Literacy is a fundamental resource highly correlated with

Literacy is a fundamental resource highly correlated with educational attainment. Broadly, literacy has been defined as using printed and written information to function in society, to achieve one’s goals, and to develop one’s knowledge and potential. Literacy enables individuals to gain knowledge about how to attain desired goals in any of the countless interactions that shape daily life e.g., in a clinical care setting, with utility companies, schools, nursing homes, family care providers, rental agencies, or banks. Literacy conceptually entails several skills, including obtaining, understanding, and using printed information. Results from the National Adult Literacy Survey indicate approximately 90 million adult Americans have limited levels of literacy (Kirsch, Jungeblut, Jenkins, & Kolstad, 2002). Few studies have examined literacy as a possible mediator of the relationship between education and health. In 2006, Schillinger found that literacy partially mediated the relationship between education and glycemic control (Schillinger, Barton, Karter, Wang, & Adler, 2006). Literacy has also been shown to partially mediate the link between education and BMS354825 manufacturer knowledge but not hypertension control (Pandit et al., 2009). Recently published work indicated that literacy partially mediates the relationship between education and mortality (Nguyen et al., 2016). To the authors’ knowledge, these remain the only published studies formally evaluating literacy as a mediator between education and health, and no prior work has evaluated the role of literacy in mediating effects of education on mental health outcomes. While there has been robust evidence linking education and depression or depressive symptoms, there has been limited understanding of the pathways that explain this association. Literacy is a foundational skill conferred by schooling. Literacy increases the capacity to obtain, process, and understand health information (Baker et al., 2007; Weiss, Hart, & Pust, 1991). Literacy facilitates the comprehension of prescriptions, health care worker’s instructions for disease management, printed nutrition information, and publicly available health information (Weiss et al., 1991). Literacy can impact health by influencing access and utilization of health care, the patient-provider relationship, and self-care (Paasche-Orlow & Wolf, 2007). Lower adult literacy is associated with less knowledge of health outcomes such as smoking, hypertension, diabetes, lower use of screening and preventive services (DeWalt, Berkman, Sheridan, Lohr, & Pignone, 2004) as well as poorer mental and self-rated health, and higher hospital admissions (Berkman, Sheridan, Donahue, Halpern, & Crotty, 2011). Literacy can impact depressive symptoms in a multitude of ways. Being able to understand and use written text facilitates tasks of daily living such as paying bills or completing job applications. Literacy enables comprehension of prescription and medical treatment instructions, obtaining and understanding provider and public health messages regarding health promoting behaviors, health care check-ups, and screenings, which can influence engagement in health promoting behaviors and health status. This is important for depression because physical inactivity (Fox, 1999; Strawbridge, Deleger, Roberts, & Kaplan, 2002) and poor health status (Tanaka, Sasazawa, Suzuki, Nakazawa, & Koyama, 2011) have been shown to predict depression. Furthermore, by enabling reading, literacy can provide individuals with a greater sense of self-efficacy. One study showed that self-efficacy among individuals with limited literacy improved as Coated vesicles participated in an adult literacy program. (Francis, Weiss, Senf, Heist, & Hargraves, 2007). A study of patients with type 2 diabetes found that patients with higher health literacy received more diabetes-related education and had greater self-efficacy (Bohanny et al., 2013). Lastly, low literacy is stigmatized in our society; thus, the shame or embarrassment connected to limited reading ability may impact mental health (Parikh, Parker, Nurss, Baker, & Williams, 1996). A qualitative study of low literacy adults found engagement with health care professionals was affected by persistent anxiety that their literacy difficulties would be discovered. Multiple strategies to feign understanding or leave situations where there would be a risk of discovery were utilized (Easton, Entwistle, & Williams, 2013).