ORIGINAL ARTICLE

Health communication method and primary care seekingafter screening for early type 2 diabetes in a Japanesehealthcare setting

Rie Ueki • Masao Ichikawa • Yuri Hiranuma •

Takashi Naito • Takami Maeno • Taiga Shibayama

Received: 1 July 2013 / Accepted: 16 September 2013 / Published online: 15 October 2013

� The Japan Diabetes Society 2013

Abstract

Objective Whereas many people at high risk of devel-

oping type 2 diabetes are detected through screening in a

Japanese healthcare setting, they do not necessarily seek

primary care for diagnosis and treatment in the early stages

of the disease. This study aimed to identify the most

effective health communication method for the diabetes

screening report to encourage primary care consultation.

Methods This facility-based cohort study involved 1,128

Japanese participants identified from the routine diabetes

screening database from 2003 to 2009 who were consid-

ered to be at high risk of type 2 diabetes. Multiple logistic

regression analyses were performed to estimate the relative

effectiveness of the health communication method—a let-

ter or an interview—regarding the likelihood of seeking

primary care. The study controlled for sex, age, family

history of diabetes, perceived symptoms, recommendation

for diabetes care, undergoing treatment for other diseases,

detection of comorbidity, request for referral to a specialist,

and counseling by a public health nurse or dietician after

screening.

Results The proportion of participants who sought pri-

mary care after screening was 7 %. Those who received

feedback on diabetes screening via physician interview

were more likely to seek primary care consultation (odds

ratio 2.6, 95 % confidence interval 1.2–5.6).

Conclusion Health communication in the form of an

interview with a physician after diabetes screening may

encourage people at high risk of type 2 diabetes to seek

primary care, yet very few seek primary care in the early

stage of the disease. Therefore, more effective communi-

cation methods are needed.

Keywords Health communication �Type 2 diabetes �Screening � Primary care � Cohort study

Background

In Japan, the number of people with type 2 diabetes is

increasing as a result of lifestyle changes and aging of the

population. In 2007, the Japanese Ministry of Health,

Labour and Welfare (MHLW) estimated that approxi-

mately 8.9 million Japanese out of the total population of

127 million were affected by diabetes [1] and that lifestyle-

related diseases, including diabetes, accounted for about

60 % of all mortality and one third of all medical expen-

ditures [2, 3]. Since 2000, the MHLW—under the National

Health Promotion Movement in the 21st Century (Health

Japan 21)—has striven to reduce the burden of lifestyle-

related diseases by encouraging routine screenings for

these diseases [3, 4]. Under Health Japan 21, priority is

given to preventing and controlling type 2 diabetes and its

associated complications. In 2008, the MHLW required

health insurers to provide screening and counseling/guid-

ance specifically focused on metabolic syndrome [3].

Consequently, the number of people who had a screening

for diabetes increased from 45 million to 60 million during

R. Ueki (&)

Doctoral Program in Nursing Sciences, Graduate School of

Comprehensive Human Sciences, University of Tsukuba,

1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575, Japan

e-mail: s1130474@u.tsukuba.ac.jp

M. Ichikawa � T. Maeno � T. Shibayama

Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai,

Tsukuba, Ibaraki 305-8575, Japan

Y. Hiranuma � T. Naito � T. Maeno

Total Health Evaluation Center Tsukuba, 1-2 Amakubo,

Tsukuba, Ibaraki 305-0005, Japan

123

Diabetol Int (2014) 5:122–128

DOI 10.1007/s13340-013-0143-x

the last decade [5]. Today, many people who are at high

risk of type 2 diabetes are detected in Japanese healthcare

settings through diabetes screening, which examines fast-

ing plasma glucose (FPG) and glycosylated hemoglobin

(HbA1c) [1, 5, 6].

Whereas diabetes screening should lead those at high

risk to seek primary care for diagnosis and treatment, this

does not happen in many cases [1, 7, 8]. Previous studies

suggest that such patients might not be aware of the

importance of primary care because they have no notice-

able symptoms [8]. In addition, the screening reports were

not communicated well enough to prompt such patients to

seek primary care in the early stages of the disease [4, 6].

In Japan, the common methods of communicating the

screening reports are by letter, or by interview with a

physician at the health checkup in the healthcare setting.

Compared with a letter, an interview should be a more

effective method because it allows prompt face-to-face

feedback with a professional [9]. Previous studies found

that mass screening reports were better communicated by

interview than by sending a letter [10, 11]. Among people

with impaired glucose tolerance, interviews by healthcare

providers after a screening reportedly had a greater effect

than a letter with regard to changes in lifestyle, including

weight control and improved diet [6, 12].

However, it is uncertain whether an interview would

encourage people to seek primary care in the early stages of

the disease. In this study, we investigated whether people

identified to be at high risk of type 2 diabetes at screening

were more likely to seek primary care if the screening

results were communicated by interview than by letter.

Methods

Study design and setting

We conducted a facility-based cohort study in a Japa-

nese healthcare setting of adults at high risk of type 2

diabetes. They were identified through annual diabetes

screenings included in their routine health checkups at

the Total Health Evaluation Center Tsukuba, located

approximately 50 km northeast of the Tokyo metro-

politan area covering a population of approximately

216,000.

Participants

Study participants were adults who were identified

through annual screening programs to be at high risk of

developing type 2 diabetes. We found 4,513 such people

in the database of the Total Health Evaluation Center,

Tsukuba, for the years 2003 through 2009; of these indi-

viduals, 3,385 who had been undergoing treatment for

diabetes were excluded. Consequently, 1,128 adults, (957

men and 171 women) aged 54 ± 7.9 years [mean ±

standard deviation (SD), range 31–84] were assessed

(Fig. 1).

Individuals were informed that their anonymous data

would be used in this study but could be withdrawn at any

time. The research ethics committees of both the Health

Evaluation Center Tsukuba and the Graduate School of

Comprehensive Human Sciences at the University of

Tsukuba approved the study.

People had annual diabetes screenings at the Total Health Evaluation Center Tsukuba for the years 2003 through 2009 (n=59,674)

Those who without risk of type 2 diabetes (n=55,161)

People at a high risk of type 2 diabetes: FPG ≥ 7.0 mmol/L or HbA1c (JDS) ≥ 6.5 % coexistent with FPG ≥ 7.0 mmol/L (n=4,513)

Those who had been undergoing treatment for diabetes (n=3,385)

Participants (n=1,128) a

: 957 men and 171 women aged 31-84 years

Health communication methods after diabetes screening b

Letter group (n=242) Interview group (n=886)

Fig. 1 Process of sampling. aStudy participants were adults who had annual diabetes screenings and identified to be at a high risk of type 2

diabetes. bHealth communication methods were by letter or interview, depending upon the particular scheme ordered by each health insurer

Health communication for type 2 diabetes 123

123

Diabetes screening and health communication methods

A high risk of diabetes at screening was assessed according

to the criteria of the Committee of the Japan Diabetes

Society (JDS), namely, FPG C 7.0 mmol/L or HbA1c C

6.5 % (JDS) coexistent with FPG C 7.0 mmol/L [13, 14].

HbA1cwas determined by the standard measurement

method [13–15]. Screenings were conducted during routine

health checkups for adults as required by health insurers

according to the national health promotion policy. Blood

pressure and anthropometric measurements, chest X-ray,

electrocardiography and blood tests were also performed.

A physician communicated results by letter or interview to

all individuals. The communication method depended upon

the health checkup scheme ordered by each health insurer.

According to the guidelines [13], the physician should

assess the results and communicate the following com-

ments to the individual, as appropriate: no problem; in need

of a change of lifestyle; in need of further examination; in

need of medical treatment [4, 13]. It was expected that at-

risk individuals would thus change their lifestyle habits

according to appropriate health guidance [4], and they

could obtain lifestyle counseling from a public health nurse

or dietitian if they asked for it in advance of attending the

screening. For this study, we focused on the comments ‘‘in

need of further examination’’ and ‘‘in need of medical

treatment.’’ The physician communicated the comments by

letter or interview to those at high risk of diabetes and

recommended seeking primary care for confirmatory

diagnosis and treatment of diabetes within 1 month. Both

communication methods included the same type of infor-

mation and differed only in form. In both methods, the

participants received screening test results along with their

reference ranges and advice to improve on the results. The

letter was sent out a few days after the screening; the

interview was conducted for about 10 min at the physical

examination by a physician after the end of screening. In

the interview, questions and answers were possible, unlike

in the letter. The forms of communication methods were

uniform for each health insurer.

Data

We examined longitudinal participant data at baseline and

at 1-year follow-up. The database stored laboratory data,

records of physical assessment by a physician, and the

medical questionnaires completed by study participant self-

report regarding health status and medical histories. Our

main outcome was whether participants sought primary

care for type 2 diabetes within 1 year after their diabetes

screening. Data regarding other factors known to be related

to seeking primary care were also collected: sex [8, 11];

age [8, 11]; family history of diabetes [8]; self-reported

perceived symptoms, such as thirst [8, 16, 17]; whether

recommended to seek immediate medical treatment or

further examination for diabetes [11, 16]; whether under-

going treatment for any diseases other than diabetes [8,

17]; whether diseases other than diabetes were detected

through other screenings at the same time [16]; whether the

participant requested a physician to issue the referral letter

to a diabetes care specialist [11]; and whether the partici-

pant received counseling by a public health nurse or die-

titian other than a physician after the screening [6]. FPG,

HbA1c, and clinical data including body mass index (BMI)

were also obtained. HbA1c value was eventually presented

as a National Glycohemoglobin Standardization Program

(NGSP) equivalent value calculated using the formula;

HbA1c (%) = 1.02 9 HbA1c (JDS) (%) ? 0.25 (%) [18].

Statistical analysis

The proportion of individuals who sought primary care

after screening was compared between the interview and

letter groups. We also made comparisons between groups

regarding sex, age; family history of diabetes (yes/no),

perceived symptoms (any/none), recommendation for dia-

betes care (medical treatment/further examination),

undergoing treatment for other diseases (any/none),

comorbidity detected at screening (any/none), request for

referral to a specialist (yes/no), counseling by a public

health nurse or dietitian (yes/no), and clinical data

including FPG (mmol/L), HbA1c (%), and BMI (kg/m2).

Multiple logistic regression analyses were performed to

estimate the relative effect of the communication method

in terms of seeking primary care, adjusting for the above

factors. The adjusted odds ratio (OR) and its 95 % confi-

dence interval (CI) were obtained. Statistical significance

was considered as P \ 0.05. All analyses were performed

by SPSS version 17.0 (SPSS Inc., Chicago, IL, USA).

Results

Of the 1,128 participants, 242 (21 %) were in the letter

group and 886 (79 %) in the interview group. The number

of people who sought primary care after the screening was

84 (7 %): 8 (3 %) in the letter group and 76 (9 %) in the

interview group. There were 41 (4 %) who received the

comment ‘‘in need of medical treatment for diabetes’’ and

1,087 (96 %) who were recommended to have a further

diagnostic examination for diabetes in primary care. In

those who received the comments ‘‘in need of medical

treatment’’: FPG and HbA1c were higher, at 9.9 mmol/L

and 8.6 %, respectively, compared with the group ‘‘in need

of further examination’’: FPG 7.9 mmol/L, HbA1c 6.6 %.

Table 1 shows participant characteristics at baseline. In the

124 R. Ueki et al.

123

letter group, FPG was higher than in the interview group,

and 121 (50 %) of the letter group were aware of some

symptoms compared with 338 (38 %) in the interview

group. Compared with the interview group, a higher pro-

portion of the letter group had other diseases detected at

screening. Conversely, a higher proportion of the interview

group requested a referral to a specialist in diabetes care

(8 % vs. 2 %) and received counseling by a public health

nurse or dietitian (20 % vs. 3 %). There were no significant

differences between groups in terms of sex, age, HbA1c,

BMI, family history of diabetes, recommendation for dia-

betes care, and undergoing treatment for other diseases.

Table 2 shows the relative effect of the communication

method and other factors known to have an effect on

seeking primary care. The interview group was more likely

to seek primary care than the letter group (OR 2.6, 95 % CI

1.2–5.6). A recommendation for medical treatment (OR 3.7,

95 % CI 1.6–8.7) and request for referral to a specialist (OR

3.4, 95 % CI 1.8–6.4) were related to seeking primary care.

Discussion

As hypothesized, participants who received communication

of the results of their diabetes screening in an interview were

more likely to seek primary care than those who received the

information in a letter. An interview may therefore be more

effective in motivating high-risk individuals to seek primary

care after their screening. This finding is supported by pre-

vious studies showing that interviews achieve better patient

understanding of the results of mass screening compared

with communication by letter [9–11].

Besides the communication method, content also influ-

enced individuals in seeking primary care. Those recom-

mended to undergo medical treatment were more likely to

seek primary care than those recommended to undergo a

further examination, possibly because they were convinced

that their condition was serious enough to require prompt

medical attention [11, 16]. In addition, their seeking pri-

mary care may have been further influenced by referral to a

specialist in diabetes care [11]. However, referral to a

specialist was only provided to those who requested it

when the physician informed them about their screening

report, and thus, they may have been more highly moti-

vated to seek such care.

A previous study showed that counseling by a public

health nurse after screening promoted a healthier lifestyle

[6]. However, in our study, the relative effect of counseling

by healthcare providers other than a physician was not

significant. Since 2008, specific health checkups and

counseling guidance focusing on metabolic syndrome have

been promoted through Health Japan 21 with the aim of

preventing lifestyle-related diseases [3]. In our study, we

could not determine the effect of specific counseling

because there were not enough data from the start of this

counseling program. Further studies are required to

Table 1 Characteristics of participants at baseline

Total Letter group Interview group P value

Number 1,128 242 886

Sex, malesa 957 (84.8) 204 (84.3) 753 (85.0) 0.763

Age (years)b 53.9 ± 7.9 54.1 ± 7.7 53.8 ± 8.0 0.515

FPG (mmol/L)b 8.0 ± 1.5 8.5 ± 1.9 7.9 ± 1.4 \ 0.001

HbA1c (%)b,c 6.7 ± 1.1 6.9 ± 1.1 6.7 ± 1.1 0.428

BMI (kg/m2)b 25.3 ± 3.6 25.6 ± 4.0 25.2 ± 3.5 0.131

Family history of diabetesa 411 (36.4) 87 (36.0) 324 (36.6) 0.880

Perceived symptomsa 459 (40.7) 121 (50.0) 338 (38.1) 0.001

Recommendation for diabetes carea

Medical treatment 41 (3.6) 10 (4.1) 31 (3.5) 0.698

Further examination 1087 (96.4) 232 (95.9) 855 (96.5)

Undergoing treatment for other diseasesa 431 (38.2) 79 (32.6) 352 (39.7) 0.052

Comorbidity detected at screeninga 709 (62.9) 177 (73.1) 532 (60.0) \0.001

Referral to a specialista 79 (7.0) 5 (2.1) 74 (8.4) \0.001

Counseling by a PHN or a dietitiana 185 (16.4) 6 (2.5) 179 (20.2) \0.001

FPG fasting plasma glucose level, HbA1c glycolated hemoglobin, BMI body mass index, PHN public health nursea Number (%); differences between interview and letter group calculated using the v2 testb Mean ± standard deviation; differences between interview and letter group calculated using Student’s t testc HbA1c (%) estimated as a National Glycohemoglobin Standardization Program equivalent value (%) calculated by the formula: HbA1c

(%) = 1.02 9 HbA1c (Japan Diabetes Society) (%) ? 0.25 (%)

Health communication for type 2 diabetes 125

123

determine whether counseling by healthcare providers

encourages those at high risk of diabetes to seek primary

care.

Participants undergoing treatment for other diseases

were not significantly more likely to seek primary care for

diabetes. In Japan, medical services are provided separately

in each specialty, which may deter seeking primary care.

Our findings suggest that more active cooperation between

healthcare providers and specialists in medical care may be

necessary in the Japanese healthcare setting other than in

diabetes care.

We found that only a small proportion of participants

overall (7 %) sought primary care in the year following

their screening. Only 20 % of those who were advised to

have medical treatment sought primary care. In contrast,

previous studies show that *30–40 % of participants with

type 2 diabetes detected through screening sought primary

care [7, 8]. This is possibly because their follow-up period

was longer (3 years) than ours (1 year) [8]. Also, partici-

pants of the previous studies were specifically recruited and

voluntarily participated in the study, unlike in our study

[7], resulting in a greater proportion of participants seeking

primary care for diabetes. In addition, most of our study

participants were middle-aged male employees who tend to

give higher priority to their work than their own healthcare

needs and who thus might have hesitated to take time off

for a primary care consultation [7, 8]. It should also be

noted that the previous studies included individuals with

type 2 diabetes [8], whereas our study included those

suspected at an earlier stage of having diabetes. Therefore,

our study suggests that it may be difficult to encourage

people identified at screening to be at high risk of diabetes

to seek primary care at an early stage. Nevertheless, they

should be made aware that delaying medical attention may

increase the risk of developing more severe symptoms and

complications [8]: progressive diabetic complications may

lead to death in the middle-aged and a lower quality of life

in those with a long duration of diabetes [5]. Although our

findings suggest that an interview with a physician may

help increase the number of individuals to seek primary

care, further efforts should be made increase the rate

overall, for example, by referral and active feedback

between healthcare providers and specialists in diabetes

care.

Population-based screening for type 2 diabetes has

been recommended by a number of national organizations

as well as Health Japan 21 because early detection can

help control the disease and reduce its complications.

However, there is uncertainty regarding direct evidence

that screening reduces the burden of diabetes [19–22].

Our findings suggest that more active communication

methods for those identified as being at high risk of type

2 diabetes would encourage them to access initial diabetes

care. Further studies to identify the effect of early

detection and intervention on longitudinal outcomes are

also required.

There were several limitations to our study. First, we

focused on adults who had annual diabetes screenings in

order to determine whether they had already been under-

going treatment for diabetes and also whether they had

sought primary care for confirmatory diagnosis and treat-

ment after they were identified as being at high risk.

Table 2 Effect of health communication method on seeking primary

care (n = 1,128)

Variables Seeking primary

care

Adjusted

OR

95 %

CI

P value

Health communication methoda

Interview 76 (8.6) 2.6 1.2–5.6 0.014

Letter 8 (3.3)

Sexa

Females 19 (11.1) 1.6 0.9–2.9 0.087

Males 65 (6.8)

Age (years)b 55.7 ± 7.1 1.0 1.0–1.1 0.019

Family history of diabetesa

Yes 36 (8.8) 1.5 0.9–2.4 0.101

No 48 (6.7)

Perceived symptomsa

Any 29 (6.3) 0.7 0.5–1.2 0.232

None 55 (8.2)

Recommendation for diabetes carea

Medical

treatment

8 (19.5) 3.7 1.6–8.7 0.002

Further

examination

76 (7.0)

Undergoing treatment for other diseasesa

Any 36 (8.4) 1.2 0.7–2.0 0.454

None 48 (6.9)

Comorbidity detected at screeninga

Any 53 (7.5) 1.0 0.6–1.7 0.805

None 31 (7.4)

Referral to a specialista

Yes 16 (20.3) 3.4 1.8–6.4 \0.001

No 68 (6.5)

Counseling by a PHN or a dietitiana

Yes 14 (7.6) 0.8 0.4–1.4 0.399

No 70 (7.4)

Multiple logistic regression analyses were performed to estimate the

relative effect of the health communication method with adjustment

for the other factors

OR odds ratio, CI confidence intervala Number (%) of persons who sought primary care according to each

factorb Mean ± standard deviation (years) of persons who sought primary

care

126 R. Ueki et al.

123

Therefore, those who did not have annual diabetes

screenings were not considered. However, the proportion

of those identified to be at high risk and who attended

health checkups the next year was 61 % in our target

population, which is similar to the annual uptake rate of

general health checkups reported in the national survey

[23]. Moreover, this proportion did not largely differ

between letter and interview groups (58 % vs. 62 %), so

our findings should not be greatly distorted. Second, par-

ticipants were restricted to employees and their family

members, and most were men. Thus, findings of this study

might not be generalizable to women and those who do not

have or cannot afford to have diabetes screening. Finally,

work-related factors that may affect seeking primary care,

such as workload [7] and capacity and willingness of

employers to play a role in their employees’ health man-

agement [10, 16], were not considered in our analysis

because that information was not available in the database.

If we could estimate the relative effect of work-related

factors, it would be useful for advising employers to sup-

port their employees’ health care.

In conclusion, an interview with a physician after dia-

betes screening has the potential to encourage people at

high risk of type 2 diabetes to seek primary care. How-

ever, as the overall proportion seeking primary care is

very low in the early stages, more active support and

cooperation between healthcare teams should be

considered.

Acknowledgments We are grateful to Dr. Katsuya Yamazaki of

Kawai Clinic for his comments on an earlier draft.

Conflict of interest None.

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