Linking health literacy and health disparities: conceptual implications and empirical results

Health literacy, defined as “(…) the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.” (IOM, 2004), has been found to be an important concept in explaining differences in health. Limited health literacy has been linked, amongst others, to worse general health (Wolf, Gazmararian, & Baker, 2005), less usage of preventive healthcare services (Bennett, Chen, Soroui, & White, 2009), higher risk of hospital admissions (Scott, Gazmararian, Williams, & Baker, 2002), and eventually higher mortality (Baker et al., 2007). Particular in groups that are afflicted by socioeconomic disadvantages limited health literacy has been found to be more prevalent, thus lending itself as an important factor to consider when talking about health disparities in general. Research on the concept of health literacy in the last twenty years has largely evolved in the United States (US) and conceptualizations, as well as the development of measurements, have been so far predominantly developed in the US. Only little research has yet focused on its transferability to other contexts to explore whether underlying constructs and relevant measures will show the same patterns. Further, in how far commonly found relationships between health literacy and health outcomes or behaviors will also hold true in other countries than the US. The work presented in this dissertation sets out to test in how far health literacy can be transferred to other contexts and how far patterns found concur with those found in the US. Further, it aims at contributing to the still ongoing debate on the conceptualization and operationalization of health literacy, as well as on the conceptual pathways that link health literacy to differences in health. By providing the results of two studies that aimed at validating a short measure of functional health literacy in two different countries, this dissertation provides evidence on the fact that commonly used measures of health literacy are also valid when used in other contexts. Further, that the concept of health literacy and its underlying constructs are transferable to other parts of the world (Part I). Having established a potential cross-cultural and linguistic validity of the concept of health literacy, two studies are presented that aimed at testing the relationship between health literacy and healthcare costs in a sample of diabetes patients in Switzerland. Thereby, testing whether hypothesized relationships would also hold true in the Swiss context. Further, to contribute to the empirical literature by providing evidence on a still largely understudied relationship in the field of health literacy. Results confirmed hypothesized relationships, showing that lower levels of health literacy indeed were related to higher healthcare costs (Part II). The dissertation also aims at contributing to the current discussion in how far health literacy contributes to differences in health outcomes. In particular those that are often associated with other social determinants that are closely linked to unjust distribution of wealth or education. In the US for example ethnic and racial minorities have been most often found to be afflicted by the negative outcomes of health. Health literacy as a potential explanatory variable in this relationship has been widely discussed, yet little is known about its exact role in this relationship. The dissertation presents a conceptual discussion on the relevant issues that may have prevented health literacy to be more systematically integrated into research on disparities and to not fully leverage its potential for interventions in the field. Further, by means of a systematic review the work at hand aims to outline the current empirical knowledge on health literacy and health disparities. Results of this review indeed point to the fact that little systematic evidence is yet available, due to the lack of systematic testing of potential pathways describing how health literacy contributes to disparities. Further, disparities as such are only seldom sufficiently described in the literature and are predominantly treated as confounders. Lastly, a study is presented that tested for differences in health literacy by comparing three immigrant groups in Switzerland to the general Swiss population, and explored in how far the interplay between health literacy and acculturation might explain health differences. This dissertation contributes to the discussion on the conceptualization and operationalization of health literacy by providing evidence on its transferability and that its underlying constructs might be sufficiently applicable to other contexts. Further, the relationships identified do not only have implications for researchers but for healthcare practitioners and policy makers as well. In particular the relationship found between health literacy and costs has the potential to significantly leverage health literacy as a topic on the healthcare agenda. Finally, by discussing and identifying gaps on current knowledge on how health literacy contributes to disparities, and by identifying differential effects by means of different measures, this work presents a first careful stepping stone on how to systematically disentangle potential pathways linking health literacy to health disparities

The relationship between functional health literacy and the use of the health system by diabetics in Switzerland

BACKGROUND: Observational studies from the USA have suggested that patients with low health literacy (HL) have higher health care costs and use an inefficient mix of health care services. To date, there were no studies from Europe that investigated the impact of HL on the use of the health system. The purpose of this study was to measure functional HL among persons having type 2 diabetes and to investigate the relationship between functional HL and health care costs and utilization. METHODS: The study population were insured persons of the basic health insurance plan of the largest health insurer in Switzerland. Persons selected for participation had been reimbursed for diabetes medications in 2010-11, were aged 35-70 years and did not live in a long-term care institution. The level of functional HL was measured by one screening question. The following dependent variables were used: total costs, outpatient costs, inpatient costs, days admitted and number of physician visits attended. All multiple regression analyses were adjusted for age, gender, education, duration of diabetes, treatment with insulin (yes/no) and other chronic disease (yes/no). RESULTS: High levels of functional HL were associated with lower total costs (P = 0.007), lower outpatient costs (P = 0.004) and less physician visits (P = 0.001). In the standard insurance plan with free access to all health professionals subgroup, the effects found were more pronounced. CONCLUSIONS: Persons with low functional HL need extra medical support, and therefore have higher health care cost

How does Switzerland's health sector contribute to the economy?

Health matters. The health sector is an important and innovative industry, as well as a source of stable employment for many people. Health systems support active and productive populations, reduce inequities and poverty and promote social cohesion. A strong health system makes good economic sense and underpins the overall sustainable development agenda Countries around the world are grappling with the health, economic and fiscal implications of the COVID-19 pandemic. As they begin to recover from the crisis, difficult decisions will need to be made about how to allocate scarce resources. These snapshots share valuable evidence for policy-makers on how investing in health sectors and health systems helps to achieve national economic objectives

Measuring health literacy in Italy: the validation study of the HLS-EU-Q16 and of the HLS-EU-Q6 in Italian language

Health literacy (HL) is the capacity of individuals, families, and communities to make sound health decisions in the context of everyday life: at home, at the workplace, and in the community, marketplace, healthcare sector, and political arena. The aim of this study is to validate the Italian version of the short form (HLS-EU-Q16) and of the short-short form (HLS-EU-Q6) of the HLS-EU-Q47, as a part of a research conducted to assess the level of HL in a population-based sample in Florence. Two-hundred twenty-three subjects (57% females; age: 53.7±11.8 years) were interviewed. The results provided the first evidence for the reliability and validity of the HLS-EU-Q instruments (HLS-EU-Q16, HLS-EU-Q6, General-HL Index) in Italian general population. The differences in some of the results with respect to other published studies lay for specific cultural characteristics, that affect HL level and the relationships between HL, antecedents, and outcomes

Health literacy in Mainland China: Validation of a functional health literacy test in simplified Chinese

Health literacy tests in the Chinese-speaking parts of the world have been mainly developed in traditional Chinese to be used in Hong Kong or Taiwan. So far no validated tool in simplified Chinese to assess functional health literacy in Mainland China has been developed. The aim of the study was to validate the simplified Chinese version of the Short Test of Functional Health Literacy in Adults (S-TOFHLA). The traditional Chinese version was translated into simplified Chinese and 150 interviews in an outpatient department of a public hospital in Mainland China were conducted. Predictive validity was assessed by known predictors for health literacy and convergent validity by three health literacy screening questions. The Cronbach's α for the reading comprehension part was 0.94 and 0.90 for the numeracy items. Participants with lower education and men had significantly lower levels of health literacy. The reading comprehension part was significantly correlated with two of the health literacy screening questions. Our results indicate that the simplified Chinese version of the S-TOFHLA is a reliable measure of health literacy to be used in Mainland China

The Effect of Vaccine Literacy on Parental Trust and Intention to Vaccinate after a Major Vaccine Scandal.

Health literacy, and more specifically vaccine literacy, might be an important factor in reducing the negative effects of exposure to misleading reports on vaccination. This study explores the association between vaccine literacy and vaccination-related outcomes after misleading reports on a scandal concerning locally produced childhood vaccines had emerged in 2016 in China. Data for this study came from a cross-sectional survey, which was conducted in April 2016 in Hangzhou, China. Data were collected in kindergartens and community health centers among parents of children up to 6 years of age. Data were analyzed for 1864 participants. Binary logistic regression models showed that, after controlling for socio-demographics and children's age, parents who had better vaccine literacy (<0.05) were more likely to trust and choose domestically produced vaccines, which account for about 95% of the total vaccinations in China. This study provides evidence on a still largely understudied relationship between vaccine literacy and vaccination-related outcomes. Findings might suggest that higher literacy levels could reduce some of the negative effects of being exposed to misleading information on vaccination, eventually leading to less vaccination hesitancy

Socio-demographics of the overall sample.

<p>Socio-demographics of the overall sample.</p