Abstract
Background People with limited health literacy and hypertension may lack the self-management skills needed to manage their illness, contributing to the onset and progression of important adverse health outcomes (e.g., multimorbidity). This study aimed to assess the association between health literacy and the onset and progression of hypertension-related multimorbidity among people with hypertension and whether this association is mediated by components of self-management (i.e., motivation, self-efficacy beliefs and problem-solving). Methods The study sample included data from 21,725 adult participants with hypertension who were followed in the Lifelines Cohort Study. Using causal mediation analysis with natural effect models, the total and direct effect of health literacy on hypertension-related multimorbidity and the indirect effects of motivation, self-efficacy beliefs and problem-solving were studied. Results First, after controlling for age, sex, smoking status, education level and monthly income, the total and direct effects of health literacy on the onset of hypertension-related multimorbidity were null (OR: 1.00, 95% CI: 0.99–1.01); however, an increase in problem-solving scores had an indirect effect on the onset of hypertensionrelated multimorbidity (OR: 0.99, 95% CI: 0.98–0.99). Second, a change from limited health literacy to adequate health literacy (OR: 0.99, 95% CI: 0.98–0.99) and an increase in motivation (OR: 0.99; 95% CI: 0.99–1.00), self-efficacy beliefs (OR: 0.99; 95% CI: 0.98–0.99) and problem-solving (OR: 0.99; 95% CI: 0.98–0.99) scores had direct and indirect effects, respectively, on the progression of hypertension-related multimorbidity. Conclusions A change from limited health literacy to adequate health literacy had no direct effect on the onset of hypertension-related multimorbidity but did decrease the likelihood of its progression. Problem-solving indirectly mediated only the onset; meanwhile, motivation, self-efficacy beliefs and problem-solving mediated the progression of hypertension-related multimorbidity. Improving health literacy and self-management skills can play a crucial role in preventing or delaying the onset or progression of hypertension-related multimorbidity. These improvements can *Correspondence: F.G. Linares-Jimenez f.g.linares.jimenez@umcg.nl Full list of author information is available at the end of the article Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the arti