Curtis Laura M, Davis Terry C, Arnold Connie L, Gan Jennifer M, McSweeney Jean C, Hur Scott, Kwasny Mary J, Wolf Michael S, Hadden Kristie
Division of General Internal Medicine, Northwestern University Feinberg School of Medicine,Chicago, Illinois, USA.
Department of Medicine and Feist-Weiller Cancer Center, Louisiana State University Health Shreveport, Shreveport, Louisiana, USA.
Health Lit Commun Open. 2024;2(1). doi: 10.1080/28355245.2024.2382133. Epub 2024 Jul 25.
Adults with diabetes mellitus (DM) living in rural areas often face limited access to medical and specialist care, minimal exposure to diabetes education, and transportation challenges. Rural residents also tend to be older, poorer, less educated, under-insured and have lower health literacy compared to their urban counterparts.
We tested the effectiveness of the American College of Physicians (ACP) diabetes health literacy intervention in rural community clinics to improve a range of diabetes-related patient outcomes and determine whether the intervention reduces disparities by health literacy.
We recruited 756 English-speaking adults with uncontrolled Type 2 DM from rural clinics in Arkansas. Trained health coaches reviewed the ACP Diabetes Guide and conducted counseling and action-planning monthly to participants randomized to the intervention. The enhanced usual care (EUC) arm received an American Diabetes Association workbook and was followed as usual. Interviews were conducted at baseline, 3 and 6 months, and clinical outcomes, including hemoglobin A1C and blood pressure values, were extracted from charts through 12 months post-baseline. Health literacy was measured at baseline using the Newest Vital Sign (NVS). Our primary outcome was A1C at 6 months, with other clinical values and self-reported diabetes-related knowledge, self-efficacy, distress, and self-care behaviors examined as secondary outcomes.
Participants had a mean age of 55.8 (SD=11.7), 68% were female, two-thirds had an annual household income <$15,000, and 52% had limited health literacy. Overall, the intervention had little effect on outcomes at 6 and 12 months, including our primary outcome of A1C at 6 months (Intervention Least Squared Means (LSM) 8.28, 95% CI 8.11, 8.46; EUC LSM 8.44, 95% CI 8.26, 8.61). Diabetes knowledge was greater in those with adequate (LSM 9.46, 95% CI 9.25, 9.67) compared to those with limited health literacy (LSM 8.11, 95% CI 7.91, 8.23, p<0.001) at baseline. This disparity remained in the EUC arm after 6 months but disparities were mitigated in the intervention arm (interaction p<0.001).
Our intensive intervention was well received, but insufficient to improve outcomes. Strategies may need to attend to other barriers faced by rural patients beyond health literacy to improve health behaviors and outcomes.
生活在农村地区的成年糖尿病患者往往面临获得医疗和专科护理的机会有限、接受糖尿病教育的机会极少以及交通不便等问题。与城市居民相比，农村居民往往年龄更大、更贫困、受教育程度更低、保险不足且健康素养较低。
我们测试了美国医师协会（ACP）糖尿病健康素养干预措施在农村社区诊所的有效性，以改善一系列与糖尿病相关的患者结局，并确定该干预措施是否能减少健康素养方面的差异。
我们从阿肯色州的农村诊所招募了756名英语口语能力良好且2型糖尿病控制不佳的成年人。经过培训的健康教练会查阅《ACP糖尿病指南》，并每月为随机分配到干预组的参与者进行咨询和制定行动计划。强化常规护理（EUC）组收到一本美国糖尿病协会的工作手册，并按常规方式随访。在基线、3个月和6个月时进行访谈，并从基线后12个月的病历中提取临床结局，包括糖化血红蛋白和血压值。在基线时使用最新生命体征（NVS）测量健康素养。我们的主要结局是6个月时的糖化血红蛋白，其他临床值以及自我报告的糖尿病相关知识、自我效能感、痛苦和自我护理行为作为次要结局进行检查。
参与者的平均年龄为55.8岁（标准差=11.7），68%为女性，三分之二的家庭年收入低于15,000美元，52%的健康素养有限。总体而言，该干预措施在6个月和12个月时对结局影响不大，包括我们6个月时的主要结局糖化血红蛋白（干预组最小二乘均值（LSM）8.28，95%置信区间8.11，8.46；EUC组LSM 8.44，95%置信区间8.26，8.61）。在基线时，健康素养充足的人（LSM 9.46，95%置信区间9.25，9.67）的糖尿病知识比健康素养有限的人（LSM 8.11，95%置信区间7.91，8.23，p<0.001）更多。6个月后，这种差异在EUC组中仍然存在，但在干预组中差异有所减轻（交互作用p<0.001）。
我们的强化干预措施受到好评，但不足以改善结局。可能需要采取策略来解决农村患者除健康素养之外面临的其他障碍，以改善健康行为和结局。
