Education, literacy, and health: Mediating effects on hypertension knowledge and control
Introduction
Over the past several decades, studies have repeatedly highlighted the strong association between lower educational attainment and poor health outcomes, including mortality [1], [2], [3], [4], [5]. These relationships have remained significant even after adjusting for relevant socioeconomic indicators. While there have been many plausible explanations proposed to understand this association, the causal pathways between education and health are still not entirely clear.
Recent investigations have examined the role of adult literacy skills as a mediating factor to the education–health relationship [6], [7], [8]. Literacy is a multifaceted concept that includes many of the cognitive and social skills learned through formal education processes; reading and numeracy are just a few of the fundamental components [9]. A significant body of research has consistently documented a strong, graded relationship between both education and literacy skills with health knowledge [10], [11], [12]. Fewer studies to date have evaluated the relationship between literacy and health outcomes, including mortality; those documenting positive associations found literacy to be the more dominant predictor compared to years of education [6], [7], [8].
In this study, we sought to examine whether literacy mediated the association between education, hypertension knowledge and control among a sample of adults receiving care at safety net clinics in diverse areas of the United States. We hypothesized that educational attainment would be significantly related to a patient's understanding of disease and treatment, and that this relationship would be strongly mediated by literacy skills. The associations between education, literacy, and hypertension control were thought to be more complex, as acquisition of knowledge often does not translate to behavior.
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Setting and participants
We recruited consecutive patients with diagnosed hypertension and scheduled appointments from six primary care safety net clinics in Grand Rapids, MI, Chicago, IL, and Shreveport, LA. Clinics in Grand Rapids (n = 2) and Chicago (n = 2) were all affiliated with federally qualified health centers. One clinic in Shreveport was a community health center and the other a public hospital ambulatory care clinic. The institutional review boards at each location approved the study procedures. Eligible
Results
Table 1 provides both an overall statistical description of the study population and stratifications by educational attainment and health literacy level. The mean age of patients was 53.6 years (SD = 12.0); 67.9 percent were female, and 78.5 percent were African American. A third of subjects were recruited from each of the study sites, 30.6 percent from Chicago, 36.1 percent from Grand Rapids, and 33.3 percent from Shreveport. Most participants (65.8%) were unemployed, and 43.9 percent did not
Discussion
Few studies to date have attempted to examine in detail the link between education, literacy, and health [8], [17]. In this multi-site study among medically underserved patient populations, approximately half of adults with diagnoses of hypertension were uncontrolled. Those who reported fewer years of schooling possessed less knowledge of the disease and its treatment and were at greater risk for not having their hypertension under control. Limited literacy skills mediated the relationship
Acknowledgements
Funding for this study was provided in part by a research grant awarded to Cherry Street Health Services by the Michigan Department of Community Health. Dr. Tang is a National Research Service Award postdoctoral fellow at the Institute for Healthcare Studies, which is supported under an institutional award from the Agency for Healthcare Research and Quality, T-32 HS 000078. Dr. Persell is supported by career development award 1 K08 HS015647-01 from the Agency for Healthcare Research and Quality.
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