Aging & Mental Health

Vol. 14, No. 7, September 2010, 870–873

The mediating effect of self-efficacy on the relationship between health literacy and health
status in Korean older adults: A short report
Su Hyun Kima* and Xu Yub
a
College of Nursing, Research Institute of Nursing Science, Kyungpook National University,
101 Dongin-dong, Jung-gu, Daegu, South Korea 700422; bSchool of Nursing, University of Nevada,
Las Vegas, NV 89154-3018, USA
(Received 27 August 2009; final version received 17 March 2010)

Objectives: Limited health literacy has been shown to be associated with poor health status. However, research to
date has not elucidated the factors that mediate the relationship between low literacy and poor health outcomes.
The purpose of this study was to examine the mediating effect of self-efficacy on the relationship between health
literacy and health status in Korean older adults.
Method: A cross-sectional study of 103 community-dwelling Korean older adults was conducted from June 2007
to September 2007.
Results: The study found that low health literacy was associated with poorer physical and mental health status,
and the effect of health literacy on physical and mental health status was mediated through self-efficacy.
Conclusion: The study suggests that interventions to improve the delivery of care for older adults with low health
literacy need to include not only improving the readability of health-related materials, but also enhancing the self-
efficacy of each individual.
Keywords: health literacy; mental health; physical health; self-efficacy

Introduction living with human immunodeficiency virus (HIV)/

Although limited health literacy has been shown to be
associated with poor health status (Gazmararian et al.,
1999; Wolf, Gazmararian, & Baker, 2005), research to
date has not elucidated the factors that mediate the
relationship between low health literacy and poor
health outcomes (DeWalt, Boone, & Pignone, 2007).
Researchers have suggested that health care providers
develop easy-to-read educational materials for those
with limited health literacy; however, they also pointed
out that enhancing the readability of health-related
information alone may be ineffective in improving
health outcomes (DeWalt et al., 2007; Pignone,
DeWalt, Sheridan, Berkman, & Lohr, 2005). In terms
of managing chronic illness in older adults, the will or
capacity to carry out a health care plan is an important
factor for self-management of illnesses (Paasche-Orlow
& Wolf, 2007). Previous studies suggested that self-
efficacy, an individual’s own perceived ability to
perform a specified behavior that predicts self-care of
chronic illnesses (Bandura, 1977), may influence the
effect of low health literacy on adverse health out-
comes (DeWalt et al., 2007; Paasche-Orlow & Wolf,
2007; Wolf et al., 2007).
However, findings from the studies of the relation-
ships among health literacy, self-efficacy, and health
outcomes have been inconsistent. In studies on patients
with diabetes, self-efficacy was associated with health
behavior or diabetes-related quality of life, while health
literacy was unrelated to self-efficacy (DeWalt et al.,
2007; Sarkar, Fisher, & Schillinger, 2006). In people
acquired immune deficiency syndrome (AIDS) who
are taking antiretroviral medication, health literacy
was not associated with self-efficacy (Colbert, 2007).
On the other hand, a low level of health literacy was a
significant factor for predicting improper adherence to
HIV medication regimens, and self-efficacy mediated
the impact of low health literacy on medication
adherence in patients with HIV (Wolf et al., 2007).
Torres and Marks (2009) also reported that a positive
relationship existed between health literacy and self-
efficacy regarding hormone therapy among postmen-
opausal women, and these variables accounted for
75% of the variance for behavioral intent concerning
the treatment.
As an older population with chronic illnesses is
rapidly increasing in South Korea, it is imperative to
develop strategies to manage chronic illnesses.
Particularly, because the illiterate older Korean pop-
ulation are estimated to constitute 19.2% (Chung
et al., 2005), the impact of health literacy on their
health status would be considerable. Only a few
studies, however, have discussed health literacy in
older Korean population. In a previous work, we have
reported that Korean older adults have a low level of
health literacy, and the limited level of health literacy is
associated with higher rates of chronic medical condi-
tions and lower subjective health status (Kim, 2009;
Kim & Lee, 2008). The mechanism of the effect of
health literacy on health status in Korean older adults
is still unknown. For this study, we sought to

*Corresponding author. Email: suhyun_kim@knu.ac.kr

ISSN 1360–7863 print/ISSN 1364–6915 online

ß 2010 Taylor & Francis
DOI: 10.1080/13607861003801011
http://www.informaworld.com
 Aging & Mental Health
investigate whether health literacy is mediated through
self-efficacy on influencing the health status in Korean
older adults. Improving the understanding of how
health literacy affects health outcomes would greatly
enhance the ability of health care providers to improve
care for older adults with low health literacy (Lee,
Arozullah, & Cho, 2004).
Methods
Design
This study employed a cross-sectional design to inves-
tigate the mediating effect of self-efficacy on the
relationship between health literacy and health status
in Korean older adults.
Sample and procedures
The study sample and methods have been previously
described in detail (Kim, 2009). From July 2007 to
September 2007, we collected data from 103 older
adults enrolled in community-based senior welfare
centers in Daegu, Busan, and the Kyungpook prov-
inces of Korea. Community-based senior welfare
centers in Korea provide a diverse range of activities
and support services for older adults who indepen-
dently function in the community, such as continuing
education, recreational activities, and day-care ser-
vices. The eligibility criteria for this study were that
persons must be 60 years old or above, and have no
apparent communicative or cognitive impairments.
The exclusion criteria were those who had a severe
vision problem not correctable with glasses, or who
could not tell the year they were born or the current
month, year, or the place they lived in.
The institutional review board approved the study
before collecting the data. We explained the purpose of
the study to the directors of the community-based
senior welfare centers and collected data at the centers
in which the directors gave permission for the study. A
trained research assistant received referrals of inter-
ested patients from the centers and obtained informed
consent from each participant before data collection.
Instruments
The Korean Test of Functional Health Literacy in
Adults (KTOFHLA; Kim & Lee, 2008) was used to
measure health literacy. KTOFHLA, developed based
on the Test of Functional Health Literacy in Adults
(TOFHLA; Parker, Baker, Williams, & Nurss, 1995),
consists of two parts. The numeracy section is an
eight-item test, which measures an individual’s ability
to comprehend directions for taking medicines, mon-
itoring blood glucose level, and keeping clinical
appointments. The reading comprehension section is
a seven-item test, which measures the ability to
understand the preparation steps for an abdominal
sonogram, health promotional materials, and informed
871
consent. A total score of the KTOFHLA was calcu-
lated (possible range 0–15), with higher scores indicat-
ing a higher health literacy. Validity of the test was
demonstrated in community-dwelling Korean older
adults, and the discrimination index ranged from 0.20
to 0.72 (Kim & Lee, 2008). Cronbach’s alpha coeffi-
cient was 0.82 in this study.
Self-efficacy was measured using a 10-item scale of
the General Self-Efficacy Scale (GSE; Schwarzer &
Jerusalem, 1995). The items reflect the belief that one
can perform difficult tasks in various domains of
human functioning that are relevant for behavioral
change (Schwarzer, 2007). Participants were asked to
respond to each statement by endorsing the item on a
four-point Likert scale. A total self-efficacy score was
calculated (possible range 10–40), with higher scores
indicating a higher self-efficacy. Cronbach’s alpha
coefficient was 0.87 in a study on Korean adults
(Scholz, Gutiérrez-Doña, Sud, & Schwarzer, 2002) and
this study. The validity of GSE was also documented in
a previous study (Schwarzer, 2007).
Physical and mental health status was measured
using the Physical Component Summary (PCS-12)
and Mental Component Summary (MCS-12) of the
Medical Outcomes Study 12-item Short Form. The
validity and reliability of the instruments were dem-
onstrated (Ware, Kosinski, & Keller, 1996).
Cronbach’s alpha coefficients were 0.88 for PCS-12
and 0.84 for MCS-12 in this study.
Data analysis
To analyze the pathways linking health literacy and
physical and mental health status, a series of regression
analyses were performed as described by Baron and
Kenny (1986). First, physical or mental health was
regressed onto health literacy. Next, the proposed
mediator of self-efficacy was regressed onto health
literacy. Finally, physical or mental health was
regressed onto both health literacy and self-efficacy.
In a mediational model, it is expected that once a
mediator is added, the relation between the predictor
and the outcome would be changed to non-significant
(Baron & Kenny, 1986). Separate tests for the medi-
ating models of physical and mental health were
performed. Sobel’s (1988) test was conducted to
determine whether an indirect effect of the predictor
and outcome variables by means of a mediator would
be significantly different from zero. Data analysis was
performed using Statistical Package for the Social
Sciences (SPSS, version 12.0), with statistical signifi-
cance set at p 5 0.05.
Results
The participants’ mean age was 72.3 years (SD ¼ 4.9
years); 58.3% were female. The mean years of educa-
tion was 8.89 (SD ¼ 0.74). The average income was
562,000 won a month (approximately US$ 590).
872 S.H. Kim and X. Yu
Self-efficacy 0.82*
0.41**
0.43*** Physical health
0.33 (0.67*)
0.41 (0.58*)
Health literacy Mental health
Figure 1. Self-efficacy as a mediator of health literacy
toward physical and mental health. Path coefficients in
parentheses indicate a relationship between predictor and
outcome before the mediator was included.
Notes: Unstandardized betas coefficients are represented.
*p 5 0.05, **p 5 0.01 and ***p 5 0.001.
The mean score of health literacy was 5.48 (SD ¼ 3.53,
range 0–15) and self-efficacy was 26.79 (SD ¼ 4.67).
The mean scores of PCS-12 and MCS-12 were 44.05
(SD ¼ 10.45) and 47.32 (SD ¼ 8.24), respectively.
In a path analysis to understand the mechanism of
the relationship between health literacy and health
status (Figure 1), self-efficacy met the three criteria as
being a mediator (Baron & Kenny, 1986). In fulfilling
the first criterion, health literacy significantly predicted
with low health literacy (Francis, Weiss, Senf, Heist, &
Hargraves, 2007; Paasche-Orlow & Wolf, 2007; Torres
& Marks, 2009).
To date, enhancing health-related knowledge by
developing easy-to-read health-related materials has
been a hallmark response to those with low health
literacy (Ad Hoc Committee on Health Literacy for the
Council on Scientific Affairs, American Medical
Association, 1999; Billek-Sawbney & Reicherter,
2005; Speros, 2005; Wolf et al., 2007). However,
health care providers and health researchers need to
be aware that behavioral change does not always
follow knowledge change (DeWalt et al., 2004). Based
on the findings from this study, a change in psycho-
social factors, such as self-efficacy needs to be com-
bined in order to maximize the effectiveness of
interventions for those with low health literacy.
Interventions for older adults with low health literacy
need to be comprehensive and should include not only
improving the readability of health-related materials,
but also enhancing the self-efficacy through empower-
ing approaches to care (Wolf et al., 2007). When
delivering health education to achieve better health
physical health ( ¼ 0.67, SE ¼ 0.29, p ¼ 0.02) and outcomes, health care providers could utilize optimal
mental health ( ¼ 0.58, SE ¼ 0.23, p ¼ 0.01). In fulfill- self-efficacy enhancing strategies, such as facilitation of
ing the second criterion, health literacy significantly achievable performance accomplishments, exposure to
predicted self-efficacy ( ¼ 0.41, SE ¼ 0.13, p ¼ 0.001). vicarious experiences, and the use of social and verbal
In fulfilling the third criterion for a partial mediator, persuasion to adopt health behavior (Marks,
after controlling health literacy, self-efficacy did not Allegrante, & Lorig, 2005).
significantly predict physical health ( ¼ 0.33, There are limitations for this study. As it has
SE ¼ 0.28, p ¼ 0.24), or mental health ( ¼ 0.41,
SE ¼ 0.23, p ¼ 0.08). Sobel’s test confirmed a signifi-
cant indirect effect of health literacy on physical and
mental health via self-efficacy (Z ¼ 2.46, p ¼ 0.014;
Z ¼ 1.97, p ¼ 0.048, respectively).
Discussion
Results from this study provide support for previous
findings that the effects of literacy on physical and
mental health status are mediated through self-efficacy
(Wolf et al., 2007). To the authors’ knowledge, this is
the first study that documents the associations among
health literacy, self-efficacy, and physical and mental
health status in older populations of non-English or
non-Spanish countries. Although this study did not
clarify the association between self-efficacy and health
behavior, which may be an intermediate step affecting
health status, the study findings elucidated one of the
individual-level characteristics affecting the mecha-
nisms of the health literacy-health outcomes relation-
ship (Paasche-Orlow & Wolf, 2007). This study
suggests that to improve the health outcomes for
older adults with a low literacy, not only health-related
knowledge but also psychosocial factors related to
health outcomes need to be addressed. In particular,
this finding supports the hypothetical idea that it is
possible to improve physical and mental health out-
comes through enhancement of self-efficacy for those
utilized cross-sectional data, causal relationships
between health literacy, self-efficacy, and health
status could not be established. It would have been
appropriate to measure self-efficacy with health
behavior-specific self-efficacy scale rather than GSE
Scale. The measure of health literacy has focused on
the ability to read and understand health care infor-
mation and has not incorporated the ability to access
health-related information and make informed deci-
sions. Thus, the health literacy measure may be related
to education level. It could have been possible to
observe the pure effect of health literacy if education
level was controlled. However, because the major focus
of this study was to investigate the mediating effect of
self-efficacy on the relationship between health liter-
acy and health status, adjusting for education was
not performed in order to avoid the possibility of
misestimation from over-adjustment (Dewalt,
Berkman, Sheridan, Lohr & Pignone, 2004). Finally,
this study was conducted on older adults in community
social welfare centers and the findings may not be
generalizable to other populations.
Conclusion
This study demonstrated the mechanism between
health literacy and health status through a mediating
factor – self-efficacy. Specifically, low health literacy
was associated with poor physical and mental health
 Aging & Mental Health
status, and the effect of health literacy on physical and
mental health status was mediated through self-
efficacy. This study highlights the importance of
incorporating interventions to improve self-efficacy as
well as developing easy-to-read health-related mate-
rials in order to maximize the effectiveness of educa-
tional interventions for improving health outcomes in
older populations with low literacy.
Acknowledgments
This research was supported by the Kyungpook National
University Research Fund awarded to Dr. Kim in 2006.
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