{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,12]],"date-time":"2026-05-12T16:14:28Z","timestamp":1778602468386,"version":"3.51.4"},"reference-count":35,"publisher":"BMJ","issue":"3","license":[{"start":{"date-parts":[[2026,5,12]],"date-time":"2026-05-12T00:00:00Z","timestamp":1778544000000},"content-version":"unspecified","delay-in-days":11,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"name":"Sant\u00e9 publique France","award":["N\/A"],"award-info":[{"award-number":["N\/A"]}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open Diab Res Care"],"accepted":{"date-parts":[[2026,4,11]]},"published-print":{"date-parts":[[2026,5]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Health literacy is a multidimensional determinant of health that influences diabetes outcomes and social inequities in health (SIH). Studies often measure it unidimensionally, failing to capture people\u2019s diverse health literacy skills. We identified multidimensional health literacy profiles among adults living with type 2 diabetes (T2D) in France and described their clinical, behavioral and social characteristics with a view to informing future tailored interventions.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Research design and methods<\/jats:title>\n                    <jats:p>This study used a cross-sectional design based on a subsample of the Entred 3 national survey, combining self-reported questionnaire data with linked administrative health data covering the previous 10 years. Health literacy was assessed using the Health Literacy Questionnaire (HLQ) among 510 individuals with T2D who completed the cross-sectional survey online. Hierarchical clustering based on standardized HLQ scores identified distinct health literacy clusters.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>We identified 13 health literacy clusters among the online survey participants, labelled from A to M, five requiring tailored public health and clinical responses. Substantial heterogeneity concerning health literacy skills and associations with SIH and health outcomes was observed. For example, cluster A demonstrated strong self-management skills counteracted by severe barriers to care navigation and information comprehension in a highly vulnerable setting. Furthermore, cluster D reflected globally low health literacy scores, poor health outcomes and high exposure to risk factors despite recent diabetes diagnosis. A third example is cluster K, which highlighted strong relational and cognitive skills but limited engagement in self-care and significant exposure to risk factors despite favorable socioeconomic conditions.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Health literacy profiles reflect complex combinations of skills, risks and social determinants, which can potentially inform how to tailor public health interventions, so that no group is left behind.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjdrc-2026-005977","type":"journal-article","created":{"date-parts":[[2026,5,12]],"date-time":"2026-05-12T15:40:15Z","timestamp":1778600415000},"page":"e005977","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Health literacy profiles of people living with type 2 diabetes: a cluster-based approach to inform tailored interventions\u2013the Entred 3 study"],"prefix":"10.1136","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0009-0003-1808-1355","authenticated-orcid":false,"given":"Roxane","family":"Agius","sequence":"first","affiliation":[{"name":"Department of Non-Communicable Diseases and Trauma, F-94415, Sant\u00e9 publique France, Saint-Maurice, France"},{"name":"CESP, INSERM, UVSQ, Paris-Saclay University, Villejuif, France"},{"name":"Paris-Est University, Cr\u00e9teil, France"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Laurent","family":"Rigal","sequence":"additional","affiliation":[{"name":"CESP, INSERM, UVSQ, Paris-Saclay University, Villejuif, France"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Henri","family":"Panjo","sequence":"additional","affiliation":[{"name":"CESP, INSERM, UVSQ, Paris-Saclay University, Villejuif, France"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Richard H","family":"Osborne","sequence":"additional","affiliation":[{"name":"Global Health and Equity Development Hub, Violet Vines Marshman Centre for Rural Health Research, La Trobe Rural Health School, Room W106, Level 1, David Myers Building West, Bundoora, VIC 3083, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sandrine","family":"Fosse-Edorh","sequence":"additional","affiliation":[{"name":"Department of Non-Communicable Diseases and Trauma, F-94415, Sant\u00e9 publique France, Saint-Maurice, France"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Xavier","family":"Debussche","sequence":"additional","affiliation":[{"name":"Wound and Healing Expert Center, Max Querrien Hospital Centre of Paimpol, Paimpol, France"},{"name":"CIC 1410, INSERM, Saint-Pierre R\u00e9union, France"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2026,5,12]]},"reference":[{"key":"2026051208400856000_14.3.e005977.1","unstructured":"International Diabetes Federation . IDF atlas, 11th edn. Atlas du diab\u00e8te, 2025. Available: https:\/\/diabetesatlas.org\/fr\/resources\/idf-diabetes-atlas-2025\/"},{"key":"2026051208400856000_14.3.e005977.2","unstructured":"Sant\u00e9 Publique France . Pr\u00e9valence du diab\u00e8te en France (2023) \u2013 Donn\u00e9es Odisse, Available: https:\/\/odisse.santepubliquefrance.fr\/explore\/dataset\/diabete-prevalence-france\/ [Accessed 05 Nov 2025]."},{"key":"2026051208400856000_14.3.e005977.3","doi-asserted-by":"crossref","first-page":"55","DOI":"10.1016\/j.puhe.2023.12.022","article-title":"Income and professional inequalities in chronic diseases: prevalence and incidence in France","volume":"228","author":"Allain","year":"2024","journal-title":"Public Health (Fairfax)"},{"key":"2026051208400856000_14.3.e005977.4","doi-asserted-by":"crossref","first-page":"101509","DOI":"10.1016\/j.diabet.2024.101509","article-title":"Eleven-year trends in socioeconomic inequalities in the prevalence and incidence of pharmacologically treated type 2 diabetes in France, 2010\u20132020","volume":"50","author":"Guion","year":"2024","journal-title":"Diabetes Metab"},{"key":"2026051208400856000_14.3.e005977.5","doi-asserted-by":"publisher","DOI":"10.2337\/dci20-0023"},{"key":"2026051208400856000_14.3.e005977.6","unstructured":"Health literacy development for the prevention and control of noncommunicable diseases: volume 1. Overview, (health literacy development for the prevention and control of noncommunicable diseases). Licence: CC BY-NC-SA 3.0 IGO. Geneva World Health Organization; 2022. Available: https:\/\/iris.who.int\/bitstream\/handle\/10665\/364203\/9789240055339-eng.pdf?sequence=1 [accessed 28 Feb 2024]"},{"key":"2026051208400856000_14.3.e005977.7","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2022-010362","article-title":"Health literacy development is central to the prevention and control of non-communicable diseases","volume":"7","author":"Osborne","year":"2022","journal-title":"BMJ Glob Health"},{"key":"2026051208400856000_14.3.e005977.8","doi-asserted-by":"publisher","DOI":"10.1146\/annurev-publhealth-090419-102529"},{"key":"2026051208400856000_14.3.e005977.9","doi-asserted-by":"crossref","first-page":"1007","DOI":"10.1007\/s11606-019-04832-y","article-title":"The Role of Health Literacy in Diabetes Knowledge, Self-Care, and Glycemic Control: a Meta-analysis","volume":"34","author":"Marciano","year":"2019","journal-title":"J Gen Intern Med"},{"key":"2026051208400856000_14.3.e005977.10","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2020-046759","article-title":"Health literacy in context: struggling to self-manage diabetes - a longitudinal qualitative study","volume":"12","author":"Debussche","year":"2022","journal-title":"BMJ Open"},{"key":"2026051208400856000_14.3.e005977.11","doi-asserted-by":"crossref","DOI":"10.1186\/1471-2458-13-658","article-title":"The grounded psychometric development and initial validation of the Health Literacy Questionnaire (HLQ)","volume":"13","author":"Osborne","year":"2013","journal-title":"BMC Public Health"},{"key":"2026051208400856000_14.3.e005977.12","doi-asserted-by":"crossref","DOI":"10.1155\/2016\/7823130","article-title":"The Relationship between Health Literacy and Health Behaviour in People with Diabetes: A Danish Population-Based Study","volume":"2016","author":"Friis","year":"2016","journal-title":"J Diabetes Res"},{"key":"2026051208400856000_14.3.e005977.13","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2015-009627","article-title":"Gaps in understanding health and engagement with healthcare providers across common long-term conditions: a population survey of health literacy in 29,473 Danish citizens","volume":"6","author":"Friis","year":"2016","journal-title":"BMJ Open"},{"key":"2026051208400856000_14.3.e005977.14","doi-asserted-by":"crossref","DOI":"10.1177\/2050312118801250","article-title":"Characterisation of health literacy strengths and weaknesses among people at metabolic and cardiovascular risk: Validity testing of the Health Literacy Questionnaire","volume":"6","author":"Debussche","year":"2018","journal-title":"SAGE Open Med"},{"key":"2026051208400856000_14.3.e005977.15","doi-asserted-by":"crossref","DOI":"10.1186\/s12889-025-22118-3","article-title":"Health literacy among individuals with type 2 diabetes in France: greater social inequalities among women; the Entred 3 study","volume":"25","author":"Agius","year":"2025","journal-title":"BMC Public Health"},{"key":"2026051208400856000_14.3.e005977.16","unstructured":"Osborne RH , Elmer S , Hawkins M , et al . The ophelia manual. The optimising health literacy and access (ophelia) process to plan and implement national health literacy demonstration projects. Melbourne, Australia Centre for Global Health and Equity, School of Health Sciences, Swinburne University of Technology; 2021. Available: https:\/\/healthliteracydevelopment.com\/the-ophelia-manual\/"},{"key":"2026051208400856000_14.3.e005977.17","doi-asserted-by":"crossref","first-page":"441","DOI":"10.1007\/s00038-018-1186-3","article-title":"Identifying diabetes cases in health administrative databases: a validation study based on a large French cohort","volume":"64","author":"Fuentes","year":"2019","journal-title":"Int J Public Health"},{"key":"2026051208400856000_14.3.e005977.18","unstructured":"Rothman KJ , Lash TL , Greenland S . Modern epidemiology, 3rd edition. Lippincott Williams&Wilkins, 2008. Available: https:\/\/www.rti.org\/publication\/modern-epidemiology-3rd-edition"},{"key":"2026051208400856000_14.3.e005977.19","doi-asserted-by":"crossref","DOI":"10.1186\/s12874-020-00962-8","article-title":"Translation method is validity evidence for construct equivalence: analysis of secondary data routinely collected during translations of the Health Literacy Questionnaire (HLQ)","volume":"20","author":"Hawkins","year":"2020","journal-title":"BMC Med Res Methodol"},{"key":"2026051208400856000_14.3.e005977.20","doi-asserted-by":"crossref","DOI":"10.1136\/bmjdrc-2017-000437","article-title":"Higher health literacy is associated with better glycemic control in adults with type 1 diabetes: a cohort study among 1399 Danes","volume":"5","author":"Olesen","year":"2017","journal-title":"BMJ Open Diab Res Care"},{"key":"2026051208400856000_14.3.e005977.21","doi-asserted-by":"publisher","DOI":"10.1007\/s11136-011-9903-x"},{"key":"2026051208400856000_14.3.e005977.22","doi-asserted-by":"publisher","DOI":"10.1007\/s40273-019-00876-4"},{"key":"2026051208400856000_14.3.e005977.23","first-page":"1044","article-title":"Assessment of antihypertensive compliance using a self-administered questionnaire: development and use in a hypertension clinic","volume":"30","author":"Girerd","year":"2001","journal-title":"Presse Med"},{"key":"2026051208400856000_14.3.e005977.24","doi-asserted-by":"publisher","DOI":"10.1080\/01969727408546059"},{"key":"2026051208400856000_14.3.e005977.25","doi-asserted-by":"crossref","first-page":"128198","DOI":"10.1016\/j.neucom.2024.128198","article-title":"From A-to-Z review of clustering validation indices","volume":"601","author":"Hassan","year":"2024","journal-title":"Neurocomputing"},{"key":"2026051208400856000_14.3.e005977.26","unstructured":"Marmot M , Goldblatt P , Allen J , et al . Fair society, healthy lives (the marmot review). London Institute of Health Equity \/ University College London; 2010. Available: https:\/\/www.instituteofhealthequity.org\/resources-reports\/fair-society-healthy-lives-the-marmot-review"},{"key":"2026051208400856000_14.3.e005977.27","unstructured":"Health literacy and awareness (WP06). Jacardi. Available: https:\/\/jacardi.eu\/what-we-do\/ [Accessed 04 Dec 2025]."},{"key":"2026051208400856000_14.3.e005977.28","first-page":"75","article-title":"Large diversity in Danish health literacy profiles: perspectives for care of long-term illness and multimorbidity","volume":"30","author":"Aaby","year":"2020","journal-title":"Eur J Public Health"},{"key":"2026051208400856000_14.3.e005977.29","doi-asserted-by":"crossref","first-page":"e663","DOI":"10.1093\/pubmed\/fdae165","article-title":"Measuring health literacy to inform actions to address health inequities: a cluster analysis approach based on the Australian national health literacy survey","volume":"46","author":"Cheng","year":"2024","journal-title":"J Public Health (Oxf)"},{"key":"2026051208400856000_14.3.e005977.30","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2023-077440","article-title":"Profiles of health literacy and digital health literacy in clusters of hospitalised patients: a single-centre, cross-sectional study","volume":"14","author":"Andersen","year":"2024","journal-title":"BMJ Open"},{"key":"2026051208400856000_14.3.e005977.31","doi-asserted-by":"publisher","DOI":"10.1111\/jorc.12314"},{"key":"2026051208400856000_14.3.e005977.32","doi-asserted-by":"crossref","first-page":"529","DOI":"10.1111\/jorc.12515","article-title":"Health literacy profiles in kidney transplanted patients: A cluster analysis","volume":"50","author":"Vidnes","year":"2024","journal-title":"J Ren Care"},{"key":"2026051208400856000_14.3.e005977.33","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1016\/j.puhe.2016.01.001","article-title":"Health literacy: applying current concepts to improve health services and reduce health inequalities","volume":"132","author":"Batterham","year":"2016","journal-title":"Public Health (Fairfax)"},{"key":"2026051208400856000_14.3.e005977.34","doi-asserted-by":"crossref","DOI":"10.1093\/eurpub\/ckae144.1706","article-title":"Systematic review of the Health Literacy Questionnaire (HLQ) for global health literacy development","volume":"34","author":"Hawkins","year":"2024","journal-title":"Eur J Public Health"},{"key":"2026051208400856000_14.3.e005977.35","unstructured":"Australian Bureau of Statistics . National health survey: health literacy. Canberra ABS; 2018. Available: https:\/\/www.abs.gov.au\/statistics\/health\/health-conditions-and-risks\/national-health-survey-health-literacy\/latest-release [accessed 07 Aug 2025]"}],"container-title":["BMJ Open Diabetes Research &amp; Care"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjdrc-2026-005977","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,12]],"date-time":"2026-05-12T15:40:25Z","timestamp":1778600425000},"score":1,"resource":{"primary":{"URL":"https:\/\/drc.bmj.com\/lookup\/doi\/10.1136\/bmjdrc-2026-005977"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5]]},"references-count":35,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2026,5,12]]},"published-print":{"date-parts":[[2026,5]]}},"alternative-id":["10.1136\/bmjdrc-2026-005977"],"URL":"https:\/\/doi.org\/10.1136\/bmjdrc-2026-005977","relation":{},"ISSN":["2052-4897"],"issn-type":[{"value":"2052-4897","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5]]}}}