An international comparison of the association among literacy, education, and health across the United States, Canada, Switzerland, Italy, Norway, and Bermuda: implications for health disparities.

The relationship between education and health is well-established, but theoretical pathways are not fully understood. Economic resources, stress, and health behaviors partially explain how education influences health, but further study is needed. Previous studies show that health literacy mediates the education-health relationship, as do general literacy skills. However, little is known whether such mediation effects are consistent across different societies. This study analyzed data from the International Assessment of Adult Literacy and Life Skills Survey conducted in Canada, the United States, Italy, Norway, Switzerland, and Bermuda to investigate the mediation effects of literacy on the education-health relationship and the degree of such mediation in different cultural contexts. Results showed that literacy skills mediated the effect of education on health in all study locations, but the degree of mediation varied. This mediation effect was particularly strong in Bermuda. This study also found that different types of literacy skills are more or less important in each study location. For example, numeracy skills in the United States and prose (reading) literacy skills in Italy were stronger predictors of health than were other literacy skills. These findings suggest a new direction for addressing health disparities: focusing on relevant types of literacy skills.