIENTS WITH TYPE 2 DIABETES
By
Judy L. Hinchman-Flynn
Doctor of Nursing Practice Degree
DNP, Penn West University, 2024
MSN, State University of New York at Buffalo, 1999
BSN, University of Pittsburgh, 1995
A DNP Research Project Submitted to Penn West University
In Partial Fulfillment of the Requirements for the Doctor of Nursing Practice Degree
April 2024

___4/30/24___
Date
__4/26/2024__
Date
__4/28/24____
Date
4/28/24
____________
Date

______Robin

R. Weaver, PhD, RN, CNE___________

Committee Chair
__Donna Falsetti, DrPH, CRNP_______________
Committee Member
___Trisha L. Wright, DNP, CRNP, FNP-BC, ATC______________
Committee Member
______________________________________________________
Dean of the College of Health and Human Services
Clarion University

HEALTH LITERACY AND DIABETES SELF-MANAGEMENT

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Evaluating the Relationship between Health Literacy and Self-Efficacy on Diabetes SelfManagement after participation in a Web-Based Educational Program for Patients with
Type 2 Diabetes

Judy Hinchman-Flynn MSN, FNP
Doctor of Nursing Practice Degree Candidate
Clinical Advisor:
Dr. Robin Weaver
Penn West University

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The following committee members have approved the Clinical Scholarly Project.
Dr. Robin Weaver_____________________________________________
Dr. Donna Falsetti, DrPH, MSN, FNP______________________________
Dr. Trisha Wright DNP__________________________________________

February 2024

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Table of Contents
Abstract------------------------------------------------------------------------------------------5
Chapter 1 Introduction-------------------------------------------------------------------------6
Concept Definitions----------------------------------------------------------------------------6
Health Literacy------------------------------------------------------------------------------6
Diabetes Self-Management----------------------------------------------------------------8
Self-Efficacy---------------------------------------------------------------------------------8
Chapter 2 Literature Review--- -------------------------------------------------------------10
Bandura’s theory of Self-Efficacy------------------------------------------------------14
Chapter 3 Methodology-----------------------------------------------------------------------15
Chapter 4 Results and Discussion-----------------------------------------------------------20
AAHLS--------------------------------------------------------------------------------------19
DMSES--------------------------------------------------------------------------------------21
Table 1---------------------------------------------------------------------------------------23
Chapter 5 Summary, Conclusions, and Recommendations------------------------------26
Limitations-----------------------------------------------------------------------------------26
Future research------------------------------------------------------------------------------28
References---------------------------------------------------------------------------------------29
Appendices--------------------------------------------------------------------------------------34
Appendix A Consent Form----------------------------------------------------------------34
Appendix B AAHLS-----------------------------------------------------------------------36
Appendix C DMSES-----------------------------------------------------------------------39
Appendix D Web-based Educational Program-----------------------------------------42

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Appendix E Fleisch-Kincaid Results----------------------------------------------------- 43
Appendix F Educational Pamphlet--------------------------------------------------------44

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Abstract
Research has supported health literacy as one of the determinants in diabetes management (Fang
et al., 2020; Kim & Utz, 2019; Robatsarpooshi et al., 2020; Van der Heide et al., 2014). Low
health literacy has led to poor health outcomes in diabetes management (Poureslami et al., 2017;
Van der Heide et al., 2014; Wang et al. et al., 2016). Research lacks interventions aimed at
improving diabetes self-management for individuals with low health literacy (Jiang et al., 2019;
Kim & Utz, 2019; Vandenbosch et al., 2018). This doctoral quality improvement project aims to
evaluate the relationship between health literacy and diabetes self-management skills after
participation in a web-based educational pilot program for adult patients with Type 2 diabetes in a
rural community in Western Pennsylvania.
Keywords: health literacy and Type 2 diabetes, self-efficacy and Type 2 diabetes, rural health
literacy

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Evaluating the relationship between Health Literacy and Self-Efficacy on Diabetes SelfManagement after participation in a Web-Based Educational Program for Patients with
Type 2 Diabetes

Chapter 1 Introduction
Diabetes affects 30.3 million people in the United States (United States Centers for
Disease Control [USCDC], 2017). Ninety percent of those people affected have Type 2 diabetes
(USCDC, 2017). This chronic and often life-long disease contributes to 237 billion dollars to
healthcare costs in the United States yearly (USCDC, 2017). Complications associated with
diabetes include heart disease, stroke, kidney disease, and blindness (USCDC, 2017). According
to Rural Healthy People 2020, diabetes incidence is 17 percent higher in rural regions (Rural
Health Information Hub, 2020). The purpose of this doctoral project is to evaluate the
relationship between health literacy and diabetes self-management after participation in a webbased educational pilot program for patients with Type 2 diabetes in rural health clinics in
Western Pennsylvania.
Definitions
Health Literacy
Personal health literacy is defined by Santana et.al., 2021, in the Healthy People 2030
Initiative as “the degree to which individuals have the ability to find, understand, and use
information and services to inform health-related decisions and actions for themselves" (p.
S259). This definition of health literacy was expanded by the Healthy People 2030 Initiative to
include the importance of organizations having a role in facilitating personal health literacy
(Santana et al., 2021). Health literacy is divided into three types: functional, communicative, and

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critical (Wang et al., 2016). Wang, Hsu, and Lee et al. (2016) define functional health literacy as
reading and writing skills. Communicative health literacy pertains to one’s ability to obtain
information and understand it (Wang et al., 2016). Critical or conceptual health literacy relates to
the individual’s ability to analyze information in order to make informed decisions (Wang et al.,
2016). Poureslami et.al. (2017) identify several reasons why health literacy is essential.
Inadequate health literacy can increase the prevalence of chronic disease, increase the degree of
poor outcomes associated with chronic disease, increase the cost of disease management, and
lead to health inequities. Health literacy involves more than just the level of education attained. It
is a complex process. A person may have high literacy skills and good verbal communication
skills but still have low health literacy, and a person may be very fluent in communication yet be
unable to interpret written material (Healthy People, 2020). Health literacy also entails the ability
of an individual to understand the health care system and basic health functioning (Department
of Health and Human Services, 2010). In May 2013 in Vancouver, a panel of multidisciplinary
health literacy experts and policymakers from the United States, Canada, the United Kingdom,
and Australia assembled to discuss health literacy and provide a summary of their 4-day meeting
(Poureslami et al., 2017). The authors explained that health literacy extends beyond an
individual’s ability to process and understand information and empowers them to take action
(Poureslami et al., 2017). Past definitions of health literacy focused on the individual patient.
Poureslami et al. (2017) recognize a paradigm shift in health literacy ideology toward focusing
on the provider. The responsibility falls on the provider to ensure equity in health care and
provide health services that discourage inequality due to low health literacy. Unfortunately,
healthcare providers are inadequately trained to recognize and implement health information
sensitive to patients' low health literacy needs (Robatsarpooshi et al., 2020).

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Diabetes Self-Management
Diabetes self-management refers to the ability of an individual to perform skills and
health behaviors necessary for improving diabetes outcomes. Wang et al. (2016) prioritize
diabetes self-management skills as essential for diabetes care. Diabetes is a chronic disease with
life-long implications. It is paramount that patients with diabetes master these skills to improve
outcomes. Poor health literacy can hinder patients' ability to master diabetes self-management
skills (Robatsarpooshi et. al., 2020; Vandenbosch et al., 2018) Self-management skills may
include glucose monitoring, reading food labels for diet adherence, weight control, exercise,
preventative care, and medication adherence (Kim & Utz, 2019).
Self-Efficacy
Self-efficacy is a term closely related to self-management and should be defined for
clarity. It enables an individual to solve problems with their diabetes management when they
arise (Rural Health Information Hub, 2020). Several confounding factors can influence selfmanagement behaviors, such as social support, health beliefs, attitudes, motivation, and selfefficacy (Yao et al., 2019). Self-efficacy is theoretically based on the social cognitive theory
(Yao et al., 2019). Bandura (1995), a psychologist known for his extensive work on selfefficacy, explains self-efficacy as “beliefs in one’s capabilities to organize and execute the
course of action required to manage prospective situations” (p. 2). In a descriptive, crosssectional study by Yao et al. (2019), the researchers sampled 2,166 patients with Type 2 diabetes
from several providences in China. The researchers conducted a face-to-face survey and
concluded that self-efficacy was a critical element of self-management and that patients required
self-confidence to manage their disease effectively (Yao et al., 2019). Of particular interest in
this study was that the researchers determined rural areas to be deficient in self-management

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skills versus their urban counterparts (Yao et al., 2019). The researchers attributed this variance
to lower socioeconomic levels in rural areas and the disparity between rural and urban areas
related to a lack of adequate healthcare services (Yao et al., 2019). The researchers
acknowledged the limitations of this study as the study methods prohibited drawing inferences
and also acknowledged the need for further research with tested measures versus one developed
by the researchers (Yao et al., 2019).

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Chapter 2 Literature Review
The relationship between health literacy and diabetes self-management skills has been
established in multiple studies in the literature (Fang et al., 2020; Kim & Utz, 2019;
Robatsarpooshi et al., 2020; Van der Heide et al., 2014). Kim and Utz (2019) evaluated the
effectiveness of a Korean study involving a social media-based self-management intervention. In
a randomized, controlled trial, the researchers sampled 151 patients from endocrinology clinics
and compared social media and telephone self-management interventions to groups of high and
low health literacy participants. The researchers concluded that the findings of this study were
that both methods proved effective at enhancing self-management and that the gap between high
health literacy and low health literacy was bridged, contingent that the intervention was sensitive
to low health literate individuals (Kim & Utz, 2019). Previous studies support that individuals
with low health literacy will improve self-management skills with face-to-face contact (Kim et
al., 2019).
Kim, Song, and Park (2019) conducted a descriptive, qualitative study of 20 participants
in South Korea in 2016. The researchers determined that participants with low health literacy, as
measured on the Korean Functional Health Literacy Test, would do better with a hands-on
approach to diabetes education (Kim et al., 2019). Although many participants reported
enhanced motivation and learned self-management behaviors, there appeared to be a disconnect
in applying the information they learned to real life (Kim et al., 2019).
Many of the studies reviewed for this doctoral project showed some conflicting results.
One reason may be due to conflicting definitions of health literacy and the wide variety of
instruments available that measure the different types of health literacy. In addition, it has been

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acknowledged in some studies that limitations of functional health literacy hindered the
participants' understanding of the surveys (Rodrigues et al., 2019; Van der Heide et al., 2014;
Vandenbosch et al., 2018; Wang et al., 2016).
Interestingly, in a study by Quartuccio et al. (2017), data supports that gender in low
health literacy may differ. In a survey of 2,510 older adults with a mean age of 76 years old, the
researchers found that female participants with low health literacy showed higher hemoglobin
A1C and fasting blood glucose levels than their male counterparts (Quartuccio et al., 2017). In
contrast, in a study in Brazil by Rodrigues et al. (2019) of 303 patients with Type 2 diabetes, the
researchers determined that low health literacy was unrelated to medication adherence. Younger
male participants, scoring higher on health literacy measures, were less compliant with their
medication regimens (Rodrigues et al., 2019). Rodrigues et al. (2019) attribute the results to
male participants' carelessness.
In a large, Dutch, observational, cross-sectional study, 4,265 patients with diabetes were
studied to determine the extent to which health literacy was associated with diabetes selfmanagement (Van der Heide et al., 2014). The researchers determined that low health literacy
may be associated with some diabetes self-management skills and outcomes (Van der Heide et
al., 2014). For example, participants with lower health literacy scores were less likely to exercise
and monitor their diabetes through self-glucose monitoring (Van der Heide et al., 2014).
However, the researchers acknowledge that low health literacy may be one of many factors that
contribute to self-management. Psychosocial elements may also play a role, such as the
perception of disease severity, social support, attitudes, and motivation to change (Van der Heide
et al., 2014).

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The literature review for this doctoral quality improvement project yielded two
systematic reviews and a meta-analysis. Kim and Lee (2016) performed a systematic review and
meta-analysis aimed at self-management interventions for individuals with low health literacy.
Using rigorous review processes, the authors analyzed 13 studies meeting inclusion criteria from
select databases such as PubMed, CINAHL, and EMBASE from 2000 to 2015 (Kim & Lee,
2016). The data was divided into four intervention categories: spoken communication, written
communication, empowerment-based interventions, and language/cultural category (Kim & Lee,
2016). The authors concluded that all of the interventions improved diabetes outcomes, such as
hemoglobin A1c, with spoken methods of communication having the most favorable outcomes
(Kim & Lee, 2016).
In another systematic review and meta-analysis, Jiang et al. (2019) reviewed 16 studies
related to self-efficacy education for patients with Type 2 diabetes. The authors examined
studies from PubMed, Web of Science, EBSCO, CNKI, Wanfang, and Sinomed until January
2018 (Jiang et al., 2019). Their analysis discovered inadequate RCT-based research and a lack of
substantial studies that stand up to research rigor (Jiang et al., 2019). The authors concluded that
self-efficacy education likely benefits adults with Type 2 diabetes (Jiang et al., 2019).
It is apparent from this literature review that the research supports low health literacy
impacts on self-efficacy and diabetes self-management (Kim et al., 2019; Kim & Utz, 2019; Van
der Heide et al., 2014; Yao et al., 2019). However, more research is needed regarding the
effectiveness of educational interventions (Vandenbosch et al., 2018).
The American Association of Diabetes Educators (AADE) recommends seven critical
components of diabetes self-management education (Association of Diabetes Care and Education
& Education Specialists [ADCES], 2020). The AADE 7 focuses on healthy eating, being active,

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self-glucose monitoring, medication adherence, the ability to problem solve, reducing risks, and
promoting healthy coping skills (ADCES, 2020). In 2015, the American Diabetes Association
(ADA), AADE, and Academy of Nutrition and Dietetics developed a position statement on
diabetes self-management education (Powers et al., 2015). The position statement outlined
diabetes self-management education and support:
DMSE/S programs are designed to address the patient’s health beliefs, cultural
needs, current knowledge, physical limitations, emotional concerns, family
support, financial status, medical history, health literacy, numeracy, and other
factors that influence each person's ability to meet self-management challenges.
(Powers et al., 2015 p. 1323)
Vandenbosch et. al. (2018) conducted one of the few studies I found in the literature,
specifically on self-management education. The study encompassed nine countries and
examined newly diagnosed patients with diabetes who received some type of a DMSE
program. The programs were either one-on-one, group education, IT-web-based, or peerled group educational programs (Vandenbosch et al., 2018). The researchers clearly
outlined the limitations of this study. The study lacked adequate control to draw causal
relationships, the samples across nine countries were heterogeneous, and using multiple
interviewers could have potentially posed reliability threats (Vandenbosch et al., 2018).
The research results favored that all methods of diabetes self-management education
improved self-management skills (Vandenbosch et al., 2018). Participants with high
health literacy performed better than those with low health literacy, and the individual
and group-type programs were shown to have more favorable outcomes (Vandenbosch et

HEALTH LITERACY AND DIABETES SELF-MANAGEMENT
al., 2018). The researchers found no link between health literacy and the type of selfmanagement program the participants attended (Vandenbosch et al., 2018).
In conclusion, there are several recurring themes in literature. The lack of RCTs is
apparent (Jiang et al., 2019). Descriptive studies predominated the search results. In the
articles reviewed, the majority of the research favors low health literacy's association
with a lack of self-efficacy and diabetes self-management skills (Kim & Utz, 2019;
Robatsarpooshi et al., 2020; Van der Heide et al., 2014). However, many studies fail to
differentiate between the types of health literacy (Vandenbosch et al., 2018). Studies
measuring effective interventions are also lacking. Future research to evaluate specific
interventions is warranted.
Bandura’s theory on self-efficacy is the theoretical framework for this project.
Bandura (1995) describes self-efficacy as “beliefs in one's capabilities to organize and
execute the course of action required to manage prospective situations” (p. 2). Bandura
(1995) explains that there are 4 processes to self-efficacy: cognitive, motivational,
affective, and selection. The cognitive processes are guided by positive or negative
thoughts that lead to successful or unsuccessful outcomes (Bandura, 1995). Motivational
processes are determined by one’s belief in success (Bandura, 1995). The affective
processes involve stressors that affect motivation (Bandura, 1995). The selection
processes involve people’s environment and how it influences self-efficacy (Bandura,
1995). All four processes affect self-efficacy and thus influence people's motivation for
change (Bandura, 1995). Understanding Bandura’s theory can explain the barriers to selfefficacy and diabetes self-management and hence, the reason why this theory was chosen
for this project.

14

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Chapter 3 Methodology
The sample will consist of patients who present to a rural health clinic for care in
Western Pennsylvania. The sample will be a convenience sample. Inclusion criteria will include
all adult patients, 18 years old or older, who present to a rural health clinic and have been
diagnosed by their primary care provider with Type 2 diabetes. Exclusion criteria include
children under 18 years of age, patients who have never been diagnosed with diabetes, and
patients with Type 1 diabetes.
Patients who meet inclusion criteria and desire to participate will receive informed
consent. The provider will explain informed consent, and the participant will acknowledge they
meet the inclusion criteria and agree to participate by answering yes on the designated consent
form (Appendix A). The project will be described in detail, providing transparency. Informed
consent is outlined and explained that this project is voluntary, participants can withdraw at any
time, and there will not be any repercussions for withdrawing. Upon consent, participants will
acknowledge their consent by verifying the inclusion criteria. The investigator will retain the
consent forms.
Participants will be chosen as they present for an office visit. Data collection will occur
over two months. The provider will direct the patient to take the All-Aspects Health Survey
(AAHLS). This survey will be completed before the office visit. The All Aspects of Health
Literacy Scale (AAHLS) tool measures the three types of health literacy: functional,
communicative, and critical (Chinn & McCarthy, 2011). (Appendix B) The instrument has a
Cronbach alpha of 0.74%, attesting to its reliability (Chinn & McCarthy, 2011). This tool was
chosen because it is one of the only tools that measure the three types of health literacy as

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defined by Nutbeam’s Health Literacy Model, and it is simple to administer (Chinn & McCarthy,
2011). This tool consists of 13 items that are easy to use on a web-based forum or paper
application. Nutbeam’s model identified three health literacy types linked to individual and
social benefits (Rowlands et al., 2015). These benefits can empower patients and are social
determinants of health outcomes (Rowlands et al., 2015).
Functional health literacy refers to reading and writing skills, numeracy, and basic
knowledge regarding health and medical systems (Chinn & McCarthy, 2011). Communicative
health literacy is a social skill that measures the ability to interact and communicate (Chinn &
McCarthy, 2011). Critical skills are measured by one's ability to analyze health information
before making decisions (Chinn & McCarthy, 2011). Once the data from the AAHLS is
collected, it will be recorded and compared for functional, communicative, and critical elements
of health literacy post-intervention. The AAHLS asks participants to rate their responses to the
questions. Some questions are yes/no responses. Some questions ask participants to rate
frequency on a 3-point scale, such as "rarely," "sometimes," and "often." In the functional
literacy category, the tools ask, "How often do you need someone to help you when you are
given information to read by your doctor, nurse, or pharmacist?"; " When you need help, can you
easily get a hold of someone to assist you?"; "Do you need help to fill in official documents?"
(Barsell et al., 2020, p. 121).
Under the Communicative health literacy category, the tool asks, "When you talk to a
doctor or nurse, do you give them all the information about your health?"; "When you talk to a
doctor or nurse, do you ask questions you need to ask?"; and "When you talk to a doctor or
nurse, do you make sure they explain anything you do not understand?" (Barsell et al., 2020, p.
121). Critical health literacy questions include "Are you someone who likes to find out lots of

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different information about your health?"; "How often do you think carefully about whether
health information makes sense in your particular situation?"; "How often do you try to work out
whether information about your health can be trusted?"; "Are you the sort of person who might
question your doctor or nurses' advice based on your own research?" (Barsell et al., 2020, p.
121). The last category the AAHLS addresses is empowerment (Barsell et al., 2020).
Empowerment questions include "Do you think there are plenty of ways to have a say in what
the government does about health?"; "Within the last 12 months, have you taken action to do
something about a health issue?" and "What do you think matters the most for everyone's health?
a. Information and encouragement lead to a healthy lifestyle or
b. Good housing, education, decent jobs, and good local facilities?" (Barsell et al., 2020
p. 121).
There are several limitations to the AAHLS. Utilization of the AAHLS has been limited
in prior research (Barsell et al., 2020). The developers tested the instrument on a population in
England that was primarily Asian with limited English language skills and on a population
lacking diversity (Barsell et al., 2020). The tool has also been faulted for using outdated
techniques in factor analysis (Barsell et al., 2020). However, this tool would be the best suited
for this project. Health literacy is a relatively new and evolving concept. Therefore, there are
limited instruments that would be easy to use in a paper and web-based forum.
Once the data is complete, participants' health literacy responses will be compared to the
Diabetes Management Self-Efficacy pre-educational program (Appendix C). The Diabetes
Management Self-Efficacy scale will be analyzed pre- and post-educational program intervention
for change in diabetes self-management. Although the developers of the AAHLS tool did not
specify what constitutes low health literacy, it was determined for this study that any questions

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involving functional and communicative health literacy categories indicating needing assistance
(sometimes, often, or yes) would be considered in the low health literate category. In addition,
any "no" answers in the critical health literacy category would also constitute meeting the low
health literacy category.
After completion of the AAHLS, the participants will be asked questions to complete the
DMSES-Diabetes Management Self-Efficacy Scale- 20 item measure that evaluates patient’s
confidence in performing self-care tasks with a Cronbach alpha 0.81% (Van der Bijl et al.,
1999). The DMSES is recognized as the most frequently used scale to measure diabetes
management self-efficacy (Messina et al., 2018). The instrument asks participants about specific
self-skills such as whether they check their blood sugar when necessary, correct blood sugars
that are too high or low, manage weight, make good food choices, and follow a diet including
when not at home or with social gatherings, monitor feet, manage diet and medications when ill,
exercise, and taking medication as prescribed (Messina et al., 2018).
According to Lee et al. (2020), in a systematic review of self-efficacy instruments, the
authors identified the DMSES as the best instrument with "high-quality evidence for structural
and internal consistency and sufficient moderate-quality evidence for reliability and convergent
validity" (p. 2). However, the authors acknowledge that none of the instruments evaluated,
including DMSES, measured all of the relevant elements in Bandura's self-efficacy model (Lee
et al., 2020). This instrument was chosen due to its reliability, validity, and ease of use.
The provider will then prompt the participant to review an educational web-based
program (Appendix D). The web-based educational program will contain information outlined
by the Association of Diabetes Care and Education Specialists (ADCES, 2020). This educational
Information, AADE-7, provides a framework that promotes diabetes self-management skills and

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is the foundation diabetes educators use to enhance patients' skills in self-management (ADCES,
2020). AADE-7 offers instruction on diet, exercise, blood sugar monitoring, taking medications,
problem-solving, coping, and risk reduction (ADCES, 2020). The educational information was
written at a Flesch-Kincaid reading level of 7.5 grade or below (Appendix E). According to the
National Institute of Health's "Clear & Simple: Developing Effective Print Materials for LowLiteracy Audiences (2018), it is recommended to either develop educational material 2-3 levels
below your target audience or to develop material for the third to fifth reading level. Emphasis
will be placed on using plain language, visual communication, and large font. Upon completing
the educational activity, the participants will complete the DMSES (Diabetes Management SelfEfficacy Scale) again. The data will be compared for each participant's pre- and post-educational
intervention. Comparisons will be made between AAHLS and DMSES pre- and postintervention for low-health literate participants. Participants will be given a pamphlet at the end
of the surveys that provides them with future access to the web-based educational program
(Appendix F).

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Chapter 4 Results and Discussion
A total of twenty respondents participated in the project. However, eight respondents did
not complete all of the three surveys. Twelve respondents completed all three surveys. The
respondents’ ages ranged from 60-75 years of age. The mean age was 65.9 years. Fifty-eight
percent of the participants were female, and forty-two percent were male. All of the respondents
were Caucasian. All of the respondents met the inclusion criteria. All were over the age of 18
and were diagnosed with Type 2 diabetes. All respondents consented to participation in the
project. The project purpose, participant expectations, the handling of data, and privacy were
addressed with each participant. The participants were informed that the project’s objective was
to contribute to the body of knowledge for patients with diabetes. A convenience sample of an
office in a small, rural primary care clinic was used. Each participant was advised that they may
choose to quit the project at any time. The investigator will receive no monetary or non-monetary
benefit from the project other than completion of doctoral degree requirements.
The respondents initially completed the AAHLS (All Aspects of Health Literacy Scale)
(Appendix B). Health literacy was scored on participants' Functional and Critical Health
Literacy. Functional health literacy refers to reading and writing skills, numeracy, and basic
knowledge regarding health and medical systems (Chinn & McCarthy, 2011). The first three
questions of the AAHLS assessed functional health literacy (Chinn & McCarthy, 2011). Thirtythree to 40% of the respondents acknowledged needing assistance with information provided by
medical providers. Thirty- three of the respondents required assistance in completing documents.
Fifty-eight percent of the respondents felt they could find assistance if needed. It was arbitrarily
established before the initiation of the project that low health literacy would be defined as

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21

answering any of the AAHLS questions indicating deficiencies in either functional,
communicative, critical, or empowerment questions.
For comparison purposes, according to the United States Census Bureau (2022), 92.6%
of McKean County residents have a high school diploma or higher. Nineteen percent of residents
have a bachelor's degree or higher (U.S. Census Bureau, 2020). Ninety-five percent of McKean
County residents are Caucasian (U.S. Census Bureau, 2020). Nearly fifteen percent of McKean
County is under the age of sixty-five and disabled (U.S. Census Bureau, 2020). Twenty-one
percent of the population is over the age of 65 (U.S. Census Bureau, 2020) Almost seven
percent of McKean County is less than sixty-five and uninsured (U.S. Census Bureau, 2020).
None of the participants in this study were college-educated. The majority of the participants
completed a high school education. The convenience sample represented the rural community in
which the project took place.
Communicative health literacy assessment in the AAHLS consists of three questions used
to assess Communicative health literacy. Communicative health literacy is a social skill that
measures the ability to interact and communicate (Chinn & McCarthy, 2011). The respondents
were asked if they gave all the information the doctor, nurse, or pharmacist needed to help them
(Chinn & McCarthy, 2011). The respondents could choose between rarely, occasionally, or
often. One hundred percent of the respondents answered often. The second communicative
question was, "When you talk to your doctor, nurse, or pharmacist, do you ask the questions you
need to ask?" (Chinn & McCarthy, 2011). One hundred percent of the respondents answered
often. The third communicative question asked, "When you talk to your doctor, nurse, or
pharmacist, do you make sure they explain anything you do not understand?” (Chinn &

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22

McCarthy, 2011). Ninety-two percent of the respondents answered often. Eight percent of the
respondents answered sometimes.
The third element of the AAHLS involves critical health literacy. Four questions address
critical health literacy. Critical health literacy is one’s ability to process health information to
formulate appropriate decisions (Chinn & McCarthy, 2011). The first question asks, “Are you
someone who likes to find out lots of different information about your health?” (Chinn &
McCarthy, 2011). Again, respondents may respond often, sometimes, or rarely. This question
resulted in a variety of responses. Forty-two percent of the respondents answered "often ."
Thirty-three percent answered "sometimes," and twenty-five percent answered "rarely."
Critical health literacy question number two asked, "How often do you think carefully
about whether health information makes sense in your situation?". Results in this question varied
as well. Thirty-three percent of the respondents answered "often". Fifty percent answered
“sometimes.” Seventeen percent of the respondents answered "rarely.”
Critical health literacy question number three asks, "How often do you work out whether
information about your health can be trusted?" The respondents could choose the answers: often,
sometimes, or rarely. Thirty-three of the respondents answered "often". Seventeen percent
answered "sometimes", and fifty percent answered “rarely.” Consistently found throughout this
project, critical health literacy in this population is lacking in this population subset. The last
critical health literacy question asks, "Are you the sort of person who might question your doctor
or nurse's advice based on your own research?". The respondents can answer "Yes, definitely,
maybe, sometimes, and not really." Seventeen percent of the respondents answered "Yes,
definitely." Fifty-eight percent of respondents answered "Maybe, sometimes," and twenty-five
percent of respondents answered, "Not really."

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23

After completing the AAHLS, participants were directed to complete the Diabetes SelfManagement Efficacy Scale (Appendix C). The participants then reviewed the diabetes
educational web-based education website. After completing the web-based educational program,
the participants completed the DMSES again. The investigator navigated the web-based
educational program with each participant, ensuring the completion of each educational section.
The DMSES consists of 20 questions relating to the ability to manage their diabetes
(Messina et al., 2018). Table 1 reports the data from the DMSES pre-and post-educational
material.
Table 1
DMSES Pre- and post-educational material
DMSES
Questions

Pre-educational
Website

Post
Educational Website

N
N=12
Y

N

Y

N

1. I am confident that I am able to check my blood
sugar if necessary.

100
%

0

100
%

0

2. I am confident that I am able to correct my blood sugar when
my sugar level is too high.

92%

8%

75%

25%

3. I am confident that I am able to correct my blood sugar when
my sugar level is too low.

92%

8%

100
%

0

4. I am confident that I am able to choose the
correct foods.

100
%

0

92%

8%

5. I am confident that I am able choose different foods
and stick to a healthy eating plan.

83%

17%

92%

8%

6. I am confident that I am able to keep my weight
under control.

92%

8%

75%

25%

7. I am confident I am able to examine my
feet for cuts.

100
%

-0

100
%

0

HEALTH LITERACY AND DIABETES SELF-MANAGEMENT

24

8. I am confident that I am able to take
enough exercise.
83%

17%

92%

8%

100
%

0

100
%

0

10. I am confident that I am able to follow a healthy eating plan
most of the time.

83%

17%

92%

8%

11. I am confident that I am able to take more exercise than the
doctor advises me to.

83%

17%

92%

8%

100
%

0

13. I am confident that I am able to follow a healthy eating plan
when I am away from home.

92%

8%

75%

25%

14. I am confident that I am able to adjust my eating plan when I
am away from home.

92%

8%

67%

33%

15. I am confident that I am able to follow a healthy eating plan
when I am on a holiday.

75%

25%

67%

33%

16. I am confident that I am able to follow a healthy
eating pattern when eating out or at a party.

75%

25%

75%

25%

17. I am confident that I am able to visit my doctor once a year
to monitor my diabetes.

100
%

0

100
%

0

18. I am confident that I am able to adjust my eating plan when
I am feeling stressed or anxious.
.

75%

19. I am confident that I am able to take my
medications as prescribed.

100
%

0

100
%

0

20. I am confident that I am able to adjust my
medication when I am ill.

83%

17%

92%

8%

9. I am confident that I am able to adjust my eating
plan when I am ill.

12. I am confident that when taking more exercise, I am able to
adjust my eating plan.

25%

92%

8%

75%

25%

Diabetes Self-Management Self-Efficacy Scale (Messina et al., 2018)
The results of the pre-post DMSES testing after the web-based educational program was
administered showed eight out of twenty questions in which the participants felt more confident.
Seven questions remained the same, and the participants were less confident in five questions.
Question three asked the participants if they were confident correcting low blood sugar (Messina
et al., 2018). Ninety-two percent answered yes in the pre-DMSES, and one hundred percent
answered yes in the post-DMSES. In question five, the participants were only eighty-three

HEALTH LITERACY AND DIABETES SELF-MANAGEMENT

25

percent confident they could choose different foods and stick to a healthy diet. Post-educational
program, the participants were ninety-two percent confident. Question eight addresses the
participants' confidence to get enough exercise. The participants were eighty-three percent
confident pre-program and ninety-two percent confident post-program. Questions eleven and
twelve also addressed exercise, and the results showed increased confidence after the educational
program. The participants also felt more confident answering question twenty. This question
asked if the participants were confident they could adjust their medication when ill (Messina et
al., 2018). Participant's confidence increased from eighty-three percent to ninety-two percent
after the educational program. Questions that the participants were less confident about include
correcting blood sugar that is too high, choosing the correct foods, keeping weight under control,
and sticking to a diet plan away from home.

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26

Chapter 5 Summary, Conclusions, and Recommendations
The data provided by this project is interesting. It contributes to our body of knowledge
regarding health literacy and self-efficacy in diabetes. However, several confounding variables
limit the project's generalizability. The use of a select, convenience sample is a significant
limitation to the generalizability of the project. The sample consisted of a small subset of
participants, lacking diversity, who received care in a specific primary care rural health clinic.
The sample demographics represented the county census statistics fairly well but lacked diversity
to be generalized to a larger population. In addition, all participants had an established providerpatient relationship with the investigator. It is possible that the participants inaccurately
answered questions in an attempt to please the investigator. It is also possible that the
participants could feel that there could be repercussions for answering accurately. A blind study
would have been more reliable. This was attempted using a strictly web-based project; however,
lack of participation and inaccurate survey answering prohibited this. Unfortunately, the
participants would only complete one or two of the surveys in the web-based format.
There is also bias in this methodology because a single provider may use specific
techniques to educate patients with diabetes that other providers may not. For example, this
provider may discuss the importance of obtaining hemoglobin A1Cs for glycemic control,
whereas other providers may discuss this testing with their patients in less detail. On the basis of
having a single provider could lead to bias in their knowledge of diabetes self-management
skills.
Another limitation pertains to accuracy in answering the surveys due to apathy from form
completion. Despite attempts to choose user-friendly instruments, the participants had to answer

HEALTH LITERACY AND DIABETES SELF-MANAGEMENT

27

fifty-three questions and review seven pages of educational material. This invariably increased
the time of their office visit, and the participants may have wanted to rush through the surveys.
The surveys themselves appeared labor-intensive in this setting. A strictly web-based survey and
educational program would have been ideal if there was interest. There may have been a couple
of reasons for the lack of interest. One reason may have been the need for more confidence in
using the internet, given the age of the study participants. Another reason could have been a
confusing web design.
In addition, there may also be a disconnect between acting on and wanting to change
diabetes outcomes. A repeating theme participants confided during the administration was that
they had the knowledge but were unwilling to change habits that led to improved glycemic
control. Kim et al. (2019), in a qualitative study of health literacy, reported a disconnect in
applying self-management skills despite participants' motivation and learned self-management
techniques. Bandura (1995) defined health literacy as “beliefs in one’s capabilities to organize
and execute the course of action required to manage prospective situations” (p. 2). Apparent in
this project is that the belief in one's capabilities does not equate to being capable of change. The
respondents in this project expressed confidence in their diabetes self-management skills, yet
once educated on diabetes, they felt less confident in several categories. Future research is
paramount to determine how to motivate patients to change their health habits. Future health
literacy instruments should focus on assessing patient empowerment.
The instrument administered to participants in this project answered questions indicating
a deficiency in functional, communicative, critical, or empowering health literacy. All of the
participants met the criteria established for this project for low health literacy. However, this
instrument does not gauge the degree of health illiteracy, and the instruments fall short of

HEALTH LITERACY AND DIABETES SELF-MANAGEMENT

28

addressing more recent definitions of health literacy. According to Lui et al. (2020), in a
systematic review of the meaning of health literacy, the authors acknowledge that the
fundamental basics of health literacy do not address the ability of patients to synthesize health
information to formulate educated decisions regarding their health. In essence, it is not just about
numeracy or communication but more about the ability to process large amounts of information
to improve self-efficacy (Lui et al., 2020). Health care is a complex system to navigate. The
inability to navigate the system leads to poor health outcomes in those with lower health literacy
(Lui et al., 2020). Future research is necessary to provide a quantitative ability to gauge the
degree of health literacy, address broader definitions of health literacy, and study-specific actions
or methods that could be used to improve health literacy. The Healthy People 2030 Initiative has
recognized the need for the healthcare industry to address personal and organizational health
literacy deficiencies to improve health disparities that arise in the current system (Santana et al.,
2021).

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29

References
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Behaviors. https://www.diabeteseducator.org/living-with-diabetes/aade7-self-carebehaviors
Bandura, A. (1995). Self-efficacy in changing societies. Cambridge University Press.
Barsell, J., Everhart, R., & Perrin, P. (2020). Refining the factor structure of the All Aspects
Health Literacy Scale. American Journal of Behavior, 44(2), 118-129.
https://doi.org/10.5993/AJHB.44.2.1
Chinn, D., & McCarthy, C. (2011). All Aspects of Health Literacy Scale (AAHLS): Developing
a tool to measure Functional, Communicative, and Critical Health Literacy in primary
care health settings. Patient Education and Counseling, 90. 247-253.
Department of Health and Human Services. (2010). Action plan to improve health literacy
https://health.gov/sites/default/files/2019-09/Health_Literacy_Action_Plan.pdf
Fang, G., Bailey, S., Annis, I., Paasche-Orlow, M., Wolf, M., Martin, L., Emch, M., Brookhart,
M., & Farris, K. (2020). Effects of estimated community-level health literacy on
treatment initiation and prevention care among older adults with newly diagnosed
diabetes. Patient Preference and Adherence, 14, 1-11.
https://doi.org/10.2147/PPA.5211784
Healthy People 2020. (2020, May 15). Health literacy social determinants of health.
https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinantshealth/interventions-resources/health-literacy

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Jiang, X., Wang, J., Lu, Y., Jiang, H., & Li, M. (2019). Self-efficacy focused education in
persons with diabetes: A systematic review and meta analysis. Psychological Research
and Behavior Management, 12, 67-79. https://doi.org/10.2147/PRBM.S192571
Kim, S., & Lee, A. (2016). Health-literacy-sensitive diabetes self-managment interventions: A
systematic review and meta-analysis. Worldviews on Evidence-Based Nursing, 13(4), 119. https://doi.org/10.1111.wvn.12157
Kim, S., & Utz, S. (2019). Effectiveness of a social media-based, health literacy-sensitive
diabetes self-management intervention: A radomized controlled trial. Journal of Nursing
Scholarship, 51(6), 661-669. https://doi.org/10.1111/jnu.12521
Kim, S., Song, Y., & Park, J. (2019). Patients' experience of diabetes self-management
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Lee, J., Lee, H., & Chae, D. (2020). Self-efficacy instruments for type 2 diabetes self-care:
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76(8), 1-25. https://doi.org/10.1111/jan.14411
Lui, C., Wang, D., Lui, C., Wang, X., Chen, H., Ju, X., & Zhang, X. (2020). What is the
meaning of health literacy? A systematic review and qualitative synthesis. Family
Medicine and Community Health, 2, 1-7. https://doi.org/10.1136/fmch-2020-000351
Messina, R., Rucci, P., Sturt, J., Mancini, T., & Fantini, M. (2018). Assessing self-efficacy
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HEALTH LITERACY AND DIABETES SELF-MANAGEMENT

Appendices

34

HEALTH LITERACY AND DIABETES SELF-MANAGEMENT

35

Appendix A
Jump Start Diabetes:
Consent:
1. I am 18 years of age or older and have Type 2 Diabetes.
Yes
No
2. I understand that this survey is voluntary. The information collected will be used in
a study. My information is anonymous. By answering yes, I agree to participate and
understand I can withdraw at any time during the survey process.
Yes
No

HEALTH LITERACY AND DIABETES SELF-MANAGEMENT

36

Appendix B

AAHLS Questionnaire
1.

How often do you need someone to help you when you are given information to
read by your doctor, nurse, or pharmacist?
Often
Sometimes
Rarely

2.

When you need help, can you easily get a hold of someone to assist you?
Often
Sometimes
Rarely

3. Do you need help to fill in official documents?
Often
Sometimes
Rarely
4. When you talk to a doctor or nurse, do you give them all the information they
need to help you?
Often
Sometimes
Rarely
5. When you talk to a doctor or nurse, do you ask the questions you need to ask?
Often

HEALTH LITERACY AND DIABETES SELF-MANAGEMENT

37

Sometimes
Rarely
6. When you talk to a doctor or nurse, do you make sure they explain anything you
do not understand?
Often
Sometimes
Rarely
7.

Are you someone that likes to find out lots of different information about your
health?
Often
Sometimes
Rarely

8. How often do you think carefully about whether health information makes sense
in your particular situation?
Often
Sometimes
Rarely
9. How often do you try to work out whether information about your health can be
trusted?
Often
Sometimes
Rarely

HEALTH LITERACY AND DIABETES SELF-MANAGEMENT

38

10. Are you the sort of person who might question your doctor’s or nurse’s advice
based on your own research?
Yes, definitely.
Sometimes, maybe
Not really
11. Do you think there are plenty of ways to have a say in what the government does
about health?
Yes, definitely.
Sometimes, maybe
Not really
12. In the past 12 months, have you taken action to do something about a health
issue that effects your family or community?
Yes
No
13. What do you think matters most for everyone’s health?
a. Information and encouragement to lead to healthy lifestyles.
b. Good housekeeping, education, decent jobs, and good local facilities

HEALTH LITERACY AND DIABETES SELF-MANAGEMENT

39

Appendix C
DMSES Questionnaire
1.

I am confident I am able to check my blood sugar if necessary.
Yes
No

2.

I am confident that I am able to correct my blood sugar when my sugar level is too
high.
Yes
No

3. I am confident that I am able to correct my blood sugar when my sugar level is too
low.
Yes
No
4. I am confident that I am able to choose the correct foods.
Yes
No
5. I am confident that I am able to choose different foods and stick to a healthy eating
pattern.
Yes
No
6. I am confident that I am able to keep my weight under control.
Yes
No

HEALTH LITERACY AND DIABETES SELF-MANAGEMENT

40

7. I am confident that I am able to examine my feet for cuts.
Yes
No
8. I am confident that I am able to take enough exercise.
Yes
No
9. I am confident that I am able to adjust my eating plan when I am ill.
Yes
No
10. I am confident that I am able to follow a healthy eating plan most of the time.
Yes
No
11. I am confident that I am able to take more exercise than the doctor advises me to.
Yes
No
12. I am confident that when taking more exercise, I am able to adjust my eating plan.
Yes
No
13. I am confident that I am able to follow a healthy eating plan when I am away from
home.
Yes
No
14. I am confident that I am able to adjust my eating plan when I am away from home.

HEALTH LITERACY AND DIABETES SELF-MANAGEMENT

41

Yes
No
15. I am confident that I am able to follow a healthy eating plan when I am on a
holiday.
Yes
No
16. I am confident that I am able to follow a healthy eating pattern when I am eating
out or at a party.
Yes
No
17. I am confident that I am able to visit my doctor once a year to monitor my diabetes.
Yes
No
18. I am confident that I am able to adjust my eating plan when I am feeling stressed or
anxious.
Yes
No
19. I am confident that I am able to take my medications as prescribed.
Yes
No
20. I am confident that I am able to adjust my medications when I am ill.
Yes
No

HEALTH LITERACY AND DIABETES SELF-MANAGEMENT

Appendix D
Link to web-based educational program

www.jumpstartdiabetes.org

42

HEALTH LITERACY AND DIABETES SELF-MANAGEMENT
Appendix E
Flesch-Kincaid Results for web-based educational program

43

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44

Appendix F

Type 2 Diabetes
An educational brochure
The website may be accessed at
www.jumpstartdiabetes.org

AADE 7
Healthy Eating:
A healthy eating plan is a personal plan that promotes weight loss, low calories and low in
fats.
Exercise:
Exercise for weight loss and improve heart function.
Monitoring:
Monitor blood sugar by self-glucose monitoring and lab work to improve diabetes control.
Routine vision checks and foot care.
Medications:
Take medications regularly to improve blood sugar control.
Problem Solving:
Knowing how to manage high and low blood sugar levels.

HEALTH LITERACY AND DIABETES SELF-MANAGEMENT

45

Coping:
Learn to reduce stress.
Reduce Risks:
Keep blood sugar levels under control to prevent heart disease, stroke, kidney disease and
blindness.
Reference
Association of Diabetes Care and Specialists (n.d.), AADE7 Self-care behaviors. (2020).
Retrieved from Association of Diabetes Care and Education & Education Specialists :
https://www.diabeteseducator.org/living-with-diabetes/aade7-self-care-behaviors