Health literacy and nutritional self-efficacy in older adults: the chain- mediating role of perceived social support and positive mental health

Health literacy and nutritional self-efficacy in older adults: the chain- mediating role of perceived social support and positive mental health | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Health literacy and nutritional self-efficacy in older adults: the chain- mediating role of perceived social support and positive mental health Zhanghao Pei, Suyan Chen, Zhenxiang Zhang, Yipu Sai, Yongxia Mei This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7113698/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Objectives To explore the impact of health literacy on nutritional self-efficacy in older adults and the chain-mediated effects of perceived social support and positive mental health between the two. Methods A total of 265 older adults who met the inclusion criteria in five communities in Zhengzhou City, Henan Province, from July to December 2024 were selected as survey respondents. Questionnaires were administered using the General Information Questionnaire, the short-form Mandarin Health Literacy Scale (s-MHLS), the Nutritional Self-Efficacy Questionnaire Chinese version (NSEQ), the Perceived Social Support Scale (PSSS), and the Positive Mental Health Scale Chinese version (PMHS). Spearman correlation analysis was used to explore the correlation between the variables, AMOS 24.0 software was used to construct the chain mediation model, and the Bootstrap method was used to test the chain mediation model. Results The nutritional self-efficacy score of older adults was (100.28 ± 18.59), and there was a correlation between health literacy, nutritional self-efficacy, perceived social support, and positive mental health ( P < 0.001). The mediation model showed that the direct effect of health literacy on nutritional self-efficacy was significant in older adults, and health literacy also indirectly affected nutritional self-efficacy through perceived social support ( β = 0.136, P < 0.001) and positive mental health ( β = 0.077, P < 0.001). Perceived social support and positive mental health acted as chain mediators between health literacy and nutritional self-efficacy ( β = 0.051, P < 0.001), with the total indirect effect accounting for 34.73% of the total effect. Conclusion Nutritional self-efficacy among older adults is at an intermediate level. Perceived social support and positive mental health play a mediating role between health literacy and nutritional self-efficacy in older adults. Healthcare professionals and related personnel should pay attention to educating the elderly on health literacy, popularizing knowledge of diseases, and improving their nutritional self-efficacy by enhancing their ability to appreciate social support and maintain positive mental health. Health literacy Nutritional self-efficacy Perceived social support Positive mental health Mediation analysis Chain mediation Figures Figure 1 Figure 2 1. Introduction With the rapid development of the aging population, China's elderly population is expected to reach 310 million by 2024, accounting for 22.0% of the total population (Ning, 2025 -01-20). Due to aging, individual body functions deteriorate, predisposing to adverse health outcomes such as increased risk of chronic disease onset, and older adults are usually exposed to greater nutritional risks (The, 2022 ). Studies have shown that more than 70% of older adults in China have inadequate nutritional intake, poor nutritional attitudes, and poor nutritional status (Jian et al., 2021 ). In addition, chronic diseases such as hypertension, diabetes, and obesity suffered by middle-aged and older adults are diet-related (Wahlqvist, 2005 ). Therefore, nutritional factors underlie many factors contributing to older adults' health problems. Due to the limited access to nutritional information for older adults and the influence of traditional dietary concepts, nutritional cognition and self-efficacy in this population are severely hampered (J. Liu et al., 2022 ; Terp, Kayser, & Lindhardt, 2021 ). Nutritional self-efficacy is defined as an individual's confidence in his or her ability to achieve the nutritional behavioral goals required in a given domain and predicts nutritional behavior (Shamsalinia et al., 2019 ). Reduced nutritional self-efficacy can be a risk factor for older adults in coping with nutritional challenges by hindering their access to effective nutritional information and reducing their ability to make sound nutritional decisions (Luo, Wan, & Bian, 2023 ). Health literacy is predictive of self-efficacy and enables individuals to evaluate their self-behavior correctly(Osborn, Paasche-Orlow, Bailey, & Wolf, 2011 ). Studies have pointed out that improving the level of health literacy in older adults can effectively improve social support (Yongbing et al., 2017 ); in addition, Bandura's self-efficacy theory suggests that self-efficacy is influenced by social support such as verbal persuasion, especially from others or from those in authority (Bandura, 1986 ), which further indicates that good perceived function of social support and the quality of social support can enhance self-efficacy. There is a positive correlation between the two (Al-Dwaikat, Rababah, Al-Hammouri, & Chlebowy, 2021 ). The results of Li Pingping's study indicate that psychological state and nutritional status are mutually influential; depression will lead to malnutrition in older people, and malnutrition will aggravate psychological depression, forming a vicious circle (Pingping, Rui, Jun, Shan, & Hui, 2018 ), while health literacy intervention can effectively improve the physical and mental health of older people (Liqun, 2020 ). A good psychological state is an important basis for ensuring nutritional absorption. Studie (Leung, Chen, Lue, & Hsu, 2007 ) has shown that family is an important source of social support for older adults, and psychological symptoms are negatively correlated with family involvement. Older adults with higher levels of family involvement have fewer psychological symptoms and better mental health, which in turn suggests that good levels of social support have a facilitating effect on mental health (Shiping, 2012 ; Zhaojing & Bin, 2021 ), and the two may have a chain-mediated impact on health literacy and nutritional self-efficacy. Previous studies have confirmed that health literacy, perceived social support, and positive mental health are independent influences on nutritional self-efficacy in older adults. Still, fewer studies have explored the intrinsic links between these variables. Given this, the present study aimed to explore the relationships among health literacy, perceived social support, positive mental health, and nutritional self-efficacy of older adults by constructing a chain mediation model, to elucidate their internal interaction mechanisms, and provide a theoretical basis for improving nutritional self-efficacy of older adults. Questions and assumptions It has not been demonstrated that navigating social support and positive mental health has a moderating effect on nutritional self-efficacy and health literacy in older adults. In this study, a chain mediation model was used to assess the direct and indirect roles of health literacy and nutritional self-efficacy. The COM-B model (Michie, Stralen, & West, 2011 ) describes the interactions between behavior, ability, opportunity, and motivation. It is evident that health literacy is closely related to navigating social support and promoting positive mental health, and that health literacy reinforces intrinsic drives to achieve more comprehensive and lasting behavioral change. Based on the social support theory (Cobb & Sidney, 1976 ) and the health belief theory model (Dharani et al., 2019 ), the direct impact of health literacy on self-efficacy and the role of appreciative social support on positive mental health is evident. We therefore hypothesize that appreciative social support and positive mental health in older adults may play an important role in the relationship between health literacy and nutritional self-efficacy (see Fig. 1 ). 2. Methods 2.1 Research subjects From July to December 2024, 265 older adults who met the inclusion criteria in five communities in Zhengzhou City, Henan Province, were selected as the survey subjects using the convenience sampling method. Inclusion criteria: (1) age ≥ 60 years old; (2) normal reading, writing, and language comprehension and communication skills; able to complete the questionnaire on their own or under the guidance of the researcher; (3) informed consent and voluntary participation in this study. Exclusion criteria: (1) People with mental illness and serious cognitive dysfunction; (2) People with other serious physical illnesses who cannot cooperate to complete the survey. 2.2 Sample size calculation The questionnaire in this study contains general information, the short-form Mandarin health literacy scale, a perceived social support scale, a positive mental health scale, and a nutritional self-efficacy questionnaire, according to the sample size standard of 5–10 times the number of independent variables. A total of 16 independent variables were included in this study, and the sample size was calculated as 160, taking into account 20% of invalid questionnaires. 16*10/(1-0.20) = 200, and a final sample size of 256 older adults was included in this study. 2.3 Research tools 2.3.1 General information questionnaire The general information questionnaire was designed by the researcher himself according to the purpose of the study, including gender, age, place of residence, education level, marital status, per capita monthly income of the family, and the presence or absence of chronic diseases of the elderly. 2.3.2 The short-form health literacy assessment scale The short-form health literacy assessment scale (Chung, Chen, Peng, & Chi, 2015 ) (s-MHLS) was developed by Taiwanese scholars to assess the self-perceived health literacy of older adults and was later revised by Li Shaojie et al. (Li, Cui, & Xu, 2023 ) for use in community-based health literacy surveys of older adults. The short-form health literacy assessment scale (s-MHLS) has a one-way structure with 10 items and uses a 5-point Likert scale, with “strongly disagree” to “strongly agree” assigned a score of 1 to 5, respectively. The total score was 10–50, and the higher the total score, the better the health literacy. The Cronbach's α coefficient of the scale in this study was 0.831. 2.3.3 Chinese version of Nutrition Self-Efficacy Questionnaire (NSEQ) The Nutrition Self-Efficacy Questionnaire (NSEQ) was developed by Shamsalinia et al. (Shamsalinia et al., 2019 ) and later translated into Chinese by Luo Peilin (Luo et al., 2023 ), including 29 items in 3 dimensions, namely, adherence efficacy (14 items), preventive behaviors (10 items), and information effectiveness (5 items). Likert 5 scale, from “completely disagree” to “completely agree,” 5 options, in order of 1–5 points, with a total score of 29–145; the higher the score, the higher the nutrition self-efficacy. In this study, the total Cronbach's α of the scale was 0.905, and the Cronbach's α of each dimension was 0.791, 0.789, and 0.831. 2.3.4 Perceived Social Support Scale (PSSS) The perceived Social Support Scale (PSSS), compiled by Zimet (Blumenthal et al., 1987 ) et al. and revised by Jiang Qianjin (Zimet, Powell, Farley, Werkman, & Berkoff, 1990 ), is an instrument for measuring individuals' self-perception of multidimensional social support, which includes family support (entries 3, 4, 8, 11), friends support (entries 6, 7, 9, 12), and significant others support (entries 1, 2, 5, 10) 3 dimensions, a total of 12 entries, using a 7-point scale (1 to 7 points), a total score of 12 to 84, the higher the score the higher the comprehension of the social support, 12 to 36 points is a low level of support, 37 points to 60 points is an intermediate level of support, 61 points to 84 points is a high level of support. The total Cronbach's α of the scale in this study was 0.906, and the Cronbach's α of each dimension was 0.839, 0.821, and 0.821. 2.3.5 Chinese version of the Positive Mental Health Scale (PMHS) The Positive Health Mental Scale (PMHS) was developed by German scholar Lukat (Lukat, Margraf, Lutz, Van, & Becker, 2016) by the definition of PMH as screening the entries from a library of standardized entries and finally forming a nine-item positive mental health scale. After that, our scholar Ding Tengyun et al (Ding, Wu, & Li, 2023 ) translated and modified it into a Chinese version of the scale according to the national conditions of China, and the study verified that the Chinese version of the PMHS has good validity and reliability in the Chinese cultural context. The scale is rated on a 4-point scale, from “strongly disagree” to “strongly agree,” with a total score of 9–36. The Cronbach's α coefficient of the Chinese version of the PMHS in this study was 0.912. 2.4 Data collection This study adopts a face-to-face method to collect data. The investigators were uniformly trained before the survey, including the purpose of the survey, the language of communication in the survey, the problems that might be encountered in the survey, how to deal with them, and the on-site verification of the survey questionnaire. Team members were required to obtain informed consent from the study subjects before the scale collection and explain the method of filling out the scale and the precautions to be taken. Team members guide the research subjects to fill in the questionnaire independently. If they are unable to fill in the questionnaire, the team members will collect the information in the form of questions and answers, but they shall not intervene in their choices to fully ensure the authenticity and validity of the data. At the end of the survey, the completeness and standardization of the scale were checked on-site, and the questionnaires with no missing items and consistent logic were recorded as valid questionnaires. 2.5 Statistical methods SPSS 21.0 statistical software was used to analyze the data; non-normally distributed information was expressed by [ M ( P 25, P 75)], and comparisons between groups were made by the Mann-Whitney U test or the Kruskal-Wallis test; correlation analyses between two variables were performed by Spearman's rank correlation analysis; and analyses of factors influencing the nutritional self-efficacy of elderly people were performed by multiple linear regression analysis. Differences were considered statistically significant at P < 0.05. AMOS 24.0 software was used to establish the chain mediation model in this study. Mediation effects were tested using the Bootstrap method with a sample size of 5000, and a mediating effect was indicated when the 95% CI did not include zero. Partial mediation models are determined by the criterion that the independent variable in the model can affect the dependent variable directly or indirectly through the mediating variable (Shrout & Bolger, 2002 ). 3. Results 3.1 General condition of the elderly and scores of s-MHLS, PSSS, PMHS, NSEQ A total of 265 questionnaires were distributed in this study, and 256 valid questionnaires were recovered, with a valid recovery rate of 96.6%. The age of the study participants ranged from 60 to 92 years old, with a mean age of (68.3 ± 6.6) years. s-MHLS, PSSS, PMHS, and NSEQ scores averaged (34.7 ± 7.9), (61.1 ± 14.0), (27.1 ± 6.5), and (100.3 ± 18.6). s-MHLS, PSSS, PMHS, and NSEQ scores. The mean scores for the friends support, family support, and significant others support sub-dimensions of the PSSS were (21.52 ± 5.51), (19.73 ± 5.21), and (19.89 ± 5.47); and the mean scores for the adherence efficacy, preventive behaviors, and information effectiveness sub-dimensions of the NSEQ were (47.91 ± 10.00), (35.54 ± 7.80), and (16.83 ± 4.41) points, as shown in Table 1 . Table 1 Health Literacy, Nutritional Self-Efficacy, Perceived Social Support, and Positive Mental Health Scores of Older Adults (n = 256) Variables Range of score Score (x ̅±s) Health literacy 10 ~ 50 34.70 ± 7.94 Perceived Social Support 12 ~ 84 61.14 ± 13.97 Family support 4 ~ 28 21.52 ± 5.51 Friends support 4 ~ 28 19.73 ± 5.21 Significant others support 4 ~ 28 19.89 ± 5.47 Positive mental health 10 ~ 40 27.15 ± 6.50 Nutrition self-efficacy 29 ~ 145 100.28 ± 18.59 Adherence efficacy 14 ~ 70 47.91 ± 10.00 Preventive behavior 10 ~ 50 35.54 ± 7.80 Information effectiveness 5 ~ 25 16.83 ± 4.41 3.2 Comparison of NSEQ scores of older adults with different characteristics The results of the study showed that the NSEQ scores of males were lower than those of females, and the differences were statistically significant when comparing the NSEQ scores of elderly people with different levels of literacy, per capita household income, and the presence or absence of chronic illnesses (P 0.05), as shown in Table 2 . Table 2 Comparison of NSEQ scores for older adults with different characteristics Group N % M ( P 25, P 75) Z / H P Gender Male 144 56.3 102.0(85.5, 110.0) -1.82 a 0.069 Female 112 43.8 103.0(93.0, 116.0) Place of residence Large and medium-sized cities 146 57.0 103.0(92.0, 115.3) 7.278 b 0.064 Suburban 58 22.7 104.0(88.0, 110.0) County and town municipalities 29 11.3 89.0(76.0, 106.5) Rural 23 9.0 105.0(91.0, 118.0) Educational level Illiterate 29 11.3 87.0(74.5, 106.5) 18.034 b 0.003 Elementary school 60 22.3 105.0(89.25, 116.0) Secondary school 79 30.9 107.0(96.0, 114.0) High school/middle school 64 25.0 95.0(89.0, 1105.0) College/Undergraduate 19 7.4 109.0(91.0, 121.0) Graduate and above 5 2.0 103.0(84.0, 121.5) Marital status Married 206 80.5 103.0(90.8, 113.3) 6.191 b 0.103 Unmarried 35 13.7 96.0(81.0, 108.0) Divorced 6 2.3 103.0(93.0, 110.5) Widow 9 3.5 118.0(90.0, 124.5) Monthly income (RMB) 5000 81 31.6 98.0(91.0, 113.0) Chronic disease No 91 35.5 97.0(88.0, 106.0) -3.06 a 0.002 Yes 165 64.5 106.0(91.0, 117.0) Note: a indicates Z -value; b indicates H -value 3.3 Correlation analysis of health literacy, PSSS, PMHS, and NSEQ in older adults The results of Spearman correlation analysis showed that health literacy was positively correlated with NSEQ, PSSS, and PMHS (r = 0.646, P < 0.001; r = 0.505, P < 0.001; r = 0.401, P < 0.001); PSSS was positively correlated with NSEQ and PMHS (r = 0.589, P < 0.001; r = 0.508, P < 0.001); PMHS was positively correlated with NSEQ (r = 0.536, P < 0.001), as shown in Table 3 . Table 3 Results of correlation analysis of health literacy, PSSS, PMHS, and NSEQ among older adults Variable Health literacy Perceived social support Positive mental health Nutritional self-efficacy Health literacy 1 - - - Perceived social support 0.505*** 1 - - Positive mental health 0.401*** 0.508*** 1 - Nutritional self-efficacy 0.646*** 0.589*** 0.536*** 1 *** p < 0.001 3.4 Mediation analysis of the effect of health literacy on nutritional self-efficacy among older adults The chain mediation model was established, and the model fitting indexes were:χ2/df = 4.335, GFI = 0.941, NFI = 0.0.930, IFI = 0.946, TLI = 0.903, and CFI = 0.945; and RMSEA = 0.114, which was poorly fitted. Therefore, the Bollen-Stine method was used to correct the model. After 5000 Bootstrap sampling corrections the model χ2/df = 1.296, GFI = 0.979, NFI = 0.979, IFI = 0.995, TLI = 0.991, CFI = 0.995; RMSEA = 0.034, the model fit was good. As shown in Fig. 2 , the explicit variable factor loadings for the latent variables comprehension, social support, and positive mental health were all > 0.5. 3.5 Mediation effect test As shown in Table 4, the 95% CI of each mediating path did not include 0, and the mediating effect was significant. The total effect of health literacy on nutritional self-efficacy was significant [ β = 0.763, 95% CI (0.641, 0.871), P < 0.001]; the mediating effect of the indirect effect of health literacy on nutritional self-efficacy, the mediating effect of perceived social support, and positive mental health was significant [ β = 0.265, 95% CI (0.180, 0.368), P < 0.001]; The direct effect of health literacy on nutritional self-efficacy was significant [ β = 0.498, 95% CI (0.262, 0.511), P < 0.001]. The model was a partial mediation model. Table 4 Bootstrap Analysis of Health Literacy, Perceived Social Support, and Positive Mental Health on Nutritional Self-Efficacy in Older Adults Model pathway Point estimate 95% CL SE Z P Total effect HL → NSE 0.763 （0.641,0.871） 0.058 13.155 <0.001 Indirect effect 0.265 （0.180,0.368） 0.049 5.408 <0.001 HL → PSS → NSE 0.136 （0.055,0.246） 0.048 2.833 <0.001 HL → PMH → NSE 0.077 （0.030,0.151） 0.029 2.655 <0.001 HL → PSS → PMH → NSE 0.051 （0.023,0.102） 0.019 2.684 <0.001 Direct effect HL → NSE 0.498 （0.262,0.511） 0.059 8.441 <0.001 Abbreviations: HL, Health literacy; NSE, Nutritional self-efficacy; PSS, Perceived social support; PMH, Positive mental health. 4. Discussion The health literacy score of the elderly in this study was (34.70±7.94), which was lower than the findings of Chung et al (Chung et al., 2015) and may be related to the lower education level of the included population (65.63% in junior high school and below) and the higher percentage of elderly with chronic diseases (65.63% in junior high school and below). Studie (Tavakoly Sany et al., 2024) has shown that older adults with high nutritional self-efficacy have greater ability and confidence to achieve nutritional behaviors, as well as set higher goals, become more engaged, and thus are more likely to achieve nutritional behaviors. The nutritional self-efficacy score in this study was (100.28±18.59), which is higher than the findings of Tavakoly Sany et al (Tavakoly Sany et al., 2024). This may be related to the nutritional knowledge base of older adults, who are not limited to acquiring nutritional knowledge on their own but are also influenced by their families, friends, and society, and increasing the nutritional knowledge of older adults is conducive to the realization of healthy eating behaviors. Secondly, older adults' attitudes toward healthy eating affect food choices, and increasing attitudes toward healthy eating can help them make better food choices, develop healthier eating habits, and contribute to nutritional self-efficacy. The results of this study showed that the elderly's perceived social support score was (61.14±13.97), which was at a medium level, and the score was slightly lower than the results of the study by Pang Fangfang et al (Pang, Zhao, Su, & Guan, 2019). At present, the source of social support for the elderly in China's community is relatively single, mostly originating from the family, with a lack of support from friends, resulting in a loose social network and insufficient social support available (Rui, Shoumei, Xinxin, & Yumei, 2022). Due to the decline of physical function and self-care ability of the elderly, their dependence on their family members increases, while the actual support provided by their children is insufficient because of their work and life. Thus, the elderly feel less supported by their families, resulting in a slightly lower level of perceived social support. The positive mental health score of the elderly in this study was (27.15±6.50), which is slightly lower than the findings of Lukat et al (Lukat et al., 2016), and there is room for further improvement. The positive mental health status of the elderly is influenced by many factors such as educational level, social relationship status, residential status, and physical health status (Oi Yuling, 2017). In this study, older adults with a high level of education (high school or middle college or above) scored higher; older adults with good marital status scored higher; and older adults without chronic diseases scored higher. With the development trend of population aging, urbanization, and intergenerational separation of living styles, there are more and more empty nesters or elderly people living alone. It is difficult to satisfy the emotional and spiritual comfort needs of the elderly, and their mental health is in a worrying situation (Zhang, Zhang, & Guo, 2010), so more attention should be paid to the mental health problems of the elderly in actual life to achieve healthy and active aging. This study verified the positive effect of both health literacy and nutritional self-efficacy among older adults (r=0.646, P<0.001), and the higher the level of health literacy, the stronger the nutritional self-efficacy, which is consistent with the findings of Darvishpour (Y. Liu, Meng, Tu, & Liu, 2020). Health literacy predicts self-efficacy and self-care behavior, and people with higher health literacy can have better self-efficacy and self-care behavior (Y. Liu et al., 2020). The present study showed that perceived social support was positively related to nutritional self-efficacy, which is consistent with the findings of Chu Hui (Hui, 2020). Good perceived functioning of social support and quality of social support can help to improve self-efficacy and promote changes in health behaviors (Al-Dwaikat et al., 2021). Meanwhile, the improvement of self-efficacy can help to improve the mindset and mood of the elderly, which in turn can enable them to obtain more social support. The present study also showed that positive mental health is positively correlated with nutritional self-efficacy, which is in line with studies such as Tavakoly Sany (Tavakoly Sany et al., 2024). Positive psychology and self-efficacy are important psychological resources for individuals in the face of adversity, and older adults with high levels of positive psychology are more likely to develop positive self-efficacy beliefs, and there is a close intrinsic link between the two (Berdida, Lopez, & Grande, 2023). Older adults with good health literacy not only have good disease self-management ability but also can take the initiative to use social support to maintain healthy living behaviors and access to health information, and thus, better nutritional behaviors (Fields et al., 2021; Khodabandeh, Avarasin, & Nikniaz, 2017). The results from this study indicate that nutritional self-efficacy in older adults is strongly associated with health literacy, perceived social support, and positive mental health. The direct and indirect effects of health literacy on nutritional self-efficacy were significant, suggesting that we should not only focus on improving health literacy to enhance nutritional self-efficacy in older adults but also on changing unhealthy behaviors by improving older adults' perceptions of social support and positive mental health. In terms of direct effect, health literacy has a significant effect on nutritional self-efficacy, accounting for 65.27% of the total effect. Health literacy is closely related to the level of self-efficacy, health outcomes, and quality of life, and improving the health literacy of the population, enhancing self-efficacy, and changing poor lifestyles can help to improve the quality of life (Yaru et al., 2018). It is suggested that healthcare professionals can provide personalized health education and health promotion according to the different educational levels and realistic conditions of the elderly, etc., to popularize health knowledge, teach health skills, cultivate healthy behaviors and lifestyles, and take responsibility for their health, to achieve the purpose of enhancing nutritional self-efficacy and promoting individual health. Among the three mediating effect paths, the largest effect size was found when perceived social support was an independent mediating variable, accounting for 17.82% of the total effect. It is more confirmed that the health and diet quality of older adults is related to social support, socioeconomic status, and culture (Sheiham et al., 2001). Community healthcare workers should fully mobilize and leverage the social support resources available to the elderly during health education and chronic disease management. This will encourage the elderly to use various social supports and participate more actively in activities. Healthcare workers should also work with communities and families to build a comprehensive social support system. In this way, it will enhance the emotional attachment of the elderly, promote their self-efficacy, and continuously improve their self-health management abilities. This study showed that positive mental health plays a chain mediating role between health literacy and nutritional self-efficacy in older adults, with the path effect accounting for 10.09% of the total effect. Positive mental health emphasizes that mental health does not only refer to the absence of any problems but also includes the production and increase of various positive qualities and positive strengths of an individual (Cheng, Ren, & Ma, 2009). Focusing on the positive mental health status of the elderly can enable them to fully recognize their strengths and inspire their confidence in achieving healthy eating and other nutritional behaviors. Compared with other age groups, the elderly are more prone to some psychological problems, so attention should be paid to their positive mental health status, mobilizing their intrinsic positive energy, positively facing nutritional problems, and improving the sense of well-being and satisfaction of the elderly. The present study confirmed the chain mediating role played by appreciative social support and positive mental health between health literacy and nutritional self-efficacy in older adults, but the path effect value was small at 6.68%. The results of Barrera's study showed that perceived social support is the support that individuals subjectively experience, which is the subjective perception and satisfaction evaluation of respect, understanding, and support from social others (Barrera, 1986), and it is an important support for maintaining mental health (Chen, Li, Zhou, Liu, & Xu, 2021). GE Fang-Jun (Ge et al., 2012) found that social support contributes to mental health and also suggested that social relationships are an important determinant of mental health, with higher levels of social support being associated with better psychological status. It is suggested that family members and healthcare professionals should focus on emotional communication with older adults, strengthen psychological cognition, and maintain an optimistic mindset to better cope with the challenges posed by nutritional health problems and improve their ability and confidence in their nutritional management. 5 Limitations There were several limitations in this study. First, due to the limited availability of human and time resources, the subjects of this study were selected from only a few communities in Zhengzhou City, and the sample size and survey area may be insufficient, resulting in limited sample representativeness. Second, this study is a cross-sectional survey. Causality could not be determined, so it is necessary to carry out a multicenter, large-sample longitudinal study in the future, as well as to consider factors such as organization and the environment, and to comprehensively explore the influence of nutritional self-efficacy and mechanisms to provide a theoretical basis for improving nutritional self-efficacy. In the future, multi-center and large-sample longitudinal studies should be conducted, and organizational and environmental factors should be taken into account to comprehensively explore the factors and mechanisms of nutritional self-efficacy to provide a theoretical basis for improving nutritional self-efficacy in the elderly. 5. Conclusion The results of this study show that the nutritional self-efficacy of the elderly is at a moderate level. Health literacy not only directly affects the nutritional self-efficacy of the elderly but also positively affects nutritional self-efficacy through the realization of social support and positive mental health. Older adults should strengthen the acquisition of health information and effective communication, improve their own health literacy and knowledge of chronic diseases, maintain a positive psychology, and positively perceive social support to improve the quality of life and health of older adults. Declarations Acknowledgments The authors thank all the investigators and participants of this study Funding information This research received no external funding. Conflict of interest statement There are no conflicts of interest declared by the author(s). Author contributions Study proposal: Zhanghao Pei, Suyan Chen, Zhenxiang Zhang; Data collection: Zhanghao Pei, Yipu Sai, Yongxia Mei; Data analysis and drafting of the manuscript: Zhanghao Pei, Yipu Sai. Approval of data analysis: Suyan Chen, Yongxia Mei; Approval of the manuscript: Suyan Chen, Zhenxiang Zhang; Read and approved the final manuscript: all authors. Data availability statement Relevant data generated during this study are available upon reasonable request from the corresponding author. Due to privacy or ethical restrictions, these data are not publicly available. Ethical approval The ZZU University Ethics Committee reviewed and approved the work (ZZURIB2024127). The authors state all participants were informed of the purpose of the study and provided informed consent. All procedures were carried out in compliance with the rules and regulations set by the Department of Scientific Research at ZZU University, and participants' privacy and human rights were protected through the use of anonymous data collection. References Al-Dwaikat TN, Rababah JA, Al-Hammouri MM, Chlebowy DO. Social Support, Self-Efficacy, and Psychological Wellbeing of Adults with Type 2 Diabetes. 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J Affect Disord. 2021;279:111–6. http://doi:10.1016/j.jad.2020.09.137 . Cheng X, Ren J, Ma T. The Characters of Positive Mental Health. [积极心理健康的内涵解析]. Psychol Sci. 2009;32(2):487–9. Chung MH, Chen LK, Peng LN, Chi MJ. Development and validation of the health literacy assessment tool for older people in Taiwan: potential impacts of cultural differences. Arch Gerontol Geriatr. 2015;61(2):289–95. http://doi:10.1016/j.archger.2015.06.015 . Cobb, Sidney. social Support as a Moderator of Life Stress. Psychosom Med. 1976;38(5):300–14. Dharani Y, Dhrupadh, Samantha, Hajna S, Griffin. Effects of Mobile Health App Interventions on Sedentary Time, Physical Activity, and Fitness in Older Adults: Systematic Review and Meta-Analysis. J Med Internet Res. 2019;21(11):e14343. Ding T, Wu K, Li Y. Validity and reliability of the Chinese version of the Positive Mental Health Scale in urban adults. [积极心理健康量表中文版测评城市成年人的效度和信度]. Chin Mental Health J. 2023;37(6):532–7. Fields B, Lee A, Piette JD, Trivedi R, Mor MK, Obrosky DS, Rosland AM. Relationship between adult and family supporter health literacy levels and supporter roles in diabetes management. Fam Syst Health. 2021;39(2):224–33. http://doi:10.1037/fsh0000503 . Ge F, Zhao L, Liu J, Zhou M, Guo Y, Zhang Q. Correlation between Social Support and Mental Health of the Aged Based on Pearson Correlation Coefficient: A Meta-Analysis. [基于Pearson相关系数的老年人社会支持与心理健康相关性研究的Meta分析]. Chin J Evidence-Based Med. 2012;12(11):1320–9. Hui C. Correlation Analysis of Self-efficacy and Social Support in Community Elderly Patients withHypertension. Health Educ Health Promotion. 2020;15(4):373–5. Jian Z, Kun SP, Yun ZL, Ye S, Kai Y, Jing Y, Hua ZW. Malnutrition in Relation with Dietary, Geographical, and Socioeconomic Factors among Older Chinese %J. Biomed Environ Sci. 2021;34(05):337–47. Khodabandeh M, Avarasin SM, Nikniaz L. (2017). The Relationship between Health Literacy, Perceived Self-efficacy and Self-care Performance of Female Senior High School Students in Health Promoting Schools of Miyaneh, 2016–2017 . Leung KK, Chen CY, Lue BH, Hsu ST. Social support and family functioning on psychological symptoms in elderly Chinese. Archives Gerontol Geriatr. 2007;44(2):203–13. Li S, Cui G, Xu H. (2023). Revision of brief health literacy assessment scale among the older adults and its reliability and validity test. [老年人简短健康素养评估量表的修订及信效度检验.]. Zhong nan da xue xue bao. Yi xue ban = Journal of Central South University. Medical sciences, 48 (1), 123–129. http://doi:10.11817/j.issn.1672-7347.2023.220011 Liqun F. Analysis of the impact of health literacy intervention on self-care and physical and mental health of the elderly. China Health Care Nutr. 2020;30(7):177. Liu J, Xu W, Zhu J, Zhao Y, Xiao M, Zhao Q. The status and influencing factors of malnutrition among the institutionalized elderly. [养老机构老年人营养不良现状及影响因素分析]. J Nurs Sci. 2022;37(3):97–100. Liu Y, Meng H, Tu N, Liu D. The Relationship Between Health Literacy, Social Support, Depression, and Frailty Among Community-Dwelling Older Patients With Hypertension and Diabetes in China. Front Public Health. 2020;8:280. http://doi:10.3389/fpubh.2020.00280 . Lukat J, Margraf J, Lutz R, Van dV, William M, Becker ES. Psychometric properties of the Positive Mental Health Scale (PMH-scale). BMC Psychol. 2016;4(1):8. Luo P, Wan J, Bian W. Chinesization and Rasch model analysis of the nutritional self-efficacy questionnaire in elderly patients with chronic eye disease. [营养自我效能量表的汉化及在老年慢性眼病患者中的Rasch模型分析]. J Nurs Sci. 2023;38(14):106–11. Michie S, Stralen MMV, West R. The Behaviour Change Wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6(1):42. Ning C. -01-20). Steady economic performance in 2024 and successful achievement of major development goals. China Information Daily; 2025. Oi Yuling GH, Xiumin hang, et al. Mental health status quo of elderly in urban communities and its influencing factors. Chin Nurs Res. 2017;31(1):26–8. Osborn CY, Paasche-Orlow MK, Bailey SC, Wolf MS. The mechanisms linking health literacy to behavior and health status. Am J Health Behav. 2011;35(1):118–28. http://doi:10.5993/ajhb.35.1.11 . Pang F, Zhao J, Su Y, Guan R. Empathy and Geriatric Depression: Mediating of Perceived Social Support and Resilience. [老年人共情能力与抑郁:领悟社会支持和心理弹性的多重中介作用]. Chin J Clin Psychol. 2019;27(2):330–3. Pingping L, Rui S, Jun G, Shan J, Hui L. (2018). Correlation between nutritional status, dietary self-efficacy and mental health of hospitalized elderly patients with chronic diseases. Technological Trend, 34 . Rui Y, Shoumei Z, Xinxin Z, Yumei L. Factors Associated with Older Adults' Intention to Use Community-based Elderly Care: a Study Using the Decision Tree and Logistic Regression Models. Chin Gen Pract. 2022;25(1):87–93. Shamsalinia A, Ghadimi R, Chafjiri RT, Norouzinejad F, Pourhabib A, Ghaffari F. Nutrition self-efficacy assessment: designing and psychometric evaluation in a community-dwelling elderly population. J Health Popul Nutr. 2019;38(1):38. http://doi:10.1186/s41043-019-0203-3 . Sheiham A, Steele JG, Marcenes W, Lowe C, Finch S, Bates CJ, Walls AW. The relationship among dental status, nutrient intake, and nutritional status in older people. J Dent Res. 2001;80(2):408–13. http://doi:10.1177/00220345010800020201 . Shiping lYY. The Research on the Status of Social Support of Medical Students. J Jinzhou Med Univ. 2012;33(3):263–5. Shrout PE, Bolger N. Mediation in experimental and nonexperimental studies: new procedures and recommendations. Psychol Methods. 2002;7(4):422–45. Tavakoly Sany SB, Ahangari H, Rasoulifar A, Salimi M, Jamali J, Tehrani H. Nutrition self-efficacy intervention to improve nutritional status of Iranian older adults. J Health Popul Nutr. 2024;43(1):22. http://doi:10.1186/s41043-024-00519-1 . Terp R, Kayser L, Lindhardt T. It is not rocket science. - Older peoples' understanding of nutrition - A qualitative study. Appetite. 2021;156:104854. http://doi:10.1016/j.appet.2020.104854 . The L. Population ageing in China: crisis or opportunity? Lancet. 2022;400(10366):1821. http://doi:10.1016/s0140-6736(22)02410-2 . Wahlqvist ML. Dietary fat and the prevention of chronic disease. Asia Pac J Clin Nutr. 2005;14(4):313–8. Yaru J, Huaxin S, Xiaoxia Q, Xiaoyu T, Na L, Lijuan D, Cuili W. The Moderating Effect of Residence Style on the Relationship between Social Support and Depression in Widowed Elderly Women. Chin J Gerontol. 2018;38(22):5557–60. Yongbing L, Ping T, Chu CY, Liu Q, Yanfei LL, Yuhua L. A Typical Correlation Analysis of Health Literacy and Social Support among Older Adults in Nursing Institutions. Chin J Gerontol. 2017;37(3):726–8. Zhang H, Zhang X, Guo S. Relationship between mental health and social support in elderly people living alone. [独居老年人心理健康状况与社会支持关系]. China Public Health. 2010;26(4):466–7. Zhaojing L, Bin L. Consumption Structure in Urban and Rural Areas and Self-Rated Health of the Elderly: A Survey Based on Chinese General Social. Surv %J Sustain. 2021;13(20):11530–11530. Zimet GD, Powell SS, Farley GK, Werkman S, Berkoff KA. Psychometric characteristics of the Multidimensional Scale of Perceived Social Support. J Pers Assess. 1990;55(3–4):610–7. http://doi:10.1080/00223891.1990.9674095 . Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7113698","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":511202195,"identity":"b901e2c4-4a0c-4fb9-b90e-1ba6966bf232","order_by":0,"name":"Zhanghao Pei","email":"","orcid":"","institution":"Zhengzhou University","correspondingAuthor":false,"prefix":"","firstName":"Zhanghao","middleName":"","lastName":"Pei","suffix":""},{"id":511202196,"identity":"8b22836c-5994-4047-8948-bb2df4d2ab65","order_by":1,"name":"Suyan Chen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3UlEQVRIiWNgGAWjYDACCRiDvQFMMTYQr4XnAMlaJBKI1MI/u/nYw59th+XNJZ8//szDYCO74QDzswd4LblzLN2Yt+2w4c7ZCQnGPAxpxhsOsJkb4NNiIJFjJs3Ydphxw+2EA8k8DIcTNxzgYZPAryX/myTQYfYbbh5sOMzD8J8YLTlsEkCHJW64wczYzMNwgLAWiRtpZtI859KTN5xJY2acY5BsPPMwmxleLfwzkp9J/iiztt1w/PjjD28q7GT7jjc/w6sFCpph7gRiZiLUA0EdccpGwSgYBaNgZAIA009IiGGqTsEAAAAASUVORK5CYII=","orcid":"","institution":"Zhengzhou University","correspondingAuthor":true,"prefix":"","firstName":"Suyan","middleName":"","lastName":"Chen","suffix":""},{"id":511202197,"identity":"f248f924-e039-4080-aed6-39a72871975d","order_by":2,"name":"Zhenxiang Zhang","email":"","orcid":"","institution":"Zhengzhou University","correspondingAuthor":false,"prefix":"","firstName":"Zhenxiang","middleName":"","lastName":"Zhang","suffix":""},{"id":511202198,"identity":"e91eb23f-51fa-4353-a58a-22bbcdee9df7","order_by":3,"name":"Yipu Sai","email":"","orcid":"","institution":"Zhengzhou University","correspondingAuthor":false,"prefix":"","firstName":"Yipu","middleName":"","lastName":"Sai","suffix":""},{"id":511202199,"identity":"6916a6a6-4bad-4c4b-b7f2-719784af7742","order_by":4,"name":"Yongxia Mei","email":"","orcid":"","institution":"Zhengzhou University","correspondingAuthor":false,"prefix":"","firstName":"Yongxia","middleName":"","lastName":"Mei","suffix":""}],"badges":[],"createdAt":"2025-07-13 13:53:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7113698/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7113698/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":91116062,"identity":"2c301004-a5cd-4eb5-a3cb-814e3591f0f6","added_by":"auto","created_at":"2025-09-11 17:37:49","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":28787,"visible":true,"origin":"","legend":"\u003cp\u003eStructural equation modeling: c: the relationship between health literacy and nutritional self-efficacy; a1: the relationship between health literacy and navigational social support; b1: the relationship between navigational social support and nutritional self-efficacy; a2: the relationship between health literacy and positive mental health; b2: the relationship between positive mental health and nutritional self-efficacy; and d1: the relationship between navigational social support and positive mental health.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7113698/v1/cf7f321daf3a0df9d2593a48.png"},{"id":91115299,"identity":"9f493736-000a-4753-9f0c-c741c9e9adfa","added_by":"auto","created_at":"2025-09-11 17:21:49","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":91966,"visible":true,"origin":"","legend":"\u003cp\u003eChain mediation model of older adults' perceived social support and positive mental health in the relationship between health literacy and nutritional self-efficacy\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7113698/v1/384f9737d45d998a47e16b21.png"},{"id":91116492,"identity":"0eb7134a-a453-4a85-8b7a-ae8819db81f7","added_by":"auto","created_at":"2025-09-11 17:45:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1090133,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7113698/v1/ad7da050-20b8-45c5-a5a6-0f0e87b88d14.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Health literacy and nutritional self-efficacy in older adults: the chain- mediating role of perceived social support and positive mental health","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eWith the rapid development of the aging population, China's elderly population is expected to reach 310\u0026nbsp;million by 2024, accounting for 22.0% of the total population (Ning, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2025\u003c/span\u003e-01-20). Due to aging, individual body functions deteriorate, predisposing to adverse health outcomes such as increased risk of chronic disease onset, and older adults are usually exposed to greater nutritional risks (The, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Studies have shown that more than 70% of older adults in China have inadequate nutritional intake, poor nutritional attitudes, and poor nutritional status (Jian et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). In addition, chronic diseases such as hypertension, diabetes, and obesity suffered by middle-aged and older adults are diet-related (Wahlqvist, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). Therefore, nutritional factors underlie many factors contributing to older adults' health problems. Due to the limited access to nutritional information for older adults and the influence of traditional dietary concepts, nutritional cognition and self-efficacy in this population are severely hampered (J. Liu et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Terp, Kayser, \u0026amp; Lindhardt, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Nutritional self-efficacy is defined as an individual's confidence in his or her ability to achieve the nutritional behavioral goals required in a given domain and predicts nutritional behavior (Shamsalinia et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Reduced nutritional self-efficacy can be a risk factor for older adults in coping with nutritional challenges by hindering their access to effective nutritional information and reducing their ability to make sound nutritional decisions (Luo, Wan, \u0026amp; Bian, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHealth literacy is predictive of self-efficacy and enables individuals to evaluate their self-behavior correctly(Osborn, Paasche-Orlow, Bailey, \u0026amp; Wolf, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Studies have pointed out that improving the level of health literacy in older adults can effectively improve social support (Yongbing et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2017\u003c/span\u003e); in addition, Bandura's self-efficacy theory suggests that self-efficacy is influenced by social support such as verbal persuasion, especially from others or from those in authority (Bandura, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e1986\u003c/span\u003e), which further indicates that good perceived function of social support and the quality of social support can enhance self-efficacy. There is a positive correlation between the two (Al-Dwaikat, Rababah, Al-Hammouri, \u0026amp; Chlebowy, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The results of Li Pingping's study indicate that psychological state and nutritional status are mutually influential; depression will lead to malnutrition in older people, and malnutrition will aggravate psychological depression, forming a vicious circle (Pingping, Rui, Jun, Shan, \u0026amp; Hui, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), while health literacy intervention can effectively improve the physical and mental health of older people (Liqun, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). A good psychological state is an important basis for ensuring nutritional absorption. Studie (Leung, Chen, Lue, \u0026amp; Hsu, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2007\u003c/span\u003e) has shown that family is an important source of social support for older adults, and psychological symptoms are negatively correlated with family involvement. Older adults with higher levels of family involvement have fewer psychological symptoms and better mental health, which in turn suggests that good levels of social support have a facilitating effect on mental health (Shiping, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Zhaojing \u0026amp; Bin, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), and the two may have a chain-mediated impact on health literacy and nutritional self-efficacy. Previous studies have confirmed that health literacy, perceived social support, and positive mental health are independent influences on nutritional self-efficacy in older adults. Still, fewer studies have explored the intrinsic links between these variables. Given this, the present study aimed to explore the relationships among health literacy, perceived social support, positive mental health, and nutritional self-efficacy of older adults by constructing a chain mediation model, to elucidate their internal interaction mechanisms, and provide a theoretical basis for improving nutritional self-efficacy of older adults.\u003c/p\u003e\u003cp\u003e\u003cb\u003eQuestions and assumptions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIt has not been demonstrated that navigating social support and positive mental health has a moderating effect on nutritional self-efficacy and health literacy in older adults. In this study, a chain mediation model was used to assess the direct and indirect roles of health literacy and nutritional self-efficacy. The COM-B model (Michie, Stralen, \u0026amp; West, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) describes the interactions between behavior, ability, opportunity, and motivation. It is evident that health literacy is closely related to navigating social support and promoting positive mental health, and that health literacy reinforces intrinsic drives to achieve more comprehensive and lasting behavioral change. Based on the social support theory (Cobb \u0026amp; Sidney, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e1976\u003c/span\u003e) and the health belief theory model (Dharani et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), the direct impact of health literacy on self-efficacy and the role of appreciative social support on positive mental health is evident. We therefore hypothesize that appreciative social support and positive mental health in older adults may play an important role in the relationship between health literacy and nutritional self-efficacy (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Research subjects\u003c/h2\u003e\u003cp\u003eFrom July to December 2024, 265 older adults who met the inclusion criteria in five communities in Zhengzhou City, Henan Province, were selected as the survey subjects using the convenience sampling method. Inclusion criteria: (1) age\u0026thinsp;\u0026ge;\u0026thinsp;60 years old; (2) normal reading, writing, and language comprehension and communication skills; able to complete the questionnaire on their own or under the guidance of the researcher; (3) informed consent and voluntary participation in this study. Exclusion criteria: (1) People with mental illness and serious cognitive dysfunction; (2) People with other serious physical illnesses who cannot cooperate to complete the survey.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Sample size calculation\u003c/h2\u003e\u003cp\u003eThe questionnaire in this study contains general information, the short-form Mandarin health literacy scale, a perceived social support scale, a positive mental health scale, and a nutritional self-efficacy questionnaire, according to the sample size standard of 5\u0026ndash;10 times the number of independent variables. A total of 16 independent variables were included in this study, and the sample size was calculated as 160, taking into account 20% of invalid questionnaires. 16*10/(1-0.20)\u0026thinsp;=\u0026thinsp;200, and a final sample size of 256 older adults was included in this study.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Research tools\u003c/h2\u003e\u003cdiv id=\"Sec6\" class=\"Section3\"\u003e\u003ch2\u003e2.3.1 General information questionnaire\u003c/h2\u003e\u003cp\u003eThe general information questionnaire was designed by the researcher himself according to the purpose of the study, including gender, age, place of residence, education level, marital status, per capita monthly income of the family, and the presence or absence of chronic diseases of the elderly.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section3\"\u003e\u003ch2\u003e2.3.2 The short-form health literacy assessment scale\u003c/h2\u003e\u003cp\u003eThe short-form health literacy assessment scale (Chung, Chen, Peng, \u0026amp; Chi, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) (s-MHLS) was developed by Taiwanese scholars to assess the self-perceived health literacy of older adults and was later revised by Li Shaojie et al. (Li, Cui, \u0026amp; Xu, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) for use in community-based health literacy surveys of older adults. The short-form health literacy assessment scale (s-MHLS) has a one-way structure with 10 items and uses a 5-point Likert scale, with \u0026ldquo;strongly disagree\u0026rdquo; to \u0026ldquo;strongly agree\u0026rdquo; assigned a score of 1 to 5, respectively. The total score was 10\u0026ndash;50, and the higher the total score, the better the health literacy. The Cronbach's α coefficient of the scale in this study was 0.831.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section3\"\u003e\u003ch2\u003e2.3.3 Chinese version of Nutrition Self-Efficacy Questionnaire (NSEQ)\u003c/h2\u003e\u003cp\u003eThe Nutrition Self-Efficacy Questionnaire (NSEQ) was developed by Shamsalinia et al. (Shamsalinia et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) and later translated into Chinese by Luo Peilin (Luo et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), including 29 items in 3 dimensions, namely, adherence efficacy (14 items), preventive behaviors (10 items), and information effectiveness (5 items). Likert 5 scale, from \u0026ldquo;completely disagree\u0026rdquo; to \u0026ldquo;completely agree,\u0026rdquo; 5 options, in order of 1\u0026ndash;5 points, with a total score of 29\u0026ndash;145; the higher the score, the higher the nutrition self-efficacy. In this study, the total Cronbach's α of the scale was 0.905, and the Cronbach's α of each dimension was 0.791, 0.789, and 0.831.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section3\"\u003e\u003ch2\u003e2.3.4 Perceived Social Support Scale (PSSS)\u003c/h2\u003e\u003cp\u003eThe perceived Social Support Scale (PSSS), compiled by Zimet (Blumenthal et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e1987\u003c/span\u003e) et al. and revised by Jiang Qianjin (Zimet, Powell, Farley, Werkman, \u0026amp; Berkoff, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e1990\u003c/span\u003e), is an instrument for measuring individuals' self-perception of multidimensional social support, which includes family support (entries 3, 4, 8, 11), friends support (entries 6, 7, 9, 12), and significant others support (entries 1, 2, 5, 10) 3 dimensions, a total of 12 entries, using a 7-point scale (1 to 7 points), a total score of 12 to 84, the higher the score the higher the comprehension of the social support, 12 to 36 points is a low level of support, 37 points to 60 points is an intermediate level of support, 61 points to 84 points is a high level of support. The total Cronbach's α of the scale in this study was 0.906, and the Cronbach's α of each dimension was 0.839, 0.821, and 0.821.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section3\"\u003e\u003ch2\u003e2.3.5 Chinese version of the Positive Mental Health Scale (PMHS)\u003c/h2\u003e\u003cp\u003eThe Positive Health Mental Scale (PMHS) was developed by German scholar Lukat (Lukat, Margraf, Lutz, Van, \u0026amp; Becker, 2016) by the definition of PMH as screening the entries from a library of standardized entries and finally forming a nine-item positive mental health scale. After that, our scholar Ding Tengyun et al (Ding, Wu, \u0026amp; Li, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) translated and modified it into a Chinese version of the scale according to the national conditions of China, and the study verified that the Chinese version of the PMHS has good validity and reliability in the Chinese cultural context. The scale is rated on a 4-point scale, from \u0026ldquo;strongly disagree\u0026rdquo; to \u0026ldquo;strongly agree,\u0026rdquo; with a total score of 9\u0026ndash;36. The Cronbach's α coefficient of the Chinese version of the PMHS in this study was 0.912.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Data collection\u003c/h2\u003e\u003cp\u003eThis study adopts a face-to-face method to collect data. The investigators were uniformly trained before the survey, including the purpose of the survey, the language of communication in the survey, the problems that might be encountered in the survey, how to deal with them, and the on-site verification of the survey questionnaire. Team members were required to obtain informed consent from the study subjects before the scale collection and explain the method of filling out the scale and the precautions to be taken. Team members guide the research subjects to fill in the questionnaire independently. If they are unable to fill in the questionnaire, the team members will collect the information in the form of questions and answers, but they shall not intervene in their choices to fully ensure the authenticity and validity of the data. At the end of the survey, the completeness and standardization of the scale were checked on-site, and the questionnaires with no missing items and consistent logic were recorded as valid questionnaires.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e2.5 Statistical methods\u003c/h2\u003e\u003cp\u003eSPSS 21.0 statistical software was used to analyze the data; non-normally distributed information was expressed by [\u003cem\u003eM\u003c/em\u003e (\u003cem\u003eP\u003c/em\u003e25, \u003cem\u003eP\u003c/em\u003e75)], and comparisons between groups were made by the Mann-Whitney \u003cem\u003eU\u003c/em\u003e test or the Kruskal-Wallis test; correlation analyses between two variables were performed by Spearman's rank correlation analysis; and analyses of factors influencing the nutritional self-efficacy of elderly people were performed by multiple linear regression analysis. Differences were considered statistically significant at \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003cp\u003eAMOS 24.0 software was used to establish the chain mediation model in this study. Mediation effects were tested using the Bootstrap method with a sample size of 5000, and a mediating effect was indicated when the 95% \u003cem\u003eCI\u003c/em\u003e did not include zero. Partial mediation models are determined by the criterion that the independent variable in the model can affect the dependent variable directly or indirectly through the mediating variable (Shrout \u0026amp; Bolger, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2002\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e3.1 General condition of the elderly and scores of s-MHLS, PSSS, PMHS, NSEQ\u003c/h2\u003e\u003cp\u003eA total of 265 questionnaires were distributed in this study, and 256 valid questionnaires were recovered, with a valid recovery rate of 96.6%. The age of the study participants ranged from 60 to 92 years old, with a mean age of (68.3\u0026thinsp;\u0026plusmn;\u0026thinsp;6.6) years. s-MHLS, PSSS, PMHS, and NSEQ scores averaged (34.7\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9), (61.1\u0026thinsp;\u0026plusmn;\u0026thinsp;14.0), (27.1\u0026thinsp;\u0026plusmn;\u0026thinsp;6.5), and (100.3\u0026thinsp;\u0026plusmn;\u0026thinsp;18.6). s-MHLS, PSSS, PMHS, and NSEQ scores. The mean scores for the friends support, family support, and significant others support sub-dimensions of the PSSS were (21.52\u0026thinsp;\u0026plusmn;\u0026thinsp;5.51), (19.73\u0026thinsp;\u0026plusmn;\u0026thinsp;5.21), and (19.89\u0026thinsp;\u0026plusmn;\u0026thinsp;5.47); and the mean scores for the adherence efficacy, preventive behaviors, and information effectiveness sub-dimensions of the NSEQ were (47.91\u0026thinsp;\u0026plusmn;\u0026thinsp;10.00), (35.54\u0026thinsp;\u0026plusmn;\u0026thinsp;7.80), and (16.83\u0026thinsp;\u0026plusmn;\u0026thinsp;4.41) points, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eHealth Literacy, Nutritional Self-Efficacy, Perceived Social Support, and Positive Mental Health Scores of Older Adults (n\u0026thinsp;=\u0026thinsp;256)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRange of score\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eScore (x ̅\u0026plusmn;s)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth literacy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10\u0026thinsp;~\u0026thinsp;50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e34.70\u0026thinsp;\u0026plusmn;\u0026thinsp;7.94\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerceived Social Support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12\u0026thinsp;~\u0026thinsp;84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e61.14\u0026thinsp;\u0026plusmn;\u0026thinsp;13.97\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFamily support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u0026thinsp;~\u0026thinsp;28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e21.52\u0026thinsp;\u0026plusmn;\u0026thinsp;5.51\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFriends support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u0026thinsp;~\u0026thinsp;28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e19.73\u0026thinsp;\u0026plusmn;\u0026thinsp;5.21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSignificant others support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u0026thinsp;~\u0026thinsp;28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e19.89\u0026thinsp;\u0026plusmn;\u0026thinsp;5.47\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePositive mental health\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10\u0026thinsp;~\u0026thinsp;40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e27.15\u0026thinsp;\u0026plusmn;\u0026thinsp;6.50\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNutrition self-efficacy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29\u0026thinsp;~\u0026thinsp;145\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e100.28\u0026thinsp;\u0026plusmn;\u0026thinsp;18.59\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdherence efficacy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14\u0026thinsp;~\u0026thinsp;70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e47.91\u0026thinsp;\u0026plusmn;\u0026thinsp;10.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePreventive behavior\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10\u0026thinsp;~\u0026thinsp;50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e35.54\u0026thinsp;\u0026plusmn;\u0026thinsp;7.80\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInformation effectiveness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u0026thinsp;~\u0026thinsp;25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e16.83\u0026thinsp;\u0026plusmn;\u0026thinsp;4.41\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Comparison of NSEQ scores of older adults with different characteristics\u003c/h2\u003e\u003cp\u003eThe results of the study showed that the NSEQ scores of males were lower than those of females, and the differences were statistically significant when comparing the NSEQ scores of elderly people with different levels of literacy, per capita household income, and the presence or absence of chronic illnesses (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and there was no statistically significant difference when comparing the NSEQ scores of elderly people with different genders, places of residence, and marital status (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), as shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of NSEQ scores for older adults with different characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGroup\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eM\u003c/em\u003e(\u003cem\u003eP\u003c/em\u003e25, \u003cem\u003eP\u003c/em\u003e75)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003eZ\u003c/em\u003e/\u003cem\u003eH\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e144\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e56.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e102.0(85.5, 110.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-1.82\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.069\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e112\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e43.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e103.0(93.0, 116.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003ePlace of residence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLarge and medium-sized cities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e146\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e57.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e103.0(92.0, 115.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e7.278\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e0.064\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSuburban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e22.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e104.0(88.0, 110.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCounty and town municipalities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e11.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e89.0(76.0, 106.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e105.0(91.0, 118.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003eEducational level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIlliterate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e11.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e87.0(74.5, 106.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003e18.034\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003e0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eElementary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e22.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e105.0(89.25, 116.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSecondary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e30.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e107.0(96.0, 114.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHigh school/middle school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e25.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e95.0(89.0, 1105.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCollege/Undergraduate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e109.0(91.0, 121.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGraduate and above\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e103.0(84.0, 121.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eMarital status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e206\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e80.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e103.0(90.8, 113.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e6.191\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e0.103\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnmarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e13.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e96.0(81.0, 108.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDivorced\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e103.0(93.0, 110.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWidow\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e118.0(90.0, 124.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eMonthly income\u003c/p\u003e\u003cp\u003e(RMB)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;2000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e28.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e99.0(81.5, 109.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e6.613\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.037\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2000\u0026thinsp;~\u0026thinsp;5000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e103\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e40.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e105.0(94.0, 116.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;5000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e31.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e98.0(91.0, 113.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eChronic disease\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e35.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e97.0(88.0, 106.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-3.06\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e165\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e64.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e106.0(91.0, 117.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003eNote: a indicates \u003cem\u003eZ\u003c/em\u003e-value; b indicates \u003cem\u003eH\u003c/em\u003e-value\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Correlation analysis of health literacy, PSSS, PMHS, and NSEQ in older adults\u003c/h2\u003e\u003cp\u003eThe results of Spearman correlation analysis showed that health literacy was positively correlated with NSEQ, PSSS, and PMHS (r\u0026thinsp;=\u0026thinsp;0.646, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; r\u0026thinsp;=\u0026thinsp;0.505, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; r\u0026thinsp;=\u0026thinsp;0.401, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001); PSSS was positively correlated with NSEQ and PMHS (r\u0026thinsp;=\u0026thinsp;0.589, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; r\u0026thinsp;=\u0026thinsp;0.508, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001); PMHS was positively correlated with NSEQ (r\u0026thinsp;=\u0026thinsp;0.536, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), as shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eResults of correlation analysis of health literacy, PSSS, PMHS, and NSEQ among older adults\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHealth literacy\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePerceived social support\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePositive mental health\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNutritional self-efficacy\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth literacy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerceived social support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.505***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePositive mental health\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.401***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.508***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNutritional self-efficacy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.646***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.589***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.536***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e*** \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e3.4 Mediation analysis of the effect of health literacy on nutritional self-efficacy among older adults\u003c/h2\u003e\u003cp\u003eThe chain mediation model was established, and the model fitting indexes were:χ2/df\u0026thinsp;=\u0026thinsp;4.335, GFI\u0026thinsp;=\u0026thinsp;0.941, NFI\u0026thinsp;=\u0026thinsp;0.0.930, IFI\u0026thinsp;=\u0026thinsp;0.946, TLI\u0026thinsp;=\u0026thinsp;0.903, and CFI\u0026thinsp;=\u0026thinsp;0.945; and RMSEA\u0026thinsp;=\u0026thinsp;0.114, which was poorly fitted. Therefore, the Bollen-Stine method was used to correct the model. After 5000 Bootstrap sampling corrections the model χ2/df\u0026thinsp;=\u0026thinsp;1.296, GFI\u0026thinsp;=\u0026thinsp;0.979, NFI\u0026thinsp;=\u0026thinsp;0.979, IFI\u0026thinsp;=\u0026thinsp;0.995, TLI\u0026thinsp;=\u0026thinsp;0.991, CFI\u0026thinsp;=\u0026thinsp;0.995; RMSEA\u0026thinsp;=\u0026thinsp;0.034, the model fit was good. As shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, the explicit variable factor loadings for the latent variables comprehension, social support, and positive mental health were all \u0026gt;\u0026thinsp;0.5.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003e3.5 Mediation effect test\u003c/h2\u003e\u003cp\u003eAs shown in Table\u0026nbsp;4, the 95% \u003cem\u003eCI\u003c/em\u003e of each mediating path did not include 0, and the mediating effect was significant. The total effect of health literacy on nutritional self-efficacy was significant [\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.763, 95% \u003cem\u003eCI\u003c/em\u003e (0.641, 0.871), \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001]; the mediating effect of the indirect effect of health literacy on nutritional self-efficacy, the mediating effect of perceived social support, and positive mental health was significant [\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.265, 95% \u003cem\u003eCI\u003c/em\u003e (0.180, 0.368), \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001]; The direct effect of health literacy on nutritional self-efficacy was significant [\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.498, 95% \u003cem\u003eCI\u003c/em\u003e (0.262, 0.511), \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001]. The model was a partial mediation model.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;4 Bootstrap Analysis of Health Literacy, Perceived Social Support, and Positive Mental Health on Nutritional Self-Efficacy in Older Adults\u003c/p\u003e\u003c/div\u003e\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eModel pathway\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePoint estimate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e95%\u003cem\u003eCL\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eSE\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eZ\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal effect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHL → NSE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.763\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e（0.641,0.871）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.058\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13.155\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIndirect effect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.265\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e（0.180,0.368）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.049\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.408\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHL → PSS → NSE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.136\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e（0.055,0.246）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.048\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.833\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHL → PMH → NSE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.077\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e（0.030,0.151）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.029\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.655\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHL → PSS → PMH → NSE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.051\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e（0.023,0.102）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.684\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDirect effect\u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHL → NSE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.498\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e（0.262,0.511）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.059\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.441\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: HL, Health literacy; NSE, Nutritional self-efficacy; PSS, Perceived social support; PMH, Positive mental health.\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe health literacy score of the elderly in this study was (34.70±7.94), which was lower than the findings of Chung et al (Chung et al., 2015) and may be related to the lower education level of the included population (65.63% in junior high school and below) and the higher percentage of elderly with chronic diseases (65.63% in junior high school and below).\u003c/p\u003e\n\u003cp\u003eStudie (Tavakoly Sany et al., 2024) has shown that older adults with high nutritional self-efficacy have greater ability and confidence to achieve nutritional behaviors, as well as set higher goals, become more engaged, and thus are more likely to achieve nutritional behaviors. The nutritional self-efficacy score in this study was (100.28±18.59), which is higher than the findings of Tavakoly Sany et al (Tavakoly Sany et al., 2024). This may be related to the nutritional knowledge base of older adults, who are not limited to acquiring nutritional knowledge on their own but are also influenced by their families, friends, and society, and increasing the nutritional knowledge of older adults is conducive to the realization of healthy eating behaviors. Secondly, older adults' attitudes toward healthy eating affect food choices, and increasing attitudes toward healthy eating can help them make better food choices, develop healthier eating habits, and contribute to nutritional self-efficacy.\u003c/p\u003e\n\u003cp\u003eThe results of this study showed that the elderly's perceived social support score was (61.14±13.97), which was at a medium level, and the score was slightly lower than the results of the study by Pang Fangfang et al (Pang, Zhao, Su, \u0026amp; Guan, 2019). At present, the source of social support for the elderly in China's community is relatively single, mostly originating from the family, with a lack of support from friends, resulting in a loose social network and insufficient social support available (Rui, Shoumei, Xinxin, \u0026amp; Yumei, 2022). Due to the decline of physical function and self-care ability of the elderly, their dependence on their family members increases, while the actual support provided by their children is insufficient because of their work and life. Thus, the elderly feel less supported by their families, resulting in a slightly lower level of perceived social support.\u003c/p\u003e\n\u003cp\u003eThe positive mental health score of the elderly in this study was (27.15±6.50), which is slightly lower than the findings of Lukat et al (Lukat et al., 2016), and there is room for further improvement. The positive mental health status of the elderly is influenced by many factors such as educational level, social relationship status, residential status, and physical health status (Oi Yuling, 2017). In this study, older adults with a high level of education (high school or middle college or above) scored higher; older adults with good marital status scored higher; and older adults without chronic diseases scored higher. With the development trend of population aging, urbanization, and intergenerational separation of living styles, there are more and more empty nesters or elderly people living alone. It is difficult to satisfy the emotional and spiritual comfort needs of the elderly, and their mental health is in a worrying situation (Zhang, Zhang, \u0026amp; Guo, 2010), so more attention should be paid to the mental health problems of the elderly in actual life to achieve healthy and active aging.\u003c/p\u003e\n\u003cp\u003eThis study verified the positive effect of both health literacy and nutritional self-efficacy among older adults (r=0.646, P\u0026lt;0.001), and the higher the level of health literacy, the stronger the nutritional self-efficacy, which is consistent with the findings of Darvishpour (Y. Liu, Meng, Tu, \u0026amp; Liu, 2020). Health literacy predicts self-efficacy and self-care behavior, and people with higher health literacy can have better self-efficacy and self-care behavior (Y. Liu et al., 2020). The present study showed that perceived social support was positively related to nutritional self-efficacy, which is consistent with the findings of Chu Hui (Hui, 2020). Good perceived functioning of social support and quality of social support can help to improve self-efficacy and promote changes in health behaviors (Al-Dwaikat et al., 2021). Meanwhile, the improvement of self-efficacy can help to improve the mindset and mood of the elderly, which in turn can enable them to obtain more social support. The present study also showed that positive mental health is positively correlated with nutritional self-efficacy, which is in line with studies such as Tavakoly Sany (Tavakoly Sany et al., 2024). Positive psychology and self-efficacy are important psychological resources for individuals in the face of adversity, and older adults with high levels of positive psychology are more likely to develop positive self-efficacy beliefs, and there is a close intrinsic link between the two (Berdida, Lopez, \u0026amp; Grande, 2023).\u003c/p\u003e\n\u003cp\u003eOlder adults with good health literacy not only have good disease self-management ability but also can take the initiative to use social support to maintain healthy living behaviors and access to health information, and thus, better nutritional behaviors (Fields et al., 2021; Khodabandeh, Avarasin, \u0026amp; Nikniaz, 2017). The results from this study indicate that nutritional self-efficacy in older adults is strongly associated with health literacy, perceived social support, and positive mental health. The direct and indirect effects of health literacy on nutritional self-efficacy were significant, suggesting that we should not only focus on improving health literacy to enhance nutritional self-efficacy in older adults but also on changing unhealthy behaviors by improving older adults' perceptions of social support and positive mental health.\u003c/p\u003e\n\u003cp\u003eIn terms of direct effect, health literacy has a significant effect on nutritional self-efficacy, accounting for 65.27% of the total effect. Health literacy is closely related to the level of self-efficacy, health outcomes, and quality of life, and improving the health literacy of the population, enhancing self-efficacy, and changing poor lifestyles can help to improve the quality of life (Yaru et al., 2018). It is suggested that healthcare professionals can provide personalized health education and health promotion according to the different educational levels and realistic conditions of the elderly, etc., to popularize health knowledge, teach health skills, cultivate healthy behaviors and lifestyles, and take responsibility for their health, to achieve the purpose of enhancing nutritional self-efficacy and promoting individual health.\u003c/p\u003e\n\u003cp\u003eAmong the three mediating effect paths, the largest effect size was found when perceived social support was an independent mediating variable, accounting for 17.82% of the total effect. It is more confirmed that the health and diet quality of older adults is related to social support, socioeconomic status, and culture (Sheiham et al., 2001). Community healthcare workers should fully mobilize and leverage the social support resources available to the elderly during health education and chronic disease management. This will encourage the elderly to use various social supports and participate more actively in activities. Healthcare workers should also work with communities and families to build a comprehensive social support system. In this way, it will enhance the emotional attachment of the elderly, promote their self-efficacy, and continuously improve their self-health management abilities.\u003c/p\u003e\n\u003cp\u003eThis study showed that positive mental health plays a chain mediating role between health literacy and nutritional self-efficacy in older adults, with the path effect accounting for 10.09% of the total effect. Positive mental health emphasizes that mental health does not only refer to the absence of any problems but also includes the production and increase of various positive qualities and positive strengths of an individual (Cheng, Ren, \u0026amp; Ma, 2009). Focusing on the positive mental health status of the elderly can enable them to fully recognize their strengths and inspire their confidence in achieving healthy eating and other nutritional behaviors. Compared with other age groups, the elderly are more prone to some psychological problems, so attention should be paid to their positive mental health status, mobilizing their intrinsic positive energy, positively facing nutritional problems, and improving the sense of well-being and satisfaction of the elderly.\u003c/p\u003e\n\u003cp\u003eThe present study confirmed the chain mediating role played by appreciative social support and positive mental health between health literacy and nutritional self-efficacy in older adults, but the path effect value was small at 6.68%. The results of Barrera's study showed that perceived social support is the support that individuals subjectively experience, which is the subjective perception and satisfaction evaluation of respect, understanding, and support from social others (Barrera, 1986), and it is an important support for maintaining mental health (Chen, Li, Zhou, Liu, \u0026amp; Xu, 2021). GE Fang-Jun (Ge et al., 2012) found that social support contributes to mental health and also suggested that social relationships are an important determinant of mental health, with higher levels of social support being associated with better psychological status. It is suggested that family members and healthcare professionals should focus on emotional communication with older adults, strengthen psychological cognition, and maintain an optimistic mindset to better cope with the challenges posed by nutritional health problems and improve their ability and confidence in their nutritional management.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e5 Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere were several limitations in this study. First, due to the limited availability of human and time resources, the subjects of this study were selected from only a few communities in Zhengzhou City, and the sample size and survey area may be insufficient, resulting in limited sample representativeness. Second, this study is a cross-sectional survey. Causality could not be determined, so it is necessary to carry out a multicenter, large-sample longitudinal study in the future, as well as to consider factors such as organization and the environment, and to comprehensively explore the influence of nutritional self-efficacy and mechanisms to provide a theoretical basis for improving nutritional self-efficacy. In the future, multi-center and large-sample longitudinal studies should be conducted, and organizational and environmental factors should be taken into account to comprehensively explore the factors and mechanisms of nutritional self-efficacy to provide a theoretical basis for improving nutritional self-efficacy in the elderly.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThe results of this study show that the nutritional self-efficacy of the elderly is at a moderate level. Health literacy not only directly affects the nutritional self-efficacy of the elderly but also positively affects nutritional self-efficacy through the realization of social support and positive mental health. Older adults should strengthen the acquisition of health information and effective communication, improve their own health literacy and knowledge of chronic diseases, maintain a positive psychology, and positively perceive social support to improve the quality of life and health of older adults.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank all the investigators and participants of this study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere are no conflicts of interest declared by the author(s).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy proposal: Zhanghao Pei, Suyan Chen, Zhenxiang Zhang; Data collection: Zhanghao Pei, Yipu Sai, Yongxia Mei; Data analysis and drafting of the manuscript: Zhanghao Pei, Yipu Sai. Approval of data analysis: Suyan Chen, Yongxia Mei; Approval of the manuscript: Suyan Chen, Zhenxiang Zhang; Read and approved the final manuscript: all authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRelevant data generated during this study are available upon reasonable request from the corresponding author. Due to privacy or ethical restrictions, these data are not publicly available.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe ZZU University Ethics Committee reviewed and approved the work (ZZURIB2024127). The authors state all participants were informed of the purpose of the study and provided informed consent. All procedures were carried out in compliance with the rules and regulations set by the Department of Scientific Research at ZZU University, and participants' privacy and human rights were protected through the use of anonymous data collection.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAl-Dwaikat TN, Rababah JA, Al-Hammouri MM, Chlebowy DO. Social Support, Self-Efficacy, and Psychological Wellbeing of Adults with Type 2 Diabetes. West J Nurs Res. 2021;43(4):288\u0026ndash;97. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://doi:10.1177/0193945920921101\u003c/span\u003e\u003cspan address=\"http://doi:10.1177/0193945920921101\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBandura A. Social foundations of thought and action: a social cognitive theory /. 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J Pers Assess. 1990;55(3\u0026ndash;4):610\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://doi:10.1080/00223891.1990.9674095\u003c/span\u003e\u003cspan address=\"http://doi:10.1080/00223891.1990.9674095\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Health literacy, Nutritional self-efficacy, Perceived social support, Positive mental health, Mediation analysis, Chain mediation","lastPublishedDoi":"10.21203/rs.3.rs-7113698/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7113698/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e\u003cp\u003eTo explore the impact of health literacy on nutritional self-efficacy in older adults and the chain-mediated effects of perceived social support and positive mental health between the two.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA total of 265 older adults who met the inclusion criteria in five communities in Zhengzhou City, Henan Province, from July to December 2024 were selected as survey respondents. Questionnaires were administered using the General Information Questionnaire, the short-form Mandarin Health Literacy Scale (s-MHLS), the Nutritional Self-Efficacy Questionnaire Chinese version (NSEQ), the Perceived Social Support Scale (PSSS), and the Positive Mental Health Scale Chinese version (PMHS). Spearman correlation analysis was used to explore the correlation between the variables, AMOS 24.0 software was used to construct the chain mediation model, and the Bootstrap method was used to test the chain mediation model.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe nutritional self-efficacy score of older adults was (100.28\u0026thinsp;\u0026plusmn;\u0026thinsp;18.59), and there was a correlation between health literacy, nutritional self-efficacy, perceived social support, and positive mental health (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The mediation model showed that the direct effect of health literacy on nutritional self-efficacy was significant in older adults, and health literacy also indirectly affected nutritional self-efficacy through perceived social support (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.136, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and positive mental health (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.077, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Perceived social support and positive mental health acted as chain mediators between health literacy and nutritional self-efficacy (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.051, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with the total indirect effect accounting for 34.73% of the total effect.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eNutritional self-efficacy among older adults is at an intermediate level. Perceived social support and positive mental health play a mediating role between health literacy and nutritional self-efficacy in older adults. Healthcare professionals and related personnel should pay attention to educating the elderly on health literacy, popularizing knowledge of diseases, and improving their nutritional self-efficacy by enhancing their ability to appreciate social support and maintain positive mental health.\u003c/p\u003e","manuscriptTitle":"Health literacy and nutritional self-efficacy in older adults: the chain- mediating role of perceived social support and positive mental health","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-11 17:21:44","doi":"10.21203/rs.3.rs-7113698/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"170299626742389657161892429143105836986","date":"2025-09-06T14:43:47+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-04T09:50:21+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-13T13:49:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-25T06:58:51+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-24T10:55:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Geriatrics","date":"2025-07-24T10:51:52+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a02ef1cf-7ef7-4dbe-8203-1e27620a1b0f","owner":[],"postedDate":"September 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-11T17:21:45+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-11 17:21:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7113698","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7113698","identity":"rs-7113698","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}