Health Literacy: Determinant of Health or Status Indicator?

An increasing burden of preventable diseases, persistent health inequalities, and new infectious diseases call for responsible citizens to take care of their health and health decisions. Therefore, health literacy appears to be a promising concept to foster better health behaviours. However, health literacy is a broad concept and interventions targeting health literacy show mixed results. Against this background, this thesis’ aim is twofold. First, it explores health literacy as determinant of health. Secondly, and entwined with the first, it aims to provide a better conceptual understanding of health literacy.
For the empirical analyses, data from Swiss male young adults were used. Three studies were carried out, each with different statistical approaches, to obtain a better understanding of the pathways between health literacy, its contextual factors, and favourable health outcomes. The studies’ results do not support the notion that health literacy – as a distinct phenomenon – has a causal importance to health. Rather, the findings suggest that health literacy should be acknowledged as a multifactorial phenomenon with many different dimensions, dependencies, and conversion factors. The latter either amplify or impede health literacy’s positive effects on health. Finally, the results indicate that potential health literacy interventions are likely to only address a selection of these aspects and may have limited or no benefit on health depending on personal and contextual factors.
This umbrella text also presents conceptual work that could not be presented in the three journal articles. The health literacy staircase model (HL-SM) introduced here, describes the embeddedness of health literacy in contextual factors and addresses the complex path from knowledge to decision-making and decision-implementation. Further, it discusses several shortcomings of previous health literacy definitions and conceptualizations that are presented in the introduction section. The HL-SM was developed after the second publication and inspired the third study that explores the role of decision-making ability as a mediator from health literacy to health.
This thesis calls for more health literacy research focussing on informed health decision-making in every-day contexts. Further, health literacy research is urged to give more emphasis to the concept’s boundaries, dependencies, and conversion factors. Without paying attention to prevailing contextual factors, there is considerable danger towards an individualization of a primarily societal problem.