Hearing Difficulty, Health Literacy, and Poorer Health Among Adults in the United States: 2016 Behavioral Risk Factor Surveillance Study

OBJECTIVES: Adults with hearing loss experience poorer health outcomes than their hearing counterparts. As hearing loss becomes more prevalent in the United States, research examining how to reduce health disparities among this population is needed. This study aimed to estimate the associations between hearing loss and each of poor physical and mental health, evaluate health literacy as a mediator of these relationships, and estimate the proportion of cases of poor physical and mental health that are attributable to having lower health literacy among adults with hearing loss. DESIGN: The 2016 Behavioral Risk Factor Surveillance System survey included cross-sectional data on self-reported hearing difficulty, health literacy, and number of days of poor physical and mental health in the past 30 days in a subpopulation of adults aged 18 and over among 17 US states and territories (N = 104,792). The number of days of poor physical and mental health was split into 5 categories (0, 1 to 10, 11 to 20, 21 to 29, and all 30 days). Age-stratified weighted complex survey logistic regression models estimated the total and direct effects of hearing difficulty on poor physical and mental health, and the indirect effects mediated by health literacy. Outcomes for poor physical and mental health were modeled separately as 1+ days versus 0 days, 11+ days versus ≤10 days, 21+ days versus ≤20 days, and all 30 days versus <30 days. Models were adjusted for age, sex, race/ethnicity, education, income, marital status, and health insurance coverage. Population attributable fractions were used to estimate the proportion of adults with hearing difficulties who experienced poor physical and mental health due to having lower health literacy. RESULTS: Compared with those without hearing difficulties, those with hearing difficulties had a higher prevalence of lower health literacy (70.3% versus 56.2%), 30 days of poor physical health (16% versus 6.4%), and 30 days of poor mental health (10.7% versus 5.3%). Odds ratios for the total effect of hearing difficulty ranged from 1.68 (95% confidence interval [CI]: 1.44 to 1.92) to 1.87 (95% CI: 1.66 to 2.08) for poor physical health and 1.68 (95% CI: 1.51 to 1.85) to 2.20 (95% CI: 1.81 to 2.59) for poor mental health. The indirect effect of hearing difficulty mediated through health literacy explained between 3.8 and 4.8% of the total effect for poor physical health and 2.3 and 6.6% for poor mental health. When stratified by age, the total effect generally declined as age increased, while the indirect effect stayed relatively consistent. Over 218,000 cases of poor physical health lasting 30 days and over 115,000 cases of poor mental health lasting 30 days were attributable to having lower health literacy. CONCLUSIONS: The results show that those with hearing difficulties experience significantly poorer physical health, poorer mental health, and lower health literacy. Health literacy was determined to be a significant mediator between hearing difficulty and both poor physical and mental health. Findings suggest that improving health literacy among this population would reduce the number of days of poor physical and mental health in the past month experienced by adults with hearing difficulty in the United States.