Health literacy mediates the association of education levels with engagement in leisure-time physical activity and muscle-strengthening exercise: a population-based study of Korea.

Abstract

Background: Health literacy is recognized as a major determinant of wellbeing. We examined how health literacy links the association of educational level with participation in leisure-time physical activity (LTPA) and muscle-strengthening exercise (MSE).

Methods: We analyzed a nationwide sample of 5248 adults. Education attainment was grouped into four groups: elementary school, middle school, high school, and college. Health literacy was assessed using the Health Literacy Index for the Community (HLIC). The Global Physical Activity Questionnaire was also employed, with engagement in ≥150 min of moderate-to-vigorous LTPA per week and MSE ≥ twice weekly defined as meeting recommended levels. Counterfactual-based mediation analyses were conducted to estimate the natural indirect effects (NIE), presented as odds ratios (ORs) with 95% confidence intervals (CIs).

Results: Among the participants, 20.5% and 25.2% met the recommended LTPA and MSE levels, respectively. Compared with those with an education attainment of elementary school or below, ORs (95% CI) for the NIE of education level on LTPA, mediated through the HLIC, were 1.06 (1.02-1.09) for middle school, 1.10 (1.04-1.15) for high school, and 1.14 (1.06-1.21) for college or above, accounting for 65.8%, 19.5%, and 16.4% of the total effects, respectively. For MSE, the ORs (95% CI) of the NIE were 1.06 (1.03-1.10) for middle school, 1.12 (1.07-1.17) for high school, and 1.16 (1.10-1.24) for college or above, accounting for 31.8%, 27.1%, and 24.8% of the total effects.

Conclusion: Health literacy may serve as a key mechanism contributing to disparities in physical activity across different educational levels. Key messages What is already known on this topic: Health literacy has garnered considerable public health interest as a key determinant of health disparities. Although previous studies have reported that health literacy is positively associated with engagement in physical activity, research on its mediating role in the association between educational attainment and leisure-time physical activity (LTPA) and muscle-strengthening exercise (MSE) is scarce in the literature. What this study adds: This study demonstrated that health literacy mediates a meaningful proportion of the link between high educational attainment and engagement in the recommended levels of LTPA or MSE. This suggests that health literacy can be an important factor underlying disparities in physical activity across varying education levels. How this study might affect research, practice, or policy: Our findings suggest that proactive policy interventions are required to enhance health literacy among individuals with low educational levels and to promote physical activity.