Background: During the early phase of the COVID-19 pandemic, higher health literacy may have intensified anxiety because active information seeking occurred under profound uncertainty. Whether this association persisted in later phases remains unclear.

Methods: We analyzed two repeated panel surveys of Japanese adults conducted in 2020 (n=3,486) and December 2025 (n=2,965) using comparable questionnaires. Anxiety was classified as no/low, high, or fear. Health literacy was divided into communicative (items 1–3) and critical (items 4–5) domains. Primary analyses applied baseline-anchored tertiles defined by the 2020 distribution. Covariate-adjusted multinomial logistic regression models (sex, age, education, employment, and area) tested wave-by-health literacy interactions. Free-text responses were coded using a refined rule-based dictionary, incorporating common spelling variants, to quantify thematic mentions. Adjusted wave effects on category presence were estimated.

Results: Overall anxiety declined substantially in 2025 compared with 2020. In adjusted models, in 2020, higher communicative health literacy was associated with greater likelihood of high anxiety and fear. In 2025, this pattern attenuated and shifted toward lower anxiety, most clearly for fear. Free-text content also changed, with decreased emphasis on uncertainty, policy and healthcare strain, and daily-life disruption, and increased references to vaccination and normalization, including comparisons with seasonal infections; however, uncertainty remained as prevalent as the newly increased topics.

Conclusions: The association between communicative health literacy and anxiety reversed between 2020 and 2025, paralleling marked shifts in narrative content. Risk communication strategies should reflect the evolving information environment and pandemic phase, promoting constructive information appraisal rather than anxiety amplification.

One sentence summary of the abstract
Across repeated surveys in 2020 and 2025, the association between communicative health literacy and COVID-19 anxiety reversed, while free-text narratives shifted from uncertainty and system strain toward vaccination and normalization, highlighting the importance of phase-specific risk communication that supports constructive information appraisal.