Socioeconomic inequalities in health outcomes persist in Spanish society. These inequalities may be analysed from different perspectives, including education and gender. The covid-19 pandemic potentially contributed to increasing inequalities in employment, wealth, and health. However, there has been very little research on inequalities in health or well-being in a post-lockdown context. In this article, socioeconomic inequalities in self-reported health (a subjective assessment of one’s own health status) are explored among a representative sample of the Spanish population aged 50-79 in March-April 2022. 

Of all the possible factors that may have an impact on socioeconomic inequalities in health, this research focuses on two critical elements: health literacy and the socioeconomic digital divide. Health literacy refers to the ability of individuals to meet and understand the complex demands for promoting and maintaining health in modern society, a subject of growing public concern. The socioeconomic digital divide refers to the differences in possibilities for access to technology and Internet usage between social classes.

The results from the survey show that men, as well as high-educated groups, tend to report better health than women and their low-educated counterparts, respectively. For example, 66% of high-educated women and 75% of high-educated men reported good health, whereas these percentages fell to 50% and 62% among low-educated women and men, respectively. The results obtained highlight significant differences in health which may be influenced by several factors.

Although previous studies have explored sex and gender gaps in health, little is known about the role played by two factors that in recent years have become increasingly important in society and scientific debates: health literacy and Internet usage in the Spanish population. Firstly, a better ability to understand medical knowledge and advice may be associated with better health outcomes. Secondly, Internet usage is linked to improved health outcomes and a potentially higher ability to gain access to health information.

The survey results suggest that, in 2022, groups with adequate levels of health literacy have a higher probability of reporting good health than groups with an insufficient health literacy level among women (63% vs. 47%), but not among men (69% vs. 74%). In other words, adequate health literacy levels seem significant for determining perceived health in women, but not in men. Explanations for this finding are multifactorial, but it is likely that women with “adequate” health literacy levels also have healthier lifestyles (e.g., diet, drinking habits, physical activity). Nonetheless, it is important to remember that men and women may respond differently to surveys, and that men in the age bracket considered are a more highly selected subpopulation than that of women, as mortality rates are higher among men than among women.

To gain a better understanding of the interplay between education and health literacy, different analyses in which these two factors interacted were carried out. It was found that, generally, adequate levels of health literacy were related to better health across all education levels and sexes. A possible explanation for this result is that health literacy skills may help to handle adverse health situations and may be related to healthier lifestyles. The exception to this finding is the high-educated men group, in which insufficient health literacy levels are associated with better health than adequate health literacy levels. This finding, however, is not statistically significant. 

Figure 3 shows the interaction between education and health literacy and its impact on health inequality. The group reporting worse health was that of women with a low health literacy level and a low education level, and health literacy seems to be a crucial factor for this group. In other words, among low-educated women, adequate levels of health literacy substantially increase their chances of having good health: from 34% among women with inadequate levels of health literacy to 55% among women with adequate levels of health literacy.

The second critical component that has rapidly become an important skill is Internet usage, which is used as a proxy for the socioeconomic digital divide. Proper Internet usage depends on both individual technical skills and individual resources for Internet accessibility. In general, the results of the survey suggest that men who have used the Internet over the last three months have a higher probability of reporting good health (72%) than those who have not used it over the same period of time (58%). The same pattern is also observed among women, although the difference is narrower (62% vs. 50%).

These data show that, in post-lockdown Spain, Internet usage is positively associated with good self-reported health. There are two possible explanations behind this result. Firstly, Internet usage is positively related to health promotion, health prevention and overall health outcomes. Secondly, the fact that Internet users are a selected sub-population should not be disregarded. In previous literature, it has been shown that there is a positive relationship between Internet usage and both socioeconomic status and good health.

In order to assess educational gradients in the association between Internet usage and health, results are presented for both low- and high-educated groups. Those with high education tend to report better health, regardless of their Internet usage. Furthermore, in low-educated groups, the probability of reporting good health is higher among Internet users (66% in men and 54% in women) than in non-Internet users (50% in men and 40% in women). These results suggest a more significant role of Internet usage in determining health outcomes among low-educated women. 

Health differences across subpopulation groups persist in Spain. In this study, with its focus on the Spanish population aged 50-79, educational inequalities in health are documented. Specifically, two key and overlooked factors – i.e., health literacy and Internet usage – were examined. Both factors are significant determinants of social life, and potential health outcomes. Our findings suggest that it is important to take these two factors into account when assessing health inequalities. Low-educated women are the people who would potentially benefit most from improving both their health literacy and Internet usage. The results from this article reinforce the argument that it is crucial to implement social policies to promote health and well-being, particularly among the more disadvantaged groups in order to improve their health literacy levels and Internet accessibility. 

This study has two main limitations that should be taken into account. Firstly, Internet usage is considered a key variable for measuring the digital divide, and we are aware that a more comprehensive examination of the role played by the digital divide in health inequalities would require consideration of more factors. And secondly, it must be acknowledged that health literacy and Internet usage may be related, which suggests that future studies should address this phenomenon.

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