Patient Education and Counseling 103 (2020) 2142–2154

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Patient Education and Counseling

journal homepage: www.elsevier.com/locate/pateducou

Review Article

Health literacy in rural and urban populations: A systematic review

Noor Aljassim, Remo Ostini*
Rural Clinical School, University of Queensland, Locked bag 9009, Toowoomba DC., QLD, 4350 Australia

A R T I C L E I N F O A B S T R A C T

Article history: Objective: This review assessed whether health literacy differences exist between rural and urban
Received 30 December 2019 populations and whether rurality is a determinant.
Received in revised form 9 April 2020 Methods: Eight online databases were searched using the keywords “health literacy”, “rural” and “urban”,
Accepted 5 June 2020
and related terms. Peer-reviewed original research comparing health literacy levels between rural and
urban populations were evaluated for strength of evidence. A narrative synthesis summarised the results
Keywords: of included studies.
Health literacy
Results: Nineteen articles met inclusion criteria and were of sufficient methodological quality for data
Rural
Urban
extraction. The majority of studies found that urban populations had higher health literacy than rural
Health disparities populations. Differences were more likely to be found in developing than developed countries. Studies that
Social determinants of health performed covariate analysis indicated that rurality may not be a significant determinant of health literacy.
Conclusion: Evidence suggests that rurality alone does not explain rural-urban health literacy differences
and that sociodemographic factors play important roles.
Practice implications: These findings could be used to help inform the development of evidence-based
interventions specifically for rural populations, at both health policy and clinical levels; for example, by
tackling healthcare access challenges. The findings also provide a lens through which to consider efforts to
reduce rural-urban health outcome disparities.
© 2020 Elsevier B.V. All rights reserved.

Contents

1. Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2143
1.1. Rural-urban health disparities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2143
1.2. Health literacy and health outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2143
1.3. Factors that influence health literacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2144
1.4. Rurality: an additional influence on health literacy? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2144
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2144
2.1. Study design and research questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2144
2.2. Search strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2144
2.3. Relevance and quality appraisal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2144
2.4. Data extraction and analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2144
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2144
3.1. Search results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2144
3.2. Study characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2145
3.3. Overall unadjusted health literacy comparisons between rural and urban populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2145
3.4. Rural-urban health literacy comparisons in developed and developing countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2145
3.5. Health literacy as a direct measure or as knowledge of conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2151
3.6. Research addressing potential confounding factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2151
4. Discussion and conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2151
4.1. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2151
4.1.1. Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2152

* Corresponding author.
E-mail addresses: noor.aljassim@uq.net.au (N. Aljassim), r.ostini@uq.edu.au (R. Ostini).

https://doi.org/10.1016/j.pec.2020.06.007
0738-3991/© 2020 Elsevier B.V. All rights reserved.
 N. Aljassim, R. Ostini / Patient Education and Counseling 103 (2020) 2142–2154 2143

4.2. Practice implications ............ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2152

4.3. Conclusion . . . . . . . . ............ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2153
Funding . . . . . . . . . . . . . . . . ............ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2153
Ethics approval and consent to participate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2153
References . . . . . . . . . . . . . . ............ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2153

1. Background Numeracy skills are also required to successfully navigate the

healthcare system and are an important component of health
1.1. Rural-urban health disparities literacy. These skills include the abilities to “access, process,
interpret, communicate and act on numerical, quantitative,
Health disparities between rural and urban populations exist graphical, biostatistical, and probabilistic health information”, all
globally, with agreement that more must be done to improve the of which are important in making health decisions [13]. Health
health of rural populations [1]. Some rural populations have excess literacy encompasses skills required both in clinical situations as
mortality rates [2]. In developed countries, such as Australia, well as health promotion and preventative health contexts outside
research suggests that this excess mortality is mostly attributable clinical settings [14].
to diseases with strong ties to modifiable risk factors [3–5]. Rural The growing interest in health literacy is influenced by a
Australians tend to have poorer health behaviours and higher rates stronger contemporary focus on preventative health and modifi-
of health risk factors, such as hypertension [6]. For example, rural able risk factors, due to the increasing burden of non-communica-
residents are less likely to meet dietary guidelines or report as ble diseases, as well as the increasing complexity of healthcare
much leisure physical activity as urban residents [5]. Women in systems, which demands higher health literacy [15]. As the amount
rural areas are more likely to smoke and males are more likely to of health information available for consumers continues to expand,
report risky alcohol consumption [4,5]. Rural and remote areas in and as advances in technology and the delivery of healthcare
Australia have higher prevalence of chronic diseases such as services continue to develop, health literacy will be crucial in
diabetes and cardiovascular disease, and greater mortality rates equipping people to understand and evaluate a wide variety of
associated with these chronic diseases compared to major cities sources in order to make health-related decisions [16].
[6]. In developing countries, rural infant mortality rates are 8–16 Low health literacy is prevalent. Paasche-Orlow et al. [17] found
percentage points higher than in urban populations and children in that 26 % of the population in the United States had low health
rural populations have higher growth stunting rates [7,8]. Globally, literacy and 20 % had marginal health literacy. In 2006, 59 % of
the maternal mortality ratio is higher in rural regions compared to 15 75 year olds in Australia had inadequate health literacy levels
urban regions and the highest maternal mortality ratios are found and low health literacy was present across all levels of education
in low-income countries [9]. Some developing countries, such as [18].
Cambodia, Mexico, Nigeria and Zambia, have worse healthcare Health literacy has been described as both a ‘risk factor’ and an
service coverage and access to health care in rural areas due to ‘asset’ [19]. Low health literacy is linked to poorer health
deficits in healthcare workers or lack of access to a national health outcomes; thus, it is considered a risk factor [20]. Alternatively,
service scheme [9]. as an asset, health literacy can be seen as a means to empowering
Several factors contribute to poorer health outcomes outside individuals and communities to exert greater control over their
major cities. These include socioeconomic disadvantage, health- health and over a wide range of social and environmental
care access issues due to geographic isolation or shortages of determinants of health [19]. Both perspectives play an important
healthcare providers and services, greater exposure to injury, role in population health. Health literacy is also seen as an
transport and communication difficulties, and diseconomies of important policy issue, as it is central to public healthcare quality,
scale due to sparsely distributed populations [1,3,4]. However, cost, safety and informed decision-making [21–23].
there is evidence that when geographical barriers are overcome, Low health literacy can be a barrier to accessing and receiving
use of healthcare services is still lower in some rural communities safe and effective healthcare [24]. It impacts the doctor-patient
[3,10]. Furthermore, some authors have concluded that barriers to relationship, contributes to inappropriate use of healthcare
self-management, such as lack of formal education and poverty, services and is associated with worse health outcomes [20,24].
are likely to be multiplied in areas with fewer health professionals For example, low health literacy is associated with higher use of
and health infrastructure [11]. Smith and colleagues [2] suggest the emergency department, more hospitalisations and less
that most of the variation in health status is due to socioeconomic preventative health service use [20]. Furthermore, those with
factors. However, Patterson et al. [5] found that adjusting for lower health literacy are more likely to present when sicker,
socioeconomic status did not explain differences in health risk resulting in delayed diagnosis and treatment at more advanced
factors between rural and urban groups. Other factors that also stages of disease [25]. As well as having negative impacts on health
differ between rural and urban areas may contribute to the health outcomes, this pattern of service use may be more expensive and
disparities that exist. Given the role of health literacy in health thus place a financial burden on healthcare systems [25,26]. Those
outcomes, it may be one of those factors. with low health literacy are also more likely to make medication
errors, for example, due to misinterpreting labels and health
1.2. Health literacy and health outcomes messages, being unable to identify medication and misunder-
standing instructions [20]. Low health literacy therefore has
One of the most widely used definitions of health literacy is that negative impacts on the implementation of health management
adopted by the United States Institute of Medicine and Healthy plans, self-management of disease and individual health behav-
People 2010: iours, and may in this way influence health outcomes.
“Health literacy is the degree to which individuals have the Disparities in disease knowledge, management, severity,
capacity to obtain, process and understand basic health informa- quality of life and treatment preferences previously entirely
tion and services needed to make appropriate health decisions” attributed to other factors, such as race/ethnicity, may be partially
[12]. due to health literacy [27,28]. Therefore, in order to understand
2144 N. Aljassim, R. Ostini / Patient Education and Counseling 103 (2020) 2142–2154
health disparities between different populations, it is important to
investigate the place of health literacy in these populations [29].
1.3. Factors that influence health literacy
There is a considerable literature regarding factors associated
with health literacy. Educational attainment was an early measure
of the association between education and health [16] and
significantly contributes to health literacy [17]. In particular,
having less than a high school level education is associated with
low health literacy [25]. However, ‘years of schooling’ alone is not a
reliable predictor of health literacy [16,30]. Other well-docu-
mented factors associated with lower health literacy include:
lower income, physical or mental conditions that impair cognition
or communication abilities, race/ethnicity (African-American or
Hispanic in United States studies), cultural minority group status
and having a non-English speaking background in an English
speaking country [17,24,25,30–32]. Older age, particularly greater
than 65 years, is commonly reported as a significant factor.
However, levels of health literacy still vary within that age group
based on socioeconomic status and education level [25].
1.4. Rurality: an additional influence on health literacy?
Rural populations tend to have poorer health outcomes than
urban populations with multiple factors potentially contributing to
this disparity. Given its association with health outcomes, health
literacy may be one such factor. This possibility would be
supported if it were demonstrated that health literacy is lower
in rural areas. In that case, it is of particular interest to determine
whether rurality itself is independently associated with health
literacy. Data from the Australian Bureau of Statistics shows a
possible difference in health literacy between rural and urban
populations. They found that 42 % of Australians living in major
cities, but only 36 % of those living in outer regional areas, achieved
a health literacy skill level in the three highest (of five) skill levels
measured [18]. Geographic isolation, local health responses and
broader social structures all influence the way people obtain,
process and understand health information and all play a role in
rural and remote health [33]. Various conceptions of health literacy
also acknowledge the role that culture plays [16,25]. This may
provide a mechanism for understanding any impact of rurality on
health literacy. For example, rural communities may have a
distinctive culture with associated attitudes, knowledge, beliefs
and practices related to health, which uniquely contribute to
poorer health outcomes. The documented associations between
health literacy and health outcomes, and known rural-urban
health disparities, support investigating health literacy differences
between rural and urban communities.
The aim of this systematic review is to determine whether
health literacy differences exist between rural and urban
populations and if so, whether rurality is the main determinant
of these differences. The findings of this systematic review may be
used to inform future health literacy interventions in rural areas.
2. Methods
2.1. Study design and research questions
This study is a systematic review of literature on health literacy
in rural and urban populations with the study design guided by the
PRISMA statement [34]. See additional file 1 for PRISMA checklist.
The research questions that this systematic review answers are:
1 Is there a difference in health literacy between rural and urban
populations?
2 If there is a difference, is it due to living in a rural area, or do
other sociodemographic variables play important roles?
2.2. Search strategy
Eight databases were searched to find studies that compared
health literacy in rural and urban populations: PubMed, EMBASE,
Web of Science, CINAHL, PsycINFO, ERIC, Scopus and Informit.
Additional file 2 details the search strategies for each database.
Searches were conducted from September to October 2016.
Only peer reviewed original research in English with an
available electronic full text publication was included. Non-
original research and articles with no primary data collected,
such as literature reviews, editorials or opinion pieces were
excluded. Conference papers, case reports and other studies
published only in abstract form were also excluded. Studies were
required to report health literacy levels using either a health
literacy measurement tool, or an assessment of knowledge of a
health topic as a proxy for health literacy. Only studies that
compared health literacy levels between rural and urban
populations were included. There was no restriction for year of
publication, as research on health literacy in rural and urban areas
is not common and such a limitation could potentially result in
exclusion of relevant literature.
2.3. Relevance and quality appraisal
One reviewer completed the title scan. Two reviewers then
independently reviewed abstracts for relevance, with a third
appraiser reviewing in cases of disagreement.
Original research was appraised using a formal tool previously
designed and used by one of the reviewers for research using a
range of quantitative methods (See additional file 3) [32]. The
quality appraisal tool assessed the rationale and aim, sample
selection, method, presentation and interpretation of results and
the overall strength of the findings. Two reviewers appraised each
article independently. Disagreements on article quality were
resolved by consensus. No formal assessment of publication bias
was conducted, but as this systematic review is not providing a
combined effect size, the potential effect on the reliability of the
results presented is limited.
2.4. Data extraction and analysis
Data was extracted from the articles of sufficient methodologi-
cal quality using a data collection table. The following data was
collected: study design, country, study setting (i.e. clinical,
community, national survey), participant characteristics, study
variables including the measure of health literacy, and main,
relevant study outcomes. The summary measures varied depend-
ing on the study. As the range of methods included made the data
unsuitable for meta-analysis, data from the studies were tabulated
and a narrative synthesis of the results was applied to summarise
the strength of evidence around the differences in health literacy in
rural and urban settings.
3. Results
3.1. Search results
The search results and article selection process are outlined in
Fig. 1. The search strategy identified 177 unique titles to scan for
relevance with 97 abstracts subsequently screened for inclusion
(references available in additional file 4). Fifty-three studies met
the inclusion criteria and full texts were retrieved for appraisal.
 N. Aljassim, R. Ostini / Patient Education and Counseling 103 (2020) 2142–2154
Fig. 1. Outline of study selection procedure.
Thirty-four studies were then excluded, leaving 19 studies for the
review (Table 1). The primary reasons for exclusion for each
appraised study were:
 No/inappropriate/unclear measure of health literacy: 9 articles
 No urban-rural comparison or data collected for only one of the
groups: 12 articles
 Sample not well defined or properly selected: 2 articles
 Methodology unclear: 7 articles (e.g. no indication of method of
statistical comparison)
 Results unclear: 3 articles (e.g. survey results presented with
separate data for each question with no indication of which
answers were correct or how responses were scored; multiple
statistical comparisons with no error-rate correction; mistakes
in result calculations)
 Review article: 1 article
3.2. Study characteristics
All 19 articles included were descriptive, cross-sectional studies
and covered a variety of topics. The most commonly investigated
health literacy topic was non-communicable diseases (e.g.
cardiovascular disease) with 32 % of studies on this topic. General
health literacy was the focus of 26 % of studies, 21 % investigated
mental health literacy, 11 % were related to communicable disease
(e.g. HIV), and 10 % were related to emergency care (e.g. obstetric
emergencies). Studies were conducted in 11 different countries
across a range of study settings, including national surveys (16 %),
general community-based samples (47 %), hospital inpatient/
outpatient departments or community clinics (26 %) and schools
(11 %).
2145
3.3. Overall unadjusted health literacy comparisons between rural and
urban populations
Sixteen of the 19 included studies provided unadjusted rural-
urban health literacy comparisons. Twelve of those 16 studies
found differences in health literacy between rural and urban
groups. Eleven studies (69 %) reported overall higher health
literacy in urban populations [35,36,38,40,42,46,48–50,52,53].
One study [41] found that rural – specifically, inner regional –
populations had better mental health literacy compared to those
from major cities. However, Griffiths et al. (47) found no differences
when comparing those from major cities and those from outer
regional/remote/very remote areas. Four studies (25 %) found no
difference in health literacy between rural and urban groups
[37,44,45,51].
3.4. Rural-urban health literacy comparisons in developed and
developing countries
Eight studies were conducted in developed countries. One
study from a developed country did not provide an unadjusted
comparison [47]. Of the seven that did provide unadjusted
comparisons, four found differences in health literacy between
rural and urban groups, with three (43 %) reporting higher health
literacy in urban areas [38,42,52] and one reporting higher mental
health literacy in inner regional Australia [41]. Three (43 %) found
no difference [37,45,51].
Eleven studies were conducted in developing countries. Two
studies did not provide unadjusted comparisons [39,43]. Of the
nine studies that did, eight (89 %) found that health literacy was
higher in urban groups [35,36,40,46,48–50,53]. Only one found no
difference [44].
 2146
Table 1
Study characteristics and results for 19 included studies.

Reference Country; Setting Study design & sample Study variables including measure of health Results & Conclusions
Developed/ characteristics literacy (HL)
developing
Alphonsa, Sharma India; Developing Neurology & cardiology Descriptive, cross- HL: knowledge regarding oral Main effect:
[35] outpatient & inpatient sectional; anticoagulation therapy Higher mean knowledge scores in urban areas (p = 0.047; t test)
departments N = 240; Adult patients Demographic variables: place of residence Covariate analyses:
(18+) (rural/urban), age, gender, education No HL comparisons accounting for potential confounders
level, monthly income, marital status Knowledge score differences significant for: Gender, Education, Income
Banke-Thomas, Burkina Faso; General community Descriptive, cross- HL: knowledge of obstetric fistulas Main effect:
Kouraogo [36] Developing sectional; Demographic variables: place of residence, Women in rural areas were 3 times less likely (OR 0.35, 95 % CI 0.16,
N = 121; Young adults age, level of education, marital status, age 0.79) to demonstrate sufficient knowledge
(18 20); Women, who at first marriage, number of previous Covariate analysis:
had not suffered/were pregnancies, age at first pregnancy In stratified analyses, negative association between rural residence and
not currently suffering knowledge was strong among women without school education (OR

N. Aljassim, R. Ostini / Patient Education and Counseling 103 (2020) 2142–2154

from obstetric fistula 0.17, 95 % CI 0.05, 0.55), but attenuated and no longer significant among
women with any schooling (OR 0.45, 95 % CI 0.13, 1.56). Rural residents
were 4 times more likely to know that they may have pregnancy
complications that would require emergency treatment, regardless of
education status or previous pregnancy (OR 4.17, 95% CI 1.63, 10.66)
Beauchamp, Australia; Community based Descriptive, cross- HL: Health Literacy Questionnaire Main effect:
Buchbinder [37] Developed healthcare services sectional; N = 813; Demographic variables: place of residence, No statistically significant differences in HL between rural and urban
Adults (18+) age, sex, living alone, private health groups for any of the nine domains of HL assessed in the questionnaire
insurance status, Indigenous status, (p > 0.05; ANOVA)
country of birth (Australia or overseas), Covariate analysis:
whether English is main language spoken No HL comparisons accounting for potential confounders
at home, pre-existing health conditions, Significantly lower health literacy: Do not speak English at home; Born
education level overseas
Davis, Arnold [38] USA; Developed Women who were Descriptive, cross- HL: REALM, dichotomised into <9th grade Main effect:
patients at government sectional; N = 1189; level or 9th grade Higher proportion of low HL in rural compared to urban clinics (61.9 %
supported health Adults aged 40 89 vs. 47.5 %; p < 0.0001; χ2)
clinics HL score not focus of study Covariate analysis:
Demographic variables: place of residence No HL comparisons accounting for potential confounders
Demaio, Otgontuya Mongolia; Community residents Descriptive, cross- HL: knowledge of hypertension Main effect:
[39] Developing sectional; N = 3450; Demographic variables: place of residence, No unadjusted comparison provided
Adults aged 15 64 age, gender, employment status, Covariate analysis:
education level Rural-urban differences adjusted for gender, age, education level and
employment status:
 No differences in having never heard of blood pressure before
 Urban more likely to perceive hypertension as risk to health (rural
77.7 %, urban 79%; MOR 1.2, 95% CI 1.1 1.5)
 Urban more aware of 3 main organs at risk from hypertension (rural
54.3 %, urban 57%; MOR 1.2, 95% CI 1.1 1.4)
 More urban participants perceived blood pressure screening as
important (rural 95.5 %, urban

 97.4 %; MOR 1.8, 95% CI 1.2 2.7)

 More urban participants aware that salt can raise blood pressure
(rural 70.9 %, urban 75.1%; MOR 1.2, 95% CI 1.1 1.4)

Deresse and Ethiopia; Community based Descriptive, cross- HL: epilepsy knowledge assessing Authors used α = 0.05 to indicate significance; α = 0.01 used in this analysis
Shaweno [40] Developing study sectional; N = 1316; aetiology, presentation and whether to account for multiple comparisons
Adults (18+) epilepsy is contagious
Demographic variables: place of residence, Main effect:
age, sex, marital status, occupation, Differences in rural-urban agreement for 2 of 9 questions on cause of
religion, ethnicity, education level epilepsy:
 Brain disease or injury (correct): urban 40.6 % agreed, rural 14%
agreed (p < 0.001; χ2)
  Evil spirit (incorrect): urban 20.3 % agreed, rural 34.6% agreed (p <
0.001; χ2)

No significant differences in agreement for: hereditary, birth defect,

mental or emotional disorder, witchcraft, punishment from God, blood
disorder or unknown aetiology (all p > 0.01, χ2)
4 of 6 questions on manifestations of epilepsy showed rural-urban
differences:
 More urban participants said yes to periods of amnesia (urban 7.7 %,
rural 2.7%; p < 0.001; χ2), rolling up of eyes (urban 38.5%, rural 16.3%;
p < 0.001; χ2) and foaming at the mouth (urban 76.4%, rural 68.9%; p =
0.002, χ2) as manifestations.
 More rural (63.3 %) compared to urban (54.8 %) said yes to loss of
consciousness (p = 0.005, χ2)

No differences in agreement for convulsions and transient change in

behaviour.

N. Aljassim, R. Ostini / Patient Education and Counseling 103 (2020) 2142–2154

No significant difference in agreement regarding whether epilepsy is
contagious.
Covariate analysis:
No covariate analysis done for urban-rural HL differences
Demographic factors: significant differences in education levels
between rural and urban groups (p < 0.001, χ2)
Griffiths, Australia; Data from an Australian Descriptive, cross- HL: Mental health literacy assessed with a Main effect:
Christensen [41] Developed national household sectional; N = 3998; questionnaire based on 4 vignettes
survey of mental health Adults (18+) Demographic variables: place of residence Inner regional more likely than major cities to recognise depression
literacy (major city, inner regional, outer with suicidal ideation (OR 1.6, 95 % CI 1.02 2.51) and chronic
regional/remote/very remote), age, sex, schizophrenia (OR 1.84, 95% CI 1.32 2.58).
education No differences between inner regional residents and major city
residents in recognising depression (without suicidal ideation) and
early schizophrenia.
No differences between outer regional/remote/very remote and major
city residents for all four mental health conditions.
Covariate analysis:
Differences mentioned above remain significant after adjusting for
demographic status (effect sizes not reported). Inner regional more
likely
Halverson, USA; Developed Participants were Descriptive, cross- HL: assessed using a survey containing Main effect:
Martinez-Donate newly diagnosed sectional; N = 1682; questions derived from STOFHLA and
[42] cancer patients Adults aged 18 79 REALM
selected from the Demographic variables: place of residence HL differed between places of residence (χ2(2) = 7.3, p = 0.02) with 54.9%
Wisconsin Cancer (rural, urban or mixed rural-urban), of residents in urban areas, 53.9% in mixed rural-urban areas and 61.4%
Reporting System income, level of education, age, sex, in rural areas having low HL.
database health insurance status, cancer site, Covariate analysis:
cancer stage at time of diagnosis, age at Factors included in mediation analysis:
diagnosis, race/ethnicity and mode of Income (χ2(10) = 46.7, p < 0.0001) and education (χ2(10) = 26.9, p = 0.002)
survey completion varied between places of residence; both lower among rural residents.
Multivariate models
3 multivariate models, all include control variables: cancer site, cancer
stage, race/ethnicity, health insurance, survey mode, age at diagnosis,
sex.
Partially adjusted Model 1: significant relationship between
hypothesised mediators (education and income) and HL. Lower levels of
education and lower income associated with low HL.
Partially adjusted Model 2 (excluding education and income): low HL
more likely in rural patients than mixed rural-urban patients (OR 1.33,
95 % CI 1.06 1.67), no HL difference in urban compared with mixed
rural-urban patients (OR 0.98, 95% CI 0.73 1.32).
Fully adjusted model (including rurality, education, income levels and

2147
control variables): HL differences between places of residence were
attenuated (rural HL levels compared to mixed rural-urban OR 1.14, 95 %
 2148
Table 1 (Continued)
Reference Country; Setting Study design & sample Study variables including measure of health Results & Conclusions
Developed/ characteristics literacy (HL)
developing
CI 0.9 1.45; urban HL levels compared to mixed rural-urban OR 0.74,
95% CI 0.74 1.36); therefore effects of rurality on HL may be fully
mediated by education and income differences.
Loo and Furnham Malaysia; General community Descriptive, cross- HL: knowledge and beliefs on depression Main effect:
[43] Developing sectional; N = 409; No unadjusted rural-urban comparison.
Chinese Malaysian Demographic variables: place of residence, Covariate analysis:
Adults aged 17 77 age, sex, ethnicity, education, marital Significant difference in mean knowledge composite score for the
status, religiosity depression questions (F(1,400) = 29.21, p < 0.001, ANCOVA), urban
participants with higher levels of knowledge regarding depression.
Loo and Furnham Malaysia; General community Descriptive, cross- HL: Mental health knowledge, specifically, Main effect:
[44] Developing sectional; N = 314; causes and treatment of depression No differences between urban and rural participants for knowledge
Indian Malaysian composite score (F(1,312) = 3.29, p > 0.05, test not reported).

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Adults aged 18 75 Demographic variables: place of residence, Covariate analysis:
age, race/ethnicity, religion, gender, Causes of depression
education level, marital status, MANCOVA follow-up (adjusted for highest educational qualifications):
religiousness, political orientation significant differences for 2 of 7 factors, ‘health and lifestyle’ (F(1,309) =
7.25, p < 0.05) and ‘trauma and stress’ (F(1,309) = 19.34, p < 0.001);
endorsed more strongly by urban participants. Other factors (illness and
willpower, supernatural and superstitious, individual and freedom,
biological and brain, family and self) not significantly different.
Treatment of depression
MANCOVA follow-up: significant differences for 1 of 5 factors,
‘counselling and social support’ (F(1,309) = 17.69, p < 0.0001); urban
participants endorsed factor more strongly. Other factors (faith healer
and exorcism, religion and lifestyle, medication and hospital,
psychological treatments) not significantly different.
Martin, Ruder [45] USA; Developed 2003 National Descriptive, cross- HL: Health literacy scale; assessed ability to Main effect:
Assessment of Adult sectional; N = 17,466; effectively use health-related materials and No significant difference in unadjusted mean HL scores between rural
Literacy Adults (18+) accomplish specific tasks and urban groups (test not specified).
Study aim to develop predictive models to Covariate analysis:
estimate HL Linear regression model for predicting mean HL score: rurality did not
make a significant contribution to the model
Demographic variables: place of residence, Probit model for predicting ‘above basic’ HL: rurality did not make a
gender, age, race/ethnicity, education, significant contribution to the model
poverty status, marital status, language Unadjusted covariate comparisons: older individuals, ethnic minorities,
other than English spoken at home, years less education, lower incomes, divorced/widowed/separated, living in
residing in the US US for fewer years, lower mean HL (p < 0.001 for all, test not specified).
Naidoo and Taylor South Africa; High school students Descriptive, cross- HL: HIV knowledge Main effect:
[46] Developing sectional; N = 378; The rural-urban comparison of HL was Significant differences between rural and urban students for 4
Sexually active small part of study. Study primarily questions. More urban students knew:
adolescents aged focussed on assessing which factors
14 23 influence HIV counselling and testing rates
Demographic variables: place of residence,  HIV positive mother can transmit HIV to her baby by breast feeding (p
age, sex, school grade, living with one or = 0.036, χ2)
more parents  Drinking from a cup of a person with HIV does not give you HIV (p =
0.002, χ2)
 Sharing a toilet with a HIV positive person does not give you HIV (p =
0.02, χ2)

More rural students knew traditional (alternative) medicines do not

cure HIV (p = 0.002, χ2).
Covariate analysis:
No covariate analysis
Paek, Reber [47] USA; Developed School students HL: self-reported HL questionnaire with Main effect:
responses recorded on a 5-point scale No unadjusted rural-urban comparison
 Descriptive, cross- Aim of this study to develop health
sectional; N = 452; 7th socialisation model to understand
grade students adolescent HL. Rural-urban aspect of HL
was small part of study
Demographic variables: place of residence,
sex, race, health status
Interpersonal and media health
socialisation factors: access to health
information sources, friends’ & parents’
risky health behaviours
Peng, Wang [48] China; Developing Community members Descriptive, cross- HL: Mental health literacy
sectional; N = 1563; Age Demographic variables: place of residence,
15+ sex, education level, age, marital status,
occupation
Covariate analysis: Residence (rural, urban) not significant predictor of
HL in regression model with other demographic characteristics (sex,
race, health status).
Demographic factors with significant contributions: male sex (r = 0.13, p
< 0.05), health status (r = 0.13, p < 0.05). Race not significant
contribution.
Interpersonal (e.g. access to parents for health information) and media
(e.g. using the internet) socialisation factors made significant
contributions in the model, even after controlling for demographic
factors.
Main effect:
Higher mental health literacy for urban participants (mean proportion
correct responses urban = 70.5, rural = 66.2; t = 6.18; p < 0.001).
Covariate analysis:
No rural-urban HL effect (standardised beta = 0.005, t = 0.16, p = 0.875,
multiple regression). Other variables in model: Education, t = 6.55, p <

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0.001; Age, t = -3.57, p < 0.001; Occupation, t = 2.82, p = 0.005; Gender, t
= -1.44, p = 0.149; Marital status, t = 0.78, p = 0.435
Stanifer, Turner Tanzania; Community-based Descriptive, cross- HL: Chronic kidney disease knowledge Main effect:
[49] Developing sample sectional; N = 606; Aim of study to investigate potential factors Significant difference in weighted mean knowledge between rural
Adults (18+) that impact knowledge of chronic kidney (2.99) and urban (3.73) residents: mean difference (95 % CI) = 0.74 (0.20,
disease. Rurality was one aspect of the 1.28)
study
Demographic variables: rurality, sex, age, Covariate analysis:
education, ethnicity No significant rural-urban difference in weighted mean knowledge
scores in multivariable linear regression model.
Differences in HL based on education significant in the multivariable
model; those with secondary education or further have higher heath
literacy scores than those with no education.
Wei [50] Taiwan; Community-based Descriptive, cross- HL: Mandarin Health Literacy Main effect:
Developing sample sectional; N = 752; Scale, Rural-urban comparison of HL a Significant differences in HL based on rurality (χ2(1) = 23.6, p < 0.001);
Adults (18+) peripheral aspect of the study 57.3% of rural residents and 74.6% of urban residents with adequate HL.
Demographic variables: place of residence, Covariate analysis:
age, gender, education level, occupation, No covariate analysis for rural-urban comparison.
household income Unadjusted comparisons for other demographic factors:
 Age (χ2(3) = 20.71, p < 0.001): older people with lower HL
 Education (χ2(3) = 76.33,
 p < 0.001): higher HL with higher education
 Occupation (χ2(4) = 28.38, p < 0.001)
 Household income (χ2(4) = 65.3, p < 0.001): greater income have
higher HL
 Gender not significant

Wong, Christie [51] Australia; Private rheumatology Descriptive, cross- HL: REALM, TOFHLA Main effect:
Developed clinics sectional; N = 223, Demographic variables: place of residence, REALM
Adult patients (18+) age, sex, ethnicity, marital status, No significant rural-urban differences
occupation, country of birth, primary TOFHLA
language spoken at home, Aboriginal or No significant rural-urban differences
Torres Strait Islander heritage, years Rheumatology drug literacy test
completed at school, further education, No significant rural-urban differences in understanding instructions for
internet use rheumatology drugs
Covariate analysis:
No covariate analysis done on rural-urban comparison
Relationships between HL & sociodemographic variables (Spearman):
Weak negative correlation for TOFHLA & increasing age (r = -0.32, p <
0.01); moderate positive correlation for TOFHLA & school years
completed (r = 0.42, p < 0.01); moderate positive correlation for
rheumatology drug literacy & Internet use (r = 0.45, p < 0.01)

2149
Stratified HL scores (Mann-Whitney U test):
 2150
Table 1 (Continued)
Reference Country; Setting Study design & sample Study variables including measure of health Results & Conclusions
Developed/ characteristics literacy (HL)
developing
 Females higher on REALM (p = 0.009) & TOFHLA (p = 0.036) than
males
 English as primary language at home higher on REALM (p = 0.001) &
TOFHLA (p = 0.046)
 University education higher on REALM (p = 0.006) & TOFHLA (p =
0.001)
 Currently employed higher on REALM (p = 0.003) & TOFHLA (p =
0.001) than currently unemployed
 Use internet higher on REALM (p = 0.001), TOFHLA (p = 0.001) than do
not use internet

Zahnd, Scaife [52] USA; Developed 2003 National Descriptive, cross- HL: Health literacy scale from NAAL Main effect:

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Assessment of Adult sectional; N = 18,110; questions; assessed ability to effectively use Rural participants have lower HL scores (p < 0.001, χ2). Rural with lower
Literacy Adults health-related materials and accomplish percentage HL proficient compared to urban (7.7% vs. 12.7%, p < 0.001,
specific tasks χ2); more rural people with basic HL (24.8% vs. 20.9%, p < 0.001, χ2). No
difference in proportion of rural and urban people with below basic HL.
Demographic variables: place of residence, Linear regression model showed rural participants with lower HL scores
age, gender, race/ethnicity, education, (β coefficient (SE) = -6.75 (2.56); p = 0.01).
income Covariate analysis:
Simultaneously controlling for age, gender, race/ethnicity, education
and income, differences in HL based on rurality no longer significant (β
coefficient (SE) = 2.93 (2.20); p = 0.19).
Zhang, Seale [53] China; Developing Community sample Descriptive, cross- HL: influenza HL, including knowledge Main effect:
sectional; N = 13,035; about symptoms and vaccine, and
Adults (18+) from rural comprehension of influenza-related
and urban districts of materials
Beijing after 2009 Rural-urban comparison a small part of the Urban group higher mean knowledge score (4.73) than rural group
H1N1 influenza study (4.57) (F = 63.968; p < 0.001; ANOVA).
pandemic Demographic variables: place of residence, Covariate analysis:
sex, age, education level, employment No covariate analysis for rural-urban comparisons
status Other demographic factors analysed:
 Females higher scores (4.67) than males (4.62) (F = 4.925; p = 0.026;
ANOVA)
 Significantly lower scores with increasing age (F = 31.064; p < 0.001;
ANOVA);
 Significantly higher scores in those with a higher level of education (F
= 158.175; p < 0.001; ANOVA);
 Employment status not significant factor
 N. Aljassim, R. Ostini / Patient Education and Counseling 103 (2020) 2142–2154
3.5. Health literacy as a direct measure or as knowledge of conditions
Eight of the 19 studies used direct health literacy measures,
such as Rapid Estimate of Adult Literacy in Medicine (REALM) or
Test of Functional Health Literacy in Adults (TOFHLA), while the
remaining studies used knowledge of specific health conditions,
such as mental health or cancer, as a proxy for health literacy. One
of these studies used a validated condition-specific knowledge
measure, two used robust national survey data, and four relied on
measures used in previous studies. Three studies used tools that
were not explicitly validated but described robust development
processes and one study relied on strong face validity to support
the knowledge measure’s validity. All of the disease-specific
knowledge tools were designed for population or cohort-level
research and none were used for the clinical management of
patients.
Among the studies that used direct health literacy measures,
one did not provide unadjusted comparisons [47]. Of the
remaining seven, four (57 %) found that health literacy was higher
in urban groups [38,42,50,52], while three (43 %) found no
difference [37,45,51].
Two of the 11 that used disease knowledge as a measure of
health literacy did not provide unadjusted comparisons [39,43]. Of
the remaining nine, eight (89 %) found differences between rural
and urban groups [35,36,40,41,46,48,49,53] and only one found no
difference [44].
3.6. Research addressing potential confounding factors
In addition to rurality effects, 10 studies also presented separate
results for health literacy comparisons based on other demograph-
ic variables. These variables included sex, age, education level,
occupation, socioeconomic status (income and/or private health
insurance status), race/ethnicity, language spoken at home, length
of time spent in the country of the study, marital status, and access
to media and interpersonal socialisation agents. Nine studies
reported significant differences in health literacy based on
education level, with lower levels of education being associated
with lower health literacy [35,37,42,45,48–51,53]. Lower health
literacy was also found to be typically associated with older age,
lower income, lower socioeconomic status, ethnic minority status,
language other than English spoken at home (in English speaking
countries), shorter time spent living in the country of the study and
less access to media and other information sources
[35,37,42,45,47,49–51,53]. With regards to gender, differences
were found in several studies; some found higher health literacy in
males [35,37,47] and others in females [51,53].
Some studies also presented results for comparisons of
demographic factors between rural and urban groups. Notably,
six studies found significant differences in education levels
between rural and urban groups, with urban groups having higher
levels of education [38,40,41,43,44,52].
Eleven studies performed statistical covariate analysis in the
context of rural-urban health literacy comparisons. After covariate
analysis, six (55 %) studies concluded that rurality itself does not
have a significant impact on health literacy. Of these six studies,
four had reported higher health literacy in urban groups based on
unadjusted comparisons [42,48,49,52], one reported no difference
[45] and one did not provide an unadjusted comparison [47].
Across these six studies, education, age, gender, socioeconomic
status and race/ethnicity were consistently found to be confound-
ing variables that attenuated rural-urban differences in health
literacy. For example, Halverson et al. (40) found that the main
effect differences in health literacy between rural and urban
groups were fully mediated by education and income differences
(they also adjusted for age, sex, health insurance status, clinical
2151
factors and mode of survey completion). Likewise, Zahnd and
colleagues [52] reported that whilst differences in health literacy
exist between rural and urban populations, the differences are
explained by the confounding variables age, gender, race/ethnicity,
education and income. Peng et al. [48] also found that rurality was
no longer significantly associated with health literacy levels after
controlling for education, age and occupation.
Martin and colleagues [45] investigated factors that may
predict health literacy levels and concluded that rurality itself
does not affect health literacy, but that gender, age, race/ethnicity,
education level, income, marital status and time in the United
States, were associated with health literacy [45]. In a more complex
analysis, Stanifer and colleagues [49] found that health literacy
differences by education remained significant in a multivariable
model after accounting for rural-urban differences, but that
rurality itself was no longer a significant predictor of health
literacy in this model. A study of school student health literacy
levels also found similar effects: rurality is not a significant
predictor of health literacy, but sex and health status were
significant predictors [47].
In contrast, four (36 %) studies found significant differences in
health literacy between rural and urban groups after covariate
analysis. Of these four, one had reported differences based on
unadjusted comparisons [41], one did not find a difference in
unadjusted comparisons [44] and two did not provide unadjusted
comparisons [39,43]. The only study to report higher health
literacy in a rural group (inner regional residents compared to
urban residents) found that the difference remained significant
after adjusting for age, sex and education [41]. A study on
hypertension knowledge did not report unadjusted comparisons,
but found that the urban group were more health literate when
adjusted for gender, age, education level and employment status
[39]. Similarly, two studies found that urban residents had higher
mental health literacy for some questions in their surveys than
rural residents after adjusting for age, sex, ethnicity, education,
marital status and religiosity [43,44]. The study that had initially
found no rural-urban health literacy difference used mean
knowledge composite scores for that comparison, but then
performed covariate analysis for each section of the survey and
found health literacy differences there [44].
Banke-Thomas et al. [36] found mixed results after covariate
analysis. Initially, they found that urban participants had higher
health literacy on crude analysis. When they stratified results by
education level, they found that among women without education,
urban participants still had higher health literacy. However, among
women with any schooling, there was no longer a significant
difference between rural and urban groups. Nevertheless, regard-
less of education status or previous pregnancy, rural residents
were more likely to know that they may have had pregnancy
complications that would require emergency treatment [36].
4. Discussion and conclusion
4.1. Discussion
This systematic review found that, based on overall unadjusted
comparisons, the majority of studies identified differences in
health literacy between rural and urban populations, with all but
one of those studies reporting higher health literacy in urban
groups.
Once other sociodemographic variables were considered, just
over half of the studies concluded that rurality itself is not a
significant determinant of health literacy levels. Initially, most of
these studies found significant differences based on unadjusted
comparisons, but these were attenuated after covariate analysis.
The confounding variables that typically mitigated the rural-urban
2152 N. Aljassim, R. Ostini / Patient Education and Counseling 103 (2020) 2142–2154
differences were: education, age, gender, socioeconomic status and
race/ethnicity. These findings are consistent with the conclusions
of previous studies [25], indicating that studies that carefully
controlled for confounders tended to find no difference between
rural and urban groups after covariate analysis. Most of those
studies also used direct health literacy measures and were
conducted in developed countries. In keeping with this trend,
none of the studies that concluded that there were significant
differences after covariate analysis had used direct health literacy
measures. Most of those were also conducted in developing
countries.
The one study conducted in a developed country (Australia)
that found differences after covariate analysis had classified
location of residence into three groups: ‘major city’, ‘inner regional’
and ‘outer regional/remote/very remote’ [41], whereas other
studies dichotomised the location variable. There is some
suggestion in an Australian Institute of Health and Welfare
(2016) report that there may be differences between inner regional
and remote populations. Thus, separating ‘rural’ into subgroups
may have an impact on the broader differences that have been
investigated.
Based on unadjusted comparisons, a greater proportion of
studies from developing countries reported significant differences
in health literacy between rural and urban populations, compared
to studies from developed countries. This may suggest that rurality
is not solely responsible for health literacy differences and that
other factors, such as socioeconomic status and availability of
healthcare resources, may play larger roles. Alternatively, rural and
urban regions in developing countries may differ in other, health
literacy relevant ways, from those in developed countries. The
Global Monitoring Report 2013 mentions that rural-urban
disparities are greater in developing countries, partly due to rapid
urbanisation and poverty [8]. Rurality may play a more substantial
role in health literacy in developing countries than in developed
countries.
It is also important to consider the impact that indigenous
populations may have on these results. Indigenous population
proportions in some rural regions are greater than those in urban
regions [2]. Indigenous residents are known to experience a
relative socioeconomic disadvantage, have worse health outcomes
and face barriers to healthcare access, such as a lack of culturally
appropriate services [2]. Furthermore, traditional beliefs about the
causes of various diseases, which can vary from mainstream
biomedical explanations, are still held by some indigenous
communities [54,55]. A study in New Zealand revealed that a
higher proportion of the Maori population compared to the non-
Maori population have low health literacy [56]. Crengle [57]
suggest that based on similarities in the socioeconomic disadvan-
tages faced by indigenous populations in several different
countries, it is likely that the findings in the New Zealand study
will be generalisable.
The measure of health literacy may also impact results. Studies
that used knowledge of a specific health topic, for example
depression, were more likely to report significant unadjusted
health literacy differences between rural and urban groups than
those that used direct measures of health literacy, such as REALM.
This may suggest that whilst a population may have adequate
general health literacy skills, this does not necessarily translate
into sufficient knowledge of specific diseases. Explanations for this
gap between general health literacy and specific disease knowl-
edge and skills may include access to relevant resources or
specialist clinicians as a function of financial or geographical
barriers, public health promotion, personal experience in seeing a
healthcare professional for that condition and knowing a family
member or friend with the condition. These factors may differ
between rural and urban populations [3,33], potentially resulting
in differences in health literacy between these populations when
measured by knowledge of a disease.
Several definitions of health literacy acknowledge that it is
dependent on both the individual and the health system [58–60].
However, some health literacy measures, such as REALM and
TOFHLA, only assess the individual aspect [58]. Measuring
knowledge of specific health conditions may indirectly account
for broader system-based aspects of health literacy that REALM
and TOFHLA do not assess, as knowledge of specific conditions
partly relies on public health promotion and communication
across the broader health system, the media and individuals. Thus,
it is important to recognise that whilst some studies found no
differences between rural and urban populations using direct
health literacy measures, this may not necessarily mean that rural
and urban populations are equally equipped in terms of knowledge
and skills to manage certain health conditions.
4.1.1. Limitations
One of the main limitations of this systematic review is that its
topic was not the primary focus of several of the included studies.
Health literacy comparisons between rural and urban groups were
a secondary or incidental consideration for some of the studies. As
such, the relationship was not always as thoroughly investigated,
for example, with robust covariate analysis, as in studies where the
rural-urban health literacy comparison was the main focus. This
decreased the overall strength of the evidence available for this
systematic review. However, as the rural-urban health literacy
comparison was a subordinate focus, this may ameliorate the risk
of publication bias, as authors may not have been concerned with
the portrayal of these finding.
All studies were descriptive cross-sectional studies, which have
their inherent potential limitations, such as difficulties in
measuring all relevant exposures and potential confounding
factors.
There are many definitions of health literacy in use [16]. The
studies in this review applied different definitions and measure-
ments of health literacy, which made it difficult to strictly define. In
saying this, a narrative analysis, as was done in this study, is more
appropriate and better able to accommodate these differences in
analytical methods than a meta-analysis. Furthermore, different
studies classified health literacy levels differently. For example,
some presented results as mean scores, while others dichotomised
results or analysed each survey question separately. Some studies
also used the same national survey data differently. This may have
impacted the overall findings of those individual studies.
There were also no consistent definitions of ‘rural’ and ‘urban’ in
the included studies. However, each study’s definition was relevant
to the country it was conducted in. Nevertheless, to the extent that
different study outcomes may to be associated with different ways
of measuring health literacy and different definitions of rurality,
this could potentially influence the review’s conclusions.
There is a possibility that some relevant studies were excluded;
for example, grey literature was not searched. This, in addition to
potential publication bias, could have distorted the overall findings
of the systematic review. However, multiple databases that cover
broad fields of research related to the topic were searched to
ensure that relevant peer-reviewed published literature was
included.
4.2. Practice implications
The findings of this review may be used to inform the
development of evidence-based interventions specifically for rural
populations. As previously mentioned, several authors have
highlighted the importance of addressing health literacy as a
policy issue and in everyday clinical opportunities to improve
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health outcomes [21–23]. In the context of rural-urban differences
in health outcomes, health literacy provides a lens through which
to consider efforts to reduce health disparities.
4.3. Conclusion
This systematic review has identified rural populations as a
group with generally lower health literacy and suggested some
potential reasons for this. While this review suggests that living in
a rural area is typically not the reason for health literacy disparities,
the disparities exist and require attention. It is essential that
healthcare providers in rural regions are aware of the health
literacy disparity, especially as there is evidence that health
professionals tend to overestimate patients’ health literacy in
hospitals [25,61].
Suggested target areas for health literacy interventions include
patient education, health professional education, simplification of
the healthcare system to enhance access, and simplification of
information for patients [29]. The use of technology to deliver
health literacy interventions is an emerging field of research but
barriers may exist in regions where mobile phone or internet
services are not available or reliable. Targeting the education
system has also been recommended, for example, introducing
common medical terminology, healthcare system navigation and
preventative health topics in schools [29]. Mabachi and colleagues
[62] assessed the utility of the 2010 Agency for Healthcare
Research and Quality Health Literacy Universal Precautions Toolkit,
which lists 20 brief interventions, including both individual and
system approaches, that can be applied by healthcare providers.
Their study identified some key barriers to implementation, such
as staff capacity; difficulty generating staff enthusiasm and
commitment; limited support from leadership; bureaucratic
challenges, such as inability to gain administrative approval for
changing patient forms; and technological challenges [62]. This
highlights the importance of healthcare system attitudes in
addressing health literacy challenges.
Beyond the kinds of broadly applicable target areas for health
literacy interventions described above, consideration must be
given to the possible distinctive health literacy needs of rural
communities, which may require tailored interventions to produce
meaningful change. Unnecessary complexity in the healthcare
system exacerbates the underlying social determinants that
contribute to health disparities [29]. Addressing this poses a
challenge to systems that have been organised by the most
educated and affluent. Recent community-based health literacy
intervention research argues that communities require unique
interventions that are relevant, understandable and useful for
specific communities [63]. This approach is likely to be particularly
important in rural areas given the diversity that exists across rural
communities.
Considering our finding that the measure of health literacy used
may affect whether health literacy differences are identified,
health literacy interventions in rural places may need to address
both broad health literacy skills and specific condition-based
health education in order to increase overall health literacy and
disease knowledge. There is evidence that enhancing health
literacy through intensive disease-specific education and simplifi-
cation of information is beneficial [64].
Future research could include a more global assessment of
health literacy differences in rural and urban regions with studies
in South America and Europe, as there were no studies from those
populations in this systematic review. In future health literacy
rural-urban comparisons it may be worthwhile to delineate rural
into ‘remote’ and ‘regional’ areas in some countries, such as
Australia, Canada and the United States, as there is evidence that
these two segments of the population can be different, both in
2153
terms of health outcomes and health literacy [6,41]. It may also be
worthwhile considering Indigenous populations explicitly in
health literacy studies.
Furthermore, there is a need for research regarding whether the
relationship between health literacy and health outcomes differs
between rural and urban populations. If this were the case, rurality
would then still be an important factor in rural health literacy,
despite the evidence that rurality does not seem to be a risk factor
for low health literacy. Future research may investigate this gap in
the literature in an attempt to better understand rural-urban
health disparities.
This systematic review found that rural populations tend to
have lower health literacy than their urban counterparts.
However, there is evidence that rurality itself does not entirely
explain these differences with factors including education, age,
gender, socioeconomic status and race/ethnicity often accounting
for rural-urban health literacy differences. Knowing that rurality
itself is not a risk factor for lower health literacy has important
implications for future research and the design of health literacy
interventions in rural areas, with the ultimate aim of empowering
disadvantaged communities and mitigating rural-urban health
disparities.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Ethics approval and consent to participate
Ethics approval provided by the University of Queensland:
negligible risk study
Declaration of Competing Interest
None.
Appendix A. Supplementary data
Supplementary material related to this article can be found, in the
online version, at doi:https://doi.org/10.1016/j.pec.2020.06.007.
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