{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,21]],"date-time":"2026-10-21T10:38:03Z","timestamp":1792579083817,"version":"4.5.0"},"reference-count":58,"publisher":"Oxford University Press (OUP)","issue":"5","license":[{"start":{"date-parts":[[2026,10,21]],"date-time":"2026-10-21T00:00:00Z","timestamp":1792540800000},"content-version":"vor","delay-in-days":50,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100002341","name":"Research Council of Finland","doi-asserted-by":"publisher","award":["363107"],"award-info":[{"award-number":["363107"]}],"id":[{"id":"10.13039\/501100002341","id-type":"DOI","asserted-by":"publisher"}]},{"name":"European Union\u2019s Horizon Europe Programme","award":["101081327"],"award-info":[{"award-number":["101081327"]}]},{"DOI":"10.13039\/501100009047","name":"Strategic Research Council","doi-asserted-by":"publisher","award":["352509"],"award-info":[{"award-number":["352509"]}],"id":[{"id":"10.13039\/501100009047","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100009047","name":"Strategic Research Council","doi-asserted-by":"publisher","award":["352511"],"award-info":[{"award-number":["352511"]}],"id":[{"id":"10.13039\/501100009047","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,9,1]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>Health literacy is associated with health-related quality of life (HRQoL), but the role of perceived stress and possible differences by chronic disease burden remain unclear. We used data from a cross-sectional 2024 quota-based online panel survey of 4003 Finnish adults. The path models included 3716 participants with complete data and used post-stratification weights based on age group and gender. Health literacy was assessed with the HLS-Q12, perceived stress with the PSS-10, and HRQoL with the EuroQol five-dimension, five-level instrument (EQ-5D-5L). Path analysis estimated direct, indirect, and total associations, and multigroup models compared the main associations across three chronic disease-burden groups, adjusting for age, gender, education, employment status, and financial strain. Higher health literacy was associated with lower perceived stress, and higher perceived stress with poorer HRQoL. The indirect association through perceived stress represented approximately four-fifths of the total association based on unstandardized coefficients. The negative perceived stress-HRQoL association became progressively stronger across disease-burden groups on the unstandardized metric and was approximately twice as large among adults with multiple chronic diseases as among those with no chronic disease. The health literacy-stress association was similar across groups. These findings identify a stress-related pattern within the health literacy-HRQoL association and suggest that the association between stress and HRQoL may be particularly important among adults with multiple chronic diseases. Integrated health promotion approaches combining accessible communication, navigation support, stress-sensitive care, and efforts to reduce treatment burden warrant prospective evaluation.<\/jats:p>","DOI":"10.1093\/heapro\/daag157","type":"journal-article","created":{"date-parts":[[2026,10,21]],"date-time":"2026-10-21T09:38:54Z","timestamp":1792575534000},"source":"Crossref","is-referenced-by-count":0,"title":["Health literacy, perceived stress, and health-related quality of life in Finnish adults: differences by chronic disease burden"],"prefix":"10.1093","volume":"41","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4306-3170","authenticated-orcid":false,"given":"Jing","family":"Zhou","sequence":"first","affiliation":[{"name":"School of Law, Shanghai Lixin University of Accounting and Finance , 995 Shangchuan Road, Pudong New District, Shanghai 201209 ,","place":["China"]},{"name":"Department of Social Sciences, University of Eastern Finland , P.O. Box 1627, FI-70211 Kuopio ,","place":["Finland"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1314-1895","authenticated-orcid":false,"given":"Hanna","family":"Rekola","sequence":"additional","affiliation":[{"name":"Department of Social Sciences, University of Eastern Finland , P.O. Box 1627, FI-70211 Kuopio ,","place":["Finland"]},{"name":"Social, Wellbeing, and Rescue Research Centre, Wellbeing Services County of North Savo , P.O. Box 1711, FI-70211 Kuopio ,","place":["Finland"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tommi","family":"Tolmunen","sequence":"additional","affiliation":[{"name":"Institute of Clinical Medicine, School of Medicine, University of Eastern Finland , P.O. Box 100, FI-70029 Kuopio ,","place":["Finland"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Timo","family":"Lakka","sequence":"additional","affiliation":[{"name":"Institute of Biomedicine, School of Medicine, University of Eastern Finland , P.O. Box 1627, FI-70211 Kuopio ,","place":["Finland"]},{"name":"Department of Clinical Physiology and Nuclear Medicine, Kuopio University Hospital , P.O. Box 1711, FI-70211 Kuopio ,","place":["Finland"]},{"name":"Kuopio Research Institute of Exercise Medicine , Yliopistonrinne 3, FI-70210 Kuopio ,","place":["Finland"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ismo","family":"Linnosmaa","sequence":"additional","affiliation":[{"name":"Department of Health and Social Management, Faculty of Social Sciences and Business Studies, University of Eastern Finland , P.O. Box 1627, FI-70211 Kuopio ,","place":["Finland"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6330-5176","authenticated-orcid":false,"given":"Marjorita","family":"Sormunen","sequence":"additional","affiliation":[{"name":"Department of Nursing Science, University of Turku , Medisiina B, FI-20014 Turun yliopisto ,","place":["Finland"]},{"name":"Institute of Public Health and Clinical Nutrition, University of Eastern Finland , P.O. Box 1627, FI-70211 Kuopio ,","place":["Finland"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Juho","family":"Str\u00f6mmer","sequence":"additional","affiliation":[{"name":"Wellpro Impact Solutions Oy , Kauppakatu 39, FI-40100 Jyv\u00e4skyl\u00e4 ,","place":["Finland"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tomi","family":"M\u00e4ki-Opas","sequence":"additional","affiliation":[{"name":"Department of Social Sciences, University of Eastern Finland , P.O. Box 1627, FI-70211 Kuopio ,","place":["Finland"]},{"name":"Social, Wellbeing, and Rescue Research Centre, Wellbeing Services County of North Savo , P.O. Box 1711, FI-70211 Kuopio ,","place":["Finland"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,10,21]]},"reference":[{"key":"2026102105384642700_daag157-B1","doi-asserted-by":"publisher","DOI":"10.1093\/heapro\/daac114","article-title":"Critical health literacy: reflection and action for health","volume":"37","author":"Abel","year":"2022","journal-title":"Health Promot Int"},{"key":"2026102105384642700_daag157-B2","doi-asserted-by":"publisher","DOI":"10.1016\/j.pmedr.2021.101338","article-title":"Multimorbidity in Finnish and Swedish speaking Finns; association with daily habits and socioeconomic status\u2014Nordic EpiLung cross-sectional study","volume":"22","author":"Anders\u00e9n","year":"2021","journal-title":"Prev Med Rep"},{"key":"2026102105384642700_daag157-B3","doi-asserted-by":"publisher","DOI":"10.3389\/fpubh.2016.00159","article-title":"Use your words carefully: what is a chronic disease?","volume":"4","author":"Bernell","year":"2016","journal-title":"Front Public Health"},{"key":"2026102105384642700_daag157-B4","doi-asserted-by":"publisher","DOI":"10.31478\/201206a","article-title":"Ten attributes of health literate health care organizations","volume":"2","author":"Brach","year":"2012","journal-title":"NAM Perspect"},{"key":"2026102105384642700_daag157-B5","doi-asserted-by":"publisher","DOI":"10.1093\/abm\/kaaf073","article-title":"The effect of health literacy interventions on self-management in chronic diseases: a systematic review","volume":"59","author":"Cabezas","year":"2025","journal-title":"Ann Behav Med"},{"key":"2026102105384642700_daag157-B6","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen-2021-056090","article-title":"Gender differences of health literacy in persons with a migration background: a systematic review and meta-analysis","volume":"12","author":"Chakraverty","year":"2022","journal-title":"BMJ Open"},{"key":"2026102105384642700_daag157-B7","doi-asserted-by":"publisher","DOI":"10.1016\/j.jclinepi.2024.111487","article-title":"Systematic review reveals that EQ-5D minimally important differences vary with treatment type and may decrease with increasing baseline score","volume":"174","author":"Cheng","year":"2024","journal-title":"J Clin Epidemiol"},{"key":"2026102105384642700_daag157-B8","doi-asserted-by":"publisher","DOI":"10.1016\/j.eclinm.2023.101860","article-title":"Global and regional prevalence of multimorbidity in the adult population in community settings: a systematic review and meta-analysis","volume":"57","author":"Chowdhury","year":"2023","journal-title":"eClinicalMedicine"},{"key":"2026102105384642700_daag157-B9","doi-asserted-by":"publisher","first-page":"493","DOI":"10.1093\/ageing\/afw229","article-title":"A life course approach to health literacy: the role of gender, educational attainment and lifetime cognitive capability","volume":"46","author":"Clouston","year":"2017","journal-title":"Age Ageing"},{"key":"2026102105384642700_daag157-B10","doi-asserted-by":"publisher","first-page":"1685","DOI":"10.1001\/jama.298.14.1685","article-title":"Psychological stress and disease","volume":"298","author":"Cohen","year":"2007","journal-title":"JAMA"},{"key":"2026102105384642700_daag157-B11","doi-asserted-by":"publisher","first-page":"385","DOI":"10.2307\/2136404","article-title":"A global measure of perceived stress","volume":"24","author":"Cohen","year":"1983","journal-title":"J Health Soc Behav"},{"key":"2026102105384642700_daag157-B12","first-page":"31","volume-title":"The Social Psychology of Health","author":"Cohen","year":"1988"},{"key":"2026102105384642700_daag157-B13","doi-asserted-by":"publisher","first-page":"7","DOI":"10.1002\/hec.3564","article-title":"Valuing health-related quality of life: an EQ-5D-5L value set for England","volume":"27","author":"Devlin","year":"2018","journal-title":"Health Econ"},{"key":"2026102105384642700_daag157-B14","doi-asserted-by":"publisher","DOI":"10.3390\/ijerph17051683","article-title":"The relationship between health literacy, quality of life, and subjective health: results of a cross-sectional study in a rural region in Germany","volume":"17","author":"Ehmann","year":"2020","journal-title":"Int J Environ Res Public Health"},{"key":"2026102105384642700_daag157-B15","volume-title":"Glossary: Ability to Make Ends Meet","author":"Eurostat","year":"2025"},{"key":"2026102105384642700_daag157-B16","doi-asserted-by":"publisher","first-page":"1342","DOI":"10.1037\/a0031808","article-title":"Cumulative risk and child development","volume":"139","author":"Evans","year":"2013","journal-title":"Psychol Bull"},{"key":"2026102105384642700_daag157-B17","doi-asserted-by":"publisher","DOI":"10.1186\/s12913-018-3275-7","article-title":"Establishing the HLS-Q12 short version of the European Health Literacy Survey Questionnaire: latent trait analyses applying Rasch modelling and confirmatory factor analysis","volume":"18","author":"Finbr\u00e5ten","year":"2018","journal-title":"BMC Health Serv Res"},{"key":"2026102105384642700_daag157-B18","doi-asserted-by":"publisher","DOI":"10.1016\/j.aprim.2025.103300","article-title":"Health literacy in healthy adults: a systematic review of recent evidence","volume":"57","author":"Gon\u00e7alves-Fern\u00e1ndez","year":"2025","journal-title":"Atenci\u00f3n Primaria"},{"key":"2026102105384642700_daag157-B19","doi-asserted-by":"publisher","DOI":"10.3390\/ijerph17207650","article-title":"Moving health literacy research and practice towards a vision of equity, precision and transparency","volume":"17","author":"Guo","year":"2020","journal-title":"Int J Environ Res Public Health"},{"key":"2026102105384642700_daag157-B20","doi-asserted-by":"publisher","first-page":"1727","DOI":"10.1007\/s11136-011-9903-x","article-title":"Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L)","volume":"20","author":"Herdman","year":"2011","journal-title":"Qual Life Res"},{"key":"2026102105384642700_daag157-B21","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1080\/02813432.2025.2492296","article-title":"Multimorbidity and health related quality of life in midlife\u2014a longitudinal study from Northern Finland Birth Cohort 1966","volume":"44","author":"Junttila","year":"2026","journal-title":"Scand J Prim Health Care"},{"key":"2026102105384642700_daag157-B22","doi-asserted-by":"publisher","DOI":"10.2196\/31530","article-title":"Digitally supported lifestyle intervention to prevent type 2 diabetes through healthy habits: secondary analysis of long-term user engagement trajectories in a randomized controlled trial","volume":"24","author":"Lavikainen","year":"2022","journal-title":"J Med Internet Res"},{"key":"2026102105384642700_daag157-B23","volume-title":"Stress, Appraisal, and Coping","author":"Lazarus","year":"1984"},{"key":"2026102105384642700_daag157-B24","doi-asserted-by":"publisher","DOI":"10.1186\/s12875-024-02586-z","article-title":"Treatment burden in multimorbidity: an integrative review","volume":"25","author":"Lee","year":"2024","journal-title":"BMC Prim Care"},{"key":"2026102105384642700_daag157-B25","doi-asserted-by":"publisher","DOI":"10.1186\/s12913-025-12457-7","article-title":"Health literacy interventions and health literacy-related outcomes for older adults: a systematic review","volume":"25","author":"Marshall","year":"2025","journal-title":"BMC Health Serv Res"},{"key":"2026102105384642700_daag157-B26","doi-asserted-by":"publisher","first-page":"23","DOI":"10.1037\/1082-989X.12.1.23","article-title":"Bias in cross-sectional analyses of longitudinal mediation","volume":"12","author":"Maxwell","year":"2007","journal-title":"Psychol Methods"},{"key":"2026102105384642700_daag157-B27","doi-asserted-by":"publisher","DOI":"10.1186\/1472-6963-14-281","article-title":"Rethinking the patient: using Burden of Treatment Theory to understand the changing dynamics of illness","volume":"14","author":"May","year":"2014","journal-title":"BMC Health Serv Res"},{"key":"2026102105384642700_daag157-B28","doi-asserted-by":"publisher","first-page":"412","DOI":"10.1037\/met0000144","article-title":"Thanks coefficient alpha, we\u2019ll take it from here","volume":"23","author":"McNeish","year":"2018","journal-title":"Psychol Methods"},{"key":"2026102105384642700_daag157-B29","doi-asserted-by":"publisher","first-page":"213","DOI":"10.1136\/bmjqs-2024-017411","article-title":"Equity in Choosing Wisely and beyond: the effect of health literacy on healthcare decision-making and methods to support conversations about overuse","volume":"34","author":"Muscat","year":"2025","journal-title":"BMJ Qual Saf"},{"key":"2026102105384642700_daag157-B30","doi-asserted-by":"publisher","first-page":"e287","DOI":"10.1016\/S2666-7568(24)00007-2","article-title":"Prevalence of multimorbidity and polypharmacy among adults and older adults: a systematic review","volume":"5","author":"Nicholson","year":"2024","journal-title":"Lancet Healthy Longev"},{"key":"2026102105384642700_daag157-B31","doi-asserted-by":"publisher","first-page":"259","DOI":"10.1093\/heapro\/15.3.259","article-title":"Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century","volume":"15","author":"Nutbeam","year":"2000","journal-title":"Health Promot Int"},{"key":"2026102105384642700_daag157-B32","doi-asserted-by":"publisher","first-page":"159","DOI":"10.1146\/annurev-publhealth-090419-102529","article-title":"Understanding and responding to health literacy as a social determinant of health","volume":"42","author":"Nutbeam","year":"2021","journal-title":"Annu Rev Public Health"},{"key":"2026102105384642700_daag157-B33","volume-title":"Country Health Profile 2025: Finland. State of Health in the EU","author":"OECD\/European Observatory on Health Systems and Policies","year":"2025"},{"key":"2026102105384642700_daag157-B34","doi-asserted-by":"crossref","first-page":"S19","DOI":"10.5993\/AJHB.31.s1.4","article-title":"The causal pathways linking health literacy to health outcomes","volume":"31","author":"Paasche-Orlow","year":"2007","journal-title":"Am J Health Behav"},{"key":"2026102105384642700_daag157-B35","doi-asserted-by":"publisher","first-page":"205","DOI":"10.1177\/002214650504600206","article-title":"Stress, health, and the life course: some conceptual perspectives","volume":"46","author":"Pearlin","year":"2005","journal-title":"J Health Soc Behav"},{"key":"2026102105384642700_daag157-B36","volume-title":"EQ-5D-5L:n soveltuvuus terveydentilan ja toimintakyvyn itsearviointiin terveydenhuollossa ja v\u00e4est\u00f6tutkimuksissa: Toimintakyvyn arviointi v\u00e4est\u00f6tutkimuksissa -asiantuntijaryhm\u00e4n hyv\u00e4ksym\u00e4\u00e4n TOIMIA-arviointiin pohjautuen","author":"Penttinen","year":"2025"},{"key":"2026102105384642700_daag157-B37","doi-asserted-by":"publisher","DOI":"10.1186\/s12889-020-09639-9","article-title":"Quality of life and mortality in the general population: a systematic review and meta-analysis","volume":"20","author":"Phyo","year":"2020","journal-title":"BMC Public Health"},{"key":"2026102105384642700_daag157-B38","doi-asserted-by":"publisher","DOI":"10.3390\/ijerph182413132","article-title":"Health literacy, health behaviors, and body mass Index impacts on quality of life: cross-sectional study of university students in Surabaya, Indonesia","volume":"18","author":"Prihanto","year":"2021","journal-title":"Int J Environ Res Public Health"},{"key":"2026102105384642700_daag157-B39","doi-asserted-by":"publisher","DOI":"10.1186\/s12955-020-01541-7","article-title":"The impact of health literacy on college students\u2019 psychological disturbances and quality of life: a structural equation modeling analysis","volume":"18","author":"Rababah","year":"2020","journal-title":"Health Qual Life Outcomes"},{"key":"2026102105384642700_daag157-B40","doi-asserted-by":"publisher","DOI":"10.1016\/j.socscimed.2024.117531","article-title":"Financial strain measures and associations with adult health: a systematic literature review","volume":"364","author":"Samuel","year":"2025","journal-title":"Social Science & Medicine"},{"key":"2026102105384642700_daag157-B41","doi-asserted-by":"publisher","first-page":"S258","DOI":"10.1097\/PHH.0000000000001324","article-title":"Updating health literacy for healthy people 2030: defining its importance for a new decade in public health","volume":"27","author":"Santana","year":"2021","journal-title":"J Public Health Manag Pract"},{"key":"2026102105384642700_daag157-B42","doi-asserted-by":"publisher","first-page":"1487","DOI":"10.1007\/s11136-015-1184-3","article-title":"Health literacy and health-related quality of life in adults with type 2 diabetes: a longitudinal study","volume":"25","author":"Sayah","year":"2016","journal-title":"Qual Life Res"},{"key":"2026102105384642700_daag157-B43","doi-asserted-by":"publisher","DOI":"10.1007\/s40520-025-03259-2","article-title":"Health literacy as a buffer: mitigating the impact of multimorbidity on functional health in older adults","volume":"37","author":"Sch\u00f6nenberg","year":"2025","journal-title":"Aging Clin Exp Res"},{"key":"2026102105384642700_daag157-B44","doi-asserted-by":"publisher","first-page":"174","DOI":"10.1007\/s10880-023-09962-4","article-title":"Reactivity of health-related quality of life to perceived stress: the buffering role of psychosocial resources in a longitudinal study of adults with and without HIV","volume":"31","author":"Serrano","year":"2024","journal-title":"J Clin Psychol Med Settings"},{"key":"2026102105384642700_daag157-B45","doi-asserted-by":"publisher","first-page":"1041","DOI":"10.1016\/j.jclinepi.2012.05.005","article-title":"Cumulative complexity: a functional, patient-centered model of patient complexity can improve research and practice","volume":"65","author":"Shippee","year":"2012","journal-title":"J Clin Epidemiol"},{"key":"2026102105384642700_daag157-B46","doi-asserted-by":"publisher","DOI":"10.1177\/02654075261451291","article-title":"Do age and sex moderate the mediating role of perceived stress in the association between loneliness and depression? A population-based study with Finnish adults","author":"Sj\u00f6blom","year":"2026","journal-title":"J Soc Pers Relat"},{"key":"2026102105384642700_daag157-B47","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0321227","article-title":"An update on health literacy dimensions: an umbrella review","volume":"20","author":"Smith","year":"2025","journal-title":"PLoS One"},{"key":"2026102105384642700_daag157-B48","doi-asserted-by":"publisher","DOI":"10.1177\/26335565251314828","article-title":"A systematic review of the use of burden of treatment theory","volume":"15","author":"Smyth","year":"2025","journal-title":"J Multimorb Comorb"},{"key":"2026102105384642700_daag157-B49","doi-asserted-by":"publisher","DOI":"10.1186\/1471-2458-12-80","article-title":"Health literacy and public health: a systematic review and integration of definitions and models","volume":"12","author":"S\u00f8rensen","year":"2012","journal-title":"BMC Public Health"},{"key":"2026102105384642700_daag157-B50","doi-asserted-by":"publisher","DOI":"10.1186\/s12889-020-08991-0","article-title":"Establishing the efficacy of interventions to improve health literacy and health behaviours: a systematic review","volume":"20","author":"Walters","year":"2020","journal-title":"BMC Public Health"},{"key":"2026102105384642700_daag157-B51","doi-asserted-by":"publisher","DOI":"10.1186\/s12905-015-0190-5","article-title":"Health literacy as a moderator of health-related quality of life responses to chronic disease among Chinese rural women","volume":"15","author":"Wang","year":"2015","journal-title":"BMC Women\u2019s Health"},{"key":"2026102105384642700_daag157-B52","doi-asserted-by":"publisher","first-page":"169","DOI":"10.1007\/s11136-023-03508-9","article-title":"Relationship between multimorbidity, functional limitation, and quality of life among middle-aged and older adults: findings from the longitudinal analysis of the 2013\u20132020 Survey of Health, Ageing, and Retirement in Europe (SHARE)","volume":"33","author":"Wilk","year":"2024","journal-title":"Qual Life Res"},{"key":"2026102105384642700_daag157-B53","doi-asserted-by":"publisher","DOI":"10.1186\/s12889-024-19343-7","article-title":"Multimorbidity, health Literacy, and quality of life among older adults in an urban slum in India: a community-based cross-sectional study","volume":"24","author":"Yogesh","year":"2024","journal-title":"BMC Public Health"},{"key":"2026102105384642700_daag157-B54","doi-asserted-by":"publisher","DOI":"10.2196\/56231","article-title":"Digital health literacy in patients with common chronic diseases: systematic review and meta-analysis","volume":"27","author":"Zaghloul","year":"2025","journal-title":"J Med Internet Res"},{"key":"2026102105384642700_daag157-B55","doi-asserted-by":"publisher","DOI":"10.1080\/07853890.2025.2451195","article-title":"Workload-capacity imbalances and their impact on self-management complexity in patients with multimorbidity: a multicenter cross-sectional study","volume":"57","author":"Zhao","year":"2025","journal-title":"Ann Med"},{"key":"2026102105384642700_daag157-B56","doi-asserted-by":"publisher","first-page":"709","DOI":"10.3760\/cma.j.cn112148-20230401-00186","article-title":"Association between cardiometabolic diseases and quality of life and the mediation effect of perceived stress","volume":"51","author":"Zhao","year":"2023","journal-title":"Zhonghua Xin Xue Guan Bing Za Zhi"},{"key":"2026102105384642700_daag157-B57","doi-asserted-by":"publisher","DOI":"10.1186\/s12955-018-1031-7","article-title":"The relationship between health literacy and quality of life: a systematic review and meta-analysis","volume":"16","author":"Zheng","year":"2018","journal-title":"Health Qual Life Outcomes"},{"key":"2026102105384642700_daag157-B58","doi-asserted-by":"publisher","DOI":"10.3389\/ijph.2026.1609337","article-title":"Structural validation and measurement invariance of the HLS-Q12 health literacy instrument in Finnish adults: comparing traditional and alignment methods","volume":"71","author":"Zhou","year":"2026","journal-title":"Int J Public Health"}],"container-title":["Health Promotion International"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/heapro\/article-pdf\/41\/5\/daag157\/72221881\/daag157.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/heapro\/article-pdf\/41\/5\/daag157\/72221881\/daag157.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,21]],"date-time":"2026-10-21T09:38:59Z","timestamp":1792575539000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/heapro\/article\/doi\/10.1093\/heapro\/daag157\/8960340"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,1]]},"references-count":58,"journal-issue":{"issue":"5","published-print":{"date-parts":[[2026,9,1]]}},"URL":"https:\/\/doi.org\/10.1093\/heapro\/daag157","relation":{},"ISSN":["0957-4824","1460-2245"],"issn-type":[{"value":"0957-4824","type":"print"},{"value":"1460-2245","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2026,10]]},"published":{"date-parts":[[2026,9,1]]},"article-number":"daag157"}}