This was an observational, multicentere, cross-sectional study, which included hospitalized patients with stroke from September 2022 to March 2023 in the emergency and critical care center of tertiary hospitals in three stroke centers: West China Hospital of Sichuan University, West China Tianfu Hospital of Sichuan University, and West China Shangjin Hospital of Sichuan University. The patient recruitment process of this study strictly adhered to the ethical review requirements as follows: physicians initially screened eligible patients with stroke according to the inclusion and exclusion criteria of the study, and after obtaining preliminary consent from the patients, the research team conducted extensive face-to-face communication with the patients. The survey consisted of three main questionnaires, and each participant took approximately 15‐20 minutes to complete all the questionnaires; all the participants’ questionnaires were collected at once. Quality control measures were implemented during the data collection process, with researchers receiving uniform language training and participants being interviewed face-to-face and asked to complete the questionnaires independently. For patients who were unable to complete the questionnaire, the investigators asked the items neutrally and objectively to ensure the accuracy of the questionnaire.

The inclusion criteria were (1) stroke diagnosis based on computed tomography or magnetic resonance imaging results, (2) mental and physical fitness to participate, and (3) willingness to participate and cooperate. The exclusion criteria were (1) severe complications and loss of self-management, (2) associated with psychiatric disease or intellectual disability, (3) unwillingness to participate in the survey, or (4) participation in other research projects at the same time.

SPSS software (version 26.0; IBM Corp) was used for data analysis, and Microsoft Excel spreadsheets were used for data entry. Quantitative data were expressed as mean (standard deviation), and comparisons between groups were made using t tests or one-way analysis of variance. Categorical data were expressed as proportions (%), and comparisons between groups were made using the χ² test. Regression analysis was performed to determine the relationship between HIL, stroke knowledge, and self-management. Regression analysis was also used to test whether HIL in patients with stroke mediated the relationship between stroke knowledge and self-management based on relevant analysis results. A P value <.05 was considered statistically significant.

Prior to data collection, the study was approved by the Ethics Committee on Biomedical Research, West China Hospital, Sichuan University (2023 Review (688)). All participants provided consent to participate in the study on a voluntary basis, and the data were anonymized. No benefits or compensation were offered or given to any participant.

A total of 550 stroke survivors were recruited and 514 valid questionnaires were recovered, with a valid recovery rate of 93.45%. The flowchart showing the inclusion and exclusion of patients is shown in Figure 1.

The general characteristics of the study participants are given in Table 1. Of the 514 participants, 338 (65.8%) were male and had a mean (SD) self-management ability score of 157.05 (18.78) points. Of the 514 participants, 465 (90.4%) of the participants were aged 50‐85 years, among whom the minimum age of first stroke was 20 years. Furthermore, the distribution of residence locations revealed that the majority of the participants, 331/514 (64.4%), resided in urban areas, with a substantial proportion having completed middle school as their highest level of education (185/514, 36%). The initial incidence of stroke was predominantly observed among individuals aged 60 years and older.

The mean (SD) estimated stroke knowledge score of 514 patients with stroke was 17.61 (6.46) points, the mean (SD) total score on the HIL scale was 61.17 (13.58) points, and the mean (SD) total score on the stroke self-management assessment scale was 158.70 (19.07) points. The scores for each dimension are shown in Table 2.

Table 3 shows the correlations between stroke knowledge, HIL, and self-management. Stroke knowledge was positively correlated with self-management (r=0.668, P<.001) and the HIL score (r=0.138, P<.001), while HIL was positively correlated with self-management (r=0.155, P<.001).

Based on the mediation effect testing process proposed by Wen and Ye [17], the theoretical model and rationale based on the construction by Tang and Wang [18] and Mao [19], a mediation model was established with self-management as the dependent variable, stroke knowledge as the independent variable, and HIL as the mediating variable. In the first step, regression analysis was performed, where stroke knowledge was the independent variable and self-management was the dependent variable, and the coefficient c was tested. In the second step, regression analysis was performed using stroke knowledge as the independent variable and HIL as the dependent variable, and the coefficient a was tested. In the third step, regression analysis was performed with stroke knowledge and HIL as the independent variables and self-management as the dependent variable, with coefficients b and c. The results showed that coefficients a, b, and c were significant, indicating a partial mediating effect of HIL between stroke knowledge and stroke self-management behaviors. Details are shown in Table 4.

The bootstrap mediation test was conducted using SPSS software (version 26.0). The bootstrap method is a repeated sampling method that treats the original sample as a whole, extracts a large number of new subsamples by repeated sampling with replacement, and obtains statistics. The 95% CI was calculated by repeating the sample 5000 times. The bootstrapped 95% CI for the overall effect of the model did not include a value of 0 (β=1.199, 95% CI 1.059, 1.339). The direct effect of stroke knowledge on self-management in terms of bootstrap 95% CI did not include a value of 0 (β=.656, 95% CI 0.514, 0.798). The mediated effect path was stroke knowledge, followed by HIL, and finally self-management, and the bootstrap 95% CI for its indirect effect did not include a 0 value (β=.543, 95% CI 0.431, 0.663), indicating a significant mediating effect of HIL between stroke knowledge and self-management (Table 5). The mediation pathway is detailed in Figure 2.

There was a positive correlation between stroke knowledge, HIL and self-management. Using the Bootstrap test, the total effect, indirect effect, and direct effect of stroke knowledge on self-management were estimated to be 1.199, 0.543, and 0.656, respectively. The 95% CI did not include 0, indicating the significance of the total effect, indirect effect, and direct effect. This indicates that HIL partially mediates the relationship between stroke knowledge and self-management behavior; stroke knowledge and HIL can directly influence the level of self-management in patients with stroke. Stroke knowledge may also indirectly affect the self-management in patients with stroke through the partial mediating effect of HIL; the direct effect was larger than the indirect effect in this study.

The mean (SD) total knowledge level score of patients with stroke was 17.61(6.457), with the highest score in the dimension of lifestyle, and the lowest score in the knowledge of emergency measures for stroke, which was overall moderate. This result was slightly lower than that reported in other studies [20,21], which was related to factors such as differences in the patients’ educational level and residence in the western region. This study mainly focused on elderly patients with primary and junior high school education, who have relatively weak learning and adaptation abilities [22]. The mean (SD) HIL score of the patients with stroke was 61.17 (13.58), with the highest health information evaluation score and the lowest health information access score among the dimensions, a result consistent with the findings by Wang et al [23]. Although patients with stroke had moderate levels of HIL, they lacked the ability to access high-quality health information. The mean (SD) total self-management score of patients with stroke was 158.7 (19.07) points, which was moderately low, lower than the survey results obtained by Zhou et al [21] but higher than that obtained by Huang et al [24], with the highest score for daily life management and the lowest score for rehabilitation and exercise management among the dimensions. This may be due to a general lack of knowledge about stroke and self-management skills among first-time patients with stroke and their families. Previous studies have shown substantial enhancements in self-efficacy, activities of daily living, and health-related quality of life in patients with stroke following the implementation of self-management interventions [25-27]. Consequently, it is imperative to enhance the self-management competencies of patients with stroke.

A positive correlation was identified between stroke knowledge, HIL, and stroke self-management behaviors. Sufficient knowledge about stroke is a necessary but not sufficient condition for establishing self-management behaviors. In this study, stroke knowledge had a direct effect on self-management, suggesting that the accumulation of more relevant knowledge about stroke disease or treatment and care may directly encourage such patients to adopt healthy coping behaviors and develop good habits. This was also observed by Fisher et al [28], who suggested that information may have a direct impact on behaviors in situations where novel behavioral skills or complex transformation processes are not required in prevention or self-care processes. Self-management is the process of translating professional knowledge guidelines into daily life [29,30]. The ability to obtain health information in HIL directly affects the level of stroke knowledge of an individual. Patients with lower levels of education have restricted access to information due to their limited reading and comprehension skills [18,31]. Health educators can provide more direct knowledge about stroke management through effective health education, such as hospital education, community health lectures, and health manuals. In community education, as shown in the study by Yang et al [32] and Singh et al [33], community-based group rehabilitation and culturally relevant education are effective in improving patients’ quality of life, HIL, and self-management.

HIL is the influencing factor of self-management behaviors. The higher the level of HIL, the more health information is sought, thus promoting more active self-management behaviors [18,22]. However, simple accumulation of knowledge does not necessarily lead to changes in self-management behaviors [34,35], that is, knowledge is not necessarily successfully translated into self-management behaviors. With the COM-B model [36], we can see that the translation of knowledge into behaviors also depends on the ability of patients to recognize the importance of this knowledge. This also depends on their ability to appropriately evaluate the applicability of the knowledge and apply it to health behaviors decisions, and involves a distinction between “knowing knowledge” and “whether to do it.” Stroke self-management is a process that is highly dependent on individual health decision-making, and a weak ability to evaluate information may lead patients to engage in unhealthy behaviors [37,38], in line with the health empowerment theory model. For example, patients who are aware of stroke warning signals may not necessarily respond quickly and take appropriate coping measures, thereby missing the best time for rescue and treatment of the condition. Patients with varying degrees of HIL have unique needs regarding self-management educational content [4,39]. Health professionals must direct their focus towards the older population and those with low literacy levels within their clinical practice, using the HIL scale dimension score to identify patients’ deficiencies and take the individual circumstances of patients into account when formulating a rehabilitation, exercise, and follow-up program as well as self-management education content that is both realistic and patient-centred.

Good HIL means that individuals are aware of the importance of health information and their performance in evaluation and applicability is more pronounced. Good HIL also helps patients to accumulate knowledge about stroke and to make full use of self-management knowledge in health decision-making. As posited by Alzayer et al [40], concerted efforts must be made to enhance awareness and educate the public. These measures ought to be initiated at the outset in order to enhance the HIL level of patients with stroke, facilitate the transformation of knowledge pertaining to stroke into self-management behaviors, and improve the self-management effect of affected patients to ensure optimal treatment outcomes.

Some limitations of this study include the lack of control trials in healthy individuals. Only a population from three hospitals was included, and patients with stroke in the community were not included. The self-report instrument and convenience sampling method may have potential response bias. In addition, this study was a cross-sectional study and could not explore possible causal relationships. Further research should be performed in other regions to confirm and explore intervention studies.

The self-management of patients with stroke was found to be at a moderate to low level and needs further improvement. There is a correlation between HIL and self-management in various items; the higher the HIL, the better were the self-management behaviors. In addition, HIL is a mediating factor between stroke knowledge and self-management behaviors and can effectively promote the translation of knowledge into behaviors.