Health literacy and urban–rural disparities: a cross-sectional study of access, adherence, and quality of life across the neurological spectrum

Background Health literacy is critical for chronic disease self-management, yet remains understudied in neurological populations, particularly in low- and middle-income countries. This study examined health literacy prevalence, socioeconomic determinants, and their intersectional associations with healthcare utilization and quality of life among adults with chronic neurological conditions in China. Methods A cross-sectional survey was conducted at a tertiary hospital from March 2022 to September 2025. Health literacy was assessed using the Brief Health Literacy Screen (BHLS). We used multivariable modified Poisson regression and intersectional analysis with multiplicative interaction terms to evaluate associations with healthcare access, emergency department utilization, medication adherence, and quality of life (EQ-5D-5L). Results Among the 1,120 participants (mean age 57.0 years, 41.6% women), low health literacy prevalence was 33.6%, ranging from 28% in epilepsy to 68% in dementia. Education was the strongest predictor (adjusted prevalence ratio [aPR] 2.42), followed by rural residency (aPR 1.42), lowest income quintile (aPR 1.52), out-of-pocket financing (aPR 1.34), and digital exclusion (no smartphone: aPR 1.28). Low health literacy was independently associated with higher emergency department utilization (aPR 1.58), poor medication adherence (aPR 1.89), and lower quality of life (adjusted β − 3.7). These cross-sectional associations do not establish causal directionality, and reverse causation—whereby adverse health outcomes impair functional literacy—cannot be excluded. Cost barriers increased 2.5-fold from 6.9% in high to 17.3% in low literacy groups. Urban–rural residence and income demonstrated independent associations with outcomes, with no statistically significant multiplicative interactions detected, resulting in substantial cumulative disparities across socioeconomic strata. Conclusion One-third of adults with neurological conditions in China have low health literacy, with pronounced socioeconomic and geographic disparities. These findings indicate that disadvantage accumulates through independent structural pathways, supporting multi-level interventions—including rural service expansion, universal health literacy precautions, and digital inclusion strategies—to achieve health equity.