# The role of health literacy in the association between nationality and health status among university students: a cross-sectional study

## TL;DR

International university students in Japan report lower health status than Japanese students, but this difference depends on their health literacy levels.

## Contribution

This study reveals that health literacy modifies the relationship between nationality and health status among university students.

## Key findings

- International students had a lower prevalence of good health status compared to Japanese students.
- Health literacy significantly influenced the health status differences between nationalities.
- Among students with sufficient health literacy, international students had better health status than Japanese students.

## Abstract

Immigrants often face numerous health-related challenges, which may result in a lower health status (HS) as compared with the domestic population. This study examined the association between nationality and HS among university students in Japan and the role of health literacy (HL) on this association.

Web-based self-administered surveys were conducted with 1,366 university students across six of Japan’s eight regions between February 20 and August 10, 2023. Nationality and HS were measured using a self-reported questionnaire, and HS was categorized into two groups: good or not good. HL was assessed by the 47-item European Health Literacy Survey.

International students (61%) had a lower prevalence of good HS than Japanese students (73%) (p < 0.0001). Even after adjusting for sociodemographic and educational variables, international students showed a lower prevalence of good HS as compared with Japanese students (odds ratios [95% confidence interval]: 0.72 [0.53, 0.99], p = 0.04). However, when considering HL level, the association attenuated (p = 0.2), and the interaction of HL and nationality was observed (p < 0.0001). A subgroup analysis showed that international students had a higher prevalence of good HS as compared to Japanese students among the students with sufficient HL level (1.63, [1.03, 2.58], p = 0.03), whereas among the students with inadequate HL level, international students had a lower prevalence of good HS (0.34, [0.20, 0.58], p < 0.0001).

Although international students had a lower prevalence of good HS as compared to Japanese students, the direction of the association differs based on the level of HL.