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Cited by 14Health Literacy and Information AccessibilityHealth disparities and outcomesHealth and Wellbeing Research

Effect modification by geographic area on the association between health literacy and self-rated health: A nationwide cross-sectional study in Japan

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Ishikawa, Hirono, Ogawa, Runa, Otsuki, Aki, Saito, Junko, Yaguchi-Saito, Akiko, Kuchiba, Aya, Fujimori, Maiko, Fukuda, Yoshiharu +31 more·2023·BMC Public Health
DOI 10.1186/s12889-023-15897-0PMC PMC10209573
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Abstract

Background: Health literacy (HL) has gained increasing attention as a factor related to health behaviors and outcomes. This study aimed to investigate geographic differences in HL levels and effect modification by geographic area on their relationship with self-rated health in the Japanese population using a nationwide sample. Methods: Data for this study were derived from a nationally representative cross-sectional survey on health information access for consumers in Japan using a mailed self-administered questionnaire in 2020 (INFORM Study 2020). Valid responses from 3,511 survey participants, selected using two-stage stratified random sampling, were analyzed in this study. HL was measured using the Communicative and Critical Health Literacy Scale (CCHL). Multiple regression and logistic regression analyses were conducted to examine the associations between geographic characteristics and HL and effect modification on the association between HL and self-rated health by geographic area, controlling for sociodemographic characteristics. Results: The mean HL score was 3.45 (SD = 0.78), somewhat lower compared with previous studies on the Japanese general population. HL was higher in Kanto area than in Chubu area, after controlling for sociodemographic factors and municipality size. Furthermore, HL was positively associated with self-rated health after controlling for sociodemographic and geographic factors; however, this association was more evident in eastern areas than in western areas. Conclusion: The findings indicate geographic differences in HL levels and effect modification by geographic area on the relationship between HL and self-rated health in the general Japanese population. HL was more strongly associated with self-rated health in eastern areas than in western areas. Further investigation is needed to explore the moderating effects of areal features, including the distribution of primary care physicians and social capital, when formulating strategies to improve HL in different contexts.

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  • The health literacy of the Japanese general population was lower than that of European countries.

    “Also, it has been reported that the health literacy of the Japanese general population was lower than that of European countries (Nakayama et al., 2015).”

    From Digital health literacy and trust in health information sources: A comparative study of university students in Japan, the United States, and India (2025) · cites this paper as Ishikawa et al., 2023

    The Discussion (page unavailable) reports that more Japanese than European residents found it difficult to know where to obtain professional help when ill. That is a narrower comparison than the claim that overall health literacy was lower in Japan. The References name a Nakayama et al. (2015) paper whose title states the broader claim, but this source does not itself report that overall comparison. (LLM, conf=0.78)

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  • Previous research has demonstrated associations between general health literacy and socioeconomic status.

    “Subjective social status was positively associated with DHLI scores, which was consistent with previous research that has demonstrated associations between general health literacy and socioeconomic status (Duong et al., 2017; Ishikawa et al., 2023; Sorensen et al., 2015), as well as between socioeconomic status and digital health literacy (Estrela et al., 2023; Jiang et al., 2025).”

    From Digital health literacy and trust in health information sources: A comparative study of university students in Japan, the United States, and India (2025) · cites this paper as Ishikawa et al., 2023

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Authors
Ishikawa, H., Ogawa, R., Otsuki, A., Saito, J., Yaguchi-Saito, A., Kuchiba, A., Fujimori, M., Fukuda, Y., Shimazu, T., INFORM Study Group, Hayakawa, M., Hosono, S., Inoue, M., Kaji, Y., Katanoda, K., Matsuda, T., Matsuoka, Y. J., Odawara, M., Takahashi, H., Takahashi, M., Uchitomi, Y., Umezawa, J., Watanabe, O., Yoshimi, I., Kreps, G. L., Sakurai, N., Momosaka, T., Akiyama, M., Miyawaki, R., Okubo, R., Akamatsu, R., Kawasaki, Y., Fujisaki, K., Ogawa, L., Imamura, H., Nakaya, K., Nakaya, N., Mitsutake, S., & Sasai, H.
Affiliations
  • Teikyo University (JP)
  • National Cancer Centre Japan (JP)
  • National Cancer Center Institute for Cancer Control (JP)
Corresponding author
  • Ishikawa, Hirono
  • Shimazu, Taichi
ORCID
Venue
BMC Public Health
Publisher
Springer Science and Business Media LLC
Published
2023-05-25
Volume
23
Issue
1
Pages
952-952
ISSN
1471-2458 (ISSN-L)
DOI
10.1186/s12889-023-15897-0
PMC
PMC10209573
OpenAlex
W4378222335
Cited by
14
References
1
Citations by year
2026: 6 · 2025: 3 · 2024: 5
FWCI
4.23
Type
journal article
Language
en
Open access
Licence
Locations
  • BMC Public Health (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
  • Institutional Repositories DataBase (IRDB) (submittedVersion, cc-by-nc-nd)
Funders
  • Japan Society for the Promotion of Science (20H03919)
  • National Cancer Center Japan (30‐A‐18, 2021‐A‐19)
Topics
  • Health Sciences › Health Professions › General Health Professions › Health Literacy and Information Accessibility
  • Social Sciences › Health › Health disparities and outcomes
  • Health Sciences › Health Professions › General Health Professions › Health and Wellbeing Research
Keywords
health literacy, self-rated health, regional variation, effect modification, Japanese population, Kanto region, Chubu region, health information access, social capital
MeSH terms
Cross-Sectional Studies, Humans, Japan, Surveys and Questionnaires, Health Behavior, Health Literacy

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