Data analysis in this study was primarily conducted using SPSS 27.0 and AMOS 29.0 software. The analysis process was divided into four parts: descriptive statistics, correlation analysis, and chain mediation effect analysis. First, descriptive statistics were performed on study variables and demographic characteristics. Continuous data were expressed as mean ± standard deviation (M ± SD), and categorical variables as frequencies and percentages. Skewness (< |3|) and kurtosis (< |8|) within these ranges were considered indicative of normal distribution.

Subsequently, internal consistency (Cronbach's α) was calculated for each scale, and confirmatory factor analysis was used to test structural validity, with evaluation indices including chi-square to degrees of freedom ratio (χ²/df), comparative fit index (CFI), goodness-of-fit index (GFI), and root mean square error of approximation (RMSEA); criteria were χ²/df < 3.00, CFI and GFI > 0.80, and RMSEA < 0.08 for good model fit. Pearson correlation analysis was employed to explore bivariate correlations between death literacy, psychological adaptation, cognitive reappraisal, and self-management behaviors. Prior to mediation analysis, collinearity diagnostics were conducted on independent and mediating variables, with variance inflation factor (VIF) < 5 indicating no severe multicollinearity.

Finally, a structural equation model was constructed based on stress-coping theory, with death literacy as the independent variable, self-management behaviors as the dependent variable, psychological adaptation and cognitive reappraisal as sequential mediators, and demographic characteristics as controls. Bias-corrected nonparametric percentile bootstrapping (Bootstrap = 5,000 resamples) was used to estimate indirect effects and 95% confidence intervals (CI). If the CI did not include 0, the mediation effect was considered significant. This study utilized the SPSS PROCESS macro (Model 6) to analyze the chain mediating roles of psychological adaptation and cognitive reappraisal.

Given that all measurement questionnaires in this study utilized 5-point Likert scales, data were sourced from the same location, and responses may be influenced by social desirability, there is a potential for common method bias. Therefore, participant recruitment employed anonymization and data confidentiality measures to mitigate bias.

We conducted Harman's single-factor test by subjecting all variable items to exploratory factor analysis. The results indicated that the first factor accounted for 23.354% of the total variance, which is below the critical threshold of 40%. Thus, this study is free from common method bias.

Descriptive statistics and correlation analyses were performed on death literacy, psychological adaptation, cognitive reappraisal, and self-management behaviors, as shown in Tables 3, 4. The scores were as follows: death literacy (M = 3.304, SD = 0.623); psychological adaptation (M = 3.429, SD = 0.679); cognitive reappraisal (M = 3.426, SD = 0.657); and self-management behaviors (M = 3.416, SD = 0.597). The core variables all exceeded the critical value (M = 2.5). The skewness ranged from −0.292 to 0.033, and kurtosis ranged from −0.186 to 1.549. According to the approximate normality criteria proposed by Kline (57), the study variables met the assumptions of approximate normality.

As shown in Table 4, death literacy was significantly and positively correlated with psychological adaptation (r = 0.523, p < 0.001, strong correlation), cognitive reappraisal (r = 0.593, p < 0.001, strong correlation), and self-management behaviors (r = 0.495, p < 0.001, moderate correlation). Psychological adaptation was significantly and positively correlated with cognitive reappraisal (r = 0.637, p < 0.001, strong correlation) and self-management behaviors (r = 0.511, p < 0.001, strong correlation). Cognitive reappraisal was significantly and positively correlated with self-management behaviors (r = 0.561, p < 0.001, strong correlation).

To enhance the accuracy of the study, smoking, alcohol consumption, cancer stage, treatment modality, and gender were included as control variables in the research model. Based on collinearity diagnostics, variance inflation factors < 5 indicated no severe multicollinearity. With death literacy as the independent variable, psychological adaptation and cognitive reappraisal as mediators, and self-management behaviors as the dependent variable, a chain mediation model was constructed. This study employed Process Model 6 to analyze the chain mediating roles of psychological adaptation and cognitive reappraisal (Bootstrap: 5,000 resamples).

The results indicated that death literacy significantly and positively predicted psychological adaptation [β = 0.553, p < 0.001, 95% CI = (0.473, 0.633)]; death literacy positively predicted cognitive reappraisal [β = 0.382, p < 0.001, 95% CI = (0.305, 0.459)]; and death literacy positively predicted self-management behaviors [β = 0.190, p < 0.001, 95% CI = (0.105, 0.276)]. Psychological adaptation significantly and positively predicted cognitive reappraisal [β = 0.445, p < 0.001, 95% CI = (0.372, 0.518)]; psychological adaptation positively predicted self-management behaviors [β = 0.195, p < 0.001, 95% CI = (0.111, 0.279)]. Cognitive reappraisal significantly and positively predicted self-management behaviors [β = 0.277, p < 0.001, 95% CI = (0.188, 0.367)]. Detailed analysis results are presented in Table 5.

The mediation effect analysis, as shown in Table 6 and Figure 1, revealed that the total effect of death literacy on self-management behaviors was 0.472, of which 59.75% was explained by the mediating roles of psychological adaptation and cognitive reappraisal. Further examination showed that the chain mediating path of death literacy → psychological adaptation → cognitive reappraisal → self-management behaviors was significant [β = 0.068, SE = 0.018, 95% CI = (0.031, 0.102)], accounting for 14.40% of the total effect. From the individual mediation paths, death literacy → psychological adaptation → self-management behaviors exhibited a significant mediating effect [β = 0.109, SE = 0.037, 95% CI = (0.036, 0.181)], accounting for 23.09% of the total effect; death literacy → cognitive reappraisal → self-management behaviors exhibited a significant mediating effect [β = 0.106, SE = 0.029, 95% CI = (0.054, 0.170)], accounting for 22.46% of the total effect.

This study enriches the social psychological connotations of death literacy from a theoretical perspective by introducing a concept primarily applied in public death education and end-of-life care into the context of psychological and behavioral research on gastric cancer patients. Previous studies have often focused on single-dimensional psychological traits such as death anxiety, death avoidance, or death acceptance (58), whereas this study empirically verifies the positive impact of death literacy on patients' self-management behaviors, revealing that individuals' positive understanding of death at cognitive, emotional, and behavioral levels can translate into specific health management motivations. This finding breaks through the traditional theoretical assumption that death-related variables predominantly exert negative psychological effects, suggesting that death literacy represents not merely a level of cognitive understanding of death issues but a psychological resource for integrating ultimate life meanings, reshaping life goals, and forming behavioral intentions. From a theoretical construction viewpoint, this study confirms that death literacy can serve as an important personality-based psychological foundation for promoting adaptive behavioral changes, further expanding the boundaries of positive death perspectives in behavioral research on cancer patients within health psychology (59), and providing new cognitive coordinates for establishing context-specific death-related health psychological theories in the future.

This study reveals the chain mediating pathway of psychological adaptation and cognitive reappraisal in the process by which death literacy influences self-management behaviors, theoretically deepening the dynamic understanding of psychological regulation mechanisms in cancer patients. Psychological adaptation, as the core process for integrating internal emotions, cognitions, and behavioral responses when facing disease threats, is confirmed to play a key mediating role between death literacy and self-management; this indicates that when patients approach death issues with an open and peaceful attitude, they are more likely to achieve effective life and treatment management through positive psychological integration. Cognitive reappraisal further constitutes a critical psychological mechanism for converting psychological adaptation into health behaviors, reflecting individuals' positive action orientations formed after reinterpreting the meanings of disease events (60). The chain mediation model in this study refines existing cancer psychological regulation theories, demonstrating that positive cognitive processing and emotion regulation strategies serve as bridges connecting meaning construction and behavioral execution, revealing the internal logic of cognition-emotion-behavior linkages, and providing new theoretical fulcrums for understanding how gastric cancer patients rebuild behavioral initiative amid psychological dilemmas.

Grounded in stress-coping theory, this study elucidates the internal psychological mechanisms by which death literacy influences self-management behaviors in gastric cancer patients through psychological adaptation and cognitive reappraisal, expanding the explanatory boundaries of this theory in the field of cancer psychology. Traditional stress-coping models emphasize individuals' cognitive appraisals and coping strategy selections when facing disease threats but primarily focus on stress response alleviation and emotion management (61), with less attention to the regulatory roles of individual meaning construction and existential cognition. By incorporating death literacy into this theoretical framework, this study highlights that individuals' understanding and attitudes toward death not only affect the primary cognitive appraisal process but also profoundly reshape the pathways for reinterpreting the meanings of stressful events. When death is integrated into the life meaning system, individuals are more inclined to adopt positive emotion regulation methods and adaptive coping strategies, thereby promoting the self-maintenance of health behaviors (62). Psychological adaptation and cognitive reappraisal realize a psychological progression mechanism of stress appraisal-emotion regulation-behavior transformation in this process, extending the applicability of stress-coping theory from passive regulation of external pressures to active growth processes based on meaning reconstruction. Consequently, this study proposes a new pathway for psychological stress models in cancer patients: death literacy as a antecedent cognitive resource improves stress appraisals and enhances psychological resilience, facilitating individuals' positive psychological transformations and health behavior maintenance under disease pressures (63). This not only enriches the theoretical connotations of stress-coping theory in chronic disease psychology but also provides new theoretical bases for understanding how cancer patients achieve psychological adaptation and behavioral restoration in high-stress contexts.

This study finds that death literacy has a significant positive promoting effect on self-management behaviors in gastric cancer patients, offering important insights for clinical psychological interventions and health education practices. Traditional oncology interventions often focus on disease control and lifestyle guidance while overlooking patients' psychological construction and meaning understanding of death issues. First, the results demonstrate that death literacy functions as a positive psychological resource that fosters psychological adaptation and self-management behaviors. In practical terms, this highlights the necessity of incorporating structured death education programs into standard oncological care. Such programs should go beyond informational sessions to include guided discussions and reflective exercises, enabling patients to explore their perceptions of mortality and reduce death-related anxiety. For example, clinicians and psychologists can jointly facilitate group-based “life and death dialogue” workshops or narrative therapy sessions during chemotherapy or postoperative rehabilitation. These interventions help patients reframe their understanding of death as part of the life continuum, thereby improving acceptance and internal control. Additionally, a multidisciplinary integration model (MDT-based psychological pathway) is recommended for clinical implementation. Oncologists, psychologists, nurses, and social workers can collaborate to assess individual patients' death literacy and psychological adaptation levels during hospitalization or post-surgery follow-ups. Based on assessment outcomes, individualized psycho-educational plans can be jointly developed and continuously adjusted. Incorporating these modules into digital health platforms or hospital information systems can further enhance accessibility and long-term monitoring of psychological and behavioral outcomes.

The study results indicate that psychological adaptation and cognitive reappraisal play chain mediating roles in the mechanism by which death literacy influences self-management behaviors, providing precise theoretical support for clinical psychological intervention designs. Gastric cancer patients often face complex physiological burdens and psychological conflicts during disease progression, while traditional psychological interventions typically emphasize only disease acceptance or emotional stability, neglecting cognitive processing and meaning reconstruction in coping processes. The findings of this study suggest that clinical psychological support should integrate psychological adaptation training and cognitive reappraisal strategies to help patients achieve positive meaning construction during stress processes. For example, psychologists can employ reappraisal techniques from cognitive behavioral therapy to guide patients in reinterpreting the relationships between disease and life, shifting from uncertainty to growth experiences; simultaneously, psychological adaptation training modules, such as emotion recognition, expressive writing on death-related emotions, and mindfulness relaxation, can be established to promote psychological repair and emotional stability. Through integrated interventions, patients' psychological resilience can be effectively strengthened, enabling them to more capably adjust behaviors proactively to manage symptoms and treatment rhythms, thereby achieving a benign match between psychological mechanisms and health behaviors.

The significant mediating role of psychological adaptation suggests that patients require targeted psychological adaptation training to translate cognitive understanding into emotional stability and behavioral adjustment. This training can consist of structured modules focusing on emotional recognition and regulation, resilience and coping exercises, and goal reorientation and meaning reconstruction. Specific techniques such as cognitive reappraisal exercises, problem-solving therapy, and mindfulness-based stress reduction can be integrated into routine nursing follow-ups or counseling sessions. By strengthening patients' adaptive capacities, these interventions facilitate consistent engagement in diet control, symptom monitoring, and adherence to medical regimens.

The clinical application value of this study lies in revealing the core roles of death literacy and psychological regulation factors in patients' health behaviors, providing theoretical bases for transforming clinical nursing and rehabilitation models. Previous clinical care systems have emphasized physiological treatments and short-term medical adherence while overlooking individuals' internal psychological regulation mechanisms when facing life-and-death issues. This study suggests that healthcare institutions should incorporate death literacy enhancement into hospital humanistic care management systems, implementing human-centered communication principles in diagnostic and therapeutic interactions. For instance, healthcare providers can use open-ended conversation techniques to explore patients' understandings of disease and death, combined with meaning-oriented counseling methods, to reduce anxiety and resistance arising from avoiding death topics. This model transformation not only helps improve doctor-patient trust and treatment adherence but also extends nursing behaviors from biomedical care to psychological and social dimensions, achieving the clinical goal of “holistic care.” By embedding psychological assessment and intervention components into clinical pathways, it can effectively promote self-efficacy and life initiative in gastric cancer patients during disease management processes.

The practical implications of this study also lie in providing promotable theoretical evidence for optimizing psychological health management systems for oncology patients and public health policies. With the increasing trend of cancer as a chronic disease, mere medical interventions can no longer meet patients' comprehensive needs at psychological, social, and value levels. The mechanisms of death literacy, psychological adaptation, and cognitive reappraisal revealed in this study offer scientific bases for developing hierarchical and continuous psychological support systems. Social and health management departments can accordingly establish multilevel psychological service networks in communities and hospitals, combining death education, psychological counseling, and health management courses, while training healthcare personnel in core competencies for death communication and psychological interventions. Simultaneously, this study emphasizes the importance of disease meaning education, which can promote organic connections among “end-of-life care—oncology psychology—health promotion,” facilitating synergistic improvements in patients' quality of life and psychological health. In the future, incorporating death literacy interventions into national standardized pathways for psychological rehabilitation of cancer patients can not only optimize medical resource allocation but also construct culturally adaptive psychological health promotion systems at the macro level, realizing interdisciplinary development from oncology to integrative and social medicine.

This study employed a cross-sectional design, which can reveal correlations and mediation mechanisms among variables but cannot verify the causal pathways between death literacy, psychological adaptation, cognitive reappraisal, and self-management behaviors in a temporal sequence. Since data were collected at a single time point, individual psychological states and behavioral responses may be influenced by transient emotions, treatment progress, medical environments, and other external factors, thereby limiting the directionality and stability of inferences. Additionally, the study sample was sourced from three tertiary Grade A hospitals in Zhejiang Province, and although it covered patients at different stages and treatment types, the regional characteristics are evident, with the sample generally exhibiting high medical accessibility and relatively high cultural levels, potentially restricting the generalizability of the results. Future research should adopt longitudinal or tracking designs to dynamically monitor the long-term effects of changes in death literacy on self-management behaviors, further validating the temporal and sustained nature of the chain mediation pathway; simultaneously, expanding sample sources to patients from different regions, cultural backgrounds, and medical levels can enhance the model's external validity and cultural adaptability, thereby improving the cross-population promotional value of the results.

This study used self-report questionnaires as the primary data collection method, and although the scales demonstrate high reliability and validity both domestically and internationally, they may still be subject to social desirability bias, self-reporting bias, and recall bias. Some patients may overestimate their psychological adaptation or self-management levels due to social approval motives, thereby interfering with true responses. Furthermore, while the scales for death literacy, psychological adaptation, and cognitive reappraisal have undergone cultural revisions, their specificity for gastric cancer populations requires further validation. Future research recommends integrating multimethodological strategies, such as combining quantitative and qualitative data, through in-depth interviews and focus groups to explore the subjective construction processes of death literacy from patients' life experiences and cultural contexts. Additionally, during data collection, multiple information sources, including observations from family members, caregivers, or clinicians, can be incorporated to form more comprehensive psychological and behavioral profiles. Studies may also adopt physiological or behavioral indicators (e.g., treatment adherence, physical activity monitoring) as objective validations to enhance data ecological validity and reduce methodological biases affecting result interpretations.

Although this study constructed a relatively complete chain mediation model based on stress-coping theory, there remains room for theoretical deepening. First, death literacy in the model primarily serves as a cognitive-level predictor, while its emotional and social dimensions (e.g., death communication experiences, social support systems) may also play key roles in self-management behaviors. Second, this study did not include potential moderating variables such as social support, religious beliefs, cultural orientations, or disease stages, which may exert important interactive effects on model path strengths. Future research can incorporate moderated mediation models or multilevel linear analyses to explore differential effects of various demographic and psychological characteristics on the model's mechanisms. Additionally, variables such as meaning construction and psychological resilience should be integrated into the theoretical framework to further elucidate the functional pathways of death literacy in psychological growth and behavioral reshaping from existential and positive psychology perspectives. By expanding the dimensions of theoretical models, the psychological and behavioral transformation mechanisms from death orientation to life meaning generation in gastric cancer patients can be revealed within broader psychosocial frameworks.