How educational inequality among rural residents relates to healthy lifestyle behaviors in later life: evidence from the Northern China lifestyle medicine cohort baseline

Educational inequality affects health, but its link to healthy lifestyles among older adults in low-resource rural settings remains unclear. This study utilized baseline data from the Northern China Lifestyle Medicine Cohort (July 2023–January 2024). Adults aged 65 and older with hypertension or diabetes in the National Basic Public Health Service program were included. A composite Healthy Lifestyle Score (HLS, range 0–7) was constructed from seven behavioral indicators. We employed linear/logistic regression and propensity score matching (PSM) to analyze associations between educational attainment and lifestyle outcomes. Among 10,459 adults (57.2% female), 34.0% were illiterate. The mean HLS was 4.69 (SD = 1.24). Each educational attainment increase added 0.17 points to HLS (95% CI: 0.14–0.20). Higher education was positively linked to a healthy diet (OR = 1.15, 95% CI: 1.10–1.21), adequate sleep (OR = 1.17, 95% CI: 1.11–1.23), physical activity (OR = 1.18, 95% CI: 1.11–1.24), and leisure activity (OR = 1.34, 95% CI: 1.27–1.41), but negatively with non-drinking (OR = 0.82, 95% CI: 0.77–0.88). After PSM adjustment, illiterate participants had a significantly lower HLS (4.59, 95% CI: 4.55–4.63) than non-illiterate counterparts (4.89, 95% CI: 4.84–4.93), a net difference of 0.30 points. These findings highlight that higher educational attainment is consistently associated with healthier lifestyle choices among older adults in resource-limited rural areas. Strengthening rural education and integrating health literacy into public health strategies could be pivotal for promoting healthy aging.