The Intersections Between Social Determinants of Health, Health Literacy, and Health Disparities

Abstract

This chapter synthesizes what is known about the relationship between social disadvantage and measures of low health literacy (LHL), and reviews the research examining whether LHL is an explanatory factor connecting social disadvantage, health outcomes, and health disparities. Written from a U.S. perspective, the chapter then offers a novel conceptual framework that presents how the social determinants of health might interact with LHL to result in health disparities. The framework articulates relationships that reflect public health pathways and healthcare pathways, which include their related health literacies. In addition, the chapter highlights as an exemplar one important potential causal mechanism in the healthcare pathway by exploring the communication model in outpatient care, as communication has been very well-studied with respect to both health disparities and HL. The chapter then, provides two examples of HL interventions aligned with the conceptual framework, one of which addresses the health care literacy pathway, and the other addresses the public health literacy pathway. The chapter continues with a number of cautionary statements based on the inherent limitations of current HL research, including problems and concerns specific to the attribution of HL as an explanatory factor for extant socioeconomic and racial/ethnic health disparities. The chapter closes with recommendations regarding future research directions.

Keywords: communication; discrimination; health disparities; health literacy; health policy; measurement; public health; race and ethnicity; social ecological model.

Figures

Figure 1.

Percentage of adults in each health literacy level, by race/ethnicity (2003)

Figure 2.

Percentage of adults in each health literacy level, by highest educational attainment (2003)

Figure 3.

Average health literacy scores of adults, by poverty threshold (2003)

Figure 4.

Average health literacy scores of adults by language spoken before starting school (2003)

Figure 5:

Conceptual Framework for the Pathways that Connect Social Determinants of Health, Health Literacy and Health Disparities. Pathways on the right represent healthcare pathways; those on the left represent public health pathways

Figure 6.

Model for successful communication with vulnerable patients in the outpatient clinical encounter. (From: Schillinger D, et al. The Next Frontier in Communication and the ECLIPPSE Study: Bridging the Linguistic Divide in Secure Messaging. J Diabetes Res 2017)