Introduction

Due to declining fertility rates and longer life expectancy, many countries face unprecedented rapid growth in elderly individuals1; China is the fastest-aging country with the largest elderly population globally2. The latest 2020 Census results estimated that 18.7% of the population is over 603, profoundly affecting the healthcare system and economic development4. Population aging contributes to increased chronic disease prevalence; this prevalence is increasing globally and is causing approximately 41 million (71%) deaths yearly5. The chronic disease prevalence in elderly patients is the highest6. As a vulnerable group, elderly patients with chronic diseases have a large health gap with others.

Health literacy is the capacity of individuals to obtain, handle, and comprehend essential health information and services needed to make adequate health decisions: basic functions (i.e., literacy and numeracy), interactivity (i.e., patient willingness to form co-building partnerships with healthcare providers), and key skills (i.e., patient’s ability to differentiate between available health services). These are necessary to function properly in the healthcare delivery system7,8,9. Health literacy predicts individual health better than age, income, education level, and race10. It is a critical factor for achieving health outcomes and quality of life for people with chronic illnesses11.

The “Healthy China 2030 Plan,” launched in 2016, emphasizes the need to enhance the national health literacy of the whole population, especially to strengthen the intervention and management of key groups such as elderly individuals with chronic diseases. Health literacy gaps significantly affect disparities in health behaviors and outcomes. Individuals with low health literacy may deliberately avoid disease-related information due to fear of disease, distrust of medical staff, and poor initiative in seeking health information12,13,14. Furthermore, people with low health literacy are more inclined to cancer fatalism, believing that cancer outcomes are determined by fate, affecting active screening and treatment compliance15,16. The progressive development of chronic diseases in the elderly population will also cause cognitive and emotional disorders, further hindering their access to and understanding of health information17. Patients with low or insufficient health literacy lacking health-related cognition and understanding ability may be unable to access health information effectively and interact with medical professionals. It makes controlling chronic diseases difficult and causes poor health outcomes18,19, affecting elderly individual mortality: Elderly often have poor perceptions of health status, delayed diagnosis, lower adherence to treatment, and misuse of health care resources, escalating health care costs9,18,20. Therefore, improving the health literacy of elderly individuals with chronic illnesses can reduce disease-related risk factors, delay disease occurrence and development, and improve the effective utilization of medical and health resources21.

Personality can reflect the individual tendency to respond in a given situation22, making individuals with different personalities have different social relationships, affecting their health-related behaviors and outcomes: compliance with the medical system, the success of treatment, and health status and mortality risk24. The Big Five personality model–including agreeableness, neuroticism, extraversion, openness, and conscientiousness–is the most influential and widely accepted personality theory used to explore the link between personality and health. Extraversion, agreeableness, neuroticism, openness and conscientiousness describes interpersonal interaction degree, the quality of interpersonal orientation, emotional stability, the willingness to accept new ideas and goal-oriented motivation, respectively24. Recently, the relationship between the Big Five personality and health literacy has been reported, and a Japanese study found that the health literacy of older people is negatively correlated to neuroticism and positively correlated with openness, a sense of conscientiousness, and extraversion25. Interpersonal factors also impact the eHealth literacy of elderly individuals26; family relationships (the most important relationship among elderly individuals) are an integral part of social networks and cultural identity that maintain and promote e-Health literacy among elderly individuals27,28. As the core figure of family chronic disease management and health promotion, the subjective initiative of elderly individuals with chronic illnesses is extremely important; self-efficacy is an important factor of subjective initiative that can evaluate and improve chronic disease prevention and self-management29,30,31. Family support can improve the self-efficacy of older people in the community, directly or indirectly affecting healthy aging through health-promoting behaviors31. To further clarify the influencing mechanism of personality traits on health literacy in elderly patients with chronic diseases, this study used reciprocal determinism in social cognitive theory. In this theory, individual behavior is determined by the interaction of personal attributes, social and family environment, and behavior32. For example, individual beliefs and thinking styles will change the influence of the environment on their behavior. However, it does not mean the interactions have the same strength or occur simultaneously33. Such interactions go beyond the common notion that the person or the environment directly determines behavior, and we can promote health-related behavior by understanding and intervening among these aspects.

Personality traits describe individual internal qualities and are relatively stable34; interventions targeting personality may not necessarily affect health outcomes24. However, in triadic reciprocal causality, individuals are both the product and the influencer of their environment33. Therefore, this study uses family communication and self-efficacy as mediating variables to explore the mechanism and ways of personality on health literacy of elderly individuals with chronic illnesses to further understand the explicit behavior of internal personality characteristics of elderly individuals with chronic illnesses35, which is helpful for health professionals to identify risk groups and take targeted intervention measures to enhance the health literacy of elderly individuals with chronic illnesses.

Theory and hypotheses

Relationship between big five personalities and health literacy

Personality is described as comparatively persistent modes of thoughts, emotion, and behaviors that are biologically grounded and develop within family and cultural contexts22, guiding individuals toward specific life paths that produce long-term health outcomes23. The American Institute of Medicine report calls for patient-centeredness in the healthcare system, emphasizing attention to the patient’s thinking and behavior patterns to better meet their needs. The Big Five personality trait is a simple and reliable potential source of individual differences in healthy development22,36. Neuroticism is significantly negatively correlated to health literacy, and neurotic individuals are prone to emotions such as anxiety and fear37, resulting in persistent psychological distress; this will affect health status physiologically and lead to poor health behaviors such as reduced compliance38. Moreover, health literacy knowledge is partly transmitted through social media, and neurotic individuals are more sensitive and socially isolated and may lack communication and support related to health literacy, lowering the health literacy level39. Extroversion, openness, conscientiousness, and agreeableness were positively correlated to health literacy, individuals with higher conscientiousness having positive health behaviors and were likely to adhere to treatment protocols and work toward health goals strictly40. Conversely, low conscientiousness meant a lack of self-control and planning38. Individuals with high openness have a higher cognitive level, are sensitive to health information40, and tend to understand and follow medical advice23. The positive attitude inherent in extroversion allows them to accept aging and disease better41, and their sociable characteristics encourage them to participate in social activities and connect with other patients, further increasing disease adaptability38. Agreeableness is characterized by a tendency to trust others, associated with lower morbidity in older adults and good medication adherence in patients with chronic diseases42,43,44.

Mediating effects of family communication

Communication behaviors such as sharing and talking about experiences are important components of successful coping with traumatic events45. Family communication is the interchange of verbal and non-verbal messages between family members46. Effective family communication can help patients understand the trauma caused by the disease, provide them with good family emotional support, and reduce loneliness and other emotional distress to resist the negative events they experience effectively45,47. Different personality traits have different communication characteristics, affecting the perception of family support48. Some personality deficits are also significant factors in low-income family communication. Extroverts have strong social skills, are good at maintaining and strengthening close relationships, and talk to family members about everyday problems. Agreeableness is characterized by altruism and compassion, a large degree of trust in one’s family, a high level of satisfaction with family relationships49, and a greater willingness to communicate one’s thoughts and feelings. Individuals with an open personality may communicate ideas more honestly and value self-expression50. People with high conscientiousness are generally more reliable, can effectively balance family responsibilities with other social roles51, and are more confident in expressing their opinions52, actively caring for family needs, and taking on more responsible roles. Contrary to conscientiousness, neuroticism is characterized by low conscientiousness, lack of social competence, and avoidant personality disorder53. Individuals with higher neuroticism are lonelier39, perceive themselves as difficult to include and accept by others, and lack close relationships and communication with their families.

Moreover, patients with cervical cancer health literacy were found to positively correlate to family communication54. Family-centered networks are viable resources for effectively disseminating health literacy messages and are key to promoting health54. Well-communicated families tend to share health-related information more freely, can communicate openly and effectively about health issues, help create an environment for health literacy development55, and form personal health-related knowledge, attitudes, and behaviors56. Strong family communication enables family members to provide emotional support to each other and share health-related decision-making processes57. This engagement promotes critical thinking and a deeper understanding of health-related information.

Mediating effects of self-efficacy

Self-efficacy is the perception that an individual believes in their ability to perform the actions needed to achieve a valuable outcome14; it can help the individual work to build and maintain a sense of control over life58. As the basis of social cognitive function adaptation, the Big Five personality is related to self-efficacy in chronic disease management24. Neuroticism, which involves negative self-perception and evaluation, may affect an individual’s ability to achieve desired outcomes and negatively correlates to self-efficacy in healthy behaviors59,60.Extroversion, conscientiousness, and openness individuals tend to regard things as challenges, positively evaluate coping resources61, and have a high sense of self-efficacy.

As an active resource in the fight against disease61, self-efficacy is important in self-management, self-care, and controlling bad behaviors in patients with chronic diseases21; high levels of self-efficacy are assumed to compensate for lacking health literacy20. The higher the self-efficacy of individuals with chronic illnesses, the stronger the awareness of the importance of early diagnosis of diseases and the higher the motivation for treatment compliance and self-management62,63. However, patients with low self-efficacy have a higher sense of helplessness, believing that the disease is random or inevitable and cannot be controlled and changed64. Lack of confidence in action and less likely to involve in decisions related to their health20. Therefore, increasing self-efficacy may help elderly individuals with chronic illnesses to effectively cope with diseases and maintain a high quality of life65, improve their health literacy, and further promote the development of healthy aging31.

Chain mediating effects of family communication and self-efficacy

Family management of chronic diseases is time-consuming and complex, far beyond the general diagnosis and treatment; family-centered empowerment– the ultimate goal of health literacy19–is needed to help families and individuals manage chronic diseases66. Some experts believe that neglecting empowerment makes health literacy difficult to improve. The family-centered empowerment model aims to enhance the ability of the family system to promote the health of their members, positively enhancing the self-efficacy of individuals with chronic illnesses67. Self-efficacy, a central component of social cognitive theory and one of the key concepts of the family-centered empowerment model33,67, is related to personality tendencies and the surrounding environment of disease management in patients with chronic diseases58. Family members can help older people overcome perceived ageism through communication to improve their self-efficacy and use multiple ways to seek scientific health information to improve health literacy26.

This research aims to identify the relationship between personality traits and health literacy in elderly individuals with chronic illnesses. What is the role of family health and self-efficacy in influencing personality characteristics on health literacy? Given these problems, this study proposes the following hypotheses: Fig. 1 shows the theoretical assumptions.

Fig. 1
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Theoretical assumptions.

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H1: Different personality traits significantly predict health literacy in elderly individuals with chronic illnesses.

H2: Different personality traits can indirectly predict health literacy in elderly individuals with chronic illnesses through the mediating effect of family communication.

H3: Different personality traits can indirectly predict the health literacy of elderly individuals with chronic illnesses through the mediating effect of self-efficacy.

H4: Different personality traits can indirectly predict the health literacy of elderly individuals with chronic illnesses through the chain mediating effect of family communication and self-efficacy.

Methods

Participants and procedures

“Psychology and Behavior Investigation of Chinese Residents in 2022” was conducted by multistage sampling from June 20 to August 31, 2022. Based on the population pyramid, quota sampling of the selected residents in 148 cities; 202 districts; 390 townships, towns, and streets; and 780 communities and villages from 31 provinces, autonomous regions, and municipalities (excluding Hong Kong, Macao, and Taiwan), which was conducted with the quota attributes of sex, age, and urban-rural distribution to obtain the samples68,69. This study was registered in the China Clinical Trial Registry (registration no. ChiCTR2200061046). Ethical approval was granted by Shanxi Institute of International Trade & Commerce (JKWH-2022-02). All participants signed the informed consent documents before participation in this study. All methods were performed following relevant guidelines and regulations. Herein, we selected elderly participants with chronic illnesses.

The inclusion criteria for the study participants were: aged ≥ 60 years with chronic diseases; Chinese; Chinese permanent resident population with an annual travel time of ≤ 1 month; participated voluntarily and filled in the informed consent form; aware of the meaning of each questionnaire item, and completed the questionnaires independently. If the respondent could think but did not have enough action ability to answer the questionnaire, the investigator would conduct a one-to-one interview and then answer the questions on their behalf. The exclusion criteria were individuals with comatose or mental disturbed and those involving in similar research projects. Finally, 2251 residents were enrolled in this study. Figure 2 shows a detailed flowchart of the enrollment.

Fig. 2
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Flow diagram of participant enrollment.

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Assessment instruments

The big five inventory-10 (BFI-10)

The BFI-10 was used to assess personality characteristics on a 5-point Likert-type scale ranging from 1 (totally disagree) to 5 (totally agree), including extraversion (items 1, 6), agreeableness (items 2, 7), conscientiousness (items 3, 8), neuroticism (items 4, 9), and openness (items 5, 10). Items 1, 3, 4, 5, and 7 are reverse-scored. Because only two items were present per dimension in the BFI-10, no Cronbach’s α value was calculated. The BFI-10 scales retain significant levels of reliability and validity70, the Cronbach’s alpha coefficients of neuroticism, conscientiousness, extraversion, openness, and agreeableness were 0.753, 0.786, 0.723, 0.714, and 0.759, respectively58.

The family communication scale (FCS)

The FCS was used to assess the communication between family members71,72,73; FCS contains ten items and is measured on a 5-point Likert scale ranging from “strongly disagree” to “strongly agree“74. The summed scores ranged between 10 and 50 points. Higher scores represent better communication between family members. The Cronbach’s α of FCS was 0.956. The FCS is reliable and valid in measuring positive communication in the Chinese population75.

The new general self-efficacy scale–short form (NGSES-SF)

The NGSES-SF is an instrument to assess participants’ belief in their overall competence to perform in various situations, consisting of three parsimonious items in this study, including self-efficacy level, intensity, and universality76. Each item was scored on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree), resulting in a score ranging from 3 to 15 points. Higher scores represent greater self-efficacy. The Cronbach’s α for the NGSES-SF was 0.914. NGBES-SF has better reliability and validity than NGSES in studying Chinese residents, which can be applied to research and practice76.

Health literacy scale-short form (HLS-SF)

The HLS-SF was used to measure participants’ health literacy77, consisting of nine items in three dimensions: health care, disease prevention, and health promotion in this study. Each item is scored on a 4-point scale from 0 (very difficult) to 3 (very easy). The summed items have a total score from 0 to 27, with a higher score demonstrating better health literacy. The Cronbach’s α of HLS-SF was 0.917. The HLS-SF is reliable and valid in previous studies of the entire population of six Asian countries77.

Data collection

This study conducts screening and uniform training for investigators to ensure that they are familiar with standardized procedures and criteria for questionnaire filling, and tests are conducted according to the training content, and those who pass the test are assigned regional and specific tasks. In the process of questionnaire distribution, scientific research design principles and statistical requirements are followed to control possible deviations in the data collection process. The collected questionnaires were summarized and evaluated at different stages of questionnaire distribution.

Statistical analysis

SPSS 26.0 and AMOS 26.0 were used to analyze the data, and a two-sided p < 0.05 indicated statistical significance. Descriptive statistics and correlation analyses were performed first. Shapiro-Wilk normality test was used to test the normality of data. Spearman correlation analysis was used to analyze the correlation between variables due to the non-normality of data. SEM analysis and full information likelihood estimation were used to test the hypothesized mediation model, and bootstrap analysis with 5000 replications was used to verify the significance of total effect, direct effect, and total indirect effect. PRODCLIN procedure was used to verify the significance of each indirect effect in the mediation model78. The indicators of good model fit included root mean square error of approximation (RMSEA) < 0.06, comparative fit index (CFI), and Tucker Lewis index (TLI) > 0.9.

Results

Participant characteristics

Table 1 presents the demographic characteristics of elderly patients with chronic diseases. Of these participants, 50.9% were female, and 49.5% were between 60 and 69 years old; 51.1% of respondents completed only primary school or low, and 82.1% of subjects were married; 55.8% of elderly people with chronic illnesses lived in urban; 33.7% or 30.8% of elderly people with chronic illnesses had two or three children. The 41.0% had a family per capita monthly income of 3001–6000 yuan.

Table 1 Demographic characteristics (n = 2251).
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Common method deviation test

Because all variables are used in the questionnaire survey method—all derived from self-reports by the subjects common method deviations may exist. Therefore, the Harman one-way ANOVA was used to test this issue. In all projects, six factors had initial eigenvalues > 1, and the first factor accounted for 38.81% of the total variance, which was < 40% of the critical value79. Consequently, this study had no serious problem of common method bias.

Correlation analysis of big five personality traits, self-efficacy, family communication, and health literacy

The variables had a non-normal distribution; therefore, the Spearman correlation analysis was used. Correlation analysis was conducted using the total scores of Big Five personality traits, self-efficacy, family communication, and health literacy (Table 2). Extraversion, agreeableness, conscientiousness, and openness were positively correlated with health literacy (P < 0.001), while neuroticism was negatively correlated to health literacy (P < 0.001); Extraversion, agreeableness, conscientiousness, openness, and self-efficacy were positively correlated to family communication (P < 0.01). Neuroticism was negatively correlated to family communication (P < 0.001), and Extraversion, agreeableness, conscientiousness, and openness were positively correlated to self-efficacy (P < 0.001). Neuroticism was negatively correlated to self-efficacy (P < 0.001).

Table 2 Descriptive statistics and correlations between the research variables (n = 2251).
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SEM analysis of big five personality, family communication, self-efficacy, and health literacy

Structural equation modeling was used to test the study hypotheses. The model estimation method was maximum likelihood estimation. The structural equation model was constructed with neuroticism, extraversion, agreeableness, sense of responsibility, and openness as predictive variables, family communication and self-efficacy as mediating variables, and health literacy as outcome variables. Significance tests were estimated using the bias-corrected bootstrap method and repeated 5000 times after being put back. Through the path coefficient analysis, it was found that openness was not significant for family communication paths. The effects of conscientiousness, agreeableness, and neuroticism on health literacy failed to reach a significant level. Therefore, we adjusted the model to identify the mechanism of action of Big Five personality traits on health literacy (Fig. 3). The results of the adjusted model fit well: χ2 = 79.105, df = 20, RMSEA = 0.036, CFI = 0.993, TLI = 0.983, GFI = 0.993, AGFI = 0.981.

Fig. 3
figure 3

Path model of family communication and self-efficacy mediating the relationship between Big Five personality and health literacy. Standardized estimates were reported for each path. *p < 0.05; **p < 0.01; ***p < 0.001.

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Neuroticism and openness significantly affected health literacy; the effect values were − 0.041 and 0.091. Family communication mediated between extraversion, agreeableness, conscientiousness, neuroticism, and health literacy; the mediating effect was 0.057, 0.110, 0.101, and − 0.057, respectively. Self-efficacy mediated between extraversion, agreeableness, conscientiousness, openness, neuroticism, and health literacy, and the mediating effect was 0.019, 0.013, 0.029, 0.008, and − 0.020, respectively. Family communication and self-efficacy mediated between extraversion, agreeableness, conscientiousness, neuroticism, and health literacy, and the mediating effect was 0.010, 0.020, 0.018, and − 0.010, respectively. The bias-corrected Bootstrap method was used to verify the significance of the total effect, direct effect, and total mediation effect (Table 3). This study also used MacKinnon’s development and applied the PRODCLIN2 procedure of the product fractional step method to verify the mediation effect of each path separately77(Table 4). If “Extraversion→family communication→self-efficacy” has a mediating effect, and “family communication→self-efficacy→health literacy” also has a mediating effect, it indicates that the chain mediating effect of family communication and self-efficacy exists. The results showed that none of the 95% confidence intervals of the above mediating effects included 0, indicating that the mediating effects were all significant.

Table 3 Standardized path coefficients of the assumed model (n = 2251).
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Table 4 PRODCLIN test results for indirect mediation effects (n = 2251).
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Discussion

The results showed that the health literacy level of elderly people with chronic illnesses was significantly correlated to the Big Five personality traits, family communication, and self-efficacy. Neuroticism and openness directly affect health literacy. Family communication mediates the effects of extraversion, agreeableness, conscientiousness, and neuroticism on health literacy; self-efficacy mediates the effects of Big Five personalities on health literacy. Extroversion, agreeableness, conscientiousness, and neuroticism can influence health literacy in older patients with chronic diseases through a chain mediating effect of family communication and self-efficacy.

Herein, neuroticism and openness can directly affect the health literacy of elderly people with chronic illnesses. High-level neuroticism inherently has a higher burden of disease42, including persistent psychological distress, increased mental illness, and all-cause mortality37; it is also more likely to have unhealthy eating habits and poor self-management behaviors80,81.Therefore, neuroticism can directly affect health literacy in elderly people with chronic illnesses, consistent with studies on breast cancer survivors and older people in the Japanese community25,82. Openness is closely related to the education level and cognitive function of older people, and older people with a high level of openness are more concerned about their health. They will participate in physical examinations more actively40. Nevertheless, our study failed to find a direct impact of extraversion, agreeableness, and conscientiousness on health literacy in older patients with chronic diseases, which needs further validation.

Family communication mediates the influence of extraversion, agreeableness, conscientiousness, and neuroticism on health literacy in elderly people with chronic illnesses. Individuals with high extroversion are flexible and sociable, tend to social encouragement, and are more likely to establish good relationships with other patients38, elicit positive reactions from others, gain trust from others49, and actively seek support to face difficulties–they are successful communicators52. Agreeableness tends to avoid conflict49, understand helping or cooperating with others, and correlate to support levels44,83. Therefore, patients with agreeableness are more likely to get family support and form attachment relationships to meet their desire for a sense of belonging84, increasing patients’ tendency to communicate with family members. Furthermore, the more emotions individuals show in family communication, the easier it is to express their feelings and openly talk about their affairs47. Highly conscientious individuals are often associated with social and environmental factors that promote positive health outcomes, such as higher social status and strong marital relationships85; individuals become more emotionally stable and conscientious with age23. Older people are often committed to collecting health-related information and disseminating it to the younger generation, contributing to family health communication86. Older people with higher openness have higher cognitive behavioral and mental flexibility levels and are not constrained by conservative values43. Openness means more curiosity and willingness to accept new ideas24; they may directly obtain information about diseases through social media25. The influence of family communication on their health status may be lower than their control and cognition of health. Therefore, the effect of openness on family communication in elderly patients with chronic diseases is insignificant. High neurotic individuals are more sensitive and defensive, leading to social inhibition at the cognitive and emotional levels, negatively correlated to willingness to communicate82. Therefore, extraversion, agreeableness, and conscientiousness positively affect family communication in elderly people with chronic illnesses, and neuroticism is a negative predictor of family communication. As the most basic social environment of older people, the family can directly affect the perception of the health status of elderly individuals87; stable family relationships are also predictors of positive health outcomes84. Maintaining close contact with family members leads to more effective conflict resolution and healthier family relationships47, reducing psychological problems and increasing resilience through mutual support47,88. The complexity and uncertainty of the development of chronic diseases bring unpredictable pressure on family members because they cannot rely on previous disease knowledge and coping methods89. Good family communication enables members to absorb new information through discussion and consultation and share their worries and anxiety90, which helps families understand the health changes of elderly people with chronic illnesses and then help them manage and cope with potential disease risks and maintain physical and mental health87. Health communication also transmits information about health management, which is related to life expectancy and the quality of life of family members86. Negative and avoidant family communication affects psychological distress and interpersonal conflicts90, reducing self-esteem and confidence in disease management in elderly patients with chronic diseases91. Therefore, family communication mediated the effects of extraversion, agreeableness, conscientiousness, and neuroticism on health literacy.

Our results show that the Big Five personalities can affect the health literacy level of elderly people with chronic illnesses through self-efficacy. Extroverted elderly individuals talk about daily problems with their families, express their thoughts and feelings, and receive more support and help from the outside world92; such positive interactions are an important source of self-efficacy for them31. Additionally, the optimism and external attribution style of extroverted older people help them to be less affected by environmental pressure and have a higher self-efficacy35. Openness individuals are curious and have a high level of cognition40; agreeableness comes from pleasant social behavior and tends to understand and cooperate83. Openness and agreeableness individuals tend to establish strong social relationships23, which can improve their self-efficacy by providing effective support for patients with chronic diseases93. Conscientiousness refers to individuals having a high level of self-control36, being able to effectively adapt and cope with stress, being inclined to follow control norms94, and having high motivation and self-efficacy for successfully achieving health goals38,52. Neurotic individuals are more pessimistic and anxious about their health status23, a negative predictor of self-efficacy in older people41. Low self-efficacy can mediate the effect of neuroticism on depressive symptoms in elderly individuals41. Therefore, the Big Five personality significantly affected self-efficacy, aligning with the previous findings24,41. Self-efficacy, which reflects the perception of the possibility of controlling their lives and achieving goals in people with chronic diseases64, is the most important prerequisite for changing behavior and can influence healthy behaviors through direct or indirect effects95. Chronic disease patients with high self-efficacy have stronger exercise and medication compliance38,64, are more likely to adopt the advice of medical staff, and can more actively seek and use resources to improve their health status and reduce the helplessness caused by disease95. Patients with low self-efficacy have difficulty in effective self-management and more negative emotions, such as anxiety, depression, and learned helplessness96,97. The persistence of such chronic stress reduces resistance to infection and further reduces disease control23. Therefore, elderly patients with chronic diseases who are extraversion, agreeableness, openness, and conscientiousness can increase their health literacy by improving their self-efficacy.

This study found that family communication and self-efficacy mediate between extraversion, agreeableness, neuroticism and conscientiousness, and health literacy in elderly people with chronic illnesses. Elderly people with chronic diseases with high extroversion, agreeableness, neuroticism, and conscientiousness can provide positive emotions to family members through positive family communication88. Family members can also understand the disease progress, thoughts, and wishes of the patients by communicating, forming family joint decision-making, and providing corresponding support for them. Self-efficacy, the perceived control of social relationships, is a psychosocial pathway of social support operation that can mediate the effect of support on the physical and mental health of older people. For older people, family members may be extremely important social and emotional resources98,99, and family support has a greater impact on their well-being. Therefore, positive family communication may increase family support for elderly people with chronic illnesses and improve their self-efficacy. Neuroticism is characterized by an avoidant personality53. Under threat, individuals with such avoidant personalities will have stronger negative reactions, and it is not easy to maintain good relationships and interpersonal communication100. Neurotic elderly people with chronic illnesses are threatened by disease progression and poor physical condition. They may be more prone to negative emotions and communication, and pressure cannot be released and responded to, decreasing self-efficacy and poor health literacy. Therefore, extraversion, agreeableness, conscientiousness, and neuroticism can affect the health literacy of elderly people with chronic illnesses through the chain-mediating effect of family communication and self-efficacy.

Limitations

This study had certain limitations. First, this is a cross-sectional survey, which cannot explore the causal relationship between the Big Five personality traits and the health literacy of elderly people with chronic illnesses and draw directional conclusions; therefore, longitudinal studies should be used to investigate better the mechanism of change between the Big Five personality traits and health literacy. Second, this study is a large sample multi-center study from China, and the results have certain universality. However, our object was elderly people with chronic illnesses, and there is no classification study and discussion of specific chronic diseases. Future research could be more specific based on the type of chronic diseases and should also consider other confounding factors that affect the health literacy of elderly people with chronic disease. Third, the data collection method was self-report, which is prone to measurement errors due to subjectivity. Subsequently, alternative data collection method, such as multi-angle approaches to collecting personality traits and health literacy of patients with chronic diseases, can be explored to reduce potential response bias from the use of self-reports in this study. Finally, different levels of Big Five personality traits also produce different results, and future research should be based on different degrees of Big Five personality traits.

Conclusions

Individual health literacy differences exist among elderly patients with chronic illnesses with different personality traits. Family communication and self-efficacy positively influence the health literacy of elderly patients with chronic illnesses with extraversion, agreeableness, and conscientiousness. Therefore, nurses can improve health literacy by paying attention to the communication within the family of elderly patients with chronic diseases with extraversion, agreeableness, conscientiousness, and the subjective initiative of patients themselves. Openness can directly or indirectly affect health literacy through self-efficacy. The nurses should help establish and strengthen open in elderly patients with chronic disease control to improve health literacy. Elderly chronic disease patients with higher neuroticism have a lower level of health literacy, which is the focus of the intervention. Neuroticism is directly related to health literacy and affects the health literacy of elderly patients with chronic illnesses through family communication and self-efficacy. Therefore, nurses should pay attention to family communication and emotional support when coping with neurotic elderly patients with chronic diseases, encourage patients to participate actively in chronic disease self-management, reduce negative self-perception and evaluation, and improve their health literacy.