Does Literacy Mediate the Relationship between Education and Health Outcomes? A Study of a Low-Income Population with Diabetes

• Published in: Public health reports (1974) Vol. 121; no. 3; pp. 245 - 254
• Main Authors: Schillinger, Dean, Barton, Lauren R., Karter, Andrew J., Wang, Frances, Adler, Nancy
• Format: Journal Article
• Language: English
• Published: Los Angeles, CA Association of Schools of Public Health 01.05.2006; SAGE Publications
• Subjects: Biological and medical sciences; Diabetes; Diabetes complications; Diabetes Mellitus - blood; Diabetes. Impaired glucose tolerance; Education; Educational attainment; Educational Status; Endocrine pancreas. Apud cells (diseases); Endocrinopathies; Etiopathogenesis. Screening. Investigations. Target tissue resistance; Glycemic Index; Health literacy; Health outcomes; Health Status; Humans; Insurance, Health; Literacy; Male; Medical sciences; Middle Aged; Miscellaneous; Modeling; Models, Biological; Poverty; Public health; Public health. Hygiene; Public health. Hygiene-occupational medicine; San Francisco; Surveys and Questionnaires; Type 2 diabetes mellitus; San Francisco; Endocrinopathy; Human; Poverty; Prognosis; Socioeconomic status; Diabetes mellitus; Personal income; Income; Evolution; Health education; Literacy; Public health
• ISSN: 0033-3549; 1468-2877
• DOI: 10.1177/003335490612100305

Objectives: We sought to determine whether literacy mediates the relationship between education and glycemic control among diabetes patients. Methods: We measured educational attainment, literacy using the Short Test of Functional Health Literacy in Adults (s-TOFHLA), and glycemic control (HbA1c) in 395 diabetes patients at a U.S. public hospital. We performed path analysis to compare two competing models to explain glycemic control. The direct effects model estimated how education was related to HbA1c; the mediational model estimated the strength of the direct relationship when the additional pathway from education to literacy to HbA1c was added. Results: Both the model with a direct effect of education on HbA1c and the model with literacy as a mediator were supported by good fit to observed data. The mediational model, however, was a significant improvement, with the additional path from literacy to HbA1c reducing the discrepancy from observed data (p&lt0.01). After including this path, the direct relationship between education and HbA1c fell to a non-significant threshold. Conclusions: In a low-income population with diabetes, literacy mediated the relationship between education and glycemic control. This finding has important implications for both education and health policy.