Health Literacy in Patients With Type 2 Diabetes Mellitus.

The HLQ (Osborne et al.,2013) consists of 9 scales representing 9 dimensions of health literacy: Feeling understood and supported by healthcare providers; Having sufficient information to manage my health;Actively managing my health;Social support for health;Appraisal of health information;Ability to actively engage with healthcare providers;Navigating the healthcare system;Ability to find good health information;Understand health information well enough to know what to do.

Each HLQ scale has 4-6 items. The HLQ does not provide one overall summative score. The scoring of the HLQ is 9 scale scores, calculated by averaging the item scores within each scale with equal weighting. The 9 scale scores will reflect a person's strengths and needs in the different dimensions of health literacy, with higher scores meaning greater health literacy.

For Scales 1 to 5, the score range is between 1 and 4 (4 response options). For Scales 6 to 9, the score range is between 1 and 5 (5 response options).

Knowledge about DM will be measured by the Diabetes Knowledge Scale (DKN-A). The DKN-A, with 15 multiple-choice questions, addresses several aspects related to general knowledge of diabetes, through 5 categories: a) basic physiology, including the action of insulin; b) hypoglycemia; c) food groups and their replacements; d) management of diabetes in the presence of another disease; e) general principles for disease care. The measurement scale is 0-15 and each item has the following score: one (1) for a correct answer and zero (0) for an incorrect answer. Items 1 to 12 require a single correct answer. For questions 13 to 15, two answers are correct and both must be correct to obtain a score of one. A score of 0 to 8 points indicates little knowledge and greater than 8 points indicates good knowledge about diabetes (Dunn et al., 1984).

Self-efficacy will be assessed using the Diabetes Management Self-efficacy Scale for Patients with Type 2 Diabetes Mellitus (DMSES). The DMSES has 20 items, distributed across four factors (specific nutrition and weight; general nutrition and drug treatment; physical exercise; blood glucose). The scale items describe the behaviors that people with DM should perform for each of the aforementioned care practices and ask whether they feel able to perform these practices (Bijl; Poelgeest-Eeltink; Shortridge-Baggett, 1999). A Likert-type scale is used to respond to each item, with the following response and scoring pattern: definitely yes (5 points); probably yes (4 points); don't know (3 points); probably no (2 points); definitely no (1 point). SE is determined by the overall mean of the instrument: the scores for each item are added together and divided by the number of items. Higher means indicate greater self-efficacy.

Glycosylated hemoglobin (HbA1c) is a blood test that measures the average blood glucose levels over the last 3 to 4 months and is routinely used to assess glycemic control in people with diabetes. The target HbA1c result for people with diabetes is around 7.0%, however it varies according to age and presence of comorbidities. Higher values indicate that blood glucose levels are not adequate.

The health conditions questionnaire includes the following items:

• Presence of diseases associated with DM: Eye problems Kidney problems Blood circulation problems Foot problems Other

• Presence of other morbidities: High blood pressure Obesity Chronic kidney disease Heart disease Depression Anxiety disorder Hypothyroidism Hyperthyroidism Fibromyalgia Cancer Asthma Hypercholesterolemia Cartilage/bone inflammation/degeneration Other

• Smoking: Yes No

• Use of alcoholic beverages: Yes No

• Practice of physical activity: Yes No

• Body mass index: Underweight: BMI less than 18.5 kg/m² Normal weight: BMI between 18.5 and 24.9 kg/m² Overweight: BMI between 25 and 29.9 kg/m² Obesity: defined as a BMI ≥ 30 kg/m²

• Abdominal circumference (reference values): Women: ≤ 80 cm Men: ≤ 94 cm

• Number of consultations with nurses, physicians, and nutritionists over the past six months (assessed only in the second data collection phase)