Enhancing Cardiac Health Outcomes through Knowledge and Health Information Literacy Evidence from a Pilot Study

Enhancing Cardiac Health Outcomes through Knowledge and Health Information Literacy Evidence from a Pilot Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Enhancing Cardiac Health Outcomes through Knowledge and Health Information Literacy Evidence from a Pilot Study Ghulam Farid, Prof. Khalid Mahmood, Syeda Hina Batool This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8826635/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 18 You are reading this latest preprint version Abstract Purpose The study aims at investigating the improvement of health outcomes through patient knowledge, activation, and health information literacy guided by the framework of health literacy skills (HLS) and (integrated theory of health behaviour change) ITHBC model Method A cross-sectional survey was carried out adapted structured questionnaire to collect data from 140 cardiac patients at Mayo Hospital, Lahore Pakistan. The sample was taken from the targeted population, including pilot testing, using a purposeful sampling method. The smart PLS used for PLS-SEM Structural Equation Modelling. Results The study reveals that the majority of patients, have family support (111.79%) when needed, colleagues (22.16%), and relatives (21.15%) when things go wrong. Family support is the most common, followed by colleagues (20%) and relatives (16%). The majority of cardiac patients have family and relatives accompanying them during doctor visits. This research reveals notable connections and mediating effects between Health Information Literacy (HIL), Patient Activation (PA), Prior Knowledge (PK), and Health-Related Behavior Outcomes (HRBO). Results show that HIL has a highly positive impact on both PA (path coefficient = 0.249, p = 0.002) and PK (path coefficient = 0.296, p = 0.000). PA has a positive effect on HRBO (path coefficient = 0.366, p = 0.000), and PK has a strong influence on HRBO (path coefficient = 0.438, p = 0.000). PK has also a significant effect on PA (path coefficient = 0.397, p = 0.000). Conclusion The findings of this study showed that HIL, PA and PK have a significant effect on HRBO. PA and PK both have positive effects on HRBO, and HIL has positive effects on PA and PK. In addition, PA mediates the effects of HIL on HRBO, whereas PK plays mediating roles in linking either HIL and HRBO or HIL and PA. Health Information Literacy Skills Health Literacy Health Need Prior Knowledge Patient Activation Social Support Health Outcomes Health Behavior Cardiac patients Pakistan Figures Figure 1 Figure 2 Introduction Cardiovascular disease (CVD) remains the leading cause of death worldwide, with an incidence of nearly 1 in 3 deaths. The number CVD) related deaths increased from 12.1 million in 1990 to 20.5 million in 2021, an increase of 60% ( 1 ). This increase is largely growth of population, aging, and lifestyle changes. More than 80% of CVD deaths happen in low- and middle-income countries face a dual health burden associated with both communicable and non-communicable diseases contributing to the problem. ( 1 , 2 ) Cardiovascular disease (CVD) causes 18 million deaths each year globally, ( 1 ) with significant differences between low- and middle-income countries (LMICs) and high-income countries. response from LMICs contributes disproportionately to the global burden of CVDS, accounting for 80% of total global CVD-related deaths. ( 2 ) A bigger worry is that premature deaths account for almost half of all deaths in developing countries. High-income countries produced 81.1% of the total global CVD research between 2008 and 2017 while having only 8.1% and 8.5% of absolute global CVD disability-adjusted life-year loss and death rates, respectively. ( 3 ) Health information literacy (HIL) is the cognitive and social skill that determine the motivation and ability of individuals to access, comprehend, and utilize information in a way that helps individuals promote and maintain good health. ( 4 ) HIL means the attainment of a level of knowledge, personal skills and confidence to take action to improve personal and community health by changing personal lifestyles and living conditions. So, HIL is not just about reading pamphlets and making appointments. HIL is important to empowerment as it improves peoples access to health information and their ability to use it effectively. ( 5 ) Mueed et al. ( 6 ) found that cardiac patients in Pakistan have limited knowledge and awareness about medication and follow-up procedures. The study ( 7 ) revealed that both males and females have adequate HIL, with disease knowledge. However, women had limited HIL in general health information, and men had limited HIL in health promotion and disease prevention. HIL and patient activation have a positive association with health-related behavior and outcomes ( 8 , 9 ). To enhance self-management techniques among cardiac patients, it is necessary to address both levels and determinants of HIL and patient activation ( 10 ). Bahrom et al., ( 11 ) suggests creating patient-activation therapies to enhance self-management abilities, including skill development, tailored care plans, and mentorship. The study concluded that patients from 65 and older, whose visit-related expectations have been detected and addressed by doctors with the greatest accuracy, report the highest levels of health proactivity ( 12 ). The research shows that individuals with higher education and salaries tend to have better patient activation. Additionally, health literacy, particularly the ability to understand and use health-related information, was found to be a statistically significant predictor of patient activation ( 13 ). The study reveals that individuals with cardiac disease often have low health literacy and are less active, linked to socioeconomic factors and a negative attitude towards sickness. The findings are being used to develop a self-management program for these individuals. In order to comprehend their disease and manage their treatment regimens, patients with chronic diseases need health information skills ( 14 , 15 ). HIL has been regarded as a significant determinant of health, and previous studies have demonstrated that health literacy is positively linked to health outcomes and health-related behavior. ( 5 , 16 ) For the prevention, clinical management, and control of noncommunicable diseases (NCDs), health information literacy (HIL) has emerged as a key component of modern public health, empowering individuals and health systems to make informed and evidence-based decisions. The effectiveness of interventions for HIL on health outcomes concerning NCDs had been significant in previous study of cardiac patients. ( 17 , 18 ) Moreover, low health literacy is prevalent among people with cardiac disease, where prior investigations have suggested that nearly 40% of cardiac individuals possess a HIL and patient activation level that is insufficient for effective health outcome. Low HIL is also associated with a considerable economic burden, accounting for an estimated 3% to 5% of overall healthcare expenditures globally, although this has yet to be investigated in cardiovascular disease. ( 19 , 20 ) Singh et al ( 21 ) study on heart patients and found that patients with good knowledge, motivation, and skills delay seeking care for cardiac patient symptoms. Cardiac patient’s self-management requires understanding the condition and effective management techniques. The factors such as health literacy, awareness, and patient activation can support self-management in ambulatory cardiac patients. Patient activation positively impacts patient behaviors and health outcomes, with higher activation associated with better habits. To reduce CVD risk and mortality, extensive healthcare policy changes and public awareness campaigns are needed. Elder heart failure patients' self-care behaviors are correlated with health literacy and perceived social support ( 22 ). Despite having health information literacy, they evaded care seeking, highlighting the need for further research on the influence of health information literacy on health-associated behavior and outcomes. There is no literature available in the Pakistani setting on HIL, patient activation, and disease knowledge that improves the health outcomes of cardiac patients to using the he health literacy skills (HLS) conceptual framework. The aim of this study is to explore the phenomena of HIL, prior knowledge, and patient activation to improve the cardiac patient outcomes and test the HLS model with the use of the theory of integrated health behavior change. Statement of Problem Poor HIL in Pakistan hinders disease prevention and management, particularly cardiovascular disease (CVDs). This lack of knowledge and awareness leads to poor health behaviors and decisions, reducing early diagnosis, medication adherence, and lifestyle factors. To achieve better results, health literacy is essential. HIL is essential to advance the health outcomes in the world since it is a means to provide the means of successfully accessing, comprehending, and applying health-related information. HIL of low has also been reported as a contributor to the propagation of cardiac disease especially in those areas where the level of knowledge, patient activation and quality of life is inadequate ( 23 ). The chronic disease management as in the case of heart disease is an area where HIL should be strong since it can promote the results of patients as observed in other countries such as Pakistan where heart disease is a major cause of death among patients with cardiac problems ( 24 ). There have been no extensions made to HLS model to HIL, prior knowledge and health related behaviour and outcomes with prolonged patient activation construct. The template in this line of study must be bridged even more. Out of this gap, the current study relies on Integrated Theory of Health Behavior Change (ITHBC) ( 25 ) to form empirical evidence that would help in addressing improved understanding of health information literacy in different socioeconomic settings. Research Objectives The research objectives are: To examine the influence of health information literacy on patient activation of cardiac patients. To investigate the influence of health information literacy and health-related behaviours and outcomes of cardiac patients. To explore the mediating role of patient activation in the relationship between HIL and health-related behaviours and outcomes of cardiac patients. Theoretical Framework The research has been based on the Health Literacy Skills (HLS) Framework to assess the impact of health information literacy skills, prior knowledge, patient activation, and health outcomes in the context of cardiac care. The HLS Framework provides that the phenomena of health information literacy are dynamic and multidimensional and is more than the issue of ability to read and understand the health information to the ability to access, comprehend, evaluate and use health information to make well-informed decisions ( 26 , 27 ). The study also incorporates the Integrated Theory of Health Behavior Change (ITHBC) on the behavior change process on the conversion of health information literacy to valuable behavior change and health improvement. Some of the key processes that lead to a long-lasting health behavior change that the ITHBC emphasized are the interaction of knowledge and faith, the ability to self-regulate, and social facilitation ( 25 ). This theory is quite applicable to the sphere of patient-centered care since it emphasizes that patients participate in the process of interpreting their health information, which is self-efficacy and the desire to improve the health results. Knowing the behavior as it pertains to the behaviors, the ITHBC will develop a theoretical prism in recognizing the relationship of the health problem, patient activation and eventual health rewards. The study gives a theoretical research model that gives 4 major constructs as prior knowledge, health information literacy skills, patient activation, and health-related behavior. Knowledge is foundational of the explanations of patients of the received information on health. Health information literacy prepares patients to be analytical in their means of evaluating the sources of information and make sound health choices. Patient activation demonstrates the level of motivation, confidence and competence in areas of management of personal health and medical treatment ( 28 ). The visible results of such a process are the health-related behaviors, such as treatment adherence, self-care and preventive practices. The existing study offers an extensive means of understanding the effect of the health information literacy as a cognitive resource and not a stimulus of behaviour with the integration of the HLS Framework and ITHBC. The model of the study highlights the crucial role of cardiac patients to the process of attaining better health outcomes and is consistent with the recent transition to the empowerment-based model of the modern healthcare system. Hypothesis H1: Health information literacy has significant impact on patient activation of cardiac patients. H2: Health information literacy has significant impact on prior knowledge. H3: Prior knowledge has positive impact on patient activation. H4: Prior knowledge has positive impact on health outcomes H5: Patient activation has positive impact on health outcomes H6: Patient activation has mediating role between HIL and health outcomes. H7: Patient knowledge has mediating role between HIL and health outcomes. Research Methodology Method The research design adopted in this study incorporates a cross-sectional research design that involves the collection of data regarding the exposures and the results of the study subjects at a specific time. In contrast to longitudinal follow up cohort studies and retrospective comparison of cases starting with cohort studies, cross-sectional studies provide a description of current relationships among variables within set population (29,30). The type is particularly applicable in studies that are more related to health, behavior, and social sciences in which the objective to investigate is to explore the patterns, associations or the determiners and not to demonstrate long-term connections. The cross-sectional study design is consistent with the quantitative research technique, which offers an opportunity to measure the pre-defined variables in a systematic manner and verify the research objectives or hypotheses statistically. The design enables the efficient study of the interrelations of the variables of exposure (e.g. health information literacy, prior knowledge, patient activation, and health related behaviors and outcomes). Population This study's target population consists of adult heart patients, Patients who were suffered with heart conditions of any kind, The population of the study were cardiac patients who were admitted to the Cardiac Surgery and Cardiology Department of Mayo Hospital Lahore. The participants were chosen in accordance with the study's inclusion criteria, which were based on age, gender, disease features, and qualifications. Inclusion Criteria The following inclusion criteria are used to choose study participants: 1. At least madrasa ( Religious and Islamic educational institution that provides structured instruction in reading, writing, comprehension, and interpretation, often in Arabic and/or the local language ) to university qualified adult cardiac patients. 2. Patients with heart conditions of any kind were included. Exclusion Criteria Participants were excluded according to the following criteria to guarantee that they were appropriate for the study: Non-cardiac patients: All patients free of any type of heart or cardiovascular disease. Patients aged less than 18 years: The present study did not include patients aged <18 years. Patients in acute or critical condition: Cardiac patients who were in an acute or critical stage of their illness (e.g., in the intensive care unit) were excluded as their condition could compromise their ability to participate effectively. Patients with non-cardiac comorbidities that may influence the study outcomes: Patients that refused to participate (no consent). Sampling Technique and Sample Size Sampling method being used in this study is Convenience Sampling. A non-random sampling approach (e.g., convenience sampling), wherein participants were chosen based on their availability and accessibility to the researcher instead of a random selection process. One of the main uses of non-probability sampling occurs when the existence of restrictions on time, budgets, or the accessibility of subjects limits the ability to select a representative random sample. A total of 144 adult cardiac patients were enrolled through non-probability convenience sampling technique from the Cardiac Surgery and Cardiology Department of Mayo Hospital Lahore. Patients were convenient and, on admission to, or while visiting the outpatient department of the hospital were willing to participate in the study. Tool Development and Measurement of Constructs A questionnaire as an instrument for the data collection purpose was used. The instrument was divided into three parts; Demographic information Questions about patient knowledge and awareness, health care terminologies, and illness experience about disease. In the third part of the instrument, the researcher was distributed in constructs in Likert scale like health information literacy, patient activation, and health outcomes of cardiac patients in Punjab, Pakistan. In this study, the data collection tool was a semi-structured questionnaire, which was adapted according to existing literature on the variants of previously published (26,27,28) instruments which were valid and demonstrated their validity in earlier research works. The process of adaptation made sure that the questionnaire was theoretically based and fit to the context in measuring the level of health information literacy, patient activation and health outcomes with cardiac patients in Punjab, Pakistan. Ethical approval: This study is based on a PhD research project approved by the Advanced Studies and Research Board (ASRB), University of the Punjab, Lahore, Pakistan (Registration No. D/3081/Acad) on dated September 12, 2022. The study protocol was conducted in accordance with the guidelines of the ICMJE recommendations, the principles of the Declaration of Helsinki, and the ethical standards of the World Medical Association. Consent to participate: The researcher upheld study ethics, obtained written consent from participants, used a semi structured questionnaire, communicated the study's purpose, and maintained data confidentiality, avoiding shared with any person or organization. Written informed consent was obtained from all participants before data collection. For participants under the age of 18 years, written informed consent was obtained from their parent or legal guardian prior to inclusion in the study (Appendix B). Consent to publish: Not applicable Delimitation of the Study The Mayo Hospital for Heart Patients in Lahore was the exclusive focus of the investigation. The study excluded non-teaching clinical settings, private consultant clinics, and other departments. The frame of the target population does not include different cardiac settings in other Pakistani provinces. Reliability and Validity of the Instrument The study utilized pilot testing to prepare for data collection. The instrument used in the study was marked as 'adapted', ensuring its validity and reliability. Smart PLS was applied to check the reliability of the instrument. Table 1: Cronbach Alpha and Composite Reliability Cronbach's alpha Composite reliability (rho_a) Composite reliability (rho_c) Average variance extracted (AVE) References HIL 0.975 0.98 0.977 0.74 26-28, 29, 30 HRBO 0.808 0.827 0.861 0.512 31-33 PA 0.749 0.759 0.833 0.502 34-35 PK 0.879 0.897 0.9 0.454 36-38 Measures of reliability and validity Table 3. Reliability and validity statistics for four constructs: Health Information Literacy (HIL), Health-Related Behavioral Outcomes (HRBO), Patient Activation (PA), and Prior Knowledge (PK). It comprises of Cronbach's Alpha, Composite Reliability (rho_a), Composite Reliability (rho_c) and Average Variance Extracted (AVE). These measures help to establish the reliability and validity of the constructs employed in the research. Cronbach's Alpha Cronbach’s alpha indicates the internal consistency or reliability of a scale. Values above 0.7 generally taken acceptable. HIL has an excellent internal consistency with a very high Cronbach’s alpha of 0.975. The flexible Cronbach’s alpha for HRBO is acceptable 0.808 and indicates a reliable measurement of the construct. PA's Cronbach's alpha of 0.749 is still within an acceptable range, but slightly lower than the others. PK has an excellent Cronbach’s alpha of 0.879, overall, indicating good internal consistency. Composite Reliability (rho_a and rho_c) There are two types of composite reliability: rho_a and rho_c. Composite reliability above 0.7 means high reliability. For HIL (Health Information Literacy) composite reliability for rho_a is 0.98 and rho_c is 0.977, showing very high composite reliability for HIL and indicates that all items are significant to represent the Health Information Literacy construct. The value of rho_a and rho_c for HRBO are respectively 0.827 and 0.861 which are above the cutoff point of 0.7 defining a good level of reliability. Both PA rho_a (0.759) and rho_c (0.833), also suggesting acceptable reliability. The PK has rho_a of 0.897 and rho_c of 0.9, both excellent. AVE: Average Variance Extracted AVE denotes the explanation of variance information of construct with the relative variance of measurement error. AVE values of 0.50 or higher support that the construct explains at least 50% of the variance of the items, therefore also indicative of good convergent validity. Based on these threshold values, as AVE value of HIL is 0.74, implying high convergent validity since, AVE>0.50. The AVE for HRBO was 0.512, which is marginally greater than 0.50, indicating acceptable convergent validity. Convergent validity was plumbed as AVE was above 0.50, with AVE for PA being 0.502. Given that PK has an AVE of 0.454 (below the desired value of 0.50), we can say that it has potentially low validity. All constructs display acceptable to excellent internal consistency and composite reliability, indicating that the scales were used in the study reliably represents their constructs. The Health Information Literacy (HIL) construct has the highest reliability and validity measurement in comparison with other constructs, which is classified with high Cronbach’s alpha, composite reliability, and AVE value. While HRBO, PA, and PK display acceptable levels of reliability and convergent validity, PK has a slightly lower AVE indicating that while acceptable results were found for PK there may be implications for improving measurements. Data Collection Procedure After revision by expert and supervisors, the questionnaire was finalized and the researcher provided step-by-step method of filling the questionnaire to all cardiac patients. The researcher assisted the cardiac patients to fill the questionnaire in the cardiovascular department of Outpatient Department (OPD) and ward from Mayo Hospital, Lahore to collect the data. Data Analysis Plan The researcher statistically analyzed the quantitative data using (SPSS) version 22. For the hypothesis and objectives of the research the statistical analysis such as descriptive statistics like frequency of distribution, tables graphs, and Smart PLS for inferential statistics regression, hierarchical regression was used to test the model. Results The findings of the sociodemographic of the data (table 2), the sample was male (71.4%) and includes older age groups (44.3% aged >50 years). Nearly half have a low income (i.e. earn less than 32,000 PKR). They also have varying levels of educational attainment, with many unaided and only going to madrassa. Occupationally, there are private sector employees, homemakers, students. Culturally coherent with linguistic ethnicity, Punjabi and Urdu dominate (Table 2). Table 2: Sociodemographic of the data Variable Category N(%) Age <30 years 23(16.4%) 31-40 years 27(19.3%) 41-50 years 28(20.0%) 51-60 years 29(20.7%) Above 60 years 33(23.6%) Gender Male 100(71.4%) Female 40(28.6%) Monthly Income in Pakistani Rupees <32000 79(56.4%) 32001-50000 37(26.4%) 50001-70000 53.6% () 70001-90000 7(5.0%) 90001-11000 2(1.4%) Above 111000 4(2.9%) Other 6 (4.3%) Education Uneducated 39(27.9%) Madrassa 19(13.6%) School Level 46(32.9%) College Level 9(6.4%) Under Graduation (University) 15(10.7%) Post-Graduation (University) 10(7.1%) Other 2(1.4%) Employment / Occupation Student 18(12.9%) Farmer 19(13.6%) Businessman 11(7.9%) Private Job 27(19.3%) Government Job 13(9.3%) Health Care Professional 1(0.7%) Educationalist 1(0.7%) Housewife 26(18.6%) Other 24(17.1%) Culture Urdu 31(22.1%) Punjabi 60(42.9%) Saraiki 35(25.0%) Potohari 7(5.0%) Sindhi 3(2.1%) Pashtoo 2(1.4%) Other 2(1.4%) Figure 1 indicated that the majority of patients have family support (111, 79%) when they need help; when things go wrong, they have again family support (82, 58%), colleagues (22, 16%), and relatives (21, 15%). When patients have joys and sorrows, the family supports them 77 (55%), colleagues 28 (20%), and relatives 23 (16%). Talks about problems: the majority of cardiac patients have family (70, 50%) and relatives (37, 26%) accompany them during doctor visits, the family supports (74, 53%) and relatives (45, 32%). Table 2 indicated the reliability of the instrument; Cronbach alpha is a measure of internal consistency and composite reliability in the context of construct reliability. Cronbach's alpha should be close to 0.70 and 0.90, indicating that item reliability is high. Composite reliability (CR) values must be > 0.70, once again seen in Table 4 where composite reliability values of each construct are higher than 0.7, suggesting that there was no construct reliability issue. The same applies to rho_A and rho_A values. Table 3: Regression Coefficients (Path analysis of direct effects) Hypothesis Path coefficients Total effects T stat P Decision H1 HIL -> PA 0.249 0.366 3.033 0.002 Accepted H2 HIL -> PK 0.296 0.296 4.208 0.000 Accepted H3 PA -> HRBO 0.366 0.366 4.116 0.000 Accepted H4 PK -> HRBO 0.438 0.584 5.77 0.000 Accepted H5 PK -> PA 0.397 0.397 4.513 0.000 Accepted Specific indirect effects H6 HIL -> PA -> HRBO 0.091 0.091 2.866 0.004 Accepted H7 HIL -> PK -> HRBO 0.13 0.13 3.253 0.001 Accepted HIL -> PK -> PA 0.118 0.118 2.134 0.033 HIL -> PK -> PA -> HRBO 0.043 0.043 2.316 0.021 PK -> PA -> HRBO 0.145 0.145 2.764 0.006 H1: Health information literacy has significant impact on patient activation. H2: Health information literacy has significant impact on prior knowledge. H3: Patient activation has positive impact on health outcomes. H4: Prior knowledge has positive impact on. health outcomes. H5: Prior knowledge has positive impact on patient activation. H6: Patient activation has mediating role between HIL and health outcomes. H7: Patient knowledge has mediating role between HIL and health outcomes. Hypotheses Path Coefficients Total Effects t-statistics p-values Hypotheses Link to the Paper The findings can be summarized as follows: The path coefficient of Health Information Literacy (HIL -> PA) is 0.249, which is moderate positive. This effect is indeed significant as evidenced by the t-statistic (3.033) and p-value (0.002) so we will accept this hypothesis. H2 (HIL -> PK): The path coefficient of 0.296 indicates that the effect of HIL on the (PK) has a moderate strength in the positive direction. Since both the t-statistic (4.208) and p-value (0.000) in such cases are statistically significant, the effect is accepted. H3 (PA -> HRBO): The path coefficient of 0.366 indicates that patient activation positively affects HRBO. The relationship is highly significant (t = 4.116; p = 0.000), therefore the hypothesis is accepted. H4 (PK -> HRBO): Hypothesis four indicates the path coefficient whose value is 0.438 shows significance of magnitude from predictor, prior knowledge (PK) to group- mean, health-related behavioral outcomes (HRBO), and as per very high t-statistic (5.77) and a low p-value (0.000) we can say that this hypothesis is accepted. H5 (PK -> PA): Prior knowledge (PK) plays a significant role to the patient activation (PA) with a path coefficient of 0.397. The t-statistic (4.513) and the p-value (0.000) indicate that this effect is statistically significant, leading to an acceptance of this hypothesis. Mediating Effects: The specific indirect effects detail the way one variable impacts on another via a third ‘mediating’ variable. Results for the indirect effects were: H6 (HIL→PA→HRBO): The indirect effect of HIL on health-related behavioral outcomes by means of the process of patient activation (PA) is significant (path coefficient = 0.091, t = 2.866, p = 0.004), confirming patient activation as a mediator in the relationship between HIL and health outcomes. This hypothesis is accepted. H7 (HIL -> PK -> HRBO): The indirect effect of HIL on health-related behavioral outcomes through prior knowledge (PK) is significant (path coefficient = 0.13, t = 3.253, p = 0.001), confirming that prior knowledge mediates the relationship between HIL and HRBO. This hypothesis is accepted. HIL→PK→PA: The indirect effect of HIL on PA via PK is also significant (path coefficient = 0.118, t = 2.134, p = 0.033), indicating prior knowledge explains how HIL would influence patient activation. This result is accepted. HIL -> PK -> PA -> HRBO: The indirect effect of HIL on health-related behavioral outcomes (HRBO) through prior knowledge (PK) and patient activation (PA) are statistically significant (path coefficient = 0.043, t = 2.316, p = 0.021), implying that HIL and health outcomes are mediated by both PK and PA. This hypothesis is accepted. PK → PA → HRBO: The mediating effect of patient activation between prior knowledge and health-related behaviors is significant according to the indirect effect (path coefficient = 0.145, t = 2.764, p = 0.006), which gives supportive evidence of its mediating role. This hypothesis is accepted. Table 4: Heterotrait-monotrait ratio (HTMT) – Matrix HIL HRBO PA PK HIL 1 HRBO 0.253 1 PA 0.366 0.573 1 PK 0.296 0.611 0.47 1 HIL and HRBO (0.253) shows a positive correlation of 0.253 that suggests a positive correlation of these two variables. HIL and PA (0.366): A correlation of 0.366 means there is a moderate positive correlation, so as HIL increases, so does PA. HRBO vs PA (0.573): A positive correlation of 0.573 indicates a moderate positive correlation between the two, stronger than the previous comparison. Correlation between HIL and PK (0.296): A correlation of 0.296 indicates a weak positive relationship. HRBO and PK (0.611) : A correlation of 0.611 shows a moderate to strong positive relationship. PA and PK (0.47): There is a moderately positive correlation of 0.47 between PA and PK. Table 5: Cross-factors (Outer) Loading and Outer Weights Outer loadings HILSkills10 <- HIL 0.771 HILSkills11 <- HIL 0.786 HILSkills12 <- HIL 0.837 HILSkills13 <- HIL 0.857 HILSkills14 <- HIL 0.877 HILSkills15 <- HIL 0.9 HILSkills16 <- HIL 0.888 HILSkills17 <- HIL 0.879 HILSkills18 <- HIL 0.893 HILSkills19 <- HIL 0.923 HILSkills20 <- HIL 0.917 HILSkills21 <- HIL 0.916 HILSkills22 <- HIL 0.815 HILSkills8 <- HIL 0.762 HILSkills9 <- HIL 0.859 PKAK1 <- PK 0.754 PKAK2 <- PK 0.776 PKAK3 <- PK 0.709 PKAK4 <- PK 0.734 PKAK5 <- PK 0.715 PKAK6 <- PK 0.65 PKIE1 <- PK 0.728 PKIE2 <- PK 0.68 PKIE3 <- PK 0.565 PKIE4 <- PK 0.532 PKIE5 <- PK 0.507 PatientActivation1 <- PA 0.772 PatientActivation2 <- PA 0.767 PatientActivation3 <- PA 0.714 PatientActivation4 <- PA 0.581 PatientActivation5 <- PA 0.692 WHOQoL1 <- HRBO 0.631 WHOQoL2 <- HRBO 0.86 WHOQoL3 <- HRBO 0.788 WHOQoL4 <- HRBO 0.747 WHOQoL5 <- HRBO 0.616 WHOQoL6 <- HRBO 0.614 The outer loadings give the relation of each indicator with its relative latent variable (for instance, HIL, PK, PA, and HRBO). The association strength between latent and indicator variables is the higher the outer loading. Loadings over 0.70 are generally acceptable. Discussion The results demonstrate the beneficial effects of family support on cardiac patients, who primarily include family members and relatives when visiting a doctor. Higher HIL was linked to greater engagement in self-care activities and better patient outcomes, as evidenced by the positive correlation found between HIL and patient activation, prior knowledge, and health behavior. The study also suggests and similar with (26), Persistent disparities in income, wealth, and other socioeconomic determinants are consistently associated with inferior cardiovascular health and diminished quality of life among cardiac patients and constitute major contributors to racial and ethnic disparities in cardiovascular disease (CVD) outcomes. (39-40) Together, these conditions provide emotional and material support, support the patients in joy and sorrow, create role models and set attitudes and practices toward health and health care and the findings support the study. (41) Previous studies have shown a significant associational relationship between deprived socioeconomic status and a smaller/ poorer social network. (15) In contrast, however, mixed-income neighborhoods can increase positive community-level interaction, expand social networks, and benefit health overall. (42 Furthermore, prior studies have mostly been centered on diseased populations, for example, sufferers with cardiac conditions or cardiovascular disease (CVD), in contrast to being centered on population. The total observed relationship between health information literacy (HIL) and health related behavioral outcome (HRBO) is r = 0.253 which is a very modest but positive correlation, meaning that increases in HIL are correlated with increases in health-related behaviors. The study also supports our study and expands the scientific knowledge in terms of HIL and PA (0.366) health behaviors among people without diseases in this study. (3, 30-43) The instrument, the EU-HLS-Q47 was used and moving to communicative and HIL from basic and functional health literacy requires; higher-level skills including cognitive skills, literacy, communication capacity, social and self-efficacy. (44-45) Hence, the functional level of health literacy may be insufficient to modify behavior regarding health. The study noted that only communicative and critical health literacy, but not functional literacy, were related to health-related lifestyle behaviours in the study. Several plausible mechanistic links between health literacy and health actions and outcomes have been hypothesized in previous studies. (5, 46-47) The HIL plays a fundamental role in determining health outcomes through disease knowledge, positive attitudes, patient activation, and behavior change among cardiac patients and support with our findings HIL and HRBO (0.253) shows a positive correlation of 0.253 that suggests a positive correlation of these two variables. HIL and PA (0.366), A correlation of 0.366 means there is a moderate positive correlation, so as HIL increases, so does PA. HRBO vs PA (0.573). (33-38, 48) According to the existing evidence and the results from our study, HIL appears to be a major target for national health promotion. According to World Health Organization (WHO), raising health literacy is one of the important elements in the 2030 agenda for sustainable development. (52) A great amount of data proves that a healthy lifestyle prevents many diseases (48-51), such as obesity, diabetes, cardiovascular disease, stroke, or cancers. In addition to this causal relationship between healthy lifestyle and disease prevention, our finding that high health literacy facilitates people's improvement of health-related lifestyle behaviors supports the national health promotion program including health literacy intervention as one of its core targets. (51-52) The results of this study show significant associations between HIL, Health-Related Behavioural Outcomes (HRBO), patient activation (PA) and Prior Knowledge (PK). These correlations contribute to the understanding of education, behavior, and knowledge in cardiac patient management. Understanding how these factors interact and impact inbound or outbound productivity eventually provides a measure of patient risk involved in heart management (such as readmission rate, prevention, lifestyle habits, etc) and increasingly becomes important for interpreting these relationships. The correlation between health information literacy (HIL) and health-related behavioral outcomes (HRBO) (r = 0.573) varies between moderate and positive. This indicates that higher levels of HIL are related to better health-related behaviors among patients. The strength of this association suggests that educational interventions that improve the health information literacy of patients may be an effective way to empower patients to manage their health in a proactive manner and adopt behaviors that are conducive to optimal health outcomes. This aligns with literature suggesting that health education is strongly associated with lifestyle changes, including medication adherence, diet changes, and healthy behaviours. This correlation is powerful, a testament to the importance of structured educational programs in steering patients in the right direction. (52-55) The study shows a moderate positive association between Health Information Literacy (HIL) and patient activation (PA), with patients embedding physical activity in their daily lives when given appropriate educational resources. This finding underscores the critical role of health information literacy (HIL) in promoting active patient engagement in managing health, particularly in the prevention and treatment of cardiovascular disease (55-56). Health-related behavioral outcomes (HRBO) and prior knowledge (PK) were highly positively correlated (r = 0.611) which suggests that patients with a higher level of knowledge about their cardiac condition are more likely to exhibit healthier behaviors. This highlights the importance of educational interventions for the promotion of effective self-care and optimal cardiac outcomes (57-58). This study indicates the role of knowledge in the implementation of health practices. When patients have known their disease, they tend to practice health-promoting behaviors such as taking treatment schedules, keeping check of their disease and attending physicians whenever it is needed. These findings concur with the concept of health literacy in that increased knowledge is usually linked with increased health behaviours and health outcomes. This must therefore prompt the cardiac patients to be prepared with accessible and trustworthy information, capable of empowering them to make their moves in order to assume their own health (59-63). To conclude, the general results reveal that consumer HIL is statistically predictive of patient knowledge and behaviour and partly determine health outcomes. HIL was found to have moderate to strong correlations with HRBO, PA and PK. The findings endorse a thorough and patient education which is not focused solely on making the patients stronger in their health education but also aimed at enabling them to make better healthy lifestyle choices. Managing the disease on a long-term basis and patient engagement improvement in underserved and marginalized patients, in particular, are the overall directions that should be explored in the future as part of the HIL research. The next avenue to research is on how digital health literacy can be applied to enhance health inequity and the increasing role of medical librarians and information professionals in enhancing outcomes and reducing clinical errors. The cause and effects of health literacy, patient behaviors and health outcomes, on individual, community and societal levels are complex and versatile and hence can develop influential context-specific evidence to be used to initiate deterrence to the development of evidence-based programs of education and healthcare policies. Limitation The results of the investigation, it cannot be generalized, though there is no knowledge of certain limitations in the study besides crucial correlations between HIL, HRBO, PA, and PK. Longitudinal researches can give more information about the interconnection between behavior or education changes with time and long-term patient outcomes. Conclusion Cardiac patients mainly engage family members and relatives while going for a doctor's visit, so the findings highlight the positive impact of family support on cardiac patients. There was a positive association between HIL and patient activation as well as prior knowledge and health behavior, signifying that better HIL was related to higher involvement with self-care activities and better patient outcomes. Recommendation Health systems should facilitate greater family engagement in cardiac care, through initiatives such as counseling or support groups. HIL is positively associated with key health outcomes, including patient activation (PA), health-related behavior and outcomes (HRBO), and prior knowledge (PK); therefore, HIL may represent a target of optimization. Promote exercise as part of cardiac rehab programs. Use digital platforms, workshops, or provider-led sessions to strengthen knowledge dissemination on heart health, self-care management, and lifestyle changes. Society, libraries, and health care professionals should contribute to better outcomes of CP to conduct awareness sessions, seminars about cardiac disease. Implication It recommends that health care, information providers create programs in which family members are actively included, awareness sessions and walks, health literacy programmes, knowledge about disease and education for self-care and disease. Improving self-management of chronic conditions, such as heart disease, could also result from community/family support interventions. Medical Library Professionals The study findings highlight the critical role of medical library professionals in supporting patient care and cardiac health outcomes. By facilitating access to reliable, evidence-based health information and promoting health information literacy, medical librarians can empower patients and healthcare providers to make informed decisions, enhance patient engagement, and support effective self-management of cardiovascular conditions. Integrating targeted information literacy programs into clinical and community settings can further strengthen the impact on cardiac health outcomes. Future Research The findings are to be considered exploratory since this study was a pilot one, and its sample size is small. Nevertheless, the results give a comprehensive empirical basis to further studies on a large-scale basis. The further research is needed to extend the determined correlations and evaluate their longitudinal effects using the data about large and more heterogeneous groups and with respect to all the provinces of Pakistan. His/her national studies would raise external validity and give possibility to make meaningful generalization of results nationally. The primary idea of the further research is the application of mixed-methods designs, which will apply quantitative procedures to assess the relations and outcomes and qualitative ones to comprehend patient experience, contextual procedures and processes. These designs would help to gain a better insight into the role of health information literacy (HIL) in the process of patient activation, self-care practices, and self-management of chronic diseases in diverse demographic and socioeconomic groups. Abbreviations HIL Health Information Literacy PA Patient activation PK Prior Knowledge HRBO Health Related Behaviour and Outcomes CVD Cardiovascular Disease ITHBC Integrated Theory of Health Behaviour Change) LMICs Low- and Middle-Income Countries Declarations Acknowledgements I would like to acknowledge the dr. Atta Ullah Khan Niazi (Associate Professor), King Edward Medical University and Institute of Information Management who allowed data collection Conflict of interest All authors declare no conflict of interest Consent to participate Informed Consent and Ethical Declaration Consent to publish Not applicable Ethical approval It was obtained the permission letter from Institute of Information Management, University of the Punjab, Lahore (n. D. 3081. Academic) Disclosures and declarations Sources of funding, or a declaration that no funding was received. Consent to Participate The informed consent was obtained; the authors are attesting that the participants were aware of the study purpose, risks and benefits. Data Availability Statement The datasets generated during and/or analysed during the current study are not publicly available due [REASON(S) WHY DATA ARE NOT PUBLIC] but are available from the corresponding author on reasonable request.]. 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Additional Declarations No competing interests reported. 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The\u0026ensp;number CVD) related deaths increased from 12.1\u0026nbsp;million in 1990 to 20.5\u0026nbsp;million in 2021, an increase of 60% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). This increase is largely growth of population, aging, and lifestyle changes. More than 80% of CVD\u0026ensp;deaths happen in low- and middle-income countries face a dual health burden associated with both communicable and non-communicable diseases contributing to the problem. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eCardiovascular disease (CVD) causes 18\u0026nbsp;million deaths each year globally, (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) with significant differences\u0026ensp;between low- and middle-income countries (LMICs) and high-income countries. response from LMICs contributes disproportionately\u0026ensp;to the global burden of CVDS, accounting for 80% of total global CVD-related deaths. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) A bigger worry is that premature deaths account for almost half of all deaths\u0026ensp;in developing countries. High-income countries produced 81.1% of the total global CVD research between 2008 and 2017 while having only 8.1% and 8.5% of absolute global CVD disability-adjusted life-year loss and death rates,\u0026ensp;respectively. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eHealth information literacy (HIL) is the cognitive and social skill that determine the motivation and ability of individuals to access, comprehend, and utilize information in a way that helps individuals\u0026ensp;promote and maintain good health. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) HIL means the attainment of a level of knowledge, personal skills and confidence to take action to improve personal and community\u0026ensp;health by changing personal lifestyles and living conditions. So, HIL is not just about reading pamphlets and making\u0026ensp;appointments. HIL is important to empowerment as it improves peoples access to health information\u0026ensp;and their ability to use it effectively. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eMueed et al. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) found that cardiac patients in Pakistan have limited knowledge and awareness about medication and follow-up procedures. The study (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) revealed that both males and females have adequate HIL, with disease knowledge. However, women had limited HIL in general health information, and men had limited HIL in health promotion and disease prevention.\u003c/p\u003e \u003cp\u003eHIL and patient activation have a positive association with health-related behavior and outcomes (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo enhance self-management techniques among cardiac patients, it is necessary to address both levels and determinants of HIL and patient activation (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Bahrom et al., (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) suggests creating patient-activation therapies to enhance self-management abilities, including skill development, tailored care plans, and mentorship. The study concluded that patients from 65 and older, whose visit-related expectations have been detected and addressed by doctors with the greatest accuracy, report the highest levels of health proactivity (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe research shows that individuals with higher education and salaries tend to have better patient activation. Additionally, health literacy, particularly the ability to understand and use health-related information, was found to be a statistically significant predictor of patient activation (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe study reveals that individuals with cardiac disease often have low health literacy and are less active, linked to socioeconomic factors and a negative attitude towards sickness. The findings are being used to develop a self-management program for these individuals. In order to comprehend their disease and manage their treatment regimens, patients with chronic diseases need health information skills (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHIL has been regarded as a significant determinant of health, and previous studies have demonstrated that health literacy\u0026ensp;is positively linked to health outcomes and health-related behavior. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) For the prevention, clinical management, and control of noncommunicable diseases (NCDs), health information literacy (HIL) has emerged as a key component of modern public health, empowering individuals and health systems to make informed and evidence-based decisions. The effectiveness of interventions for HIL on health\u0026ensp;outcomes concerning NCDs had been significant in previous study of cardiac patients. (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) Moreover, low health literacy is prevalent among people with cardiac disease, where prior investigations have suggested that nearly 40% of cardiac individuals possess a HIL and patient activation level that\u0026ensp;is insufficient for effective health outcome. Low HIL is also associated with a considerable economic burden, accounting for an estimated 3% to\u0026ensp;5% of overall healthcare expenditures globally, although this has yet to be investigated in cardiovascular disease. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) Singh et al (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) study on heart patients and found that patients with good knowledge, motivation, and skills delay seeking care for cardiac patient symptoms.\u003c/p\u003e \u003cp\u003eCardiac patient\u0026rsquo;s self-management requires understanding the condition and effective management techniques. The factors such as health literacy, awareness, and patient activation can support self-management in ambulatory cardiac patients. Patient activation positively impacts patient behaviors and health outcomes, with higher activation associated with better habits. To reduce CVD risk and mortality, extensive healthcare policy changes and public awareness campaigns are needed. Elder heart failure patients' self-care behaviors are correlated with health literacy and perceived social support (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Despite having health information literacy, they evaded care seeking, highlighting the need for further research on the influence of health information literacy on health-associated behavior and outcomes. There is no literature available in the Pakistani setting on HIL, patient activation, and disease knowledge that improves the health outcomes of cardiac patients to using the he health literacy skills (HLS) conceptual framework. The aim of this study is to explore the phenomena of HIL, prior knowledge, and patient activation to improve the cardiac patient outcomes and test the HLS model with the use of the theory of integrated health behavior change.\u003c/p\u003e\n\u003ch3\u003eStatement of Problem\u003c/h3\u003e\n\u003cp\u003ePoor HIL in Pakistan hinders disease prevention and management, particularly cardiovascular disease (CVDs). This lack of knowledge and awareness leads to poor health behaviors and decisions, reducing early diagnosis, medication adherence, and lifestyle factors. To achieve better results, health literacy is essential. HIL is essential to advance the health outcomes in the world since it is a means to provide the means of successfully accessing, comprehending, and applying health-related information. HIL of low has also been reported as a contributor to the propagation of cardiac disease especially in those areas where the level of knowledge, patient activation and quality of life is inadequate (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The chronic disease management as in the case of heart disease is an area where HIL should be strong since it can promote the results of patients as observed in other countries such as Pakistan where heart disease is a major cause of death among patients with cardiac problems (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). There have been no extensions made to HLS model to HIL, prior knowledge and health related behaviour and outcomes with prolonged patient activation construct. The template in this line of study must be bridged even more. Out of this gap, the current study relies on Integrated Theory of Health Behavior Change (ITHBC) (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) to form empirical evidence that would help in addressing improved understanding of health information literacy in different socioeconomic settings.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eResearch Objectives\u003c/h2\u003e \u003cp\u003eThe research objectives are:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo examine the influence of health information literacy on patient activation of cardiac patients.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo investigate the influence of health information literacy and health-related behaviours and outcomes of cardiac patients.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo explore the mediating role of patient activation in the relationship between HIL and health-related behaviours and outcomes of cardiac patients.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Theoretical Framework","content":"\u003cp\u003eThe research has been based on the Health Literacy Skills (HLS) Framework to assess the impact of health information literacy skills, prior knowledge, patient activation, and health outcomes in the context of cardiac care. The HLS Framework provides that the phenomena of health information literacy are dynamic and multidimensional and is more than the issue of ability to read and understand the health information to the ability to access, comprehend, evaluate and use health information to make well-informed decisions (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe study also incorporates the Integrated Theory of Health Behavior Change (ITHBC) on the behavior change process on the conversion of health information literacy to valuable behavior change and health improvement. Some of the key processes that lead to a long-lasting health behavior change that the ITHBC emphasized are the interaction of knowledge and faith, the ability to self-regulate, and social facilitation (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). This theory is quite applicable to the sphere of patient-centered care since it emphasizes that patients participate in the process of interpreting their health information, which is self-efficacy and the desire to improve the health results. Knowing the behavior as it pertains to the behaviors, the ITHBC will develop a theoretical prism in recognizing the relationship of the health problem, patient activation and eventual health rewards.\u003c/p\u003e \u003cp\u003eThe study gives a theoretical research model that gives 4 major constructs as prior knowledge, health information literacy skills, patient activation, and health-related behavior. Knowledge is foundational of the explanations of patients of the received information on health. Health information literacy prepares patients to be analytical in their means of evaluating the sources of information and make sound health choices. Patient activation demonstrates the level of motivation, confidence and competence in areas of management of personal health and medical treatment (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). The visible results of such a process are the health-related behaviors, such as treatment adherence, self-care and preventive practices. The existing study offers an extensive means of understanding the effect of the health information literacy as a cognitive resource and not a stimulus of behaviour with the integration of the HLS Framework and ITHBC. The model of the study highlights the crucial role of cardiac patients to the process of attaining better health outcomes and is consistent with the recent transition to the empowerment-based model of the modern healthcare system.\u003c/p\u003e\n\u003ch3\u003eHypothesis\u003c/h3\u003e\n\u003cp\u003e \u003cem\u003eH1: Health information literacy has significant impact on patient activation of cardiac patients.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eH2: Health information literacy has significant impact on prior knowledge.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eH3: Prior knowledge has positive impact on patient activation.\u003c/em\u003e \u003c/p\u003e\n\u003ch3\u003eH4: Prior knowledge has positive impact on health outcomes\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eH5: Patient activation has positive impact on health outcomes\u003c/h2\u003e \u003cp\u003e \u003cem\u003eH6: Patient activation has mediating role between HIL and health outcomes.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eH7: Patient knowledge has mediating role between HIL and health outcomes.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e "},{"header":"Research Methodology","content":"\u003cp\u003e\u003cstrong\u003eMethod\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research design adopted in this study incorporates a cross-sectional research design that involves the collection of data regarding the exposures and the results of the study subjects at a specific time. In contrast to longitudinal follow up cohort studies and retrospective comparison of cases starting with cohort studies, cross-sectional studies provide a description of current relationships among variables within set population (29,30). The type is particularly applicable in studies that are more related to health, behavior, and social sciences in which the objective to investigate is to explore the patterns, associations or the determiners and not to demonstrate long-term connections.\u003c/p\u003e\n\u003cp\u003eThe cross-sectional study design is consistent with the quantitative research technique, which offers an opportunity to measure the pre-defined variables in a systematic manner and verify the research objectives or hypotheses statistically. The design enables the efficient study of the interrelations of the variables of exposure (e.g. health information literacy, prior knowledge, patient activation, and health related behaviors and outcomes).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePopulation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study\u0026apos;s target population consists of adult heart patients, Patients who were suffered with heart conditions of any kind, The population of the study were cardiac patients who were admitted to the Cardiac Surgery and Cardiology Department of Mayo Hospital Lahore. The participants were chosen in accordance with the study\u0026apos;s inclusion criteria, which were based on age, gender, disease features, and qualifications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe following inclusion criteria are used to choose study participants:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1. At least madrasa (\u003cem\u003eReligious and Islamic educational institution that provides structured instruction in reading, writing, comprehension, and interpretation, often in Arabic and/or the local language\u003c/em\u003e) to university qualified adult cardiac patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2. Patients with heart conditions of any kind were included.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants were excluded according to the following criteria to guarantee that they\u0026ensp;were appropriate for the study:\u003c/p\u003e\n\u003cp\u003eNon-cardiac patients: All\u0026ensp;patients free of any type of heart or cardiovascular disease.\u003c/p\u003e\n\u003cp\u003ePatients aged less than 18 years: The present study did not\u0026ensp;include patients aged \u0026lt;18 years.\u003c/p\u003e\n\u003cp\u003ePatients in acute or critical condition: Cardiac patients who were in an acute or critical\u0026ensp;stage of their illness (e.g., in the intensive care unit) were excluded as their condition could compromise their ability to participate effectively.\u003c/p\u003e\n\u003cp\u003ePatients with non-cardiac comorbidities that may influence the study outcomes:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePatients that refused to participate\u0026ensp;(no consent).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSampling Technique and Sample Size\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSampling method\u0026ensp;being used in this study is Convenience Sampling. A non-random sampling approach (e.g., convenience sampling), wherein participants were\u0026ensp;chosen based on their availability and accessibility to the researcher instead of a random selection process. One of the main uses of non-probability sampling occurs when the existence of restrictions on time, budgets, or the accessibility of subjects limits the ability to select a\u0026ensp;representative random sample.\u003c/p\u003e\n\u003cp\u003eA total of 144\u0026ensp;adult cardiac patients were enrolled through non-probability convenience sampling technique from the Cardiac Surgery and Cardiology Department of Mayo Hospital Lahore. Patients were convenient and, on\u0026ensp;admission to, or while visiting the outpatient department of the hospital were willing to participate in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTool Development and Measurement of Constructs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA questionnaire as an instrument for the data collection purpose was used. The instrument was divided into three parts;\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eDemographic information\u003c/li\u003e\n \u003cli\u003eQuestions about patient knowledge and awareness, health care terminologies, and illness experience about disease.\u003c/li\u003e\n \u003cli\u003eIn the third part of the instrument, the researcher was distributed in constructs in Likert scale like health information literacy, patient activation, and health outcomes of cardiac patients in Punjab, Pakistan.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eIn this study, the data collection tool was a semi-structured questionnaire, which was adapted according to existing literature on the variants of previously published (26,27,28) instruments which were valid and demonstrated their validity in earlier research works. The process of adaptation made sure that the questionnaire was theoretically based and fit to the context in measuring the level of health information literacy, patient activation and health outcomes with cardiac patients in Punjab, Pakistan.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthical approval:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is based on a PhD research project approved by the Advanced Studies and Research Board (ASRB), University of the Punjab, Lahore, Pakistan (Registration No. D/3081/Acad) on dated September 12, 2022. The study protocol was conducted in accordance with the guidelines of the ICMJE recommendations, the principles of the Declaration of Helsinki, and the ethical standards of the World Medical Association.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent to participate:\u003c/em\u003e\u003c/strong\u003e The researcher upheld study ethics, obtained written consent from participants, used a semi structured questionnaire, communicated the study\u0026apos;s purpose, and maintained data confidentiality, avoiding shared with any person or organization. Written informed consent was obtained from all participants before data collection. For participants under the age of 18 years, written informed consent was obtained from their parent or legal guardian prior to inclusion in the study (Appendix B).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent to publish:\u003c/em\u003e\u003c/strong\u003e Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDelimitation of the Study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Mayo Hospital for Heart Patients in Lahore was the exclusive focus of the investigation. The study excluded non-teaching clinical settings, private consultant clinics, and other departments. The frame of the target population does not include different cardiac settings in other Pakistani provinces.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReliability and Validity of the Instrument\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study utilized pilot testing to prepare for data collection. The instrument used in the study was marked as \u0026apos;adapted\u0026apos;, ensuring its validity and reliability. Smart PLS was applied to check the reliability of the instrument.\u003c/p\u003e\n\u003cp\u003eTable 1: Cronbach Alpha and Composite Reliability\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eCronbach\u0026apos;s alpha\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eComposite reliability (rho_a)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eComposite reliability (rho_c)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eAverage variance extracted (AVE)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eReferences\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHIL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.975\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.977\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26-28, 29, 30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHRBO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.808\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.827\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.861\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.512\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e31-33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.749\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.759\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.833\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.502\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e34-35\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.879\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.897\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.454\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e36-38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eMeasures of reliability and validity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 3. Reliability and validity statistics for four constructs: Health Information Literacy (HIL), Health-Related Behavioral Outcomes (HRBO),\u0026ensp;Patient Activation (PA), and Prior Knowledge (PK). It comprises of Cronbach\u0026apos;s Alpha, Composite\u0026ensp;Reliability (rho_a), Composite Reliability (rho_c) and Average Variance Extracted (AVE). These measures help to establish the reliability and validity of\u0026ensp;the constructs employed in the research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCronbach\u0026apos;s Alpha\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCronbach\u0026rsquo;s\u0026ensp;alpha indicates the internal consistency or reliability of a scale. Values above 0.7 generally\u0026ensp;taken acceptable. HIL has an excellent internal consistency\u0026ensp;with a very high Cronbach\u0026rsquo;s alpha of 0.975. The flexible Cronbach\u0026rsquo;s alpha for HRBO is acceptable 0.808 and\u0026ensp;indicates a reliable measurement of the construct. PA\u0026apos;s Cronbach\u0026apos;s alpha of\u0026ensp;0.749 is still within an acceptable range, but slightly lower than the others. PK has an excellent Cronbach\u0026rsquo;s alpha of 0.879, overall, indicating\u0026ensp;good internal consistency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eComposite Reliability\u0026ensp;(rho_a and rho_c)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere are two types of\u0026ensp;composite reliability: rho_a and rho_c. Composite reliability above\u0026ensp;0.7 means high reliability. For HIL (Health Information Literacy) composite reliability for rho_a is 0.98 and\u0026ensp;rho_c is 0.977, showing very high composite reliability for HIL and indicates that all items are significant to represent the Health Information Literacy construct. The value of rho_a and rho_c for HRBO are respectively 0.827 and 0.861 which are above the cutoff\u0026ensp;point of 0.7 defining a good level of reliability. Both PA rho_a (0.759)\u0026ensp;and rho_c (0.833), also suggesting acceptable reliability. The PK has rho_a of 0.897 and rho_c\u0026ensp;of 0.9, both excellent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAVE:\u0026ensp;Average Variance Extracted\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAVE denotes the explanation of variance information of\u0026ensp;construct with the relative variance of measurement error. AVE values of 0.50 or higher support that the construct explains at least 50% of the variance of the items, therefore also indicative of good\u0026ensp;convergent validity.\u003c/p\u003e\n\u003cp\u003eBased on these threshold\u0026ensp;values, as AVE value of HIL is 0.74, implying high convergent validity since, AVE\u0026gt;0.50. The AVE for HRBO was 0.512, which is marginally\u0026ensp;greater than 0.50, indicating acceptable convergent validity. Convergent validity was plumbed as AVE was above 0.50, with AVE for PA\u0026ensp;being 0.502.\u003c/p\u003e\n\u003cp\u003eGiven that PK has an AVE of 0.454 (below the desired value of 0.50), we can say that it\u0026ensp;has potentially low validity.\u003c/p\u003e\n\u003cp\u003eAll constructs display acceptable to excellent internal consistency and composite reliability, indicating that the scales were used in the study\u0026ensp;reliably represents their constructs.\u003c/p\u003e\n\u003cp\u003eThe Health Information Literacy (HIL) construct has\u0026ensp;the highest reliability and validity measurement in comparison with other constructs, which is classified with high Cronbach\u0026rsquo;s alpha, composite reliability, and AVE value.\u003c/p\u003e\n\u003cp\u003eWhile HRBO, PA, and PK display acceptable levels of reliability and convergent\u0026ensp;validity, PK has a slightly lower AVE indicating that while acceptable results were found for PK there may be implications for improving measurements.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection Procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter revision by expert and supervisors, the questionnaire was finalized and the researcher\u0026ensp;provided step-by-step method of filling the questionnaire to all cardiac patients. The researcher assisted the cardiac patients to fill the questionnaire in the cardiovascular department of Outpatient Department (OPD) and ward from Mayo Hospital, Lahore to collect the data.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis Plan\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe researcher statistically analyzed the quantitative data using\u0026ensp;(SPSS) version 22. For the hypothesis and objectives of the research the statistical analysis such as descriptive statistics like frequency of distribution, tables graphs, and Smart PLS for inferential statistics regression, hierarchical regression was used to test the model.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe findings of the sociodemographic of the data (table 2), the sample was male (71.4%) and includes\u0026ensp;older age groups (44.3% aged \u0026gt;50 years). Nearly half have a\u0026ensp;low income (i.e. earn less than 32,000 PKR). They also have varying levels of educational attainment, with many unaided and only going to\u0026ensp;madrassa. Occupationally, there are private sector employees,\u0026ensp;homemakers, students. Culturally coherent with linguistic ethnicity, Punjabi and\u0026ensp;Urdu dominate (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Sociodemographic of the data\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u0026lt;30 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e23(16.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e31-40 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e27(19.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e41-50 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e28(20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e51-60 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e29(20.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eAbove 60 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e33(23.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e100(71.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e40(28.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonthly Income in Pakistani Rupees\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u0026lt;32000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e79(56.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e32001-50000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e37(26.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e50001-70000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e53.6% ()\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e70001-90000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e7(5.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e90001-11000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e2(1.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eAbove 111000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e4(2.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e6 (4.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eUneducated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e39(27.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eMadrassa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e19(13.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eSchool Level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e46(32.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eCollege Level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e9(6.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eUnder Graduation (University)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e15(10.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003ePost-Graduation (University)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e10(7.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e2(1.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"9\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmployment / Occupation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eStudent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e18(12.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eFarmer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e19(13.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eBusinessman\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e11(7.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003ePrivate Job\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e27(19.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eGovernment Job\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e13(9.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eHealth Care Professional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e1(0.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eEducationalist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e1(0.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eHousewife\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e26(18.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e24(17.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCulture\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eUrdu\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e31(22.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003ePunjabi\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e60(42.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eSaraiki\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e35(25.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003ePotohari\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e7(5.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eSindhi\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e3(2.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003ePashtoo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e2(1.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e2(1.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eFigure 1 indicated that the majority of patients have family support (111, 79%) when they need help; when things go wrong, they have again family support (82, 58%), colleagues (22, 16%), and relatives (21, 15%). When patients have joys and sorrows, the family supports them 77 (55%), colleagues 28 (20%), and relatives 23 (16%). Talks about problems: the majority of cardiac patients have family (70, 50%) and relatives (37, 26%) accompany them during doctor visits, the family supports (74, 53%) and relatives (45, 32%).\u003c/p\u003e\n\u003cp\u003eTable 2 indicated the reliability of the instrument; Cronbach alpha is a measure of internal consistency and composite reliability in the context of\u0026ensp;construct reliability. Cronbach\u0026apos;s alpha should be close to 0.70\u0026ensp;and 0.90, indicating that item reliability is high. Composite reliability\u0026ensp;(CR) values must be \u0026gt; 0.70, once again seen in Table 4 where composite reliability values of each construct are higher than 0.7, suggesting that there was no construct reliability issue. The same applies\u0026ensp;to rho_A and rho_A values.\u003c/p\u003e\n\u003cp\u003eTable 3: Regression Coefficients (Path analysis of direct effects)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"594\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHypothesis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 214px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePath coefficients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal effects\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eT stat\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDecision\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eH1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003eHIL -\u0026gt; PA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e0.249\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e0.366\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e3.033\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eAccepted\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eH2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003eHIL -\u0026gt; PK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e0.296\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e0.296\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e4.208\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eAccepted\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eH3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003ePA -\u0026gt; HRBO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e0.366\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e0.366\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e4.116\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eAccepted\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eH4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003ePK -\u0026gt; HRBO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e0.438\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e0.584\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e5.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eAccepted\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eH5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003ePK -\u0026gt; PA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e0.397\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e0.397\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e4.513\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eAccepted\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 519px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpecific indirect effects\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eH6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003eHIL -\u0026gt; PA -\u0026gt; HRBO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e0.091\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e0.091\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e2.866\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eAccepted\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eH7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003eHIL -\u0026gt; PK -\u0026gt; HRBO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e3.253\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eAccepted\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003eHIL -\u0026gt; PK -\u0026gt; PA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e0.118\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e0.118\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e2.134\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.033\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003eHIL -\u0026gt; PK -\u0026gt; PA -\u0026gt; HRBO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e0.043\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e0.043\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e2.316\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003ePK -\u0026gt; PA -\u0026gt; HRBO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e0.145\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e0.145\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e2.764\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eH1: Health information literacy has significant impact on patient activation.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eH2: Health information literacy has significant impact on prior knowledge.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eH3: Patient activation has positive impact on health outcomes.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eH4: Prior knowledge has positive impact on. health outcomes.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eH5: Prior knowledge has positive impact on patient activation.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eH6: Patient activation has mediating role between HIL and health outcomes.\u003c/p\u003e\n\u003cp\u003eH7: Patient knowledge has mediating role between HIL and health outcomes.\u003c/p\u003e\n\u003cp\u003eHypotheses Path Coefficients Total Effects t-statistics p-values Hypotheses Link to\u0026ensp;the Paper The findings can be summarized\u0026ensp;as follows:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe path coefficient of Health Information Literacy (HIL\u0026ensp;-\u0026gt; PA) is 0.249, which is moderate positive. This effect is indeed significant as evidenced by the t-statistic\u0026ensp;(3.033) and p-value (0.002) so we will accept this hypothesis. H2 (HIL -\u0026gt; PK): The path coefficient of 0.296 indicates that the effect\u0026ensp;of HIL on the (PK) has a moderate strength in the positive direction. Since both the t-statistic\u0026ensp;(4.208) and p-value (0.000) in such cases are statistically significant, the effect is accepted. H3 (PA -\u0026gt; HRBO):\u0026ensp;The path coefficient of 0.366 indicates that patient activation positively affects HRBO. The relationship\u0026ensp;is highly significant (t = 4.116; p = 0.000), therefore the hypothesis is accepted. H4\u0026ensp;(PK -\u0026gt; HRBO): Hypothesis four indicates the path coefficient whose value is 0.438 shows significance of magnitude from predictor, prior knowledge (PK) to group- mean, health-related behavioral outcomes (HRBO), and as per very high t-statistic (5.77) and a low p-value (0.000) we can say that this hypothesis is accepted. H5 (PK -\u0026gt; PA): Prior knowledge (PK)\u0026ensp;plays a significant role to the patient activation (PA) with a path coefficient of 0.397. The t-statistic (4.513) and the p-value (0.000) indicate that this effect is statistically significant, leading to\u0026ensp;an acceptance of this hypothesis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMediating Effects:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe specific indirect effects detail the way one variable impacts on\u0026ensp;another via a third \u0026lsquo;mediating\u0026rsquo; variable. Results for the indirect\u0026ensp;effects were:\u003c/p\u003e\n\u003cp\u003eH6 (HIL\u0026rarr;PA\u0026rarr;HRBO): The indirect effect of HIL on health-related behavioral outcomes by means of the process of patient activation (PA) is significant (path coefficient\u0026ensp;= 0.091, t = 2.866, p = 0.004), confirming patient activation as a mediator in the relationship between HIL and health outcomes. This hypothesis is accepted. H7 (HIL -\u0026gt; PK -\u0026gt; HRBO):\u0026ensp;The indirect effect of HIL on health-related behavioral outcomes through prior knowledge (PK) is significant (path coefficient = 0.13, t = 3.253, p = 0.001), confirming that prior knowledge mediates the relationship between HIL and HRBO. This hypothesis is accepted. HIL\u0026rarr;PK\u0026rarr;PA: The indirect effect of HIL on PA via PK is also significant (path coefficient = 0.118, t = 2.134, p = 0.033), indicating prior knowledge explains\u0026ensp;how HIL would influence patient activation. This result is accepted.\u003c/p\u003e\n\u003cp\u003eHIL -\u0026gt; PK -\u0026gt; PA -\u0026gt; HRBO: The indirect effect of HIL on health-related behavioral outcomes (HRBO) through prior knowledge (PK) and patient activation (PA) are statistically significant (path coefficient = 0.043, t\u0026ensp;= 2.316, p = 0.021), implying that HIL and health outcomes are mediated by both PK and PA. This hypothesis is accepted. PK \u0026rarr; PA \u0026rarr; HRBO: The mediating effect of\u0026ensp;patient activation between prior knowledge and health-related behaviors is significant according to the indirect effect (path coefficient = 0.145, t = 2.764, p = 0.006), which gives supportive evidence of its mediating role. This hypothesis is accepted.\u003c/p\u003e\n\u003cp\u003eTable 4: Heterotrait-monotrait ratio (HTMT) \u0026ndash; Matrix\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHIL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHRBO\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePK\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHIL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHRBO\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e0.253\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e0.366\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e0.573\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePK\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e0.296\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e0.611\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHIL and HRBO (0.253) shows a positive correlation of 0.253 that suggests\u0026ensp;a positive correlation of these two variables. HIL and PA (0.366): A correlation of 0.366\u0026ensp;means there is a moderate positive correlation, so as HIL increases, so does PA. HRBO vs PA (0.573): A positive correlation of 0.573 indicates a moderate positive correlation between the\u0026ensp;two, stronger than the previous comparison. Correlation between HIL and PK (0.296): A correlation of 0.296 indicates\u0026ensp;a weak positive relationship. HRBO and PK (0.611)\u0026ensp;: A correlation of 0.611 shows a moderate to strong positive relationship. PA and PK (0.47): There is a moderately positive correlation of\u0026ensp;0.47 between PA and PK.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5: Cross-factors (Outer) Loading and Outer Weights\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003eOuter loadings\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eHILSkills10 \u0026lt;- HIL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.771\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eHILSkills11 \u0026lt;- HIL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.786\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eHILSkills12 \u0026lt;- HIL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.837\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eHILSkills13 \u0026lt;- HIL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.857\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eHILSkills14 \u0026lt;- HIL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.877\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eHILSkills15 \u0026lt;- HIL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eHILSkills16 \u0026lt;- HIL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.888\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eHILSkills17 \u0026lt;- HIL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.879\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eHILSkills18 \u0026lt;- HIL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.893\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eHILSkills19 \u0026lt;- HIL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.923\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eHILSkills20 \u0026lt;- HIL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.917\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eHILSkills21 \u0026lt;- HIL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.916\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eHILSkills22 \u0026lt;- HIL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.815\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eHILSkills8 \u0026lt;- HIL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.762\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eHILSkills9 \u0026lt;- HIL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.859\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003ePKAK1 \u0026lt;- PK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.754\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003ePKAK2 \u0026lt;- PK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.776\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003ePKAK3 \u0026lt;- PK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.709\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003ePKAK4 \u0026lt;- PK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.734\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003ePKAK5 \u0026lt;- PK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.715\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003ePKAK6 \u0026lt;- PK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003ePKIE1 \u0026lt;- PK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.728\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003ePKIE2 \u0026lt;- PK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003ePKIE3 \u0026lt;- PK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.565\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003ePKIE4 \u0026lt;- PK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.532\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003ePKIE5 \u0026lt;- PK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.507\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003ePatientActivation1 \u0026lt;- PA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.772\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003ePatientActivation2 \u0026lt;- PA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.767\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003ePatientActivation3 \u0026lt;- PA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.714\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003ePatientActivation4 \u0026lt;- PA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.581\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003ePatientActivation5 \u0026lt;- PA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.692\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eWHOQoL1 \u0026lt;- HRBO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.631\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eWHOQoL2 \u0026lt;- HRBO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eWHOQoL3 \u0026lt;- HRBO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.788\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eWHOQoL4 \u0026lt;- HRBO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.747\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eWHOQoL5 \u0026lt;- HRBO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.616\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eWHOQoL6 \u0026lt;- HRBO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.614\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eThe outer loadings give the relation of each\u0026ensp;indicator with its relative latent variable (for instance, HIL, PK, PA, and HRBO). The association strength between latent\u0026ensp;and indicator variables is the higher the outer loading. Loadings over 0.70 are generally acceptable.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe results demonstrate the beneficial effects of family support on cardiac patients, who primarily include family members and relatives when visiting a doctor. Higher HIL was linked to greater engagement in self-care activities and better patient outcomes, as evidenced by the positive correlation found between HIL and patient activation, prior knowledge, and health behavior. The study also suggests and similar with (26), Persistent disparities in income, wealth, and other socioeconomic determinants are consistently associated with inferior cardiovascular health and diminished quality of life among cardiac patients and constitute major contributors to racial and ethnic disparities in cardiovascular disease (CVD) outcomes. (39-40)\u003c/p\u003e\n\u003cp\u003eTogether, these conditions provide emotional and material support, support the patients in joy and sorrow, create role models and set attitudes and practices toward health and health care and the findings support the study. (41) Previous studies have shown a significant associational relationship between deprived socioeconomic status and a smaller/ poorer social network. (15) In contrast, however, mixed-income neighborhoods can increase positive community-level interaction, expand social networks, and benefit health overall. (42\u003c/p\u003e\n\u003cp\u003eFurthermore, prior studies have mostly been centered on diseased populations, for example, sufferers with cardiac conditions or cardiovascular disease (CVD), in contrast to being centered on population. The total observed relationship between health information literacy (HIL) and health related behavioral outcome (HRBO) is r = 0.253 which is a very modest but positive correlation, meaning that increases in HIL are correlated with increases in health-related behaviors.\u003c/p\u003e\n\u003cp\u003eThe study also supports our study and expands the scientific knowledge in terms of HIL and PA (0.366) health behaviors among people without diseases in this study. (3, 30-43)\u003c/p\u003e\n\u003cp\u003eThe instrument, the EU-HLS-Q47 was used and moving to communicative and HIL from basic and functional health literacy requires; higher-level skills including cognitive skills, literacy, communication capacity, social and self-efficacy. (44-45) Hence, the functional level of health literacy may be insufficient to modify behavior regarding health. The study noted that only communicative and critical health literacy, but not functional literacy, were related to health-related lifestyle behaviours in the study. Several plausible mechanistic links between health literacy and health actions and outcomes have been hypothesized in previous studies. (5, 46-47) The HIL plays a fundamental role in determining health outcomes through disease knowledge, positive attitudes, patient activation, and behavior change among cardiac patients and support with our findings HIL and HRBO (0.253) shows a positive correlation of 0.253 that suggests a positive correlation of these two variables. HIL and PA (0.366), A correlation of 0.366 means there is a moderate positive correlation, so as HIL increases, so does PA. HRBO vs PA (0.573). (33-38, 48)\u003c/p\u003e\n\u003cp\u003eAccording to the existing evidence and the results from our study, HIL appears to be a major target for national health promotion. According to World Health Organization (WHO), raising health literacy is one of the important elements in the 2030 agenda for sustainable development. (52) A great amount of data proves that a healthy lifestyle prevents many diseases (48-51), such as obesity, diabetes, cardiovascular disease, stroke, or cancers. In addition to this causal relationship between healthy lifestyle and disease prevention, our finding that high health literacy facilitates people's improvement of health-related lifestyle behaviors supports the national health promotion program including health literacy intervention as one of its core targets. (51-52)\u003c/p\u003e\n\u003cp\u003eThe results of this study show significant associations between HIL, Health-Related Behavioural Outcomes (HRBO), patient activation (PA) and Prior Knowledge (PK). These correlations contribute to the understanding of education, behavior, and knowledge in cardiac patient management. Understanding how these factors interact and impact inbound or outbound productivity eventually provides a measure of patient risk involved in heart management (such as readmission rate, prevention, lifestyle habits, etc) and increasingly becomes important for interpreting these relationships.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe correlation between health information literacy (HIL) and health-related behavioral outcomes (HRBO) (r = 0.573) varies between moderate and positive. This indicates that higher levels of HIL are related to better health-related behaviors among patients. The strength of this association suggests that educational interventions that improve the health information literacy of patients may be an effective way to empower patients to manage their health in a proactive manner and adopt behaviors that are conducive to optimal health outcomes.\u003c/p\u003e\n\u003cp\u003eThis aligns with literature suggesting that health education is strongly associated with lifestyle changes, including medication adherence, diet changes, and healthy behaviours. This correlation is powerful, a testament to the importance of structured educational programs in steering patients in the right direction. (52-55)\u003c/p\u003e\n\u003cp\u003eThe study shows a moderate positive association between Health Information Literacy (HIL) and patient activation (PA), with patients embedding physical activity in their daily lives when given appropriate educational resources.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis finding underscores the critical role of health information literacy (HIL) in promoting active patient engagement in managing health, particularly in the prevention and treatment of cardiovascular disease (55-56).\u003c/p\u003e\n\u003cp\u003eHealth-related behavioral outcomes (HRBO) and prior knowledge (PK) were highly positively correlated (r = 0.611) which suggests that patients with a higher level of knowledge about their cardiac condition are more likely to exhibit healthier behaviors. This highlights the importance of educational interventions for the promotion of effective self-care and optimal cardiac outcomes (57-58).\u003c/p\u003e\n\u003cp\u003eThis study indicates the role of knowledge in the implementation of health practices. When patients have known their disease, they tend to practice health-promoting behaviors such as taking treatment schedules, keeping check of their disease and attending physicians whenever it is needed. These findings concur with the concept of health literacy in that increased knowledge is usually linked with increased health behaviours and health outcomes. This must therefore prompt the cardiac patients to be prepared with accessible and trustworthy information, capable of empowering them to make their moves in order to assume their own health (59-63).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo conclude, the general results reveal that consumer HIL is statistically predictive of patient knowledge and behaviour and partly determine health outcomes. HIL was found to have moderate to strong correlations with HRBO, PA and PK. The findings endorse a thorough and patient education which is not focused solely on making the patients stronger in their health education but also aimed at enabling them to make better healthy lifestyle choices. Managing the disease on a long-term basis and patient engagement improvement in underserved and marginalized patients, in particular, are the overall directions that should be explored in the future as part of the HIL research. The next avenue to research is on how digital health literacy can be applied to enhance health inequity and the increasing role of medical librarians and information professionals in enhancing outcomes and reducing clinical errors. The cause and effects of health literacy, patient behaviors and health outcomes, on individual, community and societal levels are complex and versatile and hence can develop influential context-specific evidence to be used to initiate deterrence to the development of evidence-based programs of education and healthcare policies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe results of the investigation, it cannot be generalized, though there is no knowledge of certain limitations in the study besides crucial correlations between HIL, HRBO, PA, and PK. Longitudinal researches can give more information about the interconnection between behavior or education changes with time and long-term patient outcomes.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eCardiac patients mainly engage family members and relatives while going for a doctor's visit, so the findings highlight the positive impact of family support on cardiac patients. There was a positive association between HIL and patient activation as well as prior knowledge and health behavior, signifying that better HIL was related to higher involvement with self-care activities and better patient outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecommendation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHealth systems should facilitate greater family engagement in cardiac care, through initiatives such as counseling or support groups. HIL is positively associated with key health outcomes, including patient activation (PA), health-related behavior and outcomes (HRBO), and prior knowledge (PK); therefore, HIL may represent a target of optimization. Promote exercise as part of cardiac rehab programs. Use digital platforms, workshops, or provider-led sessions to strengthen knowledge dissemination on heart health, self-care management, and lifestyle changes. Society, libraries, and health care professionals should contribute to better outcomes of CP to conduct awareness sessions, seminars about cardiac disease. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIt recommends that health care, information providers create programs in which family members are actively included, awareness sessions and walks, health literacy programmes, knowledge about disease and education for self-care and disease. Improving self-management of chronic conditions, such as heart disease, could also result from community/family support interventions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMedical Library Professionals\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study findings highlight the critical role of medical library professionals in supporting patient care and cardiac health outcomes. By facilitating access to reliable, evidence-based health information and promoting health information literacy, medical librarians can empower patients and healthcare providers to make informed decisions, enhance patient engagement, and support effective self-management of cardiovascular conditions. Integrating targeted information literacy programs into clinical and community settings can further strengthen the impact on cardiac health outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFuture Research\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe findings are to be considered exploratory since this study was a pilot one, and its sample size is small. Nevertheless, the results give a comprehensive empirical basis to further studies on a large-scale basis. The further research is needed to extend the determined correlations and evaluate their longitudinal effects using the data about large and more heterogeneous groups and with respect to all the provinces of Pakistan. His/her national studies would raise external validity and give possibility to make meaningful generalization of results nationally. The primary idea of the further research is the application of mixed-methods designs, which will apply quantitative procedures to assess the relations and outcomes and qualitative ones to comprehend patient experience, contextual procedures and processes. These designs would help to gain a better insight into the role of health information literacy (HIL) in the process of patient activation, self-care practices, and self-management of chronic diseases in diverse demographic and socioeconomic groups.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eHIL\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealth Information Literacy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePA\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePatient activation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePK\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePrior Knowledge\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eHRBO\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealth Related Behaviour and Outcomes\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCVD\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCardiovascular Disease\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eITHBC\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntegrated Theory of Health Behaviour Change)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eLMICs\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLow- and Middle-Income Countries\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eI would like to acknowledge the dr. Atta Ullah Khan Niazi (Associate Professor), King Edward Medical University and Institute of Information Management who allowed data collection\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declare no conflict of interest\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed Consent and Ethical Declaration\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIt was obtained the permission letter from Institute of Information Management, University of the Punjab, Lahore (n. D. 3081. Academic)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosures and declarations\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSources of funding, or a declaration that no funding was received.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe informed consent was obtained; the authors are attesting that the participants were aware of the study purpose, risks and benefits.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated during and/or analysed during the current study are not publicly available due [REASON(S) WHY DATA ARE NOT PUBLIC] but are available from the corresponding author on reasonable request.].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGF\u003c/strong\u003e: writing the manuscript,\u003cstrong\u003e\u0026nbsp;data\u003c/strong\u003e collection, and analysis, \u003cstrong\u003eKM\u003c/strong\u003e: Supervised the project, \u003cstrong\u003eSHB\u003c/strong\u003e: Review and supervised\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCardiovascular diseases. 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Assessing the impact of health information orientation and health information literacy on patients\u0026rsquo; engagement with health information. J Inform Sci. 2024 Feb;19:01655515241227871.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Health Information Literacy Skills, Health Literacy, Health Need, Prior Knowledge, Patient Activation, Social Support, Health Outcomes, Health Behavior, Cardiac patients, Pakistan","lastPublishedDoi":"10.21203/rs.3.rs-8826635/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8826635/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eThe study aims at investigating the improvement of health outcomes through patient knowledge, activation, and health information literacy guided by the framework of health literacy skills (HLS) and (integrated theory of health behaviour change) ITHBC model\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eA cross-sectional survey was carried out adapted structured questionnaire to collect data from 140 cardiac patients at Mayo Hospital, Lahore Pakistan. The sample was taken from the targeted population, including pilot testing, using a purposeful\u0026ensp;sampling method. The smart PLS used for PLS-SEM Structural Equation Modelling.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe study reveals that the majority of patients, have family support (111.79%) when needed, colleagues (22.16%), and relatives (21.15%) when things go wrong. Family support is the most common, followed by colleagues (20%) and relatives (16%). The majority of cardiac patients have family and relatives accompanying them during doctor visits. This research reveals notable connections and mediating effects between Health Information Literacy (HIL), Patient Activation\u0026ensp;(PA), Prior Knowledge (PK), and Health-Related Behavior Outcomes (HRBO). Results show that HIL has a highly positive impact on both PA (path coefficient\u0026thinsp;=\u0026thinsp;0.249, p\u0026thinsp;=\u0026thinsp;0.002) and PK (path\u0026ensp;coefficient\u0026thinsp;=\u0026thinsp;0.296, p\u0026thinsp;=\u0026thinsp;0.000). PA has a positive effect on HRBO (path coefficient =\u0026ensp;0.366, p\u0026thinsp;=\u0026thinsp;0.000), and PK has a strong influence on HRBO (path coefficient\u0026thinsp;=\u0026thinsp;0.438, p\u0026thinsp;=\u0026thinsp;0.000). PK has also a\u0026ensp;significant effect on PA (path coefficient\u0026thinsp;=\u0026thinsp;0.397, p\u0026thinsp;=\u0026thinsp;0.000).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe\u0026ensp;findings of this study showed that HIL, PA and PK have a significant effect on HRBO. PA and PK both have positive effects on HRBO, and HIL has positive\u0026ensp;effects on PA and PK. In addition, PA mediates the effects of HIL on HRBO, whereas PK plays\u0026ensp;mediating roles in linking either HIL and HRBO or HIL and PA.\u003c/p\u003e","manuscriptTitle":"Enhancing Cardiac Health Outcomes through Knowledge and Health Information Literacy Evidence from a Pilot Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-19 12:39:13","doi":"10.21203/rs.3.rs-8826635/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-23T12:34:12+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"201279172058418773706776075022558947040","date":"2026-03-17T05:09:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"129306754766170734946535926506065778362","date":"2026-03-16T15:00:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-16T03:02:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"249535899744555847048320123702489195918","date":"2026-03-15T20:51:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"235976653793336273036544454205072815012","date":"2026-03-14T15:28:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-14T01:35:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-08T10:36:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"134304452322626521856245503237172706612","date":"2026-03-06T22:12:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"265962451206741555740484146237155240655","date":"2026-03-03T02:26:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"222490446112190161948122757395586587200","date":"2026-03-02T14:00:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"52560189848114743808743806414329005134","date":"2026-02-28T12:52:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"96299767930073739253742789505695787282","date":"2026-02-28T12:14:17+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-28T10:45:09+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-25T10:55:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-17T12:20:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-17T06:37:53+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Public Health","date":"2026-02-17T06:32:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6ead24fb-3375-4eba-971c-17c955d2416c","owner":[],"postedDate":"February 19th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T14:40:24+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-19 12:39:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8826635","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8826635","identity":"rs-8826635","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}