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<journal-id journal-id-type="publisher-id">Front. Public Health</journal-id>
<journal-title>Frontiers in Public Health</journal-title>
<abbrev-journal-title abbrev-type="pubmed">Front. Public Health</abbrev-journal-title>
<issn pub-type="epub">2296-2565</issn>
<publisher>
<publisher-name>Frontiers Media S.A.</publisher-name>
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<article-meta>
<article-id pub-id-type="doi">10.3389/fpubh.2024.1355392</article-id>
<article-categories>
<subj-group subj-group-type="heading">
<subject>Public Health</subject>
<subj-group>
<subject>Original Research</subject>
</subj-group>
</subj-group>
</article-categories>
<title-group>
<article-title>Health literacy mediates the relationships of cognitive and physical functions with health-related quality of life in older adults</article-title>
</title-group>
<contrib-group>
<contrib contrib-type="author" equal-contrib="yes"><name><surname>Chow</surname> <given-names>Bik C.</given-names></name><xref ref-type="aff" rid="aff1"><sup>1</sup></xref><xref ref-type="aff" rid="aff2"><sup>2</sup></xref><xref rid="fn00001" ref-type="author-notes"><sup>&#x2020;</sup></xref>
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<contrib contrib-type="author" equal-contrib="yes"><name><surname>Jiao</surname> <given-names>Jiao</given-names></name><xref ref-type="aff" rid="aff1"><sup>1</sup></xref><xref ref-type="aff" rid="aff2"><sup>2</sup></xref><xref rid="fn00001" ref-type="author-notes"><sup>&#x2020;</sup></xref>
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<contrib contrib-type="author"><name><surname>Duong</surname> <given-names>Tuyen V.</given-names></name><xref ref-type="aff" rid="aff3"><sup>3</sup></xref><xref ref-type="aff" rid="aff4"><sup>4</sup></xref>
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<contrib contrib-type="author"><name><surname>Hassel</surname> <given-names>Holger</given-names></name><xref ref-type="aff" rid="aff5"><sup>5</sup></xref><xref ref-type="aff" rid="aff6"><sup>6</sup></xref>
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<contrib contrib-type="author"><name><surname>Kwok</surname> <given-names>Timothy C. Y.</given-names></name><xref ref-type="aff" rid="aff7"><sup>7</sup></xref>
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<contrib contrib-type="author"><name><surname>Nguyen</surname> <given-names>Minh H.</given-names></name><xref ref-type="aff" rid="aff4"><sup>4</sup></xref><xref ref-type="aff" rid="aff8">
<sup>8</sup></xref>
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<contrib contrib-type="author" corresp="yes"><name><surname>Liu</surname> <given-names>Huaxuan</given-names></name><xref ref-type="aff" rid="aff9"><sup>9</sup></xref><xref ref-type="corresp" rid="c001"><sup>&#x002A;</sup></xref>
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<aff id="aff1"><sup>1</sup><institution>Department of Sport, Physical Education and Health, Hong Kong Baptist University</institution>, <addr-line>Kowloon Tong, Hong Kong SAR</addr-line>, <country>China</country></aff>
<aff id="aff2"><sup>2</sup><institution>Dr. Stephen Hui Research Centre for Physical Recreation and Wellness, Hong Kong Baptist University</institution>, <addr-line>Kowloon Tong, Hong Kong SAR</addr-line>, <country>China</country></aff>
<aff id="aff3"><sup>3</sup><institution>School of Nutrition and Health Sciences, Taipei Medical University</institution>, <addr-line>Taipei</addr-line>, <country>Taiwan</country></aff>
<aff id="aff4"><sup>4</sup><institution>International PhD Program in Medicine, College of Medicine, Taipei Medical University</institution>, <addr-line>Taipei</addr-line>, <country>Taiwan</country></aff>
<aff id="aff5"><sup>5</sup><institution>Institute for Applied Health Sciences, Coburg University of Applied Sciences and Arts</institution>, <addr-line>Coburg</addr-line>, <country>Germany</country></aff>
<aff id="aff6"><sup>6</sup><institution>Berlin Institute for Health and Social Affairs</institution>, <addr-line>Berlin</addr-line>, <country>Germany</country></aff>
<aff id="aff7"><sup>7</sup><institution>Department of Medicine &#x0026; Therapeutic and School of Public Health, The Chinese University of Hong Kong, Shatin</institution>, <addr-line>Hong Kong SAR</addr-line>, <country>China</country></aff>
<aff id="aff8"><sup>8</sup><institution>School of Preventive Medicine and Public Health, Hanoi Medical University</institution>, <addr-line>Hanoi</addr-line>, <country>Vietnam</country></aff>
<aff id="aff9"><sup>9</sup><institution>School of Physical Education and Sport Science, Fujian Normal University</institution>, <addr-line>Fuzhou, Fujian</addr-line>, <country>China</country></aff>
<author-notes>
<fn fn-type="edited-by" id="fn0001">
<p>Edited by: Kathleen Potempa, University of Michigan, United States</p>
</fn>
<fn fn-type="edited-by" id="fn0002">
<p>Reviewed by: Karolina Kopacz, Medical University of Lodz, Poland</p>
<p>Laura Struble, University of Michigan, United States</p>
</fn>
<corresp id="c001">&#x002A;Correspondence: Huaxuan Liu, <email>bella_liuhx@fjnu.edu.cn</email></corresp>
<fn id="fn00001" fn-type="equal">
<p><sup>&#x2020;</sup>These authors have contributed equally to this work</p>
</fn>
</author-notes>
<pub-date pub-type="epub">
<day>14</day>
<month>03</month>
<year>2024</year>
</pub-date>
<pub-date pub-type="collection">
<year>2024</year>
</pub-date>
<volume>12</volume>
<elocation-id>1355392</elocation-id>
<history>
<date date-type="received">
<day>13</day>
<month>12</month>
<year>2023</year>
</date>
<date date-type="accepted">
<day>16</day>
<month>02</month>
<year>2024</year>
</date>
</history>
<permissions>
<copyright-statement>Copyright &#x00A9; 2024 Chow, Duong, Jiao, Hassel, Kwok, Nguyen and Liu.</copyright-statement>
<copyright-year>2024</copyright-year>
<copyright-holder>Chow, Duong, Jiao, Hassel, Kwok, Nguyen and Liu</copyright-holder>
<license xlink:href="http://creativecommons.org/licenses/by/4.0/">
<p>This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.</p>
</license>
</permissions>
<abstract>
<sec id="sec1">
<title>Background</title>
<p>Declining cognitive function (CF) and physical function (PF) relate to poorer health-related quality of life (HRQoL) in older adults. As health literacy (HL) facilitates health information utilization, it may mediate links between functionality and HRQoL appraisals. This study examined HL as an intermediary between joint CF and PF contributions and HRQoL in Hong Kong older adults.</p>
</sec>
<sec id="sec2">
<title>Methods</title>
<p>490 older adults aged 50&#x2013;80&#x2009;years completed assessments from March to July 2021. Health Literacy Survey Questionnaire Short Form 12 questions (HLS-SF12), Montreal Cognitive Assessment (MoCA), Senior Fitness Test (SFT) and 12-Item Short-Form Health Survey version 2 (SF-12v2) were used to assess HL, CF, PF and HRQoL, respectively. Path analysis tested a model with HL mediating CF/PF predictors and HRQoL outcome.</p>
</sec>
<sec id="sec3">
<title>Results</title>
<p>Results for direct effects indicated that CF significantly associated with PF (&#x03B2;&#x2009;=&#x2009;0.115, SE&#x2009;=&#x2009;0.012, <italic>p</italic>&#x2009;&#x003C;&#x2009;0.001), PF significantly connected to HL (&#x03B2;&#x2009;=&#x2009;0.101, SE&#x2009;=&#x2009;0.022, <italic>p</italic>&#x2009;&#x003C;&#x2009;0.001), and HL significantly related to HRQoL (&#x03B2;&#x2009;=&#x2009;0.457, SE&#x2009;=&#x2009;0.049, <italic>p</italic>&#x2009;&#x003C;&#x2009;0.001). Meanwhile, PF significantly linked to HRQoL directly (&#x03B2;&#x2009;=&#x2009;0.156, SE&#x2009;=&#x2009;0.025, <italic>p</italic>&#x2009;&#x003C;&#x2009;0.001) as well as indirectly (&#x03B2;&#x2009;=&#x2009;0.046, 95% CI [0.028, 0.067]). Significant mediating effect of HL was found on the relationship of PF and HRQoL.</p>
</sec>
<sec id="sec4">
<title>Conclusion</title>
<p>Findings confirm CF and PF joint impacts on HL and HRQoL in older adults, elucidating HL&#x2019;s mediating role in translating functionality levels into HRQoL. Fostering enduring health knowledge access may thus buffer effects of age-related declines on well-being. Results can inform interventions leveraging this pathway to promote resilient trajectories.</p>
</sec>
</abstract>
<kwd-group>
<kwd>health literacy</kwd>
<kwd>older adults</kwd>
<kwd>cognitive function</kwd>
<kwd>physical function</kwd>
<kwd>health-related quality of life</kwd>
</kwd-group>
<contract-num rid="cn1">RC-FNRA-IG/19-20/SOSC/05</contract-num>
<contract-num rid="cn2">G-HKBU202/20</contract-num>
<contract-sponsor id="cn1">HKBU Faculty Research Niche Area</contract-sponsor>
<contract-sponsor id="cn2">Germany/Hong Kong Joint Research Scheme 2020/2</contract-sponsor>
<counts>
<fig-count count="2"/>
<table-count count="3"/>
<equation-count count="0"/>
<ref-count count="105"/>
<page-count count="12"/>
<word-count count="9827"/>
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<custom-meta-wrap>
<custom-meta>
<meta-name>section-at-acceptance</meta-name>
<meta-value>Aging and Public Health</meta-value>
</custom-meta>
</custom-meta-wrap>
</article-meta>
</front>
<body>
<sec sec-type="intro" id="sec5">
<title>Introduction</title>
<p>Health literacy (HL) is a contemporary topic in today&#x2019;s healthcare research. It refers to &#x201C;the personal, cognitive and social skills which determine the ability of individuals to gain access to, understand, and use information to promote and maintain good health&#x201D; (<xref ref-type="bibr" rid="ref1">1</xref>). As evidenced in the World Health Organization&#x2019;s 2019 report on health promotion, strengthening HL across populations can empower citizens to take charge of their health needs (<xref ref-type="bibr" rid="ref2">2</xref>). Studies indicate that nearly half (47%) of individuals in eight European countries have inadequate or problematic general HL (<xref ref-type="bibr" rid="ref3">3</xref>). Inadequate HL is of particular concern for older adults, who often have increased demands for health information and services to maintain well-being. While global aging populations continue expanding, academic inquiry into how HL impacts quality of life for older adults remains insufficient, with most previous studies adopting a clinical orientation rather than a public health perspective (<xref ref-type="bibr" rid="ref4 ref5 ref6">4&#x2013;6</xref>). To promote healthy aging among older population in community settings, elucidating the role of HL vis-&#x00E0;-vis health status and quality of life is critical. The current study therefore sought to examine HL&#x2019;s association with bodily functions and Health-related quality of life (HRQoL) in older adults, guided by the rationale delineated below.</p>
<sec id="sec6">
<title>Relationships among HRQoL, CF, and PF, and the potential role of HL</title>
<p>Health-related quality of life (HRQoL) is a multidimensional concept used to assess how health conditions influence overall well-being and quality of life. It encompasses physical, psychological, and social well-being (<xref ref-type="bibr" rid="ref7">7</xref>). Research shows that advanced age correlates with diminished HRQoL in older adults (<xref ref-type="bibr" rid="ref8">8</xref>, <xref ref-type="bibr" rid="ref9">9</xref>). Declines in cognitive function (CF) and physical function (PF)&#x2014;which can occur together or separately&#x2014;are key health issues impacting HRQoL (<xref ref-type="bibr" rid="ref10">10</xref>). CF includes memory, verbal fluency, letter and pattern comparison, listening span, and processing speed (<xref ref-type="bibr" rid="ref10 ref11 ref12 ref13">10&#x2013;13</xref>). Mild cognitive impairment is common in older adults (<xref ref-type="bibr" rid="ref14">14</xref>, <xref ref-type="bibr" rid="ref15">15</xref>) and can cause difficulties conducting daily activities (<xref ref-type="bibr" rid="ref16">16</xref>, <xref ref-type="bibr" rid="ref17">17</xref>). Lower cognitive levels may increase psychological problems like mental illness (<xref ref-type="bibr" rid="ref18">18</xref>) or dementia (<xref ref-type="bibr" rid="ref19">19</xref>). Meanwhile, PF is considered as the ability to perform activities of daily living (<xref ref-type="bibr" rid="ref20">20</xref>). Age-related PF decline stems from decreasing muscle strength, bone deterioration, and organ function (<xref ref-type="bibr" rid="ref10">10</xref>, <xref ref-type="bibr" rid="ref21">21</xref>), lowering mobility and independence, worsening quality of life (<xref ref-type="bibr" rid="ref22">22</xref>). Adequate PF enables older adults to preserve functionality and independence in daily living without major difficulty or dependence on others (<xref ref-type="bibr" rid="ref23">23</xref>). For older adults, preserving cognitive and physical health helps enable better quality of life (<xref ref-type="bibr" rid="ref24">24</xref>).</p>
<p>As some older adults experience age-related changes in cognitive and functional status, having adequate health literacy (HL) skills enables self-management of health and preservation of independence for older adults. Yet little research has examined the interconnections between cognitive function (CF), physical function (PF), HL, and health-related quality of life (HRQoL) concurrently (<xref ref-type="bibr" rid="ref25">25</xref>, <xref ref-type="bibr" rid="ref26">26</xref>). Older people with more adequate CF and PF would suffer less physical or mental difficulties and be more likely to perceive themselves as better able to achieve daily activities, indicating higher perceived behavioral control (<xref ref-type="bibr" rid="ref25">25</xref>), which closely relates to HL (<xref ref-type="bibr" rid="ref27">27</xref>, <xref ref-type="bibr" rid="ref28">28</xref>). HL represents abilities to address health issues, and positively impacts HRQoL (<xref ref-type="bibr" rid="ref4">4</xref>, <xref ref-type="bibr" rid="ref29">29</xref>). A framework suggests individual traits (including CF and PF) directly impact HL, which subsequently influences health outcomes (<xref ref-type="bibr" rid="ref26">26</xref>). Accordingly, positive outcomes could enhance functional independence and quality of life (<xref ref-type="bibr" rid="ref1">1</xref>). HL has long been considered a mediating factor due to its potentially modifiable influence on personal/social determinants of health (<xref ref-type="bibr" rid="ref30">30</xref>). Therefore, it is reasonable to hypothesize HL as a viable mediator between CF and PF jointly and HRQoL. Elucidating HL&#x2019;s ability to potentially buffer, mitigate or mediate these relationships allows for targeted improvements in older people&#x2019;s healthcare policy, planning and education to promote healthy aging.</p>
</sec>
<sec id="sec7">
<title>The impact of HL on CF, PF, and HRQoL</title>
<p>Health literacy (HL) significantly impacts health management activities and outcomes (<xref ref-type="bibr" rid="ref31 ref32 ref33">31&#x2013;33</xref>). Inadequate HL often causes difficulty understanding and implementing health information, hindering health management (<xref ref-type="bibr" rid="ref6">6</xref>). Older people face higher risk for low HL than younger populations (<xref ref-type="bibr" rid="ref11">11</xref>, <xref ref-type="bibr" rid="ref34">34</xref>). Outcomes of limited HL include self-care problems like taking medications, managing chronic disease, utilizing preventive services (<xref ref-type="bibr" rid="ref35">35</xref>, <xref ref-type="bibr" rid="ref36">36</xref>), and poorer health (<xref ref-type="bibr" rid="ref37">37</xref>), negatively impacting health-related quality of life (HRQoL). Although prior studies suggest a strong HL-HRQoL linkage, findings vary across countries and cultures (<xref ref-type="bibr" rid="ref38">38</xref>). Some research finds associations between low HL and poorer HRQoL (<xref ref-type="bibr" rid="ref39 ref40 ref41">39&#x2013;41</xref>), while other studies find no relationship (<xref ref-type="bibr" rid="ref42">42</xref>). Further investigation on HL&#x2019;s impact on HRQoL in aging populations is warranted.</p>
<p>As for the relationship between health literacy (HL) and cognitive function (CF) and physical function (PF) jointly, previous research has shown significant connections with poor HL separately. First, lower HL associates with worse CF (<xref ref-type="bibr" rid="ref11 ref12 ref13">11&#x2013;13</xref>). Some research also indicates CF highly impacts constructing HL in older adults (<xref ref-type="bibr" rid="ref34">34</xref>, <xref ref-type="bibr" rid="ref43">43</xref>). Moreover, age-related CF decline may lead the older adults to feel shame and embarrassment, diminishing effective communication and exacerbating HL issues (<xref ref-type="bibr" rid="ref44">44</xref>). Second, inadequate HL associates with limited PF (<xref ref-type="bibr" rid="ref31">31</xref>, <xref ref-type="bibr" rid="ref35">35</xref>, <xref ref-type="bibr" rid="ref45 ref46 ref47">45&#x2013;47</xref>). While most literature shows HL impacts PF, evidence also suggests PF may reciprocally influence HL, as differing PF levels produce different situational needs that fluctuate HL (<xref ref-type="bibr" rid="ref30">30</xref>, <xref ref-type="bibr" rid="ref46">46</xref>, <xref ref-type="bibr" rid="ref47">47</xref>). Understanding these relationship details is important for mitigating CF and PF impacts on health-related quality of life (HRQoL). However, little research has examined HL, CF and PF interconnections or their combined influence on older adults&#x2019; HRQoL.</p>
</sec>
<sec id="sec8">
<title>The CF and PF interplay</title>
<p>Although cognitive function (CF) and physical function (PF) often concurrently decline in older adults, their interdependency remains unclear with inconsistent findings. A few studies demonstrate CF and PF associations (<xref ref-type="bibr" rid="ref48">48</xref>, <xref ref-type="bibr" rid="ref49">49</xref>) but rarely explore predictor relationships. PF requires motor coordination and balance, which utilize cognitive skills like coordination and information processing, suggesting CF could affect PF (<xref ref-type="bibr" rid="ref50">50</xref>). Meanwhile, some interventions using aerobic exercises (e.g., Yoga, Tai-chi) effectively promote CF (<xref ref-type="bibr" rid="ref51">51</xref>, <xref ref-type="bibr" rid="ref52">52</xref>), indicating PF impacts CF. However, other research found non-significant CF-PF links after controlling for age, claiming their effects may not be fully distinguishable (<xref ref-type="bibr" rid="ref53">53</xref>). Overall, limited knowledge exists regarding the CF and PF interplay.</p>
</sec>
<sec id="sec9">
<title>The current research</title>
<p>While prior research suggests socioeconomic factors influence health literacy (HL) and health-related quality of life (HRQoL) connections (<xref ref-type="bibr" rid="ref30">30</xref>), most studies predominantly focus on these social factors, rarely considering how declining bodily functions, particularly cognitive function (CF) and physical function (PF), impact this relationship. Functional differences may lead to varying situational demands and complexities. Underestimating functional determinant effects or confusing HL&#x2019;s potential role can cause inappropriate health outcome explanations (<xref ref-type="bibr" rid="ref54">54</xref>). This study tested HL&#x2019;s mediating role between combined CF and PF and HRQoL in older adults in Hong Kong. Clarifying HL&#x2019;s role and revealing its potential effects provides evidence to promote well-being and HRQoL in older adults. Moreover, this research utilized lab observation for rigorous PF data collection from a relatively large sample to support the findings. Results may inform future empirical research and interventions to improve HL and HRQoL among older populations. Health services targeting low PF or CF can be tailored and practical strategies to reduce disparities considered based on this study.</p>
</sec>
<sec id="sec10">
<title>Hypothesis</title>
<p>A theoretical model was developed to examine the synergistic relationship between cognitive function (CF) and physical function (PF), and how they jointly affect health-related quality of life (HRQoL) through the mediator of health literacy (HL). Specifically, the model proposes that CF and PF combine to contribute directly to varying levels of HL. Meanwhile, HL may act as an intermediary between the joint contribution of CF and PF, and eventual HRQoL. In other words, the interaction of CF and PF is hypothesized to firstly impact HL levels, which in turn affects HRQoL. Therefore, the relationship between CF and PF is expected to contribute indirectly to HRQoL, by first influencing HL levels, which then lead to HRQoL. The proposed structural model illustrating these pathways is shown in <xref ref-type="fig" rid="fig1">Figure 1</xref>. The model suggests the following hypotheses:</p>
<fig position="float" id="fig1">
<label>Figure 1</label>
<caption>
<p>General theoretical model relating cognitive function, physical function, health literacy status to health-related quality of life outcomes.</p>
</caption>
<graphic xlink:href="fpubh-12-1355392-g001.tif"/>
</fig>
<disp-quote>
<p><italic>Hypothesis 1:</italic> CF and PF levels combine to directly impact HL.</p>
</disp-quote>
<disp-quote>
<p><italic>Hypothesis 2:</italic> HL mediates the relationship between CF and HRQoL.</p>
</disp-quote>
<disp-quote>
<p><italic>Hypothesis 3:</italic> HL mediates the relationship between PF and HRQoL.</p>
</disp-quote>
<disp-quote>
<p><italic>Hypothesis 4:</italic> Increased HL levels contribute positively to HRQoL.</p>
</disp-quote>
</sec>
</sec>
<sec sec-type="methods" id="sec11">
<title>Methods</title>
<sec id="sec12">
<title>Participants</title>
<p>Chinese adults ages 50&#x2013;80 residing in the community were recruited to participate through social media, posters and flyers. Exclusion criteria aimed to ensure a relatively homogeneous sample appropriate for assessing culture-specific HL correlated with health status (<xref ref-type="bibr" rid="ref55">55</xref>). Subjects were ineligible if they had severe cognitive/hearing impairment, inability to walk independently, lack of Chinese language proficiency, or less than 10&#x2009;years resided in the city. Inclusion criteria were: (1) community-dwelling adults aged 50&#x2013;80&#x2009;years; and (2) ability and consent to participate in a one-hour face-to-face assessment session including health literacy (HL), cognitive function (CF), health-related quality of life (HRQoL) by questionnaires, and physical function (PF) by a series of physical fitness tests. Through direct communication and observation, the research assistant first inquired with potential participants about their language proficiency and hearing ability, then determined whether participants could respond clearly during a normal conversation. After this screening procedure, individuals who met the language and hearing requirements were invited to participate in the study. A total of 500 participants completed questionnaires and physical fitness tests conducted in an indoor laboratory. After data cleaning for missing information, the final sample was comprised of 490 older adults [female: 355 (72%); male: 135 (28%)] and their mean age was 66.04&#x2009;&#x00B1;&#x2009;0.28&#x2009;years old. For this sample, half of the participants (54%) were within 60&#x2013;69&#x2009;years old, while 15 and 31% were of age range in 50&#x2013;59 and 70&#x2013;80, respectively. Strict eligibility criteria ensured recruitment of an appropriate sample to address the study aims of examining correlations between culture-specific health literacy and health indicators among older Chinese adults.</p>
</sec>
<sec id="sec13">
<title>Ethical considerations</title>
<p>All participants were informed of the objectives of the study, the procedure of data collection, and the potential risks of physical tests. Prior to their participation, each participant had signed a written consent. The consent form stated that all data were anonymous, encrypted and stored safely with limited access to the principal investigator only. To ensure privacy and confidentiality, all personal information would not appear publicly in any form. Data and the coded list would be destroyed a year upon completion of the study. This study obtained ethical approval from the Research Committee of the University (Ref. No.: REC/19-20/0162) and was conducted in accordance with the established ethical guidelines.</p>
</sec>
<sec id="sec14">
<title>Procedures</title>
<p>Data collection was conducted between March to July, 2021. Participants signed informed consent before taking the survey. During the survey, participants completed self-reported questionnaires included basic demographics, health literacy (HL), cognitive function (CF), health-related quality of life (HRQoL) measures. Also, they took a battery of physical fitness tests to measure physical function (PF), including muscular strength, endurance, balance, agility and flexibility.</p>
</sec>
<sec id="sec15">
<title>Measurements</title>
<sec id="sec16">
<title>Independent variable</title>
<sec id="sec17">
<title>Cognitive function</title>
<p>CF was assessed by the Montreal Cognitive Assessment (MoCA) (<xref ref-type="bibr" rid="ref56">56</xref>). The MoCA is used widely for testing CF among the older people, the Hong Kong version of MoCA has been validated (Cronbach&#x2019;s &#x03B1;&#x2009;=&#x2009;0.767) (<xref ref-type="bibr" rid="ref57">57</xref>). It consists of 30 test items for assessing six areas of cognitive domains, including short-term memory, visuospatial abilities, executive functioning, phonemic fluency, verbal abstraction, attention, concentration, and working memory, language, repetition of complex sentences, and orientation to time and place. The total score of the MoCA ranges from 0 to 30, with a score of 26 and higher considered as normal and 26 or lower as an indicative of cognitive impairment.</p>
</sec>
<sec id="sec18">
<title>Physical function</title>
<p>PF was assessed by the Senior Fitness Test (SFT) (<xref ref-type="bibr" rid="ref58">58</xref>). It is widely used to evaluate physical function in the older people who are healthy with or without cognitive impairment for both research and clinical purposes. The SFT is a six-item physical fitness battery that includes Chair Stand, Biceps Curl, Chair Sit-and-Reach, Back Scratch, 2.4-m Up-and-Go, and 2-min Step in Place tests. Test scores can be compared to the normative values obtained from a sample of healthy Hong Kong older people (<xref ref-type="bibr" rid="ref59">59</xref>). Scores of the six unweighted subscales will be transformed into percentile scores from 0 to 100 by gender and the average of these scores is the final score of PF.</p>
</sec>
</sec>
<sec id="sec19">
<title>Dependent variable</title>
<sec id="sec20">
<title>Health-related quality of life</title>
<p>HRQoL was assessed using the 12-item Short-Form Health Survey Questionnaire (SF-12v2) (<xref ref-type="bibr" rid="ref60">60</xref>), which is the most widely used generic HRQoL instrument for evaluating functional health and well-being. The SF-12v2 was originally adapted from the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) (<xref ref-type="bibr" rid="ref61">61</xref>) to retain its eight domains: Bodily Pain, General Health, Vitality, Social Functioning (each with one item); and Physical Functioning, Mental Health, Role Physical, and Role Emotional (each with two items). Notably, the &#x201C;Physical Functioning&#x201D; domain asks about perception of limitation in moderate physical activities and stair climbing, to determine the extent to which these activities affect daily life. It differs from the &#x201C;Physical Function (PF)&#x201D; measured by the SFT in the current research because the SFT is a physiological measure involving physical movements, a strict index describing people&#x2019;s muscular performance and bodily abilities. The abbreviated SF-12v2 enables assessment even among those with limited attention spans or mental health problems. Following the procedures used in Lam et al. (<xref ref-type="bibr" rid="ref60">60</xref>), the Physical and Mental summary scale scores are derived first by z score transformation and then summation of the scale scores is transformed into the population mean of 50 and standard deviation of 10. The range of HRQOL total score is from 0 to 100 with out of range scores set to either the high or low limit accordingly. The Chinese version has been validated (Cronbach&#x2019;s &#x03B1;&#x2009;=&#x2009;0.67&#x2013;0.82 for different subscales) (<xref ref-type="bibr" rid="ref60">60</xref>).</p>
</sec>
</sec>
<sec id="sec21">
<title>Mediate variable</title>
<sec id="sec22">
<title>Health literacy</title>
<p>HL was assessed by the 12-item Short-Form (HLS-SF12) of the 47-item European Health Literacy Survey Questionnaire (HLS-EU-Q47) (<xref ref-type="bibr" rid="ref62">62</xref>). The HLS-SF12 is composed of 12 4-point Likert Scale items, which ranged from very difficult to very easy, and it retains the original 12 hypothetical components of comprehensive HL demonstrated in the HLS-EU-Q47. The HL matrix is constructed from four steps of information processing (finding health information, understanding health information, judging health information, and applying health information) interacting with three health domains (health care, disease prevention, and health promotion), which created a total of 12 dimensions or components of HL (<xref ref-type="bibr" rid="ref63">63</xref>). The sum of the scores is the total score of HL. Total score computation follows the procedures used in Duong et al. (<xref ref-type="bibr" rid="ref62">62</xref>), and the current study transformed the score into a 0&#x2013;100 scale instead. The HLS-SF12 has been validated across six Asian countries (<xref ref-type="bibr" rid="ref62">62</xref>) as being valid and reliable (Cronbach&#x2019;s &#x03B1;&#x2009;=&#x2009;0.85).</p>
</sec>
</sec>
</sec>
<sec id="sec23">
<title>Data analysis</title>
<p>This study proposed a theoretical model where cognitive function (CF) and physical function (PF) have a synergistic relationship, which is associated with varying health literacy (HL) status and subsequent impacts on health-related quality of life (HRQoL). The analysis was conducted in three stages. First, descriptive statistics characterized the variables. Next, Pearson correlations examined associations between HL, CF, PF, and HRQoL measures (HLS-SF12, MoCA, SFT and HRQoL), with age adjusted as a covariant. Finally, path analysis tested the overall theoretical model, including relationships among the multiple predictor and outcomes. Path analysis enables simultaneous testing of models with multiple dependent variables, making it well-suited for this study&#x2019;s proposed model. In summary, the descriptive, correlation, and path analyses were conducted sequentially to provide insights into the relationships in the hypothesized model.</p>
<p>Descriptive statistics and bivariate correlations for all variables were calculated using IBM SPSS Statistics version 25.0 (IBM Corp., Armonk, N.Y., United States). Cases with missing data were handled by listwise deletion. Means, standard deviations and further statistical analyses included Pearson correlation were examined.</p>
<p>The proposed theoretical model was tested using structural equation modeling (SEM) software, Mplus 8 (<xref ref-type="bibr" rid="ref64">64</xref>). Path analysis examined how health literacy (HL) status could relate to cognitive function (CF) and physical function (PF) and concurrently act as a mediator between health-related quality of life (HRQoL) and CF and PF. The regression coefficient (&#x03B2;) and standardized regression coefficient (&#x002A;&#x03B2;) showed the effect size of relationships in the model, while &#x002A;&#x03B2; was obtained using z-scores for regression instead of raw scores. With a sample size of 500, there was adequate power for SEM testing (<xref ref-type="bibr" rid="ref65">65</xref>, <xref ref-type="bibr" rid="ref66">66</xref>).</p>
<p>The model was tested using maximum likelihood parameter estimation (MLPE) with listwise deletion of missing cases. Model fit was evaluated using: chi-square goodness-of-fit (&#x03C7;<sup>2</sup>), comparative fit index (GFI), Tucker-Lewis index (TLI), standardized root mean residual (SRMR), and root mean square error of approximation (RMSEA) (<xref ref-type="bibr" rid="ref66">66</xref>). Good fit was defined as: non-significant &#x03C7;<sup>2</sup>; CFI and TLI &#x003E; 0.95, SRMR and RMSEA &#x003C;0.05. Bootstrapping with 5,000 samples was utilized to examine the indirect effects (<xref ref-type="bibr" rid="ref67">67</xref>).</p>
</sec>
</sec>
<sec sec-type="results" id="sec24">
<title>Results</title>
<p>A summary of participants&#x2019; demographic information is presented in <xref ref-type="table" rid="tab1">Table 1</xref>, showing the descriptive statistics for health literacy (HL) (Mean&#x2009;=&#x2009;3.28, SD&#x2009;=&#x2009;0.50), cognitive function (CF) (Mean&#x2009;=&#x2009;26.3, SD&#x2009;=&#x2009;3.28), physical function (PF) (six items&#x2019; Means and SDs, see <xref ref-type="table" rid="tab1">Table 1</xref>), and health-related quality of life (HRQoL) (Mean&#x2009;=&#x2009;3.87, SD&#x2009;=&#x2009;0.61). <xref ref-type="table" rid="tab2">Table 2</xref> shows the partial correlations among variables as controlled by age variation. The results indicated all partial correlations were significant with the exception of the correlation between CF and HRQoL (<italic>r</italic>&#x2009;=&#x2009;0.06, <italic>p</italic>&#x2009;=&#x2009;0.226). However, their relationship was significant if not adjusted by age variance (<italic>r</italic>&#x2009;=&#x2009;0.09, <italic>p</italic>&#x2009;&#x003C;&#x2009;0.05).</p>
<table-wrap position="float" id="tab1">
<label>Table 1</label>
<caption>
<p>Descriptive statistics of whole sample and by gender of health literacy, cognitive, physical functions and health-related quality of life measures.</p>
</caption>
<table frame="hsides" rules="groups">
<thead>
<tr>
<th align="left" valign="top" rowspan="2">Variable</th>
<th align="center" valign="top">Whole sample (<italic>N</italic> =&#x2009;490)</th>
<th align="center" valign="top">Female (<italic>N</italic> =&#x2009;355)</th>
<th align="center" valign="top">Male (<italic>N</italic> =&#x2009;135)</th>
</tr>
<tr>
<th align="center" valign="top">Mean, SD</th>
<th align="center" valign="top">Mean, SD</th>
<th align="center" valign="top">Mean, SD</th>
</tr>
</thead>
<tbody>
<tr>
<td align="left" valign="top">Age</td>
<td align="center" valign="top">66.04, 6.26</td>
<td align="center" valign="top">65.93, 6.32</td>
<td align="center" valign="top">66.38, 6.11</td>
</tr>
<tr>
<td align="left" valign="top">HL</td>
<td align="center" valign="top">3.28, 0.50</td>
<td align="center" valign="top">3.26, 0.52</td>
<td align="center" valign="top">3.31, 0.44</td>
</tr>
<tr>
<td align="left" valign="top">CF</td>
<td align="center" valign="top">26.30, 3.28</td>
<td align="center" valign="top">26.24, 3.36</td>
<td align="center" valign="top">26.47, 3.08</td>
</tr>
<tr>
<td align="left" valign="top">PF (Fit-Chair Stand, counts)</td>
<td align="center" valign="top">15.13, 5.17</td>
<td align="center" valign="top">14.82, 5.01</td>
<td align="center" valign="top">15.94, 5.53</td>
</tr>
<tr>
<td align="left" valign="top">PF (Fit-Arm Curl, counts)</td>
<td align="center" valign="top">16.04, 4.82</td>
<td align="center" valign="top">15.54, 4.48</td>
<td align="center" valign="top">17.33, 5.43</td>
</tr>
<tr>
<td align="left" valign="top">PF (Fit-Step Test, counts)</td>
<td align="center" valign="top">91.55, 19.99</td>
<td align="center" valign="top">89.95, 19.04</td>
<td align="center" valign="top">95.75, 21.81</td>
</tr>
<tr>
<td align="left" valign="top">PF (Fit-Up Go, s)</td>
<td align="center" valign="top">5.00, 1.43</td>
<td align="center" valign="top">5.10, 1.44</td>
<td align="center" valign="top">4.74, 1.38</td>
</tr>
<tr>
<td align="left" valign="top">PF (Fit-Leg Extend, cm)</td>
<td align="center" valign="top">8.22, 12.86</td>
<td align="center" valign="top">10.16, 12.07</td>
<td align="center" valign="top">3.09, 13.52</td>
</tr>
<tr>
<td align="left" valign="top">PF (Fit-Back Scratch, cm)</td>
<td align="center" valign="top">1.41, 7.78</td>
<td align="center" valign="top">2.52, 6.87</td>
<td align="center" valign="top">&#x2212;1.52, 9.18</td>
</tr>
<tr>
<td align="left" valign="top">HRQoL</td>
<td align="center" valign="top">3.87, 0.61</td>
<td align="center" valign="top">3.80, 0.62</td>
<td align="center" valign="top">4.03, 0.53</td>
</tr>
</tbody>
</table>
</table-wrap>
<table-wrap position="float" id="tab2">
<label>Table 2</label>
<caption>
<p>Pearson correlations of all variables controlled by age variation (<italic>N</italic>&#x2009;=&#x2009;490).</p>
</caption>
<table frame="hsides" rules="groups">
<thead>
<tr>
<th/>
<th align="center" valign="top">HL</th>
<th align="center" valign="top">CF</th>
<th align="center" valign="top">PF</th>
<th align="center" valign="top">HRQoL</th>
</tr>
</thead>
<tbody>
<tr>
<td align="left" valign="top" colspan="5">HL</td>
</tr>
<tr>
<td align="left" valign="top">
<italic>r</italic>
</td>
<td align="center" valign="top">1</td>
<td align="center" valign="top">0.13</td>
<td align="center" valign="top">0.19</td>
<td align="center" valign="top">0.42</td>
</tr>
<tr>
<td align="left" valign="top"><italic>p</italic> value</td>
<td align="center" valign="top">&#x2014;<xref ref-type="table-fn" rid="tfn1">
<sup>a</sup></xref></td>
<td align="center" valign="top">0.006</td>
<td align="center" valign="top">&#x003C;0.000</td>
<td align="center" valign="top">&#x003C;0.000</td>
</tr>
<tr>
<td align="left" valign="top" colspan="5">CF</td>
</tr>
<tr>
<td align="left" valign="top">
<italic>r</italic>
</td>
<td align="center" valign="top">&#x2014;</td>
<td align="center" valign="top">1</td>
<td align="center" valign="top">0.28</td>
<td align="center" valign="top">0.06</td>
</tr>
<tr>
<td align="left" valign="top"><italic>p</italic> value</td>
<td align="center" valign="top">&#x2014;</td>
<td align="center" valign="top">&#x2014;<xref ref-type="table-fn" rid="tfn1">
<sup>a</sup></xref></td>
<td align="center" valign="top">&#x003C;0.000</td>
<td align="center" valign="top">0.226</td>
</tr>
<tr>
<td align="left" valign="top" colspan="5">PF</td>
</tr>
<tr>
<td align="left" valign="top">
<italic>r</italic>
</td>
<td align="center" valign="top">&#x2014;</td>
<td align="center" valign="top">&#x2014;</td>
<td align="center" valign="top">1</td>
<td align="center" valign="top">0.3</td>
</tr>
<tr>
<td align="left" valign="top"><italic>p</italic> value</td>
<td align="center" valign="top">&#x2014;</td>
<td align="center" valign="top">&#x2014;</td>
<td align="center" valign="top">&#x2014;<xref ref-type="table-fn" rid="tfn1">
<sup>a</sup></xref></td>
<td align="center" valign="top">&#x003C;0.000</td>
</tr>
<tr>
<td align="left" valign="top" colspan="5">HRQoL</td>
</tr>
<tr>
<td align="left" valign="top">
<italic>r</italic>
</td>
<td align="center" valign="top">&#x2014;</td>
<td align="center" valign="top">&#x2014;</td>
<td align="center" valign="top">&#x2014;</td>
<td align="center" valign="top">1</td>
</tr>
<tr>
<td align="left" valign="top"><italic>p</italic> value</td>
<td align="center" valign="top">&#x2014;</td>
<td align="center" valign="top">&#x2014;</td>
<td align="center" valign="top">&#x2014;</td>
<td align="center" valign="top">&#x2014;<xref ref-type="table-fn" rid="tfn1">
<sup>a</sup></xref></td>
</tr>
</tbody>
</table>
<table-wrap-foot>
<fn id="tfn1">
<label>a</label>
<p>Not available.</p>
</fn>
</table-wrap-foot>
</table-wrap>
<p>To investigate whether health literacy (HL) would mediate the relation between cognitive function (CF) and physical function (PF) towards health-related quality of life (HRQoL), a path model was tested using Mplus Version 8 (<xref ref-type="bibr" rid="ref64">64</xref>). An adequate good-to-fit model was indicated with the fit indices as &#x03C7;<sup>2</sup>&#x2009;=&#x2009;4.759, &#x03C7;<sup>2</sup>/df&#x2009;=&#x2009;2.380 (<italic>p</italic>&#x2009;=&#x2009;0.0926), CFI&#x2009;=&#x2009;0.988, TLI&#x2009;=&#x2009;0.964, RMSEA&#x2009;=&#x2009;0.053, SRMR&#x2009;=&#x2009;0.019. <xref ref-type="fig" rid="fig2">Figure 2</xref> shows the significant direct and indirect effects of the variables involved in the model. Results for direct effects indicated that CF significantly predicted PF, &#x03B2;&#x2009;=&#x2009;0.115, SE&#x2009;=&#x2009;0.012, &#x03B2;&#x002A;&#x2009;=&#x2009;0.385, <italic>p</italic>&#x2009;&#x003C;&#x2009;0.001; PF significantly predicted HL, &#x03B2;&#x2009;=&#x2009;0.101, SE&#x2009;=&#x2009;0.022, &#x03B2;&#x002A;&#x2009;=&#x2009;0.200, <italic>p</italic>&#x2009;&#x003C;&#x2009;0.001; and HL significantly predicted HRQoL, &#x03B2;&#x2009;=&#x2009;0.457, SE&#x2009;=&#x2009;0.049, &#x03B2;&#x002A;&#x2009;=&#x2009;0.373, <italic>p</italic>&#x2009;&#x003C;&#x2009;0.001. Meanwhile, PF significantly predicted HRQoL directly, &#x03B2;&#x2009;=&#x2009;0.156, SE&#x2009;=&#x2009;0.025, &#x03B2;&#x002A;&#x2009;=&#x2009;0.242, <italic>p</italic>&#x2009;&#x003C;&#x2009;0.001. As would be expected from these results, the indirect effect from PF to HRQoL, tested using bootstrapped standard errors, was also significant, &#x03B2;&#x2009;=&#x2009;0.046, 95% CI [0.028, 0.067], &#x03B2;&#x002A;&#x2009;=&#x2009;0.075. These findings partially support the hypothesized mediational model.</p>
<fig position="float" id="fig2">
<label>Figure 2</label>
<caption>
<p>Model testing of direct and indirect effects.</p>
</caption>
<graphic xlink:href="fpubh-12-1355392-g002.tif"/>
</fig>
<p>For the computation of mediating effect, the standardized betas were used. The direct effect of physical function (PF), after taking into account the mediation effect of health literacy (HL), on health-related quality of life (HRQoL) is &#x03B2;1&#x002A;&#x2009;=&#x2009;0.242 and the total effect of PF on HRQoL without the mediation by HL is &#x03B2;0&#x002A;&#x2009;=&#x2009;0.321. Thus the mediating effect of HL is determined by subtracting the direct effect from the total effect, i.e., &#x03B2;0&#x002A; &#x2212; &#x03B2;1&#x002A;&#x2009;=&#x2009;0.079. Therefore, the proportion of mediating effect to the total effect of influence in the model is 0.079/0.321, which is 24.6%.</p>
<p>The results reported above show that health literacy (HL) mediates the relationship between physical function (PF) and health-related quality of life (HRQoL). With these results, it would be interesting to see whether additional independent variables, such as Age, can act as a moderator that could influence the mediating effect between PF and HRQoL. In order to investigate the moderation effect of age on the relationship between PF and HRQoL, an interaction term, i.e., Age&#x002A;PF, was added into the hypothesized model. The results are reported in <xref ref-type="table" rid="tab3">Table 3</xref>. The results show that HL mediates the relationship between PF and HRQoL and Age&#x002A;PF is not significant (&#x03B2; = 0.000, SE&#x2009;=&#x2009;0.001, <italic>p</italic>&#x2009;=&#x2009;0.943). This new analysis is consistent with the findings from the previous results. A comparison of the results suggests that the significance level of all the other variables in the mediation analysis remain largely similar.</p>
<table-wrap position="float" id="tab3">
<label>Table 3</label>
<caption>
<p>Path analysis results for the relationship between the moderator effect of age on the mediating effect of HL.</p>
</caption>
<table frame="hsides" rules="groups">
<thead>
<tr>
<th/>
<th align="center" valign="top" colspan="3">Hypothesized model</th>
<th align="center" valign="top" colspan="3">Age as moderator model</th>
</tr>
<tr>
<th align="left" valign="top">Model parameter</th>
<th align="center" valign="top">&#x03B2;</th>
<th align="center" valign="top">SE</th>
<th align="center" valign="top">&#x03B2;&#x002A;</th>
<th align="center" valign="top">&#x03B2;</th>
<th align="center" valign="top">SE</th>
<th align="center" valign="top">&#x03B2;&#x002A;</th>
</tr>
</thead>
<tbody>
<tr>
<td align="left" valign="top">CF&#x2009;&#x2192;&#x2009;PF</td>
<td align="center" valign="top">0.115</td>
<td align="center" valign="top">0.012</td>
<td align="center" valign="top">0.385 (<italic>p</italic> &#x003C;&#x2009;0.001)</td>
<td align="center" valign="top">0.113</td>
<td align="center" valign="top">0.011</td>
<td align="center" valign="top">0.012 (<italic>p</italic> &#x003C;&#x2009;0.001)</td>
</tr>
<tr>
<td align="left" valign="top">PF&#x2009;&#x2192;&#x2009;HL</td>
<td align="center" valign="top">0.101</td>
<td align="center" valign="top">0.022</td>
<td align="center" valign="top">0.200 (<italic>p</italic> &#x003C;&#x2009;0.001)</td>
<td align="center" valign="top">0.096</td>
<td align="center" valign="top">0.08</td>
<td align="center" valign="top">0.190 (<italic>p</italic> &#x003C;&#x2009;0.001)</td>
</tr>
<tr>
<td align="left" valign="top">PF&#x2009;&#x2192;&#x2009;HRQoL</td>
<td align="center" valign="top">0.156</td>
<td align="center" valign="top">0.025</td>
<td align="center" valign="top">0.242 (<italic>p</italic> &#x003C;&#x2009;0.001)</td>
<td align="center" valign="top">0.156</td>
<td align="center" valign="top">0.026</td>
<td align="center" valign="top">0.251 (<italic>p</italic> &#x003C;&#x2009;0.001)</td>
</tr>
<tr>
<td align="left" valign="top">HL&#x2009;&#x2192;&#x2009;HRQoL</td>
<td align="center" valign="top">0.457</td>
<td align="center" valign="top">0.049</td>
<td align="center" valign="top">0.373 (<italic>p</italic> &#x003C;&#x2009;0.001)</td>
<td align="center" valign="top">0.456</td>
<td align="center" valign="top">0.055</td>
<td align="center" valign="top">0.372 (<italic>p</italic> &#x003C;&#x2009;0.001)</td>
</tr>
<tr>
<td align="left" valign="top">Age&#x002A;PF&#x2009;&#x2192;&#x2009;HL</td>
<td align="center" valign="top">&#x2014;</td>
<td align="center" valign="top">&#x2014;</td>
<td align="center" valign="top">&#x2014;</td>
<td align="center" valign="top">0</td>
<td align="center" valign="top">0.001</td>
<td align="center" valign="top">10.537</td>
</tr>
<tr>
<td align="left" valign="top">Fit index</td>
<td align="center" valign="top" colspan="3">Estimate</td>
<td align="center" valign="top" colspan="3">Estimate</td>
</tr>
<tr>
<td align="left" valign="top">RMSEA</td>
<td align="center" valign="top" colspan="3">0.049</td>
<td align="center" valign="top" colspan="3">0.721</td>
</tr>
<tr>
<td align="left" valign="top">SRMR</td>
<td align="center" valign="top" colspan="3">0.019</td>
<td align="center" valign="top" colspan="3">0.208</td>
</tr>
</tbody>
</table>
<table-wrap-foot>
<p>&#x03B2;, SE, and &#x002A; stands for unstandardized coefficient, standard error of estimate, and standardized coefficient, respectively.</p>
</table-wrap-foot>
</table-wrap>
</sec>
<sec sec-type="discussion" id="sec25">
<title>Discussion</title>
<p>This study explored the relationships among cognitive function (CF), physical function (PF) and health-related quality of life (HRQoL), and determined the mediating effect of health literacy (HL) on the relationships between CF and PF jointly and HRQoL among older adults in Hong Kong. A model was proposed and tested in the current research. Results found CF positively correlated with PF, PF associated significantly with both HL and HRQoL, supporting linkages in the hypothesized model. However, other proposed pathways were not supported -- the relationships between CF and HRQoL, and between CF and HL, were non-significant. Consequently, mediation analysis revealed HL did not mediate the effect of CF on HRQoL. Nevertheless, evidence was found for mediation of the relationship between PF and HRQoL by HL. The findings partially supported the proposed model.</p>
<p>Consistent with prior research, this study found a significant positive correlation between cognitive function (CF) and physical function (PF) among older adults (<xref ref-type="bibr" rid="ref68 ref69 ref70 ref71 ref72 ref73">68&#x2013;73</xref>). In previous research, the association between CF and PF existed not only among older adults with severe functional limitations (<xref ref-type="bibr" rid="ref68">68</xref>, <xref ref-type="bibr" rid="ref69">69</xref>) but also for the well-functioning ones (<xref ref-type="bibr" rid="ref70 ref71 ref72 ref73">70&#x2013;73</xref>). However, the relationship became weaker after adjusting for age. This aligns with evidence suggesting that while associated, CF and PF may not have a direct causal relationship. Rather, aging itself acts as a confounding and unifying factor impacting both CF and PF over time (<xref ref-type="bibr" rid="ref74">74</xref>, <xref ref-type="bibr" rid="ref75">75</xref>). Cross-sectional data limits rigorous exploration of directionality. As such, longitudinal assessment is essential to elucidate multivariate interplay between CF, PF and aging (<xref ref-type="bibr" rid="ref76">76</xref>). Findings reinforce CF and PF as markers of aging, though additional work is needed to substantiate developmental trajectories versus direct causation.</p>
<p>Regarding pathways from cognitive function (CF) and physical function (PF) to health-related quality of life (HRQoL), the proposed relationship between PF and HRQoL was supported, while the link between CF and HRQoL was not. When considering their joint influence, those with higher CF showed greater PF, which in turn associated with more adequate HL. Aligning with some prior evidence (<xref ref-type="bibr" rid="ref77">77</xref>), this positions PF as a predictor of HL, rather than simply the reverse (<xref ref-type="bibr" rid="ref45 ref46 ref47">45&#x2013;47</xref>, <xref ref-type="bibr" rid="ref78 ref79 ref80">78&#x2013;80</xref>). Declining PF over time can reduce HL in older adults, including among those without chronic conditions, expanding on findings in disease groups (<xref ref-type="bibr" rid="ref77">77</xref>, <xref ref-type="bibr" rid="ref80">80</xref>). Thus, PF impact general health knowledge access, not just functional capability. Meanwhile, the lack of direct CF-HRQoL association conflicts with studies in severe cognitive impairment (<xref ref-type="bibr" rid="ref81">81</xref>, <xref ref-type="bibr" rid="ref82">82</xref>). Mild deficits likely do not affect well-being perceptions among otherwise healthy older people (<xref ref-type="bibr" rid="ref83 ref84 ref85">83&#x2013;85</xref>). That is, HRQoL links weakly to cognitive impairment itself, but stronger to resulting disability and handicap (<xref ref-type="bibr" rid="ref85">85</xref>). As such, older adults&#x2019; undefinable cognitive changes may not relate to self-rated health or life satisfaction. Findings clarify CF-HRQoL connections may emerge only at thresholds affecting daily functioning.</p>
<p>As hypothesized, health literacy (HL) directly and positively associated with health-related quality of life (HRQoL) in this study. This result was consistent with prior evidence in Asian (<xref ref-type="bibr" rid="ref4">4</xref>, <xref ref-type="bibr" rid="ref78">78</xref>, <xref ref-type="bibr" rid="ref86">86</xref>, <xref ref-type="bibr" rid="ref87">87</xref>) and non-Asian populations (<xref ref-type="bibr" rid="ref29">29</xref>, <xref ref-type="bibr" rid="ref88">88</xref>, <xref ref-type="bibr" rid="ref89">89</xref>) positioning HL as impacting HRQoL appraisals. As found in Wang et al.&#x2019;s study (<xref ref-type="bibr" rid="ref4">4</xref>), HL moderates chronic disease effects on HRQoL. Conceptually, one&#x2019;s understanding and application of health information would shape subjective wellbeing perceptions and evaluations (<xref ref-type="bibr" rid="ref1">1</xref>, <xref ref-type="bibr" rid="ref28">28</xref>, <xref ref-type="bibr" rid="ref29">29</xref>, <xref ref-type="bibr" rid="ref31">31</xref>, <xref ref-type="bibr" rid="ref88">88</xref>, <xref ref-type="bibr" rid="ref89">89</xref>). Adequate HL enables better healthcare usage, self-management, perceived control, and calibrated expectations &#x2013; all factors feeding into HRQoL judgments. Confirming this relationship provides impetus for future research on explanatory mechanisms between HL and HRQoL. Moving beyond direct links to probe intersecting correlates and cascading effects will provide a deeper understanding of how HL translates into HRQoL outcomes. Findings solidify the need to foster HL across populations as a means to engender perceptions of fulfillment and life quality on both individual and societal levels.</p>
<p>Critically, path analysis supported health literacy (HL) as a partial mediator (24.6% mediation) between the joint contribution of cognitive function (CF) and physical function (PF) and health-related quality of life (HRQoL). Though novel, this finding is in line with emerging evidence of HL indirect effects in related contexts. For example, a study found HL moderates chronic disease influence on HRQoL (<xref ref-type="bibr" rid="ref28">28</xref>), corroborating the present mediating role. Additionally, recent work showed HL protected mental health and boosted quality of life during Covid-19 (<xref ref-type="bibr" rid="ref29">29</xref>), positioning it as an intermediary facilitating factor. While analyzed with different techniques, these studies converge on the conclusion that HL enables translation of health inputs into quality of life outputs. HL mediation has also been shown between socioeconomic status and health (<xref ref-type="bibr" rid="ref30">30</xref>), driving disparities when information utilization is inadequate. Similarly, declining body function creates difficulty that can precipitate inequities without proper health knowledge access. Findings situate HL as a leverage point through with interventions may mitigate functionality impacts on outcomes. As directly improving aging-related decline proves challenging, bolstering intermediary factors like HL may present a fruitful pathway for optimizing healthy lifespan trajectories.</p>
<p>Lastly, the hypothesized mediating effect of health literacy (HL) on the relationship between cognitive function (CF) and health-related quality of life (HRQoL) was not supported. This lacks alignment with some previous scholars who have proposed such a mediating role (<xref ref-type="bibr" rid="ref46">46</xref>, <xref ref-type="bibr" rid="ref90">90</xref>, <xref ref-type="bibr" rid="ref91">91</xref>). However, since no direct association was found between CF and HRQoL in this study, examination of HL as a mediator was rendered moot. Notably, CF is often construed as integral to HL status (<xref ref-type="bibr" rid="ref34">34</xref>, <xref ref-type="bibr" rid="ref43">43</xref>), yet the present findings failed to support this connection as well. Similar null findings have been reported across comparable analyses (<xref ref-type="bibr" rid="ref12">12</xref>, <xref ref-type="bibr" rid="ref92 ref93 ref94 ref95">92&#x2013;95</xref>), which suggest both CF and HL should differentiate between crystallized abilities (stable with age, e.g., vocabulary) versus fluid abilities (decline with age, e.g., puzzle-solving, reasoning). Specifically, only fluid CF and fluid HL may correlate significantly. In this study, HL was operationalized as a crystallized ability via the knowledge-based SF-12 components: healthcare, disease prevention, health promotion. In contrast, the multiple domains assessed by MoCA encompassed aspects of both fluid and crystallized intelligence, yet did not distinctly delineate or quantify these discrete cognitive domains. As such, the MoCA measurement could not fully capture crystallized cognitive abilities., whereas fluid abilities (e.g., attention, memory) are known to vary with hippocampal integrity (<xref ref-type="bibr" rid="ref96 ref97 ref98">96&#x2013;98</xref>). Given the SF-12&#x2019;s emphasis on measuring crystallized health knowledge that is not impacted by age-related brain changes, the hypothesized mediation pathway was likely invalidated. Future studies should implement more specialized cognitive instruments to obtain a more nuanced understanding of participants&#x2019; crystallized and fluid capabilities.</p>
<p>The confirmed model provides new insight into reciprocal pathways between health literacy (HL) and health status. HL predicted health-related quality of life (HRQoL) as expected, but was also impacted by declining functionality. This suggests reframing HL interventions as a two-way street: bolstering HL to improve outcomes, while also supporting retention of knowledge access as health changes. Moreover, the lack of association between cognitive function (CF) and HRQoL points to additional intermediary factors needing exploration to explain this pathway. Uncovering modifiers influencing when age-related cognitive losses translate into well-being perceptions will elucidate populations requiring support. These findings highlight differential effects of CF and physical function (PF) on HRQoL to inform targeted intervention. Promoting HL throughout the aging process may optimize lifelong trajectories by both preventing declines and slowing their downstream effects. Empirical testing of continued iterative impacts between HL and changing health will clarify long-term pathways suggested by the current model. Additionally, factors like education, health status and economic status may also modify the model, with likely universal influence across variables. Research shows these factors&#x2019; links to HL (<xref ref-type="bibr" rid="ref99">99</xref>, <xref ref-type="bibr" rid="ref100">100</xref>), HRQoL (<xref ref-type="bibr" rid="ref101">101</xref>, <xref ref-type="bibr" rid="ref102">102</xref>), CF (<xref ref-type="bibr" rid="ref103">103</xref>, <xref ref-type="bibr" rid="ref104">104</xref>) and PF (<xref ref-type="bibr" rid="ref46">46</xref>, <xref ref-type="bibr" rid="ref105">105</xref>). Further exploring their impacts will allow more comprehensive analysis of the relationships examined. In summary, delineating interactive relationships advances ability to strategically foster resilient trajectories amid intersecting gains and losses. Policy must attend to modifying mechanisms on multiple pathways to facilitate aging with agency and quality of life.</p>
</sec>
<sec id="sec26">
<title>Limitations and future directions</title>
<p>The current study has several limitations. First of all, as a cross-sectional study, this research cannot make a conclusion regarding causality. Additional longitudinal studies are desirable to prospectively identify the predicting effect of cognitive function (CF), physical function (PF) and health literacy (HL). Second, this study was conducted in Hong Kong and the results are only based on the responses among Hong Kong older adults, therefore its application in other groups or areas is required to be further examined. Third, the current study excluded participants with impairment in CF and PF, and those with limited Chinese proficiency, thus the findings may not be applicable to the overall population of older adults. Related studies targeting on this excluded sample are required, for their health demands should be more pressing than the healthy ones. Fourth, most of the research data were collected via self-report approach, which may lead to recall bias, over- or under-reporting, or social desirability, giving in inaccuracy results. Fifth, this study did not account for baseline levels of health status, education background, economic status, and employment history, which may have impacted the variables investigated. Future research could include these potential predictors in the model to further investigate their effects. Lastly, although the current focus of this research is the mediating effect of HL on the relationship of CF and PF jointly and health-related quality of life (HRQoL), there may still be other potential mediators that have not been taken into consideration. The mechanism of HL affecting HRQoL is also essential to be explored. Future research in these areas is warranted.</p>
</sec>
<sec sec-type="conclusions" id="sec27">
<title>Conclusion</title>
<p>The current research identified a mediating role of health literacy (HL) in linking cognitive function (CF) and physical function (PF) to health-related quality of life (HRQoL) among Hong Kong older adults. The findings provided partial support for the proposed model, elucidating HL as an intermediary factor enabling translation of age-related losses into perceptions of well-being and life quality. By fostering continuing health knowledge access, downstream effects of declining functionality may be buffered. However, full mechanisms require additional investigation, particularly surrounding fluid cognitive abilities more susceptible to late-life changes. Parsing multivariate interrelationships and downstream impacts between shifting fluid capabilities, crystallized knowledge, and physical capacity will provide clarification of boundaries around the current model. Findings lay groundwork for precisely delineating how malleable factors like HL may counterbalance aging-induced losses to facilitate maintenance of self-rated health and life quality across the second half of life.</p>
</sec>
<sec sec-type="data-availability" id="sec28">
<title>Data availability statement</title>
<p>The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.</p>
</sec>
<sec sec-type="ethics-statement" id="sec29">
<title>Ethics statement</title>
<p>The studies involving humans were approved by the Research Committee of the University (Ref. No.: REC/19-20/0162). The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.</p>
</sec>
<sec sec-type="author-contributions" id="sec30">
<title>Author contributions</title>
<p>BC: Project administration, Supervision, Writing &#x2013; original draft, Writing &#x2013; review &#x0026; editing, Investigation. JJ: Data curation, Formal analysis, Methodology, Writing &#x2013; review &#x0026; editing, Investigation. TD: Project administration, Supervision, Writing &#x2013; review &#x0026; editing. HH: Project administration, Supervision, Writing &#x2013; review &#x0026; editing, Methodology. TK: Project administration, Supervision, Writing &#x2013; review &#x0026; editing. MN: Methodology, Validation, Writing &#x2013; review &#x0026; editing. HL: Conceptualization, Writing &#x2013; original draft, Writing &#x2013; review &#x0026; editing.</p>
</sec>
</body>
<back>
<sec sec-type="funding-information" id="sec32">
<title>Funding</title>
<p>The author(s) declare financial support was received for the research, authorship, and/or publication of this article. This work was supported by the HKBU Faculty Research Niche Area grant (RC-FNRA-IG/19-20/SOSC/05), the Germany/Hong Kong Joint Research Scheme 2020/2 (G-HKBU202/20) of Research Grants Council, and Jockey Club Mus-Fit for Health Project from Hong Kong Jockey Club Charities Trust (Ref no.: 2021-0401).</p>
</sec>
<ack>
<p>The research team would like to thank the individuals who generously shared their time and experience for the purposes of this project. The authors appreciate Mr Kwai Ming WA, Mr Anthony H. L. Leung, Miss Joanne W. H. Tsang for their valuable contribution.</p>
</ack>
<sec sec-type="COI-statement" id="sec33">
<title>Conflict of interest</title>
<p>The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.</p>
<p>The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision.</p>
</sec>
<sec id="sec100" sec-type="disclaimer">
<title>Publisher&#x2019;s note</title>
<p>All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.</p>
</sec>
<ref-list>
<title>References</title>
<ref id="ref1">
<label>1.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Nutbeam</surname> <given-names>D</given-names></name>
</person-group>. <article-title>Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century</article-title>. <source>Health Promot Int</source>. (<year>2000</year>) <volume>15</volume>:<fpage>259</fpage>&#x2013;<lpage>67</lpage>. doi: <pub-id pub-id-type="doi">10.1093/heapro/15.3.259</pub-id></citation>
</ref>
<ref id="ref2">
<label>2.</label>
<citation citation-type="other"><person-group person-group-type="author"><collab id="coll1">World Health Organization</collab></person-group>. Health promotion: health literacy (<year>2019</year>). Available at: <ext-link xlink:href="https://www.who.int/healthpromotion/health-literacy/en/" ext-link-type="uri">https://www.who.int/healthpromotion/health-literacy/en/</ext-link> (Accessed Feb 27, 2022).</citation>
</ref>
<ref id="ref3">
<label>3.</label>
<citation citation-type="book"><person-group person-group-type="author"><collab id="coll2">World Health Organization</collab></person-group>. <source>Health literacy: the solid facts</source>. <publisher-loc>Copenhagen</publisher-loc>: <publisher-name>WHO</publisher-name> (<year>2013</year>).</citation>
</ref>
<ref id="ref4">
<label>4.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Wang</surname> <given-names>C</given-names></name> <name><surname>Kane</surname> <given-names>RL</given-names></name> <name><surname>Xu</surname> <given-names>D</given-names></name> <name><surname>Meng</surname> <given-names>Q</given-names></name></person-group>. <article-title>Health literacy as a moderator of health-related quality of life responses to chronic disease among Chinese rural women</article-title>. <source>BMC Womens Health</source>. (<year>2015</year>) <volume>15</volume>:<fpage>34</fpage>&#x2013;<lpage>8</lpage>. doi: <pub-id pub-id-type="doi">10.1186/s12905-015-0190-5</pub-id>, PMID: <pub-id pub-id-type="pmid">25887361</pub-id></citation>
</ref>
<ref id="ref5">
<label>5.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Leung</surname> <given-names>AY</given-names></name> <name><surname>Lou</surname> <given-names>VW</given-names></name> <name><surname>Cheung</surname> <given-names>MK</given-names></name> <name><surname>Chan</surname> <given-names>SS</given-names></name> <name><surname>Chi</surname> <given-names>I</given-names></name></person-group>. <article-title>Development and validation of Chinese health literacy scale for diabetes</article-title>. <source>J Clin Nurs</source>. (<year>2013</year>) <volume>22</volume>:<fpage>2090</fpage>&#x2013;<lpage>9</lpage>. doi: <pub-id pub-id-type="doi">10.1111/jocn.12018</pub-id>, PMID: <pub-id pub-id-type="pmid">23186320</pub-id></citation>
</ref>
<ref id="ref6">
<label>6.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Chau</surname> <given-names>PH</given-names></name> <name><surname>Leung</surname> <given-names>AYM</given-names></name> <name><surname>Li</surname> <given-names>HLH</given-names></name> <name><surname>Sea</surname> <given-names>M</given-names></name> <name><surname>Chan</surname> <given-names>R</given-names></name> <name><surname>Woo</surname> <given-names>J</given-names></name></person-group>. <article-title>Development and validation of Chinese health literacy scale for low salt consumption &#x2013; Hong Kong population (CHLSalt-HK)</article-title>. <source>PLoS One</source>. (<year>2015</year>) <volume>10</volume>:<fpage>1</fpage>&#x2013;<lpage>15</lpage>. doi: <pub-id pub-id-type="doi">10.1371/journal.pone.0132303</pub-id>, PMID: <pub-id pub-id-type="pmid">26148008</pub-id></citation>
</ref>
<ref id="ref7">
<label>7.</label>
<citation citation-type="book"><person-group person-group-type="author"><name><surname>Lawton</surname> <given-names>MP</given-names></name>
</person-group>. <article-title>Quality of life and the end of life</article-title> In: <person-group person-group-type="editor"><name><surname>Schaie</surname> <given-names>KW</given-names></name> <name><surname>Willis</surname> <given-names>SL</given-names></name></person-group>, editors. <source>Handbook of the psychology of aging</source>. <edition>5th</edition> ed. <publisher-loc>New York</publisher-loc>: <publisher-name>Academic Press</publisher-name> (<year>2001</year>). <fpage>593</fpage>&#x2013;<lpage>616</lpage>.</citation>
</ref>
<ref id="ref8">
<label>8.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Lim</surname> <given-names>LL</given-names></name> <name><surname>Fisher</surname> <given-names>JD</given-names></name></person-group>. <article-title>Use of the 12-item short-form (SF-12) health survey in an Australian heart and stroke population</article-title>. <source>Qual Life Res</source>. (<year>1999</year>) <volume>8</volume>:<fpage>1</fpage>&#x2013;<lpage>8</lpage>. doi: <pub-id pub-id-type="doi">10.1023/A:1026409226544</pub-id>, PMID: <pub-id pub-id-type="pmid">10457733</pub-id></citation>
</ref>
<ref id="ref9">
<label>9.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Al-Windi</surname> <given-names>A</given-names></name> <name><surname>Elmfeldt</surname> <given-names>D</given-names></name> <name><surname>Tibblin</surname> <given-names>G</given-names></name> <name><surname>Sv&#x00E4;rdsudd</surname> <given-names>K</given-names></name></person-group>. <article-title>The influence of sociodemographic characteristics on well-being and symptoms in a Swedish community: results from a postal questionnaire survey</article-title>. <source>Scand J Prim Health Care</source>. (<year>1999</year>) <volume>17</volume>:<fpage>201</fpage>&#x2013;<lpage>9</lpage>. doi: <pub-id pub-id-type="doi">10.1080/028134399750002412</pub-id></citation>
</ref>
<ref id="ref10">
<label>10.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Kim</surname> <given-names>DJ</given-names></name>
</person-group>. <article-title>Correlation between physical function, cognitive function, and health-related quality of life in elderly persons</article-title>. <source>J Phys Ther Sci</source>. (<year>2016</year>) <volume>28</volume>:<fpage>1844</fpage>&#x2013;<lpage>8</lpage>. doi: <pub-id pub-id-type="doi">10.1589/jpts.28.1844</pub-id>, PMID: <pub-id pub-id-type="pmid">27390430</pub-id></citation>
</ref>
<ref id="ref11">
<label>11.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Chesser</surname> <given-names>AK</given-names></name> <name><surname>Woods</surname> <given-names>NK</given-names></name> <name><surname>Smothers</surname> <given-names>K</given-names></name> <name><surname>Rogers</surname> <given-names>N</given-names></name></person-group>. <article-title>Health literacy and older adults: a systematic review</article-title>. <source>Gerontol Geriatr Med</source>. (<year>2016</year>) <volume>2</volume>:<fpage>1</fpage>&#x2013;<lpage>13</lpage>. doi: <pub-id pub-id-type="doi">10.1177/2333721416630492</pub-id>, PMID: <pub-id pub-id-type="pmid">28138488</pub-id></citation>
</ref>
<ref id="ref12">
<label>12.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Federman</surname> <given-names>AD</given-names></name> <name><surname>Sano</surname> <given-names>M</given-names></name> <name><surname>Wolf</surname> <given-names>MS</given-names></name> <name><surname>Siu</surname> <given-names>AL</given-names></name> <name><surname>Halm</surname> <given-names>EA</given-names></name></person-group>. <article-title>Health literacy and cognitive performance in older adults</article-title>. <source>J Am Geriatr Soc</source>. (<year>2009</year>) <volume>57</volume>:<fpage>1475</fpage>&#x2013;<lpage>80</lpage>. doi: <pub-id pub-id-type="doi">10.1111/j.1532-5415.2009.02347.x</pub-id>, PMID: <pub-id pub-id-type="pmid">19515101</pub-id></citation>
</ref>
<ref id="ref13">
<label>13.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Levinthal</surname> <given-names>BR</given-names></name> <name><surname>Morrow</surname> <given-names>DG</given-names></name> <name><surname>Tu</surname> <given-names>W</given-names></name> <name><surname>Wu</surname> <given-names>J</given-names></name> <name><surname>Murray</surname> <given-names>MD</given-names></name></person-group>. <article-title>Cognition and health literacy in patients with hypertension</article-title>. <source>J Gen Intern Med</source>. (<year>2008</year>) <volume>23</volume>:<fpage>1172</fpage>&#x2013;<lpage>6</lpage>. doi: <pub-id pub-id-type="doi">10.1007/s11606-008-0612-2</pub-id>, PMID: <pub-id pub-id-type="pmid">18459011</pub-id></citation>
</ref>
<ref id="ref14">
<label>14.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Jia</surname> <given-names>J</given-names></name> <name><surname>Zhou</surname> <given-names>A</given-names></name> <name><surname>Wei</surname> <given-names>C</given-names></name> <name><surname>Jia</surname> <given-names>X</given-names></name> <name><surname>Wang</surname> <given-names>F</given-names></name> <name><surname>Li</surname> <given-names>F</given-names></name> <etal/></person-group>. <article-title>The prevalence of mild cognitive impairment and its etiological subtypes in elderly Chinese</article-title>. <source>Alzheimers Dement</source>. (<year>2014</year>) <volume>10</volume>:<fpage>439</fpage>&#x2013;<lpage>47</lpage>. doi: <pub-id pub-id-type="doi">10.1016/j.jalz.2013.09.008</pub-id>, PMID: <pub-id pub-id-type="pmid">24418053</pub-id></citation>
</ref>
<ref id="ref15">
<label>15.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Lara</surname> <given-names>E</given-names></name> <name><surname>Koyanagi</surname> <given-names>A</given-names></name> <name><surname>Olaya</surname> <given-names>B</given-names></name> <name><surname>Lobo</surname> <given-names>A</given-names></name> <name><surname>Miret</surname> <given-names>M</given-names></name> <name><surname>Tyrovolas</surname> <given-names>S</given-names></name> <etal/></person-group>. <article-title>Mild cognitive impairment in a Spanish representative sample: prevalence and associated factors</article-title>. <source>Int J Geriatr Psychiatry</source>. (<year>2016</year>) <volume>31</volume>:<fpage>858</fpage>&#x2013;<lpage>67</lpage>. doi: <pub-id pub-id-type="doi">10.1002/gps.4398</pub-id>, PMID: <pub-id pub-id-type="pmid">26923809</pub-id></citation>
</ref>
<ref id="ref16">
<label>16.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Park</surname> <given-names>MJ</given-names></name>
</person-group>. <article-title>The cognition, balance, and quality of life in the elderly</article-title>. <source>J Korean Biol Nurs Sci</source>. (<year>2011</year>) <volume>13</volume>:<fpage>185</fpage>&#x2013;<lpage>92</lpage>.</citation>
</ref>
<ref id="ref17">
<label>17.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Daimiel</surname> <given-names>L</given-names></name> <name><surname>Mart&#x00ED;nez-Gonz&#x00E1;lez</surname> <given-names>MA</given-names></name> <name><surname>Corella</surname> <given-names>D</given-names></name> <name><surname>Salas-Salvado</surname> <given-names>J</given-names></name> <name><surname>Schr&#x00F6;der</surname> <given-names>H</given-names></name> <name><surname>Vioque</surname> <given-names>J</given-names></name> <etal/></person-group>. <article-title>Physical fitness and physical activity association with cognitive function and quality of life: baseline cross-sectional analysis of the PREDIMED-plus trial</article-title>. <source>Sci Rep</source>. (<year>2020</year>) <volume>10</volume>:<fpage>1</fpage>&#x2013;<lpage>2</lpage>. doi: <pub-id pub-id-type="doi">10.1038/s41598-020-59458-6</pub-id>, PMID: <pub-id pub-id-type="pmid">32103064</pub-id></citation>
</ref>
<ref id="ref18">
<label>18.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Lee</surname> <given-names>SY</given-names></name>
</person-group>. <article-title>Influencing factors of cognitive function and depression in elderly</article-title>. <source>J Korean Acad Soc Home Health Care Nurs</source>. (<year>2012</year>) <volume>19</volume>:<fpage>150</fpage>&#x2013;<lpage>61</lpage>.</citation>
</ref>
<ref id="ref19">
<label>19.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Song</surname> <given-names>D</given-names></name> <name><surname>Doris</surname> <given-names>SF</given-names></name></person-group>. <article-title>Effects of a moderate-intensity aerobic exercise programme on the cognitive function and quality of life of community-dwelling elderly people with mild cognitive impairment: a randomised controlled trial</article-title>. <source>Int J Nurs Stud</source>. (<year>2019</year>) <volume>93</volume>:<fpage>97</fpage>&#x2013;<lpage>105</lpage>. doi: <pub-id pub-id-type="doi">10.1016/j.ijnurstu.2019.02.019</pub-id>, PMID: <pub-id pub-id-type="pmid">30901716</pub-id></citation>
</ref>
<ref id="ref20">
<label>20.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Painter</surname> <given-names>P</given-names></name> <name><surname>Stewart</surname> <given-names>AL</given-names></name> <name><surname>Carey</surname> <given-names>S</given-names></name></person-group>. <article-title>Physical functioning: definitions, measurement, and expectations</article-title>. <source>Adv Ren Replace Ther</source>. (<year>1999</year>) <volume>6</volume>:<fpage>110</fpage>&#x2013;<lpage>23</lpage>. doi: <pub-id pub-id-type="doi">10.1016/S1073-4449(99)70028-2</pub-id></citation>
</ref>
<ref id="ref21">
<label>21.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Sampaio</surname> <given-names>A</given-names></name> <name><surname>Marques-Aleixo</surname> <given-names>I</given-names></name> <name><surname>Seabra</surname> <given-names>A</given-names></name> <name><surname>Mota</surname> <given-names>J</given-names></name> <name><surname>Marques</surname> <given-names>E</given-names></name> <name><surname>Carvalho</surname> <given-names>J</given-names></name></person-group>. <article-title>Physical fitness in institutionalized older adults with dementia: association with cognition, functional capacity and quality of life</article-title>. <source>Aging Clin Exp Res</source>. (<year>2020</year>) <volume>32</volume>:<fpage>2329</fpage>&#x2013;<lpage>38</lpage>. doi: <pub-id pub-id-type="doi">10.1007/s40520-019-01445-7</pub-id>, PMID: <pub-id pub-id-type="pmid">31927709</pub-id></citation>
</ref>
<ref id="ref22">
<label>22.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Bae</surname> <given-names>EJ</given-names></name> <name><surname>Park</surname> <given-names>NJ</given-names></name> <name><surname>Sohn</surname> <given-names>HS</given-names></name> <name><surname>Kim</surname> <given-names>YH</given-names></name></person-group>. <article-title>Handgrip strength and all-cause mortality in middle-aged and older Koreans</article-title>. <source>Int J Environ Res Public Health</source>. (<year>2019</year>) <volume>16</volume>:<fpage>740</fpage>. doi: <pub-id pub-id-type="doi">10.3390/ijerph16050740</pub-id>, PMID: <pub-id pub-id-type="pmid">30823660</pub-id></citation>
</ref>
<ref id="ref23">
<label>23.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>McLeod</surname> <given-names>M</given-names></name> <name><surname>Breen</surname> <given-names>L</given-names></name> <name><surname>Hamilton</surname> <given-names>DL</given-names></name> <name><surname>Philp</surname> <given-names>A</given-names></name></person-group>. <article-title>Live strong and prosper: the importance of skeletal muscle strength for healthy ageing</article-title>. <source>Biogerontology</source>. (<year>2016</year>) <volume>17</volume>:<fpage>497</fpage>&#x2013;<lpage>510</lpage>. doi: <pub-id pub-id-type="doi">10.1007/s10522-015-9631-7</pub-id>, PMID: <pub-id pub-id-type="pmid">26791164</pub-id></citation>
</ref>
<ref id="ref24">
<label>24.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Takata</surname> <given-names>Y</given-names></name> <name><surname>Ansai</surname> <given-names>T</given-names></name> <name><surname>Soh</surname> <given-names>I</given-names></name> <name><surname>Awano</surname> <given-names>S</given-names></name> <name><surname>Yoshitake</surname> <given-names>Y</given-names></name> <name><surname>Kimura</surname> <given-names>Y</given-names></name> <etal/></person-group>. <article-title>Quality of life and physical fitness in an 85-year-old population</article-title>. <source>Arch Gerontol Geriatr</source>. (<year>2010</year>) <volume>50</volume>:<fpage>272</fpage>&#x2013;<lpage>6</lpage>. doi: <pub-id pub-id-type="doi">10.1016/j.archger.2009.04.005</pub-id>, PMID: <pub-id pub-id-type="pmid">19419777</pub-id></citation>
</ref>
<ref id="ref25">
<label>25.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Rhodes</surname> <given-names>RE</given-names></name> <name><surname>Courneya</surname> <given-names>KS</given-names></name></person-group>. <article-title>Investigating multiple components of attitude, subjective norm, and perceived control: an examination of the theory of planned behaviour in the exercise domain</article-title>. <source>Br J Soc Psychol</source>. (<year>2003</year>) <volume>42</volume>:<fpage>129</fpage>&#x2013;<lpage>46</lpage>. doi: <pub-id pub-id-type="doi">10.1348/014466603763276162</pub-id>, PMID: <pub-id pub-id-type="pmid">12713760</pub-id></citation>
</ref>
<ref id="ref26">
<label>26.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Manganello</surname> <given-names>JA</given-names></name>
</person-group>. <article-title>Health literacy and adolescents: a framework and agenda for future research</article-title>. <source>Health Educ Res</source>. (<year>2008</year>) <volume>23</volume>:<fpage>840</fpage>&#x2013;<lpage>7</lpage>. doi: <pub-id pub-id-type="doi">10.1093/her/cym069</pub-id>, PMID: <pub-id pub-id-type="pmid">18024979</pub-id></citation>
</ref>
<ref id="ref27">
<label>27.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Van Der Heide</surname> <given-names>I</given-names></name> <name><surname>Heijmans</surname> <given-names>M</given-names></name> <name><surname>Schuit</surname> <given-names>AJ</given-names></name> <name><surname>Uiters</surname> <given-names>E</given-names></name> <name><surname>Rademakers</surname> <given-names>J</given-names></name></person-group>. <article-title>Functional, interactive and critical health literacy: varying relationships with control over care and number of GP visits</article-title>. <source>Patient Educ Couns</source>. (<year>2015</year>) <volume>98</volume>:<fpage>998</fpage>&#x2013;<lpage>1004</lpage>. doi: <pub-id pub-id-type="doi">10.1016/j.pec.2015.04.006</pub-id>, PMID: <pub-id pub-id-type="pmid">25956070</pub-id></citation>
</ref>
<ref id="ref28">
<label>28.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Tsuchihashi-Makaya</surname> <given-names>M</given-names></name> <name><surname>Matsuoka</surname> <given-names>S</given-names></name> <name><surname>Ishida</surname> <given-names>H</given-names></name> <name><surname>Saka</surname> <given-names>M</given-names></name> <name><surname>Nakatsugawa</surname> <given-names>E</given-names></name></person-group>. <article-title>Perceived control mediates association between health literacy and self-care behavior in heart failure patients</article-title>. <source>Circulation</source>. (<year>2017</year>) <volume>136</volume>:<fpage>A16236</fpage>.</citation>
</ref>
<ref id="ref29">
<label>29.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Nguyen</surname> <given-names>HC</given-names></name> <name><surname>Nguyen</surname> <given-names>MH</given-names></name> <name><surname>Do</surname> <given-names>BN</given-names></name> <name><surname>Tran</surname> <given-names>CQ</given-names></name> <name><surname>Nguyen</surname> <given-names>TT</given-names></name> <name><surname>Pham</surname> <given-names>KM</given-names></name> <etal/></person-group>. <article-title>People with suspected COVID-19 symptoms were more likely depressed and had lower health-related quality of life: the potential benefit of health literacy</article-title>. <source>J Clin Med</source>. (<year>2020</year>) <volume>9</volume>:<fpage>965</fpage>. doi: <pub-id pub-id-type="doi">10.3390/jcm9040965</pub-id>, PMID: <pub-id pub-id-type="pmid">32244415</pub-id></citation>
</ref>
<ref id="ref30">
<label>30.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Nutbeam</surname> <given-names>D</given-names></name> <name><surname>Lloyd</surname> <given-names>JE</given-names></name></person-group>. <article-title>Understanding and responding to health literacy as a social determinant of health</article-title>. <source>Annu Rev Public Health</source>. (<year>2021</year>) <volume>42</volume>:<fpage>159</fpage>&#x2013;<lpage>73</lpage>. doi: <pub-id pub-id-type="doi">10.1146/annurev-publhealth-090419-102529</pub-id></citation>
</ref>
<ref id="ref31">
<label>31.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Paasche-Orlow</surname> <given-names>MK</given-names></name> <name><surname>Wolf</surname> <given-names>MS</given-names></name></person-group>. <article-title>The causal pathways linking health literacy to health outcomes</article-title>. <source>Am J Health Behav</source>. (<year>2007</year>) <volume>31</volume>:<fpage>19</fpage>&#x2013;<lpage>26</lpage>. doi: <pub-id pub-id-type="doi">10.5993/AJHB.31.s1.4</pub-id></citation>
</ref>
<ref id="ref32">
<label>32.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Baker</surname> <given-names>DW</given-names></name>
</person-group>. <article-title>The meaning and the measure of health literacy</article-title>. <source>J Gen Intern Med</source>. (<year>2006</year>) <volume>21</volume>:<fpage>878</fpage>&#x2013;<lpage>83</lpage>. doi: <pub-id pub-id-type="doi">10.1111/j.1525-1497.2006.00540.x</pub-id>, PMID: <pub-id pub-id-type="pmid">16881951</pub-id></citation>
</ref>
<ref id="ref33">
<label>33.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Cavanaugh</surname> <given-names>K</given-names></name> <name><surname>Huizinga</surname> <given-names>MM</given-names></name> <name><surname>Wallston</surname> <given-names>KA</given-names></name> <name><surname>Gebretsadik</surname> <given-names>T</given-names></name> <name><surname>Shintani</surname> <given-names>A</given-names></name> <name><surname>Davis</surname> <given-names>D</given-names></name> <etal/></person-group>. <article-title>Association of numeracy and diabetes control</article-title>. <source>Ann Intern Med</source>. (<year>2008</year>) <volume>148</volume>:<fpage>737</fpage>&#x2013;<lpage>46</lpage>. doi: <pub-id pub-id-type="doi">10.7326/0003-4819-148-10-200805200-00006</pub-id></citation>
</ref>
<ref id="ref34">
<label>34.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Lam</surname> <given-names>MH</given-names></name> <name><surname>Leung</surname> <given-names>AY</given-names></name> <name><surname>Chan</surname> <given-names>SS</given-names></name></person-group>. <article-title>Psychological and cognitive determinants of the health literacy on soon to be aged and older adults: a systematic review</article-title>. <source>I-Manager's J Nursing</source>. (<year>2011</year>) <volume>1</volume>:<fpage>46</fpage>&#x2013;<lpage>56</lpage>. doi: <pub-id pub-id-type="doi">10.26634/jnur.1.2.2214</pub-id></citation>
</ref>
<ref id="ref35">
<label>35.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Berkman</surname> <given-names>ND</given-names></name> <name><surname>Sheridan</surname> <given-names>SL</given-names></name> <name><surname>Donahue</surname> <given-names>KE</given-names></name> <name><surname>Halpern</surname> <given-names>DJ</given-names></name> <name><surname>Crotty</surname> <given-names>K</given-names></name></person-group>. <article-title>Low health literacy and health outcomes: an updated systematic review</article-title>. <source>Ann Intern Med</source>. (<year>2011</year>) <volume>155</volume>:<fpage>97</fpage>&#x2013;<lpage>107</lpage>. doi: <pub-id pub-id-type="doi">10.7326/0003-4819-155-2-201107190-00005</pub-id>, PMID: <pub-id pub-id-type="pmid">21768583</pub-id></citation>
</ref>
<ref id="ref36">
<label>36.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Sudore</surname> <given-names>RL</given-names></name> <name><surname>Yaffe</surname> <given-names>K</given-names></name> <name><surname>Satterfield</surname> <given-names>S</given-names></name> <name><surname>Harris</surname> <given-names>TB</given-names></name> <name><surname>Mehta</surname> <given-names>KM</given-names></name> <name><surname>Simonsick</surname> <given-names>EM</given-names></name> <etal/></person-group>. <article-title>Limited literacy and mortality in the elderly: the health, aging, and body composition study</article-title>. <source>J Gen Intern Med</source>. (<year>2006</year>) <volume>21</volume>:<fpage>806</fpage>&#x2013;<lpage>12</lpage>. doi: <pub-id pub-id-type="doi">10.1111/j.1525-1497.2006.00539.x</pub-id>, PMID: <pub-id pub-id-type="pmid">16881938</pub-id></citation>
</ref>
<ref id="ref37">
<label>37.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Kobayashi</surname> <given-names>LC</given-names></name> <name><surname>Wardle</surname> <given-names>J</given-names></name> <name><surname>Wolf</surname> <given-names>MS</given-names></name> <name><surname>von Wagner</surname> <given-names>C</given-names></name></person-group>. <article-title>Cognitive function and health literacy decline in a cohort of aging English adults</article-title>. <source>J Gen Intern Med</source>. (<year>2015</year>) <volume>30</volume>:<fpage>958</fpage>&#x2013;<lpage>64</lpage>. doi: <pub-id pub-id-type="doi">10.1007/s11606-015-3206-9</pub-id></citation>
</ref>
<ref id="ref38">
<label>38.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Zheng</surname> <given-names>M</given-names></name> <name><surname>Jin</surname> <given-names>H</given-names></name> <name><surname>Shi</surname> <given-names>N</given-names></name> <name><surname>Duan</surname> <given-names>C</given-names></name> <name><surname>Wang</surname> <given-names>D</given-names></name> <name><surname>Yu</surname> <given-names>X</given-names></name> <etal/></person-group>. <article-title>The relationship between health literacy and quality of life: a systematic review and meta-analysis</article-title>. <source>Health Qual Life Outcomes</source>. (<year>2018</year>) <volume>16</volume>:<fpage>201</fpage>. doi: <pub-id pub-id-type="doi">10.1186/s12955-018-1031-7</pub-id>, PMID: <pub-id pub-id-type="pmid">30326903</pub-id></citation>
</ref>
<ref id="ref39">
<label>39.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Tokuda</surname> <given-names>Y</given-names></name> <name><surname>Doba</surname> <given-names>N</given-names></name> <name><surname>Butler</surname> <given-names>JP</given-names></name> <name><surname>Paasche-Orlow</surname> <given-names>MK</given-names></name></person-group>. <article-title>Health literacy and physical and psychological wellbeing in Japanese adults</article-title>. <source>Patient Educ Couns</source>. (<year>2009</year>) <volume>75</volume>:<fpage>411</fpage>&#x2013;<lpage>7</lpage>. doi: <pub-id pub-id-type="doi">10.1016/j.pec.2009.03.031</pub-id>, PMID: <pub-id pub-id-type="pmid">19403259</pub-id></citation>
</ref>
<ref id="ref40">
<label>40.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Wang</surname> <given-names>C</given-names></name> <name><surname>Li</surname> <given-names>H</given-names></name> <name><surname>Li</surname> <given-names>L</given-names></name> <name><surname>Xu</surname> <given-names>D</given-names></name> <name><surname>Kane</surname> <given-names>RL</given-names></name> <name><surname>Meng</surname> <given-names>Q</given-names></name></person-group>. <article-title>Health literacy and ethnic disparities in health-related quality of life among rural women: results from a Chinese poor minority area</article-title>. <source>Health Qual Life Outcomes</source>. (<year>2013</year>) <volume>11</volume>:<fpage>1</fpage>&#x2013;<lpage>9</lpage>. doi: <pub-id pub-id-type="doi">10.1186/1477-7525-11-153</pub-id>, PMID: <pub-id pub-id-type="pmid">24020618</pub-id></citation>
</ref>
<ref id="ref41">
<label>41.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Panagioti</surname> <given-names>M</given-names></name> <name><surname>Skevington</surname> <given-names>SM</given-names></name> <name><surname>Hann</surname> <given-names>M</given-names></name> <name><surname>Howells</surname> <given-names>K</given-names></name> <name><surname>Blakemore</surname> <given-names>A</given-names></name> <name><surname>Reeves</surname> <given-names>D</given-names></name> <etal/></person-group>. <article-title>Effect of health literacy on the quality of life of older patients with long-term conditions: a large cohort study in UK general practice</article-title>. <source>Qual Life Res</source>. (<year>2018</year>) <volume>27</volume>:<fpage>1257</fpage>&#x2013;<lpage>68</lpage>. doi: <pub-id pub-id-type="doi">10.1007/s11136-017-1775-2</pub-id>, PMID: <pub-id pub-id-type="pmid">29322478</pub-id></citation>
</ref>
<ref id="ref42">
<label>42.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Couture</surname> <given-names>&#x00C9;M</given-names></name> <name><surname>Chouinard</surname> <given-names>MC</given-names></name> <name><surname>Fortin</surname> <given-names>M</given-names></name> <name><surname>Hudon</surname> <given-names>C</given-names></name></person-group>. <article-title>The relationship between health literacy and quality of life among frequent users of health care services: a cross-sectional study</article-title>. <source>Health Qual Life Outcomes</source>. (<year>2017</year>) <volume>15</volume>:<fpage>137</fpage>&#x2013;<lpage>6</lpage>. doi: <pub-id pub-id-type="doi">10.1186/s12955-017-0716-7</pub-id>, PMID: <pub-id pub-id-type="pmid">28683743</pub-id></citation>
</ref>
<ref id="ref43">
<label>43.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Baker</surname> <given-names>DW</given-names></name> <name><surname>Wolf</surname> <given-names>MS</given-names></name> <name><surname>Feinglass</surname> <given-names>J</given-names></name> <name><surname>Thompson</surname> <given-names>JA</given-names></name></person-group>. <article-title>Health literacy, cognitive abilities, and mortality among elderly persons</article-title>. <source>J Gen Intern Med</source>. (<year>2008</year>) <volume>23</volume>:<fpage>723</fpage>&#x2013;<lpage>6</lpage>. doi: <pub-id pub-id-type="doi">10.1007/s11606-008-0566-4</pub-id>, PMID: <pub-id pub-id-type="pmid">18330654</pub-id></citation>
</ref>
<ref id="ref44">
<label>44.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Speros</surname> <given-names>CI</given-names></name>
</person-group>. <article-title>More than words: promoting health literacy in older adults</article-title>. <source>Online J Issues Nurs</source>. (<year>2009</year>) <volume>14</volume>:<fpage>5</fpage>. doi: <pub-id pub-id-type="doi">10.3912/OJIN.Vol14No03Man05</pub-id></citation>
</ref>
<ref id="ref45">
<label>45.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Smith</surname> <given-names>SG</given-names></name> <name><surname>O'Conor</surname> <given-names>R</given-names></name> <name><surname>Curtis</surname> <given-names>LM</given-names></name> <name><surname>Waite</surname> <given-names>K</given-names></name> <name><surname>Deary</surname> <given-names>IJ</given-names></name> <name><surname>Paasche-Orlow</surname> <given-names>M</given-names></name> <etal/></person-group>. <article-title>Low health literacy predicts decline in physical function among older adults: findings from the lit cog cohort study</article-title>. <source>J Epidemiol Community Health</source>. (<year>2015</year>) <volume>69</volume>:<fpage>474</fpage>&#x2013;<lpage>80</lpage>. doi: <pub-id pub-id-type="doi">10.1136/jech-2014-204915</pub-id>, PMID: <pub-id pub-id-type="pmid">25573701</pub-id></citation>
</ref>
<ref id="ref46">
<label>46.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Serper</surname> <given-names>M</given-names></name> <name><surname>Patzer</surname> <given-names>RE</given-names></name> <name><surname>Curtis</surname> <given-names>LM</given-names></name> <name><surname>Smith</surname> <given-names>SG</given-names></name> <name><surname>O'Conor</surname> <given-names>R</given-names></name> <name><surname>Baker</surname> <given-names>DW</given-names></name> <etal/></person-group>. <article-title>Health literacy, cognitive ability, and functional health status among older adults</article-title>. <source>Health Serv Res</source>. (<year>2014</year>) <volume>49</volume>:<fpage>1249</fpage>&#x2013;<lpage>67</lpage>. doi: <pub-id pub-id-type="doi">10.1111/1475-6773.12154</pub-id>, PMID: <pub-id pub-id-type="pmid">24476068</pub-id></citation>
</ref>
<ref id="ref47">
<label>47.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Wolf</surname> <given-names>MS</given-names></name> <name><surname>Gazmararian</surname> <given-names>JA</given-names></name> <name><surname>Baker</surname> <given-names>DW</given-names></name></person-group>. <article-title>Health literacy and functional health status among older adults</article-title>. <source>Arch Intern Med</source>. (<year>2005</year>) <volume>165</volume>:<fpage>1946</fpage>&#x2013;<lpage>52</lpage>. doi: <pub-id pub-id-type="doi">10.1001/archinte.165.17.1946</pub-id></citation>
</ref>
<ref id="ref48">
<label>48.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Garcia-Pinillos</surname> <given-names>F</given-names></name> <name><surname>Cozar-Barba</surname> <given-names>M</given-names></name> <name><surname>Munoz-Jimenez</surname> <given-names>M</given-names></name> <name><surname>Soto-Hermoso</surname> <given-names>V</given-names></name> <name><surname>Latorre-Roman</surname> <given-names>P</given-names></name></person-group>. <article-title>Gait speed in older people: an easy test for detecting cognitive impairment, functional independence, and health state</article-title>. <source>Psychogeriatrics</source>. (<year>2016</year>) <volume>16</volume>:<fpage>165</fpage>&#x2013;<lpage>71</lpage>. doi: <pub-id pub-id-type="doi">10.1111/psyg.12133</pub-id>, PMID: <pub-id pub-id-type="pmid">26114989</pub-id></citation>
</ref>
<ref id="ref49">
<label>49.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Vaz-Patto</surname> <given-names>M</given-names></name> <name><surname>Bueno</surname> <given-names>B</given-names></name> <name><surname>Ribeiro</surname> <given-names>&#x00D3;</given-names></name> <name><surname>Teixeira</surname> <given-names>L</given-names></name> <name><surname>Afonso</surname> <given-names>RM</given-names></name></person-group>. <article-title>Association between handgrip strength, walking, age-related illnesses and cognitive status in a sample of Portuguese centenarians</article-title>. <source>Eur Rev Aging Phys Act</source>. (<year>2017</year>) <volume>14</volume>:<fpage>9</fpage>&#x2013;<lpage>7</lpage>. doi: <pub-id pub-id-type="doi">10.1186/s11556-017-0178-2</pub-id>, PMID: <pub-id pub-id-type="pmid">28680504</pub-id></citation>
</ref>
<ref id="ref50">
<label>50.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Baillieux</surname> <given-names>H</given-names></name> <name><surname>De Smet</surname> <given-names>HJ</given-names></name> <name><surname>Paquier</surname> <given-names>PF</given-names></name> <name><surname>De Deyn</surname> <given-names>PP</given-names></name> <name><surname>Mari&#x00EB;n</surname> <given-names>P</given-names></name></person-group>. <article-title>Cerebellar neurocognition: insights into the bottom of the brain</article-title>. <source>Clin Neurol Neurosurg</source>. (<year>2008</year>) <volume>110</volume>:<fpage>763</fpage>&#x2013;<lpage>73</lpage>. doi: <pub-id pub-id-type="doi">10.1016/j.clineuro.2008.05.013</pub-id>, PMID: <pub-id pub-id-type="pmid">18602745</pub-id></citation>
</ref>
<ref id="ref51">
<label>51.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Hariprasad</surname> <given-names>VR</given-names></name> <name><surname>Koparde</surname> <given-names>V</given-names></name> <name><surname>Sivakumar</surname> <given-names>PT</given-names></name> <name><surname>Varambally</surname> <given-names>S</given-names></name> <name><surname>Thirthalli</surname> <given-names>J</given-names></name> <name><surname>Varghese</surname> <given-names>M</given-names></name> <etal/></person-group>. <article-title>Randomized clinical trial of yoga-based intervention in residents from elderly homes: effects on cognitive function</article-title>. <source>Indian J Psychiatry</source>. (<year>2013</year>) <volume>55</volume>:<fpage>S357</fpage>&#x2013;<lpage>63</lpage>. doi: <pub-id pub-id-type="doi">10.4103/0019-5545.116308</pub-id>, PMID: <pub-id pub-id-type="pmid">24049199</pub-id></citation>
</ref>
<ref id="ref52">
<label>52.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Liu</surname> <given-names>F</given-names></name> <name><surname>Chen</surname> <given-names>X</given-names></name> <name><surname>Nie</surname> <given-names>P</given-names></name> <name><surname>Lin</surname> <given-names>S</given-names></name> <name><surname>Guo</surname> <given-names>J</given-names></name> <name><surname>Chen</surname> <given-names>J</given-names></name> <etal/></person-group>. <article-title>Can tai chi improve cognitive function? A systematic review and meta-analysis of randomized controlled trials</article-title>. <source>J Altern Complement Med</source>. (<year>2021</year>) <volume>27</volume>:<fpage>1070</fpage>&#x2013;<lpage>83</lpage>. doi: <pub-id pub-id-type="doi">10.1089/acm.2021.0084</pub-id>, PMID: <pub-id pub-id-type="pmid">34314596</pub-id></citation>
</ref>
<ref id="ref53">
<label>53.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Clouston</surname> <given-names>SA</given-names></name> <name><surname>Brewster</surname> <given-names>P</given-names></name> <name><surname>Kuh</surname> <given-names>D</given-names></name> <name><surname>Richards</surname> <given-names>M</given-names></name> <name><surname>Cooper</surname> <given-names>R</given-names></name> <name><surname>Hardy</surname> <given-names>R</given-names></name> <etal/></person-group>. <article-title>The dynamic relationship between physical function and cognition in longitudinal aging cohorts</article-title>. <source>Epidemiol Rev</source>. (<year>2013</year>) <volume>35</volume>:<fpage>33</fpage>&#x2013;<lpage>50</lpage>. doi: <pub-id pub-id-type="doi">10.1093/epirev/mxs004</pub-id>, PMID: <pub-id pub-id-type="pmid">23349427</pub-id></citation>
</ref>
<ref id="ref54">
<label>54.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Dardas</surname> <given-names>LA</given-names></name> <name><surname>Ahmad</surname> <given-names>MM</given-names></name></person-group>. <article-title>Coping strategies as mediators and moderators between stress and quality of life among parents of children with autistic disorder</article-title>. <source>Stress Health</source>. (<year>2015</year>) <volume>31</volume>:<fpage>5</fpage>&#x2013;<lpage>12</lpage>. doi: <pub-id pub-id-type="doi">10.1002/smi.2513</pub-id>, PMID: <pub-id pub-id-type="pmid">23868562</pub-id></citation>
</ref>
<ref id="ref55">
<label>55.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Fi&#x015F;ek</surname> <given-names>MH</given-names></name> <name><surname>Berger</surname> <given-names>J</given-names></name> <name><surname>Norman</surname> <given-names>RZ</given-names></name></person-group>. <article-title>Participation in heterogeneous and homogeneous groups: a theoretical integration</article-title>. <source>Am J Sociol</source>. (<year>1991</year>) <volume>97</volume>:<fpage>114</fpage>&#x2013;<lpage>42</lpage>. doi: <pub-id pub-id-type="doi">10.1086/229742</pub-id></citation>
</ref>
<ref id="ref56">
<label>56.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Nasreddine</surname> <given-names>ZS</given-names></name> <name><surname>Phillips</surname> <given-names>NA</given-names></name> <name><surname>B&#x00E9;dirian</surname> <given-names>V</given-names></name> <name><surname>Charbonneau</surname> <given-names>S</given-names></name> <name><surname>Whitehead</surname> <given-names>V</given-names></name> <name><surname>Collin</surname> <given-names>I</given-names></name> <etal/></person-group>. <article-title>The Montreal cognitive assessment, MoCA: a brief screening tool for mild cognitive impairment</article-title>. <source>J Am Geriatr Soc</source>. (<year>2005</year>) <volume>53</volume>:<fpage>695</fpage>&#x2013;<lpage>9</lpage>. doi: <pub-id pub-id-type="doi">10.1111/j.1532-5415.2005.53221.x</pub-id>, PMID: <pub-id pub-id-type="pmid">15817019</pub-id></citation>
</ref>
<ref id="ref57">
<label>57.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Yeung</surname> <given-names>PY</given-names></name> <name><surname>Wong</surname> <given-names>LL</given-names></name> <name><surname>Chan</surname> <given-names>CC</given-names></name> <name><surname>Leung</surname> <given-names>JLM</given-names></name> <name><surname>Yung</surname> <given-names>CY</given-names></name></person-group>. <article-title>A validation study of the Hong Kong version of Montreal cognitive assessment (HK-MoCA) in Chinese older adults in Hong Kong</article-title>. <source>Hong Kong Med J</source>. (<year>2014</year>) <volume>20</volume>:<fpage>504</fpage>&#x2013;<lpage>10</lpage>. doi: <pub-id pub-id-type="doi">10.12809/hkmj144219</pub-id>, PMID: <pub-id pub-id-type="pmid">25125421</pub-id></citation>
</ref>
<ref id="ref58">
<label>58.</label>
<citation citation-type="book"><person-group person-group-type="author"><name><surname>Rikli</surname> <given-names>RE</given-names></name> <name><surname>Jones</surname> <given-names>CJ</given-names></name></person-group>. <source>Senior fitness test manual</source>. <publisher-loc>Champaign, IL</publisher-loc>: <publisher-name>Human Kinetics</publisher-name> (<year>2001</year>).</citation>
</ref>
<ref id="ref59">
<label>59.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Chung</surname> <given-names>PK</given-names></name> <name><surname>Zhao</surname> <given-names>Y</given-names></name> <name><surname>Liu</surname> <given-names>JD</given-names></name> <name><surname>Quach</surname> <given-names>B</given-names></name></person-group>. <article-title>Functional fitness norms for community-dwelling older adults in Hong Kong</article-title>. <source>Arch Gerontol Geriatr</source>. (<year>2016</year>) <volume>65</volume>:<fpage>54</fpage>&#x2013;<lpage>62</lpage>. doi: <pub-id pub-id-type="doi">10.1016/j.archger.2016.03.006</pub-id>, PMID: <pub-id pub-id-type="pmid">26987081</pub-id></citation>
</ref>
<ref id="ref60">
<label>60.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Lam</surname> <given-names>ET</given-names></name> <name><surname>Lam</surname> <given-names>CL</given-names></name> <name><surname>Fong</surname> <given-names>DY</given-names></name> <name><surname>Huang</surname> <given-names>WW</given-names></name></person-group>. <article-title>Is the SF-12 version 2 health survey a valid and equivalent substitute for the SF-36 version 2 health survey for the Chinese?</article-title> <source>J Eval Clin Pract</source>. (<year>2013</year>) <volume>19</volume>:<fpage>200</fpage>&#x2013;<lpage>8</lpage>. doi: <pub-id pub-id-type="doi">10.1111/j.1365-2753.2011.01800.x</pub-id>, PMID: <pub-id pub-id-type="pmid">22128754</pub-id></citation>
</ref>
<ref id="ref61">
<label>61.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Ware</surname> <given-names>JE</given-names> <suffix>Jr</suffix></name> <name><surname>Sherbourne</surname> <given-names>CD</given-names></name></person-group>. <article-title>The MOS 36-item short-form health survey (SF-36): I. Conceptual framework and item selection</article-title>. <source>Med Care</source>. (<year>1992</year>) <volume>30</volume>:<fpage>473</fpage>&#x2013;<lpage>83</lpage>. doi: <pub-id pub-id-type="doi">10.1097/00005650-199206000-00002</pub-id>, PMID: <pub-id pub-id-type="pmid">1593914</pub-id></citation>
</ref>
<ref id="ref62">
<label>62.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Duong</surname> <given-names>TV</given-names></name> <name><surname>Aringazina</surname> <given-names>A</given-names></name> <name><surname>Kayupova</surname> <given-names>G</given-names></name> <name><surname>Nurjanah</surname> <given-names>F</given-names></name> <name><surname>Pham</surname> <given-names>TV</given-names></name> <name><surname>Pham</surname> <given-names>KM</given-names></name> <etal/></person-group>. <article-title>Development and validation of a new short-form health literacy instrument (HLS-SF12) for the general public in six Asian countries</article-title>. <source>Health Lit Res Pract</source>. (<year>2019</year>) <volume>3</volume>:<fpage>e91</fpage>&#x2013;<lpage>e102</lpage>. doi: <pub-id pub-id-type="doi">10.3928/24748307-20190225-01</pub-id>, PMID: <pub-id pub-id-type="pmid">31294310</pub-id></citation>
</ref>
<ref id="ref63">
<label>63.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>S&#x00F8;rensen</surname> <given-names>K</given-names></name> <name><surname>Van den Broucke</surname> <given-names>S</given-names></name> <name><surname>Pelikan</surname> <given-names>JM</given-names></name> <name><surname>Fullam</surname> <given-names>J</given-names></name> <name><surname>Doyle</surname> <given-names>G</given-names></name> <name><surname>Slonska</surname> <given-names>Z</given-names></name> <etal/></person-group>. <article-title>Measuring health literacy in populations: illuminating the design and development process of the European health literacy survey questionnaire (HLS-EU-Q)</article-title>. <source>BMC Public Health</source>. (<year>2013</year>) <volume>13</volume>:<fpage>1</fpage>. doi: <pub-id pub-id-type="doi">10.1186/1471-2458-13-948</pub-id>, PMID: <pub-id pub-id-type="pmid">24112855</pub-id></citation>
</ref>
<ref id="ref64">
<label>64.</label>
<citation citation-type="book"><person-group person-group-type="author"><name><surname>Muth&#x00E9;n</surname> <given-names>BO</given-names></name> <name><surname>Muth&#x00E9;n</surname> <given-names>LK</given-names></name> <name><surname>Asparouhov</surname> <given-names>T</given-names></name></person-group>. <source>Regression and mediation analysis using Mplus</source>. <publisher-loc>Los Angeles, CA</publisher-loc>: <publisher-name>Muth&#x00E9;n &#x0026; Muth&#x00E9;n</publisher-name> (<year>2017</year>).</citation>
</ref>
<ref id="ref65">
<label>65.</label>
<citation citation-type="book"><person-group person-group-type="author"><name><surname>Loehlin</surname> <given-names>JC</given-names></name>
</person-group>. <source>Latent variables models</source>. <edition>4th</edition> ed. <publisher-loc>Hillsdale, NJ</publisher-loc>: <publisher-name>The Guilford Press</publisher-name> (<year>2004</year>).</citation>
</ref>
<ref id="ref66">
<label>66.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Hooper</surname> <given-names>D</given-names></name> <name><surname>Coughlan</surname> <given-names>J</given-names></name> <name><surname>Mullen</surname> <given-names>MR</given-names></name></person-group>. <article-title>Structural equation modeling: guidelines for determining model fit</article-title>. <source>J Bus Res Methods</source>. (<year>2007</year>) <volume>6</volume>:<fpage>53</fpage>&#x2013;<lpage>9</lpage>.</citation>
</ref>
<ref id="ref67">
<label>67.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Preacher</surname> <given-names>KJ</given-names></name> <name><surname>Hayes</surname> <given-names>AF</given-names></name></person-group>. <article-title>Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models</article-title>. <source>Behav Res Methods</source>. (<year>2008</year>) <volume>40</volume>:<fpage>879</fpage>&#x2013;<lpage>91</lpage>. doi: <pub-id pub-id-type="doi">10.3758/BRM.40.3.879</pub-id>, PMID: <pub-id pub-id-type="pmid">18697684</pub-id></citation>
</ref>
<ref id="ref68">
<label>68.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Bossers</surname> <given-names>WJ</given-names></name> <name><surname>Scherder</surname> <given-names>EJ</given-names></name> <name><surname>Boersma</surname> <given-names>F</given-names></name> <name><surname>Hortobagyi</surname> <given-names>T</given-names></name> <name><surname>van der Woude</surname> <given-names>LH</given-names></name> <name><surname>van Heuvelen</surname> <given-names>MJ</given-names></name></person-group>. <article-title>Feasibility of a combined aerobic and strength training program and its effects on cognitive and physical function in institutionalized dementia patients. A pilot study</article-title>. <source>PLoS One</source>. (<year>2014</year>) <volume>9</volume>:<fpage>e97577</fpage>. doi: <pub-id pub-id-type="doi">10.1371/journal.pone.0097577</pub-id>, PMID: <pub-id pub-id-type="pmid">24844772</pub-id></citation>
</ref>
<ref id="ref69">
<label>69.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Yoon</surname> <given-names>JA</given-names></name> <name><surname>Kong</surname> <given-names>IJ</given-names></name> <name><surname>Choi</surname> <given-names>J</given-names></name> <name><surname>Baek</surname> <given-names>JY</given-names></name> <name><surname>Kim</surname> <given-names>EJ</given-names></name> <name><surname>Shin</surname> <given-names>YI</given-names></name> <etal/></person-group>. <article-title>Neural compensatory response during complex cognitive function tasks in mild cognitive impairment: a near-infrared spectroscopy study</article-title>. <source>Neural Plast</source>. (<year>2019</year>) <volume>2019</volume>:<fpage>1</fpage>&#x2013;<lpage>8</lpage>. doi: <pub-id pub-id-type="doi">10.1155/2019/7845104</pub-id>, PMID: <pub-id pub-id-type="pmid">31320893</pub-id></citation>
</ref>
<ref id="ref70">
<label>70.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Angevaren</surname> <given-names>M</given-names></name> <name><surname>Aufdemkampe</surname> <given-names>G</given-names></name> <name><surname>Verhaar</surname> <given-names>HJ</given-names></name> <name><surname>Aleman</surname> <given-names>A</given-names></name> <name><surname>Vanhees</surname> <given-names>L</given-names></name></person-group>. <article-title>Physical activity and enhanced fitness to improve cognitive function in older people without known cognitive impairment</article-title>. <source>Cochrane Database Syst Rev</source>. (<year>2008</year>) <volume>2</volume>:<fpage>CD005381</fpage>. doi: <pub-id pub-id-type="doi">10.1002/14651858.CD005381.pub2</pub-id>, PMID: <pub-id pub-id-type="pmid">18425918</pub-id></citation>
</ref>
<ref id="ref71">
<label>71.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Rosano</surname> <given-names>C</given-names></name> <name><surname>Simonsick</surname> <given-names>EM</given-names></name> <name><surname>Harris</surname> <given-names>TB</given-names></name> <name><surname>Kritchevsky</surname> <given-names>SB</given-names></name> <name><surname>Brach</surname> <given-names>J</given-names></name> <name><surname>Visser</surname> <given-names>M</given-names></name> <etal/></person-group>. <article-title>Association between physical and cognitive function in healthy elderly: the health, aging and body composition study</article-title>. <source>Neuroepidemiology</source>. (<year>2005</year>) <volume>24</volume>:<fpage>8</fpage>&#x2013;<lpage>14</lpage>. doi: <pub-id pub-id-type="doi">10.1159/000081043</pub-id></citation>
</ref>
<ref id="ref72">
<label>72.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Mielke</surname> <given-names>MM</given-names></name> <name><surname>Wiste</surname> <given-names>HJ</given-names></name> <name><surname>Weigand</surname> <given-names>SD</given-names></name> <name><surname>Knopman</surname> <given-names>DS</given-names></name> <name><surname>Lowe</surname> <given-names>VJ</given-names></name> <name><surname>Roberts</surname> <given-names>RO</given-names></name> <etal/></person-group>. <article-title>Indicators of amyloid burden in a population-based study of cognitively normal elderly</article-title>. <source>Neurology</source>. (<year>2012</year>) <volume>79</volume>:<fpage>1570</fpage>&#x2013;<lpage>7</lpage>. doi: <pub-id pub-id-type="doi">10.1212/WNL.0b013e31826e2696</pub-id>, PMID: <pub-id pub-id-type="pmid">22972644</pub-id></citation>
</ref>
<ref id="ref73">
<label>73.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Best</surname> <given-names>EA</given-names></name> <name><surname>Juarez-Colunga</surname> <given-names>E</given-names></name> <name><surname>James</surname> <given-names>K</given-names></name> <name><surname>LeBlanc</surname> <given-names>WG</given-names></name> <name><surname>Serdar</surname> <given-names>B</given-names></name></person-group>. <article-title>Biomarkers of exposure to polycyclic aromatic hydrocarbons and cognitive function among elderly in the United States (National Health and nutrition examination survey: 2001&#x2013;2002)</article-title>. <source>PLoS One</source>. (<year>2016</year>) <volume>11</volume>:<fpage>e0147632</fpage>. doi: <pub-id pub-id-type="doi">10.1371/journal.pone.0147632</pub-id>, PMID: <pub-id pub-id-type="pmid">26849365</pub-id></citation>
</ref>
<ref id="ref74">
<label>74.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Christensen</surname> <given-names>H</given-names></name> <name><surname>Mackinnon</surname> <given-names>AJ</given-names></name> <name><surname>Korten</surname> <given-names>A</given-names></name> <name><surname>Jorm</surname> <given-names>AF</given-names></name></person-group>. <article-title>The" common cause hypothesis" of cognitive aging: evidence for not only a common factor but also specific associations of age with vision and grip strength in a cross-sectional analysis</article-title>. <source>Psychol Aging</source>. (<year>2001</year>) <volume>16</volume>:<fpage>588</fpage>&#x2013;<lpage>99</lpage>. doi: <pub-id pub-id-type="doi">10.1037/0882-7974.16.4.588</pub-id>, PMID: <pub-id pub-id-type="pmid">11766914</pub-id></citation>
</ref>
<ref id="ref75">
<label>75.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Ikegami</surname> <given-names>S</given-names></name> <name><surname>Takahashi</surname> <given-names>J</given-names></name> <name><surname>Uehara</surname> <given-names>M</given-names></name> <name><surname>Tokida</surname> <given-names>R</given-names></name> <name><surname>Nishimura</surname> <given-names>H</given-names></name> <name><surname>Sakai</surname> <given-names>A</given-names></name> <etal/></person-group>. <article-title>Physical performance reflects cognitive function, fall risk, and quality of life in community-dwelling older people</article-title>. <source>Sci Rep</source>. (<year>2019</year>) <volume>9</volume>:<fpage>12242</fpage>. doi: <pub-id pub-id-type="doi">10.1038/s41598-019-48793-y</pub-id>, PMID: <pub-id pub-id-type="pmid">31439872</pub-id></citation>
</ref>
<ref id="ref76">
<label>76.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Hofer</surname> <given-names>SM</given-names></name> <name><surname>Flaherty</surname> <given-names>BP</given-names></name> <name><surname>Hoffman</surname> <given-names>L</given-names></name></person-group>. <article-title>Cross-sectional analysis of time-dependent data: mean-induced association in age-heterogeneous samples and an alternative method based on sequential narrow age-cohort samples</article-title>. <source>Multivar Behav Res</source>. (<year>2006</year>) <volume>41</volume>:<fpage>165</fpage>&#x2013;<lpage>87</lpage>. doi: <pub-id pub-id-type="doi">10.1207/s15327906mbr4102_4</pub-id>, PMID: <pub-id pub-id-type="pmid">26782909</pub-id></citation>
</ref>
<ref id="ref77">
<label>77.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Morris</surname> <given-names>NS</given-names></name> <name><surname>Mac Lean</surname> <given-names>CD</given-names></name> <name><surname>Littenberg</surname> <given-names>B</given-names></name></person-group>. <article-title>Change in health literacy over 2 years in older adults with diabetes</article-title>. <source>Diabetes Educ</source>. (<year>2013</year>) <volume>39</volume>:<fpage>638</fpage>&#x2013;<lpage>46</lpage>. doi: <pub-id pub-id-type="doi">10.1177/0145721713496871</pub-id>, PMID: <pub-id pub-id-type="pmid">23963099</pub-id></citation>
</ref>
<ref id="ref78">
<label>78.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Kim</surname> <given-names>SH</given-names></name>
</person-group>. <article-title>Health literacy and functional health status in Korean older adults</article-title>. <source>J Clin Nurs</source>. (<year>2009</year>) <volume>18</volume>:<fpage>2337</fpage>&#x2013;<lpage>43</lpage>. doi: <pub-id pub-id-type="doi">10.1111/j.1365-2702.2008.02739.x</pub-id>, PMID: <pub-id pub-id-type="pmid">19583664</pub-id></citation>
</ref>
<ref id="ref79">
<label>79.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>M&#x00F5;ttus</surname> <given-names>R</given-names></name> <name><surname>Johnson</surname> <given-names>W</given-names></name> <name><surname>Murray</surname> <given-names>C</given-names></name> <name><surname>Wolf</surname> <given-names>MS</given-names></name> <name><surname>Starr</surname> <given-names>JM</given-names></name> <name><surname>Deary</surname> <given-names>IJ</given-names></name></person-group>. <article-title>Towards understanding the links between health literacy and physical health</article-title>. <source>Health Psychol</source>. (<year>2014</year>) <volume>33</volume>:<fpage>164</fpage>&#x2013;<lpage>73</lpage>. doi: <pub-id pub-id-type="doi">10.1037/a0031439</pub-id>, PMID: <pub-id pub-id-type="pmid">23437854</pub-id></citation>
</ref>
<ref id="ref80">
<label>80.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Briggs</surname> <given-names>AM</given-names></name> <name><surname>Jordan</surname> <given-names>JE</given-names></name> <name><surname>O'Sullivan</surname> <given-names>PB</given-names></name> <name><surname>Buchbinder</surname> <given-names>R</given-names></name> <name><surname>Burnett</surname> <given-names>AF</given-names></name> <name><surname>Osborne</surname> <given-names>RH</given-names></name> <etal/></person-group>. <article-title>Individuals with chronic low back pain have greater difficulty in engaging in positive lifestyle behaviours than those without back pain: an assessment of health literacy</article-title>. <source>BMC Musculoskelet Disord</source>. (<year>2011</year>) <volume>12</volume>:<fpage>161</fpage>. doi: <pub-id pub-id-type="doi">10.1186/1471-2474-12-161</pub-id>, PMID: <pub-id pub-id-type="pmid">21756363</pub-id></citation>
</ref>
<ref id="ref81">
<label>81.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Wingo</surname> <given-names>AP</given-names></name> <name><surname>Wingo</surname> <given-names>TS</given-names></name> <name><surname>Harvey</surname> <given-names>PD</given-names></name> <name><surname>Baldessarini</surname> <given-names>RJ</given-names></name></person-group>. <article-title>Effects of lithium on cognitive performance: a meta-analysis</article-title>. <source>J Clin Psychiatry</source>. (<year>2009</year>) <volume>70</volume>:<fpage>1588</fpage>&#x2013;<lpage>97</lpage>. doi: <pub-id pub-id-type="doi">10.4088/JCP.08r04972</pub-id></citation>
</ref>
<ref id="ref82">
<label>82.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Xiao</surname> <given-names>L</given-names></name> <name><surname>Gao</surname> <given-names>Y</given-names></name> <name><surname>Zhang</surname> <given-names>L</given-names></name> <name><surname>Chen</surname> <given-names>P</given-names></name> <name><surname>Sun</surname> <given-names>X</given-names></name></person-group>. <article-title>The relationship between cognitive function and quality of life in euthymic Chinese patients with bipolar disorder</article-title>. <source>Psychiatry Res</source>. (<year>2016</year>) <volume>246</volume>:<fpage>427</fpage>&#x2013;<lpage>31</lpage>. doi: <pub-id pub-id-type="doi">10.1016/j.psychres.2016.10.026</pub-id>, PMID: <pub-id pub-id-type="pmid">27788464</pub-id></citation>
</ref>
<ref id="ref83">
<label>83.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Abrahamson</surname> <given-names>K</given-names></name> <name><surname>Clark</surname> <given-names>D</given-names></name> <name><surname>Perkins</surname> <given-names>A</given-names></name> <name><surname>Arling</surname> <given-names>G</given-names></name></person-group>. <article-title>Does cognitive impairment influence quality of life among nursing home residents?</article-title> <source>Gerontologist</source>. (<year>2012</year>) <volume>52</volume>:<fpage>632</fpage>&#x2013;<lpage>40</lpage>. doi: <pub-id pub-id-type="doi">10.1093/geront/gnr137</pub-id></citation>
</ref>
<ref id="ref84">
<label>84.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Xiang</surname> <given-names>YT</given-names></name> <name><surname>Li</surname> <given-names>LJ</given-names></name> <name><surname>Zhou</surname> <given-names>JJ</given-names></name> <name><surname>Wang</surname> <given-names>CY</given-names></name> <name><surname>Dixon</surname> <given-names>LB</given-names></name> <name><surname>Dickerson</surname> <given-names>F</given-names></name> <etal/></person-group>. <article-title>Quality of life of patients with euthymic bipolar disorder and its associations with demographic and clinical characteristics, psychopathology, and cognitive deficits</article-title>. <source>Perspect Psychiatr Care</source>. (<year>2014</year>) <volume>50</volume>:<fpage>44</fpage>&#x2013;<lpage>50</lpage>. doi: <pub-id pub-id-type="doi">10.1111/ppc.12024</pub-id>, PMID: <pub-id pub-id-type="pmid">24308864</pub-id></citation>
</ref>
<ref id="ref85">
<label>85.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Mitchell</surname> <given-names>AJ</given-names></name> <name><surname>Kemp</surname> <given-names>S</given-names></name> <name><surname>Benito-Le&#x00F3;n</surname> <given-names>J</given-names></name> <name><surname>Reuber</surname> <given-names>M</given-names></name></person-group>. <article-title>The influence of cognitive impairment on health-related quality of life in neurological disease</article-title>. <source>Acta Neuropsychiatr</source>. (<year>2010</year>) <volume>22</volume>:<fpage>2</fpage>&#x2013;<lpage>13</lpage>. doi: <pub-id pub-id-type="doi">10.1111/j.1601-5215.2009.00439.x</pub-id></citation>
</ref>
<ref id="ref86">
<label>86.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Zhang</surname> <given-names>XH</given-names></name> <name><surname>Li</surname> <given-names>SC</given-names></name> <name><surname>Fong</surname> <given-names>KY</given-names></name> <name><surname>Thumboo</surname> <given-names>J</given-names></name></person-group>. <article-title>The impact of health literacy on health-related quality of life (HRQoL) and utility assessment among patients with rheumatic diseases</article-title>. <source>Value Health</source>. (<year>2009</year>) <volume>12</volume>:<fpage>S106</fpage>&#x2013;<lpage>9</lpage>. doi: <pub-id pub-id-type="doi">10.1111/j.1524-4733.2009.00640.x</pub-id>, PMID: <pub-id pub-id-type="pmid">20586970</pub-id></citation>
</ref>
<ref id="ref87">
<label>87.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Song</surname> <given-names>L</given-names></name> <name><surname>Mishel</surname> <given-names>M</given-names></name> <name><surname>Bensen</surname> <given-names>JT</given-names></name> <name><surname>Chen</surname> <given-names>RC</given-names></name> <name><surname>Knafl</surname> <given-names>GJ</given-names></name> <name><surname>Blackard</surname> <given-names>B</given-names></name> <etal/></person-group>. <article-title>How does health literacy affect quality of life among men with newly diagnosed clinically localized prostate cancer? Findings from the North Carolina-Louisiana prostate Cancer project (PCaP)</article-title>. <source>Cancer</source>. (<year>2012</year>) <volume>118</volume>:<fpage>3842</fpage>&#x2013;<lpage>51</lpage>. doi: <pub-id pub-id-type="doi">10.1002/cncr.26713</pub-id>, PMID: <pub-id pub-id-type="pmid">22180041</pub-id></citation>
</ref>
<ref id="ref88">
<label>88.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Macabasco-O&#x2019;Connell</surname> <given-names>A</given-names></name> <name><surname>DeWalt</surname> <given-names>DA</given-names></name> <name><surname>Broucksou</surname> <given-names>KA</given-names></name> <name><surname>Hawk</surname> <given-names>V</given-names></name> <name><surname>Baker</surname> <given-names>DW</given-names></name> <name><surname>Schillinger</surname> <given-names>D</given-names></name> <etal/></person-group>. <article-title>Relationship between literacy, knowledge, self-care behaviors, and heart failure-related quality of life among patients with heart failure</article-title>. <source>J Gen Intern Med</source>. (<year>2011</year>) <volume>26</volume>:<fpage>979</fpage>&#x2013;<lpage>86</lpage>. doi: <pub-id pub-id-type="doi">10.1007/s11606-011-1668-y</pub-id>, PMID: <pub-id pub-id-type="pmid">21369770</pub-id></citation>
</ref>
<ref id="ref89">
<label>89.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Halverson</surname> <given-names>JL</given-names></name> <name><surname>Martinez-Donate</surname> <given-names>AP</given-names></name> <name><surname>Palta</surname> <given-names>M</given-names></name> <name><surname>Leal</surname> <given-names>T</given-names></name> <name><surname>Lubner</surname> <given-names>S</given-names></name> <name><surname>Walsh</surname> <given-names>MC</given-names></name> <etal/></person-group>. <article-title>Health literacy and health-related quality of life among a population-based sample of cancer patients</article-title>. <source>J Health Commun</source>. (<year>2015</year>) <volume>20</volume>:<fpage>1320</fpage>&#x2013;<lpage>9</lpage>. doi: <pub-id pub-id-type="doi">10.1080/10810730.2015.1018638</pub-id>, PMID: <pub-id pub-id-type="pmid">26161549</pub-id></citation>
</ref>
<ref id="ref90">
<label>90.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Nguyen</surname> <given-names>HT</given-names></name> <name><surname>Kirk</surname> <given-names>JK</given-names></name> <name><surname>Arcury</surname> <given-names>TA</given-names></name> <name><surname>Ip</surname> <given-names>EH</given-names></name> <name><surname>Grzywacz</surname> <given-names>JG</given-names></name> <name><surname>Saldana</surname> <given-names>SJ</given-names></name> <etal/></person-group>. <article-title>Cognitive function is a risk for health literacy in older adults with diabetes</article-title>. <source>Diabetes Res Clin Pract</source>. (<year>2013</year>) <volume>101</volume>:<fpage>141</fpage>&#x2013;<lpage>7</lpage>. doi: <pub-id pub-id-type="doi">10.1016/j.diabres.2013.05.012</pub-id>, PMID: <pub-id pub-id-type="pmid">23806477</pub-id></citation>
</ref>
<ref id="ref91">
<label>91.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Chin</surname> <given-names>J</given-names></name> <name><surname>Madison</surname> <given-names>A</given-names></name> <name><surname>Gao</surname> <given-names>X</given-names></name> <name><surname>Graumlich</surname> <given-names>JF</given-names></name> <name><surname>Conner-Garcia</surname> <given-names>T</given-names></name> <name><surname>Murray</surname> <given-names>MD</given-names></name> <etal/></person-group>. <article-title>Cognition and health literacy in older adults&#x2019; recall of self-care information</article-title>. <source>Gerontologist</source>. (<year>2017</year>) <volume>57</volume>:<fpage>261</fpage>&#x2013;<lpage>8</lpage>. doi: <pub-id pub-id-type="doi">10.1093/geront/gnv091</pub-id>, PMID: <pub-id pub-id-type="pmid">26209450</pub-id></citation>
</ref>
<ref id="ref92">
<label>92.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Kobayashi</surname> <given-names>LC</given-names></name> <name><surname>Smith</surname> <given-names>SG</given-names></name> <name><surname>O'Conor</surname> <given-names>R</given-names></name> <name><surname>Curtis</surname> <given-names>LM</given-names></name> <name><surname>Park</surname> <given-names>D</given-names></name> <name><surname>von Wagner</surname> <given-names>C</given-names></name> <etal/></person-group>. <article-title>The role of cognitive function in the relationship between age and health literacy: a cross-sectional analysis of older adults in Chicago, USA</article-title>. <source>BMJ Open</source>. (<year>2015</year>) <volume>5</volume>:<fpage>e007222</fpage>. doi: <pub-id pub-id-type="doi">10.1136/bmjopen-2014-007222</pub-id>, PMID: <pub-id pub-id-type="pmid">25908675</pub-id></citation>
</ref>
<ref id="ref93">
<label>93.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Geboers</surname> <given-names>B</given-names></name> <name><surname>Uiters</surname> <given-names>E</given-names></name> <name><surname>Reijneveld</surname> <given-names>SA</given-names></name> <name><surname>Jansen</surname> <given-names>CJ</given-names></name> <name><surname>Almansa</surname> <given-names>J</given-names></name> <name><surname>Nooyens</surname> <given-names>AC</given-names></name> <etal/></person-group>. <article-title>Health literacy among older adults is associated with their 10-years&#x2019; cognitive functioning and decline-the Doetinchem cohort study</article-title>. <source>BMC Geriatr</source>. (<year>2018</year>) <volume>18</volume>:<fpage>1</fpage>&#x2013;<lpage>7</lpage>. doi: <pub-id pub-id-type="doi">10.1186/s12877-018-0766-7</pub-id>, PMID: <pub-id pub-id-type="pmid">29558890</pub-id></citation>
</ref>
<ref id="ref94">
<label>94.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Verney</surname> <given-names>SP</given-names></name> <name><surname>Gibbons</surname> <given-names>LE</given-names></name> <name><surname>Dmitrieva</surname> <given-names>NO</given-names></name> <name><surname>Kueider</surname> <given-names>AM</given-names></name> <name><surname>Williams</surname> <given-names>MW</given-names></name> <name><surname>Meyer</surname> <given-names>OL</given-names></name> <etal/></person-group>. <article-title>Health literacy, sociodemographic factors, and cognitive training in the active study of older adults</article-title>. <source>Int J Geriatr Psychiatry</source>. (<year>2019</year>) <volume>34</volume>:<fpage>563</fpage>&#x2013;<lpage>70</lpage>. doi: <pub-id pub-id-type="doi">10.1002/gps.5051</pub-id>, PMID: <pub-id pub-id-type="pmid">30548889</pub-id></citation>
</ref>
<ref id="ref95">
<label>95.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Crespo</surname> <given-names>TS</given-names></name> <name><surname>Andrade</surname> <given-names>JM</given-names></name> <name><surname>de Farias</surname> <given-names>LD</given-names></name> <name><surname>Ferreira</surname> <given-names>AC</given-names></name> <name><surname>Souza</surname> <given-names>JG</given-names></name> <name><surname>de Barros Lima</surname> <given-names>AM</given-names></name> <etal/></person-group>. <article-title>Adherence to medication, physical activity and diet among older people living with diabetes mellitus: correlation between cognitive function and health literacy</article-title>. <source>IBRO Rep</source>. (<year>2020</year>) <volume>9</volume>:<fpage>132</fpage>&#x2013;<lpage>7</lpage>. doi: <pub-id pub-id-type="doi">10.1016/j.ibror.2020.07.003</pub-id>, PMID: <pub-id pub-id-type="pmid">33336106</pub-id></citation>
</ref>
<ref id="ref96">
<label>96.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>O&#x2019;Shea</surname> <given-names>A</given-names></name> <name><surname>Cohen</surname> <given-names>RA</given-names></name> <name><surname>Porges</surname> <given-names>EC</given-names></name> <name><surname>Nissim</surname> <given-names>NR</given-names></name> <name><surname>Woods</surname> <given-names>AJ</given-names></name></person-group>. <article-title>Cognitive aging and the hippocampus in older adults</article-title>. <source>Front Aging Neurosci</source>. (<year>2016</year>) <volume>8</volume>:<fpage>298</fpage>. doi: <pub-id pub-id-type="doi">10.3389/fnagi.2016.00298</pub-id></citation>
</ref>
<ref id="ref97">
<label>97.</label>
<citation citation-type="book"><person-group person-group-type="author"><name><surname>Cunningham</surname> <given-names>AB</given-names></name>
</person-group>. <source>Montreal cognitive assessment (MoCA) and National Institutes of Health toolbox (NIH-TB) cognition battery among healthy older adults</source>. <publisher-loc>Chicago, USA</publisher-loc>: <publisher-name>Doctoral dissertation, Adler University</publisher-name>. (<year>2019</year>).</citation>
</ref>
<ref id="ref98">
<label>98.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Jasien</surname> <given-names>JM</given-names></name> <name><surname>Mikati</surname> <given-names>MA</given-names></name> <name><surname>Kolarova</surname> <given-names>M</given-names></name> <name><surname>Smith</surname> <given-names>B</given-names></name> <name><surname>Thera</surname> <given-names>S</given-names></name> <name><surname>Lee</surname> <given-names>P</given-names></name></person-group>. <article-title>Cognitive and motor function in adults with spina bifida myelomeningocele: a pilot study</article-title>. <source>Childs Nerv Syst</source>. (<year>2021</year>) <volume>37</volume>:<fpage>1143</fpage>&#x2013;<lpage>50</lpage>. doi: <pub-id pub-id-type="doi">10.1007/s00381-020-04964-1</pub-id>, PMID: <pub-id pub-id-type="pmid">33185713</pub-id></citation>
</ref>
<ref id="ref99">
<label>99.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Zanobini</surname> <given-names>P</given-names></name> <name><surname>Lorini</surname> <given-names>C</given-names></name> <name><surname>Lastrucci</surname> <given-names>V</given-names></name> <name><surname>Minardi</surname> <given-names>V</given-names></name> <name><surname>Possenti</surname> <given-names>V</given-names></name> <name><surname>Masocco</surname> <given-names>M</given-names></name> <etal/></person-group>. <article-title>Health literacy, socio-economic determinants, and healthy Behaviours: results from a large representative sample of Tuscany region, Italy</article-title>. <source>Int J Environ Res Public Health</source>. (<year>2021</year>) <volume>18</volume>:<fpage>12432</fpage>. doi: <pub-id pub-id-type="doi">10.3390/ijerph182312432</pub-id>, PMID: <pub-id pub-id-type="pmid">34886157</pub-id></citation>
</ref>
<ref id="ref100">
<label>100.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Bayati</surname> <given-names>T</given-names></name> <name><surname>Dehghan</surname> <given-names>A</given-names></name> <name><surname>Bonyadi</surname> <given-names>F</given-names></name> <name><surname>Bazrafkan</surname> <given-names>L</given-names></name></person-group>. <article-title>Investigating the effect of education on health literacy and its relation to health-promoting behaviors in health center</article-title>. <source>J Educ Health Promot</source>. (<year>2018</year>) <volume>7</volume>:<fpage>127</fpage>. doi: <pub-id pub-id-type="doi">10.4103/jehp.jehp_65_18</pub-id></citation>
</ref>
<ref id="ref101">
<label>101.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Krawczyk-Suszek</surname> <given-names>M</given-names></name> <name><surname>Kleinrok</surname> <given-names>A</given-names></name></person-group>. <article-title>Health-related quality of life (HRQoL) of people over 65 years of age</article-title>. <source>Int J Environ Res Public Health</source>. (<year>2022</year>) <volume>19</volume>:<fpage>625</fpage>. doi: <pub-id pub-id-type="doi">10.3390/ijerph19020625</pub-id>, PMID: <pub-id pub-id-type="pmid">35055448</pub-id></citation>
</ref>
<ref id="ref102">
<label>102.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Luthy</surname> <given-names>C</given-names></name> <name><surname>Cedraschi</surname> <given-names>C</given-names></name> <name><surname>Allaz</surname> <given-names>AF</given-names></name> <name><surname>Herrmann</surname> <given-names>FR</given-names></name> <name><surname>Ludwig</surname> <given-names>C</given-names></name></person-group>. <article-title>Health status and quality of life: results from a national survey in a community-dwelling sample of elderly people</article-title>. <source>Qual Life Res</source>. (<year>2015</year>) <volume>24</volume>:<fpage>1687</fpage>&#x2013;<lpage>96</lpage>. doi: <pub-id pub-id-type="doi">10.1007/s11136-014-0894-2</pub-id>, PMID: <pub-id pub-id-type="pmid">25510216</pub-id></citation>
</ref>
<ref id="ref103">
<label>103.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>L&#x00F6;vd&#x00E9;n</surname> <given-names>M</given-names></name> <name><surname>Fratiglioni</surname> <given-names>L</given-names></name> <name><surname>Glymour</surname> <given-names>MM</given-names></name> <name><surname>Lindenberger</surname> <given-names>U</given-names></name> <name><surname>Tucker-Drob</surname> <given-names>EM</given-names></name></person-group>. <article-title>Education and cognitive functioning across the life span</article-title>. <source>Psychol Sci Public Interest</source>. (<year>2020</year>) <volume>21</volume>:<fpage>6</fpage>&#x2013;<lpage>41</lpage>. doi: <pub-id pub-id-type="doi">10.1177/1529100620920576</pub-id>, PMID: <pub-id pub-id-type="pmid">32772803</pub-id></citation>
</ref>
<ref id="ref104">
<label>104.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Moore-Harrison</surname> <given-names>TL</given-names></name> <name><surname>Speer</surname> <given-names>EM</given-names></name> <name><surname>Johnson</surname> <given-names>FT</given-names></name> <name><surname>Cress</surname> <given-names>EM</given-names></name></person-group>. <article-title>The effects of aerobic training and nutrition education on functional performance in low socioeconomic older adults</article-title>. <source>J Geriatr Phys Ther</source>. (<year>2008</year>) <volume>31</volume>:<fpage>18</fpage>&#x2013;<lpage>23</lpage>. doi: <pub-id pub-id-type="doi">10.1519/00139143-200831010-00004</pub-id>, PMID: <pub-id pub-id-type="pmid">18489804</pub-id></citation>
</ref>
<ref id="ref105">
<label>105.</label>
<citation citation-type="journal"><person-group person-group-type="author"><name><surname>Lynch</surname> <given-names>JW</given-names></name> <name><surname>Kaplan</surname> <given-names>GA</given-names></name> <name><surname>Shema</surname> <given-names>SJ</given-names></name></person-group>. <article-title>Cumulative impact of sustained economic hardship on physical, cognitive, psychological, and social functioning</article-title>. <source>N Engl J Med</source>. (<year>1997</year>) <volume>337</volume>:<fpage>1889</fpage>&#x2013;<lpage>95</lpage>. doi: <pub-id pub-id-type="doi">10.1056/NEJM199712253372606</pub-id>, PMID: <pub-id pub-id-type="pmid">9407157</pub-id></citation>
</ref>
</ref-list>
<glossary>
<def-list>
<title>Glossary</title>
<def-item><term>BP</term><def><p>Bodily Pain</p></def></def-item>
<def-item><term>CF</term><def><p>cognitive function</p></def></def-item>
<def-item><term>GFI</term><def><p>the comparative fit index</p></def></def-item>
<def-item><term>GH</term><def><p>General Health</p></def></def-item>
<def-item><term>HL</term><def><p>health literacy</p></def></def-item>
<def-item><term>HLS-EU-Q47</term><def><p>the 47-item European Health Literacy Questionnaire</p></def></def-item>
<def-item><term>HLS-SF12</term><def><p>the 12-item Short-Form of the European Health Literacy Survey Questionnaire</p></def></def-item>
<def-item><term>HRQoL</term><def><p>health-related quality of life</p></def></def-item>
<def-item><term>MH</term><def><p>Mental Health</p></def></def-item>
<def-item><term>MLPE</term><def><p>maximum likelihood parameter estimation</p></def></def-item>
<def-item><term>MoCA</term><def><p>Montreal Cognitive Assessment</p></def></def-item>
<def-item><term>PF</term><def><p>physical functions</p></def></def-item>
<def-item><term>RE</term><def><p>Role Emotional</p></def></def-item>
<def-item><term>RMSEA</term><def><p>the root mean square error of approximation</p></def></def-item>
<def-item><term>RP</term><def><p>Role Physical</p></def></def-item>
<def-item><term>SEM</term><def><p>structural equation modeling</p></def></def-item>
<def-item><term>SF</term><def><p>Social Functioning</p></def></def-item>
<def-item><term>SF-12v2</term><def><p>the 12-item Short Form Health Survey version 2</p></def></def-item>
<def-item><term>SFT</term><def><p>Senior Fitness Test</p></def></def-item>
<def-item><term>SRMR</term><def><p>the standardized root mean residual</p></def></def-item>
<def-item><term>TLI</term><def><p>the Tucker-Lewis index</p></def></def-item>
<def-item><term>VT</term><def><p>Vitality</p></def></def-item>
</def-list>
</glossary>
</back>
</article>