Health disparities; Health literacy; Mediation analysis; Socioeconomic status; Belgium; Health Surveys; Preventive Health Services/statistics & numerical data; Health Literacy/statistics & numerical data; Social Class; Health Behavior; Health Status
Abstract :
[en] [en] BACKGROUND: Health literacy (HL) has been put forward as a potential mediator through which socioeconomic status (SES) affects health. This study explores whether HL mediates the relation between SES and a selection of health or health-related outcomes.
METHODS: Data from the participants of the Belgian health interview survey 2018 aged 18 years or older were individually linked with data from the Belgian compulsory health insurance (n = 8080). HL was assessed with the HLS-EU-Q6. Mediation analyses were performed with health behaviour (physical activity, diet, alcohol and tobacco consumption), health status (perceived health status, mental health status), use of medicine (purchase of antibiotics), and use of preventive care (preventive dental care, influenza vaccination, breast cancer screening) as dependent outcome variables, educational attainment and income as independent variables of interest, age and sex as potential confounders and HL as mediating variable.
RESULTS: The study showed that unhealthy behaviours (except alcohol consumption), poorer health status, higher use of medicine and lower use of preventive care (except flu vaccination) were associated with low SES (i.e., low education and low income) and with insufficient HL. HL partially mediated the relationship between education and health behaviour, perceived health status and mental health status, accounting for 3.8-16.0% of the total effect. HL also constituted a pathway by which income influences health behaviour, perceived health status, mental health status and preventive dental care, with the mediation effects accounting for 2.1-10.8% of the total effect.
CONCLUSIONS: Although the influence of HL in the pathway is limited, our findings suggest that strategies for improving various health-related outcomes among low SES groups should include initiatives to enhance HL in these population groups. Further research is needed to confirm our results and to better explore the mediating effects of HL.
Disciplines :
Public health, health care sciences & services
Author, co-author :
Berete, Finaba ; Université de Liège - ULiège > Unité de recherche Santé publique, épidémiologie et économie de la santé (URSAPES) ; Department of Epidemiology and Public Health, Sciensano, Juliette Wytsmanstraat 14, Brussels, 1050, Belgium. finaba.berete@sciensano.be
Gisle, Lydia; Department of Epidemiology and Public Health, Sciensano, Juliette Wytsmanstraat 14, Brussels, 1050, Belgium
Demarest, Stefaan; Department of Epidemiology and Public Health, Sciensano, Juliette Wytsmanstraat 14, Brussels, 1050, Belgium
Charafeddine, Rana; Department of Epidemiology and Public Health, Sciensano, Juliette Wytsmanstraat 14, Brussels, 1050, Belgium
Bruyère, Olivier ; Université de Liège - ULiège > Département des sciences de la santé publique > Santé publique, Epidémiologie et Economie de la santé
Van den Broucke, Stephan; Research Institute for Psychological Sciences, Louvain-la-Neuve, UCLouvain, Belgium
Van der Heyden, Johan; Department of Epidemiology and Public Health, Sciensano, Juliette Wytsmanstraat 14, Brussels, 1050, Belgium
Language :
English
Title :
Does health literacy mediate the relationship between socioeconomic status and health related outcomes in the Belgian adult population?
M.C. Kulik G. Menvielle T.A. Eikemo M. Bopp D. Jasilionis I. Kulhánová et al. Educational inequalities in three smoking-related causes of death in 18 European populations Nicotine Tob Res 2014 16 5 507 18 24212763
N.E. Adler K. Newman Socioeconomic disparities in health: pathways and policies Health Aff 2002 21 2 60 76
M. Marmot J. Allen R. Bell E. Bloomer P. Goldblatt WHO European review of social determinants of health and the health divide Lancet 2012 380 9846 1011 29 22964159
H. Kröger E. Pakpahan R. Hoffmann What causes health inequality? A systematic review on the relative importance of social causation and health selection Eur J Public Health 2015 25 6 951 60 26089181
M.K. Paasche-Orlow M.S. Wolf The Causal Pathways Linking Health Literacy to Health outcomes am j Health Behav 2007 31 1 19 26
O. Husson F. Mols M.P. Fransen L.V. van de Poll-Franse N.P.M. Ezendam Low subjective health literacy is associated with adverse health behaviors and worse health-related quality of life among colorectal cancer survivors: results from the profiles registry: Health literacy and health outcomes Psycho-oncology 2015 24 4 478 86 1:STN:280:DC%2BC2M7jtlWksw%3D%3D 25241852
D. Schillinger L.R. Barton A.J. Karter F. Wang N. Adler Does literacy mediate the relationship between Education and Health Outcomes? A study of a low-income Population with Diabetes Public Health Rep 2006 121 3 245 54 16640146 1525295
Mantwill S, Monestel-Umaña S, Schulz PJ. The Relationship between Health Literacy and Health Disparities: A Systematic Review. Antonietti A, editor. PLoS ONE. 2015;10(12):e0145455.
V. Lastrucci C. Lorini S. Caini G. Bonaccorsi Florence Health Literacy Research Group Health literacy as a mediator of the relationship between socioeconomic status and health: a cross-sectional study in a population-based sample in Florence PLoS ONE 2019 14 12 e0227007 1:CAS:528:DC%2BB3cXitFSit78%3D 31869381 6927637
Y.L. Shih C.J. Hsieh Y.T. Lin Y.Z. Wang C.Y. Liu The Mediation Effect of Health Literacy on Social Support with Exchange and Depression in Community-Dwelling Middle-aged and older people in Taiwan Healthcare 2021 9 12 1757 34946483 8701837
K. Sørensen J.M. Pelikan F. Röthlin K. Ganahl Z. Slonska G. Doyle et al. Health literacy in Europe: comparative results of the European health literacy survey (HLS-EU) Eur J Public Health 2015 25 6 1053 8 25843827 4668324
N.D. Berkman S.L. Sheridan K.E. Donahue D.J. Halpern K. Crotty Low Health Literacy and Health Outcomes: an updated systematic review Ann Intern Med 2011 155 2 97 21768583
W.L. Chen C.G. Zhang Z.Y. Cui J.Y. Wang J. Zhao J.W. Wang et al. The impact of social capital on physical activity and nutrition in China: the mediating effect of health literacy BMC Public Health 2019 19 1 1713 31856789 6924071
I. van der Heide J. Wang M. Droomers P. Spreeuwenberg J. Rademakers E. Uiters The Relationship between Health, Education, and Health Literacy: results from the Dutch adult literacy and life skills Survey J Health Communication 2013 18 sup1 172 84 24093354
C. Stormacq S. Van den Broucke J. Wosinski Does health literacy mediate the relationship between socioeconomic status and health disparities? Integrative review Health Promot Int 2019 34 5 e1 17 30107564
D. Schillinger Social determinants, health literacy, and disparities: intersections and controversies HLRP: Health Lit Res Pract 2021 5 3 e234 43 34379549 8356483
J. Vandenbosch S. Van den Broucke S. Vancorenland H. Avalosse R. Verniest M. Callens Health literacy and the use of healthcare services in Belgium J Epidemiol Community Health 2016 70 10 1032 8 27116951
S. Bostock A. Steptoe Association between low functional health literacy and mortality in older adults: longitudinal cohort study BMJ 2012 344 mar15 3 e1602 1602 22422872 3307807
I. Kickbusch J.M. Pelikan F. Apfel A.D. Tsouros O. World Health Health literacy: the solid facts 2013 Copenhagen World Health Organization Regional Office for Europe 73 (The solid facts)
On behalf of the Preventive Evidence into Practice (PEP) Partnership Group U.W. Jayasinghe M.F. Harris S.M. Parker J. Litt M. van Driel et al. The impact of health literacy and life style risk factors on health-related quality of life of Australian patients Health Qual Life Outcomes 2016 14 1 68
B. Geboers S.A. Reijneveld C.J.M. Jansen A.F. de Winter Health Literacy Is Associated With Health Behaviors and Social factors among older adults: results from the LifeLines Cohort Study J Health Communication 2016 21 sup2 45 53 27661472
K. Friis M. Lasgaard G. Rowlands R.H. Osborne H.T. Maindal Health literacy mediates the relationship between educational attainment and health behavior: a Danish population-based study J Health Communication 2016 21 sup2 54 60 27668691
Rondia K, Adriaenssens J, Van Den Broucke S, Kohn L. Health literacy: what lessons can be learned from the experiences of other countries? [Internet]. Brussels, Belgium: KCE; 2019 [cited 2023 Oct 17]. Report No.: KCE Report 322. https://kce.fgov.be/sites/default/files/2021-11/KCE_322_Health_Literacy_Report.pdf.
A.J. Woudstra E.M. Smets M.G. Verdam M.P. Fransen The role of health literacy in explaining the relation between educational level and decision making about colorectal cancer screening Int J Environ Res Public Health 2019 16 23 4644 31766603 6926788
M.T. Svendsen C.K. Bak K. Sørensen J. Pelikan S.J. Riddersholm R.K. Skals et al. Associations of health literacy with socioeconomic position, health risk behavior, and health status: a large national population-based survey among Danish adults BMC Public Health 2020 20 1 1 12
S. Demarest J. Van der Heyden R. Charafeddine S. Drieskens L. Gisle J. Tafforeau Methodological basics and evolution of the Belgian health interview survey 1997–2008 Arch Public Health 2013 71 1 24 24047278 3844891
M.H. Lindberg G. Chen J.A. Olsen B. Abelsen Combining education and income into a socioeconomic position score for use in studies of health inequalities BMC Public Health 2022 22 1 1 11
A. Lindmark M. Eriksson D. Darehed Mediation analyses of the mechanisms by which socioeconomic status, comorbidity, stroke severity, and acute care influence stroke outcome Neurology 2023 101 23 e2345 54 1:CAS:528:DC%2BB2cXhvVarsbg%3D 37940549 10752643
P. Zanobini C. Lorini S. Caini V. Lastrucci M. Masocco V. Minardi et al. Health Literacy, socioeconomic status and vaccination uptake: a study on Influenza Vaccination in a Population-based sample IJERPH 2022 19 11 6925 35682508 9180363
Pelikan JM, Röthlin F, Ganahl K. Measuring comprehensive health literacy in general populations: validation of instrument, indices and scales of the HLS-EU study. In Bethesda, Maryland; 2014 [cited 2022 Jun 1]. https://www.bumc.bu.edu/healthliteracyconference/files/2014/06/Pelikan-et-al-HARC-2014-fin.pdf.
Valeri L. Statistical Methods for Causal Mediation Analysis. A dissertation presented to The Department of Biostatistics in partial fulfilment of the requirements for the degree of Doctor of Philosophy in the subject of Biostatistics. [Internet]. Harvard University; 2012. https://dash.harvard.edu/bitstream/handle/1/10403677/Valeri_gsas.harvard_0084L_10690.pdf?sequence=3.
M.J. Valente J.J.M. Rijnhart H.L. Smyth F.B. Muniz D.P. MacKinnon Causal Mediation Programs in R, M plus, SAS, SPSS, and Stata Struct Equation Modeling: Multidisciplinary J 2020 27 6 975 84
T.J. VanderWeele S. Vansteelandt Odds Ratios for Mediation Analysis for a dichotomous outcome Am J Epidemiol 2010 172 12 1339 48 21036955 2998205
Berglund PA. Multiple Imputation Using the Fully Conditional Specification Method: A Comparison of SAS®, Stata, IVEware, and R. Proceedings of the SAS Global Forum 2015 Conference Cary, NC: SAS Institute Inc. 2015;17.
SAS Institute Inc. SAS/STAT®14.3 User’s Guide The CAUSALMED Procedur [Internet]. Cary, NC: SAS Institute Inc. 2017 [cited 2022 Dec 7]. https://support.sas.com/documentation/onlinedoc/stat/143/causalmed.pdf.
J. Wang L. Geng Effects of Socioeconomic Status on Physical and Psychological Health: Lifestyle as a Mediator IJERPH 2019 16 2 281 30669511 6352250
E. Von Elm D.G. Altman M. Egger S.J. Pocock P.C. Gøtzsche J.P. Vandenbroucke The strengthening the reporting of Observational studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies Lancet 2007 370 9596 1453 7
S. Van Den Broucke A. Renwart Health literacy mediates the relationship between education level and health behaviour: Stephan Van Den Broucke Eur J Pub Health 2014 24 suppl2 cku164 012
Cellule Générale de Politique Drogues. Stratégie interfédérale 2022–2028 pour une génération sans tabac [Internet]. 2022. https://organesdeconcertation.sante.belgique.be/sites/default/files/documents/20220323_strategie_interfederale_tabac_note_de_base_fr.pdf.
K. Lucyk K.A. Simmonds D.L. Lorenzetti S.J. Drews L.W. Svenson M.L. Russell The association between influenza vaccination and socioeconomic status in high income countries varies by the measure used: a systematic review BMC Med Res Methodol 2019 19 1 153 31315574 6637551
J.M. Pelikan T. Link C. Straßmayr K. Waldherr T. Alfers H. Bøggild et al. Measuring Comprehensive, General Health Literacy in the General Adult Population: the Development and Validation of the HLS19-Q12 instrument in Seventeen Countries IJERPH 2022 19 21 14129 36361025 9659295
Duong TV, Aringazina A, Kayupova G, Nurjanah, Pham TV, Pham KM et al. Development and Validation of a New Short-Form Health Literacy Instrument (HLS-SF12) for the General Public in Six Asian Countries. HLRP: Health Literacy Research and Practice [Internet]. 2019 Apr [cited 2023 Sep 5];3(2). https://journals.healio.com/doi/https://doi.org/10.3928/24748307-20190225-01.
J.M. Pelikan K. Ganahl F. Roethlin Health literacy as a determinant, mediator and/or moderator of health: empirical models using the European health literacy survey dataset Global Health Promotion 2018 25 4 57 66
Pelikan JM. Health-literate healthcare organisations. International Handbook of Health Literacy. Policy; 2019. pp. 539–54.
M.S. Kaper J. Sixsmith S.A. Reijneveld A.F. de Winter Outcomes and critical factors for successful implementation of organizational health literacy interventions: a scoping review Int J Environ Res Public Health 2021 18 22 11906 34831658 8622809
D. Nutbeam J.E. Lloyd Understanding and responding to health literacy as a social determinant of health Annu Rev Public Health 2021 42 1 159 73 33035427
Kickbusch I, Pelikan J, Apfel F, Tsouros A. Health literacy: The solid facts. 2013. World Health Organization, Regional Office for Europe. 2013.
Brumagne A, Mannaerts D. Littératie en santé: pour une approche Globale et émancipatrice visant l’équité. Repères DoRiF. 2018;16.
Okan O, Bauer U, Levin-Zamir D, Pinheiro P, Sorensen K. International Handbook of Health Literacy. Policy; 2019.
M.C. Chouinard M. Lambert M. Lavoie S.D. Lambert É. Hudon O. Dumont-Samson et al. Measuring Health Literacy in Primary Healthcare: adaptation and validation of a French-Language Version of the Brief Health Literacy Screening among patients with chronic conditions seen in primary care Int J Environ Res Public Health 2022 19 13 7669 35805333 9265285
Van den Broucke S. Capacity building for health literacy. Int Handb Health Lit. 2019;705.
Public Health England. Local action on health inequalities: improving health literacy to reduce health inequalities. 2015.
M.K. Paasche-Orlow D. Schillinger B.D. Weiss T. Bickmore H. Cabral P. Chang et al. Health literacy and power HLRP: Health Lit Res Pract 2018 2 3 e132 3 31294288 6607841
F. Zhang P.P. Or J.W. Chung How different health literacy dimensions influences health and well-being among men and women: the mediating role of health behaviours Health Expect 2021 24 2 617 27 33539611 8077109
W. Wang S. Nelson J.M. Albert Estimation of causal mediation effects for a dichotomous outcome in multiple-mediator models using the mediation formula Statist Med 2013 32 24 4211 28
