The Relationship Between Communicative Health Literacy and Patient Loyalty in China: A Chain Mediation Study Based on Social Exchange Theory

Yang Chen,1,* Yijia He,1,* Shenyu Zhao,2 Siyuan Wu,3 Jing Zhou,1 Lingmin Hu,1 Renjie Lu2,4 1Changzhou Maternal and Child Health Care Hospital, Changzhou Medical Center, Nanjing Medical University, Changzhou, Jiangsu, 213000, People’s Republic of China; 2The Affiliated Changzhou Hospital of Xuzhou Medical University, Changzhou Third People’s Hospital, Changzhou, Jiangsu, 213000, People’s Republic of China; 3Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, People’s Republic of China; 4Changzhou Institute for Advanced Study of Public Health, Nanjing Medical University, Changzhou, Jiangsu, 213000, People’s Republic of China*These authors contributed equally to this workCorrespondence: Renjie Lu, The Affiliated Changzhou Hospital of Xuzhou Medical University, Changzhou Third People’s Hospital, Changzhou, Jiangsu, 213000, People’s Republic of China, Email renjie_lu@126.com Lingmin Hu, Changzhou Maternal and Child Health Care Hospital, Changzhou Medical Center, Nanjing Medical University, Changzhou, Jiangsu, 213000, People’s Republic of China, Email hulingmin1986@126.comObjective: In the Chinese medical context, there is a large variation in patient health literacy levels and an imbalance of power between doctors and patients. The mechanism by which communicative health literacy (CHL) influences patient loyalty (PL) remains unclear. This study aims to explore how CHL in the medical context improves PL by promoting enhancement of perceived health literacy (EPHL) and strengthening decision-making involvement satisfaction (DMIS) based on the Social Exchange Theory (SET).Methods: This study employs a questionnaire survey to collect data from five representative cities in China (Beijing, Shanghai, Guangzhou, Wuhan, and Chengdu), with a total of 4018 questionnaires collected, yielding 3264 valid questionnaires after quality control (valid rate: 81.23%). A structural equation model is used to examine the relationships between CHL, EPHL, DMIS, and PL, and to test the relevant hypotheses. Additionally, data from three cities in Jiangsu Province, China, are collected, with 2393 questionnaires collected and 1942 valid questionnaires obtained (valid rate: 81.15%), to conduct a robustness test of the model.Results: CHL was significantly positively correlated with EPHL (β=0.516), DMIS (β=0.329), and PL (β=0.192). EPHL was also significantly positively correlated with DMIS (β=0.301) and PL (β=0.355). DMIS was significantly positively correlated with PL (β=0.316). EPHL partially mediated the relationship between CHL and DMIS (32.02%), and between CHL and PL (48.80%). DMIS partially mediated the relationship between CHL and PL (35.02%). EPHL and DMIS played a chain-mediated role between CHL and PL (20.33%). DMIS partially mediated the relationship between EPHL and PL (21.11%).Conclusion: This study extends the application of SET to the realm of doctor-patient communication, and is the first to confirm the sequential process of “cognitive reserve - capability construction - emotional identification - relational return” within a Chinese context. It provides a new perspective for understanding the formation mechanism of PL and offers theoretical support for the construction of health literacy–oriented medical institutions. Future research could expand the sample scope to cover different cultural backgrounds and various types of medical institutions, thereby enhancing the model’s generalizability and further exploring its mechanisms of action.Keywords: communicative health literacy, enhancement of perceived health literacy, decision-making involvement satisfaction, patient loyalty, social exchange theory