Journal of Health Literacy

Journal of Health Literacy

Balancing Health Literacy and Healthcare Expenditures: Evidence from a Social Security Fund

Document Type : Original Article

Authors
Shokat Sanei Yarand 1
Mehdi Basakha 2, 3
Seyed Hossein Mohaqeqi Kamal 2, 3
1 Student Research Community, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.
2 Social Determinants of Health Research Center, Social Health Research Institute, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
3 Department of Social Welfare Management, School of Social Health, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.
10.22038/jhl.2025.84782.1684
Abstract
Background and Objectives: Health literacy is a crucial determinant of health outcomes and healthcare expenditures. Although health literacy is generally viewed as beneficial, its impact on healthcare expenditures, remains complex. This study aimed to 1) assess the status of health literacy and healthcare expenditures among members of a social security fund, 2) examine differences across various sociodemographic groups, and 3) explore the effect of health literacy on healthcare expenditures.

Materials and Methods: Data were collected from members of a social security fund through a health literacy questionnaire in 2022. Participants provided their insurance identification numbers, which were used to retrieve actual healthcare expenditure data from the social security fund's administrative database. This allowed for the linkage of self-reported health literacy data with corresponding expenditure records. Statistical analyses were conducted using parametric and non-parametric correlation tests, ANOVA, Kruskal-Wallis and quantile regression analysis.

Results: The mean and median of health expenditure in the sample was 703 thousand Rials  and 257.4 million IRR (equal to 143.3 and 525.3 US$, respectively), with the highest expenditures among individuals with limited disability and those self-assessing their health as poor. Health literacy scores averaged 71.7 (SD±15.1), with higher scores among women, singles, and those with higher education. A quantile regression revealed that self-rated health consistently predicted lower costs, while health literacy was linked to higher spending at median and upper quantiles. Unemployment and student status were associated with significantly reduced costs, especially among higher spenders.

Conclusion: This study underscores the complex relationship between health literacy and healthcare spending. Enhancing health literacy, while beneficial, should be accompanied by strategies to mitigate cost increases, particularly for vulnerable groups such as individuals with mild disabilities. Promoting realistic health perceptions and tailored interventions can optimize healthcare utilization, reduce unnecessary expenses, and ensure the effective allocation of resources within social security systems.
Keywords
Disability
Healthcare Expenditure
Health literacy
Socioeconomic Factors
Self-Perceived Health
Iran

Acknowledgements: The authors gratefully acknowledge the support of the institution that provided access to the data used in this study. Due to confidentiality agreements, the name of the institution cannot be disclosed.


Availability of data and materials: The data supporting the study's findings are available from the corresponding author upon reasonable request.


Conflicts of interest: The authors declarer no conflicts of interests.


Consent for publication: Not applicable. 


Ethics approval and consent to participate: All procedures performed in studies involving human participants were in accordance with the ethical standards of the Committee of Ethics in Research in the University of Social Welfare and Rehabilitation Sciences and approved by ethical code: IR.USWR.REC.1401.162. The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki.


Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.


Author contributions: MB and SHMK contributed to the study design. SSY was responsible for data collection and literature review. Data analysis and drafting of the manuscript were performed by MB; while SHMK and SSY critically reviewed the manuscript. All authors read and approved the final version of the manuscript.


Declaration: The authors used ChatGPT, to assist with the English translation of the manuscript. The final text was thoroughly reviewed and edited by the authors to ensure accuracy, clarity, and alignment with the original intent.

 

Open Access Policy: This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.To view a copy of this licence, visit https://creativecommons.org/licenses/by/4.0/

  1. World Bank. World development indicators. Washington DC: The World Bank; 2022.
  2. Capizzi S, de Waure C, Boccia S. Global Burden and Health Trends of Non-Communicable Diseases. In: Boccia S, Villari P, Ricciardi W, editors. A Systematic Review of Key Issues in Public Health. Cham: Springer International Publishing; 2015. p. 19-32. https://doi.org/10.1007/978-3-319-13620-2_3
  3. Peyman N, Samiee-roudi K. Investigating the status of health literacy among health providers of rural area. Journal of Health literacy. 2016;1(1):46-52.
  4. Ghaffari M, Hatami H, Rakhshandrrou S, Shoghli A, Heidari A. Health literacy among women referring to healthcare centers of Zanjan City, Iran: A cross-sectional study. Journal of Education and Community Health. 2018;5(1):42-8. https://doi.org/10.21859/jech.5.1.42
  5. Olyani S, Peyman N. Health literacy and health outcomes in Iranian adolescents: A systematic review. Journal of Health Literacy. 2021;6(3):78-85.
  6. Peyman N, Behzad F, Taghipour A, Esmaily H. Assessment of the effect of a health literacy educational program for health personnel on promoting self-efficacy among patients with chronic diseases. Journal of Health System Research. 2016;12(3):350-7.
  7. World Health Organisation. Health promotion glossary of terms. Geneva: World Health Organization; 2021.
  8. Delavar F, Pashaeypoor S, Negarandeh R. Health literacy index: A new tool for health literacy assessment. Journal of Hayat. 2018;24(1):1-6.
  9. Abedian Kasgari K, Peyman N, Momeni Badeleh S, Gholian Avval M, Momeni Badeleh K, Vahedian Shahroodi M, et al. Health literacy measurement in childhood: A systematic review. Journal of Pediatrics Review. 2020;8(3):163-74. https://doi.org/10.32598/jpr.8.3.850.1
  10. Mohaqeqi Kamal SH, Basakha M, Sajjadi H. The prevalence and risk factors of limited health literacy in Iran: a systematic review and meta-regression analysis. Journal of Advances in Medical and Biomedical Research. 2018;26(118):1-8. https://doi.org/10.30699/jambs.26.118.1
  11. Tavousi M, Haeri-Mehrizi A, Rakhshani F, Rafiefar S, Soleymanian A, Sarbandi F, et al. Development and validation of a short and easy-to-use instrument for measuring health literacy: The Health Literacy Instrument for Adults (HELIA). BMC public health. 2020;20:1-11. https://doi.org/10.1186/s12889-020-08787-2 PMid:32397970 PMCid:PMC7216550
  12. Eichler K, Wieser S, Brügger U. The costs of limited health literacy: a systematic review. International journal of public health. 2009;54:313-24. https://doi.org/10.1007/s00038-009-0058-2 PMid:19644651 PMCid:PMC3785182
  13. Karimi M, Tsiachristas A, Looman W, Stokes J, van Galen M, Rutten-van Mölken M. Bundled payments for chronic diseases increased health care expenditure in the Netherlands, especially for multimorbid patients. Health policy. 2021;125(6):751-9. https://doi.org/10.1016/j.healthpol.2021.04.004 PMid:33947604
  14. Basakha M, Yavari K, Sadeghi H, Naseri A. Health care cost disease as a threat to Iranian aging society. Journal of research in health sciences. 2013;14(2):152-6.
  15. Counts CJ, Skordis-Worrall J. Recognizing the importance of chronic disease in driving healthcare expenditure in Tanzania: analysis of panel data from 1991 to 2010. Health policy and planning. 2016;31(4):434-43. https://doi.org/10.1093/heapol/czv081 PMid:26318536
  16. MacLeod S, Musich S, Gulyas S, Cheng Y, Tkatch R, Cempellin D, et al. The impact of inadequate health literacy on patient satisfaction, healthcare utilization, and expenditures among older adults. Geriatric Nursing. 2017;38(4):334-41. https://doi.org/10.1016/j.gerinurse.2016.12.003 PMid:28089217
  17. Paasche-Orlow MK, Wolf MS. The causal pathways linking health literacy to health outcomes. American journal of health behavior. 2007;31(1):S19-S26. https://doi.org/10.5993/AJHB.31.s1.4
  18. Haun JN, Valerio MA, McCormack LA, Sørensen K, Paasche-Orlow MK. Health literacy measurement: an inventory and descriptive summary of 51 instruments. Journal of health communication. 2014;19(sup2):302-33. https://doi.org/10.1080/10810730.2014.936571 PMid:25315600
  19. Health Policy Institute. Low Health Literacy Skills Increase Annual Health Care Expenditures by $73 Billion: Georgetown University; [April 10, 2025]. Available from: https://hpi.georgetown.edu/healthlit/.
  20. Liu L, Huang J, Li G, Chen Z, He T. The economic costs of limited health literacy in China: evidence from China's National Health Literacy Surveillance data. BMC Health Services Research. 2022;22(1):521. https://doi.org/10.1186/s12913-022-07795-9 PMid:35443677 PMCid:PMC9020016
  21. Rasu RS, Bawa WA, Suminski R, Snella K, Warady B. Health literacy impact on national healthcare utilization and expenditure. International journal of health policy and management. 2015;4(11):747. https://doi.org/10.15171/ijhpm.2015.151 PMid:26673335 PMCid:PMC4629700
  22. Friis K, Pedersen MH, Aaby A, Lasgaard M, Maindal HT. Impact of low health literacy on healthcare utilization in individuals with cardiovascular disease, chronic obstructive pulmonary disease, diabetes and mental disorders. A Danish population-based 4-year follow-up study. European Journal of Public Health. 2020;30(5):866-72. https://doi.org/10.1093/eurpub/ckaa064 PMid:32335677 PMCid:PMC7536249
  23. Goto E, Ishikawa H, Okuhara T, Kiuchi T. Relationship of health literacy with utilization of health-care services in a general Japanese population. Preventive Medicine Reports. 2019;14:100811. https://doi.org/10.1016/j.pmedr.2019.01.015 PMid:30815332 PMCid:PMC6377410
  24. Lee S-YD, Tsai T-I, Tsai Y-W, Kuo KN. Health literacy, health status, and healthcare utilization of Taiwanese adults: results from a national survey. BMC public health. 2010;10:1-8. https://doi.org/10.1186/1471-2458-10-614 PMid:20950479 PMCid:PMC2967535
  25. Mackey LM, Blake C, Squiers L, Casey MB, Power C, Victory R, et al. An investigation of healthcare utilization and its association with levels of health literacy in individuals with chronic pain. Musculoskeletal Care. 2019;17(2):174-82. https://doi.org/10.1002/msc.1386 PMid:30762926
  26. Karimi S, Keyvanara M, Hosseini M, Jazi MJ, Khorasani E. The relationship between health literacy with health status and healthcare utilization in 18-64 years old people in Isfahan. Journal of education and health promotion. 2014;3(1):75. https://doi.org/10.4103/2277-9531.134910 PMid:25077168 PMCid:PMC4113988
  27. Ahangar A, Ahmadi AM, Mozayani A, FarajiDizaji S. Key Health Financing Policies with Approach Risk-Sharing to Promote Health Systems in Poor and Developing Countries; Africa and Eastern Mediterranean (WHO) Regions. Iranian Journal of Health Education and Health Promotion. 2018;6(2):200-2. https://doi.org/10.30699/acadpub.ijhehp.6.2.r200
  28. Montazeri A, Tavousi M, Rakhshani F, Azin SA, Jahangiri K, Ebadi M, et al. Health Literacy for Iranian Adults (HELIA): development and psychometric properties. Payesh (Health Monitor). 2014;13(5):589-99.
  29. Toçi E, Burazeri G, Myftiu S, Sørensen K, Brand H. Health literacy in a population-based sample of adult men and women in a South Eastern European country. Journal of Public Health. 2015;38(1):6-13. https://doi.org/10.1093/pubmed/fdv006 PMid:25635141
  30. Chen W, Ren H, Wang N, Xiong Y, Xu F. The relationship between socioeconomic position and health literacy among urban and rural adults in regional China. BMC Public Health. 2021;21:1-10. https://doi.org/10.1186/s12889-021-10600-7 PMid:33731069 PMCid:PMC7972343
  31. Lee HY, Lee J, Kim NK. Gender differences in health literacy among Korean adults: do women have a higher level of health literacy than men? American journal of men's health. 2015;9(5):370-9. https://doi.org/10.1177/1557988314545485 PMid:25122719
  32. Rababah JA, Al-Hammouri MM, Drew BL, Aldalaykeh M. Health literacy: exploring disparities among college students. BMC public health. 2019;19:1-11. https://doi.org/10.1186/s12889-019-7781-2 PMid:31664973 PMCid:PMC6819582
  33. Jeong SH, Kim HK. Health literacy and barriers to health information seeking: A nationwide survey in South Korea. Patient Education and Counseling. 2016;99(11):1880-7. https://doi.org/10.1016/j.pec.2016.06.015 PMid:27373962
  34. Tehrani Banihashemi S-A, Haghdoost AA, Amirkhani MA, Haghdoost AA, Alavian S-M, Asgharifard H, et al. Health Literacy and the Influencing Factors: A Study in Five Provinces of Iran. Strides in Development of Medical Education. 2007;4(1):1-9.
  35. N'Goran AA, Pasquier J, Deruaz-Luyet A, Burnand B, Haller DM, Neuner-Jehle S, et al. Factors associated with health literacy in multimorbid patients in primary care: a cross-sectional study in Switzerland. BMJ open. 2018;8(2):e018281. https://doi.org/10.1136/bmjopen-2017-018281 PMid:29440210 PMCid:PMC5829773
  36. Sultan A-A, Ozturk FO. Health literacy levels of women and related factors in Turkey. Journal of Nursing Research. 2021;29(6):e180. https://doi.org/10.1097/JNR.0000000000000452 PMid:34380974
  37. Zolfaghari A, Mohammadi Ahmad Abadi N, Shaker Ardakani S. Investigation of the Relationship Between Health Literacy and Demographic Variables of Yazd City Citizens. Iranian Journal of Health Psychology. 2019;2(1):95-102.
  38. Sørensen K, Van den Broucke S, Pelikan JM, Fullam J, Doyle G, Slonska Z, et al. Measuring health literacy in populations: illuminating the design and development process of the European Health Literacy Survey Questionnaire (HLS-EU-Q). BMC public health. 2013;13:1-10. https://doi.org/10.1186/1471-2458-13-948 PMid:24112855 PMCid:PMC4016258
  39. Sørensen K, Pelikan JM, Röthlin F, Ganahl K, Slonska Z, Doyle G, et al. Health literacy in Europe: comparative results of the European health literacy survey (HLS-EU). The European journal of public health. 2015;25(6):1053-8. https://doi.org/10.1093/eurpub/ckv043 PMid:25843827 PMCid:PMC4668324
  40. Vernon JA, Trujillo A, Rosenbaum SJ, DeBuono B. Low health literacy: Implications for national health policy2007 May 21, 2025. Available from: https://hsrc.himmelfarb.gwu.edu/cgi/viewcontent.cgi?article=1173&context=sphhs_policy_facpubs.
  41. Smith SG, Curtis LM, Wardle J, von Wagner C, Wolf MS. Skill set or mind set? Associations between health literacy, patient activation and health. PloS one. 2013;8(9):e74373. https://doi.org/10.1371/journal.pone.0074373 PMid:24023942 PMCid:PMC3762784
  42. Hibbard JH, Greene J. What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs. Health affairs. 2013;32(2):207-14. https://doi.org/10.1377/hlthaff.2012.1061 PMid:23381511
  43. Di Palo KE, Patel K, Assafin M, Piña IL. Implementation of a patient navigator program to reduce 30-day heart failure readmission rate. Progress in cardiovascular diseases. 2017;60(2):259-66. https://doi.org/10.1016/j.pcad.2017.07.004 PMid:28743529
  44. Shermont H, Pignataro S, Humphrey K, Bukoye B. Reducing pediatric readmissions: using a discharge bundle combined with teach-back methodology. Journal of nursing care quality. 2016;31(3):224-32. https://doi.org/10.1097/NCQ.0000000000000176 PMid:26845419
  45. DeSalvo KB, Fan VS, McDonell MB, Fihn SD. Predicting mortality and healthcare utilization with a single question. Health services research. 2005;40(4):1234-46. https://doi.org/10.1111/j.1475-6773.2005.00404.x PMid:16033502 PMCid:PMC1361190
  46. Devaux M. Income-related inequalities and inequities in health care services utilisation in 18 selected OECD countries. The European Journal of Health Economics. 2015;16:21-33. https://doi.org/10.1007/s10198-013-0546-4 PMid:24337894
  47. Cheah Y, Goh K, Adzis A. Sociodemographic determinants of health care expenditure: micro level evidence of a fast-growing developing country. International Journal of Social Economics. 2021. https://doi.org/10.1108/IJSE-06-2020-0393
  48. Loef B, Meulman I, Herber G-C, Kommer G, Koopmanschap M, Kunst A, et al. Socioeconomic differences in healthcare expenditure and utilization in The Netherlands. BMC Health Services Research. 2021;21. https://doi.org/10.1186/s12913-021-06694-9 PMid:34217287 PMCid:PMC8254290
  49. Mitra S, Findley PA, Sambamoorthi U. Health care expenditures of living with a disability: total expenditures, out-of-pocket expenses, and burden, 1996 to 2004. Archives of physical medicine and rehabilitation. 2009;90(9):1532-40. https://doi.org/10.1016/j.apmr.2009.02.020 PMid:19735781
  50. Hong MJ, Lee C, Lee C, Kim Y-S, Jeong JY, Park J, et al. Are high medical costs incurred by people with disabilities excessive?: an empirical analysis of Korean National Health Insurance Data. Plos one. 2022;17(1):e0262653. https://doi.org/10.1371/journal.pone.0262653 PMid:35051218 PMCid:PMC8775209
  51. Smith SK, Dixon A, Trevena L, Nutbeam D, McCaffery KJ. Exploring patient involvement in healthcare decision making across different education and functional health literacy groups. Social science & medicine. 2009;69(12):1805-12. https://doi.org/10.1016/j.socscimed.2009.09.056PMid:19846245
  52. Okunade AA, Suraratdecha C, Benson DA. Determinants of Thailand household healthcare expenditure: the relevance of permanent resources and other correlates. Health Economics. 2010;19(3):365-76. https://doi.org/10.1002/hec.1471 PMid:19405046
  53. Razimoghadam M, Yaseri M, Shahali Z, Fazaeli A, Daroudi R. The Age and Sex distribution of Hospital Admissions and Hospital Costs with a Focus on the Aging Effect: A Retrospective Analysis of Claims Data. Salmand: Iranian Journal of Ageing. 2024;18(4):518-35. https://doi.org/10.32598/sija.2023.3523.