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    • There is evidence indicating literacy has a protective effec

    2018-10-24

    There is evidence indicating literacy has a protective effect on depressive symptoms (Barnes, Tager, Satariano, & Yaffe, 2004; Gordon, Hampson, Capell, & Madhok, 2002; Sudore et al., 2006). A randomized controlled trial of adults with depression and limited literacy demonstrated combining depression care with literacy enhancement was more effective in reducing depressive symptoms than depression care alone at one year follow-up (Weiss, Francis, Senf, Heist, & Hargraves, 2006).Thus far, studies have provided evidence to support the link between education and depressive symptoms and literacy and depressive symptoms. These associations suggest that literacy may be a mediator of the effect of education on depressive symptoms, but no gtpase inhibitor study has formally tested this gtpase inhibitor hypothesis. The main objective of this paper is to test this hypothesis.
    Methods
    Results The majority of the participants were non-Hispanic White, and 62 percent had 12 or fewer years of schooling. Forty-one percent were male (Table 1). Depressive symptoms steadily declined through the follow-up period. Depressive symptoms decreased with increasing educational attainment and literacy scores (Table 2). There was a positive and statistically significant interaction between years of schooling and literacy (β = 0.04, 95% CI: 0.02, 0.06). The main effects of education and literacy were each negative while the interaction term was positive. These interaction results suggested that the protective effect of literacy on depressive symptoms attenuated by 0.04 for every unit increase in years of schooling and vice versa. These models included years of schooling, literacy, years of schooling-literacy interaction, and covariates age, sex, race/ethnicity, and early life SES. Using the IORW approach, a one standard deviation increase in educational attainment (~3 years) was associated with a 0.35-point decrement in the CES-D score (95% CI: -0.38, -0.32). This decrease represents a 0.22 standard deviation difference in depressive symptoms. The estimated effect of education on depressive symptoms mediated through literacy was -0.10 (95% CI: -0.18, -0.01), which represents 28% of the total effect, leaving the remaining 0.25 decrease in CES-D score as the natural direct effect (95% CI: -0.35, -0.16) (Table 3). The results using the Baron and Kenny approach were similar and within the 95% CI of the IORW results. The natural direct effect was statistically significant, indicating partial mediation (Table 3). The Baron and Kenny results were less variable than the IORW results. In recombinant DNA technology setting, both approaches lead to the same substantive conclusion.
    Discussion Under classic nondifferential measurement error such that errors are unrelated to the exposure or outcome, estimates of the mediated effect (indirect effect) will be biased toward the null, and estimates of the direct effect will be biased away from the null (VanderWeele, Valeri, & Ogburn, 2012). Our measurement error corrected results are consistent with nondifferential measurement error and suggest the effect of education on depressive symptoms mediated through literacy may be even larger than evidenced in our primary analysis. Education can impact depressive symptoms via several pathways. More education is associated with greater likelihood of engaging in health promoting behaviors, better health outcomes, and longer life expectancy (Egerter et al., 2009). Education is associated with decreased likelihood of smoking and greater likelihood of obtaining health care check-ups and screening, and engaging in regular physical activity (Egerter et al., 2009). Educational attainment influences occupational opportunities and earning potential. It facilitates access to information as well as resources (Adler & Newman, 2002). It can also influence health via psychological processes including increasing sense of control and social standing (Egerter et al., 2009). By affecting living and working conditions, health behaviors, and health outcomes, education can influence depression.