Decision-Making Ability: A Missing Link Between Health Literacy, Contextual Factors, and Health.

BACKGROUND: Health literacy has often been described as an important precondition for good health decisions, healthy behaviors, and health. However, reviews reveal low evidence for intervention effectiveness through health literacy. This result calls for more investigations to be done in the pathway from health literacy to health, considering intermediate outcomes of health literacy. OBJECTIVE: This study explores an important immediate objective of health literacy, namely the decision-making ability (DMA) regarding health issues. The study's hypothesis claims the DMA to be an important mediator between health literacy and health outcomes. Furthermore, the study assumes that the effect of the DMA on different health outcomes is not only contingent on health literacy but also on contextual factors. To test the above hypotheses, six different health literacy dimensions and four health outcomes have been analyzed. METHODS: Cross-sectional data from the Young Adult Survey Switzerland was used for mediation analyses (N = 4, 569, age, 18 to 25 years, all male). Multiple regression and KHB (Karlson, Holm, and Breen) decomposition analyses were applied to estimate mediation effects between health literacy and health outcomes. KEY RESULTS: Five of six health literacy dimensions explained the DMA in a linear regression model. The coefficients of the DMA explaining health outcomes were substantially reduced when health literacy items were included into the models (6.1%-20.3%). Furthermore, the associations between health literacy and the health outcomes were fully explained by contextual factors, except in the mental health model. CONCLUSIONS: The results support the hypothesis that higher health literacy levels do not necessarily lead to better health directly. Rather, health literacy is just one of multiple factors contributing to a higher DMA and, further, to favorable health outcomes. The results of this study call for more investigations in the health decision-making process and the role of contextual factors. [HLRP: Health Literacy Research and Practice. 2022;6(3):e213-e223.] Plain Language Summary: The study investigated the ability to make good health decisions while considering health literacy. The results support the intermediate function of the decision-making ability on the path to favorable health outcomes. Furthermore, it is found that the DMA as well as health literacy are highly contingent on contextual factors. The results shed light into the complex decision-making process regarding health issues.

Financial Loss and Depressive Symptoms in University Students During the First Wave of the COVID-19 Pandemic: Comparison Between 23 Countries.

Objectives: To assess the association between students' financial loss and depressive symptoms during the first wave of the coronavirus disease 2019 (COVID-19) pandemic and whether this association varied by countries having different levels of lockdown measures. Methods: This cross-sectional survey, conducted in spring 2020, included 91,871 students from 23 countries. Depressive symptoms were measured using the shortened Center for Epidemiological Studies Depression Scale and information on lockdowns retrieved from the COVID-19 government response tracker. The association between financial loss and depressive symptoms was investigated estimating prevalence ratios (PR) with multilevel Poisson models. Results: Some 13% of students suffered financial loss during the lockdown and 52% had a relatively high depression score, with large between-countries differences. Minimally and maximally adjusted models showed a 35% (PR = 1.35, 95% Confidence Interval (CI) = 1.29-1.42) and 31% (PR = 1.31, 95% CI = 1.26-1.37) higher prevalence of depressive symptoms in students who lost economic resources compared to students with stable economic resources. No substantial differences in the association were found across countries. Conclusion: Depressive symptoms were more frequent among students who suffered financial loss during the pandemic. Policy makers should consider this issue in the implementation of COVID-19 mitigating measures.

Challenging the association between health literacy and health: the role of conversion factors.

Previous studies have found substantial correlations between health literacy and various health outcomes. However, the role of social and personal factors in those links remains understudied. Applying a moderation approach, we assume that these factors function as conversion factors on the associations between health literacy and health outcomes. Consequently, we test if associations between health literacy and health outcomes are stronger among young male adults who score high in conversion factors compared to those who score low. Cross-sectional data from the Young Adult Survey Switzerland were used for the analyses (n = 9339, age = 18-25). Multiple logistic regression analyses were applied to estimate associations between health literacy and health. Moderator analyses with three conversion factors and five health outcomes were conducted. For each health outcome at least one conversion factor moderated the association between health literacy and health according to the hypothesis. Although strength and form of the moderation effect differ across analyses, generally stronger associations were found among groups with beneficial social or personal factors. The present findings support the hypothesis that conversion factors play a crucial role in the associations between health literacy and health. The findings, thus, point towards a potential risk of linear health literacy approaches that assume equal benefits from increased health literacy. Individuals with beneficial social and personal factors (those already privileged) may enjoy greater health benefits from interventions improving health literacy.

The relationship between health literacy and health outcomes among male young adults: exploring confounding effects using decomposition analysis.

OBJECTIVES: Previous studies indicate substantial correlations between low health literacy and poor health outcomes. However, empirical findings remain inconsistent and are theoretically challenging. In this study, we conceptually place health literacy within an established model of health inequality. Studying multiple pathways, we estimate the associations between health literacy and six health outcomes and decompose these associations with health literacy's covariates. METHODS: Cross-sectional data from the Young Adult Survey Switzerland was used for the analyses (n = 5959, age = 18-25). Logistic regression and KHB decomposition analyses were applied to estimate health literacy's coefficients and confounding percentages. RESULTS: Eleven covariates were associated with health literacy (p < 0.001). Ten covariates reduced the naïve health literacy coefficient when included in the regression models (confounding percentages: 36.7-86.9%). In three out of six models, the confounding effects led to non-significant health literacy coefficients. CONCLUSIONS: We found that health literacy's associations with health outcomes are confounded by socioeconomic, material, psychosocial, and health-related factors. More investigations on the causal importance of health literacy, respectively, on its potential to health promotion are required.