Health literacy level and its distribution characteristics in China
There are some differences in the definition of health literacy across different countries. The measurement tools and research perspectives are different, and the standards are not uniform. Therefore, it is difficult to directly compare the health literacy levels among individuals in different countries. The National Assessment of Adult Literacy has reported 36% of the United States adult population had basic or less-than-basic health literacy. Limited health literacy was more common in Hispanic (66%), black (58%), and American Indian and Alaska Native (48%) populations [3, 11]. Nearly 19% of African American adults had a serious lack of health literacy .
Health literacy research started late in China. In 2008, based on the research results and experiences pertaining to health literacy at home and abroad, the former Ministry of Health of China organized medical and health experts to define the 66 basic contents of Chinese health literacy and compiled the Chinese Health Literacy Monitoring Questionnaire. In the same year, the first survey of health literacy was conducted nationwide. The survey results showed that the overall level of health literacy among Chinese people was 6.48% .
In this study, the health literacy level was 22.3%. These findings indicated that the health literacy level of Chinese people has improved significantly in the past decade. However, compared with some developed countries of equal economic development, China's health literacy level is still low. Previous studies have shown that the proportions of people with adequate health literacy in the United States, the United Kingdom and Japan were 64%, 88.6% and 72.3%, respectively [11, 14, 15]. In terms of scores on different dimensions, the proportion of respondents with basic knowledge and attitudes was higher than those with healthy lifestyles and behaviours. This finding demonstrated that Chinese people had a phenomenon of inconsistency between knowledge and practice in health literacy, and health knowledge was not effectively translated into healthy lifestyles and behaviours. According to health education knowledge and belief theory, behaviour change is divided into three consecutive processes: acquiring knowledge, generating beliefs, and forming behaviours. The acquisition of health knowledge is relatively easy. The transformation from knowledge into belief and then into healthy behaviour is a relatively long process that is influenced by many factors (internal and external factors et al) .
Among the six types of health literacy, basic medical care literacy and chronic disease prevention literacy were relatively low, especially in the western region, which indicates the need to strengthen the understanding of scientific medical treatment, rational drug use and chronic disease prevention. In recent years, the incidence of chronic diseases in China has increased significantly, but the awareness of knowledge about common chronic diseases such as diabetes and high blood pressure is generally low. The phenomenon of “three high and three low” is common in the prevention and treatment of chronic diseases and is characterized by a high incidence of chronic diseases, a high prevalence, a high rate of disability, low knowledge, low control rate, and low treatment rate. It is imminent to further strengthen health education on chronic disease prevention and treatment .
Health literacy is a comprehensive performance of a country's or a region's level of social and economic development . This study showed that there were significant differences in the levels of health literacy among people in different regions, with the highest levels in the eastern region, the second-highest levels in the central region, and the lowest levels in the western region, which was consistent with the results of previous research . The proportion of adequate HL in different provinces or municipalities ranged from 10.5–47.0%. The heterogeneities of health literacy among people in different regions was also a true reflection of the imbalance in the development of economic, cultural, and medical resources in different regions of China.
Factors affecting health literacy and the emphasis on health literacy promotion in different regions
This study found that health literacy was strongly associated with education. A higher education level was independently associated with a higher health literacy level, which is consistent with the conclusions of previous studies [18–20]. A well-educated person has a stronger ability to understand, analyse, and judge scientific views, making it easier to acquire and understand health literacy-related knowledge. People with a limited education level obtained less health-related information and had less experience interacting with health professionals than the general population did . Therefore, health education interventions should be designed based on a clear understanding of the patterns of resources available among limited groups based on education levels.
The results of the present study revealed a significant correlation between economic status and health literacy in the eastern, and central regions. This result is consistent with the findings of previous studies that showed that low socioeconomic status was correlated with low health literacy and a positive relationship between personal income and health literacy [14, 22, 23]. From the perspective of economics, for middle- and high-income individuals, their basic needs for life have been met, so they pay more attention to the improvement of their quality of life. As a result, the demand for health care services is higher, and more attention and energy can be invested in their own health conditions . Health promotion programmes may be less effective for groups with low economic status because of their poor perception of their own health status, their low use of health education resources and their limited access to relevant educational services and social support .
This study found a significant association between adequate health literacy and self-rated health status. This finding is consistent with those of previous studies on health literacy among office workers . In the central and western regions, because of non-health factors, such as more economic and life pressures and less access to health education knowledge and health services, some people are seldom concerned about their own health status even if their physical condition is poor. This may be related to the fact that self-rated health status was not significantly associated with adequate health literacy in the central and western regions.
The studies evaluating the relationship between health literacy and gender yielded mixed results. Studies by Cavanaugh and Tang Chi showed that women's health literacy level was higher than that of men, which was the exact opposite of the findings of Yan et al. [6, 17, 27]. This might be due to the difference in the sample population and the region. This study showed that being female was predictive of increased health literacy levels. Women are more willing than men to obtain health information through various channels and are more active in obtaining health information . After stratification by area was performed, being female was positively correlated with adequate health literacy in the central and western regions, which might be due to the relative lack of health care resources in the central and western regions, and there are fewer ways for people to obtain health-related information. In the eastern region, various forms of health education information were available, and gender differences were not significant for the health literacy level.
Since 2011, Chinese health departments have vigorously promoted "The National Healthy Lifestyle Action", which is based on knowledge presentation, health consultation and physical examination screening. It is a roving health popularization activity that is conducted by urban and rural communities . This study revealed that health literacy was significantly associated with community health education after adjustments were made for other factors. In the central and western regions, people who received more community health education within three years had higher health literacy. Popularizing health knowledge through face-to-face community health education activities is an effective way of improving the health literacy levels of people in the central and western regions. Moreover, there may be some shortcomings in health education and health promotion in the central and western regions, and access to health knowledge is not as extensive as that in the eastern region. Thus, strengthening the publicity of health knowledge through various channels will be more helpful in improving the health literacy levels of people in the central and western regions. Community health education should combine multiple approaches based on a clear understanding of the patterns of resources available among different socio-demographic groups, such as those specifically focused on disadvantaged groups, and develop the capacity of the community as a whole to act using the social resources available .
This study has several limitations that can be improved in further research. First, we did not assess the risky health behaviours (tobacco, alcohol and drug use) of the participants in this particular study, but these behaviours will be evaluated in future studies. Second, some items were self-reported in this study. We obtained data through self-report items, such as self-rated health status. Self-reporting is prone to bias, which will make respondents more likely to provide socially desirable answers. The effect of self-report bias cannot be excluded in the present investigation. Despite these limitations, this study covered 25 provinces or municipalities in different regions of China, and examined the level of health literacy and factors in China. A focus was on differences by region. This study provided a reference for developing strategies and measures to improve health literacy.