Table 2 Summary of potential health literacy-related causal pathways for impacting on health and equity in Nepal

People in Nepal have many potential barriers to access and use healthcare services. Barriers include cost of services, cost of transport, low income and unemployment. Existing gender roles and discrimination related to local culture, knowledge of services and health problems, limited availability of services, low quality services provide large challenges for people to access and utilize services.

To overcome these barriers, the health literacy of community members needs to be high such that people are empowered to be able to make decisions about healthcare and overcome access barriers.

Many barriers to quality interactions were identified, including: local culture and gender norms, education, knowledge of health services and health problems, access to good quality information, communication skills of staff, health worker’s attitudes and organizational policy on communication with community members.

When there are one or more of these potential barriers to quality interaction with health service providers, the health literacy of a community member will need to be high.

The identified determinants of this area included gender roles and women’s autonomy, spousal support along with knowledge and education.

Improving health literacy increases understanding of health and disease as well as the available services, hence people are able to take decisions to take care of their own self and others.

The review identified few determinants of participation including the ability to engage in discussions related to gender roles and discrimination, women involvement in decision making, men’s involvement in women’s health, women’s autonomy, spousal support, knowledge and education and the health system responsiveness including communication skills of staff and the quality of health services. Another relevant ability in the community level is the ability of an individual to be able to discuss health matters and make decisions about health. This requires adequate health literacy in an individual and across a community. A strong background mechanism is likely to be educational attainment, including having an understanding of basic biomedical concepts including anatomy and basic medical terms. Without these, being empowered to participate in health negotiations and decision making is unlikely.