{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T05:49:53Z","timestamp":1791352193299,"version":"4.3.1"},"reference-count":55,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T00:00:00Z","timestamp":1791331200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Public Health"],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Stroke, the second foremost cause of mortality globally, imposes a considerable disease burden in China. Limited health literacy and difficulties adhering to post-discharge care may be associated with poorer quality of life among stroke survivors. However, the extent to which out-of-hospital adherence statistically accounts for the association between health literacy and quality of life remains insufficiently characterized.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To examine associations among health literacy, out-of-hospital adherence, and quality of life, and to assess whether out-of-hospital adherence statistically mediates the association between health literacy and quality of life in a cross-sectional sample of stroke survivors.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A cross-sectional study included 509 participants recruited through convenience sampling from four traditional Chinese medicine hospitals in Shanghai. Health literacy, out-of-hospital adherence, and stroke-specific quality of life were assessed using Chinese-language instruments. Statistical mediation was examined using PROCESS Model 4 with 5,000 bootstrap resamples.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Stroke survivors\u2019 health literacy averaged 31.40\u202f\u00b1\u202f6.78 (below threshold), with analysis skills scoring lowest (5.37\u202f\u00b1\u202f1.17); Health literacy was positively correlated with quality of life (\n                      <jats:italic>r<\/jats:italic>\n                      \u202f=\u202f0.409,\n                      <jats:italic>p<\/jats:italic>\n                      \u202f&amp;lt;\u202f0.001) and out-of-hospital adherence (\n                      <jats:italic>r<\/jats:italic>\n                      \u202f=\u202f0.223,\n                      <jats:italic>p<\/jats:italic>\n                      \u202f&amp;lt;\u202f0.001). Adherence was also positively correlated with quality of life (\n                      <jats:italic>r<\/jats:italic>\n                      \u202f=\u202f0.461,\n                      <jats:italic>p<\/jats:italic>\n                      \u202f&amp;lt;\u202f0.001). The standardized indirect effect through adherence was 0.087 (bootstrap 95% CI: 0.048\u20130.134), corresponding to approximately 21.3% of the total association in the specified model.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>These cross-sectional findings carry public-health-relevant implications for older adult stroke survivors, a fast-growing vulnerable subgroup amid China\u2019s population aging. Population-level targeted strategies to improve health literacy and post-discharge adherence may advance healthy aging by mitigating stroke-related health disparities among older adults, particularly for socio-economically disadvantaged subgroups including those with low educational attainment and rural residence. Further implementation research is required to translate these observational associations into community-tailored preventive interventions for aging populations.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fpubh.2026.1917398","type":"journal-article","created":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T04:49:46Z","timestamp":1791348586000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["The mediating role of out-of-hospital adherence between health literacy and quality of life in Chinese stroke survivors: a cross-sectional study"],"prefix":"10.3389","volume":"14","author":[{"given":"Hui Jun","family":"Sun","sequence":"first","affiliation":[{"name":"Shanghai Clinical Research and Trial Center, ShanghaiTech University","place":["Shanghai, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jia Lu","family":"Cao","sequence":"additional","affiliation":[{"name":"Nursing Department, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine","place":["Shanghai, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jia Yan","family":"Qu","sequence":"additional","affiliation":[{"name":"Department of Vascular Surgery, Yueyang Hospital of Integrated Traditional Chinese Medicine","place":["Shanghai, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mei Ting","family":"Wu","sequence":"additional","affiliation":[{"name":"School of Nursing and Health Management, Shanghai University of Medicine & Health Sciences","place":["Shanghai, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jian Ping","family":"Lu","sequence":"additional","affiliation":[{"name":"Nursing Department, Gushengtang Holdings Co., Ltd.","place":["Shanghai, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,10,7]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"7609","DOI":"10.3390\/ijms21207609","article-title":"Pathophysiology and treatment of stroke: present status and future perspectives","volume":"21","author":"Kuriakose","year":"2020","journal-title":"Int J Mol Sci"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"973","DOI":"10.1016\/S1474-4422(24)00369-7","article-title":"Global, regional, and national burden of stroke and its risk factors, 1990-2021:a systematic analysis for the global burden of disease study 2021","volume":"23","year":"2024","journal-title":"Lancet Neurol"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"439","DOI":"10.1016\/S1474-4422(19)30034-1","article-title":"Global, regional, and national burden of stroke, 1990-2016: a systematic analysis for the global burden of disease study 2016","volume":"18","author":"Johnson","year":"2019","journal-title":"Lancet Neurol"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"1160","DOI":"10.1016\/S1474-4422(23)00277-6","article-title":"Pragmatic solutions to reduce the global burden of stroke: a world stroke organization-lancet neurology commission","volume":"22","author":"Feigin","year":"2023","journal-title":"Lancet Neurol"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"795","DOI":"10.1016\/S1474-4422(21)00252-0","article-title":"Global, regional, and national burden of stroke and its risk factors, 1990-2019: a systematic analysis for the global burden of disease study 2019","volume":"20","year":"2021","journal-title":"Lancet Neurol"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"e897","DOI":"10.1016\/S2468-2667(21)00228-0","article-title":"Temporal trend and attributable risk factors of stroke burden in China, 1990\u20132019: an analysis for the global burden of disease study 2019","volume":"6","author":"Ma","year":"2021","journal-title":"Lancet Public Health"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"e2236510","DOI":"10.1001\/jamanetworkopen.2022.36510","article-title":"Effect of exercise training or complex mental and social activities on cognitive function in adults with chronic stroke: a randomized clinical trial","volume":"5","author":"Liu-Ambrose","year":"2022","journal-title":"JAMA Netw Open"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"132","DOI":"10.1177\/17474930241308142","article-title":"World stroke organization: global stroke fact sheet 2025","volume":"20","author":"Feigin","year":"2025","journal-title":"Int J Stroke"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"3238165","DOI":"10.1155\/2018\/3238165","article-title":"Stroke in the 21st century: a snapshot of the burden, epidemiology, and quality of life","volume":"2018","author":"Donkor","year":"2018","journal-title":"Stroke Res Treat"},{"key":"ref10","volume-title":"Adherence to long-term Therapies: Evidence for action","year":"2003"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"9202716","DOI":"10.1155\/2021\/9202716","article-title":"Identification of good practices in long-term exercise-based rehabilitation programs in stroke patients","volume":"2021","author":"Mameletzi","year":"2021","journal-title":"Biomed Res Int"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"625","DOI":"10.1631\/jzus.B2100999","article-title":"Research and application advances in rehabilitation assessment of stroke","volume":"23","author":"Liu","year":"2022","journal-title":"J Zhejiang Univ Sci B"},{"key":"ref13","doi-asserted-by":"publisher","first-page":"588","DOI":"10.1136\/jnnp-2021-328391","article-title":"Aetiology, secondary prevention strategies and outcomes of ischaemic stroke despite oral anticoagulant therapy in patients with atrial fibrillation","volume":"93","author":"Polymeris","year":"2022","journal-title":"J Neurol Neurosurg Psychiatry"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"146","DOI":"10.3390\/jcdd8110146","article-title":"Better medications adherence lowers cardiovascular events, stroke, and all-cause mortality risk: a dose-response meta-analysis","volume":"8","author":"Liu","year":"2021","journal-title":"J Cardiovasc Dev Dis"},{"key":"ref15","doi-asserted-by":"publisher","first-page":"15","DOI":"10.1136\/bmj.38875.675486.55","article-title":"A meta-analysis of the association between adherence to drug therapy and mortality","volume":"333","author":"Simpson","year":"2006","journal-title":"BMJ"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"358","DOI":"10.1007\/s12160-013-9515-5","article-title":"Improving adherence to medication in stroke survivors: a pilot randomised controlled trial","volume":"46","author":"O\u2019Carroll","year":"2013","journal-title":"Ann Behav Med"},{"key":"ref17","first-page":"30","article-title":"Adherence of family caregivers of patients with stroke to rehabilitation regimen","volume":"18","author":"Dehghan Nayeri","year":"2012","journal-title":"J Hayat"},{"key":"ref18","volume-title":"Adherence to Long Term Therapies: Evidence for Action","author":"Sabat\u00e9","year":"2003"},{"key":"ref19","doi-asserted-by":"publisher","first-page":"882","DOI":"10.1016\/j.amjmed.2011.12.013","article-title":"Adherence to drugs that prevent cardiovascular disease: meta-analysis on 376,162 patients","volume":"125","author":"Naderi","year":"2012","journal-title":"Am J Med"},{"key":"ref20","doi-asserted-by":"publisher","first-page":"1127","DOI":"10.1111\/jar.12873","article-title":"Development and sensibility assessment of a health-related quality of life instrument for adults with severe disabilities who are non-ambulatory","volume":"34","author":"Zalmstra","year":"2021","journal-title":"J Appl Res Intellect Disabil"},{"key":"ref21","doi-asserted-by":"publisher","first-page":"409","DOI":"10.1016\/j.fertnstert.2011.02.046","article-title":"The fertility quality of life (FertiQoL) tool: development and general psychometric properties","volume":"96","author":"Boivin","year":"2011","journal-title":"Fertil Steril"},{"key":"ref22","doi-asserted-by":"publisher","first-page":"14125","DOI":"10.3390\/ijerph192114125","article-title":"The effect of task-oriented activities training on upper-limb function, daily activities, and quality of life in chronic stroke patients: a randomized controlled trial","volume":"19","author":"Alsubiheen","year":"2022","journal-title":"Int J Environ Res Public Health"},{"key":"ref23","doi-asserted-by":"publisher","first-page":"128","DOI":"10.3390\/bs10080128","article-title":"The experience of post-stroke pain and the impact on quality of life: an integrative review","volume":"10","author":"Payton","year":"2020","journal-title":"Behav Sci (Basel)"},{"key":"ref24","doi-asserted-by":"publisher","first-page":"4","DOI":"10.1186\/s12955-023-02090-5","article-title":"Factors affecting the quality of life after ischemic stroke in young adults: a scoping review","volume":"21","author":"Gurkov\u00e1","year":"2023","journal-title":"Health Qual Life Outcomes"},{"key":"ref25","doi-asserted-by":"publisher","first-page":"107858","DOI":"10.1016\/j.jstrokecerebrovasdis.2024.107858","article-title":"The effect of professional reintegration of stroke survivors on their quality of life: a scoping review: professional integration and QoL after stroke","volume":"33","author":"Matos","year":"2024","journal-title":"J Stroke Cerebrovasc Dis"},{"key":"ref26","doi-asserted-by":"publisher","first-page":"376","DOI":"10.4103\/aian.aian_1069_21","article-title":"The quality of life of stroke survivors in the Indian setting: a systematic review and meta-analysis","volume":"25","author":"Dhandapani","year":"2022","journal-title":"Ann Indian Acad Neurol"},{"key":"ref27","doi-asserted-by":"publisher","first-page":"111466","DOI":"10.1016\/j.jpsychores.2023.111466","article-title":"Trajectories of post-stroke quality of life and long-term prognosis: results from an eleven-year prospective study","volume":"173","author":"Hu","year":"2023","journal-title":"J Psychosom Res"},{"key":"ref28","doi-asserted-by":"publisher","first-page":"599","DOI":"10.1177\/17423953211023960","article-title":"Quality of life of stroke survivors: a cross-sectional study of association with functional independence, self-reported fatigue and exercise self-efficacy","volume":"18","author":"Ogwumike","year":"2022","journal-title":"Chronic Illn"},{"key":"ref29","doi-asserted-by":"publisher","first-page":"158","DOI":"10.1111\/wvn.12714","article-title":"Non-pharmacological interventions on quality of life in stroke survivors: a systematic review and meta-analysis","volume":"21","author":"Gao","year":"2024","journal-title":"Worldviews Evid-Based Nurs"},{"key":"ref30","first-page":"664","article-title":"Quality of life in stroke patients with dysphagia: a systematic review","volume":"100","author":"Al Rjoob","year":"2022","journal-title":"Tunis Med"},{"key":"ref31","doi-asserted-by":"publisher","first-page":"1235","DOI":"10.1007\/s11065-024-09635-5","article-title":"Post-stroke cognition is associated with stroke survivor quality of life and caregiver outcomes: a systematic review and Meta-analysis","volume":"34","author":"Stolwyk","year":"2024","journal-title":"Neuropsychol Rev"},{"key":"ref32","doi-asserted-by":"publisher","first-page":"880","DOI":"10.1177\/23969873231191304","article-title":"Motor rehabilitation after stroke: European stroke organisation (ESO) consensus-based definition and guiding framework","volume":"8","author":"Kwakkel","year":"2023","journal-title":"Eur Stroke J"},{"key":"ref33","doi-asserted-by":"publisher","first-page":"105600","DOI":"10.1016\/j.jstrokecerebrovasdis.2021.105600","article-title":"Predictors of quality of life in stroke survivors: a 1-year follow-up study of a Tunisian sample","volume":"30","author":"Boudokhane","year":"2021","journal-title":"J Stroke Cerebrovasc Dis"},{"key":"ref34","volume-title":"Measures of Health Literacy: Workshop Summary","author":"Hernandez","year":"2009"},{"key":"ref35","doi-asserted-by":"publisher","first-page":"E55","DOI":"10.5888\/pcd11.130259","article-title":"Assessing the impact of health literacy on education retention of stroke patients","volume":"11","author":"Sanders","year":"2014","journal-title":"Prev Chronic Dis"},{"key":"ref36","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1080\/10810730.2010.499992","article-title":"Health literacy improvement as a national priority","volume":"15","author":"Benjamin","year":"2010","journal-title":"J Health Commun"},{"key":"ref37","doi-asserted-by":"publisher","first-page":"1880","DOI":"10.1177\/2047487317729538","article-title":"Health literacy is associated with health behaviour and self-reported health: a large population-based study in individuals with cardiovascular disease","volume":"24","author":"Aaby","year":"2017","journal-title":"Eur J Prev Cardiol"},{"key":"ref38","doi-asserted-by":"publisher","first-page":"1793","DOI":"10.1016\/j.pec.2021.11.021","article-title":"Impact of health literacy in patients with cardiovascular diseases: a systematic review and meta-analysis","volume":"105","author":"Kanejima","year":"2022","journal-title":"Patient Educ Couns"},{"key":"ref39","doi-asserted-by":"publisher","first-page":"e70020","DOI":"10.1002\/nop2.70020","article-title":"The relationships between quality of life with health literacy, social support and resilience in older stroke survivors: a structural equation model","volume":"11","author":"Chen","year":"2024","journal-title":"Nurs Open"},{"key":"ref40","doi-asserted-by":"publisher","first-page":"30","DOI":"10.1080\/10810730.2012.713442","article-title":"The health literacy skills framework","volume":"17","author":"Squiers","year":"2012","journal-title":"J Health Commun"},{"key":"ref41","doi-asserted-by":"publisher","first-page":"1481","DOI":"10.1080\/10810730.2014.954083","article-title":"Advancing health literacy measurement: a pathway to better health and health system performance","volume":"19","author":"Pleasant","year":"2014","journal-title":"J Health Commun"},{"key":"ref42","doi-asserted-by":"publisher","first-page":"481","DOI":"10.3233\/SHTI200057","article-title":"Health literacy: global advances with a focus upon the Shanghai declaration on promoting health in the 2030 agenda for sustainable development","volume":"269","author":"Pleasant","year":"2020","journal-title":"Stud Health Technol Inform"},{"key":"ref43","doi-asserted-by":"publisher","first-page":"8","DOI":"10.1016\/j.puhe.2017.12.005","article-title":"Impact of health literacy on diabetes outcomes: a cross-sectional study from Lahore, Pakistan","volume":"156","author":"Saeed","year":"2018","journal-title":"Public Health"},{"key":"ref44","doi-asserted-by":"publisher","first-page":"e12196","DOI":"10.1111\/opn.12196","article-title":"The efects of medication adherence and health literacy on health-related quality of life in older people with hypertension","volume":"13","author":"Park","year":"2018","journal-title":"Int J Older People Nursing"},{"key":"ref45","doi-asserted-by":"publisher","first-page":"e0151079","DOI":"10.1371\/journal.pone.0151079","article-title":"Efect of health literacy on quality of life amongst patients with ischaemic heart disease in Australian general practice","volume":"11","author":"Gonz\u00e1lez-Chica","year":"2016","journal-title":"PLoS One"},{"key":"ref46","doi-asserted-by":"publisher","first-page":"35","DOI":"10.1177\/0272684X19896724","article-title":"Infuence of health literacy on medication adherence among elderly females with type 2 diabetes in Pakistan","volume":"41","author":"Hussain","year":"2019","journal-title":"Int Q Community Health Educ"},{"key":"ref47","doi-asserted-by":"publisher","first-page":"2593","DOI":"10.2147\/PPA.S182172","article-title":"The infuence of quality of life on the level of adherence to therapeutic recommendations among elderly hypertensive patients","volume":"12","author":"Uchmanowicz","year":"2018","journal-title":"Patient Prefer Adherence"},{"key":"ref48","doi-asserted-by":"publisher","first-page":"e016982","DOI":"10.1136\/bmjopen-2017-016982","article-title":"Economic impact of medication non-adherence by disease groups: a systematic review","volume":"8","author":"Cutler","year":"2018","journal-title":"BMJ Open"},{"key":"ref49","doi-asserted-by":"publisher","first-page":"339","DOI":"10.13329\/j.cnki.zyyjk.2023.0066","article-title":"Chinese version of chronic disease health literacy questionnaire in Chinese population and its reliability and validity test in stroke patients","volume":"39","author":"Sun","year":"2023","journal-title":"Occup Health"},{"key":"ref50","doi-asserted-by":"publisher","first-page":"460","DOI":"10.1186\/s12883-024-03962-z","article-title":"Development and validation of the out-of-hospital adherence questionnaire for stroke patients (OHAQ-SP)","volume":"24","author":"Sun","year":"2024","journal-title":"BMC Neurol"},{"key":"ref51","doi-asserted-by":"publisher","first-page":"391","DOI":"10.3969\/j.issn.1009-0126.2003.06.010","article-title":"The study on reliability,validity and responsiveness of the Chinese version of stroke-specific quality of life","volume":"5","author":"Wang","year":"2003","journal-title":"Chinese J Geriatric Heart Brain Vessel Dis"},{"key":"ref52","doi-asserted-by":"publisher","first-page":"1388","DOI":"10.1111\/jan.16351","article-title":"E-health literacy in stroke patients: latent profile analysis and influencing factors","volume":"81","author":"Xue","year":"2025","journal-title":"J Adv Nurs"},{"key":"ref53","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":"ref54","doi-asserted-by":"publisher","first-page":"e40778","DOI":"10.2196\/40778","article-title":"The relation between eHealth literacy and health-related behaviors: systematic review and Meta-analysis","volume":"25","author":"Kim","year":"2023","journal-title":"J Med Internet Res"},{"key":"ref55","doi-asserted-by":"publisher","first-page":"223","DOI":"10.1080\/10810730.2013.825667","article-title":"The association between health literacy and cancer-related attitudes, behaviors, and knowledge","author":"Morris","year":"2013","journal-title":"J Health Commun"}],"container-title":["Frontiers in Public Health"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2026.1917398\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T04:50:00Z","timestamp":1791348600000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2026.1917398\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,10,7]]},"references-count":55,"alternative-id":["10.3389\/fpubh.2026.1917398"],"URL":"https:\/\/doi.org\/10.3389\/fpubh.2026.1917398","relation":{},"ISSN":["2296-2565"],"issn-type":[{"value":"2296-2565","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,10,7]]},"article-number":"1917398"}}