The Relationship Between Health, Education, and Health Literacy: Results From the Dutch Adult Literacy and Life Skills Survey

Figures & data

Table 1. Sample characteristics and health literacy (N = 5,136)

Characteristics ^a	n	%
Female	2,863	55.7
Age (years)
25–35	1,070	20.8
36–45	1,473	28.7
46–55	1,230	23.9
56–65	1,363	26.5
Level of education
Preprimary/primary	284	5.5
Lower secondary	1,256	24.5
Upper secondary	1,553	30.2
Tertiary	2,027	39.5
Missing	16	0.3
Self-reported general health
Excellent	797	15.5
Very good	1,198	23.3
Good	2,354	45.8
Fair	675	13.1
Poor	103	2.0
Missing	9	0.2
Mental health ^b
Good mental health	4,537	88.3
Physical health ^c
Good physical health	3,505	68.9
Health literacy level
Level 1 (very poor)	542	10.6
Level 2 (poor)	2,227	43.4
Level 3 (adequate)	2,138	41.6
Level 4 (strong)	229	4.5

Figure 1 Conceptual model of health literacy as a mediator between education and self-reported general health, self-reported physical health, and self-reported mental health, adjusting for age and sex in all steps of the model.

Table 2. Health literacy, by level of education (N = 5,120)

Level of education	Health literacy level
	Level 1 (very poor)		Level 2 (poor)		Level 3 (adequate)		Level 4 (strong)
	n	%	n	%	n	%	n	%
Tertiary	42	2.1	610	30.1	1,198	59.1	177	8.7
Upper secondary	120	7.7	755	48.6	635	40.9	43	2.8
Lower secondary	226	18.0	736	58.6	287	22.9	7	0.6
Preprimary/primary	145	51.1	121	42.6	16	5.6	2	0.7

Table 3. Results regression analyses for the total effect and direct effect of education on health

		Total effect (c) ^b (without health literacy)		Direct effect (c') ^c (including health literacy)
	Education ^a (reference: tertiary)	B	SE	B	SE
Self-reported general health	Upper secondary	−0.18**	0.032	−0.14**	0.033
	Lower secondary	−0.20**	0.034	−0.12*	0.039
	Preprimary/primary	−0.53**	0.060	−0.37**	0.071
Self-reported physical health	Upper secondary	−1.79**	0.287	−1.47**	0.304
	Lower secondary	−1.86**	0.311	−1.30*	0.356
	Preprimary/primary	−4.49**	0.551	−3.43**	0.646
Self-reported mental health	Upper secondary	−0.54	0.284	−0.32	0.294
	Lower secondary	−0.40	0.308	−0.01	0.338
	Preprimary/primary	−2.42**	0.545	−1.68*	0.607

Table 4. Mediation effect of health literacy in the association between education and health

	Education (reference: tertiary)	Mediated effect (ab)		Effect size (%)
		B	SE
Self-reported general health	Upper secondary	−0.04*	0.011	22.2
	Lower secondary	−0.06**	0.019	33.3
	Preprimary/primary	−0.12**	0.037	24.5
Self-reported physical health	Upper secondary	−0.30*	0.108	16.9
	Lower secondary	−0.54*	0.191	29.3
	Preprimary/primary	−1.03*	0.365	23.1
Self-reported mental health ^a	Preprimary/primary	−0.73*	0.243	30.3

Level	Score	Interpretation
1	0–225	Very poor health literacy skills. An individual at this level may, for example, be unable to determine from a package label the correct amount of medicine to give a child. Tasks at this level require the ability to read relatively short text, locate or enter a piece of information, and complete simple, one-step tasks such as counting, sorting dates, or performing simple arithmetic.
2	226–275	Poor health literacy skills. The capacity to deal only with simple, clear material involving uncomplicated tasks. People at this level may develop everyday coping skills, but their poor literacy makes it hard to conquer challenges such as learning new job skills. Tasks at this level require, for example, the ability to sort through distractors (plausible but incorrect pieces of information), integrate two or more pieces of information, compare and contrast information, and interpret simple graphs.
3	276–325	Adequate health literacy skills. An individual at this level has the ability to cope with the demands of everyday life and work in an advanced society. It roughly denotes the skill level required for successful high school completion and college entry. These tasks require the ability to integrate information from dense or lengthy text, integrate multiple pieces of information, and demonstrate understanding of mathematical information represented in a range of different forms. Tasks typically involve a number of steps or processes in order to solve problems.
4	326–375 376–500	Strong health literacy skills. An individual at these levels can process information of a complex and demanding nature. Tasks at this level involve multiple steps to find solutions to abstract problems. Tasks require the ability to integrate and synthesize multiple pieces of information from lengthy or complex passages and make inferences from the information. Very strong health literacy skills. Tasks at this level require the ability to search for information in dense text that has a number of distractors, make high-level inferences or use specialized background knowledge, and understand complex representations of abstract formal and informal mathematical ideas.

Level of education	Health literacy score		Equal to health literacy level
	Weighted M	SE
Total	267.60	0.805	Poor health literacy skills (2)
Tertiary	287.68	1.189	Adequate health literacy skills (3)
Upper secondary	268.71	1.116	Poor health literacy skills (2)
Lower secondary	252.98	1.249	Poor health literacy skills (2)
Preprimary/primary	220.57	2.912	Very poor health literacy skills (1)

Ware , J. E. , Kosinski , M. , & Keller , S. D. ( 1995 ). SF-12: How to score the SF-12 Physical and Mental Health Summary Scales () , 2nd ed. . Boston , MA : The Health Institute, New England Medical Center .

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