The present study showed that sociodemographic indicators, health literacy, self-efficacy, and health behavior were identified as important factors of health status. Path analysis displayed that the association between health literacy and health status occurs through three different pathways. The first pathway directly connected health literacy and self-rated health status, another went through self-efficacy, and the remaining paths were through health behavior. In addition, age and income exerted a direct influence on health literacy. Sociodemographic variables explained 14.1% of variability in health literacy, while health literacy and other variables explained 15.0% of the variability in health status.
This tool we used to assess health literacy is designed to measure an individual’s basic knowledge and concepts, healthy lifestyles and behaviors, and basic skills. Different from foreign health literacy evaluation systems, this public health-oriented tool mainly evaluates people’s ability to obtain, understand, and use health information and is unsuitable for rapid assessment of patients’ health literacy in the medical environment. The proposed tool also follows the World Health Organization’s definition of health literacy, that is, health literacy represents cognitive and social skills that determine the individual’s motivation and ability to obtain, understand, and use health information while promoting health through these pathways .
Health literacy in the model was influenced by the two sociodemographic variables of income and education. Similar to the results of Suka , health literacy increased with income. Notably, high income and health status were partially related to adequate health literacy, strong self-efficacy, and positive behavior. This finding further verified that this relationship may also be partially due the susceptibility of residents to health literacy, self-efficacy, and behavior in addition to the direct impact of high income on health status. These findings emphasized the importance of considering complex models that include different aspects of residents’ lives to understand the ways in which positive health conditions are formed further. Consequently, interventions aimed at developing positive health conditions should not be limited to measures for increasing family income because income will only slightly fluctuate over a long period of time. Meanwhile, other approaches should be considered to address residents with poor health literacy and the resultant low self-efficacy or risk behavior.
In terms of the relationship between education and health literacy, our results were also similar to Sun’s . Education was related to self-rated health status through health literacy and its consequence. On the basis of this premise, the residents will unlikely demonstrate sufficient health literacy when they present a low education level. This finding may spiral into low self-efficacy and negative health behavior, and eventually lead to serious health outcomes when ignored. The current results also support the evidence from a previous study, which reported that health literacy may be a pathway for socioeconomic status to affect health status, especially in low socioeconomic groups . Therefore, health literacy may be easier to modify than the main established socioeconomic determinants of health inequality. These findings reinforce the claim that the lack of health literacy among vulnerable groups plays a fundamental role in individuals’ health, thereby indicating that the problem of poor health status must be addressed through multi-level interventions implemented by different professions and departments.
Our results demonstrated that a positive effect existed between health literacy and self-rated health status. The significance of health literacy in the process was noticeable. This finding has repeatedly recurred in the literature over the years [37, 38]. Baker proposed that health literacy was one of the many factors that could contribute to improved health outcomes . Besides, broadly defined health literacy also included conceptual health knowledge . People with sufficient health literacy showed the initiative and enthusiasm to acquire their own health information and core knowledge of diseases while adopting corresponding health skills in daily life to seek help from others according to their own characteristics. Meanwhile, they can use social resources to enhance healthy behaviors and reduce risk factors for disease, thereby promoting a positive health status. The improvement of basic knowledge, basic skills, and lifestyle literacies will inevitably exert an impact on residents’ cognition, psychology, and health-related behavior. Moreover, positive health conditions are inseparable from the expansion of health knowledge, the formation of healthy lifestyle, or the development of health-related skills [39, 40]. People with adequate health literacy attach great importance to their own health status and autonomously learn relevant health knowledge through the Internet or other pathways to improve their health status. Although several people have already suffered from chronic diseases, the quality of life and disease management competence with sufficient health literacy is better than those with insufficient health literacy due to the mastering of knowledge, methods, or skills in dealing with diseases [41, 42].
These findings suggested that health behavior preceded self-rated health status. Consistent with the original hypothesis proposed in the model, health behavior played a mediating role between health literacy and health status. People with sufficient health literacy are more likely to seek health information through multiple channels, which changes people’s perceptions on health issues and influences them to alter their behavior, thereby making decisions that are beneficial to their health . Similarly, individuals with inferior health literacy are less likely to adopt positive behavior and may avoid obtaining health information, thereby increasing health barriers. From this perspective, the behavior is a significant factor in the process between health literacy and health status, thereby indicating that insufficient health literacy is only one of the causes of poor health status.
We also found that health literacy had an active influence on health status through self-efficacy, and this finding was consistent with that of a previous study . Our study indicated that increasing health-related knowledge and addressing related psychosocial factors were necessary to enhance the health status of residents with insufficient health literacy. Increased self-efficacy may promote beneficial results through specific behaviors, such as weight reduction , smoking cessation , and adherence to exercise programs , allowing people to avoid conditions that contribute to serious health outcomes or maintain satisfactory health conditions. However, we did not find the significant connection between self-efficacy and behavior in this study. This finding is inconsistent with our hypothesis. Some researchers postulated that self-efficacy is a predictor factor of behavior . The social cognitive theory proposed that high self-efficacy may be necessary to promote positive behavior . Self-efficacy is an important determinant in deciding to start a new behavior pattern, and the increase of self-efficacy is an essential precursor of behavior change [49,50,51]. Further research can explore the connection between self-efficacy and health behavior among residents in Qingdao.
This study has several advantages. We used the questionnaire of “2019 health literacy survey of Chinese citizens” for the first time to demonstrate the indirect pathways of health literacy to health status through self-efficacy and health behavior. Furthermore, our statistical method that uses path analysis is superior to linear regression analysis because it explains the relationship between various factors and investigates the direct and indirect relationships among the variables. Although our findings are compatible with those of previous studies, we extended known associations between health literacy and health outcomes with the 2019 Chinese Citizens Health Literacy Questionnaire through path analysis. And the significance of the model we construct was to explain the determinants of health literacy and the relationships between health literacy, self-efficacy, and health behavior. Therefore, the entry point of intervention strategies and important gaps in the pathways linking health literacy and health status can be identified.
However, several limitations of the study should be noted. First, although our findings indicated a causal relationship between variables, the nature of the cross-sectional study fails to draw conclusions about causality. Therefore, we relied on theories and existing literature to guide our findings and explain the relationship between variables over a period of time. Longitudinal influences of these factors on health status are subject to further prospective studies. Second, although the relationships between the variables in our study are statistically significant, the magnitude of the relationships is quite limited. Health literacy and other intermediate variables in the model explain only 15% of the health status of the population. This finding indicated that the differences in self-rated health status may be due to the insufficient measurement of variables or other unmeasured factors influencing health status. Hence, the relationship between health literacy and health status must be fully examined in the future investigation. Finally, our research, especially for health status, relies on self-reported measurement. If residents with high health literacy report high scores as evidence of enhanced health conditions, then effect of health literacy on health status may be overestimated.
The improvement of health literacy can effectively enhance the health status among individuals. Carrying out actions that promote national health literacy to improve health literacy among residents fundamentally is still the primary task of public health construction. In this study, we focused on the health literacy model at an individual level. Further investigation should extend the scope of health literacy beyond the individual and promote changes in the behavior of the whole people. At the same time, exploring the mechanism of health literacy affecting health status and strengthening empirical investigations on the relationship among health literacy, beliefs, behavior, and health outcomes is necessary to provide a reference for enhancing health literacy and promoting the health level among residents. And we would like to develop intervention measures for addressing health literacy and health issues at the target communities rather than at the individual level.