title: A Structural Equation Model Linking Health Literacy to Self-efficacy, Self-care Activities, and Health-related Quality of Life in Patients with Type 2 Diabetes.
abstract: OBJECTIVE
  Health literacy has been attracting increasing attention because low health literacy is considered an important predictor of adverse health outcomes in many chronic conditions, including diabetes. However, it is unclear how health literacy is associated with health outcomes. The purpose of this study was to formulate a hypothetical structural equation model linking health literacy to self-efficacy, self-care activities, and health-related quality of life (HRQOL) in patients with type 2 diabetes.
  
  
  METHODS
  A cross-sectional survey design was employed, and 459 patients with type 2 diabetes were recruited from outpatient clinics in two university hospitals. The patients completed a pack of questionnaires. The hypothetical model was tested using structural equation modeling analysis.
  
  
  RESULTS
  The values of multiple fit indices indicated that the proposed model provided a good fit to the data. Health literacy exerted not only a direct effect on self-care activities, but also an indirect effect on self-care activities via self-efficacy. However, health literacy exerted only an indirect effect on HRQOL. This structural model was invariant across hemoglobin-A1c-controlled and hemoglobin-A1c-uncontrolled groups. Based on R(2) values, the final model accounted for 20.0% of the variance in self-efficacy, 61.0% of the variance in self-care activities, and 16.0% of the variance in HRQOL.
  
  
  CONCLUSIONS
  This study suggests that self-care activities are crucial to the link between health literacy and HRQOL. Both health literacy and self-efficacy need to be considered in clinical practice for enhancing self-care activities in patients with type 2 diabetes. This approach may ultimately improve HRQOL in these patients.
authors.affiliation: Graduate School of Public Health, Ajou University, Suwon, South Korea. Electronic address: ehlee@ajou.ac.kr.
authors.forename: Eun-Hyun
authors.initials: EH
authors.lastname: Lee
authors.affiliation: Department of Nursing, Inha University, Incheon, South Korea.
authors.forename: Young Whee
authors.initials: YW
authors.lastname: Lee
authors.affiliation: Department of Nursing, Graduate School, Inha University, Incheon, South Korea.
authors.forename: Seung Hei
authors.initials: SH
authors.lastname: Moon
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003430:Cross-Sectional Studies; D003924:Diabetes Mellitus, Type 2 / Q000451:nursing* / Q000523:psychology*; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D057220:Health Literacy; D006801:Humans; D008297:Male; D008875:Middle Aged; D008962:Models, Theoretical; D011788:Quality of Life / Q000523:psychology*; D056910:Republic of Korea; D012648:Self Care / Q000523:psychology*; D020377:Self Efficacy; D011795:Surveys and Questionnaires; D055815:Young Adult
keywords: diabetes mellitus, type 2; health literacy; quality of life; self care; self efficacy