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Objective: To provide an evidence-based review of plausible causal pathways that could best explain well-established associations between limited health literacy and health outcomes. Methods: Through analysis of current findings in medical and public health literature on health literacy we derived a conceptual causal model. Results: Health literacy should be viewed as both a patient and a system phenomenon. Three distinct points along a continuum of health care are suggested to be influenced by health literacy: (1) access and utilization of health care, (2) patient-provider relation-ship, and (3) self-care. Conclusions: The conceptual model organizes what has been learned to date and underscores promising areas of future inquiry and intervention.
Key words: causal pathways, health literacy, literacy, conceptual model
Am J Health Behav. 2007;31(Suppl 1):S19-S26
Though limited health literacy has been shown to be associated with worse health outcomes,1 the causal pathways are not entirely known,2.3 and several projects have focused on explaining potential mechanisms.38 This paper provides a review of the current evidence and proposes a conceptual model describing the systemic, interactional, and self-care mechanisms by which limited health literacy is most likely to lead to worse health outcomes. By doing so, we begin to highlight some of the most promising areas for intervention research as well as important gaps in our current understanding of the pathways linking literacy and health. This is one step in what will need to be an iterative process of model specification and clarification. It is our hope that investigators will increasingly pursue research designs and analytic approaches to refine the model so that the most valid and useful explanations of the relationship between health literacy and outcomes can inform professional responses to the problem in the many diverse contexts of health care.9
It should first be recognized that limited health literacy is strongly associated with other socioeconomic indicators, including educational attainment, race/ethnicity, and age.10 Such associations make it difficult to discern the independent effect of health literacy from the complex relationships known between these latent and evolving traits that are also interrelated themselves. Yet many of the determinants of disease, in general, are interconnected in complex ways.11 In this sense, the current model is focused on the direct pathways between literacy and health outcomes, while recognizing there are likely...