Health literacy as a mediator of the relationship between socioeconomic status and health: A cross-sectional study in a population-based sample in Florence

Autoři: Vieri Lastrucci aff001;  Chiara Lorini aff001;  Saverio Caini aff002;  ;  Guglielmo Bonaccorsi aff001
Působiště autorů: Department of Health Science, University of Florence, Florence, Italy aff001;  Cancer Risk Factors and Lifestyle Epidemiology Unit, Institute for Cancer Research, Prevention and Clinical Network (ISPRO), Florence, Italy aff002
Vyšlo v časopise: PLoS ONE 14(12)
Kategorie: Research Article



Health literacy(HL) has recently been proposed as a potential mediator in the pathway through which socio-economic status(SES) affects health. However, empirical research investigating the contribution of HL in this relationship remains scarce. This study investigated whether functional HL mediates the association between SES and self-reported health(SRH) in an adult population-based sample.


The study adopted a cross-sectional design. Education level and financial status were used as measures of SES, while functional HL was assessed with the Newest Vital Sign. Moderated mediation analyses were conducted using SES variables as independent variables, SRH as dependent variable and functional HL as mediator variable. Furthermore, age, sex and chronic diseases were tested as moderators of the effect mediated by functional HL.


452 subjects completed the study (58,8% female; mean age 53,25±11,7). Results showed that functional HL mediates on average 18.5% of the association between education and SRH (p = 0.02) and 12.9% (p = 0.01) of the association between financial status and SRH. Furthermore, the proportion of effect mediated by functional HL was found to be higher in lower socio-economic classes for both SES variables considered. No significant moderation effects of age, sex or chronic diseases were observed for both SES variables.


Findings suggest that functional HL may serve as a pathway by which SES affects health status, especially in lower SES groups. HL may be a valuable and actionable intermediate target for addressing health inequalities. However, further studies are needed to better define the mediating role of HL across socio-economic classes.

Klíčová slova:

Behavioral and social aspects of health – Educational attainment – Finance – Health care policy – Health education and awareness – Population groupings – Schools – Socioeconomic aspects of health


1. Adler NE, Newman K. Socioeconomic disparities in health: pathways and policies. Health Aff (Millwood). 2002;21:60–76. doi: 10.1377/hlthaff.21.2.60 11900187

2. Mackenbach JP. The persistence of health inequalities in modern welfare states: The explanation of a paradox. Soc Sci Med. 2012;75(4):761–769. doi: 10.1016/j.socscimed.2012.02.031 22475407

3. Marmot M, Allen J, Bell R, Bloomer E, Goldblatt P; Consortium for the European Review of Social Determinants of Health and the Health Divide. WHO European review of social determinants of health and the health divide. Lancet. 2012;380:1011–1029. doi: 10.1016/S0140-6736(12)61228-8 22964159

4. Cutler DM, Lleras-Muney A. Understanding differences in health behaviors by education. J Health Econ. 2010;29(1), 1–28. doi: 10.1016/j.jhealeco.2009.10.003 19963292

5. Paasche-Orlow MK, Wolf MS. The causal pathways linking health literacy to health outcomes. Am J Health Behav. 2007;31(S1):S19–26. doi: 10.5555/ajhb.2007.31.supp.S19 17931132

6. Husson O, Mols F, Fransen MP, van de Poll-Franse LV, Ezendam NP. 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. Psycho-Oncology. 2015;24(4):478–486. doi: 10.1002/pon.3678 25241852

7. Schillinger D, Barton LR, Karter AJ, Wang F, Adler N. Does literacy mediate the relationship between education and health outcomes? A study of a low-income population with diabetes. Public Health Rep. 2006;121:245–54. doi: 10.1177/003335490612100305 16640146

8. Mantwill S, Monestel-Umana S, Schulz PJ. The relationship between health literacy and health disparities: a systematic review. PLoS One. 2015;10, e0145455. doi: 10.1371/journal.pone.0145455 26698310

9. Sørensen K, Van den Broucke S, Fullam J, Doyle G, Pelikan J, Slonska Z, et al. Health literacy and public health: a systematic review and integration of definitions and models. BMC Public Health. 2012;12:80. doi: 10.1186/1471-2458-12-80 22276600

10. Bonaccorsi G, Lastrucci V, Vettori V, Lorini C; Florence Health Literacy Research Group. Functional health literacy in a population-based sample in Florence: a cross-sectional study using the Newest Vital Sign. BMJ Open. 2019;9:e026356. doi: 10.1136/bmjopen-2018-026356 31221877

11. Paasche-Orlow MK, Parker RM, Gazmararian JA, Nielsen-Bohlman LT, Rudd RR. The prevalence of limited health literacy. J Gen Intern Med. 2005;20:175–184. doi: 10.1111/j.1525-1497.2005.40245.x 15836552

12. Lee SY, Tsai TI, Tsai YW, Kuo KN. Health literacy, health status, and healthcare utilization of Taiwanese adults: Results from a national survey. BMC Public Health. 2010;10:614. doi: 10.1186/1471-2458-10-614 20950479

13. HLS-EU Consortium. Comparative report on health literacy in eight EU member states. The European health literacy survey HLS-EU. 2012. Available from: Cited 7 July 2019

14. Baker DW, Wolf MS, Feinglass J, Thompson JA, Gazmararian JA, Huang J. Health literacy and mortality among elderly persons. Arch Intern Med. 2007;167:1503–1509. doi: 10.1001/archinte.167.14.1503 17646604

15. Adams RJ, Appleton SL, Hill CL, Dodd M, Findlay C, Wilson DH. Risks associated with low functional health literacy in an Australian population. Med J Aust. 2009;191(10):530–534. doi: 10.5694/j.1326-5377.2009.tb03304.x 19912083

16. Bennett IM, Chen J, Soroui JS, White S. The contribution of health literacy to disparities in self-rated health status and preventive health behaviors in older adults. Ann Fam Med. 2009;7:204–211. doi: 10.1370/afm.940 19433837

17. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med 2011;155(2):97–107. doi: 10.7326/0003-4819-155-2-201107190-00005 21768583

18. Lorini C, Santomauro F, Donzellini M, Capecchi L, Bechini A, Boccalini S, et al. Health literacy and vaccination: A systematic review. Hum Vaccin Immunother. 2018;14(2):478–488. doi: 10.1080/21645515.2017.1392423 Epub 2017 Dec 6. 29048987; PMCID: PMC5806657.

19. Stormacq C, Van den Broucke Wosinski J. Does health literacy mediate the relationship between socioeconomic status and health disparities? Integrative review. Health Promot Int. 2018;day062. doi: 10.1093/heapro/day062 30107564

20. Miles JN, Kulesza M, Ewing B, Shih RA, Tucker JS, D'Amico EJ. Moderated mediation analysis: An illustration using the association of gender with delinquency and mental health. J Crim Psychol. 2015;5(2):99–123. doi: 10.1108/JCP-02-2015-0010 26500722

21. Lorini C, Santomauro F, Grazzini M, Mantwill S, Vettori V, Lastrucci V, et al. Health literacy in Italy: a cross-sectional study protocol to assess the health literacy level in a population-based sample, and to validate health literacy measures in the Italian language. BMJ Open. 2017;7(11):e017812. doi: 10.1136/bmjopen-2017-017812 29138204

22. Lorini C, Lastrucci V, Mantwill S, Vettori V, Bonaccorsi G; Florence Health Literacy Research Group. Measuring health literacy in Italy: a validation study of the HLS-EU-Q16 and of the HLS-EU-Q6 in Italian language, conducted in Florence and its surroundings. Ann Ist Super Sanita. 2019;55(1):10–18. doi: 10.4415/ANN_19_01_04 30968831

23. Toçi E, Burazeri G, Myftiu S, Sørensen K, Brand H. Health literacy in a population based sample of adult men and women in a South Eastern European Country. J Public Health. 2016;38:6–13. doi: 10.1093/pubmed/fdv006 25635141

24. Unim B, De Vito C, Massimi A, D'Andrea E, Rosso A, Villari P, et al. The need to improve implementation and use of lifestyle surveillance systems for planning prevention activities: an analysis of the Italian Regions. Public Health 2016;130:51–8. doi: 10.1016/j.puhe.2015.08.009 26427315

25. Bombak AE. Self-rated health and public health: a critical perspective. Front Public Health. 2013;1:15. doi: 10.3389/fpubh.2013.00015 24350184

26. Yamada C, Moriyama K, Takahashi E. Self-rated health as a comprehensive indicator of lifestyle-related health status. Environ Health Prev Med. 2012;17(6):457–62. doi: 10.1007/s12199-012-0274-x 22426707

27. Gallagher JE, Wilkie AA, Cordner A, Hudgens EE, Ghio AJ, Birch RJ, et al. Factors associated with self-reported health: implications for screening level community-based health and environmental studies. BMC public health. 2016;16(1):640. doi: 10.1186/s12889-016-3321-5 27460934

28. DeSalvo KB, Bloser N, Reynolds K, He J, Muntner P. Mortality prediction with a single general self-rated health question. J Gen Intern Med. 2006;21(3):267–75. doi: 10.1111/j.1525-1497.2005.00291.x 16336622

29. Tingley D, Yamamoto T, Hirose K, Keele L, Imai K. Mediation: R package for causal mediation analysis. Journal of Statistical Software. 2014; 59(5):1–38. doi: 10.18637/jss.v059.i05

30. Mirowsky J. Education, social status, and health. New York: Routledge; 2017. doi: 10.4324/9781351328081

31. Borgonovi F, Pokropek A. Education and self-reported health: Evidence from 23 countries on the role of years of schooling, cognitive skills and social capital. PloS one. 2016;11.2:e0149716. doi: 10.1371/journal.pone.0149716 26901130

32. Schütte S, Chastang J-F, Parent-Thirion A, Vermeylen G, Niedhammer I. Social differences in self-reported health among men and women in 31 countries in Europe. Scand J Public Health. 2013;41(1):51–7. doi: 10.1177/1403494812469854 23341354

33. Mackenbach JP, Stirbu I, Roskam AJ, Schaap MM, Menvielle G, Leinsalu M, et al. Socioeconomic inequalities in health in 22 European countries. N Engl J Med. 2008;358:2468–2481. doi: 10.1056/NEJMsa0707519 18525043

34. Baker DW, Parker RM, Williams MV, Clark WS, Nurss J. The relationship of patient reading ability to self-reported health and use of health services. Am J Public Health. 1997;87(6):1027–1030. doi: 10.2105/ajph.87.6.1027 9224190

35. Wang J, Geng L. Effects of socioeconomic status on physical and psychological health: lifestyle as a mediator. International Journal of Environmental Research and Public Health 2019;16(2):281. doi: 10.3390/ijerph16020281 30669511

36. Dunlop S, Coyte P, McIsaac W. Socio-economic status and the utilization of physicians’ services: results from the Canadian national population health survey. Social Science and Medicine 2000; 51(1):123–133. doi: 10.1016/s0277-9536(99)00424-4 10817475

37. van der Heide L, Wang J, Droomers M, Spreeuwenberg P, Rademakers J, Uiters E. The relationship between health, education, and health literacy: results from the Dutch Adult Literacy and Life Skills Survey. J Health Commun. 2013;18(S1): 172–184. doi: 10.1080/10810730.2013.825668 24093354

38. Pandit AU, Tang JW, Bailey SC, Davis TC, Bocchini MV, Persell SD, et al. Education, literacy, and health: Mediating effects on hypertension knowledge and control. Patient Education and Counseling 2009;75(3):381–5. doi: 10.1016/j.pec.2009.04.006 19442477

39. Gupta VK, Winter M, Cabral H, Henault L, Waite K, Hanchate A, et al. Disparities in age-associated cognitive decline between African-American and Caucasian populations: the roles of health literacy and education. Journal of the American Geriatrics Society 2016;64: 1716–23. doi: 10.1111/jgs.14257 27310494

40. Zou H, Chen Y, Fang W, Zhang Y, Fan X. The mediation effect of health literacy between subjective social status and depressive symptoms in patients with heart failure. Journal of Psychosomatic Research 2016;91: 33–39. doi: 10.1016/j.jpsychores.2016.10.006 27894460

41. Streiner DL, Norman GR, Cairney J. Health measurement scales. A practical guide to their development and use (5ed.). Oxford: Oxford University Press; 2014. doi: 10.1093/med/9780199685219.001.0001

42. Litwin H, Sapir EV. Perceived income adequacy among older adults in 12 countries: findings from the survey of health, ageing, and retirement in Europe. Gerontologist. 2009;49(3):397–406. doi: 10.1093/geront/gnp036 19386829

43. Case A, Deaton A. Mortality and morbidity in the 21st century. Brookings Pap Econ Act. 2017;2017:397–476. doi: 10.1353/eca.2017.0005 29033460

44. Arber S, Fenn K, Meadows R. Subjective financial well-being, income and health inequalities in mid and later life in Britain. Social Science & Medicine 2014;100:12–20. doi: 10.1016/j.socscimed.2013.10.016 24444834

45. Szanton SL, Allen JK, Thorpe RJ Jr, Seeman T, Bandeen-Roche K, Fried LP. Effect of financial strain on mortality in community-dwelling older women. J Gerontol B Psychol Sci Soc Sci. 2008;63(6):S369–74. doi: 10.1093/geronb/63.6.s369 19092046; PMCID: PMC2874583.

46. Wilkinson LR. Financial Strain and Mental Health Among Older Adults During the Great Recession. J Gerontol B Psychol Sci Soc Sci. 2016 Jul;71(4):745–54. doi: 10.1093/geronb/gbw001 26843395

47. Shippee TP, Wilkinson LR, Ferraro KF. Accumulated financial strain and women's health over three decades. J Gerontol B Psychol Sci Soc Sci. 2012 Sep;67(5):585–94. doi: 10.1093/geronb/gbs056 22929397

48. Pelikan JM, Ganahl K, Roethlin F. Health literacy as a determinant, mediator and/or moderator of health: empirical models using the European Health Literacy Survey dataset. Glob Health Promot. 2018;25(4):57–66. doi: 10.1177/1757975918788300 30427258

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