OBJECTIVES: Kidney transplant recipients (KTRs) must manage several self-care behaviors. They have to take multiple daily medications, look for signs of acute rejection, have frequent blood draws and often manage additional chronic conditions. There is limited understanding of underlying behavioral factors that may influence KTRs’ adherence to self-care behaviors. This study aims to explore the association between self-efficacy, health literacy and adherence to self-care behaviors and to describe variations of self-efficacy based on individual KTRs’ characteristics. METHODS: KTRs who were 1 to 5 years post-transplant, over the age of 18 at the time of transplants and had a single organ transplant were eligible.  Four hundred and thirty-five eligible KTRs received a mailed survey inquiring about self-efficacy, health literacy, medication adherence, and self-care behaviors.  Self-efficacy was tested as a mediator or as a moderator of health literacy on adherence to self-care behaviors. Linear regression analyzed variations of self-efficacy in KTRs. RESULTS: One hundred and eighty-two KTRs completed the survey (42% participation rate). Mean age of responders was 59.5 (+/-12.1) years; 61.0% were male; and 38.1% were African American. The mean time since transplant was 38.0 (+/-18.1) months.  African Americans had lower self-efficacy compared to other patient groups (β= -0.61, p=0.03). An increase in functional health literacy was associated with an increase in self-efficacy (β=0.72, p<0.01). Self-efficacy was a partial mediator of functional and communicative health literacy on adherence to self-care behaviors (functional: αβ=0.32, CI: 0.11-0.60; communicative: αβ=0.37, CI: 0.11-0.71). CONCLUSIONS: This study provides new insights into the factors influencing KTRs’ adherence to self-care behaviors. Clinicians need to monitor patients with low self-efficacy and low health literacy. The teach-back method and frequent communication can help increase self-efficacy. Use of larger font, photos and visual cues will help patients with limited health literacy. These methods may optimize KTRs’ adherence to self-care behaviors.