Health Literacy and Blood Pressure Control: The Mediating Role of Self-Management Behaviors in Hypertensive Adults

BACKGROUND: Health literacy is a modifiable determinant of chronic disease management; however, its direct association with objective blood pressure control remains inconsistent. Increasing evidence suggests that health literacy may influence cardiovascular outcomes through self-management behaviors. OBJECTIVE: To examine the relationships among health literacy, hypertension management behaviors, antihypertensive treatment, and blood pressure control, and to determine whether behavioral pathways mediate the association between health literacy and blood pressure control. METHODS: This cross-sectional secondary analysis used nationally representative data from 2932 Korean adults with hypertension. Survey-weighted logistic regression was conducted to identify factors associated with blood pressure control. Multiple mediation analyses were performed to assess indirect effects through hypertension management behaviors and antihypertensive treatment. RESULTS: The weighted blood pressure control rate was 45.0%. Antihypertensive treatment was strongly associated with blood pressure control (odds ratio: 3.20, 95% confidence interval: 2.19-4.67, P < .001). Hypertension management behaviors were also positively associated with control (odds ratio: 1.09 per 1-point increase, 95% confidence interval: 1.02-1.16, P = .011). Health literacy was not independently associated with blood pressure control after adjustment. However, health literacy was significantly associated with management behaviors (β = 0.018, P = .001), which in turn were associated with blood pressure control (β = 0.102, P = .003). The indirect effect through hypertension management behaviors was significant, whereas the pathway through antihypertensive treatment was not. CONCLUSIONS: Health literacy may contribute to blood pressure control primarily through behavioral self-management pathways rather than direct effects. Nursing interventions should prioritize behavior-focused strategies that translate health literacy into sustained self-management practices.