Communication Study
Health communication, self-care, and treatment satisfaction among low-income diabetes patients in a public health setting

https://doi.org/10.1016/j.pec.2014.10.019Get rights and content

Highlights

  • Poor health communication (HC) may influence diabetes care for patients with limited resources.

  • We examined the association of HC with select diabetes factors for patients in a safety-net system in TN.

  • Predictors included self-reports of provider communication using validated measures.

  • Better communication was associated with lower medication non-adherence and higher treatment satisfaction.

  • Communication quality may be an important modifiable strategy for improving diabetes care for vulnerable populations.

Abstract

Objective

Diabetes patients with limited resources often experience suboptimal care. Less is known about the role of effective health communication (HC) in caring for low income diabetes patients.

Methods

Ten health department clinics in TN participated in a trial evaluating a literacy-sensitive communication intervention. We assessed the quality of baseline HC and measured associations with diabetes outcomes. Assessments included: demographics, measures of HC, health literacy, self-care behaviors, self-efficacy, medication non-adherence, treatment satisfaction, and A1C. Unadjusted and adjusted multivariable regression models were used to test associations.

Results

Participants (N = 411) were 49.7 ± 9.5 years, 61% female, uninsured (96%), with A1C 9.6 ± 2.1. In unadjusted analyses, better communication, was associated with lower medication non-adherence (OR 0.40–0.68, all p < 0.05), higher treatment satisfaction (OR 1.76–1.96, all p < 0.01), portion size reduction (OR 1.43, p < 0.05), diabetes self-efficacy (OR 1.41, p < 0.05), and lower A1C (β = −0.06, p < 0.01). In adjusted analyses, communication quality remained associated with lower medication non-adherence (AOR 0.39–0.68, all p < 0.05), and higher treatment satisfaction (AOR 1.90–2.21, all p < 0.001).

Conclusions

Better communication between low-income patients and providers was independently associated with lower medication non-adherence and higher treatment satisfaction.

Practice Implications

Communication quality may be an important modifiable approach to improving diabetes care for vulnerable populations.

Introduction

Approximately 26 million people in the US have been diagnosed with diabetes, placing them at increased risk for the many untoward complications of poor control [1]. Often, minority diabetes patients and those with limited resources face disproportionate challenges such as greater barriers to access, poorer health outcomes, and increased burden of disease [2]. Many of these patients seek care in public healthcare settings, where despite strong evidence about the optimal treatment of diabetes, care often remains suboptimal [2], [3], [4], [5]. Unfortunately, national efforts to achieve benchmarks in quality of care for these groups continue to fall short [6], [7].

Ineffective health communication between patients and providers in public healthcare settings may contribute to suboptimal care. Providers in these settings often report time constraints, challenge to continuity of caring for patients, and greater limitations of staffing and resources, compared to private settings [8], [9], [10]. Additionally, patient factors such as limitations in health literacy and diabetes-specific numeracy (i.e. computational) skills may potentiate existing challenges to effective health communication when attempting to provide care for vulnerable populations [11], [12]. Low health literacy and diabetes numeracy are recognized barriers to adequate diabetes care [13], [14]. We have conducted several studies among both English and Spanish-speaking diabetes patients that have identified moderate to high prevalence of limited functional health literacy and numeracy skills [15], [16], [17], [18], [19], [20]. We have also shown these limitations to be significantly associated with several diabetes-related factors such as poorer self-efficacy for self-management, less diabetes knowledge, worse medication adherence, and poorer glycemic control [15], [17], [18], [19], [20], [21], [22], [23], [24], [25]. Although patients with limited literacy and numeracy skills may experience poorer communication with their provider [26], less is known about the specific relationship between the patient–provider interaction and diabetes related outcomes; and current evidence has been shown to be of mixed quality as supported by a recent systematic review [13].

Academic and community partnerships may be an effective model for improving communication in healthcare and addressing disparities of diabetes care for underserved populations [27], [28]. The aims of this article therefore seek to address two specific research questions based on assessment of baseline data from a larger clinical trial occurring within the context of an academic-community partnership: (1) What is the perception of the quality of communication during clinical encounters by diabetes patients seeking care in a public health department setting?, and (2) What is the association among patients’ perception of the quality of communication and reports of self-care behaviors, treatment satisfaction, self-efficacy, and glycemic control?

Section snippets

Study setting and patients

In 2010 we established a partnership between an academic medical center and a regional health department in Tennessee whose state diabetes prevalence that year was high at 10.2% compared to the national average of 8.3% [1], [29]. The PRIDE Study (Partner to Improve Diabetes Education) is a prospective, cluster randomized-controlled trial designed to address health communication issues and develop a sustainable model for improving diabetes care in our region that includes both urban and rural

Results

From July 2011 through August 2013, 573 patients were approached. One hundred and sixty-two patients either declined participation or were deemed ineligible; 411 patients were consented and enrolled. Three participants were excluded from this analysis as we focused on those individuals who self-identified as Non-Hispanic White, Non-Hispanic Black, or Hispanic/Latino, resulting in a final sample size of 408 participants (Fig. 1). We observed that on average, participants were middle aged,

Discussion

In this sample of predominantly uninsured, low-income, diabetes patients, we observed significant associations between patient's perceptions of the quality of provider communication and several diabetes-related outcomes. Communication quality in this study was reflective of the provider's ability to communicate clearly, effectively elicit patient concerns, explain results of laboratory and exam findings, involve the patient in decision making, spend adequate time with the patient, and

Conflict of interest

No author has any conflicts of interest to report. ROW is supported by a NIDDK Career Development Award (05DK092470)

Acknowledgments

The authors would like to thank the administration, staff, and patients at the Middle TN Department of Health system for their collaboration in the PRIDE program. We thank the staff at the Mayo Clinic Florida Office of Academic and Research Support for helpful input on later drafts. ROW is supported by a NIDDK Career Development Award (05DK092470). The project described was supported by the following grants: NIDDK, 5R18 DK083264 and Vanderbilt University CTSA, 5UL1TR000445. Study data were

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