Author(s)

Binbin Yang ¹, Rui Yuan ¹, Yawen Wu ¹, Xinyue Zhang ¹, Houming Si ¹, Xixi Niu ¹, Pan Zhang ¹

Affiliation(s)

¹ College of Nursing and Rehabilitation, North China University of Science and Technology, Tangshan, China

Corresponding Author

Pan Zhang

ABSTRACT

Patient activation supports long-term self-management after stroke; however, the mechanisms underlying the association between health literacy and patient activation remain unclear, and self-regulatory fatigue may play a role. This study aimed to examine the association between health literacy and patient activation among patients with stroke and to determine whether self-regulatory fatigue mediates this association. This cross-sectional study included 360 patients with stroke recruited in China between September and December 2025. Validated questionnaires were used to assess health literacy, self-regulatory fatigue, and patient activation. Pearson correlation analysis and an adjusted mediation model with 5,000 bootstrap resamples were used to estimate the indirect association. The mean scores for health literacy, self-regulatory fatigue, and patient activation were 67.01 ± 9.96, 51.83 ± 6.21, and 50.35 ± 13.65, respectively. Health literacy was negatively correlated with self-regulatory fatigue (r = −0.500, p < 0.001) and positively correlated with patient activation (r = 0.596, p < 0.001), whereas self-regulatory fatigue was negatively correlated with patient activation (r = −0.612, p < 0.001). After adjustment for sociodemographic and clinical factors, higher health literacy was associated with lower self-regulatory fatigue (B = −0.125, 95% CI: −0.184 to −0.066; β = −0.200, p < 0.001). Higher self-regulatory fatigue was associated with lower patient activation (B = −0.771, 95% CI: −0.991 to −0.550; β = −0.350, p < 0.001), while health literacy remained positively associated with patient activation (B = 0.413, 95% CI: 0.286 to 0.539; β = 0.301, p < 0.001). The indirect effect was 0.096 (95% bootstrap CI: 0.045 to 0.155). Higher health literacy was associated with greater patient activation, partly through lower self-regulatory fatigue. These factors may help identify patients who require additional support; however, the cross-sectional design precludes conclusions regarding temporality or causality.

KEYWORDS

Stroke; Health Literacy; Patient Activation; Self-Regulatory Fatigue; Mediation Analysis

CITE THIS PAPER

Binbin Yang, Rui Yuan, Yawen Wu, Xinyue Zhang, Houming Si, Xixi Niu, Pan Zhang. The Association between Health Literacy and Patient Activation among Patients with Stroke: The Mediating Role of Self-Regulatory Fatigue. Social Medicine and Health Management (2026). Vol. 7, No. 2, 23-30. DOI: http://dx.doi.org/10.23977/socmhm.2026.070203.

REFERENCES

[1] GBD 2021 Stroke Risk Factor Collaborators. (2024) Global, Regional, and National Burden of Stroke and Its Risk Factors, 1990-2021: A Systematic Analysis for the Global Burden of Disease Study 2021. The Lancet Neurology, 23, 973-1003.
[2] Ouyang W., Wang R., He Y., Song Y., Mo L. and Feng L. (2024) Status and Influential Factors of Health Literacy in Patients with Ischemic Stroke: A Cross-Sectional Study. PLOS ONE, 19, e0307928.
[3] Jiang N., Feng L., Song N., Ye Y., Wei B., Tian T., Chen N., Li Y. and Jiang X. (2025) Stroke Survivors' Patient Activation and Self-Management: The Serial Mediating Role of Social Support and Resilience. Geriatric Nursing, 63, 16-25.
[4] Zeng M., Liu Y., He Y. and Huang W. (2025) Relationship Between Stroke Knowledge, Health Information Literacy, and Health Self-Management Among Patients with Stroke: Multicenter Cross-Sectional Study. JMIR Medical Informatics, 13, e63956.
[5] Hibbard J.H., Stockard J., Mahoney E.R. and Tusler M. (2004) Development of the Patient Activation Measure (PAM): Conceptualizing and Measuring Activation in Patients and Consumers. Health Services Research, 39, 1005-1026.
[6] Hibbard J.H., Mahoney E.R., Stockard J. and Tusler M. (2005) Development and Testing of a Short Form of the Patient Activation Measure. Health Services Research, 40, 1918-1930.
[7] Huang L.Y., Lin Y.P., Glass G.F. Jr. and Chan E.Y. (2021) Health Literacy and Patient Activation Among Adults with Chronic Diseases in Singapore: A Cross-Sectional Study. Nursing Open, 8, 2857-2865.
[8] Sui W. and Wan L. (2021) Association Between Patient Activation and Medication Adherence in Patients with Stroke: A Cross-Sectional Study. Frontiers in Neurology, 12, 722711.
[9] Liu Y., Jiang F., Zhang M., Niu H., Cao J., Du S., Chen H., Wang H., Gong L., Rao F. and Wu H. (2024) Health Literacy and Self-Management Among Middle-Aged and Young Hypertensive Patients: A Parallel Mediation Effect of Illness Perception and Self-Efficacy. Frontiers in Psychology, 15, 1349451.
[10] Nes L.S., Ehlers S.L., Whipple M.O. and Vincent A. (2013) Self-Regulatory Fatigue in Chronic Multisymptom Illnesses: Scale Development, Fatigue, and Self-Control. Journal of Pain Research, 6, 181-188.
[11] Ji X. and Yu H. (2023) Factors Associated with Self-Regulatory Fatigue in Chinese Older Patients with Coronary Heart Disease: A Cross-Sectional Survey. Patient Preference and Adherence, 17, 941-949.
[12] Zhou L., Li F., Liu C., Ma Q., Xiao T., Xiao R., Tang A., He B., Qiu X. and Chen X. (2025) Analysis of Factors Influencing Self-Management Positivity in Colorectal Cancer Chemotherapy Patients Based on the ABC-X Model: A Cross-Sectional Study. Nursing & Health Sciences, 27, e70147.
[13] Liu J.R., Li J. and Tian F. (2020) Development and Reliability and Validity Test of the Health Literacy Scale for Stroke Patients. Chinese Nursing Research, 34, 3220-3225.
[14] Wang L.G., Zhang J.Y., Wang J., Tao T., Fan C. and Gao W. (2015) Validity and Reliability of the Chinese Version of the Self-Regulatory Fatigue Scale in Young Adults. Chinese Mental Health Journal, 29, 290-294.
[15] Hong Y., Zou Y.F. and Wu J. (2018) Reliability and Validity of the Chinese Version of the Patient Activation Measure. Chinese Journal of Modern Nursing, 24, 3009-3015.
[16] Hayes A.F. (2022) Introduction to Mediation, Moderation, and Conditional Process Analysis: A Regression-Based Approach. 3rd Edition, The Guilford Press, New York.

Sponsors, Associates, and Links

---

• Information Systems and Economics
  
  
• Accounting, Auditing and Finance
  
  
• Industrial Engineering and Innovation Management
  
  
• Tourism Management and Technology Economy
  
  
• Journal of Computational and Financial Econometrics
  
  
• Financial Engineering and Risk Management
  
  
• Accounting and Corporate Management
  
  
• Social Security and Administration Management
  
  
• Population, Resources & Environmental Economics
  
  
• Statistics & Quantitative Economics
  
  
• Agricultural & Forestry Economics and Management
  
  
• Land Resource Management
  
  
• Information, Library and Archival Science
  
  
• Journal of Human Resource Development
  
  
• Manufacturing and Service Operations Management
  
  
• Operational Research and Cybernetics