# The association between health literacy and Health Information-Seeking Behavior among pulmonary nodule patients: a serial mediation of illness perception and self-efficacy

## TL;DR

This study shows that higher health literacy in patients with lung nodules leads to better health information-seeking behavior, partly through improved self-efficacy and reduced negative illness perceptions.

## Contribution

The study introduces a serial mediation model showing how health literacy influences health information-seeking behavior through illness perception and self-efficacy in pulmonary nodule patients.

## Key findings

- Health literacy is directly and positively associated with health information-seeking behavior.
- Self-efficacy and illness perception mediate the relationship between health literacy and information-seeking behavior.
- The serial mediation effect is modest but statistically significant, supporting the hypothesized model.

## Abstract

This study aimed to examine the association between health literacy and Health Information-Seeking Behavior (HISB) among patients with pulmonary nodules (PNs). It further assessed whether illness perception and self-efficacy were associated with this relationship using a theoretically specified serial mediation model informed by the Information-Motivation-Behavioral Skills (IMB) framework.

This cross-sectional study was conducted from February to June 2024. Patients with PNs were recruited from two tertiary hospitals in Suzhou, China, using convenience sampling. Structural equation modeling (SEM) was applied to test hypothesized associations among variables. Bias-corrected bootstrapping was used to estimate direct and indirect effects, including serial indirect effects consistent with the hypothesized ordering. Multi-group analysis examined whether model estimates differed by educational level. Reporting followed the STROBE guidelines.

Overall, 321 patients completed the survey. The mean score of HISB was 131.85 (SD = 34.96). HISB showed modest positive correlations with health literacy (r = 0.464, p < 0.01) and self-efficacy (r = 0.497, p < 0.01), and negative correlation with illness perception (r = −0.429, p < 0.01). The SEM showed excellent fit (χ2/df = 1.46, RMSEA = 0.038, CFI = 0.982). Health literacy showed association with HISB (β = 0.477, p < 0.001). Indirect associations were observed via self-efficacy [β = 0.110, 95% CI (0.062, 0.173)] and illness perception [β = 0.065, 95% CI (0.035, 0.108)]. A statistically significant but modest serial indirect effect was observed [β = 0.021, 95% CI (0.009, 0.040)], consistent with the hypothesized model. Multi-group analysis supported configural invariance across education levels, although the strength of some associations varied.

This study found both direct and indirect associations between health literacy and HISB among patients with PNs. The findings suggest that interventions that providing literacy-sensitive support, address maladaptive illness perception, and strengthen self-efficacy may help foster adaptive information-seeking and improve long-term surveillance adherence and psychological outcomes.