Chronic disease burden amplifies perceived stress pathway from health literacy to quality of life

Background

Health literacy is associated with better health-related quality of life (HRQoL), with perceived stress as a proposed connecting mechanism. Whether this pathway differs by chronic disease burden in Nordic welfare states with universal healthcare access remains unclear. We examined whether perceived stress accounted for the health literacy-HRQoL association, and whether chronic disease burden shaped this pathway.

Methods

Data came from a 2024 nationally representative survey of Finnish adults aged 18 years or older (N = 3,716). Health literacy was measured with HLS-Q12, perceived stress with PSS-10, and HRQoL with the EQ-5D-5L index (UK value set). Chronic disease burden was assessed via a 21-item physician-diagnosed checklist and grouped into three categories (none, one, two or more). Multigroup path analysis tested associations across groups, adjusting for age, gender, education, employment, and financial strain. Post-stratification weights were applied.

Results

Higher health literacy was associated with lower perceived stress (standardized coefficient = -0.29, p < .001), and higher stress with poorer HRQoL (standardized coefficient = -0.48, p < .001). The indirect association through perceived stress accounted for approximately 80% of the total health literacy-HRQoL association. Chronic disease burden progressively amplified the stress-HRQoL association: about one-third stronger with one disease and twice as strong with two or more diseases, compared with adults with no disease (all pairwise contrasts p < .05). The health literacy-stress association did not differ across groups, indicating amplification specific to the stress-HRQoL link.

Conclusions

Perceived stress appears central to linking health literacy and HRQoL, and adults with multimorbidity show greater stress-related quality-of-life vulnerability. Findings support closer integration of health literacy support and stress-management approaches in services for adults with multimorbidity.

Key messages

• Perceived stress accounted for about 80% of the association between health literacy and quality of life among Finnish adults.

• Multimorbidity doubled stress-related quality-of-life vulnerability, supporting closer integration of health literacy support and stress management.