title: Mechanisms underlying the relationship between health literacy and glycemic control in American Indians and Alaska Natives.
abstract: 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.
  
  
  CONCLUSIONS
  Interventions to improve knowledge may be particularly important in enhancing outcomes among AI/ANs with diabetes.
  
  
  CONCLUSIONS
  Strategies known to enhance patient comprehension may enable low-literate patients to develop needed diabetes knowledge.
authors.affiliation: Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA. angela.brega@ucdenver.edu
authors.forename: Angela G
authors.initials: AG
authors.lastname: Brega
authors.forename: Alfonso
authors.initials: A
authors.lastname: Ang
authors.forename: William
authors.initials: W
authors.lastname: Vega
authors.forename: Luohua
authors.initials: L
authors.lastname: Jiang
authors.forename: Janette
authors.initials: J
authors.lastname: Beals
authors.forename: Christina M
authors.initials: CM
authors.lastname: Mitchell
authors.forename: Kelly
authors.initials: K
authors.lastname: Moore
authors.forename: Spero M
authors.initials: SM
authors.lastname: Manson
authors.forename: Kelly J
authors.initials: KJ
authors.lastname: Acton
authors.forename: Yvette
authors.initials: Y
authors.lastname: Roubideaux
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000413:Alaska; D001786:Blood Glucose / Q000032:analysis*; D003924:Diabetes Mellitus, Type 2 / Q000208:ethnology / Q000628:therapy*; D005260:Female; D015438:Health Behavior; D007722:Health Knowledge, Attitudes, Practice; D057220:Health Literacy; D006801:Humans; D007198:Indians, North American / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D008962:Models, Theoretical; D012307:Risk Factors; D012959:Socioeconomic Factors; D011795:Surveys and Questionnaires
chemical_list: D001786:Blood Glucose