Tailor diabetes education to improve outcomes in Hispanic adults.

PATIENT SAFETY STARTS by providing all patients with the ability to understand their health and feel confident in managing it. For example, type 2 diabetes requires quick and accurate interpretation of health information and the ability to follow instructions for daily glucose monitoring, symptom assessment, insulin timing, carbohydrate counting, medication preparation, and appointment scheduling. As noted by Sarkar and colleagues, limited health literacy can interfere with patients’ understanding of diabetes medication instructions, including dosing, timing, and warnings, increasing their vulnerability to medication errors and serious hypoglycemia, potentially compromising patient safety. This is especially true for populations at risk for diabetes and facing barriers to health literacy, including some Hispanic adults. (See Diabetes in Hispanic adults.)

Nurses’ knowledge of these risks and barriers can help ensure patients receive appropriate education that allows them to manage their condition in the context of their cultural needs and improve health outcomes.

The role of health literacy

Healthy People 2030 defines health literacy as a patient’s ability to find, understand, and use health information to make educated decisions about their care. Health literacy involves more than reading. It includes numeracy, communication, cultural knowledge, and healthcare system navigation.

Mann and colleagues and Schillinger and colleagues found an association between limited health literacy and poorer diabetes outcomes, communication barriers, misunderstandings, and preventable safety risks. All of these factors play a role in hyperglycemia, hypoglycemia, and avoidable complications.

Brega and colleagues emphasize that health literacy is both an individual and an organizational responsibility. In addition to supporting patients in accessing care and information, clinicians and health systems also must frame that information in ways patients can understand, use, and act on with confidence. Healthy People 2030 makes attaining health literacy an overarching goal and includes objectives to improve patient–provider communication, confirm patient understanding, support shared decision-making, improve communication for adults with limited English proficiency, and increase population health literacy. The National Action Plan to Improve Health Literacy complements these objectives with seven goals, including making health information accurate, accessible, and actionable; improving communication and informed decision-making within healthcare systems; expanding culturally and linguistically appropriate community service; and increasing the use of evidence-based health literacy practices.

Hernandez and colleagues emphasize that language barriers and limited access to culturally appropriate education contribute to many care disparities, including among some Hispanic adults with type 2 diabetes. Caballero, Plasencia and colleagues, and Pignotti and colleagues note the culture-specific dietary preferences of many Hispanic patients as playing a role in diabetes care. Food strongly tied to culture, family, and unity within the Hispanic community include tortillas, rice, and beans, all typically high in carbohydrates and cause for concern among patients with type 2 diabetes.

Culturally tailored education

Orzech and colleagues and Torres and colleagues describe how culturally tailored diabetes education improves understanding and self-management behaviors among Hispanic adults. Providing patients with broad diabetes guidelines and then expecting them to match that information with their cultural norms can lead to misunderstanding.

Brega and colleagues and Healthy People 2030 emphasize the need to offer understandable, culturally appropriate, and actionable health information. For example, patients may have questions regarding carbohydrate counting and insulin dosing based on their meal choices. Without appropriate education, patients may inaccurately count carbohydrates and administer the wrong dose of medication, which can lead to dangerous blood glucose levels.

Orzech and colleagues and Torres and colleagues note that providing individualized diabetes self-management education to Hispanic adults that incorporates culture-specific foods and uses cultural examples leads to better diabetes self-care behaviors and glycemic control.

Structured support

Mann and colleagues found that Hispanic adults with limited health literacy were more than twice as likely to experience microvascular and macrovascular complications as those with higher health literacy. Although this study didn’t measure misunderstandings directly (for example, reading nutrition labels or timing of insulin), limited health literacy appears to correlate with worse self-management practices and overall risk for negative outcomes.

Health literacy and safe diabetes care are connected by the assumption that patients will read and act upon health information multiple times daily. As discussed by Mann and colleagues and Schillinger and colleagues, correct insulin dosing and carbohydrate counting, as well as symptom recognition, require accurate interpretation. The same researchers note that low health literacy can make routine diabetes self-management more difficult and increase the risk of preventable complications.

Evidence from intervention studies shows that comprehension can be improved with structured, health literacy–focused support. Houts and colleagues describe pictorial aids as a strategy for people with limited general literacy, while Hu and colleagues studied diabetes knowledge among Hispanic adults with type 2 diabetes using the Spoken Knowledge in Low Literacy in Diabetes (SKILLD) scale, a nurse-administered tool used to assess a patient’s knowledge about diabetes. In practice, pictograph-supported diabetes education might pair a simple picture of a tortilla, rice, beans, or another familiar food with the corresponding carbohydrate portion, or use a visual sequence showing when to check glucose and administer insulin. The nurse can review one image at a time, use plain language in the patient’s preferred language, and then use teach-back or show-me to confirm understanding.

Assessing. Health literacy–responsive education can help clinicians recognize when patients may have difficulty understanding health information, allowing them to adjust their teaching accordingly. Hu and colleagues highlighted the importance of assessing diabetes knowledge.

Hu and colleagues went on to examine health literacy among Hispanic adults with type 2 diabetes specifically, highlighting the value of health literacy assessment when providing diabetes education and describing the use of the SKILLD scale to identify patients who may need additional support. The Newest Vital Sign (NVS) tool also can help identify possible health literacy limitations and guide the level and format of education.

Teaching. To tailor teaching to their patients’ needs, nurses can use plain language, pictorial aids, teach-back, and culturally appropriate education. Indeed, Houts and colleagues support the use of pictorial communication.

At the system level, AHRQ recommends universal health literacy precautions, including clear communication, visual support, qualified interpreters, and confirmation of understanding. To help reduce misunderstandings and promote safer care, these practices can be integrated into routine diabetes care rather than as a task left to individual clinicians.

Emergency department use

According to Schillinger and colleagues and Hernandez and colleagues, patients with limited health literacy may experience lower quality patient–provider communication. For example, providers may not consistently explain information clearly, check understanding, invite questions, or involve patients in decisions, leaving patients challenged to adhere to medication instructions and recognize when symptoms require action.

These concerns can contribute to preventable ED use among people with diabetes. The significance for Hispanic adults is that health literacy challenges may intersect with limited English proficiency, culturally incongruent education, and barriers to accessing appropriate follow-up care. All of which increase the likelihood that early symptoms or self-management issues go unaddressed until they become urgent.

Nurses can use organizational ED usage data to identify recurrent diabetes-related visits, stratify patterns by preferred language or other relevant demographic variables when appropriate, and target high-risk transitions with interpreter services, teach-back, medication reconciliation, culturally responsive education, and timely outpatient or Diabetes Self-Management Education and Support (DSMES) referrals.

AHRQ and Santana and colleagues emphasize the role nurses play in promoting patient safety through health literacy best practices. Practical, nonjudgmental approaches, such as teach-back, can help nurses verify comprehension and prevent medication and self-care errors.

Teach-back

AHRQ describes teach-back as an evidence-based health literacy intervention aimed at promoting patient safety and engagement. This approach can help nurses verify comprehension and prevent medication and self-care errors. A systematic review by Yen and Leasure found that teach-back improves patient understanding across clinical contexts, and diabetes communication research by Schillinger and colleagues has linked teach-back with improved self-care confidence and lower hospitalization risk for ambulatory care–sensitive conditions, including type 2 diabetes.

Although Len and Leasure’s teach-back research focused on general populations and not exclusively on Hispanic adults with type 2 diabetes, many within this population experience higher rates of health literacy, language, and self-management challenges. These challenges can increase the risk of misunderstandings and preventable harm, which could be addressed through teach-back.
According to AHRQ, using the teach-back method with Hispanic adults managing type 2 diabetes, particularly those who prefer Spanish or have limited health literacy, helps nurses identify misunderstandings about insulin timing, sliding-scale dosing, nutrition labels, and foot-care instructions before preventable harm occurs.

Culture and language in safety

Many teaching and knowledge gaps that lead to safety concerns involve important cultural components. Caballero and Hernandez and colleagues describe how cultural, language, and social barriers affect diabetes self-management among Hispanic adults. For example, some Hispanic adults prefer and rely on family decision-making, have specific food traditions, and may experience hesitancy or embarrassment when asking questions.

Orzech and colleagues’ randomized controlled trial with Hispanic adults with low health literacy found that culturally tailored diabetes education programs increased motivation, improved self-management behaviors, and strengthened patient readiness to take health actions. The authors concluded that when education was culturally congruent and included familiar food, culturally meaningful scenarios, and family-centered strategies, patients were more likely to ask questions, contact their healthcare team, or seek appropriate follow-up promptly, before a self-management problem could progress to a more serious complication or require emergency care.

Community-based research also has focused on culturally tailored diabetes education. Torres and colleagues found that culturally responsive nutrition education—using local foods and cooking demonstrations—helped Hispanic adults improve their knowledge of diabetes management and reduce fear of dietary changes, potentially contributing to improved self-management.

Nursing implications

Nurses can improve safety for Hispanic patients with type 2 diabetes by implementing health literacy best practices at every bedside education encounter. Use teach-back to confirm understanding of instructions before discharge or high-risk tasks such as insulin administration or glucose monitoring. In addition, ask patients to use their own words to replay skills and restate information.

If you have concerns about patient understanding based on teach-back or clinical assessment, implement brief health literacy screening tools, such as NVS or SKILLD. These tools focus on diabetes knowledge gaps related to medication dosing, nutrition, glucose monitoring, and symptom awareness. In addition, connect patients with DSMES and community resources for ongoing support outside the clinic setting. Consider implementing DSMES referrals as part of standard practice for every patient with type 2 diabetes. (See Nursing’s role.)

Spencer and colleagues advocate partnering with promotoras (lay community health workers). These trained community members help bridge gaps between their ethnic or cultural communities and healthcare providers. They can provide education, locate resources, serve as case managers, and work with healthcare providers to coordinate care.

When caring for a Hispanic patient with type 2 diabetes, document their preferred language, request a qualified medical interpreter as needed, use teach-back to clarify understanding, provide written education materials in the patient’s preferred language, and tailor education to specific cultural requirements, such as food preferences and family involvement. These steps offer patients respectful care that can make a difference in their health outcomes.

Offer respectful care

Nurses frequently serve as the final safety net for patients before they leave a healthcare appointment or are discharged from the hospital. Every patient encounter provides an opportunity to prevent harm and to ensure a patient’s cultural needs are met.

Patricia Isela Regalado is an assistant director for the AOSVN Program at Stanbridge University in Riverside, California, and a doctoral student at Texas Woman’s University in Denton.

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Key words: health literacy, type 2 diabetes, culturally tailored education, patient safety, teach-back method