Lifestyle and its relationship with health literacy, sense of coherence and sociodemographic factors in a Spanish primary care population: a multicenter cross-sectional study

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Health behaviors are driven by a complex interplay of individual and structural factors. While health literacy and sense of coherence are widely studied as psychosocial enablers of healthy lifestyles, evidence comparing their impact against broader social determinants of health remains limited. A multicenter, cross-sectional study was conducted among primary care patients across six autonomous communities in Spain ( N = 980). This study aimed to evaluate the association of the overall lifestyle index and its dimensions with health literacy and sense of coherence while determining the relative contribution of sociodemographic and contextual factors through multivariable analysis. Dimension-specific analyses showed that better self-perceived health and spending more than two hours per week in natural environments were consistently associated with healthier diet, higher physical activity and better emotional wellbeing. Similar patterns were observed for the overall lifestyle index. In the fully adjusted model, better self-perceived health (B = 4.24; p < 0.001), female sex (B = 3.97; p < 0.001), spending more than two hours per week in natural environments (B = 3.83; p < 0.001), being retired or a pensioner (B = 3.48; p < 0.001), and higher educational attainment (B = 1.45; p < 0.001) were associated with a higher overall lifestyle index, whereas being self-employed was associated with a lower overall lifestyle index (B = − 4.90; p = 0.007). Neither health literacy nor sense of coherence remained independently associated with the overall lifestyle index after adjustment for sociodemographic and contextual factors. Lifestyle choices in this primary care population are predominantly shaped by contextual and sociodemographic factors rather than individual cognitive or psychosocial traits. These findings suggest that, in the presence of structural and sociodemographic differences, the additional independent contribution of health literacy and sense of coherence to lifestyle variance may be limited. The Ponte a 100 questionnaire provides a practical approach for identifying modifiable lifestyle behaviours in Primary Care, although its overall lifestyle index should be interpreted as a pragmatic summary measure rather than as a reflective measure of a single latent construct.