The mediating role of depressive symptoms in the relationship between health literacy and suicide-related behaviors in middle school students

Suicide-related behaviors among adolescents have garnered increasing social attention, while few studies have revealed the association between health literacy and suicide-related behaviors, and the underlying mechanism. Thus, this study aims to explore the effect of health literacy on suicide-related behaviors in Chinese adolescents, as well as the potential mediating role of depressive symptoms. A cross-sectional, questionnaire-based study was conducted among 7182 students who were selected by using stratified cluster sampling in May 2023. The Adolescent Health Literacy Scale, Center for Epidemiologic Studies Depression Scale, and three questions about the suicide-related behaviors were used to collect data. Chi-square tests were performed to compare the differences in the distribution of suicide-related behaviors across health literacy levels as well as sociodemographic characteristics. Spearman correlation analysis was performed to assess the correlations between variables. Bootstrap methods were performed to test the mediating role of depressive symptoms. The results showed that the prevalence of suicidal ideation, planning, and attempts in the past 12 months among Chinese middle school students was 26.62%, 9.27%, and 4.55%, respectively. Inadequate health literacy levels exhibited significant and positive correlation with depressive symptoms, suicidal ideation, planning, and attempts. Additionally, depressive symptoms were correlated significantly and positively with three suicide-related behaviors. Mediation analysis showed that the relationship between health literacy and suicide attempts was fully mediated by depressive symptoms and the mediation proportion was 64.9%, while depressive symptoms partially mediated the relationship between health literacy and suicidal ideation and planning, with the mediation proportion was 78.4% and 70.0%, respectively. By shedding light on these mechanisms, comprehensive health literacy improvement programs may be promising in preventing depression and suicide-related behaviors among adolescents.