A Cross-Sectional Study for Analyzing the Mediating Role of Symptom Burden in the Relationship Between Health Literacy and Quality of Life Among Perimenopausal Women in the Border Areas of Yunnan, China

Abstract

Purpose

This study aimed to examine the relationships among health literacy, symptom burden, and quality of life among perimenopausal women in the border areas of Yunnan, China, and to explore the mediating role of symptom burden.

Patients and Methods

A cross-sectional survey was conducted among 452 perimenopausal women in the border areas of Yunnan, China, using convenience sampling. Data were collected using a general information questionnaire, the Perimenopausal Health Knowledge Questionnaire, the modified Kupperman Index, and the Menopause-Specific Quality of Life Questionnaire. Descriptive statistics, univariate analysis, Pearson correlation analysis, and common method bias testing were performed using SPSS 26.0. Structural equation modeling was conducted using Mplus 8.3, and the Bootstrap method was used to test the mediating effect.

Results

The mean scores for health literacy, symptom burden, and quality of life were 10.00 ± 5.14, 16.19 ± 9.19, and 46.69 ± 26.38, respectively. Health literacy was negatively correlated with symptom burden and quality of life, whereas symptom burden was positively correlated with quality of life, with all correlations being statistically significant (P < 0.01). Symptom burden partially mediated the relationship between health literacy and quality of life, with an indirect effect of −0.081, accounting for 19.1% of the total effect.

Conclusion

Perimenopausal women in the border areas of Yunnan had relatively low levels of health literacy, a high symptom burden, and impaired quality of life. Targeted and individualized interventions should be developed according to ethnic cultural characteristics and the distribution of primary healthcare resources in this region to reduce symptom burden and improve quality of life among perimenopausal women.

Introduction

Perimenopause refers to the interval beginning with the first signs of the menopausal transition and ending 12 months after the final menstrual period.¹ It is defined by reproductive-stage and menstrual-cycle characteristics rather than by a fixed chronological age, although natural menopause generally occurs between 45 and 55 years.^1,2 Perimenopausal syndrome refers to the cluster of physical, psychological, and genitourinary symptoms associated with hormonal changes during this transition.^3,4 These symptoms vary considerably among women and may include menstrual irregularities; vasomotor symptoms such as hot flushes and night sweats; sleep disturbance and fatigue; mood and cognitive changes; musculoskeletal discomfort; and genitourinary symptoms such as vaginal dryness, dyspareunia, urinary urgency, and urinary incontinence.^1,2,4 In addition to these clinical manifestations, menopause-related hormonal changes and advancing age are associated with loss of bone density and increased risks of osteoporosis and fractures, changes in body composition and cardiovascular risk, and weakening of the pelvic support structures, which may increase the risk of pelvic organ prolapse.¹ Collectively, these symptoms and health concerns may impair women’s daily functioning and quality of life. According to the World Health Organization, women aged 50 years and older accounted for 26% of all women and girls globally in 2021, up from 22% a decade earlier.¹ China has one of the largest populations of perimenopausal women worldwide, with approximately 210 million women currently in the perimenopausal stage; this number is projected to increase to 280 million by 2030,^5,6 this growing population poses substantial challenges for health management.⁴ Among them, women living in Yunnan border areas and ethnic minority women exhibit a higher prevalence of perimenopausal syndrome. The prevalence of perimenopausal syndrome among women in western China is as high as 71.3%, which is significantly higher than the national average of 61.0%.^7,8 This may be explained by the combined effects of climatic and socioeconomic factors in Yunnan border areas, such as high altitude, strong ultraviolet radiation, relatively limited dietary diversity, insufficient healthcare resources, poor healthcare accessibility, and inadequate health education coverage. As a result, perimenopausal women in these areas often experience a more complex symptom burden, which may substantially compromise their quality of life.⁹ In this context, health management for perimenopausal women in Yunnan border areas should extend beyond the management of physical symptoms to address the role of health literacy in mitigating symptom burden and improving quality of life.

Health literacy (HL), defined as the ability to access, understand, appraise, and use health information and services to make informed health decisions, plays an important role in maintaining and promoting health.⁶ As a fundamental component of women’s health management, health literacy is essential for enabling perimenopausal women to recognize symptoms, seek timely medical care, and engage in effective self-management.¹⁰ Studies show that knowledge about perimenopause, symptom management, and support services remain generally inadequate in low- and middle-income regions and areas with relatively limited resources; women in rural and underdeveloped areas face barriers in accessing information, healthcare, and social support.¹¹ Studies have shown that health literacy is associated with symptom burden,^12,13 and that symptom burden serves as a predictor of quality of life.¹⁴ Furthermore, the level of health literacy can influence symptom management behaviors, thereby affecting patients’ quality of life.^15,16 Thus, it appears that there may be a certain association among health literacy, symptom burden, and quality of life; however, few studies have simultaneously examined the pathways among these three factors, and research in this area remains largely unexplored, particularly in frontier ethnic minority regions. Therefore, this study attempts to construct a “health literacy–symptom burden–quality of life” mediation model among perimenopausal women in the border regions of Yunnan. The aim is to verify the mediating role of symptom burden between health literacy and quality of life, explore the mechanisms through which it influences quality of life in this population, provide a basis for developing individualized intervention strategies for this group, and promote patients’ physical and mental health.

Patients and Methods

Participants

Using convenience sampling, the study recruited 452 women aged 40–65 who were seeking medical care or accompanying patients at the Longling County Health Service Center and its affiliated townships in Baoshan City, Yunnan Province, between February and May 2024. Inclusion criteria: ① Participants who provided informed consent for this study, voluntarily participated in the survey, and signed the informed consent form; ② Permanent residents of Longling County, defined as those residing at home year-round or for at least six months. Exclusion criteria: ① Pregnant or breastfeeding women; ② Individuals with mental disorders; ③ Patients with acute illnesses or malignant tumors; ④ Women who had undergone hysterectomy or hysterectomy with bilateral salpingo-oophorectomy; ⑤ Individuals with cognitive impairment or other communication difficulties.

The sample size n was estimated using the formula . Based on a prevalence rate of 61.0% reported in previous literature,⁷ with α = 0.05 (Z = 1.96) and a margin of error of 0.05, the theoretical sample size was calculated to be 366. Considering a 20% non-response rate, we planned to collect 458 questionnaires; ultimately, 452 valid questionnaires were collected. This study received formal approval from the Medical Ethics Committee of Dali University, with approval number 202401-10. All study participants were informed of the study’s purpose, content, and confidentiality principles prior to participation and voluntarily signed written informed consent forms.

Instruments

General Information Questionnaire

A self-designed questionnaire was developed based on a review of the literature. It included demographic characteristics, physical development indicators, and chronic disease history, such as age, place of residence, education level, monthly household income, height, weight, body mass index (BMI), and history of chronic diseases.

Modified Kupperman Index (KMI)

The KMI was used to assess symptom burden among perimenopausal women.^17,18 The scale consists of 13 items, including hot flashes and sweating, paresthesia, insomnia, irritability and nervousness, depression and suspicion, dizziness, fatigue, joint and muscle pain, headache, palpitation, formication, sexual life, and urinary tract infection. Each symptom is scored from 0 to 3 according to its severity. The weighted total KMI score was calculated by summing the products of each symptom severity score and its corresponding weighting coefficient. The total score ranges from 0 to 63, with 0–6 indicating no symptoms, 7–15 mild symptoms, 16–30 moderate symptoms, and >30 severe symptoms. Higher scores indicate a greater symptom burden. The Cronbach’s α coefficient of the scale was 0.85 in this study.

Menopause-Specific Quality of Life Questionnaire (MENQOL)

The MENQOL was used to assess quality of life among perimenopausal and postmenopausal women.¹⁹ The Chinese version of the MENQOL was adopted in this study. It contains 29 items across four domains: vasomotor symptoms, psychosocial symptoms, physical symptoms, and sexual symptoms. Each item is scored from 0 to 6. Domain scores were calculated by summing the item scores within each corresponding domain, and the total MENQOL score was calculated by summing all 29 item scores, yielding a possible range of 0 to 174. Higher scores indicate poorer quality of life. The Chinese version of the MENQOL has demonstrated good reliability and validity.

Perimenopausal Health Knowledge Questionnaire

The Perimenopausal Health Knowledge Questionnaire was independently developed by the research team specifically for the present study based on a review of the relevant literature and consideration of the study objectives and characteristics of the target population. It was not translated, adapted, or directly derived from any single existing questionnaire or standardized scale. The initial version was subsequently reviewed through expert consultation, and the items were revised according to the experts’ recommendations to improve their clarity, relevance, and appropriateness for assessing perimenopausal health knowledge. The finalized questionnaire was used to assess participants’ knowledge of perimenopausal health. It covers age, marital status, occupation, education level, income, menstrual and reproductive history, previous disease history, surgical history, regular physical examination, age at perimenopause onset and termination, appropriate exercise, oral health care, constipation prevention, dietary control, and common symptoms of perimenopausal syndrome. A binary scoring method was used, with 1 point assigned for a correct answer and 0 points for an incorrect or unclear answer. The total score was calculated by summing the scores of all 20 items and ranged from 0 to 20, with higher scores indicating better perimenopausal health knowledge. In this study, the total score was used as an indicator of the health knowledge component of perimenopausal health literacy. The Cronbach’s α coefficient of the questionnaire was 0.930, and the scale-level content validity index (S-CVI) was 0.92.

Data Collection

Before data collection, all interviewers received standardized training on the study procedures and questionnaire administration to ensure consistency. Eligible participants were informed of the study purpose, voluntary nature of participation, and confidentiality measures before providing written informed consent. The questionnaires were administered individually using a face-to-face approach and collected immediately after completion. Interviewers used standardized instructions and avoided influencing participants responses. All returned questionnaires were checked for completeness and logical consistency. Questionnaires with more than 50% of the items unanswered were considered invalid and excluded. Data from the valid questionnaires were independently entered by two researchers and cross-checked against the original questionnaires. A total of 452 valid questionnaires were included in the final analysis.

Data Analysis

Data organization and statistical analysis were performed using SPSS 26.0 and Mplus 8.3 Continuous variables were assessed for normality using the Kolmogorov–Smirnov (K-S) test. Normally distributed data are presented as mean ± standard deviation (x± s), and comparisons between groups were performed using the independent samples t-test or one-way analysis of variance (ANOVA); non-normally distributed data were expressed as M (P25, P75), and comparisons between groups were performed using the Mann–Whitney U-test or the Kruskal–Wallis H-test. Categorical data were expressed as n (%), and comparisons between groups were performed using the chi-square (χ²) test, with the Harman one-way test used to assess common method bias.

For the statistical analyses, the total score of the Perimenopausal Health Knowledge Questionnaire and the weighted total KMI score were used as observed measures of the health knowledge component of perimenopausal health literacy and symptom burden, respectively. The total MENQOL score was used in the descriptive and univariate analyses, whereas the four MENQOL domain scores were examined in the correlation analysis and were initially specified as indicators of the quality-of-life latent variable in the structural equation model. During evaluation of the measurement model, the vasomotor domain was excluded because of its low standardized factor loading (<0.40); therefore, the final quality-of-life latent variable was represented by the psychosocial, physical, and sexual domain scores.

Pearson correlation analysis was used to examine the associations between health literacy, symptom burden, and quality of life. A mediation model was constructed with health literacy as the independent variable, symptom burden as the mediating variable, and quality of life as the dependent variable. Model fitting was performed using maximum likelihood estimation, and fit indices were evaluated using χ²/df, RMSEA, CFI, TLI, and SRMR.²⁰ The indirect effect was tested using the Bootstrap method with 5000 repeated samples; a 95% CI that did not include 0 indicated a statistically significant mediating effect. Age, educational level, monthly household income, presence of chronic diseases, and current living status were included in the model as covariates. A P-value < 0.05 was considered statistically significant. In addition, a Harman one-way test was used to assess common method bias, and the results indicated that no significant common method bias was found.

Ethical Considerations

This study has been formally approved by the Medical Ethics Committee of Dali University, with approval number 202401–10. All participants were informed of the study’s purpose, content, and confidentiality policies prior to participation and voluntarily signed a written informed consent form.

Results

Participant Characteristics

Among the 452 participants, 70.80% lived in rural areas, 69.91% were aged 40–55 years, 92.26% were married, and 43.58% had received primary education or below. Additional participant characteristics are summarized in Table 1.

Table 1.

Univariate Analysis of Health Literacy, Symptom Burden, and Quality of Life by Demographic Characteristics (n = 452)

Item	n (%)	Health Literacy	Symptom Burden	Quality of Life
Age group
40–45 years	120 (26.55)	11.80±4.16	13.52±9.39	42.23±22.54
46–50 years	98 (21.68)	9.60±5.24	15.51±8.13	47.70±25.42
51–55 years	98 (21.68)	10.32±4.62	16.71±8.17	45.63±27.20
56–60 years	83 (18.36)	8.73±5.72	16.99±9.30	46.40±25.88
61–65 years	53 (11.73)	8.06±5.74	21.28±10.04	57.30±32.65
F value		7.465	7.377	3.141
P value		<0.001	<0.001	0.0145
Education level
Primary school or below	197 (43.58)	7.75±5.53	18.11±9.55	50.05±29.09
Junior high school	129 (28.54)	10.88±4.43	15.57±9.03	45.78±26.45
Senior high school/technical secondary school	63 (13.94)	11.51±4.00	14.25±7.76	43.17±21.70
College degree or above	63 (13.94)	13.73±2.23	13.40±8.51	41.54±19.85
F value		32.289	6.127	2.307
P value		<0.001	<0.001	0.0760
Average monthly household income (CNY)
<2000	168 (37.17)	7.74±5.43	18.48±10.43	52.54±30.67
2000–5000	179 (39.60)	10.84±4.87	15.01±7.13	43.25±23.50
5001–10,000	75 (16.59)	11.95±3.65	13.29±8.86	41.88±21.90
>10,000	30 (6.64)	12.77±3.21	17.67±10.54	46.40±21.47
F value		21.485	7.534	4.716
P value		<0.001	<0.001	0.0030
Presence of chronic disease
No	327 (72.35)	10.45±5.04	15.13±8.42	43.87±25.53
Yes	125 (27.65)	8.83±5.25	18.95±10.48	54.06±27.23
t value		−3.011	4.017	3.729
P value		0.0027	<0.001	<0.001
Current living status
Living alone	20 (4.48)	10.95±4.37	12.70±7.44	42.55±19.34
Living with spouse	92 (20.63)	11.30±4.20	14.79±7.82	43.17±20.86
Living with children	56 (12.56)	9.77±5.24	19.29±10.48	50.02±32.48
Living with spouse and children	276 (60.54)	9.55±5.37	15.89±9.03	45.87±25.77
Other	8 (1.79)	13.12±2.64	18.50±7.62	82.75±39.02
F value		3.018	3.179	4.737
P value		0.0178	0.0136	<0.001

Notes: Health literacy was measured using the Perimenopausal Health Knowledge Questionnaire (total score, 0–20). Symptom burden was assessed using the Modified Kupperman Index (total score, 0–63). The total Menopause-Specific Quality of Life Questionnaire (MENQOL) score was calculated as the sum of the four domains: vasomotor, psychosocial, physical, and sexual symptoms (total score, 0–174). The “Other” living status group had a small sample size (n = 8, 1.79%), and its relatively high health literacy score may have been influenced by individual outliers; therefore, differences in this group should be interpreted with caution.

Descriptive and Univariate Analyses

The mean scores for health literacy, symptom burden, and quality of life were 10.00 ± 5.14, 16.19 ± 9.19, and 46.69 ± 26.38, respectively. All three outcomes differed significantly according to age, educational level, average monthly household income, chronic disease status, and current living status (all P < 0.05; Table 1). These five variables were therefore included as covariates in the structural equation model.

Correlations Among the Main Variables

Health literacy was negatively correlated with symptom burden (r = −0.257, P < 0.01) and the psychosocial, physical, and sexual MENQOL domain scores (r = −0.296, −0.250, and −0.419, respectively; all P < 0.01). Symptom burden was positively correlated with the corresponding MENQOL domain scores (r = 0.419, 0.456, and 0.350, respectively; all P < 0.01). Neither health literacy nor symptom burden was significantly correlated with the vasomotor domain (both P > 0.05; Table 2).

Table 2.

Correlations Among Health Literacy, Symptom Burden, and Quality of Life (r Values, n = 452)

Variable	Health Literacy	Symptom Burden	Vasomotor Symptoms	Psychosocial Symptoms	Physical Symptoms	Sexual Symptoms
Health literacy	1
Symptom burden	−0.257**	1
Vasomotor symptoms	−0.088	0.004	1
Psychosocial symptoms	−0.296**	0.419**	0.186**	1
Physical symptoms	−0.250**	0.456**	0.198**	0.708**	1
Sexual symptoms	−0.419**	0.350**	0.078	0.374**	0.453**	1

Notes: **P < 0.01. Vasomotor, psychosocial, physical, and sexual symptoms are the four domains of the Menopause-Specific Quality of Life Questionnaire (MENQOL).

Structural Equation Model

The vasomotor domain showed a low standardized factor loading in the initial measurement model (λ = 0.155) and was therefore excluded from the final model. The covariate-adjusted final model yielded χ²/df = 5.359, RMSEA = 0.099, CFI = 0.918, TLI = 0.811, and SRMR = 0.048 (Table 3). The standardized factor loadings of the psychosocial, physical, and sexual domains ranged from 0.600 to 0.690 (all P < 0.001). The residuals of the psychosocial and physical domains were significantly correlated (r = 0.526, P < 0.001; Figure 1).

Table 3.

Fit Indices of the Structural Equation Model

Fit index	Acceptable Criterion20	Initial Model	Modified Model
χ2	—	103.135	69.667
df	—	22	13
χ2/df	<5	4.688	5.359
RMSEA	<0.08; 0.08–0.10 acceptable	0.091	0.099
CFI	>0.90	0.888	0.918
TLI	>0.90	0.796	0.811
SRMR	<0.08	0.057	0.048

Figure 1.

Structural equation model of the associations among health literacy, symptom burden, and quality of life. Values presented on the paths are standardized coefficients. Rectangles represent observed variables, the ellipse represents the latent variable, and circles represent residual terms (e1–e3). Single-headed arrows represent regression or factor-loading paths, and the curved double-headed arrow represents the residual correlation between psychosocial and physical symptoms. Age, educational level, monthly household income, chronic disease status, and living status were included as covariates but are omitted from the figure for clarity. **P < 0.01; ***P < 0.001.

Mediation Analysis

Bootstrap analysis with 5000 resamples showed that symptom burden partially mediated the relationship between health literacy and quality of life. The total, direct, and indirect effects were −0.424 (95% CI: −0.556 to −0.288), −0.343 (95% CI: −0.464 to −0.213), and −0.081 (95% CI: −0.143 to −0.033), respectively. The indirect effect accounted for 19.1% of the total effect (Table 4 and Table 5). The paths from health literacy to symptom burden (β = −0.175, P < 0.01) and from symptom burden to quality-of-life impairment (β = 0.464, P < 0.001) were statistically significant (Figure 1).

Table 4.

Bootstrap Test of the Mediating Effect of Symptom Burden

Effect Type	β	SE	Z Value	Bootstrap 95% CI
Total effect	−0.424	0.068	−6.282	−0.556, −0.288
Direct effect	−0.343	0.068	−5.146	−0.464, −0.213
Indirect effect	−0.081	0.027	−2.947	−0.143, −0.033

Notes: Fully standardized STDYX estimates were used. Bootstrap resampling was performed 5000 times, and the confidence intervals are bias-corrected Bootstrap 95% CIs.

Table 5.

Mediating Effect of Symptom Burden Between Health Literacy and Quality of Life

Item	Conclusion	Total Effect	Mediating Effect	Direct Effect	Proportion Mediated
Health literacy → symptom burden → quality of life	Partial mediation	−0.424	−0.081	−0.343	19.1%

Notes: Fully standardized STDYX estimates were used. Bootstrap resampling was performed 5000 times. A 95% CI that did not include 0 was considered evidence of a significant mediating effect. Proportion mediated = |mediating effect|/|total effect| × 100%.

Discussion

Health Literacy Among Perimenopausal Women in the Border Areas of Yunnan Needs to be Improved, and Their Symptom Burden and Impaired Quality of Life Require Attention

The mean health literacy score of perimenopausal women in the border areas of Yunnan was 10.00 ± 5.14, indicating a low-to-moderate level. The “other” living-status group had a relatively high health literacy score of 13.12 ± 2.64. However, this group accounted for only 1.79% of the sample. Therefore, this result may have been influenced by individual variation and should be interpreted with caution. Our finding is consistent with that of Khandehroo et al, who also reported limited health literacy among menopausal women in a remote rural area.¹² Limited access to health information and healthcare services may partly explain this finding. Healthcare resources are relatively scarce in border areas, and women may experience difficulties in obtaining and applying information about perimenopausal health.¹¹ Previous research also found that 58.5% of perimenopausal women had no knowledge of perimenopause or had only heard of it.¹² These findings indicate a clear need to strengthen health education for perimenopausal women in this region.

The mean modified Kupperman Index score was 16.19 ± 9.19, which was at the lower end of the moderate symptom range. This result indicates that the symptom burden among perimenopausal women in this region requires attention. A national epidemiological study reported that perimenopausal symptoms affected 61.0% of Chinese women aged 40–60 years, with a higher prevalence of 71.3% in southwestern China. Insomnia, fatigue, and irritability were among the most common symptoms.⁸

The similarity between the two studies may be related to the common biological changes of perimenopause, including declining ovarian function and fluctuating estrogen levels.^2,21 In addition, the relatively low educational and income levels of the participants, together with limited healthcare resources and insufficient symptom-management services, may increase their difficulties in recognizing and managing perimenopausal symptoms.¹¹

The mean MENQOL score was 46.69 ± 26.38. Because higher MENQOL scores indicate greater symptom-related impairment, this result suggests that the participants had impaired quality of life. The score was similar to the mean score of 51.59 ± 30.15 reported by Liu et al among perimenopausal women in Shandong Province.⁶ Although Yunnan and Shandong differ in socioeconomic conditions and healthcare resources, perimenopausal symptoms may adversely affect quality of life across different regions. Limited health education and symptom-management services may also contribute to this problem.²² Overall, limited health literacy, a substantial symptom burden, and impaired quality of life are important health concerns among perimenopausal women in the border areas of Yunnan.

Associations of Health Literacy and Symptom Burden with Quality of Life Among Perimenopausal Women

Health literacy was negatively associated with symptom burden (β = −0.175, P < 0.01) and MENQOL scores (β = −0.343, P < 0.001). Because higher MENQOL scores indicate poorer quality of life, these results suggest that women with higher health literacy tended to have a lower symptom burden and better quality of life. Similar findings were reported by Khandehroo et al¹² and Zhang et al¹⁶ Women with higher health literacy may be better able to obtain and understand information about perimenopause. They may also recognize symptoms earlier, seek appropriate healthcare, and adopt healthier self-management behaviors.¹⁶ A systematic review by Lee et al showed that higher health literacy was associated with better disease-prevention, health-promotion, and medical-adherence behaviors among middle-aged women.²³

Symptom burden was positively associated with MENQOL scores (β = 0.464, P < 0.001). This finding indicates that women with a greater symptom burden tended to have poorer quality of life. It is consistent with the findings of Rautenberg et al among menopausal-aged women in China.¹³ Perimenopausal women may experience vasomotor, psychological, physical, and sexual symptoms simultaneously.⁶ In the present study, psychological and physical symptoms were also closely related (r = 0.526, P < 0.001). This finding suggests that different symptoms may coexist and jointly affect quality of life. Previous research has also reported that anxiety and depression frequently coexist with physical symptoms such as insomnia, irritability, and hot flashes.²⁴ These overlapping symptoms may partly result from hormonal changes during the menopausal transition.²⁵

Therefore, perimenopausal health management should address both health literacy and symptom burden. Personalized health education and tiered symptom management may help women understand health information, manage their symptoms, and improve their quality of life.

Symptom Burden Partially Mediates the Association Between Health Literacy and Quality of Life

Symptom burden partially mediated the association between health literacy and quality of life. The indirect effect was −0.081 (95% CI: −0.143 to −0.033), accounting for 19.1% of the total effect. This finding suggests that higher health literacy may be associated with better quality of life partly through a lower symptom burden. However, the remaining 80.9% of the total effect was direct. Other pathways, including cognitive appraisal, psychological resilience, healthcare-seeking behavior, and social support, may also be involved.^26–28 This finding supports the pathway proposed by O’Reilly et al¹⁴ and Kang et al,¹⁵ in which health literacy may influence quality of life through symptom-management behaviors. Previous studies have also shown that health literacy may affect health-related outcomes through self-efficacy and health behaviors.²⁹ Therefore, interventions should address both health literacy and symptom burden rather than focusing only on symptom reduction.

Women with higher health literacy may be more likely to recognize perimenopausal symptoms early and adopt appropriate coping strategies, including regular sleep, a balanced diet, moderate exercise, and timely medical consultation.^30,31 They may also be more likely to use cognitive regulation, strengthen their self-efficacy, and seek appropriate medical support.^12,31 These behaviors may reduce symptom burden and its adverse effects on daily life.

Practical Implications

The findings have several practical implications for the health management of perimenopausal women in the border areas of Yunnan. First, primary healthcare institutions could incorporate routine assessments of perimenopausal health knowledge, symptom burden, and quality of life into women’s health services to identify those who require additional support. Second, community health education should use plain language, visual materials, and culturally appropriate content, with particular attention to women with lower educational levels and limited access to healthcare. Third, a tiered symptom-management pathway could be developed. Women with mild symptoms could receive guidance on sleep, diet, exercise, and other self-management strategies, whereas those with persistent, moderate, or severe symptoms should receive further clinical evaluation and appropriate referral. Physical and psychological symptoms should also be assessed together because they may coexist and jointly affect quality of life. Community education, peer support, and remote follow-up could further improve the continuity and accessibility of health services in resource-limited areas.^30,31 These strategies may support earlier identification and more individualized management of perimenopausal health needs and are consistent with the broader priorities of the Healthy China Action (2019–2030), including improving health literacy, promoting healthy lifestyles, and providing equitable, accessible, and integrated health services.³² However, their effectiveness should be evaluated in future intervention studies.

Strengths and Limitations

This study examined the associations among health literacy, symptom burden, and quality of life in an understudied population of perimenopausal women living in the border areas of Yunnan. The findings provide preliminary evidence for understanding the potential mediating role of symptom burden and may inform the development of context-specific health-management strategies in resource-limited areas.

Several limitations should also be considered. First, the participants were recruited through convenience sampling from selected healthcare institutions in Longling County, Yunnan Province. Therefore, the sample may not fully represent all perimenopausal women in other areas of Yunnan or other border regions, and the generalizability of the findings may be limited. Second, the cross-sectional design does not establish the temporal sequence or causal relationships among health literacy, symptom burden, and quality of life. Future longitudinal and intervention studies are needed to verify these relationships and further evaluate the proposed pathways.

Conclusion

In summary, this study confirms that perimenopausal women in the border areas of Yunnan had relatively low health literacy scores, moderate symptom burden, and impaired quality of life. Higher health literacy scores were associated with lower modified Kupperman Index scores, indicating a lower symptom burden. Higher health literacy scores were also associated with lower MENQOL scores, indicating better quality of life. In contrast, a greater symptom burden was associated with higher MENQOL scores and therefore poorer quality of life. Symptom burden partially mediated the association between health literacy and quality of life, accounting for 19.1% of the total effect. These findings suggest that health education and symptom management should be integrated into primary healthcare services to improve the quality of life of perimenopausal women in this region.

Funding Statement

The author(s) declare that no financial support was received for the research and/or publication of this article.

Data Sharing Statement

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Ethics Approval and Informed Consent

The study followed the Declaration of Helsinki and was approved by the Medical Ethics Committee of Dali University, with approval number 202401-10. All participants were informed of the study’s purpose, content, and confidentiality policies prior to participation and voluntarily signed a written informed consent form.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.