The Mediating Role of Treatment Adherence in the Relationship Between Health Literacy and Health Maintenance Efficacy Among Adults with Type 1 Diabetes.

Introduction Health literacy is a key determinant of diabetes self-management; however, the behavioral mechanisms linking health literacy to health maintenance efficacy in adults with type 1 diabetes mellitus (T1DM) remain insufficiently explored. Health maintenance efficacy refers to individuals' perceived ability to sustain long-term diabetes care behaviors.

Methods This cross-sectional analytical study was conducted with 368 adults diagnosed with T1DM in Turkey. Data were collected online using the European Health Literacy Survey Questionnaire (HLS-EU-Q6) and the treatment adherence and health maintenance efficacy subscales of the Chronic Illness Self-Management Scale. Descriptive statistics, Pearson correlation analysis, and mediation analysis were performed using Hayes' PROCESS Model 4 with 5000 bootstrap resamples.

Results Health literacy was positively associated with both treatment adherence and health maintenance efficacy. Treatment adherence played a partial mediating role in the association between health literacy and health maintenance efficacy (indirect effect = 0.11; 95% CI: 0.06-0.17). The final model explained 38% of the variance in health maintenance efficacy.

Conclusion Health literacy was strongly associated with health maintenance efficacy in adults with T1DM, both directly and indirectly through its association with treatment adherence. By conceptualizing health maintenance efficacy as a distinct construct reflecting the sustainability of diabetes care behaviors, the findings provide clearer insight into how health literacy relates to long-term self-management capacity. Given the cross-sectional design, these relationships should be interpreted as associative rather than causal.