Health literacy and health: rethinking the strategies for universal health coverage in Ghana

Objectives: Health literacy (HL) is generally thought to be associated with positive health behaviour, appropriate health service utilisation and acceptance of interventions to maximise health outcomes. It is, therefore, increasingly suggested that evidence-based research should investigate how HL may operate in the context of universal health coverage (UHC). However, the role of HL in the relationships between elements of UHC such as access to health care and health insurance has not been widely explored. This applies in particular in Sub-Saharan Africa, although service coverage and health outcomes vary hugely between and within many countries. This article addresses this lacuna in Ghana, today one of the Africa's most promising health systems. Study design: It is a cross-sectional study. Methods: The study used structured interviews to gather data from 779 rural and urban adults using a multistage cluster sampling approach. Results: In a three-step multiple hierarchical linear regression model, HL (B = -.09, standard error [SE] -.04) and health insurance subscription (B = -15, SE = .04) were found to be inversely associated with poor health-related quality of life (HRQoL). Access to health care did not predict HRQoL (B = -.02, SE = .02). However, the interaction between access to health care and HL produced a negative effect on poor HRQoL (B = -.08, SE = .03). The interaction between HL and health insurance subscription also showed a similar effect on HRQoL (B = -.10, SE = .03). Further analysis depicted that access to health care (beta = -.09, P = .05) and health insurance subscription (beta = -.24, P = .00) related positively to HRQoL only when HL was high. Conclusion: The article argues that where HL is low, even favourable policies for UHC are likely to miss set targets. While not losing sight of relevant sociocultural elements, enhancing HL should be a central strategy for policies aimed at bridging health inequalities and improving UHC. (C) 2018 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.