The Association Between Health Literacy and Self-rated Health Among Residents of China Aged 15–69 Years

Published:February 11, 2021DOI:


      Health literacy is a critical determinant of health. However, the association between health literacy and outcomes among Chinese residents has not been studied using nationally representative data. This study examines the association between health literacy and self-rated health among Chinese residents based on the 2017 China Health Literacy Survey.


      The 2017 China Health Literacy Survey was conducted among non-institutionalized residents aged 15–69 years from 31 provinces in China. Self-rated health was measured using a single question with a 1–5 scale. Health literacy was assessed using the Chinese Health Literacy Scale. Multilevel linear regression models examined the association between health literacy and self-rated health. Data were collected in 2017 and analyzed between 2018 and 2019.


      The final sample size was 85,384. The overall weighted mean of the self-rated health score was 4.02 (95% CI=4.00, 4.03). After adjusting for individual-, county-, and province-level covariates, Chinese residents with higher levels of health literacy were more likely to have better self-rated health (β=0.0007, SE=0.0002, p<0.001). Of 6 dimensions of health literacy, 4 (i.e., infectious diseases literacy, chronic diseases literacy, medical care literacy, and health information literacy) were associated with self-rated health. Additionally, self-rated health was associated with gender, age, education, occupation, annual household income, and chronic conditions.


      Using nationally representative data collected in 2017, this study found that self-rated health is associated with health literacy among Chinese residents aged 15–69 years. The promotion of health literacy should be an important component of health education, patient management, and health promotion.
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        • Nielsen-Bohlman L
        • Panzer AM
        • Kindig DA
        Health Literacy: A Prescription to End Confusion.
        The National Academies Press, Washington, DC2004
        • World Health Organization
        Shanghai declaration on promoting health in the 2030 Agenda for Sustainable Development.
        Health Promot Int. 2017; 32: 7-8
      1. World Health Organization. Promoting health: guide to national implementation of the Shanghai Declaration. Published 2018. Accessed September 1, 2019.

        • Kickbusch I
        • Pelikan JM
        • Apfel F
        • Tsouros AD
        Health literacy: the solid facts.
        World Health Organization Regional Office for Europe, Copenhagen, DenmarkPublished 2013
        • U.S. Department of Health and Human Services
        Healthy People 2010: understanding and improving health.
        2nd ed. U.S. Government Printing Office, Washington, DCNovember 2000 (Published)
      2. Health communication and health information technology. Accessed September 1, 2019.

        • U.S. Department of Health and Human Services
        Office of Disease Prevention and Health Promotion.
        National action plan to improve health literacy, May 2010 (Published)
        • Commission of the European Communities
        Together for health: a strategic approach for the EU 2008–2013.
        October 23, 2007 (Published)
        • World Health Organization Regional Office for Europe
        Health 2020: a European policy framework and strategy for the 21st century.
        Published 2013
        • Chinese citizens’ health literacy-basic knowledge and skills [in Chinese]
        Ministry of Health of the People's Republic of China.
        January 4, 2008 (Published)
        • Li YH.
        Introduction of 2012 Chinese residents health literacy monitoring program [in Chinese].
        Chin J Health Educ. 2014; 30: 563-565
      3. The role of governments in promoting health literacy. World Health Organization. Published 2016. Accessed 1 September 2019.

      4. The central committee of the Communist Party of China and the State Council issued the “outline of the “Healthy China 2030” plan” [in Chinese] Published October 25, 2016. Accessed 1 September 2019.

        • Institute of Medicine
        Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary.
        The National Academies Press, Washington, DC2013
        • The National Academies of Sciences, Engineering, and Medicine
        Health Literacy: Past, Present, and Future: Workshop Summary.
        The National Academies Press, Washington, DC2015
        • Pleasant A.
        Health Literacy Around the World: Part 2. Health Literacy Efforts Within the United States and a Global Overview.
        Institute of Medicine, Washington, D.C.2013
        • Berkman ND
        • Sheridan SL
        • Donahue KE
        • et al.
        Health literacy interventions and outcomes: an updated systematic review.
        Evid Rep Technol Assess (Full Rep). 2011; : 1-941
        • Sørensen K
        • Van den Broucke S
        • Fullam J
        • et al.
        Health literacy and public health: a systematic review and integration of definitions and models.
        BMC Public Health. 2012; 12: 80
        • Bostock S
        • Steptoe A.
        Association between low functional health literacy and mortality in older adults: longitudinal cohort study.
        BMJ. 2012; (344:e1602)
        • Zhou M
        • Wang H
        • Zeng X
        • et al.
        Mortality, morbidity, and risk factors in China and its provinces, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017.
        Lancet. 2019; 394: 1145-1158
        • Liu Q
        • Xu W
        • Lu S
        • et al.
        Landscape of emerging and re-emerging infectious diseases in China: impact of ecology, climate, and behavior.
        Front Med. 2018; 12: 3-22
        • Jakovljevic MB
        • Milovanovic O.
        Growing burden of non-communicable diseases in the emerging health markets: the case of BRICS.
        Front Public Health. 2015; 3: 65
      5. Xu W. Nation to promote Internet Plus healthcare. Published April 12, 2018. Accessed 1 September 2019.

        • Zhang Y
        • Xia T
        • Huang L
        • et al.
        Factors influencing user engagement of health information disseminated by Chinese Provincial Centers for Disease Control and Prevention on WeChat: observational study.
        JMIR MHealth UHealth. 2019; 7: e12245
        • Zhu R
        • Xu X
        • Zhao Y
        • Sharma M
        • Shi Z
        Decreasing the use of edible oils in China using WeChat and theories of behavior change: study protocol for a randomized controlled trial.
        Trials. 2018; 19: 631
        • Yang Q
        • Wu S
        How social media exposure to health information influences Chinese people's health protective behavior during air pollution: a theory of planned behavior perspective.
        Health Commun. 2019; 24: 1-10
        • Zhang X
        • Wen D
        • Liang J
        • Lei J
        How the public uses social media WeChat to obtain health information in China: a survey study.
        BMC Med Inform Decis Mak. 2017; 17: 66
        • Ministry of Health of the People's Republic of China Department of Maternal and Child Health Care and Community Health, Chinese Center for Health Education
        Report on the First National Health Literacy Survey Among Chinese Residents.
        Ministry of Health of the People's Republic of China, Beijing2009
        • 2017 Chinese residents’ health literacy monitoring results released [in Chinese]
        National Health Commission of the People's Republic of China.
        2018 (Published September 25)
        • National Health Commission of the People's Republic of China Department of Publicity, Chinese Center for Health Education
        Report on the 2017 Chinese Health Literacy Surveillance [in Chinese].
        National Health Commission of the People's Republic of China, Beijing2018
        • Yang R
        • Li D
        • Hu J
        • et al.
        Association between health literacy and subgroups of health risk behaviors among Chinese adolescents in six cities: a study using regression mixture modeling.
        Int J Environ Res Public Health. 2019; 16: 3680
        • Qiu C
        • Zhang X
        • Zang X
        • Zhao Y
        Acceptance of illness mediate the effects of health literacy on self-management behaviour.
        Eur J Cardiovasc Nurs. 2020; 19: 411-420
        • Chen WL
        • Zhang CG
        • Cui ZY
        • et al.
        The impact of social capital on physical activity and nutrition in China: the mediating effect of health literacy.
        BMC Public Health. 2019; 19: 1713
        • Zheng F
        • Ding S
        • Lai L
        • et al.
        Relationship between medication literacy and medication adherence in inpatients with coronary heart disease in Changsha, China.
        Front Pharmacol. 2020; 10: 1537
        • Chang A
        • Schulz PJ.
        The measurements and an elaborated understanding of Chinese eHealth Literacy (C-eHEALS) in chronic patients in China.
        Int J Environ Res Public Health. 2018; 15: 1553
        • Wang R
        • Jia X
        • Li S
        • et al.
        Research on the relationship between health literacy and health status of residents in Qingdao [in Chinese].
        Chin J Dis Control Prev. 2019; : 70-74
        • Nie X
        • Li Y
        • Li L
        • Huang X
        A study on health information literacy among urban and suburban residents in six provinces in China [in Chinese].
        Zhonghua Yu Fang Yi Xue Za Zhi. 2014; 48: 566-570
        • Zou H
        • Chen Y
        • Fang W
        • Zhang Y
        • Fan X
        The mediation effect of health literacy between subjective social status and depressive symptoms in patients with heart failure.
        J Psychosom Res. 2016; 91: 33-39
        • Hu Z
        • Qin L
        • Xu H
        Association between diabetes-specific health literacy and health-related quality of life among elderly individuals with pre-diabetes in rural Hunan Province, China: a cross-sectional study.
        BMJ Open. 2019; 9e028648
        • Wang C
        • Lang J
        • Xuan L
        • Li X
        • Zhang L
        The effect of health literacy and self-management efficacy on the health-related quality of life of hypertensive patients in a western rural area of China: a cross-sectional study.
        Int J Equity Health. 2017; 16: 58
        • Xia J
        • Wu P
        • Deng Q
        • et al.
        Relationship between health literacy and quality of life among cancer survivors in China: a cross-sectional study.
        BMJ Open. 2019; 9e028458
        • Zhang J
        • Gilmour S
        • Liu Y
        • Ota E
        Effect of health literacy on quality of life among patients with chronic heart failure in China.
        Qual Life Res. 2020; 29: 453-461
        • Jylhä M.
        What is self-rated health and why does it predict mortality? Towards a unified conceptual model.
        Soc Sci Med. 2009; 69: 307-316
        • Krause NM
        • Jay GM
        What do global self-rated health items measure.
        Med Care. 1994; 32: 930-942
        • Kutner M
        • Greenberg E
        • Jin Y
        • Paulsen C
        The health literacy of America's adults: results from the 2003 National Assessment of Adult Literacy.
        National Center for Education Statistics, Washington DCSeptember 2006
        Date accessed: September 1, 2019
        • Sørensen K
        • Pelikan JM
        • Röthlin F
        • et al.
        Health literacy in Europe: comparative results of the European health literacy survey (HLS-EU).
        Eur J Public Health. 2015; 25: 1053-1058
        • van der Heide I
        • Wang J
        • Droomers M
        • Spreeuwenberg P
        • Rademakers J
        • Uiters E
        The relationship between health, education, and health literacy: results from the Dutch Adult Literacy and Life Skills Survey.
        J Health Commun. 2013; 18: 172-184
        • Omariba DW
        • Ng E
        Immigration, generation and self-rated health in Canada: on the role of health literacy.
        Can J Public Health. 2011; 102: 281-285
        • Furuya Y
        • Kondo N
        • Yamagata Z
        • Hashimoto H
        Health literacy, socioeconomic status and self-rated health in Japan.
        Health Promot Int. 2015; 30: 505-513
        • Tsoh JY
        • Sentell T
        • Gildengorin G
        • et al.
        Healthcare communication barriers and self-rated health in older Chinese American immigrants.
        J Community Health. 2016; 41: 741-752
        • Sentell T
        • Braun KL
        Low health literacy, limited English proficiency, and health status in Asians, Latinos, and other racial/ethnic groups in California.
        J Health Commun. 2012; 17: 82-99
        • Waverijn G
        • Heijmans M
        • Spreeuwenberg P
        • Groenewegen PP
        Associations between neighborhood social capital, health literacy, and self-rated health among people with chronic illness.
        J Health Commun. 2016; 21: 36-44
        • Toci E
        • Burazeri G
        • Jerliu N
        • et al.
        Health literacy, self-perceived health and self-reported chronic morbidity among older people in Kosovo.
        Health Promot Int. 2015; 30: 667-674
        • Marques SRL
        • Escarce AG
        • Lemos SMA
        Health literacy and self-rated health in adults primary care patients.
        Codas. 2018; 30e20170127
        • Amoah PA
        • Phillips DR
        • Gyasi RM
        • Koduah AO
        • Edusei J
        Health literacy and self-perceived health status among street youth in Kumasi, Ghana.
        Cogent Med. 2017; 4
        • Lu Y
        • Qian G
        • Kang R
        • Yang Y
        • Lu P
        Health literacy and its influencing factors of chronic disease prevention and treatment in Gansu Province [in Chinese].
        Chin J Prev Contr Chron Dis. 2015; : 714-716
        • Liu Y
        • Liang J
        • Yao D
        • et al.
        Relationship of health literacy with health status and health service utilization in elderly individuals in nursing homes for seniors [in Chinese].
        Chin Gen Pract. 2014; 17: 449-452
        • Liu YB
        • Liu L
        • Li YF
        • Chen YL
        Relationship between health literacy, health-related behaviors and health status: a survey of elderly Chinese.
        Int J Environ Res Public Health. 2015; 12: 9714-9725
        • Kish L.
        A procedure for objective respondent selection within the household.
        J Am Stat Assoc. 1949; 44: 380-387
        • de Bruin A
        • Picavet HS
        • Nossikov A
        Health interview surveys. Towards international harmonization of methods and instruments.
        WHO Reg Publ Eur Ser. 1996; 58 (1–161): i-xiii
        • Li Y
        • Nie X.
        Contrast analysis of 2008 and 2012 national health literacy survey plan [in Chinese].
        Chin J Health Educ. 2014; : 176-177
        • Zha B.
        The gap of economic development expanding between eastern China and middle, western China.
        China Popul Res Newsl. 1996; : 2-3
        • National Health Commission of the People's Republic of China
        China Health Statistics Yearbook 2019 [in Chinese].
        China Union Medical University Press, Beijing2019
        • Saylor J
        • Friedmann E
        • Lee HJ
        Navigating complex sample analysis using national survey data.
        Nurs Res. 2012; 61: 231-237
        • Nie X
        • Li Y
        • Li L
        Statistical analysis method of Chinese residents’ health literacy monitoring data in 2012 [in Chinese].
        Chin J Health Educ. 2014; : 178-181
        • Li Y
        • Mao Q
        • Shi Q
        • et al.
        2012 Chinese residents’ health literacy monitoring results [in Chinese].
        Chin J Health Educ. 2015; : 99-103
        • Li L
        • Li Y
        • Nie X
        • et al.
        Analysis of factors affecting health literacy of Chinese residents in 2012 [in Chinese].
        Chin J Health Educ. 2015; : 104-107
        • Nie X
        • Li Y
        • Tao M
        • et al.
        The level of Chinese residents’ chronic disease prevention and control literacy and its influencing factors [in Chinese].
        Chin J Health Educ. 2015; : 108-111
        • Baker DW.
        The meaning and the measure of health literacy.
        J Gen Intern Med. 2006; 21: 878-883
        • Paasche-Orlow MK
        • Wolf MS.
        The causal pathways linking health literacy to health outcomes.
        Am J Health Behav. 2007; 31: S19-S26
        • Kim H
        • Xie B.
        Health literacy in the eHealth era: a systematic review of the literature.
        Patient Educ Couns. 2017; 100: 1073-1082
        • Azzopardi-Muscat N
        • Sørensen K.
        Towards an equitable digital public health era: promoting equity through a health literacy perspective.
        Eur J Public Health. 2019; 29: 13-17
        • Morris NS
        • MacLean CD
        • Littenberg B
        Literacy and health outcomes: a cross-sectional study in 1002 adults with diabetes.
        BMC Fam Pract. 2006; 7: 49
        • Williams MV
        • Baker DW
        • Parker RM
        • Nurss JR
        Relationship of functional health literacy to patients’ knowledge of their chronic disease. A study of patients with hypertension and diabetes.
        Arch Intern Med. 1998; 158: 166-172
        • Xu J
        • Zhang J
        • Feng L
        • Qiu J
        Self-rated health of population in southern China: association with socio-demographic characteristics measured with multiple-item self-rated health measurement scale.
        BMC Public Health. 2010; 10: 393
        • Hu A
        • Hibel J.
        Educational attainment and self-rated health in contemporary China: a survey-based study in 2010.
        Soc Sci J. 2013; 50: 674-680
        • Dong WL
        • Li YC
        • Wang ZQ
        • et al.
        Self-rated health and health-related quality of life among Chinese residents, China, 2010.
        Health Qual Life Outcomes. 2016; 14: 5
        • Li YH
        • Nie XQ
        • Yang C
        • Pang J
        • Zhang G
        • Tao MX
        Study on lifestyle and self-rated health among 5 kinds of occupational populations in 6 provinces in China [in Chinese].
        Zhonghua Yu Fang Yi Xue Za Zhi. 2012; 46: 214-219
        • Luckhaupt SE
        • Alterman T
        • Li J
        • Calvert GM
        Job characteristics associated with self-rated fair or poor health among U.S. workers.
        Am J Prev Med. 2017; 53: 216-224
        • Chen Y
        • While AE
        • Hicks A
        Self-rated health and associated factors among older people living alone in Shanghai.
        Geriatr Gerontol Int. 2015; 15: 457-464
        • Park JH
        • Lee KS.
        Self-rated health and its determinants in Japan and South Korea.
        Public Health. 2013; 127: 834-843
        • Liu Y
        • Huang B
        • Wang R
        • Feng Z
        • Liu Y
        • Li Z
        Exploring the association between urbanisation and self-rated health of older adults in China: evidence from a national population sample survey.
        BMJ Open. 2019; 9e029176
        • Wong IO
        • Cowling BJ
        • Lo SV
        • Leung GM
        A multilevel analysis of the effects of neighbourhood income inequality on individual self-rated health in Hong Kong.
        Soc Sci Med. 2009; 68: 124-132
        • Yang J
        • Siri JG
        • Remais JV
        • et al.
        The Tsinghua-Lancet Commission on Healthy Cities in China: unlocking the power of cities for a healthy China.
        Lancet. 2018; 391: 2140-2184
        • Nie X
        • Li Y
        • Li L
        • Shi M
        2012–2016 Chinese residents’ basic medical literacy level and its influencing factors [in Chinese].
        Chin J Health Educ. 2019; : 579-583
        • Ishikawa H
        • Kiuchi T.
        Association of health literacy levels between family members.
        Front Public Health. 2019; 7: 169