The association between health literacy and multiple health risk behaviors

Abstract Background Clustered modifiable behaviors-smoking, high-risk alcohol use, physical inactivity, and high sodium intake-drive a sizable share of the premature non-communicable disease burden. Managing these co-occurring risks may depend on health literacy (HL), the ability to find, understand, and use health information. This study examined the association between HL and multiple health risk behaviors (MHRBs) using nationally representative data from South Korea. Methods A cross-sectional analysis was conducted using data from the 2023 Korea National Health and Nutrition Examination Survey (KNHANES). The sample included 5,587 adults aged ≥ 20 years and used a complex sampling design. MHRBs were categorized into three groups (0, 1, or ≥ 2 risk behaviors) based on current smoking, high-risk alcohol use, insufficient physical activity, and high sodium intake. HL was classified as adequate (≥30) or limited (<30), and ordinal logistic regression was used to examine the association. Results Those with lower health literacy were more likely to engage in multiple health risk behaviors than those with higher health literacy (OR = 0.848, 95% CI: 0.745-0.965, p = 0.013). HL showed a stronger association with the co-occurrence of multiple risks than with single behaviors. Conclusions Individuals with lower HL were significantly more likely to engage in multiple health-risk behaviors. HL is linked to individual behaviors and patterns of risk clustering. Targeted public health interventions to improve HL may be effective in addressing NCD-related behavioral clusters. Key messages • Improving health literacy can reduce multiple health risk behaviors in adults and serve as a key strategy for promoting population health. • Public health strategies are needed to promote behaviors change by enhancing health literacy.