Journal of General Internal Medicine

, Volume 27, Issue 2, pp 207–212

A Validation Study of the Spoken Knowledge in Low Literacy in Diabetes Scale (SKILLD)

  • Kelly Marvin Jeppesen
  • Benjamin P. Hull
  • Matthew Raines
  • William F. Miser
Original Research



In 2005 the Spoken Knowledge in Low Literacy in Diabetes scale (SKILLD) was introduced as a diabetes knowledge test. The SKILLD has not been validated since its introduction.


To perform a validation analysis on the SKILLD.


Cross-sectional observational study of 240 patients with diabetes at an academic family practice center.


SKILLD’s correlation with an oral form of the Diabetes Knowledge Test (DKT) was used to assess criterion validity. A regression model tested construct validity, hypothesizing that SKILLD score was independently related to health literacy and education level. Content validity was tested using Cronbach’s Alpha for inter-item relatedness and by comparing SKILLD items with the content of a National Institutes of Health (NIH) diabetes education website. We assessed inter-rater reliability and bias using Spearman correlation coefficients and sign-rank tests between interviewers scoring the same interview.


The SKILLD demonstrated fair correlation with the DKT (Pearson’s coefficient 0.54, 95% CI = 0.49 to 0.66, p < 0.001). Health literacy, education level, male gender, household income, and years with diabetes were independent predictors of SKILLD score in the regression model. Cronbach’s Alpha for inter-item relatedness was 0.54. There were some topics on the NIH website not addressed by the SKILLD. The inter-rater correlation coefficient was 0.79 (95% CI 0.56 to 0.91, p < 0.001).


The SKILLD is an adequate diabetes knowledge test and is appropriate for people of all literacy levels. However, it should be expanded to more completely evaluate diabetes knowledge.


diabetes knowledge health literacy diabetes education validation 


  1. 1.
    National Institute of Diabetes and Digestive and Kidney Diseases. National Diabetes Statistics fact sheet: General information and national estimates of diabetes in the United States, 2005. Bethesda, MD: U.S. Department of Health and Human Services, National Institute of Health; 2005.Google Scholar
  2. 2.
    McKinlay J, Marceau L. US public health and the 21st century: diabetes mellitus. Lancet. 2000;356:757–61.PubMedCrossRefGoogle Scholar
  3. 3.
    Standards of medical care in diabetes--2009. Diabetes Care 2009;32 Suppl 1:S13-61.Google Scholar
  4. 4.
    Saaddine J, Cadwell B, Gregg E, et al. Improvements in diabetes processes of care and intermediate outcomes: United States, 1988–2002. Ann Intern Med. 2006;144(7):465–74.PubMedGoogle Scholar
  5. 5.
    Moffet HH, Parker MM, Sarkar U, et al. Adherence to laboratory test requests by patients with diabetes: the diabetes study of northern California (DISTANCE). Am J Manag Care. 2011;17(5):339–344.PubMedGoogle Scholar
  6. 6.
    Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA. 2002;288:1909–14.PubMedCrossRefGoogle Scholar
  7. 7.
    Brown SA. Effects of educational interventions in diabetes care: a meta-analysis of findings. Nurs Res. 1988;37:223–30.PubMedGoogle Scholar
  8. 8.
    Brown SA, Garcia AA, Kouzekanani K, Hanis CL. Culturally competent diabetes self-management education for Mexican Americans: the Starr County border health initiative. Diabetes Care. 2002;25:259–68.PubMedCrossRefGoogle Scholar
  9. 9.
    Scain SF, Friedman R, Gross JL. A structured educational program improves metabolic control in patients with type 2 diabetes: a randomized controlled trial. Diabetes Educ. 2009;35:603–11.PubMedCrossRefGoogle Scholar
  10. 10.
    Samuel-Hodge CD, Keyserling TC, Park S, Johnston LF, Gizlice Z, Bangdiwala SI. A randomized trial of a church-based diabetes self-management program for African Americans with type 2 diabetes. Diabetes Educ. 2009;35:439–54.PubMedCrossRefGoogle Scholar
  11. 11.
    Deakin T, McShane CE, Cade JE, Williams RD. Group based training for self-management strategies in people with type 2 diabetes mellitus. Cochrane Database Syst Rev 2005:CD003417.Google Scholar
  12. 12.
    Norris SL, Engelgau MM, Narayan KM. Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials. Diabetes Care. 2001;24:561–87.PubMedCrossRefGoogle Scholar
  13. 13.
    Hawthorne K, Robles Y, Cannings-John R, Edwards AG. Culturally appropriate health education for type 2 diabetes mellitus in ethnic minority groups. Cochrane Database Syst Rev 2008:CD006424.Google Scholar
  14. 14.
    Deakin TA, Cade JE, Williams R, Greenwood DC. Structured patient education: the diabetes X-PERT Programme makes a difference. Diabet Med. 2006;23:944–54.PubMedCrossRefGoogle Scholar
  15. 15.
    Herenda S, Tahirovic H, Poljakovic D. Impact of education on disease knowledge and glycaemic control among type 2 diabetic patients in family practice. Bosn J Basic Med Sci. 2007;7:261–5.PubMedGoogle Scholar
  16. 16.
    Iqbal N, Morgan C, Maksoud H, Idris I. Improving patients’ knowledge on the relationship between HbA1c and mean plasma glucose improves glycaemic control among persons with poorly controlled diabetes. Ann Clin Biochem. 2008;45:504–7.PubMedCrossRefGoogle Scholar
  17. 17.
    Colleran KM, Starr B, Burge MR. Putting diabetes to the test: Analyzing glycemic control based on patients’ diabetes knowledge. Diabetes Care. 2003;26:2220–1.PubMedCrossRefGoogle Scholar
  18. 18.
    Panja S, Starr B, Colleran KM. Patient knowledge improves glycemic control: is it time to go back to the classroom? J Investig Med. 2005;53:264–6.PubMedCrossRefGoogle Scholar
  19. 19.
    Corser W, Holmes-Rovner M, Lein C, Gossain V. A shared decision-making primary care intervention for type 2 diabetes. Diabetes Educ. 2007;33:700–8.PubMedCrossRefGoogle Scholar
  20. 20.
    Bendik CF, Keller U, Moriconi N, et al. Training in flexible intensive insulin therapy improves quality of life, decreases the risk of hypoglycaemia and ameliorates poor metabolic control in patients with type 1 diabetes. Diabetes Res Clin Pract. 2009;83:327–33.PubMedCrossRefGoogle Scholar
  21. 21.
    van den Arend IJ, Stolk RP, Rutten GE, Schrijvers GJ. Education integrated into structured general practice care for Type 2 diabetic patients results in sustained improvement of disease knowledge and self-care. Diabet Med. 2000;17:190–7.PubMedCrossRefGoogle Scholar
  22. 22.
    Miller CK, Gutschall M. A randomized trial about glycemic index and glycemic load improves outcomes among adults with type 2 diabetes. Health Educ Behav. 2009;36:615–26.PubMedCrossRefGoogle Scholar
  23. 23.
    Duke SA, Colagiuri S, Colagiuri R. Individual patient education for people with type 2 diabetes mellitus. Cochrane Database Syst Rev 2009:CD005268.Google Scholar
  24. 24.
    Fitzgerald JT, Funnell MM, Hess GE, et al. The reliability and validity of a brief diabetes knowledge test. Diabetes Care. 1998;21:706–10.PubMedCrossRefGoogle Scholar
  25. 25.
    Jeppesen KM, Coyle JD, Miser WF. Screening questions to predict limited health literacy: a cross-sectional study of patients with diabetes mellitus. Ann Fam Med. 2009;7:24–31.PubMedCrossRefGoogle Scholar
  26. 26.
    Schillinger D, Grumbach K, Piette J, et al. Association of health literacy with diabetes outcomes. JAMA. 2002;288:475–82.PubMedCrossRefGoogle Scholar
  27. 27.
    Powell CK, Hill EG, Clancy DE. The relationship between health literacy and diabetes knowledge and readiness to take health actions. Diabetes Educ. 2007;33:144–51.PubMedCrossRefGoogle Scholar
  28. 28.
    Aikens JE, Piette JD. Diabetic patients’ medication underuse, illness outcomes, and beliefs about antihyperglycemic and antihypertensive treatments. Diabetes Care. 2009;32:19–24.PubMedCrossRefGoogle Scholar
  29. 29.
    Berkman N, DeWalt D, Pignone M, et al. Literacy and Health Outcomes. Summary, Evidence Report/Technology Assessment No. 87 (Prepared by RTI International-University of North Carolina Evidence-based Practice Center under Contract No. 290-02-0016). AHRQ Publication No. 04-E007-1. Rockville, MD: Agency for Healthcare Research and Quality. January 2004.Google Scholar
  30. 30.
    Williams MV, Baker DW, Honig EG, Lee TM, Nowlan A. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest. 1998;114:1008–15.PubMedCrossRefGoogle Scholar
  31. 31.
    Wolf MS, Gazmararian JA, Baker DW. Health literacy and functional health status among older adults. Arch Intern Med. 2005;165:1946–52.PubMedCrossRefGoogle Scholar
  32. 32.
    Gazmararian JA, Baker DW, Williams MV, et al. Health literacy among Medicare enrollees in a managed care organization. JAMA. 1999;281:545–51.PubMedCrossRefGoogle Scholar
  33. 33.
    Paasche-Orlow MK, Parker RM, Gazmararian JA, Nielsen-Bohlman LT, Rudd RR. The prevalence of limited health literacy. J Gen Intern Med. 2005;20:175–84.PubMedCrossRefGoogle Scholar
  34. 34.
    Osborn CY, Cavanaugh K, Wallston KA, White RO, Rothman RL. Diabetes numeracy: an overlooked factor in understanding racial disparities in glycemic control. Diabetes Care. 2009;32:1614–9.PubMedCrossRefGoogle Scholar
  35. 35.
    Tang YH, Pang SM, Chan MF, Yeung GS, Yeung VT. Health literacy, complication awareness, and diabetic control in patients with type 2 diabetes mellitus. J Adv Nurs. 2008;62:74–83.PubMedCrossRefGoogle Scholar
  36. 36.
    Bains SS, Egede LE. Associations between health literacy, diabetes knowledge, self-care behaviors, and glycemic control in a low income population with type 2 diabetes. Diabetes Technol Ther. 2011;13(3):335–341.PubMedCrossRefGoogle Scholar
  37. 37.
    Kandula NR, Nsiah-Kumi PA, Makoul G, et al. The relationship between health literacy and knowledge improvement after a multimedia type 2 diabetes education program. Patient Educ Couns. 2009;75:321–7.PubMedCrossRefGoogle Scholar
  38. 38.
    Wallace AS, Seligman HK, Davis TC, et al. Literacy-appropriate educational materials and brief counseling improve diabetes self-management. Patient Educ Couns. 2009;75:328–33.PubMedCrossRefGoogle Scholar
  39. 39.
    Corkery E, Palmer C, Foley ME, Schechter CB, Frisher L, Roman SH. Effect of a bicultural community health worker on completion of diabetes education in a Hispanic population. Diabetes Care. 1997;20:254–7.PubMedCrossRefGoogle Scholar
  40. 40.
    Rothman R, Malone R, Bryant B, Horlen C, DeWalt D, Pignone M. The relationship between literacy and glycemic control in a diabetes disease-management program. Diabetes Educ. 2004;30:263–73.PubMedCrossRefGoogle Scholar
  41. 41.
    Hill-Briggs F, Renosky R, Lazo M, et al. Development and pilot evaluation of literacy-adapted diabetes and CVD education in urban, diabetic African Americans. J Gen Intern Med. 2008;23:1491–4.PubMedCrossRefGoogle Scholar
  42. 42.
    Wolff K, Cavanaugh K, Malone R, et al. The Diabetes Literacy and Numeracy Education Toolkit (DLNET): materials to facilitate diabetes education and management in patients with low literacy and numeracy skills. Diabetes Educ 2009;35:233–6, 38–41, 44–5.Google Scholar
  43. 43.
    Kleinbeck C. Reaching positive diabetes outcomes for patients with low literacy. Home Healthc Nurse. 2005;23:16–22.PubMedGoogle Scholar
  44. 44.
    Rothman RL, Malone R, Bryant B, et al. The Spoken Knowledge in Low Literacy in Diabetes scale: a diabetes knowledge scale for vulnerable patients. Diabetes Educ. 2005;31:215–24.PubMedCrossRefGoogle Scholar
  45. 45.
    Davis TC, Long SW, Jackson RH, et al. Rapid estimate of adult literacy in medicine: a shortened screening instrument. Fam Med. 1993;25:391–5.PubMedGoogle Scholar
  46. 46.
    National Diabetes Education Program. Available at: Accessed September 13, 2011.
  47. 47.
    Herenda S, Tahirovic H, Zildzic M. Impact of education on metabolic control in type 2 diabetic patients in family practice. Med Arh. 2007;61:236–9.PubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2011

Authors and Affiliations

  • Kelly Marvin Jeppesen
    • 1
  • Benjamin P. Hull
    • 2
  • Matthew Raines
    • 2
  • William F. Miser
    • 2
  1. 1.Department of Family MedicineMcKay-Dee Hospital CenterOgdenUSA
  2. 2.Department of Family MedicineThe Ohio State University College of MedicineColumbusUSA

Personalised recommendations