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Background  The importance of health literacy in dealing with the COVID-19 epidemic has been emphasized but scarcely addressed empirically. In this study, the association of health literacy with mental health, compliance with COVID-19 preventive measures and health prospects was assessed in a Belgian context.    Methods  Data were extracted from the third of a series of cross-sectional online COVID-related surveys ( n  = 32,794). Data collection took place for 1 week starting the 28th of May 2020. People residing in Belgium and aged 18 years or older could participate. Data were collected on sociodemographic background, health literacy, multimorbidity, mental health (depression, anxiety, sleeping disorder, vitality), knowledge about COVID-19, compliance with COVID-19 measures (hygiene, physical distance, covering mouth and nose on public transport and in places where physical distance cannot be respected), and health prospects (risk for health when returning to normal life and possibility of infection). Prevalence Ratio (PR) of poor mental health, non-compliance with the measures and health prospects in relation to health literacy were calculated using Poisson regressions.    Results  People showing sufficient health literacy were less likely to suffer from anxiety disorders (PR = 0.47, 95% CI = [0.42–0.53]), depression (PR = 0.46, 95% CI = [0.40–0.52]) and sleeping disorders (PR = 0.85, 95% CI = [0.82–0.87]), and more likely to have optimal vitality (PR = 2.41, 95% CI = [2.05–2.84]) than people with low health literacy. They were less at risk of not complying with the COVID-19 measures (PR between 0.60 and 0.83) except one (covering mouth and nose in places where physical distance cannot be respected). Finally, they were less likely to perceive returning to normal life as threatening (PR = 0.70, 95% CI = [0.65–0.77]) and to consider themselves at risk of an infection with COVID-19 (PR = 0.75, 95% CI = [0.67–0.84]). The associations remained significant after controlling for COVID-19 knowledge and multimorbidity.    Conclusions  These results suggest that health literacy is a crucial factor in managing the COVID-19 epidemic and offer a perspective for future studies that target health literacy in the context of virus outbreaks.    Supplementary Information  The online version contains supplementary material available at 10.1186/s12889-021-11437-w.

Mental health, compliance with measures and health prospects during the COVID-19 epidemic: the role of health literacy