Introduction

Health Literacy (HL) is the ability to obtain, understand and use health information to make informed healthcare decisions [1]. Health literacy significantly influences an individual’s ability to navigate the healthcare system, engage in self-care, manage chronic diseases, and make informed decisions, thereby profoundly impacting overall public health and individual empowerment [2]. The complexity of health literacy arises from the diverse skills required to comprehend and act on health information [3, 4]. This complexity is further influenced by factors such as socioeconomic status, educational background, cognitive abilities, and cultural context.

The World Health Organization emphasized in the Shanghai Declaration that addressing disparities in health literacy is essential for attaining sustainable development goals in the larger context of global public health [5]. Recent research has demonstrated the significance of health literacy in enhancing Universal Health Coverage (UHC), especially in Low and Middle-Income Countries (LMICs). Health literacy facilitates better access to healthcare services, improves patient-provider communication, and enhances the effective use of health information and resources. Studies show that higher health literacy levels are associated with better health outcomes, reduced healthcare costs, and increased patient engagement. Enhancing UHC requires not just building infrastructures but also equipping people to use existing channels to be able to improve their health [6].

Despite the advancements in healthcare access and educational initiatives, significant disparities in health literacy persist in Nepal. The nation’s low income exacerbates some healthcare issues, such as limited access to services and inadequate infrastructure [7]. Profound health disparities exacerbate these problems. The complexity of the healthcare environment is further increased by linguistic diversity, regional variances, and cultural customs in Nepal [8]. Very few studies have been conducted to explore the levels of health literacy levels among the general population in Nepal. Our study aims to assess the health literacy level and associated factors among adults in Rasuwa district, Nepal. Previous research has primarily focused on undergraduate students, leaving a gap in understanding health literacy among the general adult population in rural areas. This study provides new insights that can inform targeted interventions to improve health outcomes in these communities, expanding the understanding beyond academic settings.

Methodology

Study Design, Setting, Participants, and Sampling Technique

A cross-sectional study was conducted among randomly selected adults from one ward of the rural municipality of Rasuwa District, Nepal, using a structured questionnaire in February 2024. Out of 5 rural municipalities in Rasuwa District, one municipality was randomly selected (Kalika Rural Municipality) using the lottery method. The randomly selected administrative strata from the municipality was Ward no 3 (Dharapani) from Kalika Rural Municipality. The detailed flowchart of sampling is given in Fig. 1. The sampling frame includes the total population of Ward no 3 (Dharapani), i.e., 1662 according to Census 2021 [9]. Participants were eligible for inclusion in the study if they met the following criteria: they were 18 years of age or older, resided in Ward No. 3, and provided informed consent. Exclusion criteria encompassed individuals who were unable to communicate effectively due to severe health conditions. These conditions included advanced neurological disorders, severe cognitive impairments, or any other medical conditions that significantly impeded their ability to understand or participate in the study procedures.

Sample Size

The sample size was calculated using the formula n = z2pq/e2, based on 26% prevalence of adequate health literacy in a similar context [10], with a 5% error, resulting in an estimated sample of 252.

Fig. 1
figure 1

Flow chart for participants sampling and interview in the study on health literacy

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Data Collection

Data was collected through a face-to-face interview by the trained researcher using a structured questionnaire.

Measurement Instruments

Dependent Variable (Health Literacy)

The HLS-EU-Q16 questionnaire consists of 16 questions asking participants about perceived ease or difficulty in assessing/understanding/appraising/applying available health information. Each question had five response options: very easy, easy, difficult, very difficult, or do not know the answer. The English version of the survey instrument was translated into the local language (Nepali) using the translation and back-translation methods using bilingual. The final English version was further translated into Nepali by two independent bilingual translators. To avoid information bias, translators included people with both health and non-health backgrounds. The forward translation was carried out by an experienced public health professional (health) and a notarized non-health translator unknown to the concepts of the items and purpose. The Nepali version thus obtained was back translated into English by two other translators who were blinded to the original English version of the questionnaire. The back translation was reviewed, and with the help of bilingual professionals, a reconciled Nepali version of the questionnaire was obtained. The 16 questions were categorized into three categories: health promotion (4 questions), disease prevention (5 questions), and healthcare (7 questions). A five-point Likert scale was used to score the difficulty of the HLS-EU-Q16 (1, very difficult: 2, difficult: 3, easy: 4, very easy: and 0, don’t know). According to the European Health Literacy Consortium [11] The scores were rated as follows: (0–8) likely inadequate health literacy [9,10,11,12], likely problematic health literacy, and [13,14,15,16] likely sufficient health literacy. We combined ‘very easy’ and ‘easy’ into one group to create ‘adequate health literacy,’ which scored 1. We combined ‘very difficult’ and ‘difficult’ together to create ‘limited health literacy,’ scoring 0.

Variables

Socio-demographic characteristics included age, gender, ethnicity (categorized as Dalit, Janajati, Brahmin/Chhetri, Muslim, and Others as per the Health Management Information System, Nepal government classification), place of origin, the highest level of education (Illiterate, Literate, Basic, Intermediate, bachelor’s and higher), occupation, etc.

Three subjective well-being indicators were assessed: self-related financial status, self-related health status, and self-related self-esteem. Participants rated their financial situation on a scale of 1 to 6, ranging from “very poor” to “very rich” [7]. These responses were then grouped into two categories: “poor” (scores of 1 and 2) and “good” (scores of 3 to 6). Participants reported their self-rated health status on a scale of 1 to 6. Later, they were dichotomized as satisfactory health (scores 1 and 2) and unsatisfactory health (3 to 6). Self-esteem was evaluated using a validated scale created by Rosenberg [36], where participants rated the statement “I have very high self-esteem” on a scale from 1 to 7, with the lowest value indicating “not very true of me” and the highest value indicating “very true of me.”

Statistical Analysis

Data were analyzed using IBM SPSS version 25. Mean and standard deviation were used to describe the continuous variables, and absolute frequency and percentage were used to describe the categorical variables. Descriptive statistics were computed to identify the socio-demographic characteristics of the participants. A chi-square test followed by binary logistic regression analysis was performed to establish the association between health literacy and various socio-demographic variables. The statistical significance was set at p-value < 0.05.

Ethical Consideration

Ethical Approval was obtained from the Institutional Review Committee (IRC) of the Institute of Medicine (IOM), Tribhuvan University, Nepal. Official administrative approval was obtained from Kalika Rural Municipality Ward No. 3 to carry out the study among the ward’s population. Informed written consent was taken from each participant before the study.

Results

Characteristics of the Participants

A total of 253 respondents were included in the analysis. The participants’ mean age (± SD) was 46.3 ± 16 years, where more than half were females (56.1%). Brahmin/Chhetri (67.2%) was the major ethnic group, and 67.2% of the participants belonged to a nuclear family, 37.9% were illiterate, and 76.9% of them were involved in agriculture (Table 1).

Table 1 Characteristics of the study participants (n = 253)
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Level of Health Literacy

Table 2 shows that around half of the respondents (47.7%) had inadequate health literacy, while about a quarter (23.3%) had adequate health literacy.

Table 2 Level of health literacy (n = 253)
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Factors Associated with Adequate Health Literacy

Younger adults (≤ 45 years) were 1.9 (95% CI: 1.0-3.6) times more likely to have adequate health literacy than participants aged > 45 years. Participants who perceived their health status as satisfactory had higher odds of adequate health literacy at 3.1 (95% CI: 1.5–6.3) than their counterparts. The participants with self-rated satisfactory financial status were 2.9 times (95% CI: 1.5–5.5) more likely to have adequate health literacy status than who did not. The participants with satisfactory self-related esteem levels were 2.7 times more likely to have adequate health literacy (aOR = 2.7,95% CI: 1.2–6.2). The participants with sustainable income were 1.9 times more likely to have adequate health literacy (aOR = 1.9, 95% CI:1.0-3.5) than those without it. Illiterate participants were at 0.1 (95% CI: 0.04–0.4) times, and the participants with a basic level of education were at 0.1 (95% CI: 0.04–0.5) times lesser odds of having adequate health literacy as compared to the participants with bachelor and a higher level of education. The participants engaged in agriculture were less likely (aOR: 0.49, 95% CI: 0.2–0.9) to have adequate health literacy compared to those other occupations as shown in Table 3.

Table 3 Factors associated with adequate health literacy (n = 253)
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Discussion

Only 23.3% of the participants demonstrated a satisfactory degree of health literacy level. Age, education level, occupation, income, and religion were among the socioeconomic characteristics that were significantly correlated with health literacy levels. Furthermore, factors such as self-rated financial status, self-rated esteem, and self-rated health status were found to be associated with health literacy levels. These findings imply that socio-economic factors and self-perception play a significant role in health literacy disparities, potentially through mechanisms such as differential access to information, varying cognitive resources, and differing levels of motivation to engage with health information.

Our finding is supported by other studies conducted in Nepal, which show similar low health literacy levels [12, 13]. For such instance, knowledge and awareness barriers to health are contributory [14]. Limited health literacy is also highlighted as a problem in Southeast Asian countries [15] and other lower-middle-income countries (LMICs). A study conducted in Egypt found similar results, with only 31.2% of the study participants demonstrating adequate health literacy [16]. Similarly, another study conducted in sub-Saharan African countries indicated the prevalence of health literacy to be 35.2% [17]. Factors such as economic development, allocation of health resources, and accessibility to health information are potentially responsible for the limited level of health literacy in developing nations like Nepal. However, this contrasts sharply with a survey conducted in mainland Portugal, where 70% of participants showed adequate health literacy [18]. A previous study covering eight European countries indicated that 53% of individuals exhibited adequate health literacy [19]. These variations may be attributed to differences in study settings, with the European countries in the comparison being highly developed, educated, economically affluent and having better access to health resources compared to Nepal.

Younger adults were found to have greater odds of higher health literacy compared to older individuals, which is consistent with previous evidence [20,21,22,23]. The lower health literacy in the older population could be due to the digital divide among younger and older age groups. Age is a strong predictor of internet usage and, consequently health literacy, contributing to the digital divide [24]. Age-related declines in comprehension, memory, and word recognition abilities are also potentially responsible for the discrepancy of health literacy among younger and older age groups. To overcome the digital divide, targeted intervention among the older age groups is required. Digital literacy training for older adults and integrating the support of family members in the use of digital technology could help bridge the digital divide. Public health interventions should focus on enhancing family and societal support for improving health literacy among older adults, emphasizing healthy aging. However, bridging the digital divide can be difficult in rural areas where internet and telecommunication services are not yet available.

Education level strongly influences health literacy. In our study, individuals with higher secondary level, basic level, literacy, and illiteracy were 0.4, 0.1, 0.5, and 0.1 times less likely to have adequate health literacy, respectively, compared to those with a bachelor’s degree or higher. Similar results have been found in previous studies, which show positive correlations between the level of education and health literacy [25,26,27]. Higher education enhances better access to resources, critical thinking skills, empowerment, self-efficacy, and improved language and communication skills, enabling a better understanding of health-related materials and participation in health discussions and decision-making. Educational policies and programs should focus on improving health literacy at all education levels, particularly targeting those with lower educational attainment.

High self-esteem was associated with higher health literacy in our study, consistent with previous research [13]. Individuals perceiving their financial status as poor had higher odds of limited health literacy, while those with better financial status demonstrated sustainable income and better health literacy. This supports previous studies that have explored the relationship between self-esteem, financial status, and health literacy [28]. Having lower financial status and self-esteem might hinder an individual’s ability to seek and understand relevant health information, which can cause limited health literacy. Conversely, limited health literacy can also contribute to lower self-esteem. Interventions addressing financial and psychological aspects are crucial for improving health literacy. Further studies are required to investigate the temporality of these variables.

In this study, occupation was a significant risk factor in health literacy. As compared with other occupational groups, agricultural workers were 0.49 times less likely to have adequate health literacy. This finding is consistent with a study conducted in China which has also identified agricultural workers to have lower scores for health literacy as compared to other types of workers [29]. Similarly, a study conducted in Brazil mentions participants having manual occupation had lower functional health literacy levels [30]. However, there are some studies that found no meaningful association between the type of occupation and health literacy [31, 32]. The reason for the association between occupation and health literacy could be linked with income, with agricultural workers having lower income and more stressful life, subsequently leading to less time spent on considering factors important for good health. However, this merits further investigation. Interventions that involve multiple exposures are found to have the strongest results [33,34,35].

Our study finds a significant correlation between health literacy levels and self-rated health status. Compared to people with lower levels of health literacy, people with higher levels of health literacy were 3.1 times greater odds of having self-reported positive health. The reason for this association is likely because health literacy encourages preventive health care utilization and adds important information that results in positive health of the participants [36]. Furthermore, health literacy can also be a valuable tool to reduce health disparities.

Self-rated financial status is associated with health literacy. Our study finds that people with a high self-rated satisfactory level of financial status were 2.9 times more likely to have higher health literacy as compared to those who rated their financial status as unsatisfactory. This finding is substantiated by the finding of previous research, which has shown that financial resources are significantly associated with health literacy [37]. Additionally, having a sustainable income source was also identified as being associated with health literacy in this study. The reason for the association between finance and health literacy is likely because having limited financial resources results in a lack of education and other opportunities to get relevant health-related information.

To improve health literacy in Nepal, a multi-pronged approach is necessary; educational programs targeting agricultural workers, older adults, and those with lower socioeconomic status can bridge knowledge gaps. Within each of these target groups, a different contextual approach is necessary. Additionally, initiatives promoting health information in local languages and disseminating it through trusted community channels can empower individuals to take charge of their health. Addressing these challenges, Nepal can empower its citizens to make informed health decisions and improve overall health outcomes.

The study provides new insights into the health literacy status of people in Rasuwa district, but there are various limitations to be considered. The study’s scope was confined to a single rural municipality in Rasuwa District, potentially restricting the generalizability of the findings to broader regions of Nepal. The study employs a cross-sectional study design, which helps in identifying associations but does not establish causation. Additionally, reliance on self-reported data, particularly in health and financial status, introduces the possibility of response bias. Furthermore, this study does not take in account the effects of environmental factors. These limitations highlight the need for careful interpretation of the results and suggest avenues for future research to address these constraints and deepen our understanding of health literacy in Nepal. Future research should involve larger, more diverse populations across multiple regions and employ longitudinal designs to better understand health literacy trends and causal relationships. Qualitative studies could also provide deeper insights into the barriers and facilitators of health literacy in different contexts.

Conclusion

This study highlights a concerning prevalence of low health literacy among adults in Rasuwa, Nepal, with only a quarter demonstrating sufficient levels. Socioeconomic factors such as age, education, occupation, income, and self-perception significantly influence health literacy. Targeted interventions, including occupation and age-specific programs and culturally sensitive approaches, are crucial to address these disparities. These findings emphasize the need for comprehensive strategies to improve health literacy in Nepal, ultimately enhancing health outcomes and reducing health disparities.