This study is a cross-sectional study.

Using convenience sampling, older adult patients undergoing PCI procedures in the Cardiovascular Department of a Grade A tertiary hospital in Sichuan Province, China, were selected as study subjects from March to July 2024. Inclusion criteria: ① Patients meeting diagnostic and treatment criteria for coronary heart disease, fulfilling indications for PCI, and in stable physical condition post-PCI (24); ② Patients aged ≥60 years; ③ Patients with clear consciousness capable of verbal or written communication; ④ Patients who provided informed consent and voluntarily participated in the study. Exclusion criteria: ① Patients with cognitive or psychiatric disorders, or severe visual/hearing impairments; ② Patients with severe concomitant systemic diseases (e.g., liver, brain, and kidney disorders), tumor recurrence/metastasis, or severe infectious diseases. Sample size was calculated using G*Power software (version 3.1) (25). Based on Cohen’s standards (26), the power was set at 0.95, the alpha level at 0.05, and the effect size f² at 0.15 (considered a medium effect size). The study involved 23 independent variables. Using these parameters, G*Power calculated a required sample size of 234. Accounting for a 10% non-response rate, the sample size was adjusted to 260. Ultimately, 299 patients were enrolled, meeting the aforementioned criteria.

This study employed a paper-based questionnaire survey method for data collection. Prior to the formal survey, researchers provided standardized training to three survey administrators, covering questionnaire completion procedures and key considerations. Following training, research subjects were rigorously selected based on inclusion and exclusion criteria. Prior to the survey, standardized instructions were used to thoroughly explain the study’s purpose, significance, questionnaire completion methods, and precautions to participants. Paper questionnaires were distributed only after obtaining patient consent and after the patient had signed the informed consent form. For subjects unable to complete the questionnaire independently, researchers assisted by reading each item aloud to them. Disease-specific information was completed by researchers after reviewing electronic medical records or inquiring with patients. Throughout the questionnaire completion process, researchers avoided prompting or interfering with patients. Completed questionnaires were collected immediately by researchers, who promptly reviewed them for completeness. Any omissions were addressed by requesting participants to supplement the information. A total of 315 questionnaires were distributed. After excluding 16 questionnaires with logical errors or patterned responses, 299 valid questionnaires were recovered, yielding a valid recovery rate of 93.4%.

Statistical analysis was performed using SPSS 26.0. Normally distributed continuous data were described using mean ± standard deviation, while categorical data were described using frequency and proportion. Intergroup comparisons were conducted using independent t-tests or one-way ANOVA. Pearson correlation analysis was employed to explore relationships between variables. Multivariate stratified regression analysis was employed to investigate the factors influencing health promotion behaviors among older adult PCI patients and to examine the mediating effects of these variables. The mediating effect of psychological resilience on the relationship between health literacy and health promotion behaviors was analyzed using Model 4 in the Process v4.1 plugin. Bootstrap testing was performed with 5,000 samples and a 95% confidence interval (CI). Effects were considered significant when the 95% CI did not include zero. The two-tailed significance level was α = 0.05.

The study followed the Declaration of Helsinki and was approved by the Ethics Committee of Deyang People’s Hospital (2024–04-018-K01). All study subjects gave informed consent and voluntarily participated in this study.

Among the 299 older adult patients who underwent PCI in this study, 177 (59.2%) were male and 122 (40.8%) were female. The majority were aged 70 to <80 years (49.2%), and most were married (73.2%). Additional general characteristics are presented in Table 1.

Univariate analysis revealed statistically significant differences (p < 0.05) in health promotion behavior scores among older adult patients after PCI across various demographic factors: age, marital status, education level, place of residence, medical payment methods, average monthly family income, number of chronic diseases, disease duration, number of interventional treatments, and number of stent implant (see Table 1).

To further enhance the rigor of this study, the Harman single-factor analysis method was employed to conduct an unrotated exploratory factor analysis on all scale items. The results revealed 15 factors with eigenvalues greater than 1 without rotation. The first factor explained 33.74% of the variance, falling below the 40% critical threshold. Therefore, it can be concluded that no significant common method bias exists in this study.

In this study, older adult patients who underwent PCI achieved a health literacy score of 69.02 ± 10.25, a psychological resilience score of 24.51 ± 3.98, and a health promotion behavior score of 82.13 ± 11.78. Correlation analysis revealed positive correlations among health literacy, psychological resilience, and health promotion behavior (p < 0.01) (see Table 2).

In the first step of the multivariate stratified regression, variables significant in the univariate analysis of health promotion behaviors were added to the model as control variables. After controlling for these variables in the second step, health literacy was found to significantly influence health promotion behaviors, explaining 26.8% of the variance. In the third step, adding the mediating variable, psychological resilience, to the model explained an additional 29.7% of variance in health promotion behaviors. The regression coefficient for health literacy decreased from 0.743 in step two to 0.496 in step three, remaining statistically significant. The collinearity diagnosis indicates that the tolerance values for each model range from 0.232 to 0.805, and the variance inflation factors range from 1.233 to 4.313. Therefore, no multicollinearity exists among the independent variables. Preliminary statistical analysis indicates that psychological resilience partially mediates the relationship between health literacy and health promotion behaviors among older adult PCI patients (see Table 3).

All variables were standardized. Using health literacy as the independent variable, health promotion behaviors as the dependent variable, psychological resilience as the mediating variable, and age and average monthly family income as control variables, mediation analysis was conducted using Model 4 in Process v4.1.

The mediation analysis results revealed that health literacy positively predicted psychological resilience (a = 0.802, SE = 0.036, p < 0.001); health literacy positively predicted health promotion behaviors (c’ = 0.504, SE = 0.055, p < 0.001); psychological resilience positively predicted health promotion behaviors (b = 0.325, SE = 0.054, p < 0.001). The Bootstrap method revealed that psychological resilience partially mediated the positive relationship between health literacy and health promotion behaviors, with ab = 0.260, BootSE = 0.043, and a 95% CI of [0.175, 0.343]. The mediation effect accounted for 34.0% of the total effect (see Table 4 and Figure 2).

The study findings indicate that older adult patients after PCI scored (82.13 ± 11.78) points for health promotion behaviors, reflecting a moderate level. However, this score remains lower than the results reported by Chinese scholars Gong et al. (32) for patients with coronary heart disease (91.30 ± 11.83). Reasons for this discrepancy include: First, the study population comprised older adult PCI patients whose physiological functions and cognitive abilities gradually decline with age, manifesting as reduced memory and decreased mobility. This impairment affects their capacity to consistently adhere to medication regimens, attend regular follow-up appointments, and maintain moderate exercise routines (33). In contrast, the study by Gong et al. primarily involved middle-aged and young patients, a group with relatively better physiological conditions and greater physical strength and energy, providing more favorable objective conditions for implementing and maintaining healthy behaviors. Related studies also indicate that age is a significant factor contributing to variations in patient health behaviors. Older adult patients often suffer from multiple chronic diseases and symptoms such as fatigue and pain, further limiting their capacity for regular exercise and daily self-management (34). Additionally, the overall educational attainment of older adult patients in this study was generally low, which may have limited their ability to accurately comprehend health information and acquire knowledge for disease management. Lu et al. also demonstrated that insufficient health literacy directly impacts patients’ adherence to professional medical advice and the scientific rigor of their self-care behaviors (35). In contrast, the middle-aged and young patients studied by Gong et al. possessed relatively higher educational attainment, enabling them to more readily access health information through books, the internet, and other channels. This facilitated the development of scientifically grounded health knowledge, which in turn translated into proactive health promotion behaviors. Additionally, Gong et al.’s (32) study population comprised a broad range of patients with coronary artery disease, potentially including a significant number who had not undergone revascularization or were in a stable phase. In contrast, this study focused specifically on older adult patients following PCI. As an acute, invasive medical procedure, PCI may present patients with unique psychosocial challenges, such as persistent fear of restenosis, excessive preoccupation with cardiac function, and negative emotions associated with lifelong medication dependency. This intensified “patient role” and heightened disease uncertainty may create additional psychological barriers to maintaining proactive health behaviors, resulting in relatively lower behavioral scores. Furthermore, prior research indicates that older adult patients are more prone to negative emotions such as loneliness, anxiety, and depression due to factors like shifting social roles, declining physical function, and reduced social support. These psychological issues not only diminish their motivation to maintain healthy behaviors but may also further undermine treatment confidence and life enthusiasm, creating a vicious cycle between psychological state and behavior (36). Therefore, when assessing and improving health behaviors among older adult patients, it is essential to pay special attention to their unique psychological needs. The study results also reveal differences in health promotion behavior scores among older adult PCI patients across varying monthly household incomes, with patients from higher-income households exhibiting stronger health promotion behaviors—a finding consistent with previous research (37). This disparity stems from economic conditions serving as a crucial material foundation for sustaining health behaviors. Higher-income households can provide patients with better dietary options and effectively cover ongoing medical expenses such as regular follow-ups, out-of-pocket medications, and specialized rehabilitation equipment. These resources directly support the implementation and maintenance of health behaviors. Simultaneously, favorable economic conditions help alleviate the psychological burden caused by medical costs, enhancing patients’ confidence in treatment and motivation for recovery. This, in turn, further improves the adherence and sustainability of health behaviors (38).

The results of this study indicate a significant positive correlation between health literacy and health promotion behaviors (r = 0.840, p < 0.01), suggesting that older adult patients undergoing PCI exhibit higher levels of health promotion behaviors as their health literacy increases. This finding aligns with previous research (39). On one hand, higher health literacy provides the knowledge foundation for patients to correctly understand and implement health behaviors. Patients with high health literacy possess a deeper understanding of disease knowledge, treatment modalities, and key postoperative rehabilitation points. They clearly recognize the importance of health-promoting behaviors—such as taking medication on time, maintaining a balanced diet, and engaging in moderate exercise—for recovery. This facilitates the translation of abstract medical advice into concrete, actionable daily practices (35). On the other hand, patients with strong health literacy not only possess more solid knowledge reserves but also demonstrate superior information acquisition and discernment abilities. They proactively utilize multiple channels—such as medical guidance, science-based materials, or reliable online resources—to address challenges encountered during recovery. They effectively filter out false health information, make healthier decisions, and continuously refine their self-management strategies (40). Furthermore, research indicates that when patients successfully manage health issues through their knowledge base, their confidence in overcoming illness and sense of self-efficacy significantly increase. This positive psychological feedback transforms into an internal driving force for maintaining healthy behaviors, enabling them to sustain good compliance throughout the long-term rehabilitation process (41).

The results of this study indicate a significant positive correlation between health literacy and psychological resilience (r = 0.844, p < 0.01), suggesting that older adult patients undergoing PCI exhibit stronger psychological resilience with higher health literacy—a finding consistent with previous research (42). Research indicates that older adult patients often experience negative emotions such as loneliness, anxiety, and depression due to factors including physical decline, shrinking social circles, and multiple pressures stemming from illness. These psychological issues not only directly impair their mental health but also weaken their willingness and ability to manage their health (43). When older adult PCI patients possess strong health literacy, they gain a more comprehensive and in-depth understanding of disease knowledge, treatment methods, and rehabilitation precautions. This enables them to confront illness with a more positive and rational mindset, thereby enhancing psychological resilience. As a result, they can maintain optimism when facing postoperative physical discomfort and lifestyle changes, better adapt to new living conditions, and promote comprehensive physical and mental recovery (44).

The results of this study indicate that psychological resilience exhibits a significant positive correlation with health-promoting behaviors (r = 0.811, p < 0.01). This suggests that older adult patients undergoing PCI demonstrate stronger health-promoting behaviors as their psychological resilience increases, consistent with previous research findings (45). As a positive individual psychological resource, psychological resilience serves as a core capacity for coping with disease-related stress and challenges (20). Research indicates that older adult patients with robust psychological resilience exhibit superior emotional regulation and stress-coping abilities. When confronting difficulties and setbacks during rehabilitation, they recover more quickly from negative emotions and maintain a positive attitude toward treatment. This psychological advantage not only facilitates consistent treatment adherence but also encourages patients to proactively adopt and sustain healthy lifestyles, thereby significantly enhancing their overall health promotion behaviors (46). Furthermore, research by Wang et al. suggests that patients with higher psychological resilience tend to exhibit stronger problem-solving abilities. This enables them to develop more effective rehabilitation plans and proactively seek social support and professional assistance when encountering barriers to implementing health behaviors. Consequently, a virtuous cycle emerges where psychological resources and health behaviors mutually reinforce each other (47).

The findings reveal that psychological resilience mediates the relationship between health literacy and health promotion behaviors. Specifically, health literacy not only directly influences health promotion behaviors among older adult PCI postoperative patients but also indirectly affects these behaviors through the mediating effect of psychological resilience, accounting for 34.0% of the total effect. Specifically, health literacy—as the key ability for individuals to access, understand, and apply health information—effectively enhances patients’ disease cognition and self-management confidence, thereby positively influencing their psychological resilience (13). Psychological resilience, as the core psychological resource for coping with stress and adversity, can significantly improve health promotion behaviors by strengthening patients’ adaptability and persistence. Research indicates that compared to patients with lower psychological resilience, those with higher psychological resilience are better equipped to effectively cope with challenges during the rehabilitation process and proactively adjust unhealthy lifestyles, thereby forming and maintaining positive health behaviors (47). According to the Health Promotion Model, individual traits and experiences, along with behavior-specific cognition and emotions, collectively influence health behavior decisions. This theory emphasizes the pivotal role of cognitive psychological factors in behavioral change (23). On one hand, health literacy, as a crucial cognitive factor, enables patients with higher health literacy to accurately comprehend health information and translate it into practical actions, thereby promoting their health behaviors. On the other hand, higher health literacy enhances patients’ ability to adapt to stress and regulate their emotions, thereby increasing their psychological resilience and indirectly improving their health behaviors (48). Chen et al. also demonstrated that higher health literacy strengthens patients’ self-efficacy and confidence in disease management, leading to more proactive implementation of self-management-related health behaviors (42).

This study confirms the partial mediating role of psychological resilience in the relationship between health literacy and health promotion behaviors among older adult PCI patients in China. This finding provides a critical, integrated new perspective for improving health management practices in this population.

First, for clinical healthcare providers, assessing and cultivating psychological resilience must be regarded as a core component of patient evaluation and guidance, equally important to health education. This implies that during clinical communication, beyond inquiring “Do you know what to do?,” greater attention should be paid to “What psychological or emotional difficulties have you encountered in implementation?” and providing support accordingly.

Second, for health educators and rehabilitation counselors, educational content should extend beyond knowledge transmission to organically integrate psychological empowerment components. For instance, when discussing medication adherence, simultaneously teach patients techniques to manage anxiety after missed doses; when designing exercise plans, help patients set achievable small goals to enhance self-efficacy. This fundamentally embeds psychological resilience cultivation strategies within the process of improving health literacy.

Finally, for public health and rehabilitation program administrators, resource allocation and program design must recognize that supporting older adult PCI patients involves two critical phases: an initial “empowerment” stage focused on health literacy (providing clear, accessible information), followed by a later “transformation” stage centered on psychological resilience (delivering sustained psychosocial support to overcome behavioral barriers). When evaluating program effectiveness, improvements in both health literacy and psychological resilience should be incorporated as process indicators.

Based on the insights above, we further propose the following more actionable recommendations to provide reference for developing comprehensive intervention measures in the future:

(1) Precision strategies for enhancing health literacy among older adult patients: Given the information reception characteristics of older adult, low-literacy, and low-income patients, multi-tiered health education interventions should be implemented. Content design should prioritize developing rehabilitation guidance materials featuring illustrations supplemented by text, focusing on practical skills such as medication identification and administration, symptom recognition, and dietary planning. In implementation, community health centers should establish regular follow-up systems to reinforce key information delivery through face-to-face demonstrations and group lectures. Simultaneously, encourage family members to participate in the health education process, leveraging their supportive role in reinforcing information and monitoring behavior. For low-income groups, healthcare institutions are advised to provide free basic rehabilitation kits to help translate health knowledge into concrete actions.

(2) Supportive interventions to enhance psychological resilience: To address common anxiety, depression, and uncertainty about illness among older adult patients, a professional psychosocial support network should be established. At the institutional level, dedicated psychological clinics for post-PCI patients should be established, where healthcare professionals regularly assess patients’ psychological states and provide cognitive-behavioral therapy guidance to help them develop a positive disease cognition. At the community level, organize patient support groups where patients share their successful recovery stories to bolster hope and self-efficacy. Simultaneously, guide family members in recognizing patients’ psychological needs, offering emotional support and companionship to alleviate loneliness and psychological burdens.

(3) Establish a comprehensive support system for economically disadvantaged groups: For patients from households with lower monthly incomes, it is recommended to alleviate their financial burdens through multiple channels. Promote the optimization of medical insurance policies by including key post-PCI follow-up examinations and essential rehabilitation equipment within the scope of reimbursement. Medical institutions may establish “rehabilitation assistance funds” to subsidize out-of-pocket medication costs for financially disadvantaged patients. Concurrently, community health centers should provide complimentary basic rehabilitation assessments and guidance, while organizing group rehabilitation activities to reduce the economic burden for individual patients seeking standalone rehabilitation training. Encourage community pharmacies to regularly offer discounted medications for chronic diseases, employing multiple approaches to alleviate patients’ financial strain and create the necessary conditions for sustaining healthy behaviors.