A multilevel analysis of community and individual health literacy to self-reported health status

Background: Individual health literacy is a well-established predictor of health outcomes, yet limited research has simultaneously considered individual and community health literacy. This is despite the fact that community-level factors are known to impact health above and beyond individual-level factors and are important for understanding health disparities.

Objective: This study considered the relationship between community and individual health literacy on self-reported health status in a state-wide analysis.

Design: We used data from the 2008 and 2010 Hawaii Health Survey, a representative state-wide telephone survey.

Participants: The final analytical sample included 11,779 individuals within 37 communities of diverse racial/ethnic backgrounds.

Main Measures: Individual health literacy was defined by validated self-reported measurement. Community health literacy was defined as the percent of individuals within a community reporting low health literacy. Final multilevel models predicted individual self-reported health status by both individual and community health literacy controlling for relevant individual-level (education, race/ethnicity, gender, poverty, insurance status, age, and marital status) and community-level variables (community poverty and community education). Communities were defined by zip code combinations. Census data by ZCTA (ZIP Code Tabulation Areas) for community-level variables were linked to individuals through zip codes.

Key Results: In descriptive results, 18.1% of the sample had self-reported low health literacy and 14.6% had poor self-reported health. The percent of individuals within a community with low health literacy ranged from 5.37% to 35.99%. In the final multilevel logistic models, both individual (OR: 2.00; 95% CI: 1.64-2.44) and community health literacy (OR: 1.02; 95% CI: 1.00-1.04) were significantly associated with self-reported health status. Other significant factors in the final models included race/ethnicity, individual educational attainment, individual age, and individual poverty.

Conclusions: Both individual and community health literacy are significant, distinct correlates of individual general health status. Efforts to promote individual and community health literacy may work together, and separately, to improve population health and to impact health disparities. Primary care should consider and address health literacy at both the community and individual-level.