Relationships Between Health Literacy and Quality of Life in Patients With Ischaemic Stroke: The Mediating Role of Fear of Disease Progression

ABSTRACT

Background

Health literacy and fear of disease progression can predict quality of life, yet the underlying mechanisms among these three factors remain poorly understood.

Aim

This study aimed to investigate the hypothesis that health literacy among patients with ischemic stroke is associated with fear of disease progression and both directly and indirectly influence quality of life through the mediating role of fear of disease progression.

Methods

Between December 2023 and June 2024, questionnaires were distributed to 300 in‐patients with ischemic stroke selected by convenience sampling from the neurology departments of three tertiary general hospitals in the Xiangxi region of Hunan Province. Assessments were conducted using the General Information Questionnaire, the Medical Outcomes Study Short Form 36 (SF‐36), Health Literacy Management Scale (HeLMS) and Fear of Progression Questionnaire‐Short Form (FoP‐Q‐SF). Pearson correlation analysis was employed to examine the correlations between variables; AMOS 24.0 statistical analysis software was used to explore the pathways and effect sizes of fear of disease progression and health literacy on quality of life.

Results

Health literacy was positively correlated with quality of life (r = 0.412, p < 0.01), while fear of disease progression was negatively correlated with quality of life (r = −0.445, p < 0.01). Fear of disease progression partially mediated the relationship between health literacy and quality of life, accounting for 41.3% of the total effect.

Conclusions

Findings support the development of targeted psychosocial intervention strategies aimed at enhancing patients' health literacy to effectively alleviate disease‐related fear, ultimately improving quality of life and optimizing care outcomes for stroke patients.

Summary

• What Is Already Known About This Topic?

  • Improvement of patients' quality of life has become both a key indicator and a formidable challenge in evaluating the effectiveness of stroke rehabilitation.
  • Prior studies examined the positive effects of health literacy on quality of life, or the negative impact of fear of disease progression on rehabilitation
  • Studies have not systematically investigated the mediating pathways among these factors and their synergistic mechanisms within the dynamic process of stroke rehabilitation.
• What This Paper Adds?

  • Health literacy is associated with fear of disease progression.
  • Fear of disease progression for stroke patients mediates the effect of health literacy on their quality of life.
• The Implications of This Paper:

  • Nurses can further improve quality of life by developing personalized health education to improve patients' health literacy in order to reduce the fear of stroke progression.

1. Introduction

Stroke is the second leading cause of death worldwide and the primary cause of adult mortality in China, with ischemic stroke the most prevalent subtype, accounting for 80% of all cases (Tian et al. 2023). Studies have reported that over 80% of stroke survivors experience varying degrees of functional impairment, leading to a progressive decline in their quality of life and posing substantial challenges to global public health (Schindel et al. 2021). Therefore, identifying strategies to improve patients' quality of life has become a critical focus for researchers and remains an enduring subject worthy of ongoing exploration.

Health literacy is one of the relevant factors influencing stroke patients' quality of life (Ousseine et al. 2020). It refers to an individual's ability to obtain, comprehend, process and apply necessary health information and services to make appropriate health decisions for maintaining and promoting their well‐being (Berkman et al. 2010). Studies have shown a significant correlation between health literacy and quality of life, with stroke patients exhibiting higher health literacy levels typically demonstrating milder symptoms of depression and anxiety, as well as better quality of life (Xiang et al. 2021).

Studies have found that anxiety, depression and fear of disease progression (FOP) are common in stroke patients, leading to a reduced quality of life. FOP, also known as fear of recurrence, is the fear of possible progression or recurrence of the disease (Dankert et al. 2003), and it has recently received increasing attention from a wide range of scholars. Moderate FOP is a normal psychological stress response, which can enhance patients' management of the disease and alertness to disease recurrence and progression, but excessive fear can lead to psychological disorders, impaired functioning and social disorders, which can seriously affect patients' quality of life (Cao et al. 2022).

Scholars have employed multiple theories to gain deeper insights into the mechanism of FOP. Among these, the “Fear of Cancer Recurrence model” serves as one of the most widely utilized explanatory frameworks. This model delineates the causal pathway underlying the formation of disease‐related fear: Patients respond to stressful events through internal factors (such as fatigue, pain and other physical symptoms) and external factors (such as disease diagnosis and health literacy). This coping process triggers cognitive and emotional changes (including FOP and treatment perceptions), ultimately leading to behavioural outcomes (such as improved disease management and enhanced quality of life) (Cui 2022). However, to date, existing domestic and international studies have separately examined the relationships between health literacy, FOP and quality of life, lacking analysis of the interactive pathways among these three factors. Based on this, guided by the Fear of Cancer Recurrence model, this study investigates the relationships between health literacy, FOP and quality of life in patients with ischemic stroke and explores whether health literacy influences quality of life through the mediating role of fear of disease progression. The study proposes the following four hypotheses:

Health literacy is negatively correlated with fear of disease progression.

Fear of disease progression is negatively correlated with quality of life.

Health literacy is positively correlated with quality of life.

Fear of disease progression partially mediates the relationship between health literacy and quality of life.

2. Methods

2.1. Sample and Procedure

This study employed a cross‐sectional design. Between December 2023 and June 2024, 300 using convenience sampling patients with ischemic stroke were recruited as study participants from the inpatient departments of three tertiary grade A hospitals in the Xiangxi region of Hunan Province, China. Each enrolled patient received verbal information about the study and signed an informed consent form. Subsequently, researchers distributed the prepared paper questionnaires to participants on‐site. Once completed, the questionnaires were collected immediately and carefully reviewed. Any omitted or incorrectly answered questions were promptly addressed by asking participants to make corrections on the spot.

All enrolled patients met the following inclusion criteria: (1) met the diagnostic criteria for stroke established at the 4th National Cerebrovascular Disease Academic Conference, with confirmation by CT or MRI after admission; (2) age ≥ 18 years; and (3) clear consciousness and stable vital signs. Exclusion criteria included the following: (1) patients diagnosed with psychiatric disorders, (2) concurrent participation in other studies, (3) diagnosed with transient ischemic attack (TIA) and (4) aphasia.

According to the method for sample size estimation (in which sample size = number of research factors ×5–10; Ni et al. 2010), this study involved 31 independent variables, yielding an initial estimated sample size of 186–372. An additional 20% was included to account for invalid questionnaires, resulting in a final determined sample size of ~300. Through face‐to‐face interviews, 314 valid questionnaires were collected, with 14 excluded due to missing data, yielding a questionnaire recovery rate of 95.5%.

2.2. Measurements

2.2.1. Demographic and Clinical Characteristics

Demographic characteristics included age, gender, marital status, education level, residence, average monthly income, employment status, healthcare payment method, and smoking and alcohol consumption status. Medical characteristics comprised history of hypertension, diabetes, coronary heart disease, infarction site, number of comorbid chronic diseases, frequency of stroke episodes, and clinical status during acute events. All information was obtained from participants' medical records, with missing data supplemented verbally by the participants.

2.2.2. The Medical Outcomes Study Short Form 36

The Medical Outcomes Study Short Form 36 (SF‐36) was used, which includes eight dimensions of physiological function (PF), role‐physical (RF), bodily pain (BP), general health (GH), validity (VT), social function (SF), role‐emotional (RE), and mental health (MH), with a total of 36 items. Higher scores indicate better quality of life (Li et al. 2002). The Cronbach α coefficients for the eight dimensions ranged from 0.56 to 0.90 (Jiang and Li 2003). The SF‐36 is a useful measure with good reliability and validity for older adults who are relatively stable in their functioning. Seven domains of the SF‐36 reported the Cronbach α coefficients greater than 0.7, with only the social functioning domain having a coefficient of 0.63 (Zhang et al. 2012). The Cronbach α coefficient of the scale in this study was 0.972.

2.2.3. Health Literacy Management Scale

The Health Literacy Management Scale (HeLMS) was translated by Chinese scholars (Sun et al. 2012) based on the health literacy scale developed by Jordan et al. (2010). The scale consisted of 24 items with four dimensions: information accessibility (9 items), communication and interaction skills (9 items), willingness to improve health (4 items) and willingness to provide financial support (2 items) and was scored on a Likert scale of 5, with a score of 1 to 5 for each question, for a total score of 120 points. Higher scores indicate higher levels of health literacy. A score of 96 or above is considered good health literacy, while a score below 96 is considered lack of health literacy. The reliability of the scale was good, with the Cronbach α coefficients ranging between 0.857 and 0.947 and the correlation coefficients of the items with the dimension to which they belonged ranging between 0.532 and 0.950 (Sun et al. 2012). The Cronbach α coefficient of the scale in this study was 0.985.

2.2.4. Fear of Progression Questionnaire‐Short Form

The Fear of Progression Questionnaire‐Short Form (FoP Q‐SF) was translated by Chinese scholars (Wu et al. 2015) based on the FoPQ‐SF developed by Mehnert et al. (2006). The scale contains two dimensions, physiological health and social family, with six items in each dimension. The physical health dimension focuses on patients' fears about the health aspects of their illness and the social family dimension focuses on patients' fears about social family functioning. A higher total score indicates a higher level of FOP. The reliability of the scale was good, with a Cronbach α coefficient of 0.883 (Wu et al. 2015). The Cronbach α of the scale in this study was 0.966.

2.3. Statistical Analyses

All data were independently verified and entered into Excel 2016 by two researchers. Statistical analyses were performed using SPSS 23.0. Continuous variables are presented as mean ± standard deviation, while categorical variables are described using frequencies and percentages. Pearson correlation analysis was employed to examine the relationships among health literacy, FOP, and quality of life. A mediation model was constructed with AMOS 24.0, and the Bootstrap method was applied to test mediation effects. Statistical significance was defined as p < 0.05.

2.4. Ethical Considerations

The research protocol was submitted to the Medical Ethics Committee of Jishou University for review and was approved (approval number: JSDX‐2024‐0051). The study adheres to the ethical principles of “benevolence,” “respect for human dignity” and “justice.” Prior to conducting the questionnaire survey, consent for participation was obtained from stroke patients and their caregivers. The study objectives and procedures were explained in detail, and participants were informed that questionnaire content would be strictly confidential. Their right to refuse participation or withdraw at any time was guaranteed. Furthermore, all participant information was anonymized. Research data are restricted solely for use within this study and is inaccessible to individuals outside the research team.

3. Results

3.1. Sample Characteristics

Table 1 presents the participants' sociodemographic and medical characteristics.

TABLE 1.

Sample characteristics (n = 300).

Item		Number	Percentage (%)
Age (years; mean ± SD)	—	59.70 ± 12.60	—
			—
Gender	Male	211	70.30
	Female	89	29.70
Marital status	Married	266	88.20
	Unmarried	8	2.70
	Divorced or widowed	26	8.70
Average monthly income	< 2000 yuan	126	42.00
	2000–4999 yuan	114	38.00
	≥ 5000 yuan	60	20.00
Healthcare payment methods	Self‐financed	24	8.00
	Urban and rural residents' medical insurance	144	48.00
	Employee medical insurance	61	20.30
	Other	71	23.70
Education level	Primary and lower	125	41.70
	Junior middle school	69	23.00
	High school	53	17.70
	College and above	53	17.70
Residence	Urban	170	56.70
	Rural	130	43.30
Employment status	Active employees	31	10.30
	Retired	56	18.70
	Farmers	150	50.00
	Others	63	21.00
Smoking consumption status	No	168	56.00
	Yes	132	44.00
Alcohol consumption status	No	222	74.00
	Yes	78	26.00
Hypertension	No	110	36.70
	Yes	190	63.30
Diabetes	No	187	62.30
	Yes	113	37.70
Coronary heart disease	No	239	79.70
	Yes	61	20.30
Number of comorbid chronic diseases	Zero	72	24.00
	One	99	33.00
	Two	80	26.70
	Three or more	49	16.30
Infarction site	Left side	118	39.30
	Right side	109	36.30
	Bilateral stroke	73	24.30
Frequency of stroke episodes	First time	202	67.30
	Two times	73	24.30
	Third and above	25	8.30
Activity status at onset	Onset during sleep	62	20.70
	Fatigue/malaise	4	1.30
	Onset during physical exertion	115	38.30
	At rest	119	39.70

Note: Urban and rural resident basic medical insurance (URRBMI) is the basic health insurance scheme in China covering residents not enrolled in the employee‐based insurance programme.

3.2. Summary Scores of Study Variables

Table 2 presents the scores of participants on the FoP‐Q‐SF, HeLMS and SF‐36. The mean FoP‐Q‐SF score was 33.92 ± 13.19, indicating a moderate‐to‐high level. The mean HeLMS score was 87.47 ± 28.47, indicating a moderately low level. The mean SF‐36 score was 97.88 ± 31.75, indicating a moderately low level.

TABLE 2.

Scores of health literacy, fear of disease progression and quality of life (n = 300).

Item	Dimensions	Sex	—	Scores
FoP‐Q‐SF	Total score of fear of disease progression	Male	33.13 ± 13.31	33.92 ± 13.19
		Female	35.81 ± 12.77
	Physiological health	Male	16.45 ± 7.10	16.82 ± 7.09
		Female	17.71 ± 7.03
	Social family	Male	16.68 ± 6.89	17.10 ± 6.77
		Female	18.10 ± 6.41
HeLMS	Total score of health literacy	Male	91.18 ± 26.57	87.47 ± 28.47
		Female	78.70 ± 30.96
	Information accessibility	Male	34.01 ± 11.59	32.70 ± 12.16
		Female	29.60 ± 12.96
	Communication and interaction skills	Male	34.86 ± 10.24	33.22 ± 11.19
		Female	29.34 ± 12.88
	Willingness to improve health	Male	14.98 ± 4.88	14.53 ± 5.17
		Female	13.48 ± 5.72
	Willingness to provide financial support	Male	7.33 ± 2.34	7.02 ± 2.41
		Female	6.28 ± 2.45
SF‐36	Total score of quality of life	Male	100.81 ± 30.37	97.88 ± 31.75
		Female	90.95 ± 33.97
	Physiological functioning	Male	20.85 ± 6.83	20.22 ± 6.91
		Female	18.73 ± 6.92
	Role‐physical	Male	5.82 ± 1.59	5.73 ± 1.55
		Female	5.53 ± 1.46
	Bodily pain	Male	8.74 ± 2.90	8.45 ± 3.13
		Female	7.78 ± 3.54
	General health	Male	16.88 ± 5.61	16.53 ± 5.89
		Female	15.68 ± 6.86
	Role‐emotional	Male	4.66 ± 1.39	4.58 ± 1.38
		Female	4.38 ± 1.34
	Social function	Male	6.95 ± 2.49	6.61 ± 2.56
		Female	5.82 ± 2.53
	Mental health	Male	21.23 ± 8.10	20.47 ± 8.59
		Female	18.69 ± 9.45
	Validity	Male	15.68 ± 6.86	15.28 ± 7.00
		Female	14.34 ± 7.29

Abbreviations: FoP‐Q‐SF, fear of progression questionnaire‐short form; HeLMS, Health literacy management scale; SF‐36, 36‐item short‐form medical outcomes study.

3.3. Correlation Matrix for Study Variables

Health literacy was negatively correlated with FOP (r = −0.463, p < 0.01), FOP was negatively correlated with quality of life (r = −0.445, p < 0.01) and health literacy was positively correlated with quality of life (r = 0.412, p < 0.01), as shown in Table 3.

TABLE 3.

Correlation matrix for fear of disease progression, health literacy and quality of life (n = 300).

Item	FoP‐Q‐SF	HeLMS	SF‐36
FoP‐Q‐SF	1
HeLMS	−0.463**	1
SF‐36	−0.445**	0.412**	1

Note: Pearson correlation analysis was employed in this study.

^** p < 0.01.

3.4. Analysis of the Mediating Effect of FOP Between Health Literacy and Quality of Life in Ischaemic Stroke Patients

Structural equation modelling was constructed using AMOS 24.0 with health literacy as the independent variable, FOP as the mediator variable and quality of life as the dependent variable (see Figure 1). The maximum likelihood method was selected for parameter estimation. Results demonstrated good model fit: χ ²/df = 2.301 (< 3), RMSEA = 0.066 (< 0.08), CFI = 0.972 (> 0.90), TLI = 0.966 (> 0.90) and IFI = 0.972 (> 0.90). The bootstrap method with 5000 resamples and 95% confidence intervals were employed to test mediation effects. The direct effect of health literacy on quality of life was significant (95% CI did not include 0). The indirect effect of health literacy on quality of life through FOP was also significant (95% CI did not include 0). FOP partially mediated the relationship between health literacy and quality of life in stroke patients, accounting for 41.3% of the total effect. The detailed mediation analysis results are presented in Table 4.

FIGURE 1.

Mediating effect of fear of disease progression in the relationship between health literacy and quality of life.

TABLE 4.

Role effects of intermediation models (standardization).

Relation of effect	Standardized regression coefficient	95% confidence interval	p	Percentage (%)
Indirect effect	0.083	0.050 ~ 0.135	p < 0.001	41.3
Direct effect	0.118	0.038 ~ 0.192	0.005	58.7
Total effect	0.201	0.139 ~ 0.271	p < 0.001	100

4. Discussion

This study constructed a structural equation model based on the FOP theory to examine the relationships among health literacy, FOP and quality of life in patients with ischemic stroke. The results showed that health literacy was positively correlated with quality of life, while FOP was negatively correlated with quality of life. Furthermore, FOP partially mediated the relationship between health literacy and quality of life. These findings are consistent with the fear of cancer recurrence model (Lee‐Jones et al. 1997): Patients with higher health literacy are better able to acquire disease‐related knowledge and effectively cope with triggers such as physical symptoms and follow‐up visits, thereby reducing FOP and achieving higher quality of life. In contrast, patients with lower health literacy, due to insufficient cognitive resources and coping strategies, are more susceptible to fear, leading to decreased quality of life.

4.1. Current Status of Health Literacy, FOP and Quality of Life in Ischaemic Stroke Patients

The study found that the patients' health literacy score was 87.47 ± 28.47, which was below the midpoint of 100 on the scale, indicating a moderately low level. This finding is similar to the results reported by He et al. (2023). Potential contributing factors may include patients' lack of professional guidance after disengaging from the healthcare system, as well as insufficient awareness of the importance of health management and limited ability to access health information among some patients (Xie et al. 2025). Healthcare professionals should provide adequate supportive measures, such as implementing peer education programs where individuals with higher health literacy share health knowledge and skills during daily interactions, while adopting efficient health information dissemination strategies to enhance the understanding and application of health information among those with lower health literacy. These approaches can help individuals effectively translate health knowledge into practical actions, ultimately promoting the improvement of their health literacy levels.

The study found that the patients' FOP score was 33.92 ± 13.19, which was above the midpoint of 32 on the scale, indicating a moderately high level. This finding is similar to the results reported by Zhang et al. (2024) but significantly higher than the results reported by Cui (2022). This discrepancy may be attributed to the predominantly male composition of our study participants, who typically exhibit higher self‐esteem and increased concern that physical dysfunction resulting from disease progression could burden their families (Yi et al. 2022). Furthermore, having no outlet for their negative emotions, these patients tend to engage in self‐concealment behaviours and lose confidence in long‐term rehabilitation therapy, thereby exacerbating disease‐related fears (Liu et al. 2022). Healthcare professionals should closely monitor patients' psychological status and implement targeted interventions addressing these contributing factors. For instance, psychological assessments should be conducted during the early stage of admission to promptly identify individuals with high psychological distress. Taking into account patients' psychological resilience and emotional state, empathetic and patient communication approaches such as empathetic listening, guidance on relaxation training and sharing of successful cases should be adopted to help them appropriately alleviate internal burdens and common emotional triggers. Furthermore, psychological counselling can be integrated into daily ward rounds, health education and discharge guidance to provide continuous emotional support. This approach assists patients in gradually rebuilding psychological coping mechanisms, enhancing their sense of control and confidence in recovery, thereby effectively reducing their level of psychological distress.

4.2. Correlation of Health Literacy, FOP and Quality of Life in Ischaemic Stroke Patients

The findings of this study validate the initially proposed theoretical hypothesis. The results showed that among patients with ischemic stroke, health literacy was positively correlated with quality of life, FOP was negatively correlated with quality of life and health literacy was negatively correlated with FOP. Further path analysis indicated that FOP partially mediated the relationship between health literacy and quality of life.

4.2.1. Health Literacy Is Positively Associated With Quality of Life

The results of this study demonstrated a positive correlation between health literacy and quality of life in patients with ischemic stroke (r = 0.412, p < 0.01), indicating that higher health literacy levels were associated with better quality of life, which aligns with the findings reported by Butayeva et al. (2023). Existing research has shown that health literacy level is closely related to health knowledge acquisition pathways, and health knowledge further influences patients' living conditions and disease understanding. When health knowledge levels are higher, patients' quality of life shows corresponding improvement (Haack et al. 2020). Therefore, healthcare professionals should recognize the impact of health literacy on patients' quality of life and can develop targeted health education programs to enhance health knowledge levels, thereby further improving patients' quality of life.

4.2.2. FOP Is Negatively Associated With Quality of Life

The results of this study indicate a significant negative correlation between FOP and quality of life in patients with ischemic stroke (r = −0.445, p < 0.01). Specifically, higher levels of fear related to disease progression were associated with poorer quality of life, which is consistent with the findings reported by (Mehnert et al. 2009). After hospitalization, many stroke patients experience substantial physical, psychological and economic pressures, which can profoundly impact their well‐being. Furthermore, given the characteristics of stroke—including high recurrence and disability rates—most patients worry that their ability to perform daily activities may further decline following disease recurrence or progression. Such concerns often lead to anxiety and distress, ultimately resulting in reduced quality of life. Therefore, healthcare professionals should closely monitor changes in patients' psychological and emotional states, provide accurate guidance regarding disease knowledge and help alleviate their fear of the disease, thereby improving their overall quality of life.

4.2.3. Health Literacy and FOP Negatively Correlated

The findings of this study revealed a negative correlation between health literacy and FOP in patients with ischemic stroke (r = −0.463, p < 0.01). Specifically, higher health literacy levels were associated with lower degrees of fear regarding disease progression, which aligns with the research results reported by (Clarke et al. 2021). Studies have indicated that stroke patients with higher health literacy levels are better able to comprehend the disease progression process, anticipate potential future developments of their condition and maintain psychological preparedness when their condition worsens, thereby reducing their fear of disease recurrence Wang (2023). Therefore, healthcare professionals should recognize the impact of patients' health literacy levels on their fear of disease recurrence and provide accurate, personalized health education tailored to individual patient characteristics. This approach can enhance health literacy levels and subsequently alleviate fears related to disease recurrence.

4.2.4. Mediating Effects of FOP Between Health Literacy and Quality of Life in Ischaemic Stroke Patients

The results of this study demonstrate that FOP serves as a mediator between health literacy and quality of life. Specifically, health literacy influences quality of life partially through the indirect pathway of FOP, with this mediating effect accounting for 41.3% of the total effect. Adequate health literacy enhances patients' understanding of stroke onset, progression and prognosis, prompting them to adopt more appropriate coping strategies, which directly reduces their fear of stroke recurrence (Yang et al. 2023). The mechanism underlying this mediating effect may be explained by the fact that the severity of disease‐related fear—a common psychological state during illness adaptation—is itself influenced by health literacy. Simultaneously, heightened FOP exacerbates distress through negative emotions such as anxiety and concern about prognosis, thereby ultimately diminishing quality of life.

In summary, the quality of life in patients with ischemic stroke remains at a moderate level, with FOP serving as a partial mediator between health literacy and quality of life. Therefore, healthcare professionals should monitor the dynamic changes in patients' FOP. Guided by behaviour change theory (Zhang et al. 2025), a collaborative and supportive relationship can be established with patients: on one hand, multi‐stage nursing interventions can be implemented to improve negative behaviours and emotions, facilitating the transition from psychological states to practical actions; on the other hand, by integrating psychology, behavioural science and nursing care, nurses can emphasize the process of behavioural change, help patients to fully recognize their own behavioural adjustments, enhance motivation, promote recovery and thereby further improve their quality of life.

4.3. Limitations and Recommendations

This study has the following limitations: (1) This study employed a cross‐sectional design, which can only reflect the correlations among variables at a single time point and cannot infer the causal direction between health literacy, FOP and quality of life. Future studies may adopt a longitudinal design or prospective cohort study to conduct repeated measurements of the aforementioned variables at different time points, in order to clarify the causal relationships and temporal sequence among the variables and further validate the stability of the mediating effect. (2) The study population was limited to patients with ischemic stroke and did not include patients with haemorrhagic stroke or other types of stroke. Therefore, the generalizability of the study findings to the broader stroke population is limited. Future studies may expand the scope of the study population to include patients with haemorrhagic stroke and other types of cerebrovascular diseases and conduct multicentre, large‐sample studies to examine the applicability of the study findings across different stroke populations and enhance the generalizability of the results. (3) This study did not employ validated tools such as the National Institutes of Health Stroke Scale to systematically assess stroke severity. Stroke severity is an important factor that affects patients' cognitive function, self‐management ability and psychological status, and may have a direct or indirect impact on health literacy, FOP and quality of life. The lack of data on this key variable introduces limitations in controlling for confounding factors and interpreting the mediating effect in this study. Future studies should systematically employ validated tools such as the National Institutes of Health Stroke Scale to objectively assess stroke severity and include it as a key covariate in the analysis, in order to control for its potential confounding effects on the relationships among health literacy, FOP and quality of life, thereby enhancing the reliability of the mediating effect analysis.

5. Conclusion

Health literacy, FOP and quality of life are interrelated in patients with ischemic stroke, with FOP mediating the relationship between health literacy and quality of life. Based on these findings, the following recommendations are proposed for nursing practice and research. In terms of nursing practice, health literacy screening should be integrated into routine admission procedures to promptly identify high‐risk individuals; a dynamic monitoring mechanism for FOP should be established, with particular attention to patients with low health literacy, severe sequelae or weak family support; hierarchical health education should be implemented according to patients' health literacy levels, using teach‐back methods and visual materials for those with low literacy while providing detailed knowledge and self‐management guidance for those with moderate to high literacy; additionally, cognitive education should be combined with psychological counselling, incorporating empathetic listening and sharing of successful cases to interrupt the “low literacy‐high fear” vicious cycle. Regarding nursing research, future efforts should focus on developing and validating targeted health literacy intervention programs, evaluating their long‐term effects through randomized controlled trials; conducting longitudinal follow‐up studies to analyse dynamic causal relationships among variables; and introducing additional variables such as social support and coping styles to construct multiple mediation or moderation models, thereby providing a more comprehensive understanding of the pathways influencing quality of life.

Author Contributions

Hui Teng: data collection, data processing, paper writing. Ying Kuai: data collection. Xiang Su: data collection. Mengni Zhen: data collection. Yangjun Tian: data collection. Jiajia Chen: data collection. Qianqian Wu: data collection. Qingxia Shu: thesis supervision. Chunmei Li: thesis supervision.

Funding

The authors have nothing to report.

Ethics Statement

The research protocol has been submitted to the Medical Ethics Committee of Jishou University for review and evaluation (approval number: JSDX‐2024‐0051). The study adheres to the ethical principles of “benevolence,” “respect for human dignity” and “justice.” Prior to conducting the questionnaire survey, consent for participation was obtained from stroke patients and their caregivers. The study objectives and procedures were explained in detail, and participants were informed that questionnaire content would be strictly confidential. Their right to refuse participation or withdraw at any time was guaranteed. Furthermore, all participant information was anonymized. Research data are restricted solely for use within this study and is inaccessible to individuals outside the research team.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.