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The Urban-Rural Disparity in the Status and Risk Factors of Health Literacy: a Cross-Sectional Survey in Central China

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The Urban-Rural Disparity in the Status and Risk Factors of Health Literacy: a Cross-Sectional Survey in Central China International Journal of Environmental Research and Public Health Article The Urban-Rural Disparity in the Status and Risk Factors of Health Literacy: A Cross-Sectional Survey in Central China Wenna Wang 1, Yulin Zhang 2,*, Beilei Lin 1, Yongxia Mei 1, Zhiguang Ping 3 and Zhenxiang Zhang 1,* 1 School of Nursing and Health, Zhengzhou University, Zhengzhou 450001, China; [email protected] (W.W.); [email protected] (B.L.); [email protected] (Y.M.) 2 Institute of Health Education and Prevention of Chronic Non-Communicable Diseases, Henna Provincial Centers for Disease Control and Prevention, Zhengzhou 450016, China 3 School of Public Health, Zhengzhou University, Zhengzhou 450001, China; [email protected] * Correspondence: [email protected] (Y.Z.); [email protected] (Z.Z.) Received: 13 April 2020; Accepted: 25 May 2020; Published: 29 May 2020 Abstract: Health literacy is the ability of individuals to access, process, and understand health information to make decisions regarding treatment and their health on the whole; it is critical to maintain and improve public health. However, the health literacy of urban and rural populations in China has been little known. Thus, this study aims to assess the status of health literacy and explore the differences of its possible determinants (e.g., socio-economic factors) among urban and rural populations in Henan, China. A cross-sectional study, 78,646 participants were recruited from a populous province in central China with a multi-stage random sampling design. The Chinese Resident Health Literacy Scale was adopted to measure the health literacy of the respondents. In the participants, the level of health literacy (10.21%) in central China was significantly lower than the national average, and a big gap was identified between urban and rural populations (16.92% vs. 8.09%). A noticeable difference was reported in different aspects and health issues of health literacy between urban and rural populations. The health literacy level was lower in those with lower levels of education, and a significant difference was identified in the level of health literacy among people of different ages and occupations in both urban and rural areas. Note that in rural areas, as long as residents educated, they all had higher odds to exhibit basic health literacy than those uneducated; in rural areas, compared with those aged 15 to 24 years, residents aged 45 to 54 years (OR = 0.846,95% CI (0.730, 0.981)), 55 to 64 years (OR = 0.716,95% CI (0.614, 0.836)) and above 65 years (OR = 0.679, 95% CI (0.567, 0.812)) were 84.6%, 71.6%, and 67.9%, respectively, less likely to exhibit basic health literacy. Considering the lower health literacy among rural residents compared with their urban counterparts, a reorientation of the health policy-making for Chinese rural areas is recommended. This study suggests that urban–rural disparity about health literacy risk factors should be considered when implementing health literacy promotion intervention. Keywords: health literacy; urban; risk factor; rural; China 1. Introduction Health literacy is the ability of individuals to access, process, and understand health information to make decisions in terms of treatment and their health on the whole [1,2]. It is a strong predictor for health status and significantly impacts public health [3]. Existing studies suggested that high health literacy is associated with healthier lifestyles and health-promoting and -maintaining behaviors in healthy adults and people with chronic disease [4,5]. Meantime, increasing studies suggested that Int. J. Environ. Res. Public Health 2020, 17, 3848; doi:10.3390/ijerph17113848 www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2020, 17, 3848 2 of 12 inadequate health literacy is associated with many negative health outcomes (e.g., poor self-rated health, occurrence and development of chronic diseases, and increased mortality risk) [6,7]. Health literacy also displays an inverse relationship to healthcare utilization and expenditure and critically impacts health education and promotion [8]. Accordingly, health literacy is increasingly important in public health. Since health literacy affects most of the population [9], it has become more popularized over the past decade. Though China is a large country with a population of approximately 1.4 billion [10], compared with the long and comprehensive history of health literacy studies in different settings of some developed countries, (e.g., the United States or Canada), it has a late start in focusing on health literacy, and the term “health literacy” was proposed initially in the project of “the First Chinese Residents Health Literacy Monitoring Program” launched by China Center for Disease Control and prevention in 2005 and the first national survey of the public health literacy status was conducted by the Chinese Ministry of Health in the mainland of China in 2008 [11,12]. Subsequently, in 2012, the Chinese Health Education Authority issued a novel strategic plan to assess health literacy nationally; the result indicated that the health literacy monitoring work has ushered into the track of normalization and standardization [13]. As suggested by the national health literacy monitoring data, through continuous intervention, the national health literacy level of Chinese residents was steadily elevated from 6.48% in 2008 to 9.79% in 2014 [14]. However, the rapid and disproportional economic growth in urban and rural China has brought unexpected changes in public health [15]. One study conducted in the Jiangsu province of China in 2010 demonstrated that living in a rural area acts as a critical predictor of a low health literacy status [16], and a recent study conducted in Hebei Province, China has reported that that health literacy level of urban residents (19.00%) is significantly higher than that in rural areas (7.94%) [17]. Moreover, China has become an “aging society” as of 2000 and has experienced an unprecedented process in its aging population [18]. The accelerated population aging has brought about health, social, and economic issues (e.g., decreased health function attributed to disability and chronic diseases) [19], and note that the burden of chronic diseases is serious in rural China. Hence, elevating the health literacy level of residents and narrowing the gap between urban and rural health literacy is crucial to the steady improvement of public health in China. An individual with an adequate level of health literacy refers to a person that has the ability to take responsibility for his or her own health, as well as their family’s health and community health [1]. Though adequate health literacy and knowledge about associated factors are relevant in all phases of the life course to maintain health and getting involved in decisions in terms of health and health care [9], health literacy status and its risk factors between urban and rural areas have been little known. To gain insights into the health literacy and deepen the implementation of health literacy intervention among residents from a regional perspective, the aim of this study is therefore to assess the status of health literacy and to explore the differences of its possible determinants (e.g., socio-economic factors) among urban and rural populations in Henan province, China. 2. Materials and Methods 2.1. Study Population and Sampling Design This study was a cross-sectional survey and conducted in Henan, China, a populous province with 108.5 million [20], from September 2017 to May 2018. The study population was permanent residents aged 15 to 69 years in 18 provincial cities and 10 provinces directly governing counties under the jurisdiction of Henan Province, which involved those who have accumulated over 6 months of local residence in the past 12 months, regardless of whether they have local household registration. However, the residents who collectively live in military bases, hospitals, prisons, nursing homes, dormitories, and other places were excluded. A multi-stage cluster sampling method was adopted to select participants. Cluster sampling has a merit that it can fully ensure the consistency of sample structure and population while enhancing the Int. J. Environ. Res. Public Health 2020, 17, 3848 3 of 12 Int. J. Environ. Res. Public Health 2020, 17, x 3 of 12 representativeness of samples. The procedure is illustrated in Figure1. The sample size of each chosen enhancing the representativeness of samples. The procedure is illustrated in Figure 1. The sample urban resident committee or village committee is calculated by size of each chosen urban resident committee or village committee is calculated by 2 2 NN= =( µ(μα_α^2×p(1-p))/p(1 p))/δδ^2 ×deffdeff (1)(1) × − × where α denotes the significance level; μ is the value of μ when α is equal to 0.05; p is the where α denotes the significance level; µα is the value of µ when α is equal to 0.05; p is the percentage percentageof people with of people basic healthwith basic literacy; healthδ is literacy; the maximum δ is the permissiblemaximum permissible error; deff represents error; deff therepresents design theeffect design of complex effect samplingof complex adopted sampling to adjust adopted the e fftoectiveness adjust the loss effectiven due to complexess loss samplingdue to complex instead samplingof simple randominstead sampling.of simple Therandom monitoring sampling. sample The ratemonitoring of residents’ sample health rate literacy of residents’ level in Henanhealth provinceliteracy level in 2014 in Henan was 8.02% province [21]; in on 2014 that was basis, 8.02% a 95% [21]; confidence on that basis, limit a was 95% set, confidence the relative limit error was rateset, wasthe relative not greater error than rate 20%, wasde notff = greater1.5. Based than on 20%, the resultsdeff = 1.5. of urbanBased andon the rural results stratification, of urban the and invalid rural questionnairestratification, andthe invalid the refusal questi rateonnaire was not and more the than refusal 10%, rate the minimumwas not more monitoring than 10%, sample the minimum size of the provincialmonitoring municipality sample size of was the calculated provincial as municipality 3672 people was in 17 calculated provincial ascities.
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