Research paper When knowing is not enough: Emotional distress and depression reduce the positive effects of health literacy on diabetes self-management Louise Schinckus*, Florence Dangoisse, Stephan Van den Broucke, Moïra Mikolajczak Psychological Sciences Research Institute, Catholic University of Louvain, Louvain-la-Neuve, Belgium A R T I C L E I N F O Article history: Received 6 March 2017 Received in revised form 7 August 2017 Accepted 8 August 2017 Keywords: Diabetes Health literacy Self-efﬁcacy Depression Distress A B S T R A C T Objectives: Adequate self-management activities are important predictors of diabetes outcomes. As diabetes literacy and self-efﬁcacy are strong predictors of diabetes self-care, self-management education programs focus essentially on these factors. This study investigated whether emotional distress or depression moderates the relation between health literacy, self-efﬁcacy and diabetes self-care behaviors. Methods: 128 people with type 2 diabetes were recruited in hospitals, through general practitioners and via a diabetes website, and completed a questionnaire assessing health literacy, self-efﬁcacy, diabetes- related distress, depression and self-care behaviors. Results: Multiple regression analysis conﬁrms that health literacy and self-efﬁcacy signiﬁcantly predict reported self-care behaviors. Additional regression analyses reveal that distress or depression do not predict self-care behaviors directly, but moderate the effect of health literacy, which has a weaker impact in patients experiencing distress or depression. In contrast, distress and depression do not moderate the effect of self-efﬁcacy on diabetes self-care behaviors. Conclusion: Emotional distress, whether related to diabetes or not, prevents patients from acting on their competence to perform adequate self-management behaviors. Practice implications: Diabetes Professionals should pay more attention to the patients’ affective state and its inﬂuence on self-care. Psychological support should be integrated in the care for people suffering from type 2 diabetes. © 2017 Published by Elsevier Ireland Ltd. 1. Introduction Early diagnosis and appropriate management of type 2 diabetes signiﬁcantly increase the chances of preventing harmful and costly complications. Therefore, the care for patients with diabetes focuses strongly on disease management. Because managing diabetes requires extensive self-care, the capacities of patients to manage their own illness and care process are considered to be a key determinant of treatment outcomes [1]. The practice guide of the American Association of Diabetes Educators [2] speciﬁes seven self-care behaviors that are essential for people with diabetes: (a) healthy eating, (b) being active, (c) blood glucose monitoring, (d) taking medication, (e) problem solving (e.g. when there is an obstacle to dietary compliance), (f) healthy coping (e.g. speaking with friends or playing music to deal with stress), and (g) changing behaviors that increase the risk of developing diabetes complications (such as smoking or alcohol consumption). The patient’s adherence to the above-mentioned self-care behaviors is critical to achieve better glycemic control and, thereby, avoid complications associated to a poor diabetes control [3,4]. Understanding the factors that inﬂuence adherence is therefore of utmost importance. As appears from the literature, a patient’s adherence to the treatment is affected by several factors, both at the patient level (e.g. health literacy, self-efﬁcacy) and at the provider or service level (e.g. organization of health services, communication skills). The current paper focuses on three individual factors that may impact on self-care behaviors for diabetes, i.e., health literacy, self-efﬁcacy, and emotional distress. Recent studies have demonstrated the impact of these factors on self-care behaviors separately, but to our knowledge, none has examined the potential interactions between them. This study * Corresponding author at: Psychological Sciences Research Institute, Université catholique de Louvain, 10 Place Cardinal Mercier, 1348 Louvain-la-Neuve, bte L3.05.01, Belgium. E-mail address: schinckuslouise@gmail.com (L. Schinckus). http://dx.doi.org/10.1016/j.pec.2017.08.006 0738-3991/© 2017 Published by Elsevier Ireland Ltd. Patient Education and Counseling 101 (2018) 324–330 Contents lists available at ScienceDirect Patient Education and Counseling journa l homepage: www.e lsevier.com/locate/pate ducou