title: Improved self-management skills in Chinese diabetes patients through a comprehensive health literacy strategy: study protocol of a cluster randomized controlled trial.
abstract: BACKGROUND
  Diabetes self-management often involves the interpretation and application of oral, written, or quantitative information. Numerous diabetes patients in China have limited health literacy, which likely leads to poorer clinical outcomes. This study is designed to examine the efficacy and cost-effectiveness of addressing health literacy to improve self-management skills and glycemic control in Chinese diabetes patients.
  
  
  METHODS
  This is a cluster randomized controlled trial (RCT) conducted in 20 community healthcare sites in Shanghai, China. Overall, 800 diabetes patients will be randomized into intervention and control arms and will have a baseline hemoglobin A1c (HbA1c) assay and undergo a baseline survey which includes measures of health literacy and diabetes numeracy using revised Chinese versions of the Health Literacy Management Scale and Diabetes Numeracy Test Scale. During the 1-year period of intervention, while the control group will receive usual care, the intervention group will be supplemented with a comprehensive health literacy strategy which includes i) training healthcare providers in effective health communication skills that address issues related to low literacy, and ii) use of an interactive Diabetes Education Toolkit to improve patient understanding and behaviors. Assessments will be conducted at both patient and healthcare provider levels, and will take place upon admission and after 3, 6, 12, and 24 months of intervention. The primary outcome will be the improvement in HbA1c between Intervention group and Control group patients. Secondary outcomes at the patient level will include improvement in i) clinical outcomes (blood pressure, fasting lipids, body mass index, weight, smoking status), ii) patient reported self-management behaviors, and iii) patient-reported self-efficacy. Outcomes at the provider level will include: i) provider satisfaction and ii) intensity and type of care provided. The effects of the intervention will be examined in multivariable general linear models. Both cost-effectiveness and cost-utility analyses will be performed.
  
  
  CONCLUSIONS
  The main strengths of this study are its large sample size and RCT design, involvement of both patients and healthcare providers, and the long term follow-up (24-months). This project will help to demonstrate the value of addressing health literacy and health communication to improve self-management and clinical outcomes among Chinese diabetes patients.
  
  
  BACKGROUND
  ISRCTN76130594, Registration date: Sept 22, 2014.
authors.affiliation: Department of Epidemiology, School of Public Health and Key Laboratory of Public Health Safety, Ministry of Education, Fudan University, 138 Yi Xue Yuan Road, Shanghai 200032, China. wanghong.xu@fudan.edu.cn.
authors.forename: Wang Hong
authors.initials: WH
authors.lastname: Xu
authors.forename: Russell L
authors.initials: RL
authors.lastname: Rothman
authors.forename: Rui
authors.initials: R
authors.lastname: Li
authors.forename: Yingyao
authors.initials: Y
authors.lastname: Chen
authors.forename: Qinghua
authors.initials: Q
authors.lastname: Xia
authors.forename: Hong
authors.initials: H
authors.lastname: Fang
authors.forename: Junling
authors.initials: J
authors.lastname: Gao
authors.forename: Yujie
authors.initials: Y
authors.lastname: Yan
authors.forename: Peng
authors.initials: P
authors.lastname: Zhou
authors.forename: Yu
authors.initials: Y
authors.lastname: Jiang
authors.forename: Yinan
authors.initials: Y
authors.lastname: Liu
authors.forename: Fangjia
authors.initials: F
authors.lastname: Zhou
authors.forename: Wei
authors.initials: W
authors.lastname: Wang
authors.forename: Minling
authors.initials: M
authors.lastname: Chen
authors.forename: Xiao Yu
authors.initials: XY
authors.lastname: Liu
authors.forename: Xiao Na
authors.initials: XN
authors.lastname: Liu
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D044466:Asian People / Q000523:psychology*; D015415:Biomarkers / Q000097:blood; D001786:Blood Glucose / Q000187:drug effects / Q000378:metabolism; D002985:Clinical Protocols; D003153:Community Health Services; D003362:Cost-Benefit Analysis; D003920:Diabetes Mellitus / Q000097:blood / Q000175:diagnosis / Q000191:economics / Q000208:ethnology / Q000523:psychology / Q000628:therapy*; D005260:Female; D006442:Glycated Hemoglobin / Q000378:metabolism; D015438:Health Behavior / Q000208:ethnology; D017048:Health Care Costs; D007722:Health Knowledge, Attitudes, Practice / Q000208:ethnology*; D057220:Health Literacy / Q000191:economics; D006801:Humans; D008297:Male; D008875:Middle Aged; D010353:Patient Education as Topic / Q000191:economics; D012107:Research Design; D012648:Self Care / Q000191:economics / Q000523:psychology*; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D015415:Biomarkers; D001786:Blood Glucose; D006442:Glycated Hemoglobin; C517652:hemoglobin A1c protein, human