Correlation of health literacy, health management self-efficacy, and attitude in elderly patients with schizophrenia: A cross-sectional study

Abstract

Aim

The study investigated the relationship between chronic diseases and health problems, emotional health status, health literacy, health self-management attitude, and health management self-efficacy in older patients with schizophrenia. It is expected to provide multiple health perspectives in the care of older patients with schizophrenia and improve their health literacy and self-management.

Design

A cross-sectional study.

Methods

Data collection from 2020/09 to 2021/10, the study of older patients with schizophrenia who were diagnosed with schizophrenia and were over 50 years, live in residential mental rehabilitation institutions in eastern Taiwan as older people. Data were collected on demographic variables, chronic diseases, health problems, health literacy, healthy management self-efficacy, and attitudes.

Results

The study results show 61.49 years (SD = 6.57), the gender, health literacy, and health management self-efficacy can effectively explain the variance of health self-management state by 18.5% (F_(3,116) = 10.01, p < 0.000), in which health literacy (β = 0.28, t = 3.07, p = 0.003) and health management self-efficacy (β = 0.19, t = 2.03, p = 0.04) that in the analysis of predictors, emotional health status, and health literacy not only have significant explanatory power on health management self-efficacy and the performance of physical functions but are also important factors affecting the quality of life among the elderly; the important influencing factor of health management self-efficacy and health self-management behaviour is health literacy. Therefore, health literacy is crucial to the health attitudes of older patients with schizophrenia.

Conclusion

This study found that increased health literacy among older patients with schizophrenia can enhance their attitude and ability to manage their health.

Implications for the Profession and No Patient or Public Contribution

Nursing can provide nursing measures related to individual health literacy to help patients improve their health literacy, maintain the health of chronic older patients with schizophrenia, reduce elderly schizophrenia disability, enhance patients' ability to manage their self-efficacy and health self-management attitude, and improving the health and quality of life of patients.

INTRODUCTION

In people aged 54 years or less and who have a mental illness, the rate of aging is 20% faster than that in the general population and their average life expectancy is shortened by 10 to 25 years (World Health Organization, 2023; Correll et al., 2022; Wander, 2020). Patients with schizophrenia are prone to cardiovascular disease (Kritharides et al., 2017), neurological disease, and other diseases owing to cognitive impairment, the chronicity of the disease (Shojaeimotlagh et al., 2018), the side effects of drug treatment (Krause et al., 2018; Zolk et al., 2022), their static lifestyles and unhealthy behaviours (Kalinowska et al., 2021), musculoskeletal weakness, and other health problems (Crump et al., 2013). Poor diet, physical inactivity, smoking, substance abuse (Kalinowska et al., 2021), and poor self-maintenance ability to live a healthy lifestyle affect the morbidity and mortality of cardiovascular disease in such patients two to three times higher than in the general population (Petrides et al., 2019; Zaman et al., 2019; Zhang et al., 2021).

Aging and chronicity in patients with mental illness can increase negative mental symptoms and lead to overall functional declines, such as interpersonal withdrawal, poor self-care ability, or side effects after antipsychotic drugs consumption, metabolic abnormalities, weight gain, diabetes, cardiovascular diseases, and so on (Correll et al., 2022; Public Health Agency of Aging and chronic diseases: A profile of Canadian seniors, 2020). Multiple diseases due to chronicity and deterioration of living functions, a functional decline caused by disability (e.g., inability to live independently and imposition of the burden on family members) (Correll et al., 2022; Maresova et al., 2019; Public Health Agency of Aging and chronic diseases: A profile of Canadian seniors, 2020), and insufficient current medical and long-term care resources affect the complete care of patients, burdening the family and long-term care resources (Chen et al., 2019; Lavaud et al., 2021).

Older patients with schizophrenia experience increased complexity of health problems and diseases with age, affecting the demand for health care, the cost of care, and unexpected medical expenses, these individuals need high care (Chen et al., 2019; Meesters, 2014). These studies suggest that schizophrenia can have a negative impact on the physical health and functioning of older patients, which in turn affects their quality of life. (Dong et al., 2019; Hoseinipalangi et al., 2022; Solomon et al., 2021). Therefore, focusing on patients' physiological functions, early detection of health problems, and physical health maintenance is imperative. In the clinical care experience of older patients with schizophrenia, patients' ability to maintain their health positively affects their health status (Joung et al., 2021).

Health literacy is defined as the extent to which individuals possess the knowledge, motivation, and competencies to access, understand, appraise, and apply health information (Parnell et al., 2019; Sørensen et al., 2012). It is subject to change owing to environmental, personal, and situational factors. Health literacy aims to motivate healthy attitudes and decision-making (Tseng et al., 2018). Literature related to health literacy and the elderly found that low health literacy led to a lack of compliance with rules, poor health self-management, and less satisfactory health outcomes (Chesser et al., 2016; Lee & Oh, 2020). Personal health literacy is closely related to chronic disease care, health self-management and care, and maintenance of health expenditures (Liu et al., 2020). The lower health literacy in older people has been associated with sub-optimal levels of health and health outcomes, such as compliance with treatment regimes, medication adherence, and capacity for self-management (Smith et al., 2022). When health literacy is inadequate, acute medical services are more frequently used, healthcare costs and morbidity rates rise, and poor health outcomes, such as poor status and higher mortality, increase (Lin et al., 2016; Liu et al., 2020). Health literacy is increasingly being seen as a better predictor of health than many other social determinants of health including, ethnicity, education, and employment status (Smith et al., 2022).

Nurses often clinically serve as patients' healthcare providers and should focus on and help improve patients' health literacy (Parnell, 2015). Doing so can promote patients' self-management of health and reduce and control disabilities caused by diseases and health problems. Approximately 30% of people have low health literacy, the risk factors of low health literacy include old age, low education, low income, living in remote areas, and so on (Lee et al., 2010). Totally, 752 community adults were investigated using the Health Literacy Questionnaire, 6.1% had insufficient health literacy and 25.3% had marginal low health literacy (Wei, 2014). People with insufficient health literacy have a low use rate of cancer screening, low influenza vaccination rate, high probability of hospitalization, poor understanding of consuming drugs correctly, and poor understanding of drug labels and health information (Tseng et al., 2018). The economically disadvantaged elderly are unable to access better health resources or services owing to a lack of understanding. This is associated with health literacy (Lin, 2017). Therefore, this study is expected to provide multiple health perspectives in the care of older patients with schizophrenia and improve their health literacy, health self-management self-efficacy, and health management attitude.

THE STUDY Aim

Investigated the relationship between chronic diseases and health problems, emotional health status, health literacy, health self-management attitude, and health management self-efficacy in older patients with schizophrenia.

METHODOLGY Design data and older people

This is a cross-sectional correlation study, data collected during the years 2020–2021. Older patients with schizophrenia in residential mental rehabilitation institutions in eastern Taiwan were selected as older people. The inclusion criteria were as follows: (1) older patients who met the symptoms listed in the fifth edition of the Diagnostic Criteria Manual for Mental Disorders (DSM-5) (Taiwanese Society of Psychiatry, 2014), were diagnosed with schizophrenia and were over 50 years; (2) those who lived in residential mental rehabilitation institutions and continued to receive treatment in mental rehabilitation medical institutions or psychiatric clinics; (3) those who were conscious and able to communicate in Chinese and Taiwanese and respond to the questionnaire; (4) Mini-Mental State Examination (MMSE) > 20 scores; and (5)those who agreed to participate in the study and sign the consent form after the study's purpose was explained to them.

Sampling and recruitment

A simple linear regression analysis was performed. The number of samples was estimated using G-POWER version 3.1 software, with effect size = 0.15, α = 0.05, and power = 0.8. The minimum number of samples calculated was 100 (Gay, 1922), and the total number of cases received was 120. After the patients were referred by the medical team of the rehabilitation institution, a dedicated researcher completed data collection in the institution's conference room. The study was conducted after 30 patients underwent the precursor test. The study was reviewed and approved by the Research Human Test Committee.

Instrument The sociodemographic data

The sociodemographic data included age, gender, time of admission, disease diagnosis, education level, and marital status.

The scale of chronic diseases and health problems

The scale proposed by Jou and Chuang (2000) and revised by Pan et al. (2013), was added to seven health problems; in total, there were 20 chronic diseases and health problems. The older people were asked to self-evaluate the number of symptoms of chronic diseases and health problems in the last 3 months and to explore the severity of chronic diseases and health problems' interference in their daily life. On the Chronic Physical Illness and Health Problems Scale, each item was given two options: no = 0 and yes = 1. Next, the severity of the disturbance to daily life was distinguished: no impact = 0, a little inconvenience = 1, and quite inconvenient = 2. Chronic diseases and chronic health problems were scored separately, with the total score ranging from 0 to 40. Cronbach's α value of the instrumental internal consistency can reach 0.70 (Pan et al., 2013). Cronbach's alpha value for the scale in this study was 0.82.

Brief Symptom Rating Scale

The Brief Symptom Rating Scale (BSRS-5) explored five aspects: sleep disturbance, nervousness, anger, low mood, and feeling inferior to others. Here, 0–5 was the normal range, indicating good physical and mental adaptation, and 6–9 indicated mild emotional distress, suitable for stress management (it was recommended to talk to family members or friends to express emotions). A score ranging from 10 to 14 indicated moderate emotional distress (it was recommended to seek pressure relief channels or receive professional psychological counselling). A score of 15 or higher indicated severe emotional distress. It was recommended that psychiatric evaluations and professional counselling be received in such a case. The scale has good reliability, validity, and internal consistency (Cronbach's α = 0.77–0.90). The sixth question (with or without suicidal ideation) was individually scored and was an additional question. If the score was above 2 (moderate suicidal ideation), referral to professional counselling or psychiatric treatment was recommended (Lee et al., 2003). Cronbach's alpha value for the scale in this study was 0.70.

Mandarin Multidimensional Health Literacy Questionnaire

The self-reported scale developed by Wei et al. (2017) was used to measure multiple aspects of health literacy constructs, in line with local life experience and medical environment and friendly responses. The Mandarin Multidimensional Health Literacy Questionnaire (MMHLQ) consists of five health literacy cores: acquiring health information for questions 1–4, understanding health information for questions 5–8, evaluating health information concepts for questions 9–12, applying health information concepts for questions 13–16, and communicating and interacting for questions 17–20. The scale comprised 20 questions. For each item, 1 meant “very difficult,” 2 meant “difficult,” 3 meant “easy,” and 4 meant “very easy.” The maximum score was 80 points. Scores > 25–33 were limited/problematic; scores > 33–42 were sufficient; scores > 42–50 were excellent (Wei et al., 2017). The reliability of the Chinese version of Cronbach's alpha ranged from 0.85 to 0.90 (Wei et al., 2017). Cronbach's alpha value for the scale in this study was 0.97.

Health management self-efficacy

This scale is a measurement tool modified from the Self-efficacy of Chronic Patients' Health Behaviour, developed by the Stanford Patient on Education Research Center of Stanford University. In total, 10 questions covered managing or regulating chronic health problems, symptomatic fatigue, physical discomfort, regular diet and exercise, and self-confidence in maintaining a regular life. Each item was scored from 0 to 10, with a total score of 100. Individuals evaluated their self-confidence in implementing a healthy diet and exercise routine and managing health problems. The higher the level of self-confidence in life's stressful events and other issues-for example, a median score of 5 indicates the cutoff point for evaluating samples with high or low self-efficacy, that with <3 points indicate poor performance, between 4 and 5 indicates average performance, and between 6 and 8 indicates good self-efficacy. Additionally, a score between 9 and 10 is classified as excellent efficacy (Pan et al., 2013). The internal consistency Cronbach's alpha value of 250 middle-aged and elderly people in the study was 0.91 (Pan et al., 2013). Cronbach's alpha value for this scale in this study was 0.95.

Healthy self-management attitude

This part measured the patient's self-management attitude towards a healthy life. The questionnaire was used to measure the self-management attitude of healthy life in patients with chronic schizophrenia (23 questions in total) (Liao, 2020). Questions 1 and 2 were reversed The Likert five-point scoring system was used; the scores ranged from “strongly agree” with 5 points to “strongly disagree” with 1 point. The higher the score, the better the self-management attitude towards a healthy life was. In this study, Cronbach's alpha for this scale was 0.92.

RESULTS Sociodemographic data

The research sample (N = 120) comprised 80 men (66.7%) and 40 women (33.3%); the average age was 61.49 years (SD = 6.57); incidence years were 21.58 years (SD = 9.48); education level was 40.8% (n = 49) below the junior high school level, 38.3% (n = 46) at the senior high school level, and 20.8% (n = 25) at the university level or above. Additionally, 90% (n = 108) of the older people were single (unmarried, separated, widowed, or divorced) and 10% (n = 12) were married. All older people lived in mental rehabilitation institutions. Among them, 75% (n = 90) received work training in mental rehabilitation institutions, 6.7% (n = 8) received work training outside the institutions, and 18.3% (n = 22) received routine treatment activities only in institutions without work training. Additionally, 58.3% (n = 70) participated in routine rehabilitation activities in the institution, such as routine nursing and health education activities. Furthermore, 16.7% (n = 20) received participated in rehabilitation activities in the institution and individual psychotherapy with psychologists; 25% (n = 30) of the patients participated in routine rehabilitation activities in the institution, including health exercises, life symposiums, drug health education groups, handicraft functional activities, or community functional rehabilitation (Table 1).

TABLE 1 Demographic data (N = 120).

[Table omitted. See PDF]

Chronic disease, health problems, emotional health status, health literacy, health self-management attitude, and health management self-efficacy

Of the older people, 6.7% (n = 8) felt that their health was very poor or not good, 64.2% (n = 77) felt good, and 29.2% (n = 35) felt very good. Regarding the number of self-assessed chronic diseases in older patients, 15% (n = 18) were without any chronic diseases, 28.3% (n = 34) had one chronic disease, and 56.7% (n = 68) had two or more chronic diseases. Regarding the number of health problems, 45% (n = 54) of the patients reported no health problem, 23.3% (n = 28) had one health problem, 15% (n = 18) had two health problems, and 16.7% (n = 20) had three or more health problems. Furthermore, 29.2% (n = 35) of the older people experienced sleep disturbance, 24.1% (n = 29) had mild tension and anxiety, and more than 18.4% (n = 22) had mild distress. Additionally, 19.1% (n = 23) felt depressed, and that their emotions were inferior to those of others. However, 97.5% of the older people had no suicidal ideation, and only 2.5% of them had mild suicidal ideation (n = 3). The average value of health literacy was 28.47 (SD = 9.56); the highest to lowest scores were for understanding health information (M = 31.01, SD = 9.29), communicating and interacting with health professionals (M = 30.69, SD = 8.73), applying health information (M = 27.81, SD = 11.7), assessing health information (M = 26.91, SD = 11.99), and accessing health information (M = 25.90, SD = 12.84). The average score for health management self-efficacy was between 6.93 and 7.80. The average score for healthy self-management attitudes was between 3.13 and 3.98.

Differences and correlation analysis between demographic and main research variables

The results showed that (1) with respect to gender, there was a significant difference between male and female older patients in their attitudes towards health self-management (t = −2.52, p = 0.01). Women's attitude towards health self-management was higher than that of men. Health literacy in female older patients was significantly higher than that in male patients (t = −2.09, p = 0.04); (2) education level was significantly positively correlated with health literacy (r = 0.22, p = 0.02); (3) health literacy and rehabilitation work (r = 0.21, p = 0.02) had a significant positive correlation with health management self-efficacy (r = 0.23, p = 0.01); (4) there was a significant positive correlation with the total number of health problems (r = 0.435, p < 0.001) and emotional health status (r = 0.26, p = 0.004); (5) there was a significant positive correlation with emotional health status (r = 0.39, p = 0.0001) and health management self-efficacy (r = −0.19, p = 0.035); (6) emotional health status was significantly negatively correlated with health management self-efficacy (r = −0.37, p < 0.001); (7) health literacy had a significant positive correlation with health management self-efficacy (r = 0.42, p < 0.001) and healthy self-management attitude (r = 0.390, p < 0.001); (8) there was a significant positive correlation with health self-management attitude (r = 0.32, p < 0.001); (9) health self-management attitude was significantly positively correlated with gender (r = 0.22, p = 0.02); and (10) there was a significant positive correlation with health literacy (r = 0.390, p < 0.001) and health management self-efficacy (r = 0.32, p < 0.001) (Table 2).

TABLE 2 Pearson's correlation analysis table for each study variable (N = 120).

Variable	1	2	3	4	5	6	7	8	9	10
1 Age	1
2 Gender	−0.180*	1
3 Education level	0.022	0.188	1
4 Rehabilitation work	−0.087	0.170	0.096	1
5 Chronic illness	−0.002	0.006	0.093	−0.117	1
6 Health problems	−0.076	−0.138	0.031	−0.096	0.435***	1
7 Emotional health	−0.166	0.247**	−0.040	−0.089	0.262**	0.390***	1
8 Health literacy	−0.008	0.181*	0.222*	0.207*	0.014	0.051	−0.132	1
9 Health management self-efficacy	0.016	0.067	0.083	0.233**	−0.051	−0.193*	−0.372***	0.418***	1
10 management attitude	−0.098	0.226**	0.078	0.093	0.05	0.114	−0.126	0.390***	0.315***	1

^*p < 0.05

^**p < 0.01

^***p < 0.001

^****p < 0.0001.

Effects of variables on health efficacy, health management self-efficacy, and attitude

Rehabilitation work, total number of chronic diseases and health problems, emotional health status, health literacy, and health self-management attitude were predictive variables. These predictors explained 29.4% of the variation in health management self-efficacy (F_(5,114) = 10.92, p < 0.0001), of which emotional health status (β = −0.26, t = −2.99, p = 0.003) and health literacy (β = 0.30, t = 3.51, p = 0.001) were the most significant explanations for health management self-efficacy status. A total number of health problems (β = −0.12, t = −1.36, p = 0.179), rehabilitation work (β = 0.12, t = 1.54, p = 0.128), and health self-management attitudes (β = 0.17, t = 1.97, p = 0.051) were significantly affected by the efficacy (Table 3).

TABLE 3 Rehabilitation work, health problems, emotional health, health literacy, health management attitude, and health management self-efficacy (N = 120).

[Table omitted. See PDF]

^*p < 0.05

^**p < 0.01

^***p < 0.001

^****p < 0.0001.

Gender, health literacy, and health management self-efficacy can effectively explain the variance in health self-management state by 18.5% (F_(3,116) = 10.01, p < 0.000), in which health literacy represented (β = 0.28, t = 3) did not influence health management self-efficacy (β = 0.19, t = 2.03, p = 0.04). However, gender (β = 0.16, t = 1.93, p = 0.056) had no influence on attitudes towards health self-management. Health literacy and health management self-efficacy had significant explanatory power on attitudes towards health self-management, with health literacy having the highest explanatory power (Table 4).

TABLE 4 Regression analysis for gender, health literacy, health management self-efficacy, and health management attitude (N = 120).

Predictor	B	SE B	β	t	p	Adj. R2	F
Gender	3.41	1.77	0.16	1.93	0.056	0.185***	0.10.01***
Health literacy	0.25	0.08	0.28**	3.07	0.003
Health management Self-efficacy	0.09	0.05	0.19*	2.03	0.044

^*p<0.05

^**p<0.01

^***p<0.001.

DISCUSSION

The study results show that in the analysis of predictors, emotional health status (β = −0.26, t = −2.99, p = 0.003) and health literacy (β = 0.30, t = 3.51, p = 0.001) not only have significant explanatory power on health management self-efficacy and the performance of physical functions but are also important factors affecting the quality of life among the elderly (Tseng et al., 2018). Therefore, it is imperative to focus on the physiological functions of patients, early detection of health problems, and maintenance of physical health. In the clinical care experience of older patients with schizophrenia, nursing staff positively affect the health maintenance of patients to avoid secondary injuries caused by disease factors (Parnell, 2015). Older patients with schizophrenia may have other chronic diseases or multiple health problems, our research 56.7% had two or more chronic diseases and 55% had health problem; therefore, they need to be aware of mental diseases, corresponding treatment and health management methods, and health problems related to old age and health management knowledge (Parnell et al., 2019; Sørensen et al., 2012; Thomson et al., 2018). However, older patients with schizophrenia health literacy was 28.47 (SD = 9.56) are vulnerable owing to their lack of health literacy (Chesser et al., 2016; Lee & Oh, 2020).

The results showed that health literacy was the most important factor affecting health self-efficacy (r = 0.42, p < 0.001) and health management attitude (r = 0.390, p < 0.001); therefore, it was necessary to explore the health literacy of elderly psychiatric patients (Parnell et al., 2019; Sørensen et al., 2012). In this study, the five dimensions of health literacy in older patients with schizophrenia were presented as follows according to their scores (from highest to lowest): understanding health information (M = 31.01, SD = 9.29), being able to communicate and interact with health professionals (M = 30.69, SD = 8.73), applying health information (M = 27.81, SD = 11.7), evaluating health information (M = 26.91, SD = 11.99), and obtaining health information (M = 25.90, SD = 12.84). However, this health literacy was limited, May be about factors of low health literacy include old age, low education, low income, living in remote areas, and so on (Lee et al., 2010; Smith et al., 2022). So, the general community can achieve sufficient health literacy by understanding health information, obtaining health information, and communicating and interacting with professionals. However, this can help achieve limited health literacy (Wei et al., 2017). Additionally, both elderly mental patients and the general public have a limited degree of evaluation and application of health information. In this study, health literacy in older patients with schizophrenia 28.47 (SD = 9.56) was low, and the responses to at least half of the health literacy questions were difficult or very difficult (Lee et al., 2010; Wei, 2014). Therefore, in caring for mental patients' physical and mental health problems, healthcare professionals should assess and understand the difficulties encountered by patients with mental illness regarding health literacy (Parnell, 2015; Smith et al., 2022). Furthermore, they should assist psychiatric patients with low health literacy. Health education, discussion of problems, and shared decision-making can improve health literacy and strengthen health literacy-related attitudes to enhance psychiatric patients' abilities to control and improve their health management (Chesser et al., 2016; Lee & Oh, 2020; Thomson et al., 2018).

In this study, the average total score of the patients' health management self-efficacy was 72.52 (SD = 19.72). The self-efficacy of health management in the case was good, which showed that the patient was confident in performing health attitudes. The self-efficacy of health management in middle-aged people in the community studied by Pan et al. (2013) was between ordinary and good (M = 65.02, SD = 18.37). It is essential to observe and understand patients' evaluations of health management self-efficacy and their influence on health self-management attitudes from various perspectives.

Self-management of chronic diseases is a healthcare behaviour that is physically, psychologically, and socially oriented (Liu et al., 2020). Self-care activities, such as medicine use, diet control, symptom management, and exercise, are critical elements of the self-management of chronic diseases (Lin et al., 2016; Liu et al., 2020; Petrides et al., 2019; Zaman et al., 2019; Zhang et al., 2021). However, people with low health literacy cannot adequately understand the health information provider's instructions and cannot specify their conditions, which hinders them from actively seeking relevant information and having effective communication, misunderstanding healthcare personnel's suggestions, and being unaware of their shortcomings in behaviour change (Tseng et al., 2018). Otherwise, they thought they could not achieve their health goals, lacked self-confidence, and gave up self-management, thereby resulting in bad health behaviour and results (Grimaldi et al., 2016).

The influence and importance of health literacy on patients' health management self-efficacy are significant (r = 0.390, p < 0.001); therefore, it is essential to educate patients on diseases and health problems, which can improve their ability to manage health problems and health management self-efficacy, and form an attitude (Lee et al., 2016). Therefore, patients can actively participate in treatment plans, engage in personal health promotion activities, take responsibility for daily life management, coexist with chronic diseases, emphasize building partnerships, focus on their needs, and stimulate their sense of responsibility for disease care.

Regarding healthy self-management behaviour, the higher the score, the higher the self-management motivation is and the better the self-management cognition and attitude are (Chen & Lin, 2017). In this study, the average total score was 87.21 (SD = 9.96). Overall, older patients with schizophrenia had a positive attitude towards health self-management, and 35.9% (n = 43) of the patients disagreed with the prompt “I think I may be one of the causes of their health problems.” In other words, more than 30% of the patients did not think they were responsible for their health problems. This shows that health literacy is a vital factor affecting health self-management behaviour, followed by health management self-efficacy. Therefore, strengthening patients' health literacy and health management self-efficacy will affect the attitude and behaviour of older patients with schizophrenia towards health self-management.

Health literacy can directly affect health self-management behaviour (β = 0.28, t = 3), self-management of chronic diseases in the elderly can be regarded as an activity for individuals to manage their health (Petrides et al., 2019; Zaman et al., 2019; Zhang et al., 2021). The lack of health literacy is not only associated with individuals' abilities but also affected by the complexity of the healthcare environment information. To resolve this problem, medical and healthcare institutions and professionals should provide friendly care regarding public health literacy (Chang, 2020). Self-management of health is carried out by learning self-regulation skills and strengthening emotional management and problem-solving ability (Lee et al., 2016). It is promoted by improving self-efficacy (Lee et al., 2016) and strengthening social support (Rimando, 2015). The findings of this study indicate that health literacy is a significant influencing factor for both health management self-efficacy and health self-management behaviour. Consequently, health literacy plays a vital role in the health attitudes of elderly patients with schizophrenia.

CONCLUSION

The study establishes health literacy as a pivotal determinant of health management self-efficacy and self-management behaviour, reaffirming its critical role in the health behaviours of elderly patients with schizophrenia. Nurses could take to address HL issues including universal precautions and use of techniques, like the teach back approach. They should further provide nursing measures related to individual health literacy to help patients improve their health literacy, maintain the health of chronic older patients with schizophrenia, and reduce disability, to enhance patients' ability to manage their self-efficacy and health self-management attitude. In the future, we will build upon the research findings and continue to conduct experimental studies to enhance the health literacy, health self-management self-efficacy, and attitudes of elderly patients with schizophrenia.

LIMITATION

Older patients with schizophrenia are more likely to misunderstand or understand the meaning of the questions due to their low educational attainment and disease factors, so it is more difficult to complete the questionnaire alone. This study is a quantitative study of cross-sectional correlations, and it was not possible to continue to observe the gradual effect of time changes on the main research variables of older patients with schizophrenia. The study older people were patients with schizophrenia who had lived in rehabilitation institutions for a long time. Their behaviour and cognition may differ from those of patients living in the community.

AUTHOR CONTRIBUTIONS

SJL and LJW conceived the idea of the study, SJL carried out statistical analyses, LJW wrote the first draft, and all authors contributed to revisions of this draft. All authors approved the final version before submission. SJL is the guarantor for this study.

ACKNOWLEDGEMENTS

We would like to thank the participants who took part in this study.

FUNDING INFORMATION

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

CONFLICT OF INTEREST STATEMENT

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

DATA AVAILABILITY STATEMENT

The author elects to share data.

ETHICS STATEMENT

Institute Review Board (IRB)' approval was secured from the hospitals in this study.