Capsule Commentary on Lee et al., Health Literacy as a Social Determinant of Health in Asian American Immigrants: Findings from a Population-Based Survey in California.

Abstract

Lee and colleagues used population-based data from the California Health Interview Survey (CHIS) to assess the relationship between self-rated health (SRH), depressive symptoms and health literacy among five Asian American immigrant groups.1 Controlling for English proficiency and duration of U.S. residence, health literacy levels for Chinese, Korean, and Vietnamese immigrants were lower than for non-Latino whites. Health literacy was positively associated with SRH among Chinese and Koreans and negatively associated with depressive symptoms among Koreans and South Asians. These findings support the use of brief health literacy screens in routine clinical care.2 This study disaggregated Asian Americans by ethnicity to identify groups disproportionately affected by poor health literacy, which may help focus community-based interventions. However, use of the two-item health literacy measure in CHIS limits interpretation; the mechanisms linking health literacy, SRH, and depressive symptoms for these groups remain unclear and it is possible that they are inadequately captured by items focusing on reading. Language is an incomplete explanation. While a previous study showed that limited English proficiency patients with language-concordant physicians reported fewer problems with medical comprehension compared to patients with language-discordant physicians,3 the current analysis adjusted for English language proficiency and the surveyed South Asians had high levels of English proficiency. The cross-sectional study design also leaves the possibility of reverse causation, that individuals with depression have lower health literacy. Paasche-Orlow and Wolf suggest that health literacy influences three points in health care: access and utilization, patient–provider relationship, and self-care.4 A subsequent path analysis study confirmed an indirect pathway from health literacy to health status via knowledge and self-efficacy.5 Health literacy reflects the ability to not only obtain information, but also to use it appropriately. Culture can influence expectations for communication, beliefs about patients’ role in decision making, and motivation to seek help for depressive symptoms. Investigating the relationship between these factors and health literacy may help explain why the association between health literacy and outcomes differed between ethnic groups, and inform interventions to improve the health of Asian American patients.