Association between literacy and self-rated poor health in 33 high- and upper middle-income countries



To assess the relationship between general literacy proficiency and self-rated poor health by analyzing data from the Programme for the International Assessment of Adult Competencies, an international survey conducted from 2011 to 2015 in 33 high- and upper middle-income countries and national sub-regions.


Logistic regression was used to model general literacy proficiency as a predictor of self-rated poor health.


Data from 167,062 adults aged 25–65 years were analyzed. The mean overall prevalence of self-rated poor health was 24%. The odds ratio of self-rated poor health for those in the lowest level of general literacy proficiency compared to those in the highest level was 2.5 (95% CI 2.2–3.0) in the unadjusted model, and 1.9 (95% CI 1.6–2.2) in the adjusted model. This association was robust over time and across countries. General literacy proficiency attenuated 22% of the effect of self-education on self-rated poor health, in addition to a substantial independent effect of its own.


Our study provides robust and generalizable evidence that general literacy proficiency is independently associated with self-rated poor health. These results offer a potential modifiable target for policy interventions to reduce educational inequities in health.

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We would like to acknowledge the contributions of all participants of the Adult Literacy and Lifeskills (ALL) and Programme for the International Assessment of Adult Competencies (PIAAC) surveys, as well as researchers from the Organisation for Economic Cooperation and Development involved in the planning, design and implementation of the surveys and field staff in participant countries without whom this study would not have been possible.

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Corresponding author

Correspondence to S. V. Subramanian.

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The authors declare that they have no conflict of interest.

Ethical approval

The study was approved by the Institutional Review Board of the Harvard T.H. Chan School of Public Health.

Informed consent

Informed consent was obtained from all survey participants.

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Kakarmath, S., Denis, V., Encinas-Martin, M. et al. Association between literacy and self-rated poor health in 33 high- and upper middle-income countries. Int J Public Health 63, 213–222 (2018).

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  • Literacy
  • Educational attainment
  • Self-rated poor health
  • Socioeconomic status
  • OECD
  • Programme for the International Assessment of Adult Competencies