The relationship between health literacy and self-care in persons with chronic diseases: a multicenter cross-sectional study

The relationship between health literacy and self-care in persons with chronic diseases: a multicenter cross-sectional study | 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 relationship between health literacy and self-care in persons with chronic diseases: a multicenter cross-sectional study Anne Geert van Driel, John de Heide, Annemarie van der Klis, AnneLoes van Staa, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7573055/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background To examine the relationship between health literacy and self-care (maintenance, monitoring, and management) in people with chronic diseases. Methods A multicenter cross-sectional study was conducted in six hospitals (one academic, four teaching, and one general) in the Netherlands among 536 adults (≥ 18 years) with at least one chronic disease between October 2022 and June 2024. Participants completed sociodemographic data, the European Health Literacy Survey Questionnaire (HLS-EU-Q16), the Self-Care of Chronic Illness Inventory (SC-CII v4c), and the Self-Care Self-Efficacy Scale. Associations between health literacy (adequate vs. inadequate) and self-care (maintenance, monitoring and management) were tested with multivariable linear regression adjusted for age, gender, number of chronic conditions, educational level, living situation, and self-efficacy. Results Of 536 adults (mean age 67 ± 14 years, 54% men), 46% had inadequate health literacy. Mean self-care scores were 70.4 ± 14.7 (maintenance), 69.9 ± 22.3 (monitoring), and 70.9 ± 19.7 (management) on a 0-100 scale. In multivariable models, adequate health literacy is associated with better self-care maintenance (β = 5.6, 95% CI 3.1–8.1), self-care monitoring (β = 8.7, 95% CI 5.0-1.5), and self-care management (β = 5.5, 95% CI 2.1–8.9) when adjusting for all controlled variables. However, this association become non-significant after adding self-efficacy, which explained most of the residual variance. Conclusions Adequate health literacy is associated with higher self-care scores among adults with chronic diseases. However, such association was diminished when self-efficacy is accounted for, indicating that self-efficacy mediates the relationship between health literacy and self-care. Clinical trial number: Not applicable Figures Figure 1 1. Introduction Health literacy is defined as the knowledge, motivation, and competencies to access, understand, appraise, and apply information to make judgements and decisions in everyday life concerning healthcare, disease prevention and health promotion [ 1 ]. It is a strong predictor of self-care behaviors in individuals with chronic diseases [ 2 , 3 ]. Focusing on health literacy can be effective for promoting smoking cessation, enhancing physical activity, and supporting medication adherence. This in turn may improve clinical outcomes, such as mortality rates, healthcare service utilization, quality of life, and overall well-being in chronic diseases [ 4 , 5 ]. A recent systematic review [ 6 ], highlighted several factors that are strongly associated with poor health literacy, emphasizing that health literacy should be understand within a brother context rather that treated as an isolated construct. These were sociodemographic factors (e.g., older age [ 7 , 8 ] and low educational level [ 9 ]), social factors (e.g., poor family support or living alone [ 10 , 11 ]), economic factors (e.g., lower socioeconomic status), and health-related factors (e.g., number of chronic diseases [ 12 ]). Within an ageing population, chronic diseases tend to be of long duration and result from a combination of genetic, physiological, environmental and behavioral factors [ 13 ]. Chronic diseases are widespread and increasing worldwide, presenting major public health challenges and accounting for over 74% of global deaths [ 13 , 14 ] and 90% of deaths in Europe [ 15 ]. Chronic diseases include a range of conditions such as cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes, and can occur in all phases of life, but especially in elderly people [ 13 ]. People with chronic diseases experience physical and emotional symptoms, reducing their quality of life [ 16 ] and contributing to disability [ 17 ]. Self-care is an important aspect of managing chronic diseases and is strongly associated with numerous positive health outcomes [ 18 ]. The Middle Range Theory of Self-Care of Chronic Illness defines self-care as a process of maintaining health through health promoting practices and managing illness. This definition emphasizes that self-care includes various general and disease-specific actions that individuals with chronic diseases undertake to maintain their physical and emotional well-being. Activities such as adhering to medication regimens, following dietary recommendations, engaging in regular exercise are collectively known as self-care maintenance which may prevent symptom exacerbation and supports long-term disease control. Self-care monitoring refers to the process of monitoring behavior and observing oneself for changes in signs and symptoms, which is important to detect early disease-related health changes. When these changes appear, individuals can apply a variety of behaviors to relieve or correct them, which is defined as self-care management [ 19 , 20 ]. Within the context of self-care, self-efficacy – the confidence individuals have in the ability to perform self-care practices and persist despite barriers, such as poor health literacy – is a powerful and consistent influence on performance of self-care across patient populations [ 21 – 23 ]. Overall, existing research on health literacy and self-care yielded inconsistent findings. Some studies suggest a positive association between health literacy and self-care; more specifically, higher health literacy levels are regularly associated with enhanced self-care behaviors, such as medication adherence in patients with cardiovascular disease [ 24 ], the positive role of critical health literacy in patients’ self-care with chronic kidney disease [ 25 ], and improvements in diet adherence and weight management in patients with hypertension [ 26 ]. However, there are also studies suggesting absent or negative associations [ 27 , 28 ]. The inconsistencies in existing literature underscore the need for additional research to clarify the relationship between health literacy and self-care. This may guide future evidence-based strategies for optimizing patient education in individuals with chronic diseases. This study aims to examine the relationship between health literacy and self-care behaviors in people with chronic diseases. 2. Methods 2.1 Design and sample This study was a multi-center cross-sectional survey conducted from October 2022 to June 2024 in six hospitals on nursing wards in the Netherlands. Convenience sampling was used to recruit patients with chronic diseases. Inclusion criteria were (1) having at least one chronic condition (2) being aged 18 years or older, and (3) being capable of verbal communication in Dutch. Patients with an expected limited life expectancy of less than 3 months or with dementia or delirium were not eligible. The sample size for multiple regression analysis was calculated using Gpower3.1 [ 29 ]. A sample size of 536 was determined to be sufficient having a power of 0.95, an alpha of 0.05, an effect size f 2 of 0.05 and with 7 independent variables (health literacy, age, gender, chronic conditions, educational level, living situation, and self-efficacy). This research follows the STROBE guidelines for cross-sectional studies [ 30 ], see attachment 1. 2.2 Instruments Socio-demographic and clinical data of participants were collected, including age, number of chronic conditions, gender, educational level, and living situation. Health literacy was assessed by the validated 16-item version of the European Health Literacy Survey Questionnaire (HLS-EU-Q16) in Dutch, including questions that assess participants’ ability to access, understand, appraise and apply health-related information [ 31 ]. Responses are recorded on a 4-point Likert scale, ranging from 1 (very difficult) to 4 (very easy). The HLS-EU-Q16 manual recommends dichotomizing the answers from HLS-EU-Q16 (‘very difficult’/’fairly difficult’ = 0, ‘fairly easy’/ ‘very easy’ = 1; total 0–16 scores) and dividing the total scores into three categories of health literacy (‘likely inadequate health literacy’ (0–8 scores), ‘likely problematic health literacy’ (9–12 scores) and ‘likely sufficient health literacy’ (13–16 scores). The categories were dichotomized into ‘inadequate’ (likely inadequate and likely problematic) and ‘adequate’. This approach has been utilized previously [ 32 – 36 ]. According to the HLS-EU-Q16 manual, participants with more than two incomplete responses in the HLS-EU-Q16 items were excluded [ 37 ]. Cronbach’s alpha was calculated to evaluate the HLS-EU-Q16’s internal consistency in this study, providing a coefficient of 0.903, indicating strong reliability [ 38 ]. Self-care was measured using the validated Dutch version of the validated Self-Care of Chronic Illness Inventory (SC-CII v4c) [ 39 ]. This 19-item questionnaire consists of three different scales measuring self-care maintenance, self-care monitoring, and self-care management. Items were scored on a five-point Likert scale, ranging from 1 to 5, except items 13 and 19, which used a six-point Likert scale, ranging from 0 to 5. Item 13 is used to reflect the link between self-care monitoring and self-care management and item 19 reflects the perceived effect of self-care management. Both items (13 and 19) were not included in the sum scores of the self-care scales. Each scale was scored separately and then converted into a 0 to 100 scale according to the self-care scoring algorithm ( https://self-care-measures.com/self-care-scoring-algorithm/ ). Higher scores indicated better self-care, and a score of ≥ 70 was seen as an adequate level for self-care [ 40 ]. The psychometric testing of the previous version(s) of SC-CII has demonstrated credible, reliable, and generalizable results in the Western context [ 39 , 41 ]. Cronbach’s alpha was calculated for each self-care scale in this study, with internal consistency coefficients of 0.531 for self-care maintenance, 0.806 for self-care monitoring and 0.644 for self-care management [ 38 ]. Self-efficacy was measured with the Self-Care Self Efficacy Scale (SCSES) [ 42 ]. This 10-item instrument measures self-efficacy with starting each question with “How confident are you that you can…”. The phrase “how confident” captures the strength of the belief while the adjunctive clause affirms the ability to perform a specific self-care action. Items were rated on a ‘1–5’ rating scale and ranged from 0 to 100 based on the same algorithm as the SC-CII. Higher scores indicate greater self-efficacy, with a score of ≥ 70 considered an adequate level. Cronbach’s alpha was calculated for the SCES’s internal consistency in this study, yielding a coefficient of 0.869 [ 38 ]. 2.3 Data collection procedure Bachelor of Nursing students provided eligible patients with verbal and written information about the study. The written information was also supported with a QR code connected to an information video about the study. Informed consent was signed directly after receiving the information. The students filled out the socio-demographic and clinical data with the patients. To lower the threshold for people with inadequate health literacy to participate, the students helped fill out the questionnaires when educational levels of patients were vocational or lower. 2.4 Data analysis Patient characteristics were analyzed as frequencies, percentages, means, and standard deviations (SDs), where appropriate. The assumption of normality was assessed by examining the skewness and kurtosis of variables. In our sample, values of skewness (≤ 3) and kurtosis (≤ 10) indicated that the normality assumption was satisfied [ 43 ]. Differences in these characteristics based on self-care mean scores, were analyzed using an independent t-test, a one-way analysis of variance (ANOVA) and a Welch’s ANOVA (when unequal variance between groups was observed) along with appropriate post-hoc tests as needed. To give insight into the differences between inadequate and adequate health literacy on the item level, we used an independent t-test. Pearson’s correlation coefficient ( r ) was used to test the correlation between the continuous variables. The point-biserial correlation was used between health literacy (dichotomous variable) and the continuous variables. A multivariable regression analysis was used to examine the relationship of self-care in individuals with chronic conditions. Dummy variables were created for the categorial variables, including health literacy (reference: inadequate health literacy), gender (reference: man), educational level (reference: primary education), and living situation (reference: living alone). An enter method regression model was applied, and all measured independent variables (age, gender, number of chronic conditions, educational level, living situation, and self-efficacy) were entered. Initially, a basic model was developed with health literacy as the only independent variable and each separate self-care scale as the dependent variable. Secondly, health literacy and the separate self-care scales were combined and corrected for the possible confounders of age and gender. Thirdly, the variables number of chronic conditions, educational level, and living situation were adjusted and corrected in a model. Finally, self-efficacy was added to the last model. In all regression models, the adjusted R 2 , standardized coefficients (β), 95% confidence intervals (CI), and p-values were reported. Model assumptions, including linearity, homoscedasticity, and absence of multicollinearity, were assessed before finalizing the models. Statistical analyses were performed using IBM SPSS Statistics version 30.0.0.0 (171). 2.5 Ethics This cross-sectional questionnaire survey did not fall under the scope of the Dutch Medical Research Involving Human Subjects Act (WMO). However, in Erasmus Medical Center Rotterdam, an independent quality check has been carried out (METC-2022-0460) to ensure compliance with legislation and regulations. 3. Results 3.1 Patients’ characteristics A total of 543 patients with chronic diseases participated; seven invalid and incomplete questionnaires were excluded, resulting in 536 eligible patients. Among these 536 patients, inadequate health literacy was prevalent in 247 (46%) patients. Most patients (63%) were 65 years or older, 54% were men, and 62% had at least one or two chronic diseases. The most frequently mentioned conditions were lung disease (40%), heart disease (34%), hypertension (33%) and diabetes (26%). Most patients were co-habiting (65%) and had an educational level with at least primary or secondary education (42%). Mean scores (± standard deviations) were 70.4 ± 14.7 for self-care maintenance, 69.9 ±22.3 for self-care monitoring, and 70.9 ± 19.7 for self-care management. The mean score for self-efficacy was 72.1 ± 16.7, as depicted in Table 1. 3.2 Relationship between health literacy and self-care maintenance Participants with adequate health literacy demonstrated statistically significant higher self-care maintenance than those with inadequate health literacy (mean = 73.16 ± 14.65 vs. 67.18 ± 14.14) (t(534) = -4.79; p <0.001)(see Table 2). At the item level, individuals with inadequate health literacy reported statistically significantly more difficulties with stress management, dietary choices, and engaging in physical activity than those with adequate health literacy (see Figure 1A), a pattern that mirrors the modest but statistically significant positive correlation between health literacy and self-care maintenance ( r = 0.20, P <0.001) (see Table 3). The univariate model (model 1), as presented in Table 4, indicated a statistically significant relationship (β = 5.98; 95% CI, 3.53-8.44; R 2 = 0.04), suggesting that health literacy alone accounts for 4% of the variance in self-care maintenance. Adding age and gender (model 2), marginally changed the effect (β = 6.24; 95% CI, 3.73-8.75; R 2 = 0.04) and after controlling for chronic conditions, educational level, and living situation (model 3), health literacy’s effect remained statistically significant (β = 5.61; 95% CI, 3.10-8.12; R 2 = 0.07). Entering self-efficacy in the model (model 4), the effect of health literacy become non-significant (β = 0.89; 95% CI, -1.62-3.40), with the full set of independent variables accounting for 21% of the variance ( R 2 =0.21). 3.3 Relationship between health literacy and self-care monitoring Individuals with adequate health literacy scored statistically significant higher on self-care monitoring than those with inadequate health literacy (meant = 74.50 ± 21.37 vs. 64.42 ± 22.08) (t(534) = -5.36; p <0.001) (see Table 1). Item-level analysis showed statistically significant differences in four of five items, with monitoring tiredness being the only exception (see Figure 1B). This aligns with a modest but statistically significantly positive correlation between health literacy and self-care monitoring ( r = 0.23, P <0.001) (see Table 3). In the unadjusted model (model 1), health literacy alone explained about 5% of the variance in self-care monitoring (β = 10.08; 95% CI, 6.38-13.77; R 2 = 0.05). After adding age and gender (model 2) (β = 9.36; 95% CI, 5.61-13.11; adjusted R 2 = 0.06) and entering chronic conditions, educational level, and living situation (model 3), the explained variance marginally increased (β = 8.74; 95% CI, 4.96-12.53; R 2 = 0.07). When self-efficacy was added in model 4, the relationship between health literacy and self-care monitoring was no longer statistically significant, with the adjusted R 2 increasing to 0.18 (β = 2.30; 95% CI, -1.54-6.14; R 2 = 0.18) (see Table 5). 3.4 Relationship between health literacy and self-care management Mean self-care management scores were statistically significantly higher among individuals with adequate health literacy compared to those with inadequate health literacy (mean = 73.81 ± 19.48 vs. 67.41 ± 19.43) (t(534) = -3.80; p <0.001) (see Table 1). Item-level analysis (see Figure 1C) showed statistically significant differences between inadequate and adequate health literacy; the only exception was medication use to alleviate or eliminate symptoms. This pattern corresponded to a weak yet statistically significant correlation between health literacy and self-care management ( r = 0.16, P <0.001) (see Table 3). In the univariate analysis (model 1) health literacy was statistically significantly related to self-care management (β = 6.40; 95% CI, 3.09-9.71; R 2 = 0.02). In model 2 (β = 5.68; 95% CI, 2.30-8.93; R 2 = 0.03) and model 3 (β = 5.51; 95% CI, 2.10-8.93; R 2 = 0.04) the relationship between health literacy and self-care management remained statistically significant. The significance disappeared after introducing self-efficacy (model 4) (β = 0.25; 95% CI, -3.26-3.75) (see Table 6). 4. Discussion and Conclusion This cross-sectional multicenter study evaluated the relationship between health literacy and self-care in adults with chronic diseases in the context of other relevant factors such as sociodemographic, social and health-related factors. Our findings demonstrate that adequate health literacy is linked to higher self-care scores in adults with chronic diseases. However, its independent contribution becomes negligible when controlling for self-efficacy. Given that health literacy alone cannot ensure optimal self-care its impact in our study is realized in combination with motivational and confidence factors. By recognizing inadequate health literacy in patients with chronic diseases, healthcare providers can tailor interventions to meet their individual needs, ensuring that information is both accessible and actionable. Traditionally, patients receive verbal or written information from their healthcare providers. Yet, translating accessible and actionable information into lasting self-care requires self-efficacy. Prior research has proposed mediation pathways for self-efficacy between health literacy and self-care, showing that individuals with higher health literacy tend to have greater confidence in navigating health systems and managing illness, which in turn improves self-care [ 44 , 45 ]. Researchers have also examined self-efficacy in individuals with chronic conditions, finding that self-efficacy exerts a moderate to strong impact on self-care behaviors, influencing both adherence and long-term behavior change [ 46 , 47 ]. These finding confirms that improving health literacy alone may not be sufficient to enhance self-care unless accompanied by strategies to build patients’ self-efficacy [ 48 ]. This role of self-efficacy in self-care behaviors is supported by Bandura’s Social Cognitive Theory, which states that self-efficacy influences how people think, feel, motivate themselves, and act [ 49 ]. Central to promoting self-efficacy is increasing a person’s confidence that they can change their behavior, and further establish a clear, achievable goal, and making the individual believe that this goal is accomplishable [ 50 ]. To promote self-efficacy in patients with chronic diseases, effective support techniques such as education, progress monitoring, information resources, social support, and patient-provider trust and communication in self-management behavior are essential [ 51 ]. These techniques can be delivered and combined within self-management programs, telehealth- and/or mobile applications, and in more non-traditional ways like gaming or by social media [ 52 ]. Using the HLS-EU-Q16, we found 46% of participants had inadequate health literacy, consistent with previous studies reporting low health literacy in one-third to nearly half of Europeans [ 53 , 54 ]. This questionnaire examines health literacy regarding four competencies: accessing, understanding, appraising and applying health information [ 31 ]. The HLS-EU-Q16 highlights which competencies pose challenges for individuals with inadequate health literacy, but does not reveal why these competencies are lacking. An additional framework may offer more insight into these underlying reasons, distinguishing three types of literacy: 1) functional literacy – involves the basic reading and writing skills necessary for everyday tasks; 2) interactive literacy – encompasses cognitive and social skills to engage with others, extract information, and interpret various forms of communication; 3) critical literacy – advanced cognitive and social skills which can be applied to critically analyze information and use this information in real-life situations [ 55 ]. Although functional competencies typically correlate with one’s education level, the relationship is not absolute: well educated individuals may still exhibit poor health literacy [ 56 , 57 ]. Although our study did not find a direct association between educational level and health literacy, the observed link between higher education and enhanced self-care – both in maintenance and monitoring activities – suggest that education may play a role in self-care tasks such as doing physical activity, eating or avoiding special foods, relieving stress or monitoring for medication side effects. This aligns with a recent systematic review in people with heart failure, which reports that in five studies educational level positively influenced self-care [ 58 ]. Regarding reading competencies, a systematic review on the comprehensibility of drug label instructions shows that many (standard) instructions are too complex for patients to read and thereby to understand [ 59 ]. Therefore, when healthcare providers communicate in plain language it can help patients better understand their health instructions [ 60 ]. Functional literacy also includes applying numerical information. Many older adults managing chronic conditions need to monitor their health at home – for example diabetes patients monitor their blood sugar, those with hypertension record their blood pressure, and patients with COPD interpret their peak expiratory flow readings. Translating raw numbers (e.g., “154 mg/dL”) into “Is this high or normal?” requires understanding references ranges, and what actions to take if readings are out of range, making specific interventions for these groups important [ 61 – 63 ]. The SC-CII was also applied in an Italian study involving 896 adults aged 65 years and older with multiple chronic conditions. In our study, participants with inadequate health literacy had a mean self-care maintenance score of 67.2 ± 14.1, closely aligning with the Italian study with means between 66 and 67. In contrast, participants with inadequate health literacy in our study, had lower mean scores on self-care monitoring (64.4 ± 21.4) than those in the Italian study whose means varied from 73 to 76. Conversely, for self-care management, individuals with inadequate health literacy had higher mean scores (67.4 ± 19.4) than the Italian sample, whose mean ranged from 58 to 60 [ 64 ]. These differences may be explained by the greater variety of reported conditions in our study. In addition to lung and heart diseases and diabetes (as in the Italian study), our participants also reported numerous secondary conditions, which may be more difficult to monitor or easier to manage. The generic self-care instrument of the SC-CII may limit its sensitivity in assessing disease-specific self-care monitoring behaviors; especially when symptoms overlap. Disease-specific self-care instruments can better target behaviors relevant to particular conditions, making them more recognizable to patients [ 64 ]. However, in Dutch, such instruments are currently only available for heart failure. Healthcare providers may generally assume that individuals with adequate health literacy can effectively perform self-care activities. However, the item-level analysis of the SC-CII in this study, showed that these people also face challenges regarding self-care – particularly in areas like stress reduction and dietary adjustments within self-care maintenance, and difficulties with modifying eating habits in self-care management. Interventions to address these difficulties among patients with chronic conditions are described in a scoping review with 233 articles, showing that dietary intake as an intervention was relatively often examined related to self-care across all chronic conditions (59%) and there was a lack of attention to interventions addressing the psychological consequences of chronic illness, such as stress reduction [ 18 ]. Nonetheless, health care providers should not assume that individuals with adequate health literacy automatically address effective self-care activities. A renewed focus in assessing needs for supporting e.g., stress reduction, dietary adjustment and eating habits in people with chronic conditions regardless their health literacy level may be prudent. 4.1 Strengths and limitations To our knowledge, this study is the first to examine the association between health literacy (measured by the HLS-EU-Q16) and self-care (assessed using the SC-CII) among individuals with chronic conditions. One strength of this study is its large sample (N = 536) with broad age range and multimorbidity, making it representative of hospitalized individuals. Another strength of our study is that we actively accommodated individuals with limited health literacy. To inform low-literacy participants, we supplemented the written patient information leaflet with a Quick Response (QR) code linking to an informational video about the study. The use of QR codes to deliver information in a more visual format remains for now underexplored [ 65 , 66 ] and provides opportunities to further explore whether this can be used to inform low-literacy groups. We also offered participants the option to complete the forms by reading and filling out answers with a student whenever their education level suggested limited literacy. This strategy was also applied in other research [ 67 ], but also had the risk of bias in the interview process [ 68 ], although students were instructed on how to administer the questionnaires. The self-reported measures may introduce social desirability bias. In addition to the consideration of the self-reported diseases does not fully preclude potential bias. The predominance of particular socioeconomic and cultural backgrounds within our study, may limit generalization to groups with different demographic profiles. Future studies should try to involve these populations, to confirm and extend the external validity of our results. 4.2 Conclusion In this multicenter study of 536 adults with at least one chronic condition, nearly half (46%) demonstrated inadequate health literacy, and those with adequate health literacy initially reported significantly higher self-care scores. However, once self-efficacy was added to the models, health literacy no longer independently associated with self-care, indicating that self-efficacy mediates the relationship. Although improving health literacy is valuable, strategies that strengthen patients’ confidence in managing their illness – such as goal-setting and tailored feedback and coaching – may be more effectively enhance self-care. Future research should focus on developing and testing interventions that simultaneously address both health literacy and self-efficacy to optimize self-care outcomes in people with chronic diseases. 4.3 Practice implications For clinical practice, our findings suggest that embedding self-efficacy–enhancing strategies within routine chronic-care pathways may be more impactful than focusing on health-literacy interventions alone. Healthcare providers should therefore move beyond providing simplified materials and together incorporate structured goal-setting, skills practice, and tailored feedback into both in-person and virtual care encounters. Additionally, actively involving family members or caregivers when cognitive or functional literacy barriers exist can ensure that educational content and self-management plans are understood and applied consistently. By systematically integrating these self-efficacy–building components alongside clear, accessible information, healthcare teams can better empower patients to translate knowledge into sustained self-care behaviors and, ultimately, improve health outcomes. Declarations Competing interests: The authors declare no competing interests. Ethics approval and consent to participate: This survey did not fall under the scope of the Dutch Medical Research Involving Human Subjects Act (WMO). However, approval of the ethics committee of the Erasmus Medical Center Rotterdam was obtained (METC-2022-0460) to ensure compliance with legislation and regulations. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Written informed consent was obtained from all participants. Consent for publication: not applicable Funding: This study was funded by the Dutch Research Council (NWO), Doctoral Grant for Teachers programme, grant number: 023.017.060. Author Contribution All authors made a significant contribution to the work reported. The study was developed collaboratively by AGD, ALS, SH, TJ. Material preparation and data collection were performed by AGD, and AK. AGD and JH analyzed and interpreted the data. The initial draft was composed by AGD and all authors contributed to the writing, reviewing, and editing of the subsequent versions of the manuscript. All authors have agreed on the journal to which the article will be submitted and have given their final approval for publication. Data Availability The Data supporting the findings of this study are available from the corresponding author upon reasonable request. References Sørensen K, van den Broucke S, Fullam J, Doyle G, Pelikan J, Slonska Z, et al. Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health. 2012;12:80. https://doi.org/10.1186/1471-2458-12-80 . Griese L, Schaeffer D, Berens EM. 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Curr Urol Rep. 2022;23(11):319–25. https://doi.org/10.1007/s11934-022-01116-7 . Tables Table 1 to 6 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1HLSC.docx Table2HLSC.docx Table3HLSC.docx Table4HLSC.docx Table5HLSC.docx Table6HLSC.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 06 Nov, 2025 Reviewers agreed at journal 20 Oct, 2025 Reviewers invited by journal 13 Oct, 2025 Editor invited by journal 07 Oct, 2025 Editor assigned by journal 22 Sep, 2025 Submission checks completed at journal 19 Sep, 2025 First submitted to journal 19 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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16:10:08","extension":"xml","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":225751,"visible":true,"origin":"","legend":"","description":"","filename":"3361cea500fc43818b73dea762db058f1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7573055/v1/c80918c894293a9719a09351.xml"},{"id":94480065,"identity":"dc7284ca-6085-494d-8afb-18abd1013d1e","added_by":"auto","created_at":"2025-10-27 16:09:17","extension":"html","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":245108,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7573055/v1/54c65cc93b219ba2e810f050.html"},{"id":94480654,"identity":"759c56d8-ac67-45ec-9d6e-3ab5ae11bde8","added_by":"auto","created_at":"2025-10-27 16:11:34","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":571688,"visible":true,"origin":"","legend":"\u003cp\u003eSelf-care scores on item level based on health literacy levels, with figure 1A depicting ‘self-care maintenance’, figure 1B depicting ‘self-care monitoring’, and figure 1C depicting ‘self-care management. Legend: Significant differences in mean item scores between inadequate and adequate health literacy are shown with a p-value determined based on an independent t-test.\u003c/p\u003e","description":"","filename":"Figuur1ABCv001color.png","url":"https://assets-eu.researchsquare.com/files/rs-7573055/v1/f35806737397f0d6e9ca1de8.png"},{"id":94490423,"identity":"a172274c-f0aa-436f-9b57-765f8b90f250","added_by":"auto","created_at":"2025-10-27 17:09:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1104960,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7573055/v1/5d192841-20ce-493d-a121-f441eba5f28d.pdf"},{"id":94480872,"identity":"64fe2c7d-4ede-4caf-838d-563f31431a7a","added_by":"auto","created_at":"2025-10-27 16:12:06","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":16857,"visible":true,"origin":"","legend":"","description":"","filename":"Table1HLSC.docx","url":"https://assets-eu.researchsquare.com/files/rs-7573055/v1/0762b89fee2fb2b3b1e21b07.docx"},{"id":94480070,"identity":"ac40f0fa-008c-4afa-9463-5a19fc2b58bf","added_by":"auto","created_at":"2025-10-27 16:09:19","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":19765,"visible":true,"origin":"","legend":"","description":"","filename":"Table2HLSC.docx","url":"https://assets-eu.researchsquare.com/files/rs-7573055/v1/9d4436c05c68190991e344a7.docx"},{"id":94480774,"identity":"d3a1be46-5ff5-4614-9862-8ad4796db4cd","added_by":"auto","created_at":"2025-10-27 16:11:57","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":17004,"visible":true,"origin":"","legend":"","description":"","filename":"Table3HLSC.docx","url":"https://assets-eu.researchsquare.com/files/rs-7573055/v1/31889c0e6ae855f89ced03c6.docx"},{"id":94480495,"identity":"81508d03-ef70-48c3-a12f-2bbf309da4a7","added_by":"auto","created_at":"2025-10-27 16:11:16","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":18412,"visible":true,"origin":"","legend":"","description":"","filename":"Table4HLSC.docx","url":"https://assets-eu.researchsquare.com/files/rs-7573055/v1/74ebe298d06bce6045cb26fd.docx"},{"id":94480271,"identity":"34dbdf94-7dd3-4b90-8b34-0eec940cef16","added_by":"auto","created_at":"2025-10-27 16:10:29","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":18341,"visible":true,"origin":"","legend":"","description":"","filename":"Table5HLSC.docx","url":"https://assets-eu.researchsquare.com/files/rs-7573055/v1/7ec24ca909edeb69e94c5911.docx"},{"id":94480368,"identity":"462db6ae-d5fa-4866-8480-89f2a6b5f5b8","added_by":"auto","created_at":"2025-10-27 16:10:50","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":18359,"visible":true,"origin":"","legend":"","description":"","filename":"Table6HLSC.docx","url":"https://assets-eu.researchsquare.com/files/rs-7573055/v1/1fae884c1f328aae0ce23009.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The relationship between health literacy and self-care in persons with chronic diseases: a multicenter cross-sectional study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eHealth literacy is defined as the knowledge, motivation, and competencies to access, understand, appraise, and apply information to make judgements and decisions in everyday life concerning healthcare, disease prevention and health promotion [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It is a strong predictor of self-care behaviors in individuals with chronic diseases [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Focusing on health literacy can be effective for promoting smoking cessation, enhancing physical activity, and supporting medication adherence. This in turn may improve clinical outcomes, such as mortality rates, healthcare service utilization, quality of life, and overall well-being in chronic diseases [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. A recent systematic review [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], highlighted several factors that are strongly associated with poor health literacy, emphasizing that health literacy should be understand within a brother context rather that treated as an isolated construct. These were sociodemographic factors (e.g., older age [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and low educational level [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]), social factors (e.g., poor family support or living alone [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]), economic factors (e.g., lower socioeconomic status), and health-related factors (e.g., number of chronic diseases [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]).\u003c/p\u003e\u003cp\u003eWithin an ageing population, chronic diseases tend to be of long duration and result from a combination of genetic, physiological, environmental and behavioral factors [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Chronic diseases are widespread and increasing worldwide, presenting major public health challenges and accounting for over 74% of global deaths [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] and 90% of deaths in Europe [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Chronic diseases include a range of conditions such as cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes, and can occur in all phases of life, but especially in elderly people [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. People with chronic diseases experience physical and emotional symptoms, reducing their quality of life [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] and contributing to disability [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSelf-care is an important aspect of managing chronic diseases and is strongly associated with numerous positive health outcomes [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The Middle Range Theory of Self-Care of Chronic Illness defines self-care as a process of maintaining health through health promoting practices and managing illness. This definition emphasizes that self-care includes various general and disease-specific actions that individuals with chronic diseases undertake to maintain their physical and emotional well-being. Activities such as adhering to medication regimens, following dietary recommendations, engaging in regular exercise are collectively known as \u003cem\u003eself-care maintenance\u003c/em\u003e which may prevent symptom exacerbation and supports long-term disease control. \u003cem\u003eSelf-care monitoring\u003c/em\u003e refers to the process of monitoring behavior and observing oneself for changes in signs and symptoms, which is important to detect early disease-related health changes. When these changes appear, individuals can apply a variety of behaviors to relieve or correct them, which is defined as \u003cem\u003eself-care management\u003c/em\u003e [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Within the context of self-care, \u003cem\u003eself-efficacy\u003c/em\u003e \u0026ndash; the confidence individuals have in the ability to perform self-care practices and persist despite barriers, such as poor health literacy \u0026ndash; is a powerful and consistent influence on performance of self-care across patient populations [\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOverall, existing research on health literacy and self-care yielded inconsistent findings. Some studies suggest a positive association between health literacy and self-care; more specifically, higher health literacy levels are regularly associated with enhanced self-care behaviors, such as medication adherence in patients with cardiovascular disease [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], the positive role of critical health literacy in patients\u0026rsquo; self-care with chronic kidney disease [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], and improvements in diet adherence and weight management in patients with hypertension [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. However, there are also studies suggesting absent or negative associations [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe inconsistencies in existing literature underscore the need for additional research to clarify the relationship between health literacy and self-care. This may guide future evidence-based strategies for optimizing patient education in individuals with chronic diseases. This study aims to examine the relationship between health literacy and self-care behaviors in people with chronic diseases.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Design and sample\u003c/h2\u003e\u003cp\u003eThis study was a multi-center cross-sectional survey conducted from October 2022 to June 2024 in six hospitals on nursing wards in the Netherlands. Convenience sampling was used to recruit patients with chronic diseases. Inclusion criteria were (1) having at least one chronic condition (2) being aged 18 years or older, and (3) being capable of verbal communication in Dutch. Patients with an expected limited life expectancy of less than 3 months or with dementia or delirium were not eligible. The sample size for multiple regression analysis was calculated using Gpower3.1 [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. A sample size of 536 was determined to be sufficient having a power of 0.95, an alpha of 0.05, an effect size \u003cem\u003ef\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e of 0.05 and with 7 independent variables (health literacy, age, gender, chronic conditions, educational level, living situation, and self-efficacy).\u003c/p\u003e\u003cp\u003eThis research follows the STROBE guidelines for cross-sectional studies [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], see attachment 1.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Instruments\u003c/h2\u003e\u003cp\u003eSocio-demographic and clinical data of participants were collected, including age, number of chronic conditions, gender, educational level, and living situation.\u003c/p\u003e\u003cp\u003eHealth literacy was assessed by the validated 16-item version of the European Health Literacy Survey Questionnaire (HLS-EU-Q16) in Dutch, including questions that assess participants\u0026rsquo; ability to access, understand, appraise and apply health-related information [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Responses are recorded on a 4-point Likert scale, ranging from 1 (very difficult) to 4 (very easy). The HLS-EU-Q16 manual recommends dichotomizing the answers from HLS-EU-Q16 (\u0026lsquo;very difficult\u0026rsquo;/\u0026rsquo;fairly difficult\u0026rsquo; = 0, \u0026lsquo;fairly easy\u0026rsquo;/ \u0026lsquo;very easy\u0026rsquo; = 1; total 0\u0026ndash;16 scores) and dividing the total scores into three categories of health literacy (\u0026lsquo;likely inadequate health literacy\u0026rsquo; (0\u0026ndash;8 scores), \u0026lsquo;likely problematic health literacy\u0026rsquo; (9\u0026ndash;12 scores) and \u0026lsquo;likely sufficient health literacy\u0026rsquo; (13\u0026ndash;16 scores). The categories were dichotomized into \u0026lsquo;inadequate\u0026rsquo; (likely inadequate and likely problematic) and \u0026lsquo;adequate\u0026rsquo;. This approach has been utilized previously [\u003cspan additionalcitationids=\"CR33 CR34 CR35\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. According to the HLS-EU-Q16 manual, participants with more than two incomplete responses in the HLS-EU-Q16 items were excluded [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Cronbach\u0026rsquo;s alpha was calculated to evaluate the HLS-EU-Q16\u0026rsquo;s internal consistency in this study, providing a coefficient of 0.903, indicating strong reliability [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSelf-care was measured using the validated Dutch version of the validated Self-Care of Chronic Illness Inventory (SC-CII v4c) [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. This 19-item questionnaire consists of three different scales measuring self-care maintenance, self-care monitoring, and self-care management. Items were scored on a five-point Likert scale, ranging from 1 to 5, except items 13 and 19, which used a six-point Likert scale, ranging from 0 to 5. Item 13 is used to reflect the link between self-care monitoring and self-care management and item 19 reflects the perceived effect of self-care management. Both items (13 and 19) were not included in the sum scores of the self-care scales. Each scale was scored separately and then converted into a 0 to 100 scale according to the self-care scoring algorithm (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://self-care-measures.com/self-care-scoring-algorithm/\u003c/span\u003e\u003cspan address=\"https://self-care-measures.com/self-care-scoring-algorithm/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). Higher scores indicated better self-care, and a score of \u0026ge;\u0026thinsp;70 was seen as an adequate level for self-care [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. The psychometric testing of the previous version(s) of SC-CII has demonstrated credible, reliable, and generalizable results in the Western context [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Cronbach\u0026rsquo;s alpha was calculated for each self-care scale in this study, with internal consistency coefficients of 0.531 for self-care maintenance, 0.806 for self-care monitoring and 0.644 for self-care management [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSelf-efficacy was measured with the Self-Care Self Efficacy Scale (SCSES) [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. This 10-item instrument measures self-efficacy with starting each question with \u0026ldquo;How confident are you that you can\u0026hellip;\u0026rdquo;. The phrase \u0026ldquo;how confident\u0026rdquo; captures the strength of the belief while the adjunctive clause affirms the ability to perform a specific self-care action. Items were rated on a \u0026lsquo;1\u0026ndash;5\u0026rsquo; rating scale and ranged from 0 to 100 based on the same algorithm as the SC-CII. Higher scores indicate greater self-efficacy, with a score of \u0026ge;\u0026thinsp;70 considered an adequate level. Cronbach\u0026rsquo;s alpha was calculated for the SCES\u0026rsquo;s internal consistency in this study, yielding a coefficient of 0.869 [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Data collection procedure\u003c/h2\u003e\u003cp\u003eBachelor of Nursing students provided eligible patients with verbal and written information about the study. The written information was also supported with a QR code connected to an information video about the study. Informed consent was signed directly after receiving the information. The students filled out the socio-demographic and clinical data with the patients. To lower the threshold for people with inadequate health literacy to participate, the students helped fill out the questionnaires when educational levels of patients were vocational or lower.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Data analysis\u003c/h2\u003e\u003cp\u003ePatient characteristics were analyzed as frequencies, percentages, means, and standard deviations (SDs), where appropriate. The assumption of normality was assessed by examining the skewness and kurtosis of variables. In our sample, values of skewness (\u0026le;\u0026thinsp;3) and kurtosis (\u0026le;\u0026thinsp;10) indicated that the normality assumption was satisfied [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Differences in these characteristics based on self-care mean scores, were analyzed using an independent t-test, a one-way analysis of variance (ANOVA) and a Welch\u0026rsquo;s ANOVA (when unequal variance between groups was observed) along with appropriate post-hoc tests as needed. To give insight into the differences between inadequate and adequate health literacy on the item level, we used an independent t-test.\u003c/p\u003e\u003cp\u003ePearson\u0026rsquo;s correlation coefficient (\u003cem\u003er\u003c/em\u003e) was used to test the correlation between the continuous variables. The point-biserial correlation was used between health literacy (dichotomous variable) and the continuous variables.\u003c/p\u003e\u003cp\u003eA multivariable regression analysis was used to examine the relationship of self-care in individuals with chronic conditions. Dummy variables were created for the categorial variables, including health literacy (reference: inadequate health literacy), gender (reference: man), educational level (reference: primary education), and living situation (reference: living alone). An enter method regression model was applied, and all measured independent variables (age, gender, number of chronic conditions, educational level, living situation, and self-efficacy) were entered. Initially, a basic model was developed with health literacy as the only independent variable and each separate self-care scale as the dependent variable. Secondly, health literacy and the separate self-care scales were combined and corrected for the possible confounders of age and gender. Thirdly, the variables number of chronic conditions, educational level, and living situation were adjusted and corrected in a model. Finally, self-efficacy was added to the last model. In all regression models, the adjusted \u003cem\u003eR\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e, standardized coefficients (β), 95% confidence intervals (CI), and p-values were reported. Model assumptions, including linearity, homoscedasticity, and absence of multicollinearity, were assessed before finalizing the models. Statistical analyses were performed using IBM SPSS Statistics version 30.0.0.0 (171).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.5 Ethics\u003c/h2\u003e\u003cp\u003eThis cross-sectional questionnaire survey did not fall under the scope of the Dutch Medical Research Involving Human Subjects Act (WMO). However, in Erasmus Medical Center Rotterdam, an independent quality check has been carried out (METC-2022-0460) to ensure compliance with legislation and regulations.\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cem\u003e3.1 Patients\u0026rsquo; characteristics\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA total of 543 patients with chronic diseases participated; seven invalid and incomplete questionnaires were excluded, resulting in 536 eligible patients. Among these 536 patients, inadequate health literacy was prevalent in 247 (46%) patients. Most patients (63%) were 65 years or older, 54% were men, and 62% had at least one or two chronic diseases. The most frequently mentioned conditions were lung disease (40%), heart disease (34%), hypertension (33%) and diabetes (26%). Most patients were co-habiting (65%) and had an educational level with at least primary or secondary education (42%). Mean scores (\u0026plusmn; standard deviations) were 70.4 \u0026plusmn; 14.7 for self-care maintenance, 69.9 \u0026plusmn;22.3 for self-care monitoring, and 70.9 \u0026plusmn; 19.7 for self-care management. The mean score for self-efficacy was 72.1 \u0026plusmn; 16.7, as depicted in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3.2 Relationship between health literacy and self-care maintenance\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants with adequate health literacy demonstrated statistically significant higher self-care maintenance than those with inadequate health literacy (mean = 73.16 \u0026plusmn; 14.65 vs. 67.18 \u0026plusmn; 14.14) (t(534) = -4.79; \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001)(see Table 2). At the item level, individuals with inadequate health literacy reported statistically significantly more difficulties with stress management, dietary choices, and engaging in physical activity than those with adequate health literacy (see Figure 1A), a pattern that mirrors the modest but statistically significant positive correlation between health literacy and self-care maintenance (\u003cem\u003er\u0026nbsp;\u003c/em\u003e= 0.20,\u003cem\u003e\u0026nbsp;P\u003c/em\u003e\u0026lt;0.001) (see Table 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe univariate model (model 1), as presented in Table 4, indicated a statistically significant relationship (\u0026beta; = 5.98; 95% CI, 3.53-8.44; \u003cem\u003eR\u003c/em\u003e\u003csup\u003e2\u0026nbsp;\u003c/sup\u003e= 0.04), suggesting that health literacy alone accounts for 4% of the variance in self-care maintenance. Adding age and gender (model 2), marginally changed the effect (\u0026beta;\u0026nbsp;= 6.24; 95% CI, 3.73-8.75;\u003cem\u003e\u0026nbsp;R\u003c/em\u003e\u003csup\u003e2\u0026nbsp;\u003c/sup\u003e= 0.04) and after controlling for chronic conditions, educational level, and living situation (model 3), health literacy\u0026rsquo;s effect remained statistically significant (\u0026beta; = 5.61; 95% CI, 3.10-8.12; \u003cem\u003eR\u003c/em\u003e\u003csup\u003e2\u0026nbsp;\u003c/sup\u003e= 0.07). Entering self-efficacy in the model (model 4), the effect of health literacy become non-significant (\u0026beta;\u0026nbsp;= 0.89; 95% CI, -1.62-3.40), with the full set of independent variables accounting for 21% of the variance (\u003cem\u003eR\u003c/em\u003e\u003csup\u003e2\u0026nbsp;\u003c/sup\u003e=0.21).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3.3 Relationship between health literacy and self-care monitoring\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIndividuals with adequate health literacy scored statistically significant higher on self-care monitoring than those with inadequate health literacy (meant = 74.50 \u0026plusmn; 21.37 vs. 64.42 \u0026plusmn; 22.08) (t(534) = -5.36; \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001) (see Table 1). Item-level analysis showed statistically significant differences in four of five items, with monitoring tiredness being the only exception (see Figure 1B). This aligns with a modest but statistically significantly positive correlation between health literacy and self-care monitoring (\u003cem\u003er =\u0026nbsp;\u003c/em\u003e0.23,\u003cem\u003e\u0026nbsp;P\u003c/em\u003e\u0026lt;0.001) (see Table 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the unadjusted model (model 1), health literacy alone explained about 5% of the variance in self-care monitoring (\u0026beta; = 10.08; 95% CI, 6.38-13.77; \u003cem\u003eR\u003c/em\u003e\u003csup\u003e2 \u0026nbsp;\u003c/sup\u003e= 0.05). After adding age and gender (model 2) (\u0026beta; = 9.36; 95% CI, 5.61-13.11; adjusted \u003cem\u003eR\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e = 0.06) and entering chronic conditions, educational level, and living situation (model 3), the explained variance marginally increased (\u0026beta; = 8.74; 95% CI, 4.96-12.53;\u003cem\u003e\u0026nbsp;R\u003c/em\u003e\u003csup\u003e2\u0026nbsp;\u003c/sup\u003e= 0.07). When self-efficacy was added in model 4, the relationship between health literacy and self-care monitoring was no longer statistically significant, with the adjusted \u003cem\u003eR\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e increasing to 0.18 (\u0026beta; = 2.30; 95% CI, -1.54-6.14; \u003cem\u003eR\u003c/em\u003e\u003csup\u003e2\u0026nbsp;\u003c/sup\u003e= 0.18) (see Table 5).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3.4 Relationship between health literacy and self-care management\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMean self-care management scores were statistically significantly higher among individuals with adequate health literacy compared to those with inadequate health literacy (mean = 73.81\u0026nbsp;\u0026plusmn;\u0026nbsp;19.48 vs. 67.41\u0026nbsp;\u0026plusmn;\u0026nbsp;19.43) (t(534) = -3.80;\u0026nbsp;\u003cem\u003ep\u003c/em\u003e\u0026lt;0.001) (see Table 1). Item-level analysis (see Figure 1C) showed statistically significant differences between inadequate and adequate health literacy; the only \u0026nbsp;exception was medication use to alleviate or eliminate symptoms. This pattern corresponded to a weak yet statistically significant correlation between health literacy and self-care management (\u003cem\u003er =\u0026nbsp;\u003c/em\u003e0.16,\u003cem\u003e\u0026nbsp;P\u003c/em\u003e\u0026lt;0.001) (see Table 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the univariate analysis (model 1) health literacy was statistically significantly related to self-care management (\u0026beta;\u0026nbsp;= 6.40; 95% CI, 3.09-9.71;\u0026nbsp;\u003cem\u003eR\u003c/em\u003e\u003csup\u003e2\u0026nbsp;\u003c/sup\u003e= 0.02). In model 2 (\u0026beta;\u0026nbsp;= 5.68; 95% CI, 2.30-8.93;\u003cem\u003e\u0026nbsp;R\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e = 0.03) and model 3 (\u0026beta;\u0026nbsp;= 5.51; 95% CI, 2.10-8.93;\u003cem\u003e\u0026nbsp;R\u003c/em\u003e\u003csup\u003e2\u0026nbsp;\u003c/sup\u003e= 0.04) the relationship between health literacy and self-care management remained statistically significant. The significance disappeared after introducing self-efficacy (model 4) (\u0026beta; = 0.25; 95% CI, -3.26-3.75) (see Table 6).\u003c/p\u003e"},{"header":"4. Discussion and Conclusion","content":"\u003cp\u003eThis cross-sectional multicenter study evaluated the relationship between health literacy and self-care in adults with chronic diseases in the context of other relevant factors such as sociodemographic, social and health-related factors. Our findings demonstrate that adequate health literacy is linked to higher self-care scores in adults with chronic diseases. However, its independent contribution becomes negligible when controlling for self-efficacy. Given that health literacy alone cannot ensure optimal self-care its impact in our study is realized in combination with motivational and confidence factors.\u003c/p\u003e\u003cp\u003eBy recognizing inadequate health literacy in patients with chronic diseases, healthcare providers can tailor interventions to meet their individual needs, ensuring that information is both accessible and actionable. Traditionally, patients receive verbal or written information from their healthcare providers. Yet, translating accessible and actionable information into lasting self-care requires self-efficacy. Prior research has proposed mediation pathways for self-efficacy between health literacy and self-care, showing that individuals with higher health literacy tend to have greater confidence in navigating health systems and managing illness, which in turn improves self-care [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Researchers have also examined self-efficacy in individuals with chronic conditions, finding that self-efficacy exerts a moderate to strong impact on self-care behaviors, influencing both adherence and long-term behavior change [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. These finding confirms that improving health literacy alone may not be sufficient to enhance self-care unless accompanied by strategies to build patients\u0026rsquo; self-efficacy [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. This role of self-efficacy in self-care behaviors is supported by Bandura\u0026rsquo;s Social Cognitive Theory, which states that self-efficacy influences how people think, feel, motivate themselves, and act [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Central to promoting self-efficacy is increasing a person\u0026rsquo;s confidence that they can change their behavior, and further establish a clear, achievable goal, and making the individual believe that this goal is accomplishable [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. To promote self-efficacy in patients with chronic diseases, effective support techniques such as education, progress monitoring, information resources, social support, and patient-provider trust and communication in self-management behavior are essential [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. These techniques can be delivered and combined within self-management programs, telehealth- and/or mobile applications, and in more non-traditional ways like gaming or by social media [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eUsing the HLS-EU-Q16, we found 46% of participants had inadequate health literacy, consistent with previous studies reporting low health literacy in one-third to nearly half of Europeans [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. This questionnaire examines health literacy regarding four competencies: accessing, understanding, appraising and applying health information [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. The HLS-EU-Q16 highlights \u003cem\u003ewhich\u003c/em\u003e competencies pose challenges for individuals with inadequate health literacy, but does not reveal \u003cem\u003ewhy\u003c/em\u003e these competencies are lacking. An additional framework may offer more insight into these underlying reasons, distinguishing three types of literacy: 1) functional literacy \u0026ndash; involves the basic reading and writing skills necessary for everyday tasks; 2) interactive literacy \u0026ndash; encompasses cognitive and social skills to engage with others, extract information, and interpret various forms of communication; 3) critical literacy \u0026ndash; advanced cognitive and social skills which can be applied to critically analyze information and use this information in real-life situations [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAlthough functional competencies typically correlate with one\u0026rsquo;s education level, the relationship is not absolute: well educated individuals may still exhibit poor health literacy [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. Although our study did not find a direct association between educational level and health literacy, the observed link between higher education and enhanced self-care \u0026ndash; both in maintenance and monitoring activities \u0026ndash; suggest that education may play a role in self-care tasks such as doing physical activity, eating or avoiding special foods, relieving stress or monitoring for medication side effects. This aligns with a recent systematic review in people with heart failure, which reports that in five studies educational level positively influenced self-care [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. Regarding reading competencies, a systematic review on the comprehensibility of drug label instructions shows that many (standard) instructions are too complex for patients to read and thereby to understand [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. Therefore, when healthcare providers communicate in plain language it can help patients better understand their health instructions [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. Functional literacy also includes applying numerical information. Many older adults managing chronic conditions need to monitor their health at home \u0026ndash; for example diabetes patients monitor their blood sugar, those with hypertension record their blood pressure, and patients with COPD interpret their peak expiratory flow readings. Translating raw numbers (e.g., \u0026ldquo;154 mg/dL\u0026rdquo;) into \u0026ldquo;Is this high or normal?\u0026rdquo; requires understanding references ranges, and what actions to take if readings are out of range, making specific interventions for these groups important [\u003cspan additionalcitationids=\"CR62\" citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe SC-CII was also applied in an Italian study involving 896 adults aged 65 years and older with multiple chronic conditions. In our study, participants with inadequate health literacy had a mean self-care maintenance score of 67.2\u0026thinsp;\u0026plusmn;\u0026thinsp;14.1, closely aligning with the Italian study with means between 66 and 67. In contrast, participants with inadequate health literacy in our study, had lower mean scores on self-care monitoring (64.4\u0026thinsp;\u0026plusmn;\u0026thinsp;21.4) than those in the Italian study whose means varied from 73 to 76. Conversely, for self-care management, individuals with inadequate health literacy had higher mean scores (67.4\u0026thinsp;\u0026plusmn;\u0026thinsp;19.4) than the Italian sample, whose mean ranged from 58 to 60 [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]. These differences may be explained by the greater variety of reported conditions in our study. In addition to lung and heart diseases and diabetes (as in the Italian study), our participants also reported numerous secondary conditions, which may be more difficult to monitor or easier to manage. The generic self-care instrument of the SC-CII may limit its sensitivity in assessing disease-specific self-care monitoring behaviors; especially when symptoms overlap. Disease-specific self-care instruments can better target behaviors relevant to particular conditions, making them more recognizable to patients [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]. However, in Dutch, such instruments are currently only available for heart failure.\u003c/p\u003e\u003cp\u003eHealthcare providers may generally assume that individuals with adequate health literacy can effectively perform self-care activities. However, the item-level analysis of the SC-CII in this study, showed that these people also face challenges regarding self-care \u0026ndash; particularly in areas like stress reduction and dietary adjustments within self-care maintenance, and difficulties with modifying eating habits in self-care management. Interventions to address these difficulties among patients with chronic conditions are described in a scoping review with 233 articles, showing that dietary intake as an intervention was relatively often examined related to self-care across all chronic conditions (59%) and there was a lack of attention to interventions addressing the psychological consequences of chronic illness, such as stress reduction [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Nonetheless, health care providers should not assume that individuals with adequate health literacy automatically address effective self-care activities. A renewed focus in assessing needs for supporting e.g., stress reduction, dietary adjustment and eating habits in people with chronic conditions regardless their health literacy level may be prudent.\u003c/p\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e4.1 Strengths and limitations\u003c/h2\u003e\u003cp\u003eTo our knowledge, this study is the first to examine the association between health literacy (measured by the HLS-EU-Q16) and self-care (assessed using the SC-CII) among individuals with chronic conditions. One strength of this study is its large sample (N\u0026thinsp;=\u0026thinsp;536) with broad age range and multimorbidity, making it representative of hospitalized individuals. Another strength of our study is that we actively accommodated individuals with limited health literacy. To inform low-literacy participants, we supplemented the written patient information leaflet with a Quick Response (QR) code linking to an informational video about the study. The use of QR codes to deliver information in a more visual format remains for now underexplored [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e] and provides opportunities to further explore whether this can be used to inform low-literacy groups. We also offered participants the option to complete the forms by reading and filling out answers with a student whenever their education level suggested limited literacy. This strategy was also applied in other research [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e], but also had the risk of bias in the interview process [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e], although students were instructed on how to administer the questionnaires.\u003c/p\u003e\u003cp\u003eThe self-reported measures may introduce social desirability bias. In addition to the consideration of the self-reported diseases does not fully preclude potential bias. The predominance of particular socioeconomic and cultural backgrounds within our study, may limit generalization to groups with different demographic profiles. Future studies should try to involve these populations, to confirm and extend the external validity of our results.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003e4.2 Conclusion\u003c/h2\u003e\u003cp\u003eIn this multicenter study of 536 adults with at least one chronic condition, nearly half (46%) demonstrated inadequate health literacy, and those with adequate health literacy initially reported significantly higher self-care scores. However, once self-efficacy was added to the models, health literacy no longer independently associated with self-care, indicating that self-efficacy mediates the relationship. Although improving health literacy is valuable, strategies that strengthen patients\u0026rsquo; confidence in managing their illness \u0026ndash; such as goal-setting and tailored feedback and coaching \u0026ndash; may be more effectively enhance self-care. Future research should focus on developing and testing interventions that simultaneously address both health literacy and self-efficacy to optimize self-care outcomes in people with chronic diseases.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e4.3 Practice implications\u003c/h2\u003e\u003cp\u003eFor clinical practice, our findings suggest that embedding self-efficacy\u0026ndash;enhancing strategies within routine chronic-care pathways may be more impactful than focusing on health-literacy interventions alone. Healthcare providers should therefore move beyond providing simplified materials and together incorporate structured goal-setting, skills practice, and tailored feedback into both in-person and virtual care encounters. Additionally, actively involving family members or caregivers when cognitive or functional literacy barriers exist can ensure that educational content and self-management plans are understood and applied consistently. By systematically integrating these self-efficacy\u0026ndash;building components alongside clear, accessible information, healthcare teams can better empower patients to translate knowledge into sustained self-care behaviors and, ultimately, improve health outcomes.\u003c/p\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eCompeting interests:\u003c/h2\u003e\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\u003ch2\u003eEthics approval and consent to participate:\u003c/h2\u003e\u003cp\u003eThis survey did not fall under the scope of the Dutch Medical Research Involving Human Subjects Act (WMO). However, approval of the ethics committee of the Erasmus Medical Center Rotterdam was obtained (METC-2022-0460) to ensure compliance with legislation and regulations. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Written informed consent was obtained from all participants.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003cp\u003enot applicable\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e\u003cp\u003eThis study was funded by the Dutch Research Council (NWO), Doctoral Grant for Teachers programme, grant number: 023.017.060.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors made a significant contribution to the work reported. The study was developed collaboratively by AGD, ALS, SH, TJ. Material preparation and data collection were performed by AGD, and AK. AGD and JH analyzed and interpreted the data. The initial draft was composed by AGD and all authors contributed to the writing, reviewing, and editing of the subsequent versions of the manuscript. All authors have agreed on the journal to which the article will be submitted and have given their final approval for publication.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe Data supporting the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eS\u0026oslash;rensen K, van den Broucke S, Fullam J, Doyle G, Pelikan J, Slonska Z, et al. Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health. 2012;12:80. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1471-2458-12-80\u003c/span\u003e\u003cspan address=\"10.1186/1471-2458-12-80\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGriese L, Schaeffer D, Berens EM. 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Curr Urol Rep. 2022;23(11):319\u0026ndash;25. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11934-022-01116-7\u003c/span\u003e\u003cspan address=\"10.1007/s11934-022-01116-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 to 6 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7573055/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7573055/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo examine the relationship between health literacy and self-care (maintenance, monitoring, and management) in people with chronic diseases.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA multicenter cross-sectional study was conducted in six hospitals (one academic, four teaching, and one general) in the Netherlands among 536 adults (≥ 18 years) with at least one chronic disease between October 2022 and June 2024. Participants completed sociodemographic data, the European Health Literacy Survey Questionnaire (HLS-EU-Q16), the Self-Care of Chronic Illness Inventory (SC-CII v4c), and the Self-Care Self-Efficacy Scale. Associations between health literacy (adequate vs. inadequate) and self-care (maintenance, monitoring and management) were tested with multivariable linear regression adjusted for age, gender, number of chronic conditions, educational level, living situation, and self-efficacy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf 536 adults (mean age 67 ± 14 years, 54% men), 46% had inadequate health literacy. Mean self-care scores were 70.4 ± 14.7 (maintenance), 69.9 ± 22.3 (monitoring), and 70.9 ± 19.7 (management) on a 0-100 scale. In multivariable models, adequate health literacy is associated with better self-care maintenance (β = 5.6, 95% CI 3.1–8.1), self-care monitoring (β = 8.7, 95% CI 5.0-1.5), and self-care management (β = 5.5, 95% CI 2.1–8.9) when adjusting for all controlled variables. However, this association become non-significant after adding self-efficacy, which explained most of the residual variance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdequate health literacy is associated with higher self-care scores among adults with chronic diseases. However, such association was diminished when self-efficacy is accounted for, indicating that self-efficacy mediates the relationship between health literacy and self-care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number: \u003c/strong\u003eNot applicable\u003c/p\u003e","manuscriptTitle":"The relationship between health literacy and self-care in persons with chronic diseases: a multicenter cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-27 15:21:59","doi":"10.21203/rs.3.rs-7573055/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-11-06T14:00:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"252711842251296461952307462929965158737","date":"2025-10-20T13:33:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-13T10:55:51+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-07T07:00:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-22T12:24:47+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-19T06:52:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-09-19T06:48:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fd056acd-e37d-4012-91e5-7fc603397540","owner":[],"postedDate":"October 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-27T15:21:59+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-27 15:21:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7573055","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7573055","identity":"rs-7573055","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}