Pathway to Health Literacy in Korean American Immigrants: The Mediating Role of English Proficiency

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Pathway to Health Literacy in KoreanAmerican Immigrants: The MediatingRole of English ProficiencyHee Yun Lee a & Jeong-Kyun Choi ba School of Social Work, University of Minnesota, Twin Cities , St.Paul , Minnesota , USAb Department of Social Work , School of Liberal Arts, Winona StateUniversity , Winona , Minnesota , USAPublished online: 29 Mar 2012.

To cite this article: Hee Yun Lee & Jeong-Kyun Choi (2012) Pathway to Health Literacy in KoreanAmerican Immigrants: The Mediating Role of English Proficiency, Journal of Human Behavior in theSocial Environment, 22:3, 255-269, DOI: 10.1080/10911359.2012.655568

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Journal of Human Behavior in the Social Environment, 22:255–269, 2012

Copyright © Taylor & Francis Group, LLC

ISSN: 1091-1359 print/1540-3556 online

DOI: 10.1080/10911359.2012.655568

Pathway to Health Literacy in KoreanAmerican Immigrants: The Mediating Role

of English Proficiency

HEE YUN LEESchool of Social Work, University of Minnesota, Twin Cities, St. Paul, Minnesota, USA

JEONG-KYUN CHOIDepartment of Social Work, School of Liberal Arts, Winona State University,

Winona, Minnesota, USA

This study investigated predictors of and pathways to health liter-

acy among Korean American immigrants residing in New York

City (n D 407). Social Cognitive Theory guided the study and

the Chew et al. 16-item health literacy screening scale was em-

ployed. Structural equation modeling using Mplus 4.21 tested the

proposed conceptual model. Findings revealed that education and

English proficiency were the most influential predictors of health

literacy; education was directly associated with health literacy

and indirectly through language proficiency. Predictors of greater

English proficiency included higher levels of education, younger

age, and unmarried status. The findings suggest that immigrants

with minimal English abilities, little education, and no health

insurance have particular intervention needs, perhaps best met

by a patient-centered approach focusing on individual language

needs and cultural health beliefs.

KEYWORDS Health literacy, underserved immigrants, patient-

centered practice, Korean American immigrants, health disparity

Funding for this research was provided to the first author by a grant from the MinnesotaAgricultural Experiment Station (MIN-55-01). The authors extend their gratitude to the Korean

American immigrants who participated in this study.

Address correspondence to Hee Yun Lee, School of Social Work, University of Minnesota,Twin Cities, 105 Peters Hall, 1404 Gortner Avenue, St. Paul, MN 55108, USA. E-mail:

[email protected].

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256 H. Y. Lee and J.-K. Choi

INTRODUCTION

Low health literacy impacts timely access to and use of existing healthservices. Individuals with low health literacy thus report poorer physicaland mental health functioning (Baker, Parker, Williams, Clark, & Nurss,1997; Wolf, Gazmararian, & Baker, 2005). Poor health literacy also limitsunderstanding of health information. Studies have found that individualswith inadequate health literacy demonstrate less knowledge and under-standing of chronic diseases, physicians’ instructions, and health-related webinformation (Baker et al., 1997; Wolf et al., 2005). Furthermore, individualswith poor health literacy report difficulty in understanding medical diag-noses or treatment regimens, such as breast cancer screening for womenor early detection of prostate cancer for men (Davis et al., 1996; Bennettet al., 1998). Fundamental challenges compound such barriers, as seen inthe Baker and colleagues (1996) qualitative study that identified five mainchallenges facing illiterate or low-literate patients: (1) navigating the healthcare system, (2) completing forms, (3) following medication instructions,(4) interacting with health care providers, and (5) understanding appoint-ment slips.

Inadequate health literacy rates beg the question: Who are the partic-ularly disadvantaged in the area of access to and understanding of neededhealth information? Recent studies have shown that low levels of healthliteracy correspond with low levels of education and income, along witholder age and ethnic minority status (Gansler et al., 2005; Kutner, Greenberg,Jin, & Paulsen, 2006), a link that has been notable within the Asian Americanimmigrant and refugee populations.

Emerging evidence points to immigrant or refugee status as a primaryfactor with regard to access and utilization of health care services. In termsof health care access, the Carrasquillo, Carrasquillo, and Shea (2000) studyof health insurance coverage of immigrants living in the United States foundnearly 45% to be uninsured. Along the same vein, Frisbie, Cho, and Hummer(2001) found Asian American and Pacific Islander immigrants and refugeesgenerally to have less access to formal health care than non-Latino Whites.

Beyond concrete issues of access, several studies also highlight themore nebulous issues of cultural health beliefs and medical knowledge.In interviews with Vietnamese and Cambodian women in Philadelphia, forexample, Phipps, Cohen, Sorn, and Braitman (1999) found that 71% of therespondents ‘‘did not know what cancer was,’’ and 74% could not nameany prevention methods. Additional studies among Asian Americans reporta belief that cancer screening is unnecessary in the absence of symptoms(Maxwell, Bastana, & Warda, 2000; Kandula, Wen, Jacobs, & Lauderdale,2006). Clearly, considerationsof health care access, English language fluency,and cultural health beliefs only add complexity to health literacy demandsfor immigrants and refugees. Increasing health literacy levels may positively

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Pathway to Health Literacy in Korean American Immigrants 257

impact health care utilization behavior and, as a result, reduce health dispar-ities among underserved populations.

THEORETICAL FRAMEWORK:

SOCIAL COGNITIVE THEORY

A central element of social cognitive theory (Bandura, 1997, 1998, 2004) isthe role of self-efficacy in affecting outcomes. Put simply, this dimensionof the theory posits that the more one has confidence that he or she hasthe agency or capability to effect change in a certain area, the more theindividual will do so. The confidence is fueled or hindered by personal,situational, and systemic determinants (Bandura, 1998, 2004). When appliedspecifically to health promotion, social cognitive theory and its derivativeshave been used to suggest that the more an individual believes he or she hasthe power to comprehend health concepts and to execute health behaviorchange, the more invested the person will be in doing so and the greaterownership he or she will have over outcomes.

Informed by this dimension of social cognitive theory, the current studyexamines the concept of self-efficacy as an important conduit of health lit-eracy among Korean American immigrants. Specifically, this study examinestwo variables—English proficiency and possession of health insurance—asproxies indicative of respondents’ self-efficacy in understanding and process-ing health information. We believe that these variables may mediate one’slevel of health literacy, either strengthening or hindering health literacy.

Self-efficacy may well be inseparable from recent immigrants’ ability tospeak English and to access a health care system, a connection that usuallyrequires health insurance. The current medical context is not easy for anyoneto navigate, but the difficulty is more pronounced among those for whomlanguage and other cultural differences are particular barriers. Once Englishproficiency and health insurance have been obtained and acquaintance withthe medical context has been made, an individual’s sense of confidence andagency over his or her health is poised to increase. Also, one’s entrance intothe medical system affords opportunities to observe others navigating themedical system; this is an important component of social cognitive theory,in which action follows ‘‘vicarious experience’’ (Bandura, 1998, p. 626).

Therefore, we proposed that the influence of the four variables of age,gender, education, and marital status on Korean immigrants’ levels of healthliteracy would be largely mediated by self-efficacy, which we measured bymeans of two specific proxies: English proficiency and possession of healthinsurance. Figure 1 depicts the direct and indirect relationships we antici-pated among these variables, and we utilized structural equation modelingto test this conceptual framework. To our knowledge, there has been no

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FIGURE 1 Conceptual model.

attempt to investigate the pathway to health literacy among Asian Americanimmigrants.

METHOD

Research Design

A cross-sectional survey design was utilized to investigate the proposedstudy aims. A convenience sample of 407 Korean American immigrants,ages 21 to 90, was recruited in New York City in 2009. The researchersspecifically sought to ensure equal representation across age and gender, soa quota-sampling strategy was used to recruit a similar number of youngeradults, ages 21 through 59 (n D 199), and older adults, age 60 and beyond(n D 208). Ninety-eight men and 101 women comprised the younger group;similarly, the older group was made up of 107 men and 101 women. Thestudy’s research procedure was approved by the University of MinnesotaInstitutional Review Board.

Data Collection

Study participants were recruited in the cities of Corona and Flushing, NewYork. Older participants were recruited from two Korean senior centers,whereas the younger cohort was recruited from two Korean ethnic churches.Initial recruitment efforts were made by means of informational flyers posted

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in public areas of these sites, having received permission from the appro-priate personnel. Public presentations were then made at each recruitmentsite to advertise the research and to explain the purpose of the study,confidentiality, eligibility criteria, and voluntary nature of participation.

Two data collection methods were used: (1) Face-to-face interviewswere conducted with participants age 60 and older, and (2) self-administeredquestionnaires were completed by those ages 21 to 59. Pilot interviews in-formed the researchers that older adults exhibited some difficulty answeringsome of the items that had been translated to Korean from the originalmeasures in English. Face-to-face interviews with participants in the olderage bracket were, therefore, necessary to improve their understanding of theterminologies. These interviews were conducted by four bilingual interview-ers (Korean and English), who were intensively trained by the first author interms of interviewing older subjects. Interviews ranged in length from oneto one-and-a-half hour.

A total of 411 subjects completed interviews or the self-administeredquestionnaire.Of these, four questionnaires were not included in the analysisdue to the high percentage of missing data. Each participant was given $5for his or her time.

Instruments

Participants responded to a structured questionnaire—either self-administeredor by means of a personal interview—that consisted of questions aboutsociodemographic characteristics, health history, health accessibility, healthliteracy, and degree of acculturation.

DEPENDENT VARIABLE

The dependent variable in this study was health literacy, as determined bythe mean score of the Chew, Bradley, and Boyko (2004) 16-item healthliteracy screening scale. This measure uses a 5-point Likert scale (always D

0 to never D 5). One item, ‘‘How often do you have someone help youread hospital materials?’’ was not reverse-coded because those who have anextensive support system in fact may have a higher level of health literacythan those without a support system in the immigrant community. The higherthe overall score, the higher the level of health literacy demonstrated by theparticipant.

MEDIATING VARIABLES

English proficiency was measured by eight questions aimed to measureability to speak, understand, and read English. Higher scores indicated higherlevels of English proficiency. Current possession of health insurance wasmeasured dichotomously (yes D 1, no D 0).

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INDEPENDENT VARIABLES

Sociodemographic characteristics (age, gender, education, and marital status)and immigration (number of years in the United States) were used.

Data Analysis

In order to estimate the direct and indirect effects of variables on healthliteracy, this study used structural equation–modeling procedures. Structuralequation modeling has the strength to construct latent variables such ashealth literacy, language proficiency, or other social or behavioral attributes.The influence of latent variables cannot be observed directly but ratheris assessed by multiple indicators that are subject to measurement errors.Due to measurement errors, conventional statistical methodology, includingregression, cannot be used to analyze the relationship among these attributes(Yuan & Bentler, 2007). In contrast to multiple regression modeling, whichhas only one model for a given set of predictors, structural equation modelingallows many different models for a given number of variables, and thenumber of models depends on the hypothesized relations among variables(Yuan & Bentler, 2007). Structural equation modeling incorporates multipledependent variables in a model, includes variables that are both indepen-dent and dependent, and estimates both direct and indirect effects of eachpredictor on outcome variables (Bentler & Weeks, 1980; Kline, 2005). Theanalysis proceeds by specifying a model (as in Figure 1) and then translatingthe model into a series of equations or matrices (Bentler & Weeks, 1980).The model can be expressed in matrix algebra as:

� D B� C �.

If q is the number of dependent variables and r is the number of independentvariables, then � is a q � 1 vector of dependent variables, B is a q � q matrixof regression coefficients between dependent variables, is a q � r matrix ofregression coefficients between dependent and independent variables, and� is an r � 1 vector of independent variables (Ullman & Bentler, 2004). Forexample, the diagram in the current conceptual model (see Figure 1) can beconverted into eight regression equations:

health care insurance D ˇ1 age C "1;

language proficiency D ˇ2 age C ˇ3 education C ˇ4 married C "2;

health literacy D C ˇ5 age C ˇ6 education C ˇ7 female

C ˇ8 married C ˇ9 health care insurance

C ˇ10 language proficiency "3.

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These analyses employ Mplus 4.21 (Muthén & Muthén, 2007) statistical soft-ware because it offers several options for the estimation of models with miss-ing data (e.g., maximum likelihood estimation and multiple imputations).The software provides maximum likelihood estimation under conditions inwhich data are missing completely at random (MCAR) or missing at random(MAR; Little & Rubin, 2002). It provides this for continuous, censored, binary,ordered categorical (ordinal), unordered categorical (nominal), counts, orcombinations of these variable types. The present study models data asMCAR. Although this data set has only a few missing responses, maximumlikelihood estimation is used to obtain robust estimates (Yuan & Bentler,2007). Maximum likelihood estimation is popular for use with missing databecause the method preserves many of the data’s properties when MCARand MAR mechanisms are ignored; other estimation procedures may notpreserve those properties. According to Donald Rubin (1976), the propertyof parameter estimates achieved by any method is closely related to missingdata mechanisms. When missing values are not missing at random, maxi-mum likelihood estimation is still necessary to obtain consistent parameterestimates in modeling the missing data mechanism (Poon, Lee, & Tang, 1997;Tang & Lee, 1998; Yuan & Bentler, 2007).

FINDINGS

The participants’ characteristics are summarized in Table 1. Among the par-ticipants in this study, 205 (50.4%) were male and 202 (49.6%) were female.The participant ages averaged to 57.2 years. More than a quarter of theparticipants (28.6%) reported that they had earned a high school diploma,and nearly half (48.5%) reported having obtained a college-level education.Nearly two-thirds of participants (62.7%) were married, while 37.3% reportedbeing single, separated, or divorced. Around half of the participants (50.9%)reported an income of $999 per month or less, whereas the income of some22.9% ranged from $1,000 to $1,999, and another 26.3% earned $2,000 permonth or more. The average length of residence in the United States was17.7 years (standard deviation D 10.9).

The correlational analyses shown in Table 2 examine the bivariate as-sociations between the variables. The estimates suggest that the participants’health literacy was positively associated with both their educational attain-ment (r D .18, p < .001) and language proficiency (r D .23, p < .001). Itshould be noted that language proficiency was significantly associated withage (r D �.45, p < .001), education (r D .42, p < .001), and marital status(r D �.22, p < .001). It is also worthy of note that those who were olderwere more likely to have health care insurance (r D .33, p < .001). Thereare additional associations of importance: older age and female gender werevariables found to be associated with lower levels of education (r D �.36,

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TABLE 1 Demographic and Socioeconomic Characteristics (n D 407)

Variable Value Frequency Percent

Sex Male 205 50.4Female 202 49.6

Age 20–39 67 16.540–49 58 14.350–59 74 18.260–69 90 22.170 or older 118 29.0Mean (SD) 57.2 (16.6)

Education Elementary school 17 4.2Middle school 35 8.7High school 115 28.6College 195 48.5Graduate school 40 10.0

Marital status Married or cohabited 255 62.7Single, separated, or divorced 152 37.3

Monthly income $399 or less 89 21.9$400–$999 118 29.0$1000–$1999 93 22.9$2000 or more 107 26.3

Years of U.S. residence 5 years or less 73 17.96–10 years 54 13.311–20 years 110 27.021–30 years 118 29.031 years or more 52 12.8Mean (SD) 17.7 (10.9)

p < .001; r D �.18, p < .001; respectively) and female participants were morelikely to be single, separated, or divorced than were their male counterparts(r D �.31, p < .001).

The final structural equation model is shown in Figure 2. With sevendegrees of freedom, it produces a chi-square of 13.56 (p D .10), a rootmean square error of approximation of .05, a comparative fit index of .97, a

TABLE 2 Correlation, Mean, and Standard Deviation of Variables (n D 397)

Correlation 1 2 3 4 5 6 7

1. Age —2. Female �.13** —3. Education �.36*** �.18*** —4. Married .27*** �.31*** .01 —5. Health insurance .33*** .04 �.08 .07 —6. Language proficiency �.45*** .06 .42*** �.22*** �.06 —7. Health literacy �.05 .11* .18*** �.12* .12* .23*** —Mean 57.2 .49 3.51 .63 .69 1.54 3.15SD 16.6 .50 .94 .48 .46 .61 .06

*p < .05; **p < .01; ***p < .001.

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FIGURE 2 Direct and indirect effects of variables on health literacy (n D 407). Note. Chi-

square D 13.56 with degrees of freedom D 7 (p D .10); comparative fit index D .97; Tucker-Lewis index D .94; root mean square error of approximation D .05; standardized root mean

square residual D .03. *p < .05; **p < .01; ***p < .001.

Tucker-Lewis index of .94, and a standardized root mean square residual of.03. All of these indicators suggest a reasonably good fit to the data (Kline,2005). As expected, the structural parameters show the expected paths fromeducational attainment to language proficiency (beta D .32, p < .001) andhealth literacy (beta D .15, p < .01). Those who were older and marriedwere also found to have lower levels of language proficiency (beta D �.30,p < .001; beta D �.14, p < .01). Language proficiency, in turn, was estimatedto have the expected positive relationship with health literacy (beta D .17,p < .001).

Regarding health insurance, those who were older were more likely topossess health insurance (beta D .33, p < .001). Having health insurance, inturn, was found to be associated positively with health literacy (beta D .13,p < .01). This estimated association indicates that those who were insuredhad higher levels of health literacy than those who were not insured. Femaleimmigrants were also found to have higher health literacy than were maleimmigrants (beta D .13, p < .01).

Estimates concerning the decomposition of the direct and indirect effectsare displayed in Table 3. The results suggest that education attainment isboth directly (direct effect D .15, p < .01) and indirectly (indirect effect D

.05, p < .01) associated with health literacy, the latter when transmittedthough language proficiency. Contrary to expectations, the estimated indi-rect effect of age on health literacy was not significant (indirect effect D

�.01). One path—from age, to language proficiency, to health literacy—indicates that those who were older were likely to have lower health liter-

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TABLE 3 Decomposition of the Estimates of Direct and Indirect Effects (n D 407)

Dependent Independent Direct Indirect Total

Health literacy Age — �.01 �.01Female .13** — .13**Education .15** .05** .20***Married — �.03* �.03*Health insurance .13** — .13**Language proficiency .17*** — .17***

Language proficiency Age �.30*** — �.30***Education .32*** — .32***Married �.14** — �.14**

Health insurance Age .33*** — .33***

*p < .05; **p < .01; ***p < .001.

acy because they had lower language proficiency (indirect effect D �.05,p < .01). The other path—from age, to health insurance, to health liter-acy—demonstrates a positive indirect effect. Those who were older weremore likely to have health insurance, which was, in turn, positively asso-ciated with higher levels of health literacy (indirect effect D .04, p < .01).These findings suggest that the positive effect offsets the negative effect;therefore, the aggregated indirect effect of age on health literacy is notsignificant.

With respect to total effects, education (total effect D .20, p < .001) andlanguage proficiency (total effect D .17, p < .001) were estimated to be themost influential predictors of health literacy. Health insurance (total effect D

.13, p < .01) and gender (total effect D .13, p < .01) variables were alsofound to have modest but significant effects on health literacy. In addition,the strong factors to estimate language proficiency include education (totaleffect D .32, p < .001), age (total effect D �.30, p < .001), and marital status(married D 1; total effect D �.14, p < .01).

DISCUSSION

The findings of the current study indicate that the most influential predictorsof health literacy among the Korean American adults who participated in thisstudy were education level and degree of English proficiency. Educationlevel was both directly and indirectly associated with health literacy; asexpected, structural parameters showed paths from educational attainmentto English proficiency (beta D .32, p < .001), and then to health literacy(beta D .15, p < .01). In addition to education, the factors most influential inpredicting greater English proficiency were younger age, higher education,and unmarried status.

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Other variables were taken into account, including gender, possessionof health insurance, and age. Estimates concerning the decomposition ofthe direct and indirect effects showed that gender was directly linked tohealth literacy, with the female study participants on average showing higherlevels of health literacy than their male counterparts. Health insurance (totaleffect D .13, p < .01) was also found to have modest but significant directeffect on health literacy, but contrary to our expectations, it was not identifiedas a significant mediating factor between other variables and health literacy.Interestingly, age was found to be neither directly or indirectly linked tohealth literacy in terms of statistical significance.

Our findings regarding the importance of education and language profi-ciency on health literacy can be understood within the self-efficacy principleof social cognitive theory. One can surmise that immigrants’ ability to usethe English language strengthens their sense of self-efficacy in being ableto navigate the U.S. health care system. Likewise, an individual’s ability tocommunicate directly with his or her health provider or to read and under-stand health materials is likely to increase agency in health-related decisions.Confidence in one’s aptitude to understand and communicate would seemto empower the person to take an active, rather than passive, role in suchtasks as screening, follow-up, or following a medication regimen. Of course,one’s language literacy is only one piece of health literacy: Many othercultural variables play a role (Friedman, Corwin, Dominick, & Rose, 2009;Nutbeam, 2000; Shaw, Huebner, Armin, Orzech, & Vivian, 2009). However,our findings confirm that language holds a significant mediating role in healthliteracy.

The positive relationship of education with health literacy is corrob-orated by the 2003 National Assessment of Adult Literacy (NAAL) study,which surveyed more than 19,000 adults ages 16 and older in the UnitedStates. Results of the health literacy component of the broader NAAL studyindicated that lower health literacy is associated with less education (Kutneret al., 2006). In that study, there was remarkable discrepancy in healthliteracy levels according to education attained: about 76% of adults whohad never earned a high school degree were at the below basic level orbasic level, while 88% of those who completed a college degree measuredas intermediate or proficient in the area of health literacy.

However, it is noted that while health literacy typically increases aseducation levels increase, education level cannot be assumed to be a clearindicator of health literacy. In the NAAL study, for example, about 44% ofhigh school graduates still had below basic or basic health literacy, despitetheir years of schooling (Kutner et al., 2006). A 2007 study by Baker, Wolf,Feinglass, Thompson, Gazmararian, and Haung (2007) on the topic of healthliteracy and mortality among elderly persons found that reading fluencywas a stronger variable than education in predicting health literacy; in otherwords, years of formal education did not ensure that individuals could ac-

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tually read at the corresponding grade level. Along a similar vein, Wallaceand Lennon (2004) determined that patient education materials publishedby the American Academy of Family Physicians were consistently written ata ninth-grade level or higher, making such materials difficult to understandfor anyone who has less than a high school education. In fact, it has beensuggested that in order to improve physician-patient communication, mate-rials need to be written three grade levels below the educational level of thetargeted population (Jubelirer, Linton, & Magnetti, 1994).

Adding complexity to the relationship between educational level andhealth literacy in the U.S. health system is one’s degree of English fluency. It ischallenging enough for immigrants who may have earned a college degree intheir countries of origin and have strong English language skills to understandEnglish-language health information that utilizes complex medical jargon;this difficulty is only increased for recent immigrants who have limitedEnglish proficiency. As anticipated, this is supported by our study, in whichthe immigrants at highest risk for low health literacy had limited or no Englishproficiency; also, this high-risk group was found to include those who weremale, had less education, and were unmarried.

Given these challenges, it is particularly critical that health organizationsand clinics should provide health literacy interventions specifically targetedto this immigrant group with the specific demographic characteristics. Stew-art (2001) stressed a patient-centered communication approach that seeksto meet each patient’s individual health and language needs and culturalhealth beliefs. Wynia and Osborn (2010) further suggested that such patient-centered communication be extended to all forms of health communica-tion—including patient education materials, agency signage, patient forms,and training providers to be better communicators (Epstein & Street, 2007)—rather than only confined to individual clinician-patient interactions. Buildingon these suggestions, the current study’s findings highlight the necessity ofinterpreters and stress the need to design health communication materials ina way that is congruent with the language and culture of patients.

Although the current study generates critical information regarding healthliteracy among recent immigrants, there are a few limitations that shouldbe acknowledged when interpreting the study’s findings. First, while educa-tional attainment, English proficiency, and health insurance may be importantdeterminants of health literacy among Korean American immigrants, thelimitations of the present dataset prevent any causal conclusions. As the datarepresent Korean American immigrants who live in the two cities of Coronaand Flushing, New York, the findings cannot be generalized to populationsresiding in other cities or nonurban areas. Second, the present data donot take into account changes in health literacy and other predictors. Forexample, the consistency and stability of having health insurance over timemay be an important determinant of improving health literacy. To examinethese changes, a longitudinal study should be considered for further research.

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Finally, while the current study drew upon social cognitive theory’s attentionto self-efficacy in order to help explain the association between Englishproficiency and the ability to navigate health care information, this study didnot include any measures for the participants’ self-efficacy or their healthinformation–seeking process.

CONCLUSION

It is widely reported that recent immigrants with low health literacy havedifficulty navigating the health care system, tend to underutilize health ser-vices, and report poorer physical and mental health functioning, all of whichfactors are primary sources of health disparity in this population. The currentstudy revealed that Korean American immigrants characterized by beingunmarried or male and having less education, limited English proficiencyor no health insurance are at particularly high risk of having low healthliteracy. Development of patient-centered and culturally competent interven-tions is urgently needed to improve quality of care and health outcomes ofunderserved immigrant populations with limited health literacy. Likewise,careful examination of how health care policies might strengthen healthliteracy levels is a timely matter—to minimize the emotional, physical, andfinancial burden that health disparity places on certain segments of U.S.society.

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Documents

Pathway to Health Literacy in Korean American Immigrants: The Mediating Role of English Proficiency