The Mediating Role of Health Literacy in the Effect of Living in Rural Versus Urban Areas in Older Adults on Successful Aging

The Mediating Role of Health Literacy in the Effect of Living in Rural Versus Urban Areas in Older Adults on Successful Aging | 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 The Mediating Role of Health Literacy in the Effect of Living in Rural Versus Urban Areas in Older Adults on Successful Aging HATICE SELİN IRMAK, MELEK SENA ÇATALBAŞ This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8946273/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives This study investigates the mediating role of health literacy in the relationship between living environments (rural/urban) and successful aging among older adults. Methods Data were collected from 400 participants aged 65 and older (51.3% women; mean age = 71.6 ± 4.3 years) residing in Sakarya Province. Participants completed a Personal Information Form, the Health Literacy Scale, and the Successful Aging Scale. Mediation analyses were conducted using regression-based approaches and bootstrapping to examine direct and indirect effects. Results Living in rural areas was associated with lower health literacy and a reduced likelihood of successful aging. Health literacy fully mediated the relationship between living environment and successful aging (β = .6953, p<.001). After including health literacy, the direct effect of living environment became non-significant, while the explained variance in successful aging increased from 2.9% to 49%. The indirect effect was significant (B = 4.28, SE = 1.01, 95% CI [2.32, 6.25]). Conclusions Higher health literacy enhances older adults’ capacity to manage chronic conditions and adopt healthier lifestyles, thereby supporting successful aging. Rural living may indirectly hinder successful aging through its negative association with health literacy. Clinical Implications : Health literacy interventions tailored to rural populations, including community-based education and digital health tools, may reduce rural–urban disparities and promote equitable successful aging outcomes. Successful aging Health literacy Urban or rural living Aging disparities Figures Figure 1 Introduction The global aging population presents significant challenges for healthcare systems and societies. Successful aging, which encompasses maintaining physical, mental, and social well-being, is a key focus in understanding how older adults can lead fulfilling lives as they age (Rowe & Kahn, 1997 ). Central to this concept is health literacy, defined as the ability to obtain, process, and understand basic health information and services necessary for making informed health decisions (Nutbeam, 2000 ). This ability is particularly crucial for older adults, who often face complex health issues and navigate intricate healthcare systems. Research has highlighted that health literacy is a mediating factor in the relationship between living environment, specifically urban versus rural living, and successful aging. The disparities in health literacy between these two settings significantly influence health outcomes among older adults. Living in urban areas is generally associated with higher health literacy levels than in rural areas (Yu et al., 2023 ). Urban environments typically offer greater access to healthcare resources, information, and services, all of which can enhance the health literacy of their residents (Amoah et al., 2022 ). In contrast, rural areas often face challenges such as limited access to healthcare facilities, fewer informational resources, and socioeconomic disadvantages that impede health literacy (Flores et al., 2023 ). Health literacy is not merely the ability to read health-related materials; it encompasses a range of skills necessary for effective health management. This includes the ability to navigate healthcare systems, comprehend medical terminology, and engage in preventive health behaviors (Berkman et al., 2011 ). Research indicates that higher health literacy levels are associated with better health outcomes, including improved management of chronic diseases, increased use of preventive services, and enhanced overall well-being (McCoy et al., 2016 ). Conversely, low health literacy can lead to poor health management, higher rates of hospitalization, and increased mortality risk, particularly among older adults (Bostock & Steptoe, 2012 ). Health literacy is not merely the ability to read health-related materials; it encompasses a range of skills necessary for effective health management. This includes the ability to navigate healthcare systems, comprehend medical terminology, and engage in preventive health behaviors (Berkman et al., 2011 ). Research indicates that higher health literacy levels are associated with better health outcomes, including improved management of chronic diseases, increased use of preventive services, and enhanced overall well-being (McCoy et al., 2016 ). Conversely, low health literacy can lead to poor health management, higher rates of hospitalization, and increased mortality risk, particularly among older adults (Bostock & Steptoe, 2012 ). Urban residents typically enjoy better health literacy due to enhanced access to resources and information, while rural residents face significant barriers that hinder their health literacy and overall health outcomes. Addressing social determinants of health, enhancing access to information, and considering cultural factors are essential strategies for improving health literacy and promoting successful aging among older adults. In this context, this study aims to determine the mediating effect of health literacy on the effect of living in rural and urban areas on successful aging. The main hypotheses of the study are as follows: H1. There are differences between living in rural areas and urban areas in terms of successful aging. H2. There are differences between living in rural areas and urban areas in terms of health literacy. H3. Health literacy has a positive effect on successful aging. H4. Health literacy mediates the relationship between living in rural or urban areas and successful aging. Methods Participants According to TURKSTAT data for 2021, the population of the study consists of 110,389 people aged 65 and over living within the borders of Sakarya province. Considering the proportion of the elderly population in the total population, it is known that the proportion of the elderly population is 9.7% in Turkey and 10.4% in Sakarya province (TÜİK, 2022). For a population between 100,000 and 1 million people, a sample size of at least 384 people is considered sufficient (Yazıcıoğlu & Erdoğan, 2004). Accordingly, to work with as many samples as possible in the study, probabilities (p) were taken as 0.5, and it was calculated that at least 384 people should be included in the study according to the sampling error of 0.05, population size and t-table critical value of 1.96, and 400 people were included in the study. A simple random sampling technique, one of the probability sampling techniques, was used to select the individuals to be included in the study. Simple Random Sampling Technique is a sampling technique in which the probability of each unit in the universe entering the sample is equal and independent of each other, and due to these characteristics, the results (if the sample size is appropriate) can be generalized to the universe (Kerlinger & Lee, 1999; Neuman, 2014). The inclusion criteria of the study were determined as being 65 years of age or older, being capable of understanding the questions and expressing their opinions, volunteering to participate in the study, and residing within the borders of Sakarya province. Measures and Data Collection Tools The data of the study were collected using face-to-face interview techniques within the borders of Sakarya province in January and February 2024. Participants who voluntarily agreed to participate in the study and met the inclusion criteria were administered the Personal Information Form, Health Literacy Scale, and Successful Aging Scale developed by the researcher. The Personal Information Form This form was developed by the researchers after reviewing the relevant literature. There are 14 questions developed to determine the descriptive characteristics of the participants, such as gender, age, marital status, educational status, place of birth, income status, family type, number of children, place of residence, and “How is your health according to you?”. Health Literacy Scale : The 47-item HLS-EU (Health Literacy Survey in Europe) form developed by Sørensen was later transformed into the Health Literacy Index (Health Literacy Index), which Toçi, Bruzari, and Sorenson reworked and simplified together. The Turkish validity and reliability study of the scale was conducted by Bayık Temel and Aras (2017). The Health Literacy Scale consists of 25 items and four subscales: Access to information includes five items (items 1–5), the minimum score to be obtained from this subscale is 5, and the maximum score is 25. Understanding information includes seven items (items 6–12), and the minimum score to be obtained from this subscale is 7, and the maximum score is 35. The Appraisal/Evaluation subscale includes eight items (items 13–20), and the minimum score for this subscale is 8, and the maximum score is 40. The Application/Using subscale also includes five items (items 21–25), and the minimum score for this subscale is 5, and the maximum score is 25. The minimum score for the whole scale is 25, and the maximum score is 125. The scale items are answered by the participants on a Likert scale as “5: I have no difficulty at all, 4: I have little difficulty, 3: I have some difficulty, 2: I have a lot of difficulty, 1: I am unable/ have no ability/ impossible”. All items of the scale are positive, and there are no reverse items. The standard deviation of the original scale is .95, and the internal consistency coefficients (Cronbach's alpha) for the subscales range between .90 and .94. Successful Aging Scale : The successful aging scale (SAS) developed by Reker consists of 3 sub-dimensions and 13 questions. These sub-dimensions are “healthy lifestyle” (1,7,8,12), “adaptive coping” (2,3,11,13), and “commitment to life” (4,5,6,9,10). Each statement was scored from 1 to 7. The scoring of the statements is as follows: strongly agree = 7, agree = 6, somewhat agree = 5, undecided = 4, somewhat disagree = 3, disagree = 2, strongly disagree = 1. The overall internal consistency reliability of the scale (SAS) is .84, the Cronbach's alpha coefficient of the “healthy lifestyle” sub-dimension is .72, the “adaptive coping” sub-dimension is .73, and the “commitment to life” sub-dimension is .75 (Reker, 2009). Data analyses The data were analyzed using SPSS version 25 and the PROCESS MacroPlug-in. Cronbach's alpha was calculated for each scale to assess internal consistency. Demographic and variable data were summarized using descriptive statistics, including mean, standard deviation, percentage, and frequencies. The analytical phase comprised correlation and mediation analyses. The direct and indirect effects of the proposed model were tested using PROCESS- Macro Model 4. All statistical tests were conducted at a significance level of .05. Ethical Aspects of the Research Before commencing the data collection process, ethical approval was obtained from [the Ethics Committee of XX], with the approval dated [Date] and numbered [Approval Number]. The study was conducted by the principles of the Declaration of Helsinki. Resuts Demographic characteristics of respondents This section includes the sociodemographic characteristics of the individuals participating in the study. The findings related to this purpose are given in Table 1 . Table 1 Descriptive Characteristics of Participants Variables Subcategories N % Gender Female 205 51.3 Male 195 48.8 Age Groups 65–74 years 278 69.5 75–84 years 81 20.3 85 + years 41 10.3 Family Type Nuclear family 264 66.0 Extended family 80 20.0 Living alone 56 14.0 Marital Status Married 287 71.8 Single 22 5.5 Widowed 91 22.8 Place of Residence Rural 200 50.0 Urban 200 50.0 Educational Level Illiterate 53 13.3 Below high school 285 71.3 High school or above 62 15.5 Income Level Low 50 12.5 Medium 232 58.0 High 118 29.5 Overall Health Good 148 37.0 Moderate 204 51.0 Poor 48 12.0 Table 1 . Descriptive Characteristics of Participants Of the participants, 51.3% were female and 48.8% were male, with 69.5% aged between 65 and 74 years. In terms of living arrangements, 66.0% lived in nuclear families, 20.0% in extended families, and 14.0% lived alone. Regarding marital status, 71.8% were married, 5.5% were single, and 22.8% had lost their spouse. As for educational background, 13.3% were illiterate, 71.3% had an education level below high school, and 15.5% had a high school or higher education level. In terms of residential areas, 50.0% lived in rural areas, and 50.0% lived in urban areas. Income levels were distributed as 12.5% low, 58.0% medium, and 29.5% high. Finally, health status was reported as 37.0% good, 51.0% moderate, and 12.0% poor. Correlation analyze Table 2 . Correlation Analysis Results Between Health Literacy Scale Scores and Successful Aging Scale Scores of Participants Living in Rural Areas and Urban Areas Table 2 Correlation Analysis Results Between Health Literacy Scale Scores and Successful Aging Scale Scores of Participants Living in Rural Areas and Urban Areas Living in Rural Areas Living in Urban Areas SAS HLS SAS HLS SAS r 1 .646 1 .740 p .000 .000 N 200 200 There is a statistically significant positive and highly strong (r=.646; p=.000) and strong (r=.740; p=.000) statistically significant relationship between the total scores of the participants living in rural areas and the total scores of the participants living in urban areas. As the total scores of the participants living in rural and urban areas increase, the total scores of the participants living in rural and urban areas also increase. Direct effects The results of direct effects are presented in Table 3 . Separate regression analyses were conducted on the proposed conceptual model at each step. Initially, the influence of independent variables on the mediatör variable, health literacy, was determined, followed by their impact on the dependent variable, successful aging. Table 3 The mediating role of health literacy in the relationship between living in rural areas or urban areas and successful aging Predictors Variable B SE β t F Adj R 2 Step 1 Living Area (Urban = 1, Rural = 0) Health Literacy 7.5700 1.7031 .4344 4.4449* 19.7570* .0473 Step 2 Living Area (Urban = 1, Rural = 0) Successful Aging 4.8500 1.3971 .3424 3.4716* 12.0519* .0294 Step 3 Health Literacy Living Area (Urban = 1, Rural = 0) Successful Aging .5651 .5722 .0298 1.0388 .6953 .0404 18.9359* .5508 190.7242* .4900 * p < .000 Table 3 . The mediating effect of health literacy in the relationship between living in rural areas or urban areas and successful aging The results of the direct effects are presented in Table 3 . A series of regression analyses were conducted to test the proposed mediation model. In the first step, the effect of the independent variable (living in rural or urban areas) on the mediator variable (health literacy) was examined. In the second step, the effect of the independent variable on the dependent variable (successful aging) was tested. Finally, in the third step, both the independent variable and the mediator were included in the model to predict successful aging. In Step 1, living in rural or urban areas had a significant effect on health literacy (β = .4344, p<.001). In Step 2, living in rural or urban areas also significantly predicted successful aging (β = .3424, p<.001). In Step 3, health literacy remained a strong and significant predictor of successful aging (β = .6953, p.05). This pattern suggests a full mediating effect of health literacy on the relationship between living environment and successful aging. Furthermore, while living in rural or urban areas alone accounted for only a small proportion of the variance in successful aging (Adjusted R²=.0294; F = 12.0519, p<.001), the inclusion of health literacy in the model increased the explained variance substantially (Adjusted R²=.4900; F = 190.7242, p<.001). The results of the proposed model are shown in Fig. 1 . Figure. 1 Mediating effect of health literacy on the relationship between living in rural areas or urban areas and successful aging Indirect effects The direct and indirect effects at each step are shown in Table 4 . Table 4 Total, direct, and indirect regression analyses on Successful Aging Effect Type B (Unstandardized Coefficient) SE 95% CI (LLCI–ULCI) Significance Total effect of living areas on Successful Aging (X → Y) 4.8500 1.3971 [2.1035, 7.5965] Significant The direct effect of living areas on Successful Aging (X → Y controlling for M) .5722 1.0388 [–1.4701, 2.6144] Not Significant Indirect path Successful Aging > Health Literacy > Living areas (X → M → Y) 4.2778 1.0063 [2.3227, 6.2505] Significant Table 4 . Total, direct, and indirect regression analyses on Successful Aging The impact of living in rural or urban areas on the mediating variable was found to be statistically significant. Specifically, health literacy significantly predicted successful aging. However, when health literacy was included in the model, the direct effect of living in rural or urban areas on successful aging became statistically non-significant. These results indicate that health literacy fully mediates the relationship between living environment and successful aging (B = 4.2778, SE = 1.0063, 95% CI [2.3227, 6.2505]). Discussion This study examines the mediating role of health literacy in the effect of living in rural areas or urban areas on successful aging. The findings suggest that both direct and indirect effects of health literacy on successful aging are significant. H1. There are differences in successful aging between individuals living in rural areas and urban areas. The results of this study supported hypothesis 1. Living in rural areas decreases the score on the successful aging scale compared to living in urban areas. Aging in both rural and urban settings presents unique advantages and disadvantages, influencing the successful aging experience. The concept of successful aging can vary significantly based on individual needs and preferences. A substantial body of literature highlights differences in the risks of chronic diseases, disabilities, mental health conditions, and social engagement among older populations based on their place of residence (Parks, Housemann & Brownson, 2003 ; Adjaye-Gbewonyo et al., 2019 ). These disparities largely arise from economic inequality, unequal access to healthcare services, and variations in participation in social activities between older adults living in urban areas and rural areas (Chatterjee, 2019 ; Laksono, Wulandari & Soedirham, 2019 ; Sun & Lyu, 2020 ; Zhou et al., 2018 ). However, findings regarding successful aging and its association with place of residence are inconsistent across different countries and populations (Ding et al., 2020 ; Lindeman, 2005 ; Roy, 2019 ). For instance, a study conducted in China found that urban-dwelling older adults had higher successful aging scores than their rural counterparts (Ding et al., 2020 ). In contrast, research involving older adults in Korea and Japan indicated that rural residents were more likely to achieve successful aging compared to those living in urban areas (Kim et al., 2022; Takahashi et al., 2023). These mixed findings underscore the importance of understanding the various factors associated with successful aging, including individual characteristics, health-related factors, and behavioral elements. A recent study by Wang et al. (2023) emphasizes the role of social support and community engagement in promoting successful aging, particularly in rural contexts. This highlights the need for tailored health programs and policies that address the specific challenges faced by older adults in different living environments. H2: There are differences in health literacy between individuals living in rural areas and urban areas. The results of this study supported hypothesis 2. Living in rural areas decreases the score on the health literacy scale compared to living in urban areas. Research shows that there are significant differences in health literacy levels between older individuals living in rural areas and urban areas. Those living in rural areas typically face lower health literacy levels, which complicates their access to healthcare services and their ability to effectively utilize health information (Bourne et al., 2010; Towne et al., 2015). The difficulties faced by the rural elderly population in accessing healthcare negatively impact health outcomes, resulting in higher disease rates and poorer health status compared to their urban counterparts (Cohen & Greaney, 2022; Towne et al., 2015; Ge et al., 2017). In this context, the deficiencies in health literacy among individuals living in rural areas weaken their ability to manage chronic diseases and hinder their adoption of preventive health behaviors (Bostock & Steptoe, 2012 ; Singh & Aiken, 2017). Residents of urban areas generally exhibit higher health literacy, attributed to easier access to healthcare services and higher educational attainment (Weeks et al., 2023 ; Yi et al., 2024 ). Factors contributing to these differences include geographical accessibility and the availability of educational resources. Additionally, these disparities in health literacy are reflected in the utilization of healthcare services. Urban residents have greater access to health resources and therefore show higher participation in preventive healthcare services, such as annual check-ups (Ge et al., 2017). This situation indicates that the barriers faced by rural residents in seeking health care further deepen the disparities in health literacy (Towne et al., 2015). A systematic review by Svendsen et al. ( 2020 ) supports these findings, indicating that urban populations consistently demonstrate higher levels of health literacy, except in one included study. Furthermore, recent research by Jones et al. (2023) highlights that social determinants of health, such as income and social support networks, play a crucial role in shaping health literacy. Rural residents often encounter barriers related to these determinants, which can exacerbate health disparities. Overall, the evidence suggests that addressing health literacy in rural populations requires tailored interventions that consider their specific challenges, such as enhancing access to educational resources and healthcare services. Understanding these urban-rural differences is essential for developing effective public health strategies aimed at improving health outcomes for all individuals, particularly those in underserved areas. H3. Health literacy has a positive effect on successful aging. The results of this study supported hypothesis 3. Health literacy has a positive effect on successful aging. There is a growing body of research suggesting that high levels of health literacy are positively associated with health outcomes such as well-being (Harsch et al., 2021 ), access to healthcare, and overall health (Liu et al., 2015 ). Whilst higher levels of health literacy were associated with positive health outcomes, the opposite is observed when it comes to having low levels of health literacy. In this aspect, health literacy directly affects successful aging by influencing individuals' health behaviors and access to health services. Individuals with high health literacy are better able to understand and apply health information, which contributes to adopting healthier lifestyles and managing chronic diseases more effectively, and thus aging more successfully (Yu et al., 2023 ). For example, individuals with high health literacy can use health services more effectively and be more successful in managing chronic diseases (Kim, Kim, & Kim, 2024 ). In addition, health literacy can also increase individuals' ability to use social support networks, reducing social isolation and improving overall quality of life (Zhang, Chen, & Zhang, 2022 ). H4. Health literacy serves as a mediatör in the relationship between living in rural or urban areas and successful aging. Beyond exploring direct impacts, this study examined the potential mediating roles of health literacy in the relationship between living in rural areas or urban areas and successful aging. In Steps 1 and 2, we examined the impact of living in rural areas or urban areas on successful aging. Assessing other facets of the model, we uncovered that living in rural areas or urban areas significantly influenced health literacy, and in turn, health literacy had a significant impact on successful aging. In Step 3, the significant effect of living in rural or urban areas on successful aging became insignificant after the mediation analysis, suggesting that health literacy is a complete mediator in the relationship between living in rural areas or urban areas and successful aging. Therefore, it is concluded that living in rural areas has a decreasing effect on successful aging compared to living in urban areas, but this effect is indirect through deteriorating health literacy. Prior research has yielded different outcomes concerning how living in rural areas or urban areas relates to successful aging. Successful aging, characterized by physical, mental, and social well-being, is influenced by the level of health literacy. Research indicates that older adults with higher health literacy levels tend to report better self-rated health and functional abilities (Jiang et al., 2020 ). For example, Jiang et al. ( 2020 ) found that rural older adults experience functional disabilities at younger ages compared to their urban peers, which can be partly attributed to lower health literacy and access to health resources (Jiang et al., 2020 ). This highlights the critical role of health literacy in mediating the effects of living environment on successful aging, as it directly impacts the ability to navigate health systems and make informed health decisions. Health literacy can positively affect individuals' access to health services and health behaviors by increasing their ability to understand and use health information (Chen et al., 2023 ). At this point, increasing health literacy is seen as a critical strategy to improve health outcomes in rural populations. In a systematic review, Svendsen et al. ( 2020 ) showed that increasing health literacy has significant effects on access to health services and individuals' health management. Health education programs specifically designed for rural communities can help individuals improve their health knowledge and make better decisions (Wang et al., 2023). As a result, efforts to increase the health literacy of individuals living in rural areas are vital to improving their successful aging experiences and facilitating their access to health services. Clinical Implications The findings of this study highlight health literacy as a critical and modifiable factor in promoting successful aging, particularly among older adults living in rural areas. From a clinical and public health perspective, these results suggest that interventions aimed at improving successful aging should prioritize health literacy enhancement alongside traditional healthcare services. Healthcare professionals working with older adults—especially in primary care, geriatric services, and community health settings—should routinely assess health literacy levels and adapt communication strategies accordingly. Simplified health information, culturally appropriate educational materials, and repeated guidance may help older adults better understand and manage chronic conditions. At the community level, health literacy–focused programs tailored to rural populations may reduce disparities in aging outcomes. Community-based education initiatives, outreach programs led by nurses or social workers, and the use of digital health tools designed for older adults can improve access to health information and promote preventive health behaviors. Policymakers should integrate health literacy into aging and rural health strategies to support equitable and sustainable successful aging across diverse living environments. Conclusion and Recommendations This study reveals that health literacy is a critical factor in mediating the relationship between rural and urban living environments and successful aging. The results of this study and the associated literature suggest that individuals living in urban areas generally have higher levels of health literacy compared to those living in rural areas. This emphasizes that better access to health services and information in urban settings positively affects the health outcomes of older adults. In this respect, health literacy directly and indirectly affects successful aging by influencing individuals' health behaviors and access to health services. These findings indicate that policies specific to rural and urban areas should also be taken into account in the development of social policies related to aging. In particular, the development of policies specific to rural and urban areas can contribute to reducing inequalities between rural and urban areas. Moreover, these policies can also play an important role in improving the quality of life and well-being of older people. In conclusion, health literacy is a critical factor in supporting successful aging. Therefore, the following recommendations are offered to increase health literacy: Education Programs Education programs should be developed to increase health literacy in rural and urban areas. These programs should focus on strengthening individuals' ability to acquire, understand, and apply health information. Improving Access Innovative approaches, such as mobile health services and telehealth applications, should be adopted to enhance access to health information and services in rural areas. Digital Literacy Training Digital literacy training should be organized in rural communities to increase access to digital resources. This will facilitate individuals' access to online health information and improve health literacy. Cultural Sensitivity When delivering health services, approaches should be developed that are sensitive to cultural beliefs and practices in rural areas. This will help individuals better understand and use health information. Declarations IRB protocol/human subjects approval numbers : Ethics committee approval was received from [ blinded for review] (Ethics committee no: XXX dated: XXX). Consent to Participate: Informed consent was obtained from all individual participants included in the study. Funding Declaration : This work was supported by the [ blinded for review ]. Author Contribution HSI: Conceptualization, Methodology, Data curation, Investigation, Formal analysis, Writing – original draft, Visualization, Project administration, Validation, Writing – review & editing, Supervision. MSÇ: Data curation, Formal analysis, Validation, Writing – review & editing, References Adjaye-Gbewonyo, D., Rebok, G. W., Gross, A. L., Gallo, J. J., & Underwood, C. R. (2019). 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Health Promotion International , 34 (5), e1–e17. Sun, J., & Lyu, S. (2020). Social participation and urban-rural disparity in mental health among older adults in China. Journal of Affective Disorders , 274 , 399–404. Svendsen, M. T., Bak, C. K., Sørensen, K., Pelikan, J., Riddersholm, S. J., Skals, R. K., & Torp-Pedersen, C. (2020). Associations of health literacy with socioeconomic position, health risk behavior, and health status: a large national population-based survey among Danish adults. BMC public health , 20 , 1–12. Weeks, W. B., Chang, J. E., Pagán, J. A., Lumpkin, J., Michael, D., Salcido, S., & Lavista, J. M. (2023). Rural-urban disparities in health outcomes, clinical care, health behaviors, and social determinants of health and an action-oriented, dynamic tool for visualizing them. PLOS Global Public Health , 3 (10), e0002420. Yi, J., Yoon, J. Y., Won, C. W., Kim, M., & Lee, K. S. (2024). The roles of health literacy and social support in the association between smartphone ownership and frailty in older adults: a moderated mediation model. Bmc Public Health , 24 (1), 1064. Yu, Y., Wu, Y., Huang, Z., & Sun, X. (2023). Associations between media use, self-efficacy, and health literacy among Chinese rural and urban elderly: A moderated mediation model. Frontiers in Public Health , 11 , 1104904. Zhang, H., Chen, L., & Zhang, F. (2022). Revisit the effects of health literacy on health behaviors in the context of COVID-19: the mediation pathways based on the health belief model. Frontiers in public health , 10 , 917022. Zhou, Z., Zhou, Z., Gao, J., Lai, S., & Chen, G. (2018). Urban-rural difference in the associations between living arrangements and the health-related quality of life (HRQOL) of the elderly in China—evidence from Shaanxi province. PLoS One , 13(9), e0204118. 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-8946273","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":605198955,"identity":"0b70a6e4-9a6e-4bec-9ad9-ad9cb2f99712","order_by":0,"name":"HATICE SELİN IRMAK","email":"data:image/png;base64,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","orcid":"","institution":"Istanbul University-Cerrahpaşa","correspondingAuthor":true,"prefix":"","firstName":"HATICE","middleName":"SELİN","lastName":"IRMAK","suffix":""},{"id":605198956,"identity":"870410d3-7dd0-4752-a066-bbba28156e67","order_by":1,"name":"MELEK SENA ÇATALBAŞ","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"MELEK","middleName":"SENA","lastName":"ÇATALBAŞ","suffix":""}],"badges":[],"createdAt":"2026-02-23 11:08:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8946273/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8946273/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104689746,"identity":"e081878a-206b-43e8-8371-609bcc82d695","added_by":"auto","created_at":"2026-03-16 06:02:18","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":35472,"visible":true,"origin":"","legend":"\u003cp\u003eMediating effect of health literacy on the relationship between living in rural areas or urban areas and successful aging\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8946273/v1/819ab52970053b634bc73f75.png"},{"id":104782575,"identity":"65ce9111-ddf7-447b-854e-66e78a1b572d","added_by":"auto","created_at":"2026-03-17 07:57:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":969048,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8946273/v1/85504f7f-b491-4f8a-b4f9-b6e66d2a9443.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Mediating Role of Health Literacy in the Effect of Living in Rural Versus Urban Areas in Older Adults on Successful Aging","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe global aging population presents significant challenges for healthcare systems and societies. Successful aging, which encompasses maintaining physical, mental, and social well-being, is a key focus in understanding how older adults can lead fulfilling lives as they age (Rowe \u0026amp; Kahn, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e1997\u003c/span\u003e). Central to this concept is health literacy, defined as the ability to obtain, process, and understand basic health information and services necessary for making informed health decisions (Nutbeam, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2000\u003c/span\u003e). This ability is particularly crucial for older adults, who often face complex health issues and navigate intricate healthcare systems.\u003c/p\u003e \u003cp\u003eResearch has highlighted that health literacy is a mediating factor in the relationship between living environment, specifically urban versus rural living, and successful aging. The disparities in health literacy between these two settings significantly influence health outcomes among older adults. Living in urban areas is generally associated with higher health literacy levels than in rural areas (Yu et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Urban environments typically offer greater access to healthcare resources, information, and services, all of which can enhance the health literacy of their residents (Amoah et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). In contrast, rural areas often face challenges such as limited access to healthcare facilities, fewer informational resources, and socioeconomic disadvantages that impede health literacy (Flores et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHealth literacy is not merely the ability to read health-related materials; it encompasses a range of skills necessary for effective health management. This includes the ability to navigate healthcare systems, comprehend medical terminology, and engage in preventive health behaviors (Berkman et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Research indicates that higher health literacy levels are associated with better health outcomes, including improved management of chronic diseases, increased use of preventive services, and enhanced overall well-being (McCoy et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Conversely, low health literacy can lead to poor health management, higher rates of hospitalization, and increased mortality risk, particularly among older adults (Bostock \u0026amp; Steptoe, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2012\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHealth literacy is not merely the ability to read health-related materials; it encompasses a range of skills necessary for effective health management. This includes the ability to navigate healthcare systems, comprehend medical terminology, and engage in preventive health behaviors (Berkman et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Research indicates that higher health literacy levels are associated with better health outcomes, including improved management of chronic diseases, increased use of preventive services, and enhanced overall well-being (McCoy et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Conversely, low health literacy can lead to poor health management, higher rates of hospitalization, and increased mortality risk, particularly among older adults (Bostock \u0026amp; Steptoe, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2012\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUrban residents typically enjoy better health literacy due to enhanced access to resources and information, while rural residents face significant barriers that hinder their health literacy and overall health outcomes. Addressing social determinants of health, enhancing access to information, and considering cultural factors are essential strategies for improving health literacy and promoting successful aging among older adults. In this context, this study aims to determine the mediating effect of health literacy on the effect of living in rural and urban areas on successful aging. The main hypotheses of the study are as follows:\u003c/p\u003e \u003cp\u003eH1. There are differences between living in rural areas and urban areas in terms of successful aging.\u003c/p\u003e \u003cp\u003eH2. There are differences between living in rural areas and urban areas in terms of health literacy.\u003c/p\u003e \u003cp\u003eH3. Health literacy has a positive effect on successful aging.\u003c/p\u003e \u003cp\u003eH4. Health literacy mediates the relationship between living in rural or urban areas and successful aging.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eAccording to TURKSTAT data for 2021, the population of the study consists of 110,389 people aged 65 and over living within the borders of Sakarya province. Considering the proportion of the elderly population in the total population, it is known that the proportion of the elderly population is 9.7% in Turkey and 10.4% in Sakarya province (T\u0026Uuml;İK, 2022). For a population between 100,000 and 1\u0026nbsp;million people, a sample size of at least 384 people is considered sufficient (Yazıcıoğlu \u0026amp; Erdoğan, 2004). Accordingly, to work with as many samples as possible in the study, probabilities (p) were taken as 0.5, and it was calculated that at least 384 people should be included in the study according to the sampling error of 0.05, population size and t-table critical value of 1.96, and 400 people were included in the study. A simple random sampling technique, one of the probability sampling techniques, was used to select the individuals to be included in the study. Simple Random Sampling Technique is a sampling technique in which the probability of each unit in the universe entering the sample is equal and independent of each other, and due to these characteristics, the results (if the sample size is appropriate) can be generalized to the universe (Kerlinger \u0026amp; Lee, 1999; Neuman, 2014). The inclusion criteria of the study were determined as being 65 years of age or older, being capable of understanding the questions and expressing their opinions, volunteering to participate in the study, and residing within the borders of Sakarya province.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMeasures and Data Collection Tools\u003c/h3\u003e\n\u003cp\u003eThe data of the study were collected using face-to-face interview techniques within the borders of Sakarya province in January and February 2024. Participants who voluntarily agreed to participate in the study and met the inclusion criteria were administered the Personal Information Form, Health Literacy Scale, and Successful Aging Scale developed by the researcher.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eThe Personal Information Form\u003c/strong\u003e \u003cp\u003eThis form was developed by the researchers after reviewing the relevant literature. There are 14 questions developed to determine the descriptive characteristics of the participants, such as gender, age, marital status, educational status, place of birth, income status, family type, number of children, place of residence, and \u0026ldquo;How is your health according to you?\u0026rdquo;.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eHealth Literacy Scale\u003c/b\u003e: The 47-item HLS-EU (Health Literacy Survey in Europe) form developed by S\u0026oslash;rensen was later transformed into the Health Literacy Index (Health Literacy Index), which To\u0026ccedil;i, Bruzari, and Sorenson reworked and simplified together. The Turkish validity and reliability study of the scale was conducted by Bayık Temel and Aras (2017). The Health Literacy Scale consists of 25 items and four subscales: Access to information includes five items (items 1\u0026ndash;5), the minimum score to be obtained from this subscale is 5, and the maximum score is 25. Understanding information includes seven items (items 6\u0026ndash;12), and the minimum score to be obtained from this subscale is 7, and the maximum score is 35. The Appraisal/Evaluation subscale includes eight items (items 13\u0026ndash;20), and the minimum score for this subscale is 8, and the maximum score is 40. The Application/Using subscale also includes five items (items 21\u0026ndash;25), and the minimum score for this subscale is 5, and the maximum score is 25. The minimum score for the whole scale is 25, and the maximum score is 125. The scale items are answered by the participants on a Likert scale as \u0026ldquo;5: I have no difficulty at all, 4: I have little difficulty, 3: I have some difficulty, 2: I have a lot of difficulty, 1: I am unable/ have no ability/ impossible\u0026rdquo;. All items of the scale are positive, and there are no reverse items. The standard deviation of the original scale is .95, and the internal consistency coefficients (Cronbach's alpha) for the subscales range between .90 and .94.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSuccessful Aging Scale\u003c/b\u003e: The successful aging scale (SAS) developed by Reker consists of 3 sub-dimensions and 13 questions. These sub-dimensions are \u0026ldquo;healthy lifestyle\u0026rdquo; (1,7,8,12), \u0026ldquo;adaptive coping\u0026rdquo; (2,3,11,13), and \u0026ldquo;commitment to life\u0026rdquo; (4,5,6,9,10). Each statement was scored from 1 to 7. The scoring of the statements is as follows: strongly agree\u0026thinsp;=\u0026thinsp;7, agree\u0026thinsp;=\u0026thinsp;6, somewhat agree\u0026thinsp;=\u0026thinsp;5, undecided\u0026thinsp;=\u0026thinsp;4, somewhat disagree\u0026thinsp;=\u0026thinsp;3, disagree\u0026thinsp;=\u0026thinsp;2, strongly disagree\u0026thinsp;=\u0026thinsp;1. The overall internal consistency reliability of the scale (SAS) is .84, the Cronbach's alpha coefficient of the \u0026ldquo;healthy lifestyle\u0026rdquo; sub-dimension is .72, the \u0026ldquo;adaptive coping\u0026rdquo; sub-dimension is .73, and the \u0026ldquo;commitment to life\u0026rdquo; sub-dimension is .75 (Reker, 2009).\u003c/p\u003e\n\u003ch3\u003eData analyses\u003c/h3\u003e\n\u003cp\u003eThe data were analyzed using SPSS version 25 and the PROCESS MacroPlug-in. Cronbach's alpha was calculated for each scale to assess internal consistency. Demographic and variable data were summarized using descriptive statistics, including mean, standard deviation, percentage, and frequencies. The analytical phase comprised correlation and mediation analyses. The direct and indirect effects of the proposed model were tested using PROCESS- Macro Model 4. All statistical tests were conducted at a significance level of .05.\u003c/p\u003e\n\u003ch3\u003eEthical Aspects of the Research\u003c/h3\u003e\n\u003cp\u003e Before commencing the data collection process, ethical approval was obtained from [the Ethics Committee of XX], with the approval dated [Date] and numbered [Approval Number]. The study was conducted by the principles of the Declaration of Helsinki.\u003c/p\u003e"},{"header":"Resuts","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eDemographic characteristics of respondents\u003c/h2\u003e \u003cp\u003eThis section includes the sociodemographic characteristics of the individuals participating in the study. The findings related to this purpose are given 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\u003eDescriptive Characteristics of Participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\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 \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\u003eSubcategories\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 \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\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e205\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e51.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e195\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e48.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAge Groups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65\u0026ndash;74 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e278\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e69.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75\u0026ndash;84\u0026nbsp;years\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\u003e20.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85\u0026thinsp;+\u0026thinsp;years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eFamily Type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNuclear family\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e264\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e66.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExtended family\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLiving alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\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\u003e287\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e71.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWidowed\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\u003e22.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePlace of Residence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\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\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBelow high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e285\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e71.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh school or above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eIncome Level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e232\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e58.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e118\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eOverall Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e148\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e37.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e204\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e51.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Descriptive Characteristics of Participants\u003c/p\u003e \u003cp\u003eOf the participants, 51.3% were female and 48.8% were male, with 69.5% aged between 65 and 74 years. In terms of living arrangements, 66.0% lived in nuclear families, 20.0% in extended families, and 14.0% lived alone. Regarding marital status, 71.8% were married, 5.5% were single, and 22.8% had lost their spouse. As for educational background, 13.3% were illiterate, 71.3% had an education level below high school, and 15.5% had a high school or higher education level. In terms of residential areas, 50.0% lived in rural areas, and 50.0% lived in urban areas. Income levels were distributed as 12.5% low, 58.0% medium, and 29.5% high. Finally, health status was reported as 37.0% good, 51.0% moderate, and 12.0% poor.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCorrelation analyze\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Correlation Analysis Results Between Health Literacy Scale Scores and Successful Aging Scale Scores of Participants Living in Rural Areas and Urban Areas\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\u003eCorrelation Analysis Results Between Health Literacy Scale Scores and Successful Aging Scale Scores of Participants Living in Rural Areas and Urban Areas\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eLiving in Rural Areas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eLiving in Urban Areas\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHLS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHLS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003er\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.646\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.740\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e200\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThere is a statistically significant positive and highly strong (r=.646; p=.000) and strong (r=.740; p=.000) statistically significant relationship between the total scores of the participants living in rural areas and the total scores of the participants living in urban areas. As the total scores of the participants living in rural and urban areas increase, the total scores of the participants living in rural and urban areas also increase.\u003c/p\u003e\n\u003ch3\u003eDirect effects\u003c/h3\u003e\n\u003cp\u003eThe results of direct effects are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Separate regression analyses were conducted on the proposed conceptual model at each step. Initially, the influence of independent variables on the mediat\u0026ouml;r variable, health literacy, was determined, followed by their impact on the dependent variable, successful aging.\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\u003eThe mediating role of health literacy in the relationship between living in rural areas or urban areas and successful aging\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\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=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePredictors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eβ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdj R\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStep 1\u003c/p\u003e \u003cp\u003eLiving Area\u003c/p\u003e \u003cp\u003e(Urban\u0026thinsp;=\u0026thinsp;1, Rural\u0026thinsp;=\u0026thinsp;0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth Literacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.5700\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.7031\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.4344\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4.4449*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e19.7570*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.0473\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStep 2\u003c/p\u003e \u003cp\u003eLiving Area\u003c/p\u003e \u003cp\u003e(Urban\u0026thinsp;=\u0026thinsp;1, Rural\u0026thinsp;=\u0026thinsp;0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSuccessful Aging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.8500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.3971\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.3424\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.4716*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e12.0519*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.0294\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStep 3\u003c/p\u003e \u003cp\u003eHealth Literacy\u003c/p\u003e \u003cp\u003eLiving Area\u003c/p\u003e \u003cp\u003e(Urban\u0026thinsp;=\u0026thinsp;1, Rural\u0026thinsp;=\u0026thinsp;0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSuccessful Aging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.5651\u003c/p\u003e \u003cp\u003e.5722\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.0298\u003c/p\u003e \u003cp\u003e1.0388\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.6953\u003c/p\u003e \u003cp\u003e.0404\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e18.9359*\u003c/p\u003e \u003cp\u003e.5508\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e190.7242*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.4900\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e* p \u0026lt; .000\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The mediating effect of health literacy in the relationship between living in rural areas or urban areas and successful aging\u003c/p\u003e \u003cp\u003eThe results of the direct effects are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. A series of regression analyses were conducted to test the proposed mediation model. In the first step, the effect of the independent variable (living in rural or urban areas) on the mediator variable (health literacy) was examined. In the second step, the effect of the independent variable on the dependent variable (successful aging) was tested. Finally, in the third step, both the independent variable and the mediator were included in the model to predict successful aging.\u003c/p\u003e \u003cp\u003eIn Step 1, living in rural or urban areas had a significant effect on health literacy (β\u0026thinsp;=\u0026thinsp;.4344, p\u0026lt;.001). In Step 2, living in rural or urban areas also significantly predicted successful aging (β\u0026thinsp;=\u0026thinsp;.3424, p\u0026lt;.001). In Step 3, health literacy remained a strong and significant predictor of successful aging (β\u0026thinsp;=\u0026thinsp;.6953, p\u0026lt;.001), while the effect of living in rural or urban areas dropped substantially (β\u0026thinsp;=\u0026thinsp;.0404) and became statistically non-significant (p\u0026gt;.05). This pattern suggests a full mediating effect of health literacy on the relationship between living environment and successful aging.\u003c/p\u003e \u003cp\u003eFurthermore, while living in rural or urban areas alone accounted for only a small proportion of the variance in successful aging (Adjusted R\u0026sup2;=.0294; F\u0026thinsp;=\u0026thinsp;12.0519, p\u0026lt;.001), the inclusion of health literacy in the model increased the explained variance substantially (Adjusted R\u0026sup2;=.4900; F\u0026thinsp;=\u0026thinsp;190.7242, p\u0026lt;.001). The results of the proposed model are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure. 1 Mediating effect of health literacy on the relationship between living in rural areas or urban areas and successful aging\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eIndirect effects\u003c/h2\u003e \u003cp\u003eThe direct and indirect effects at each step are shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTotal, direct, and indirect regression analyses on Successful Aging\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=\"char\" char=\".\" 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=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEffect Type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB (Unstandardized Coefficient)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003cp\u003e(LLCI\u0026ndash;ULCI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSignificance\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal effect of living areas on Successful Aging (X \u0026rarr; Y)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.8500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.3971\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e[2.1035, 7.5965]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSignificant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe direct effect of living areas on Successful Aging\u003c/p\u003e \u003cp\u003e(X \u0026rarr; Y controlling for M)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.5722\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.0388\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e[\u0026ndash;1.4701, 2.6144]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot Significant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndirect path\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuccessful Aging\u0026thinsp;\u0026gt;\u0026thinsp;Health Literacy\u0026thinsp;\u0026gt;\u0026thinsp;Living areas (X \u0026rarr; M \u0026rarr; Y)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.2778\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.0063\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e[2.3227, 6.2505]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSignificant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Total, direct, and indirect regression analyses on Successful Aging\u003c/p\u003e \u003cp\u003eThe impact of living in rural or urban areas on the mediating variable was found to be statistically significant. Specifically, health literacy significantly predicted successful aging. However, when health literacy was included in the model, the direct effect of living in rural or urban areas on successful aging became statistically non-significant. These results indicate that health literacy fully mediates the relationship between living environment and successful aging (B\u0026thinsp;=\u0026thinsp;4.2778, SE\u0026thinsp;=\u0026thinsp;1.0063, 95% CI [2.3227, 6.2505]).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study examines the mediating role of health literacy in the effect of living in rural areas or urban areas on successful aging. The findings suggest that both direct and indirect effects of health literacy on successful aging are significant.\u003c/p\u003e \u003cp\u003e \u003cb\u003eH1.\u0026emsp; There are differences in successful aging between individuals living in rural areas and urban areas.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe results of this study supported hypothesis 1. Living in rural areas decreases the score on the successful aging scale compared to living in urban areas. Aging in both rural and urban settings presents unique advantages and disadvantages, influencing the successful aging experience. The concept of successful aging can vary significantly based on individual needs and preferences.\u003c/p\u003e \u003cp\u003eA substantial body of literature highlights differences in the risks of chronic diseases, disabilities, mental health conditions, and social engagement among older populations based on their place of residence (Parks, Housemann \u0026amp; Brownson, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2003\u003c/span\u003e; Adjaye-Gbewonyo et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). These disparities largely arise from economic inequality, unequal access to healthcare services, and variations in participation in social activities between older adults living in urban areas and rural areas (Chatterjee, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Laksono, Wulandari \u0026amp; Soedirham, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Sun \u0026amp; Lyu, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Zhou et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). However, findings regarding successful aging and its association with place of residence are inconsistent across different countries and populations (Ding et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Lindeman, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2005\u003c/span\u003e; Roy, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). For instance, a study conducted in China found that urban-dwelling older adults had higher successful aging scores than their rural counterparts (Ding et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). In contrast, research involving older adults in Korea and Japan indicated that rural residents were more likely to achieve successful aging compared to those living in urban areas (Kim et al., 2022; Takahashi et al., 2023).\u003c/p\u003e \u003cp\u003eThese mixed findings underscore the importance of understanding the various factors associated with successful aging, including individual characteristics, health-related factors, and behavioral elements. A recent study by Wang et al. (2023) emphasizes the role of social support and community engagement in promoting successful aging, particularly in rural contexts. This highlights the need for tailored health programs and policies that address the specific challenges faced by older adults in different living environments.\u003c/p\u003e \u003cp\u003e \u003cb\u003eH2: There are differences in health literacy between individuals living in rural areas and urban areas.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe results of this study supported hypothesis 2. Living in rural areas decreases the score on the health literacy scale compared to living in urban areas. Research shows that there are significant differences in health literacy levels between older individuals living in rural areas and urban areas. Those living in rural areas typically face lower health literacy levels, which complicates their access to healthcare services and their ability to effectively utilize health information (Bourne et al., 2010; Towne et al., 2015). The difficulties faced by the rural elderly population in accessing healthcare negatively impact health outcomes, resulting in higher disease rates and poorer health status compared to their urban counterparts (Cohen \u0026amp; Greaney, 2022; Towne et al., 2015; Ge et al., 2017). In this context, the deficiencies in health literacy among individuals living in rural areas weaken their ability to manage chronic diseases and hinder their adoption of preventive health behaviors (Bostock \u0026amp; Steptoe, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Singh \u0026amp; Aiken, 2017).\u003c/p\u003e \u003cp\u003eResidents of urban areas generally exhibit higher health literacy, attributed to easier access to healthcare services and higher educational attainment (Weeks et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Yi et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Factors contributing to these differences include geographical accessibility and the availability of educational resources. Additionally, these disparities in health literacy are reflected in the utilization of healthcare services. Urban residents have greater access to health resources and therefore show higher participation in preventive healthcare services, such as annual check-ups (Ge et al., 2017). This situation indicates that the barriers faced by rural residents in seeking health care further deepen the disparities in health literacy (Towne et al., 2015).\u003c/p\u003e \u003cp\u003eA systematic review by Svendsen et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) supports these findings, indicating that urban populations consistently demonstrate higher levels of health literacy, except in one included study. Furthermore, recent research by Jones et al. (2023) highlights that social determinants of health, such as income and social support networks, play a crucial role in shaping health literacy. Rural residents often encounter barriers related to these determinants, which can exacerbate health disparities.\u003c/p\u003e \u003cp\u003eOverall, the evidence suggests that addressing health literacy in rural populations requires tailored interventions that consider their specific challenges, such as enhancing access to educational resources and healthcare services. Understanding these urban-rural differences is essential for developing effective public health strategies aimed at improving health outcomes for all individuals, particularly those in underserved areas.\u003c/p\u003e \u003cp\u003e \u003cb\u003eH3.\u0026emsp; Health literacy has a positive effect on successful aging.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe results of this study supported hypothesis 3. Health literacy has a positive effect on successful aging. There is a growing body of research suggesting that high levels of health literacy are positively associated with health outcomes such as well-being (Harsch et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), access to healthcare, and overall health (Liu et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Whilst higher levels of health literacy were associated with positive health outcomes, the opposite is observed when it comes to having low levels of health literacy. In this aspect, health literacy directly affects successful aging by influencing individuals' health behaviors and access to health services. Individuals with high health literacy are better able to understand and apply health information, which contributes to adopting healthier lifestyles and managing chronic diseases more effectively, and thus aging more successfully (Yu et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). For example, individuals with high health literacy can use health services more effectively and be more successful in managing chronic diseases (Kim, Kim, \u0026amp; Kim, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). In addition, health literacy can also increase individuals' ability to use social support networks, reducing social isolation and improving overall quality of life (Zhang, Chen, \u0026amp; Zhang, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eH4. Health literacy serves as a mediat\u0026ouml;r in the relationship between living in rural or urban areas and successful aging.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eBeyond exploring direct impacts, this study examined the potential mediating roles of health literacy in the relationship between living in rural areas or urban areas and successful aging. In Steps 1 and 2, we examined the impact of living in rural areas or urban areas on successful aging. Assessing other facets of the model, we uncovered that living in rural areas or urban areas significantly influenced health literacy, and in turn, health literacy had a significant impact on successful aging. In Step 3, the significant effect of living in rural or urban areas on successful aging became insignificant after the mediation analysis, suggesting that health literacy is a complete mediator in the relationship between living in rural areas or urban areas and successful aging. Therefore, it is concluded that living in rural areas has a decreasing effect on successful aging compared to living in urban areas, but this effect is indirect through deteriorating health literacy. Prior research has yielded different outcomes concerning how living in rural areas or urban areas relates to successful aging.\u003c/p\u003e \u003cp\u003eSuccessful aging, characterized by physical, mental, and social well-being, is influenced by the level of health literacy. Research indicates that older adults with higher health literacy levels tend to report better self-rated health and functional abilities (Jiang et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). For example, Jiang et al. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) found that rural older adults experience functional disabilities at younger ages compared to their urban peers, which can be partly attributed to lower health literacy and access to health resources (Jiang et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). This highlights the critical role of health literacy in mediating the effects of living environment on successful aging, as it directly impacts the ability to navigate health systems and make informed health decisions.\u003c/p\u003e \u003cp\u003eHealth literacy can positively affect individuals' access to health services and health behaviors by increasing their ability to understand and use health information (Chen et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). At this point, increasing health literacy is seen as a critical strategy to improve health outcomes in rural populations. In a systematic review, Svendsen et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) showed that increasing health literacy has significant effects on access to health services and individuals' health management. Health education programs specifically designed for rural communities can help individuals improve their health knowledge and make better decisions (Wang et al., 2023). As a result, efforts to increase the health literacy of individuals living in rural areas are vital to improving their successful aging experiences and facilitating their access to health services.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eClinical Implications\u003c/h2\u003e \u003cp\u003eThe findings of this study highlight health literacy as a critical and modifiable factor in promoting successful aging, particularly among older adults living in rural areas. From a clinical and public health perspective, these results suggest that interventions aimed at improving successful aging should prioritize health literacy enhancement alongside traditional healthcare services.\u003c/p\u003e \u003cp\u003eHealthcare professionals working with older adults\u0026mdash;especially in primary care, geriatric services, and community health settings\u0026mdash;should routinely assess health literacy levels and adapt communication strategies accordingly. Simplified health information, culturally appropriate educational materials, and repeated guidance may help older adults better understand and manage chronic conditions.\u003c/p\u003e \u003cp\u003eAt the community level, health literacy\u0026ndash;focused programs tailored to rural populations may reduce disparities in aging outcomes. Community-based education initiatives, outreach programs led by nurses or social workers, and the use of digital health tools designed for older adults can improve access to health information and promote preventive health behaviors. Policymakers should integrate health literacy into aging and rural health strategies to support equitable and sustainable successful aging across diverse living environments.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eConclusion and Recommendations\u003c/h2\u003e \u003cp\u003eThis study reveals that health literacy is a critical factor in mediating the relationship between rural and urban living environments and successful aging. The results of this study and the associated literature suggest that individuals living in urban areas generally have higher levels of health literacy compared to those living in rural areas. This emphasizes that better access to health services and information in urban settings positively affects the health outcomes of older adults. In this respect, health literacy directly and indirectly affects successful aging by influencing individuals' health behaviors and access to health services.\u003c/p\u003e \u003cp\u003eThese findings indicate that policies specific to rural and urban areas should also be taken into account in the development of social policies related to aging. In particular, the development of policies specific to rural and urban areas can contribute to reducing inequalities between rural and urban areas. Moreover, these policies can also play an important role in improving the quality of life and well-being of older people. In conclusion, health literacy is a critical factor in supporting successful aging. Therefore, the following recommendations are offered to increase health literacy:\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEducation Programs\u003c/strong\u003e \u003cp\u003eEducation programs should be developed to increase health literacy in rural and urban areas. These programs should focus on strengthening individuals' ability to acquire, understand, and apply health information.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eImproving Access\u003c/strong\u003e \u003cp\u003eInnovative approaches, such as mobile health services and telehealth applications, should be adopted to enhance access to health information and services in rural areas.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eDigital Literacy Training\u003c/strong\u003e \u003cp\u003eDigital literacy training should be organized in rural communities to increase access to digital resources. This will facilitate individuals' access to online health information and improve health literacy.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCultural Sensitivity\u003c/strong\u003e \u003cp\u003eWhen delivering health services, approaches should be developed that are sensitive to cultural beliefs and practices in rural areas. This will help individuals better understand and use health information.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cb\u003eIRB protocol/human subjects approval numbers\u003c/b\u003e: Ethics committee approval was received from [\u003cem\u003eblinded for review]\u003c/em\u003e (Ethics committee no: XXX dated: XXX).\u003c/p\u003e\u003cp\u003e \u003ch2\u003eConsent to Participate:\u003c/h2\u003e \u003cp\u003e Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003e \u003cb\u003eDeclaration\u003c/b\u003e: This work was supported by the [\u003cem\u003eblinded for review\u003c/em\u003e].\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eHSI: Conceptualization, Methodology, Data curation, Investigation, Formal analysis, Writing \u0026ndash; original draft, Visualization, Project administration, Validation, Writing \u0026ndash; review \u0026amp; editing, Supervision. MS\u0026Ccedil;: Data curation, Formal analysis, Validation, Writing \u0026ndash; review \u0026amp; editing,\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAdjaye-Gbewonyo, D., Rebok, G. W., Gross, A. L., Gallo, J. J., \u0026amp; Underwood, C. R. (2019). Assessing urban-rural differences in the relationship between social capital and depression among Ghanaian and South African older adults. \u003cem\u003ePLoS One\u003c/em\u003e, 14(6), e0218620.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmoah, P. A., et al. (2022). Health literacy and access to healthcare services: A study of urban versus rural populations. \u003cem\u003eJournal of Health Communication\u003c/em\u003e, \u003cem\u003e27\u003c/em\u003e(5), 385\u0026ndash;393.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerete, F., Gisle, L., Demarest, S., Charafeddine, R., Bruy\u0026egrave;re, O., Van den Broucke, S., \u0026amp; Van der Heyden, J. 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Urban-rural difference in the associations between living arrangements and the health-related quality of life (HRQOL) of the elderly in China\u0026mdash;evidence from Shaanxi province. \u003cem\u003ePLoS One\u003c/em\u003e, 13(9), e0204118.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Successful aging, Health literacy, Urban or rural living, Aging disparities","lastPublishedDoi":"10.21203/rs.3.rs-8946273/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8946273/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjectives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study investigates the mediating role of health literacy in the relationship between living environments (rural/urban) and successful aging among older adults.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were collected from 400 participants aged 65 and older (51.3% women; mean age = 71.6 ± 4.3 years) residing in Sakarya Province. Participants completed a Personal Information Form, the Health Literacy Scale, and the Successful Aging Scale. Mediation analyses were conducted using regression-based approaches and bootstrapping to examine direct and indirect effects.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLiving in rural areas was associated with lower health literacy and a reduced likelihood of successful aging. Health literacy fully mediated the relationship between living environment and successful aging (β = .6953, p\u0026lt;.001). After including health literacy, the direct effect of living environment became non-significant, while the explained variance in successful aging increased from 2.9% to 49%. The indirect effect was significant (B = 4.28, SE = 1.01, 95% CI [2.32, 6.25]).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHigher health literacy enhances older adults’ capacity to manage chronic conditions and adopt healthier lifestyles, thereby supporting successful aging. Rural living may indirectly hinder successful aging through its negative association with health literacy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Implications\u003c/strong\u003e: Health literacy interventions tailored to rural populations, including community-based education and digital health tools, may reduce rural–urban disparities and promote equitable successful aging outcomes.\u003c/p\u003e","manuscriptTitle":"The Mediating Role of Health Literacy in the Effect of Living in Rural Versus Urban Areas in Older Adults on Successful Aging","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-16 06:02:13","doi":"10.21203/rs.3.rs-8946273/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a2b5bceb-56f1-4db0-8dbc-3a74f661814a","owner":[],"postedDate":"March 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-16T06:02:13+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-16 06:02:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8946273","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8946273","identity":"rs-8946273","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}