Health literacy and its association with sustainable healthcare attitudes among nursing students

BACKGROUND: Health literacy is a core competency in nursing education and an essential component of person-centered care. Its association extends beyond clinical communication to shaping attitudes that support sustainable, ethical, and environmentally responsible healthcare. However, this relationship remains under examined among nursing students in Middle Eastern settings. PURPOSE: To investigate the relationship between health literacy dimensions and sustainable healthcare attitudes among Saudi nursing students and to determine whether health literacy predicts sustainability-related awareness, values, and behavioral intentions. METHODS: A cross-sectional design was conducted using three independent samples: exploratory factor analysis (n = 385), confirmatory factor analysis (n = 514), and hypothesis-testing correlational analysis (n = 652). This multi-sample validation design represents a key methodological strength ensuring robust psychometric evaluation. Participants completed validated Arabic measures assessing health literacy (information literacy, communication and navigation, self-management and promotion) and sustainable healthcare attitudes (awareness/knowledge, attitudes/values, behavior/action). Correlation analysis, multiple regression, and two-way ANOVA were performed. Ethical approval and informed consent were obtained. RESULTS: Strong positive correlations were observed between all health literacy and sustainable healthcare dimensions (r = .776, p < .001). Regression analysis showed that health literacy collectively predicted 60.3% of the variance in sustainable healthcare attitudes (F(3,648) = 328.147, p < .001), with information literacy representing the strongest predictor (β = 0.349). Residence demonstrated a significant effect favoring urban students (p < .001), while gender showed no significant influence. Findings highlight that students with stronger meaning-making capacities, reflective awareness, and ability to interpret information demonstrated more developed sustainability attitudes and intentions, with the behavioral dimension reflecting self-reported intentions rather than observed behaviors. CONCLUSION: Health literacy is strongly associated with sustainability attitudes among future nurses. Integrating literacy-enhancing pedagogies may strengthen environmental stewardship, ethical responsibility, and holistic care orientations within nursing curricula.