Illness perception, self-efficacy, health literacy, adherence, and quality of life in patients with intermittent claudication – a longitudinal cohort study

Illness perception, self-efficacy, health literacy, adherence, and quality of life in patients with intermittent claudication – a longitudinal cohort 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 Illness perception, self-efficacy, health literacy, adherence, and quality of life in patients with intermittent claudication – a longitudinal cohort study Rebecka Striberger, Moncef Zarrouk, Christine Kumlien, Malin Axelsson This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2623748/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 May, 2023 Read the published version in BMC Nursing → Version 1 posted 8 You are reading this latest preprint version Abstract Background : Patients with intermittent claudication need lifelong treatment with secondary prevention to prevent cardiovascular events and progression of atherosclerotic disease. Illness perception, health literacy, self-efficacy, adherence to medication treatment, and quality of life are factors influencing patients’ self-management. Knowledge of these factors could be important when planning for secondary prevention in patients with intermittent claudication. Aim: to compare illness perception, self-efficacy, adherence to treatment, and quality of life in relation to the sex and health literacy of patients with intermittent claudication. Further, it explored changes in self-efficacy, adherence to treatment, and quality of life during the first year after diagnosis. Methods: A longitudinal cohort study was conducted with 128 participants recruited from vascular units in southern Sweden. Data were collected through medical records and questionnaires regarding illness perception, health literacy, self-efficacy, adherence to treatment, and quality of life. Results: In the subscales in illness perception, patients with sufficient health literacy reported less consequences and lower emotional representations of the intermittent claudication. They also reported higher self-efficacy and higher quality of life than patients with insufficient health literacy. In comparison between men and women in illness perception, women reported higher illness coherence and emotional representations associated with intermittent claudication compared to men. A multiple regression showed that both consequences and adherence were negative predictors of quality of life. When examining changes over time, a significant increase in quality of life was seen between baseline and 12 months, but there were no significant differences in self-efficacy and adherence to treatment. Conclusion: Illness perception differs in relation to level of health literacy and between men and women. Further, the level of health literacy seems to be of importance for patients’ self-efficacy and quality of life. This illuminates the need for new strategies for improving health literacy, illness perception, and self-efficacy over time. For example, more tailored information regarding secondary prevention could be provided to strengthen self-management to further improve quality of life in patients with intermittent claudication. illness perception self-efficacy health literacy adherence to treatment quality of life intermittent claudication secondary prevention Figures Figure 1 Figure 2 Background Patients with intermittent claudication (IC) need lifelong treatment with secondary prevention to prevent cardiovascular events and progression of the atherosclerotic disease. 1 IC is further associated with decreased quality of life (QoL) due to presence of pain and loss of walking ability, which means that living with IC involves managing symptoms to maintain QoL. 2 Importantly, many of these patients do not get secondary prevention support according to the recommendations in current guidelines. 1 , 3 , 4 Studies have shown that IC is largely unrecognized and under-treated compared to other cardiovascular diseases and that there is a lack of public and patient awareness. 5 , 6 The way patients perceive illness is one relevant aspect that determines their health-management behaviour, 7 and it can be improved by patient education. 8 – 10 Therefore, factors that influence illness perception and QoL could provide important knowledge about how to improve secondary prevention treatment in patients with IC. Approximately 236 million people globally live with peripheral arterial disease (PAD), 11 where IC is the mildest form, affecting10–20%. 12 IC is characterized by ischemic muscle pain during activity, 1 causing physical limitations and decreased QoL. 2 Since IC mainly derives from atherosclerosis, patients with IC are at significant risk of cardiovascular morbidity. 13 The risk factors consist of smoking, hypertension, hyperlipidaemia, and diabetes mellitus; accordingly, secondary prevention with smoking cessation, physical activity, dietary changes, and best medical therapy (BMT, i.e., cholesterol reduction, antithrombotic drugs, and blood pressure control) are necessary for patients with IC to prevent progression of the atherosclerosis process and to prevent further cardiovascular morbidities. 1 Research has shown the importance of patients’ adherence to treatment in relation to QoL. Positive associations between adherence and QoL have been shown in other conditions, such as myocardial infarction (MI), 14 diabetes mellitus, 15 and hypertension. 16 Besides the association between adherence to treatment and QoL, research in patients with coronary heart disease has reported positive associations between illness perceptions and QoL, where patients experiencing lower personal- and treatment control, lower illness coherence, or a cyclic timeline belief reported lower QoL. 17 However, research about associations between adherence to treatment, QoL, and illness perception in patients with IC is lacking. Patients with PAD shape their own understandings of their conditions, which may influence their management of their disease and adherence to treatment. 18 The common-sense model (CSM) is a theoretical framework describing illness perception as a process for managing a health threat. The CSM includes perception, interpretation, and response to a health threat and consists of both cognitive and emotional representations in five subscales (identity, timeline, cause, control and cure, and consequences). 19 Studies have shown associations between illness perception and adherence to secondary prevention in patients with coronary heart disease. 20 , 21 Adherence to secondary prevention medication is vital to reduce the risk of morbidity and mortality. 22 , 23 However, low adherence to medical treatment has been reported in patients with IC, where only two thirds are taking antiplatelets and statins five years after diagnosis. 24 , 25 Adherence to long-term treatment has been associated with several influencing factors, including those related to the patients (such as illness perception and self-efficacy). 26 Additionally, beliefs regarding both medicines and illness together with self-efficacy need to be addressed to better understand adherence to medication treatment. 27 Another important factor for adherence is health literacy, which is described as the ability to “access”, “understand”, “appraise”, and “apply” health-related information. Health literacy influences self-management behaviours and individual outcomes in chronic diseases. Patients with IC having inadequate or problematic health literacy reported both worse QoL and lower self-efficacy. 28 Self-efficacy is described as an individual’s belief in their own capacity to execute behaviours necessary to face challenges and to complete a specific task. 29 For instance, among patients with PAD, better self-efficacy was associated with better walking ability. 30 Importantly, individuals with limited self-efficacy tend to avoid setting goals and experience low confidence in their ability to succeed in the task ahead, 29 but nurse-led self-management programmes can enhance patients’ self-efficacy. 31 In summary, there is evidence that illness perception, adherence to treatment, health literacy, self-efficacy, and QoL influence the self-management in chronic diseases. Therefore, to develop strategies to improve care regarding secondary prevention for patients with IC, knowledge of these influencing factors needs to be evaluated. Accordingly, this study aimed to compare illness perception, self-efficacy, adherence to treatment, and quality of life in relation to the sex and health literacy of patients with intermittent claudication. Further, to explore changes in self-efficacy, adherence to treatment, and quality of life during the first year after diagnosis. Method Design This was a longitudinal cohort study in which the participants filled in the questionnaires at three different occasions (baseline, 6 months, and 12 months), and data from medical records were extracted at baseline (Figure 1). Participants The study involved three outpatient clinics for vascular diseases located in southern Sweden. All patients visiting these clinics received BMT, including medicine prescription and information of the importance of walking exercise and smoking cessation. The patients fulfilling the inclusion criteria were asked for participation by registered nurses specialized in vascular diseases. The inclusion criteria were patients diagnosed with IC (defined by clinical findings and ankle brachial index [ABI] < 0.9) and the ability to read and understand Swedish. The exclusion criteria were patients who previously received surgical treatment for IC. The sampling procedure is accounted for in Figure 1. Data collection The data were collected between 2018 and 2020. Patients interested in participation received oral and written information during the referral visit. The information were given by registered nurses specialized in vascular diseases at the three clinics included in the study. Baseline questionnaires and informed consent forms were handed out with the advice to fill in the forms at home, thus giving the patients time to consider the decision to participate. One reminder was sent to non-responders. The questionnaires were sent back to the research team using prepaid envelopes. After 6 and then 12 months, the patients received new sets of questionnaires by mail, together with prepaid envelopes. Two reminders were sent to non-responders. Background data − such as demographics, co-morbidities, clinical characteristics, and lifestyle factors − were collected through a self-reported questionnaire developed only for this study. The lifestyle factors physical activity and smoking were included based on the importance of secondary prevention for patients with PAD. 1, 13 Physical activity was self-reported, and the two questions were phrased as follows: “Are you being physically active?” ( yes/no ) and “How many times per week are you being physically active?” ( 1 – 2 , 3 – 4 , > 4 ) . ABI, blood pressure, cholesterol level, and blood glucose were collected from medical records at baseline. For comparison in illness perception between patients with IC and reference population, studies on patients with MI 32 and CABG 33 were used. The data collection process is presented in Figure 1. Questionnaires Data on illness perception, health literacy, self-efficacy, adherence to medication treatment, and QoL were collected through self-administered questionnaires described below. Illness perception The Revised Illness Perception Questionnaire (IPQ-R) was based on the Common Sense Model of self-regulation 34 and revised with the following subscales: timeline acute/chronic, timeline cyclical, consequences, personal control, treatment control, illness coherence, and emotional representations, 35 which are accounted for in Table 1. The Swedish version of the instrument was validated and contains 38 items regarding perceptions of the illness and 18 items about causes of the illness. It uses a five-point Likert scale from strongly disagree to strongly agree . The last item has an open-ended response where the patient should list the three most important causal factors of the disease. 36 Cronbach’s alphas for the subscales in the current study were α = .82 for timeline acute/chronic, α = .79 for timeline cyclical, α = .71 for consequences, α = .65 for personal control, α = .79 for treatment control, α = .92 for illness coherence, and α = .86 for emotional representations. Table 1. Interpretation of IPQ-R subscales (Moss-Morris et al., 2002) IPQ-R subscale Score range Definition Interpretation of high scores Timeline 6–30 Evaluates duration of illness The patient believes the illness is enduring Timeline cyclical 4–20 Evaluates views on cyclical nature of illness The patient believes the illness is cyclical Consequences 6–30 Evaluates views on negative consequences for patient The illness has negative consequences on the patient’s life Personal control 6–30 Evaluates views on the effect of personal control by the patient on the illness The patient has high level of control over the illness Treatment control 5–25 Evaluates views on the effectiveness of treatments available The treatment is effective for the illness Illness coherence 5–25 Evaluates the understanding of the illness The patient has greater understanding of the illness Emotional representations 6–30 Evaluates how the illness affects the patient emotionally There is a greater emotional impact associated with the illness Health literacy European Health Literacy Survey Questionnaire 16 (HLS-EU-Q16-SE) was validated and translated to Swedish and is a short version of the European Health Literacy Survey Questionnaire (HLS-EU). It consists of 16 items in four different dimensions: “access/obtain”, “understand”, “process/appraise”, and “apply/use” health related information. It uses a four-point response scale: very easy , easy , difficult , very difficult , and I don’t know. The responses very easy and easy were combined into one category (scored with one) and the responses very difficult and difficult were combined into another category (scored with zero). A sum score was calculated and divided into the three categories inadequate (0–8), problematic (9–12), and sufficient (13–16). 37 The three health literacy levels were dichotomized into two levels: “insufficient” (“inadequate” and “problematic” ) and “sufficient” health literacy. 38 Cronbach’s alpha was .91 in the current study. Self-efficacy The General Self-Efficacy Scale (S-GSE) is an instrument measuring the strength of an individual’s belief in their own ability to deal with difficult situations and setbacks. 39 The Swedish version of the instrument was validated. 40, 41 It consists of 10 items rated on a four-point Likert scale ( not all true to exactly true ). A total score was calculated where a high score indicates a high self-efficacy. 39 Cronbach’s alpha was .92 in the current study. Adherence to treatment The Medication Adherence Report Scale (MARS-5) is the instrument used to determine patients’ self-reported adherence to medication treatment. It consists of five items and uses a five-point response scale ranging from always to never. The instrument is valid and available in Swedish. 42 A total score was calculated where a higher score indicates a higher level for medication adherence. 43 Cronbach’s alpha was .57 in the current study, which is below the recommended value (α = .70). 44 Quality of life The Vascular Quality of Life Questionnaire-6 (VQ6) is a disease-specific instrument for the assessment of QoL in patients with PAD and is a short version of the Vascular Quality of Life Questionnaire (VascuQoL). 45 The instrument was translated into Swedish and showed good psychometric properties. 46, 47 It consists of six items divided into five subscales: activity (two items), emotional, pain, social, and symptoms. The items are rated on a four-point response scale. The answers were summed to a total score (6–24), where a high score indicates a high quality of life. 48 In the current study, Cronbach’s alpha was .88. Statistics For analysing the data, IBM SPSS Statistics for Windows (Version 26.0. Armonk, NY: IBM Corp) was used. A p-value of 0.05 was set to determine the significance. For categorical variables, frequencies and percentages were calculated to describe the data, and the chi-square test was used for analysing differences in proportions. Normally distributed ordinal variables were presented as mean with standard deviation, and an independent samples t-test was used to compare groups. Non-normally distributed ordinal variables were presented as median with first and third interquartile ranges, and a Mann-Whitney U-test was used to analyse differences between groups. Normal distribution was assessed using histograms and the Shapiro-Wilk test. Spearman’s correlation analysis was conducted between the subscales of illness perception, self-efficacy, adherence to medication treatment, and quality of life. A linear multiple regression was conducted with the significant variables from the Spearman’s correlation analysis and with QoL as a dependent variable. For comparison between IPQ-R scores in patients with IC and patients with myocardial infarction (MI) 32 or coronary artery bypass graft (CABG) 33 as reference population, the one-sample T-test was used. For variables with repeated measures, the Wilcoxon signed-rank test was used to analyse differences, and the significant levels were adjusted with a manual Bonferroni correction. The questionnaires’ internal consistency was tested using Cronbach’s alpha coefficient. Results A total of 158 patients were included in the study, of which 133 patients continued participation at 6 months and 128 continued at 12 months, resulting in a response rate of 73.5% at baseline, 61.9% at 6 months, and 59.5% at 12 months (Fig. 1 ). The study population at 6 months consisted of 66 men and 67 women, with a mean age of 75 years (age range 47–92). In the comparison between men and women, a difference was shown in civil status, where living alone was more common among women (p < .001). No differences appeared in age, ABI, education level, or lifestyle factors between men and women. The background characteristics of the study sample at baseline are presented in Table 2 . Table 2 Clinical characteristics, demographics, and lifestyle factors at baseline in subjects with intermittent claudication Total (n = 158) Women (n = 80) Men (n = 78) p-value Age (years) * 74.1 (7.3) 75.0 (6.6) 73.3 (7.3) 0.160 Ankle brachial index * 0.65 (0.19) 0.62 (0.19) 0.67 (0.19) 0.114 Body mass index (kg/m 2 ) ** 24.9 (25.1–26.4) 24.3 (21.6–27.9) 26.1 (23.6–29.4) 0.001 Diastolic blood pressure (mmHg) 76.0 (74.5–78.6)** 73.9 (9.1)* 79.6 (11.3)* 0.006 Systolic blood pressure (mmHg) 148.2 (135.0–160.0)** 150.7 (21.3)* 144 (129.5–160.0)** 0.089 Cholesterol (mmol/l) ** 4.5 (3.8–5.8) 5.1 (4.1–5.9) 4.1 (3.5–5.3) 0.010 Blood glucose (mmol/l) ** 6.2 (5.6–7.5) 6.1 (5.6–7.2) 6.4 (5.8–8.3) 0.811 Civil status n (%) Living alone 53 (33.5) 38 (47.5) 15 (19.2) 0.001 Cohabitation 89 (56.3) 37 (46.3) 52 (66.7) 0.001 Live-apart 5 (3.2) 3 (3.8) 2 (2.6) 0.752 Education level n (%) Elementary school 44 (27.8) 21 (26.3) 23 (29.5) 0.614 Upper-secondary school 45 (28.5) 25 (31.3) 20 (25.6) 0.465 Vocational school 26 (16.5) 10 (12.5) 16 (20.5) 0.163 University 42 (26.6) 24 (30.0) 18 (23.1) 0.349 Lifestyle factors n (%) Physical activity 125 (79.1) 65 (82.3) 60 (76.9) 0.495 Never smoker 16 (10.1) 9 (11.3) 7 (9.0) 0.655 Former smoker 108 (68.4) 50 (62.5) 58 (75.3) 0.083 Current smoker 33 (20.9) 21 (26.3) 12 (15.4) 0.101 * mean (SD): standard deviation ** median (IQR): Inter quartile range Illness perceptions The participants reported what they believed caused their illness, namely, IC. Of these causal factors, smoking was the most reported (42.7%), followed by age (21.8%), genetics (9.1%), and no idea (7.3%) (Fig. 2 ). Comparison between men and women In an illness perception comparison between men and women, women reported higher illness coherence, indicating greater understanding of IC than men (p = 0.028). Women also reported higher emotional representations associated with IC (p = 0.047) compared to men (Table 3 ). Comparison between sufficient and insufficient health literacy Patients with sufficient health literacy reported less consequences (p = 0.003) and lower emotional representations (p = 0.001) of the IC than patients with insufficient health literacy. They also reported higher self-efficacy (p = 0.049) and higher QoL (p = 0.005) than patients with insufficient health literacy (Table 3 ). Table 3 Differences between men and women and health literacy regarding illness perception, self-efficacy, adherence to medication treatment, and quality of life at six months in subjects with intermittent claudication Variables* Total (n = 133) Women (n = 67) Men (n = 66) Insufficient health literacy (n = 70) Sufficient health literacy (n = 61) p-value (w/m)* p-value (Insuff /Suff )* Illness perception subscales Timeline 24 (20.3–26.6) 24 (20–26.4) 24 (21–27) 23.5 (19.8–26.1) 24 (20.9–27.0) 0.752 0.309 Timeline cyclical 10 (8–13) 10 (8–13) 11 (8–13) 10 (8–12.8) 10.9 (8–14) 0.785 0.392 Consequences 17.5 (14–21) 18 (14–19.8) 17 (1–521) 19 (15.8–21) 16.5 (14–18) 0.432 0.003 Personal control 19 (17–22) 18.5 (17–22) 19 (17.3–21.8) 19 (17–21) 19 (17.8–22.0) 0.840 0.325 Treatment control 16 (13.8–18) 16 (14–18) 16 (13–18) 15 (13.4–18) 16.1 (14–18) 0.856 0.376 Illness coherence 19 (15–21) 20 (15.3–24) 17 (13.5–20) 18 (15–21) 19 (15–23.5) 0.028 0.194 Emotional representations 17 (13–20.8) 18 (13–22) 16 (13–18) 18 (14–22.3) 15 (12.3–18) 0.047 0.001 Self-efficacy 30 (26.5–33.5) 30 (26–34) 30 (27–32) 30 (26–32) 31 (28–35) 0.740 0.049 Adherence to treatment 25 (24–25) 25 (24–25) 25 (24–25) 25 (24–25) 25 (24–25) 0.496 0.223 Quality of life 15 (11–17) 15 (11–17) 16 (11.5–17) 13 (10–17.3) 16 (14–17) 0.152 0.005 *median (IQR) w:women m: men Insuff : insufficient health literacy Suff: sufficient health literacy Comparison between other populations Compared to study populations with MI 32 and CABG, 33 the patients with IC perceived a longer duration (i.e., timeline) and had a lower sense of both personal and treatment control compared to patients who had an MI (p < 0.001) and patients who had undergone CABG (p < 0.001). Patients with IC reported less consequences of their disease compared to those with MI (p = 0.027) and CABG (p < 0.001). Differences were also demonstrated where patients with IC reported lower illness coherence of their disease (p < 0.001) and lower emotional impact (p = 0.005) than patients with CABG (Table 4 ). Table 4 IPQ-R Mean (SD) scores in patients with IC at six months compared with patients with myocardial infarction (MI) from Alsén et al. (2010) and CABG from Hermele et al. (2007) as reference population Illness perception subscales *Intermittent Claudication (n = 133) *Myocardial infarction (n = 204) *CABG (n = 56) p-value (IC/MI) p-value (IC/CABG) Timeline 23.23 (4.27) 20.01 (5.39) 13.31 (5.14) < 0.001 < 0.001 Timeline cyclical 10.54 (3.43) 10.80 (2.89) Not measured 0.411 Consequences 17.37 (4.07) 18.18 (4.61) 19.91 (4.35) 0.027 < 0.001 Personal control 19.37 (3.76) 21.26 (3.94) 23.50 (3.35) < 0.001 < 0.001 Treatment control 15.81 (3.26) 18.08 (3.22) 21.11 (3.08) < 0.001 < 0.001 Illness coherence 17.80 (5.06) 17.12 (3.92) 19.33 (4.19) 0.144 < 0.001 Emotional representations 16.96 (4.94) 16.65 (4.80) 18.20 (4.45) 0.473 0.005 * IC: 6 months after diagnosis MI: 4 months after MI CABG: pre-surgical consultation 2–4 weeks prior to surgery Correlations The subscales timeline (r s = − 0.24; p = 0.009), timeline cyclic (r s = − 0.19; p = 0.042), personal control (r s = − 0.19; p = 0.044), and emotional representations (r s = − 0.58; p < 0.001) correlated negatively with adherence to medication treatment, indicating that higher scores on these subscales were associated with lower adherence. The subscales treatment control (r s = 0.22; p = 0.016) and illness coherence (r s = 0.21; p = 0.028) correlated positively with adherence to medication treatment, indicating that higher scores on these subscales were associated with higher adherence. Quality of life Positive associations were found between personal control and QoL (p < 0.001) and between self-efficacy and QoL (p = 0.014), indicating that higher scores were positively associated with higher QoL. A negative association was found between the consequences of the illness and QoL (p < 0.001) as well as between adherence to medication treatment and QoL (p = 0.013), indicating that experiences of higher consequences of IC and higher adherence to medication treatment were associated with lower QoL (Table 5 ). Table 5 Spearman’s correlation analysis between illness perception, self-efficacy, adherence to medication treatment and quality of life in subjects with intermittent claudication Variables Timeline Timeline cyclic Consequences Personal control Treatment control Illness coherence Emotional representations Self- efficacy Adherence to treatment Timeline cyclic −0.262 p-value (0.004) Consequences 0.190 p-value (0.037) −0.116 p-value (0.204) Personal control −0.171 p-value (0.062) 0.144 p-value (0.116) −0.170 p-value (0.058) Treatment control −0.283 p-value (0.002) 0.006 p-value (0.945) −0.103 p-value (0.267) 0.469 p-value (< 0.001) Illness coherence 0.127 p-value (0.176) −0.146 p-value (0.113) −0.025 p-value (0.783) 0.322 p-value (< 0.001) 0.372 p-value Emotional representations 0.005 p-value (0.953) 0.103 p-value (0.260) 0.488 p-value (< 0.001) −0.079 p-value (0.379) −0.043 p-value (0.643) −0.170 p-value (0.063) Self- efficacy 0.067 p-value (0.484) 0.085 p-value (0.368) −0137 p-value (0.142) 0.074 p-value (0.432) −0.081 p-value (0.394) −0.130 p-value (0.165) 0.072 p-value (0.427) Adherence to treatment −0.239 p-value (0.009) −0.188 p-value (0.042) −0.084 p-value (0.356) −0.183 p-value (0.044) 0.224 p-value (0.016) 0.205 p-value (0.028) −0.577 p-value (< 0.001) −0.057 p-value (0.540) Quality of life −0.175 p-value (0.057) 0.076 p-value (0.415) −0.568 p-value (< 0.001) 0.348 p-value (< 0.001) 0.114 p-value (0.238) −0.010 p-value (0.917) −0.108 p-value (0.243) 0.224 p-value (0.014) −0.224 p-value (0.013) Factors related to QoL A multiple regression model explained 46.5% of the variance in QoL (adjusted R square = 0.465; p < 0.001) and showed that both consequences and adherence to medication treatment were negative predictors of QoL, meaning that one unit increase in these variables decreased QoL (Table 6 ). Table 6 Multiple linear regression at six months with quality of life as dependent variable Independent variables B Standard error β p-value Consequences in illness perception −0.569 0.074 −0.576 < 0.001 Personal control in illness perception 0.167 0.087 0.143 0.057 Self-efficacy 0.096 0.056 0.123 0.088 Adherence to treatment −0.556 0.196 −0.204 0.050 R square: 0.445 Adjusted R-square: 0.465 Sign: < 0.001 Changes over time The QoL medians with inter quartile range (IQR) were 13 at baseline (11–17), 15 at 6 months (11–17), and 16 at 12 months (12–18.8). A significant increase in QoL was seen between baseline and 6 months (p = 0.033), baseline and 12 months (p < 0.001), and 6 months and 12 months (p = 0.031). After a correction for multiple comparisons (Bonferroni), the significant increase in QoL remained between baseline and 12 months (p = 0.003). No significant changes over time were seen in self-efficacy or adherence to treatment. Discussion The present study showed that illness perception differed in patients with IC in relation to sex, health literacy level, and study populations with coronary heart disease (CHD). Patients’ self-reported beliefs on the causes of IC were smoking, age, and genetics. However, even if smoking was the most commonly reported causal beliefs for the disease (42%), the majority of the participants (89%) were current or former smokers. This is in line with a previous review on illness perception in patients with PAD, which showed that the patients had different beliefs regarding smoking as a causing factor for the disease; only some acknowledged smoking as a causing factor. 18 This has also been seen in patients with COPD, who expressed uncertainty about the connection between smoking and the disease. 49 The fact that 7.3% had no idea what caused their disease emphasizes a need to improve the patients’ awareness of the aetiology of the disease. As illness perception clearly influences patients’ beliefs about the causes of IC, an educational intervention addressing their perceptions could be one option to increase their awareness and, in turn, also their QoL. For example, previous research has shown that an illness perception correction-based educational programme provided via phone calls by a nurse improved QoL in patients with heart failure. 50 In a comparison between men and women concerning illness perception, women reported higher illness coherence and higher emotional representations, indicating they have greater understanding and greater emotional impact associated with IC compared to men. The difference in illness coherence contrasts with Al-Smadi et al.’s 51 review of illness perception in patients with CHD, where four studies 32 , 36 52, 53 reported no differences between men and women and two studies 54 , 55 reported higher illness coherence in men than in women. The difference in emotional representation is in line with a review on sex differences in patients with chronic disease, where women experienced more negative stress about their condition compared to men. 56 Differences between men and women with PAD have also been studied earlier. A review showed that men and women differ in the presentation of PAD symptoms, where women more often present atypical symptoms and rest pain and, less often, IC symptoms. 57 Since differences between men and women with IC occur both in illness perception and symptom presentation, sex differences in IC patients should be further studied. Health care professionals’ awareness of potential sex differences could create preconditions for more individualized information, which could further improve the patients’ self-management of secondary prevention. Patients with sufficient health literacy reported less consequences and lower emotional representations of the IC than patients with insufficient health literacy. This concurred with previous studies on patients with COPD and cardiovascular disease, which showed that those with insufficient health literacy also experienced more emotional representations. 58 , 59 The current study also showed higher self-efficacy and higher QoL among patients with sufficient health literacy compared to those with insufficient health literacy, which is in line with previous research. 60 , 61 These findings suggest that improving patients’ health literacy may improve their self-efficacy, which in turn may positively influence their QoL. Since health literacy can be improved by information and structured education, 62 patients with IC may benefit from a more active support from the health care system. Different methods – such as motivational interviewing, individual or group support, and in-person or web- or telephone-based support – have been beneficial for improving health literacy in patients with chronic diseases. 63 Further research is needed to assess these methods for improving health literacy in patients with IC. As previously suggested, digital formats may be more accessible for patients and perhaps more cost-effective, but they need both testing and evaluation among patients with IC. In comparisons with study populations who suffered MI or had undergone a CABG, patients with IC had a lower sense of personal and treatment control. They also had lower illness coherence of their disease compared to CABG patients. This difference in illness perception may be due to the lack of systematic secondary prevention support in patients with IC. Further, an important disparity between IC and CHD is that even if both conditions derive from atherosclerosis, the care of patients with CHD includes long-term management with rehabilitation programmes, 64 which hardly exist for patients with IC. Since secondary prevention is the first line of treatment, patients with IC could benefit from more support to create more control and understanding in their process of managing the disease. A study with IC patients has shown positive experiences of nurse-led units in terms of increased awareness of their disease and increased motivation for initiating lifestyle changes. 65 This kind of support could be a way to improve patients’ self-management of IC. Consequences and adherence to medication treatment were negative predictors of QoL in patients with IC. That the perceived consequences of the disease have an impact on daily life has earlier been confirmed in a review on patients with PAD; the patients experienced involuntary isolation and loss of independence due to their disease, which affected their self-image. 18 In this study, the association between increased adherence to medication treatment and decreased QoL is a surprising result in need of consideration. A possible explanation might be that pain and loss of independence have a negative impact on QoL in patients with IC. 2 Since BMT aims to prevent cardiovascular events and decrease the atherosclerotic progression rather than relieve IC symptoms, 1 high adherence to medications does not directly affect QoL. This negative association between adherence to treatment and QoL has also been reported earlier in a review on patients with COPD. According to Agh et al., 66 the treatment with inhaler therapy in COPD may affect the patients daily life due to perceived stigma when using inhalers in public, which could explain increased QoL with low adherence. However, this reason is not applicable to patients with IC since the treatment with BMT would not affect the patients’ daily life. Since adherence to taking antiplatelets and statins decreases after five years, 24 , 25 future research with a longer perspective and, importantly, a combination of different methods to measure adherence would further illuminate associations between adherence and QoL in patient with IC. Another important aspect is that health care professionals should always remember to ask patients about their adherence behaviour since it is necessary information to enable evaluations of initiated treatment. When examining changes over time, this study found a significant increase in QoL between baseline and 12 months despite no systematic secondary prevention support. This is an interesting finding that could be explained in a review on illness perception in patients with PAD: the patients experienced a process of adaptation, where they accepted their new situation and found other values in life. 18 This corresponds to the description of QoL as the discrepancy between an individual’s hopes and expectations and present experiences. 67 Even if the improvement in QoL was rather small, having knowledge of the reason for this increase despite no interactive care or support would be valuable in the process of creating a sustainable care for patients with IC. However, this was not possible with the current study design, so further research is needed, preferably with a qualitative approach that can describe the individual experiences. The fact that self-efficacy did not change over time was an expected result since managing chronic disease processes can be demanding and motivation can decrease over time. 68 Moreover, improvements in self-efficacy most likely require support to achieve, which Sol et al. 31 have shown in patients with cardiovascular conditions. Even though QoL improved one year after visiting the outpatient clinic for vascular diseases, improving patients’ health literacy, self-efficacy, and illness perception is necessary to further improve the self-management of the disease. This may be achieved through self-management programmes, gaming, mobile applications, or social media. 69 However, future research is needed to evaluate these methods in relation to patients with IC. Strengths and limitations A strength of this study is that only validated instruments were used, thereby minimizing measurement bias. Another strength is that data extracted from medical records were used to describe medical status. However, a potential weakness is that all data from the questionnaires were self- reported, which can be inaccurate due to social desirability or failure to recollect adherence behaviour. 70 Since many of the patients scored maximum points in the adherence questionnaire, the potential ceiling effect needs to be considered. This makes it impossible to distinguish differences in adherence behaviour. Similar skewness in adherence reports has been found in previous studies. 71 – 73 Studies have shown self-reported questionnaire to overestimate patients’ adherence in other chronic conditions. 74 , 75 Nevertheless, despite the limitation, self-reported medication adherence measures can provide valuable and useful information. 70 Further research on adherence in patients with IC is recommended, preferably using different research methods, such as refill-of-prescriptions records from pharmacies in combination with self-reported data. The longitudinal design of the study enabled us to determine patterns over time. However, this study required the participants to fill in questionnaires on three occasions over one year. During this time, some of the participants decided to withdraw further participation. Significant differences were found despite a somewhat small sample size; however, differences that were not detected may exist. 76 The internal consistency of the scales, which was measured through Cronbach’s alpha or psychometric tests, was appropriate (apart from MARS and in line with previous research 32 , 44 , 66 ), which is to be considered a strength. The dropout rate during follow-up was acceptable, and patients ceasing to participate may be considered as an unavoidable attrition. 77 Conclusion Illness perception differs in some aspects in relation to the level of health literacy as well as between men and women. Further, the level of health literacy seems to be of importance for patients’ self-efficacy and QoL. This illuminates the need for new strategies to improve health literacy, illness perception, and self-efficacy over time – for example, by providing more tailored information regarding secondary prevention, preferably by using e-health tools, in order to strengthen self-management to further improve QoL in patients with IC. Abbreviations ABI: Ankle brachial index BMT: Best medical therapy CABG: Coronary artery bypass graft CHD: Coronary heart disease CSM: Common Sense Model HLS-EU: European Health Literacy Survey Questionnaire HLS-EU-Q16-SE: European Health Literacy Survey Questionnaire 16 Swedish IC: Intermittent claudication IPQ-R: The Revised Illness Perception Questionnaire IQR: Inter quartile range MARS-5: Medication Adherence Report Scale MI: Myocardial infarction PAD: Peripheral arterial disease PROM: Patient reported outcome measure QoL: Quality of life S-GSE: General Self-Efficacy Scale VascuQoL: Vascular Quality of Life Questionnaire VQ6: Vascular Quality of Life Questionnaire-6 Declarations Ethics declarations Ethics approval and consent to participate The study was approved by the Regional Ethical Review Board in Lund (Dnr 2017/609). All participants received oral and written information about the study, including information that it was voluntary to participate and that they could withdraw their participation at any time with no further explanation. Informed consent was obtained from all participants. All methods conducted adhered to the relevant guidelines and regulations in accordance with the Declaration of Helsinki. 78 Consent for publication Not applicable Availability of data and materials The dataset is available from the corresponding author on reasonable request. Competing interest The authors have no conflicts of interest to declare. Funding This research received no specific grant from any funding agency. Authors contributions All the authors (RS, MZ, CK, and MA) have participated in the design, planning, and development of the study. RS was responsible for the data collection. The analysis was conducted by RS and MA, and all authors took part in the interpretation of the results. RS drafted the manuscript, and CK, MZ, and MA reviewed and contributed with important intellectual content. The authors read and approved the final manuscript. Acknowledgement The research team is grateful to the individuals with IC who generously gave their time to participate in the study. References Aboyans V, Ricco JB, Bartelink MEL et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization (ESO)The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J . Mar 1 2018;39(9):763–816. doi: 10.1093/eurheartj/ehx095 Abaraogu UO, Ezenwankwo EF, Dall PM, Seenan CA. 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Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Moncef","middleName":"","lastName":"Zarrouk","suffix":""},{"id":182084397,"identity":"5e7fc580-1ef0-4933-a5e2-cedd0ce6af4b","order_by":2,"name":"Christine Kumlien","email":"","orcid":"","institution":"Malmö University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Christine","middleName":"","lastName":"Kumlien","suffix":""},{"id":182084398,"identity":"b251d2aa-3564-4d07-a063-793dd63badae","order_by":3,"name":"Malin Axelsson","email":"","orcid":"","institution":"Malmö University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Malin","middleName":"","lastName":"Axelsson","suffix":""}],"badges":[],"createdAt":"2023-02-24 08:59:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2623748/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2623748/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12912-023-01329-2","type":"published","date":"2023-05-17T20:50:52+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":34236700,"identity":"316e29a0-3698-4ff7-908e-560e2a38850c","added_by":"auto","created_at":"2023-03-14 14:44:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":35377,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlow chart of data collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e#Abbreviations for questionnaires:\u003c/p\u003e\n\u003cp\u003eHSL-EU-Q16-SE\u003csup\u003e: \u003c/sup\u003eHealth literacy\u003c/p\u003e\n\u003cp\u003eS-GSE: Self-efficacy\u003c/p\u003e\n\u003cp\u003eVQ6: Quality of life\u003c/p\u003e\n\u003cp\u003eIPQ-R: Illness perception\u003c/p\u003e\n\u003cp\u003eMARS-5: Adherence to treatment\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-2623748/v1/fa02d85684232738939d2641.png"},{"id":34236626,"identity":"f0e4fc80-0be7-4651-9795-aae2b5390f11","added_by":"auto","created_at":"2023-03-14 14:44:38","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":87156,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePatients self-reported causal beliefs to intermittent claudication at six months.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-2623748/v1/566c65561e07b530fb0ea9a0.png"},{"id":44730572,"identity":"a040c47e-0c41-400a-af54-ccafa8697f2d","added_by":"auto","created_at":"2023-10-16 21:32:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":726109,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2623748/v1/84dfade1-3f40-4f3d-9137-a029644b3c70.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Illness perception, self-efficacy, health literacy, adherence, and quality of life in patients with intermittent claudication – a longitudinal cohort study","fulltext":[{"header":"Background","content":"\u003cp\u003ePatients with intermittent claudication (IC) need lifelong treatment with secondary prevention to prevent cardiovascular events and progression of the atherosclerotic disease.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e IC is further associated with decreased quality of life (QoL) due to presence of pain and loss of walking ability, which means that living with IC involves managing symptoms to maintain QoL.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Importantly, many of these patients do not get secondary prevention support according to the recommendations in current guidelines.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Studies have shown that IC is largely unrecognized and under-treated compared to other cardiovascular diseases and that there is a lack of public and patient awareness.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e The way patients perceive illness is one relevant aspect that determines their health-management behaviour,\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e and it can be improved by patient education.\u003csup\u003e\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Therefore, factors that influence illness perception and QoL could provide important knowledge about how to improve secondary prevention treatment in patients with IC.\u003c/p\u003e \u003cp\u003eApproximately 236\u0026nbsp;million people globally live with peripheral arterial disease (PAD),\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e where IC is the mildest form, affecting10\u0026ndash;20%.\u003csup\u003e12\u003c/sup\u003e IC is characterized by ischemic muscle pain during activity,\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e causing physical limitations and decreased QoL.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Since IC mainly derives from atherosclerosis, patients with IC are at significant risk of cardiovascular morbidity.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e The risk factors consist of smoking, hypertension, hyperlipidaemia, and diabetes mellitus; accordingly, secondary prevention with smoking cessation, physical activity, dietary changes, and best medical therapy (BMT, i.e., cholesterol reduction, antithrombotic drugs, and blood pressure control) are necessary for patients with IC to prevent progression of the atherosclerosis process and to prevent further cardiovascular morbidities.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eResearch has shown the importance of patients\u0026rsquo; adherence to treatment in relation to QoL. Positive associations between adherence and QoL have been shown in other conditions, such as myocardial infarction (MI), \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e diabetes mellitus, \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e and hypertension.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Besides the association between adherence to treatment and QoL, research in patients with coronary heart disease has reported positive associations between illness perceptions and QoL, where patients experiencing lower personal- and treatment control, lower illness coherence, or a cyclic timeline belief reported lower QoL.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e However, research about associations between adherence to treatment, QoL, and illness perception in patients with IC is lacking.\u003c/p\u003e \u003cp\u003ePatients with PAD shape their own understandings of their conditions, which may influence their management of their disease and adherence to treatment.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e The common-sense model (CSM) is a theoretical framework describing illness perception as a process for managing a health threat. The CSM includes perception, interpretation, and response to a health threat and consists of both cognitive and emotional representations in five subscales (identity, timeline, cause, control and cure, and consequences).\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Studies have shown associations between illness perception and adherence to secondary prevention in patients with coronary heart disease.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAdherence to secondary prevention medication is vital to reduce the risk of morbidity and mortality.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e However, low adherence to medical treatment has been reported in patients with IC, where only two thirds are taking antiplatelets and statins five years after diagnosis.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e Adherence to long-term treatment has been associated with several influencing factors, including those related to the patients (such as illness perception and self-efficacy).\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e Additionally, beliefs regarding both medicines and illness together with self-efficacy need to be addressed to better understand adherence to medication treatment.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e Another important factor for adherence is health literacy, which is described as the ability to \u0026ldquo;access\u0026rdquo;, \u0026ldquo;understand\u0026rdquo;, \u0026ldquo;appraise\u0026rdquo;, and \u0026ldquo;apply\u0026rdquo; health-related information. Health literacy influences self-management behaviours and individual outcomes in chronic diseases. Patients with IC having inadequate or problematic health literacy reported both worse QoL and lower self-efficacy.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e Self-efficacy is described as an individual\u0026rsquo;s belief in their own capacity to execute behaviours necessary to face challenges and to complete a specific task.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e For instance, among patients with PAD, better self-efficacy was associated with better walking ability.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e Importantly, individuals with limited self-efficacy tend to avoid setting goals and experience low confidence in their ability to succeed in the task ahead,\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e but nurse-led self-management programmes can enhance patients\u0026rsquo; self-efficacy.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn summary, there is evidence that illness perception, adherence to treatment, health literacy, self-efficacy, and QoL influence the self-management in chronic diseases. Therefore, to develop strategies to improve care regarding secondary prevention for patients with IC, knowledge of these influencing factors needs to be evaluated. Accordingly, this study aimed to compare illness perception, self-efficacy, adherence to treatment, and quality of life in relation to the sex and health literacy of patients with intermittent claudication. Further, to explore changes in self-efficacy, adherence to treatment, and quality of life during the first year after diagnosis.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003e\u003cstrong\u003eDesign\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a longitudinal cohort study in which the participants filled in the questionnaires at three different occasions (baseline, 6 months, and 12 months), and data from medical records were extracted at baseline (Figure 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study involved three outpatient clinics for vascular diseases located in southern Sweden. All patients visiting these clinics received BMT, including medicine prescription and information of the importance of walking exercise and smoking cessation.\u0026nbsp;The patients fulfilling the inclusion criteria were asked for participation by\u0026nbsp;registered nurses specialized in vascular diseases.\u0026nbsp;The inclusion criteria were patients diagnosed with IC (defined by clinical findings and ankle brachial index [ABI] \u0026lt; 0.9) and the ability to read and understand Swedish. The exclusion criteria were patients who previously received surgical treatment for IC. The sampling procedure is accounted for in Figure 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data were collected between 2018 and 2020. Patients interested in participation received oral and written information during the referral visit. The information were given by\u0026nbsp;registered nurses specialized in vascular diseases at the three clinics included in the study.\u0026nbsp;Baseline questionnaires and informed consent forms were handed out with the\u0026nbsp;advice to fill in the forms at home, thus giving the patients time to consider the decision to participate. One reminder was sent to non-responders. The questionnaires were sent back to the research team using prepaid envelopes. After 6 and then 12 months, the patients received new sets of questionnaires by mail, together with prepaid envelopes. Two reminders were sent to non-responders. Background data \u0026minus; such as demographics, co-morbidities, clinical characteristics, and lifestyle factors \u0026minus; were collected through a self-reported questionnaire developed only for this study. The lifestyle factors physical activity and smoking were included based on the importance of secondary prevention for patients with PAD.\u003csup\u003e1, 13\u003c/sup\u003e Physical activity was self-reported, and the two questions were phrased as follows: \u0026ldquo;Are you being physically active?\u0026rdquo; (\u003cem\u003eyes/no\u003c/em\u003e) and \u0026ldquo;How many times per week are you being physically active?\u0026rdquo; (\u003cem\u003e1\u003c/em\u003e\u0026ndash;\u003cem\u003e2\u003c/em\u003e,\u003cem\u003e\u0026nbsp;3\u003c/em\u003e\u0026ndash;\u003cem\u003e4\u003c/em\u003e,\u003cem\u003e\u0026nbsp;\u0026gt;\u003c/em\u003e \u003cem\u003e4\u003c/em\u003e)\u003cem\u003e.\u003c/em\u003e ABI, blood pressure, cholesterol level, and blood glucose were collected from medical records at baseline. For comparison in illness perception between patients with IC and reference population, studies on patients with MI\u003csup\u003e32\u003c/sup\u003e and CABG\u003csup\u003e33\u003c/sup\u003e were used. The data collection process is presented in Figure 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuestionnaires\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData on illness perception, health literacy, self-efficacy, adherence to medication treatment, and QoL were collected through self-administered questionnaires described below.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIllness perception\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe Revised Illness Perception Questionnaire (IPQ-R) was based on the Common Sense Model of self-regulation\u003csup\u003e34\u003c/sup\u003e and revised with the following subscales: timeline acute/chronic, timeline cyclical, consequences, personal control, treatment control, illness coherence, and emotional representations,\u003csup\u003e35\u003c/sup\u003e which are accounted for in Table 1. The Swedish version of the instrument was validated and contains 38 items regarding perceptions of the illness and 18 items about causes of the illness. It uses a\u0026nbsp;five-point Likert scale\u0026nbsp;from \u003cem\u003estrongly disagree\u003c/em\u003e to \u003cem\u003estrongly agree\u003c/em\u003e\u003cem\u003e.\u003c/em\u003e The last item has an open-ended response where the patient should list the three most important causal factors of the disease.\u003csup\u003e36\u003c/sup\u003e Cronbach\u0026rsquo;s alphas for the subscales in the current study were \u0026alpha; = .82 for timeline acute/chronic, \u0026alpha; = .79 for timeline cyclical, \u0026alpha; = .71 for consequences, \u0026alpha; = .65 for personal control, \u0026alpha; = .79 for treatment control, \u0026alpha; = .92 for illness coherence, and \u0026alpha; = .86 for emotional representations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Interpretation of IPQ-R subscales (Moss-Morris et al., 2002)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"604\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"21.85430463576159%\"\u003e\n \u003cp\u003e\u003cstrong\u003eIPQ-R subscale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.437086092715232%\"\u003e\n \u003cp\u003e\u003cstrong\u003eScore range\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.0728476821192%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDefinition\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.635761589403973%\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterpretation of high scores\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"21.85430463576159%\"\u003e\n \u003cp\u003eTimeline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.437086092715232%\"\u003e\n \u003cp\u003e6\u0026ndash;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.0728476821192%\"\u003e\n \u003cp\u003eEvaluates duration of illness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.635761589403973%\"\u003e\n \u003cp\u003eThe patient believes the illness is enduring\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"21.85430463576159%\"\u003e\n \u003cp\u003eTimeline cyclical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.437086092715232%\"\u003e\n \u003cp\u003e4\u0026ndash;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.0728476821192%\"\u003e\n \u003cp\u003eEvaluates views on cyclical nature of illness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.635761589403973%\"\u003e\n \u003cp\u003eThe patient believes the illness is cyclical\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"21.85430463576159%\"\u003e\n \u003cp\u003eConsequences\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.437086092715232%\"\u003e\n \u003cp\u003e6\u0026ndash;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.0728476821192%\"\u003e\n \u003cp\u003eEvaluates views on negative consequences for patient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.635761589403973%\"\u003e\n \u003cp\u003eThe illness has negative consequences on the patient\u0026rsquo;s life\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"21.85430463576159%\"\u003e\n \u003cp\u003ePersonal control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.437086092715232%\"\u003e\n \u003cp\u003e6\u0026ndash;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.0728476821192%\"\u003e\n \u003cp\u003eEvaluates views on the effect of personal control by the\u003c/p\u003e\n \u003cp\u003epatient on the illness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.635761589403973%\"\u003e\n \u003cp\u003eThe patient has high level of control over the illness\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"21.85430463576159%\"\u003e\n \u003cp\u003eTreatment control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.437086092715232%\"\u003e\n \u003cp\u003e5\u0026ndash;25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.0728476821192%\"\u003e\n \u003cp\u003eEvaluates views on the effectiveness of treatments available\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.635761589403973%\"\u003e\n \u003cp\u003eThe treatment is effective for the illness\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"21.85430463576159%\"\u003e\n \u003cp\u003eIllness coherence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.437086092715232%\"\u003e\n \u003cp\u003e5\u0026ndash;25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.0728476821192%\"\u003e\n \u003cp\u003eEvaluates the understanding of the illness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.635761589403973%\"\u003e\n \u003cp\u003eThe patient has greater understanding of the illness\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"21.85430463576159%\"\u003e\n \u003cp\u003eEmotional representations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.437086092715232%\"\u003e\n \u003cp\u003e6\u0026ndash;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.0728476821192%\"\u003e\n \u003cp\u003eEvaluates how the illness affects the patient emotionally\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.635761589403973%\"\u003e\n \u003cp\u003eThere is a greater emotional impact associated with the illness\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eHealth literacy\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEuropean Health Literacy Survey Questionnaire 16 (HLS-EU-Q16-SE) was validated and translated to Swedish and is a short version of the European Health Literacy Survey Questionnaire (HLS-EU). It consists of 16 items in four different dimensions: \u0026ldquo;access/obtain\u0026rdquo;, \u0026ldquo;understand\u0026rdquo;, \u0026ldquo;process/appraise\u0026rdquo;, and \u0026ldquo;apply/use\u0026rdquo; health related information. It uses a four-point response scale: \u003cem\u003every easy\u003c/em\u003e,\u003cem\u003e\u0026nbsp;easy\u003c/em\u003e,\u003cem\u003e\u0026nbsp;difficult\u003c/em\u003e,\u003cem\u003e\u0026nbsp;very difficult\u003c/em\u003e,\u003cem\u003e\u0026nbsp;\u003c/em\u003eand\u003cem\u003e\u0026nbsp;I don\u0026rsquo;t know.\u003c/em\u003e The responses \u003cem\u003every easy\u003c/em\u003e and \u003cem\u003eeasy\u003c/em\u003e were combined into one category (scored with one) and the responses \u003cem\u003every difficult\u003c/em\u003e and \u003cem\u003edifficult\u003c/em\u003e were combined into another category (scored with zero). A sum score was calculated and divided into the three categories inadequate (0\u0026ndash;8), problematic (9\u0026ndash;12), and sufficient (13\u0026ndash;16).\u003csup\u003e37\u003c/sup\u003e The three health literacy levels were dichotomized into two levels:\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u0026ldquo;insufficient\u0026rdquo; (\u0026ldquo;inadequate\u0026rdquo; and \u0026ldquo;problematic\u0026rdquo;\u003cem\u003e)\u0026nbsp;\u003c/em\u003eand \u0026ldquo;sufficient\u0026rdquo; health literacy.\u003csup\u003e38\u003c/sup\u003e Cronbach\u0026rsquo;s alpha was .91 in the current study.\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSelf-efficacy\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe General Self-Efficacy Scale (S-GSE) is an instrument measuring the strength of an individual\u0026rsquo;s belief in their own ability to deal with difficult situations and setbacks.\u003csup\u003e39\u003c/sup\u003e The Swedish version of the instrument was validated.\u003csup\u003e40, 41\u003c/sup\u003e It consists of 10 items rated on a four-point Likert scale (\u003cem\u003enot all true\u0026nbsp;\u003c/em\u003eto \u003cem\u003eexactly true\u003c/em\u003e). A total score was calculated where a high score indicates a high self-efficacy.\u003csup\u003e39\u003c/sup\u003e Cronbach\u0026rsquo;s alpha was .92 in the current study.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAdherence to treatment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe Medication Adherence Report Scale (MARS-5) is the instrument used to determine patients\u0026rsquo; self-reported adherence to medication treatment. It consists of five items and uses a five-point response scale ranging from \u003cem\u003ealways\u0026nbsp;\u003c/em\u003eto \u003cem\u003enever.\u003c/em\u003e The instrument is valid and available in Swedish.\u003csup\u003e42\u003c/sup\u003e A total score was calculated where a higher score indicates a higher level for medication adherence.\u003csup\u003e43\u003c/sup\u003e Cronbach\u0026rsquo;s alpha was .57 in the current study, which is below the recommended value (\u0026alpha; = .70).\u003csup\u003e44\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eQuality of life\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe Vascular Quality of Life Questionnaire-6 (VQ6) is a disease-specific instrument for the assessment of QoL\u0026nbsp;in patients with PAD and is a short version of the Vascular Quality of Life Questionnaire (VascuQoL).\u003csup\u003e45\u003c/sup\u003e The instrument was translated into Swedish and showed good psychometric properties.\u0026nbsp;\u003csup\u003e46, 47\u003c/sup\u003e It consists of six items divided into five subscales: activity (two items), emotional, pain, social, and symptoms. The items are rated on a four-point response scale. The answers were summed to a total score (6\u0026ndash;24), where a high score indicates a high quality of life.\u003csup\u003e48\u003c/sup\u003e In the current study, Cronbach\u0026rsquo;s alpha was .88.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor analysing the data, IBM SPSS Statistics for Windows (Version 26.0. Armonk, NY: IBM Corp) was used.\u0026nbsp;A p-value of 0.05 was set to determine the significance.\u0026nbsp;For categorical variables, frequencies and percentages were calculated to describe the data, and the chi-square test was used for analysing differences\u0026nbsp;in proportions.\u0026nbsp;Normally distributed ordinal variables were presented as mean with standard deviation, and an independent samples t-test was used to compare groups.\u0026nbsp;Non-normally distributed ordinal variables were presented as median with\u0026nbsp;first and third interquartile ranges, and a Mann-Whitney U-test was used to analyse differences between groups.\u0026nbsp;Normal distribution was assessed using histograms and the Shapiro-Wilk test. Spearman\u0026rsquo;s correlation analysis was conducted between the subscales of illness perception, self-efficacy, adherence to medication treatment, and quality of life.\u0026nbsp;A linear multiple regression was conducted with the significant variables from the Spearman\u0026rsquo;s correlation analysis and with QoL as a dependent variable. For comparison between IPQ-R scores in patients with IC and patients with myocardial infarction (MI)\u003csup\u003e32\u003c/sup\u003e or coronary artery bypass graft (CABG)\u003csup\u003e33\u003c/sup\u003e as reference population, the one-sample T-test was used. For variables with repeated measures, the Wilcoxon signed-rank test was used to analyse differences, and the significant levels were adjusted with a manual Bonferroni correction. The questionnaires\u0026rsquo; internal consistency was tested using Cronbach\u0026rsquo;s alpha coefficient.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 158 patients were included in the study, of which 133 patients continued participation at 6 months and 128 continued at 12 months, resulting in a response rate of 73.5% at baseline, 61.9% at 6 months, and 59.5% at 12 months (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The study population at 6 months consisted of 66 men and 67 women, with a mean age of 75 years (age range 47\u0026ndash;92). In the comparison between men and women, a difference was shown in civil status, where living alone was more common among women (p\u0026thinsp;\u0026lt;\u0026thinsp;.001). No differences appeared in age, ABI, education level, or lifestyle factors between men and women. The background characteristics of the study sample at baseline are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical characteristics, demographics, and lifestyle factors at baseline in subjects with intermittent claudication\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;158)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWomen\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;80)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMen\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;78)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years) *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e74.1 (7.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75.0 (6.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e73.3 (7.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.160\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnkle brachial index *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.65 (0.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.62 (0.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.67 (0.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.114\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody mass index (kg/m\u003csup\u003e2\u003c/sup\u003e) **\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24.9 (25.1\u0026ndash;26.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24.3 (21.6\u0026ndash;27.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26.1 (23.6\u0026ndash;29.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiastolic blood pressure (mmHg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e76.0 (74.5\u0026ndash;78.6)**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e73.9 (9.1)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e79.6 (11.3)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.006\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystolic blood pressure (mmHg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e148.2 (135.0\u0026ndash;160.0)**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e150.7 (21.3)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e144 (129.5\u0026ndash;160.0)**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.089\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCholesterol (mmol/l) **\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.5 (3.8\u0026ndash;5.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.1 (4.1\u0026ndash;5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.1 (3.5\u0026ndash;5.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.010\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood glucose (mmol/l) **\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.2 (5.6\u0026ndash;7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.1 (5.6\u0026ndash;7.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.4 (5.8\u0026ndash;8.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.811\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCivil status n (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiving alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53 (33.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38 (47.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15 (19.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCohabitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e89 (56.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37 (46.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e52 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLive-apart\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2 (2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.752\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEducation level n (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElementary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44 (27.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21 (26.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23 (29.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.614\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUpper-secondary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45 (28.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25 (31.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20 (25.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.465\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVocational school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26 (16.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16 (20.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.163\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42 (26.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24 (30.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18 (23.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.349\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLifestyle factors n (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysical activity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e125 (79.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e65 (82.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e60 (76.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.495\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever smoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16 (10.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (11.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7 (9.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.655\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFormer smoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e108 (68.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50 (62.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e58 (75.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.083\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrent smoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33 (20.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21 (26.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12 (15.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.101\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e* mean (SD): standard deviation\u003c/p\u003e \u003cp\u003e** median (IQR): Inter quartile range\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eIllness perceptions\u003c/h2\u003e \u003cp\u003eThe participants reported what they believed caused their illness, namely, IC. Of these causal factors, smoking was the most reported (42.7%), followed by age (21.8%), genetics (9.1%), and no idea (7.3%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003eComparison between men and women\u003c/h2\u003e \u003cp\u003eIn an illness perception comparison between men and women, women reported higher illness coherence, indicating greater understanding of IC than men (p\u0026thinsp;=\u0026thinsp;0.028). Women also reported higher emotional representations associated with IC (p\u0026thinsp;=\u0026thinsp;0.047) compared to men (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003eComparison between sufficient and insufficient health literacy\u003c/h2\u003e \u003cp\u003ePatients with sufficient health literacy reported less consequences (p\u0026thinsp;=\u0026thinsp;0.003) and lower emotional representations (p\u0026thinsp;=\u0026thinsp;0.001) of the IC than patients with insufficient health literacy. They also reported higher self-efficacy (p\u0026thinsp;=\u0026thinsp;0.049) and higher QoL (p\u0026thinsp;=\u0026thinsp;0.005) than patients with insufficient health literacy (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDifferences between men and women and health literacy regarding illness perception, self-efficacy, adherence to medication treatment, and quality of life at six months in subjects with intermittent claudication\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;133)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWomen\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;67)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMen\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;66)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInsufficient health literacy (n\u0026thinsp;=\u0026thinsp;70)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSufficient health literacy (n\u0026thinsp;=\u0026thinsp;61)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep-value (w/m)*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e(Insuff /Suff )*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIllness perception subscales\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eTimeline\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (20.3\u0026ndash;26.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (20\u0026ndash;26.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (21\u0026ndash;27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23.5 (19.8\u0026ndash;26.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e24 (20.9\u0026ndash;27.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.752\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.309\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eTimeline cyclical\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (8\u0026ndash;13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (8\u0026ndash;13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (8\u0026ndash;13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10 (8\u0026ndash;12.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.9 (8\u0026ndash;14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.785\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.392\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eConsequences\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.5 (14\u0026ndash;21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (14\u0026ndash;19.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (1\u0026ndash;521)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19 (15.8\u0026ndash;21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16.5 (14\u0026ndash;18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.432\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePersonal control\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (17\u0026ndash;22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.5 (17\u0026ndash;22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (17.3\u0026ndash;21.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19 (17\u0026ndash;21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19 (17.8\u0026ndash;22.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.840\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.325\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eTreatment control\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (13.8\u0026ndash;18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (14\u0026ndash;18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (13\u0026ndash;18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15 (13.4\u0026ndash;18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16.1 (14\u0026ndash;18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.856\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.376\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eIllness coherence\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (15\u0026ndash;21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (15.3\u0026ndash;24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (13.5\u0026ndash;20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18 (15\u0026ndash;21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19 (15\u0026ndash;23.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.028\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.194\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEmotional representations\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (13\u0026ndash;20.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (13\u0026ndash;22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (13\u0026ndash;18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18 (14\u0026ndash;22.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15 (12.3\u0026ndash;18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.047\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-efficacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (26.5\u0026ndash;33.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (26\u0026ndash;34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 (27\u0026ndash;32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30 (26\u0026ndash;32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e31 (28\u0026ndash;35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.740\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.049\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdherence to treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (24\u0026ndash;25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (24\u0026ndash;25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (24\u0026ndash;25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25 (24\u0026ndash;25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25 (24\u0026ndash;25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.496\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.223\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuality of life\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u0026nbsp;(11\u0026ndash;17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (11\u0026ndash;17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (11.5\u0026ndash;17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13 (10\u0026ndash;17.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16 (14\u0026ndash;17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.152\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e*median (IQR)\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003ew:women\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003em: men\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eInsuff : insufficient health literacy\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eSuff: sufficient health literacy\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003eComparison between other populations\u003c/h2\u003e \u003cp\u003eCompared to study populations with MI \u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e and CABG,\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e the patients with IC perceived a longer duration (i.e., timeline) and had a lower sense of both personal and treatment control compared to patients who had an MI (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and patients who had undergone CABG (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Patients with IC reported less consequences of their disease compared to those with MI (p\u0026thinsp;=\u0026thinsp;0.027) and CABG (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Differences were also demonstrated where patients with IC reported lower illness coherence of their disease (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and lower emotional impact (p\u0026thinsp;=\u0026thinsp;0.005) than patients with CABG (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIPQ-R Mean (SD) scores in patients with IC at six months compared with patients with myocardial infarction (MI) from Als\u0026eacute;n et al. (2010) and CABG from Hermele et al. (2007) as reference population\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIllness perception subscales\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e*Intermittent\u003c/p\u003e \u003cp\u003eClaudication (n\u0026thinsp;=\u0026thinsp;133)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e*Myocardial infarction (n\u0026thinsp;=\u0026thinsp;204)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e*CABG (n\u0026thinsp;=\u0026thinsp;56)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e(IC/MI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e(IC/CABG)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eTimeline\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23.23 (4.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20.01 (5.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.31 (5.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eTimeline cyclical\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10.54 (3.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.80 (2.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot measured\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.411\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eConsequences\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17.37 (4.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.18 (4.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.91 (4.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.027\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePersonal control\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19.37 (3.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21.26 (3.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.50 (3.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eTreatment control\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15.81 (3.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.08 (3.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.11 (3.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eIllness coherence\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17.80 (5.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.12 (3.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.33 (4.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.144\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEmotional representations\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16.96 (4.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16.65 (4.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.20 (4.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.473\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cb\u003e*\u003c/b\u003eIC: 6 months after diagnosis\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eMI: 4 months after MI\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eCABG: pre-surgical consultation 2\u0026ndash;4 weeks prior to surgery\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003eCorrelations\u003c/h2\u003e \u003cp\u003eThe subscales timeline (r\u003csub\u003es\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.24; p\u0026thinsp;=\u0026thinsp;0.009), timeline cyclic (r\u003csub\u003es\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.19; p\u0026thinsp;=\u0026thinsp;0.042), personal control (r\u003csub\u003es\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.19; p\u0026thinsp;=\u0026thinsp;0.044), and emotional representations (r\u003csub\u003es\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.58; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) correlated negatively with adherence to medication treatment, indicating that higher scores on these subscales were associated with lower adherence. The subscales treatment control (r\u003csub\u003es\u003c/sub\u003e = 0.22; p\u0026thinsp;=\u0026thinsp;0.016) and illness coherence (r\u003csub\u003es\u003c/sub\u003e = 0.21; p\u0026thinsp;=\u0026thinsp;0.028) correlated positively with adherence to medication treatment, indicating that higher scores on these subscales were associated with higher adherence.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eQuality of life\u003c/h2\u003e \u003cp\u003ePositive associations were found between personal control and QoL (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and between self-efficacy and QoL (p\u0026thinsp;=\u0026thinsp;0.014), indicating that higher scores were positively associated with higher QoL. A negative association was found between the consequences of the illness and QoL (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) as well as between adherence to medication treatment and QoL (p\u0026thinsp;=\u0026thinsp;0.013), indicating that experiences of higher consequences of IC and higher adherence to medication treatment were associated with lower QoL (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSpearman\u0026rsquo;s correlation analysis between illness perception, self-efficacy, adherence to medication treatment and quality of life in subjects with intermittent claudication\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTimeline\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTimeline cyclic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eConsequences\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePersonal control\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTreatment control\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIllness coherence\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eEmotional representations\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSelf- efficacy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eAdherence to treatment\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTimeline cyclic\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;0.262\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e\u003cb\u003e(0.004)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eConsequences\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.190\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e\u003cb\u003e(0.037)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;0.116\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e(0.204)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePersonal control\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;0.171\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e(0.062)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.144\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e(0.116)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;0.170\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e(0.058)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTreatment control\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;0.283\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e\u003cb\u003e(0.002)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e(0.945)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;0.103\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e(0.267)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.469\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e\u003cb\u003e(\u0026lt;\u0026thinsp;0.001)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIllness coherence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.127\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e(0.176)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;0.146\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e(0.113)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;0.025\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e(0.783)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.322\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e\u003cb\u003e(\u0026lt;\u0026thinsp;0.001)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.372\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmotional representations\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e(0.953)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.103\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e(0.260)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.488\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e\u003cb\u003e(\u0026lt;\u0026thinsp;0.001)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;0.079\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e(0.379)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;0.043\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e(0.643)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;0.170\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e(0.063)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSelf- efficacy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.067\u003c/p\u003e \u003cp\u003ep-value (0.484)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.085\u003c/p\u003e \u003cp\u003ep-value (0.368)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;0137\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e(0.142)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.074\u003c/p\u003e \u003cp\u003ep-value (0.432)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;0.081\u003c/p\u003e \u003cp\u003ep-value (0.394)\u003c/p\u003e\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;0.130\u003c/p\u003e \u003cp\u003ep-value (0.165)\u003c/p\u003e\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.072\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e(0.427)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAdherence to treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;0.239\u003c/p\u003e \u003cp\u003ep-value \u003cb\u003e(0.009)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;0.188\u003c/p\u003e \u003cp\u003ep-value \u003cb\u003e(0.042)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;0.084\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e(0.356)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;0.183\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e\u003cb\u003e(0.044)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.224\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e\u003cb\u003e(0.016)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.205\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e\u003cb\u003e(0.028)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026minus;0.577\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e\u003cp\u003e\u003cb\u003e(\u0026lt;\u0026thinsp;0.001)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026minus;0.057\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e(0.540)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQuality of life\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;0.175\u003c/p\u003e \u003cp\u003ep-value (0.057)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.076\u003c/p\u003e \u003cp\u003ep-value (0.415)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;0.568\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e\u003cb\u003e(\u0026lt;\u0026thinsp;0.001)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.348\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e\u003cb\u003e(\u0026lt;\u0026thinsp;0.001)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.114\u003c/p\u003e \u003cp\u003ep-value (0.238)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;0.010\u003c/p\u003e \u003cp\u003ep-value (0.917)\u003c/p\u003e\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026minus;0.108\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e\u003cp\u003e(0.243)\u003c/p\u003e\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.224\u003c/p\u003e \u003cp\u003e\u003cb\u003ep-value (0.014)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026minus;0.224\u003c/p\u003e \u003cp\u003e\u003cb\u003ep-value (0.013)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e \u003ch2\u003eFactors related to QoL\u003c/h2\u003e \u003cp\u003eA multiple regression model explained 46.5% of the variance in QoL (adjusted R square\u0026thinsp;=\u0026thinsp;0.465; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and showed that both consequences and adherence to medication treatment were negative predictors of QoL, meaning that one unit increase in these variables decreased QoL (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultiple linear regression at six months with quality of life as dependent variable\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndependent variables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStandard error\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eβ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsequences in illness perception\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;0.569\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.074\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;0.576\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePersonal control in illness perception\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.167\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.087\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.143\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.057\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-efficacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.096\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.056\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.123\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.088\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdherence to treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;0.556\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.196\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;0.204\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.050\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eR square: 0.445\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eAdjusted R-square: 0.465\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eSign: \u0026lt; 0.001\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eChanges over time\u003c/h2\u003e \u003cp\u003eThe QoL medians with inter quartile range (IQR) were 13 at baseline (11\u0026ndash;17), 15 at 6 months (11\u0026ndash;17), and 16 at 12 months (12\u0026ndash;18.8). A significant increase in QoL was seen between baseline and 6 months (p\u0026thinsp;=\u0026thinsp;0.033), baseline and 12 months (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and 6 months and 12 months (p\u0026thinsp;=\u0026thinsp;0.031). After a correction for multiple comparisons (Bonferroni), the significant increase in QoL remained between baseline and 12 months (p\u0026thinsp;=\u0026thinsp;0.003). No significant changes over time were seen in self-efficacy or adherence to treatment.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study showed that illness perception differed in patients with IC in relation to sex, health literacy level, and study populations with coronary heart disease (CHD). Patients\u0026rsquo; self-reported beliefs on the causes of IC were smoking, age, and genetics. However, even if smoking was the most commonly reported causal beliefs for the disease (42%), the majority of the participants (89%) were current or former smokers. This is in line with a previous review on illness perception in patients with PAD, which showed that the patients had different beliefs regarding smoking as a causing factor for the disease; only some acknowledged smoking as a causing factor.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e This has also been seen in patients with COPD, who expressed uncertainty about the connection between smoking and the disease.\u003csup\u003e\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e The fact that 7.3% had no idea what caused their disease emphasizes a need to improve the patients\u0026rsquo; awareness of the aetiology of the disease. As illness perception clearly influences patients\u0026rsquo; beliefs about the causes of IC, an educational intervention addressing their perceptions could be one option to increase their awareness and, in turn, also their QoL. For example, previous research has shown that an illness perception correction-based educational programme provided via phone calls by a nurse improved QoL in patients with heart failure.\u003csup\u003e\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn a comparison between men and women concerning illness perception, women reported higher illness coherence and higher emotional representations, indicating they have greater understanding and greater emotional impact associated with IC compared to men. The difference in illness coherence contrasts with Al-Smadi et al.\u0026rsquo;s\u003csup\u003e\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u003c/sup\u003e review of illness perception in patients with CHD, where four studies\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e 52, 53\u003c/sup\u003e reported no differences between men and women and two studies\u003csup\u003e\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u003c/sup\u003e reported higher illness coherence in men than in women. The difference in emotional representation is in line with a review on sex differences in patients with chronic disease, where women experienced more negative stress about their condition compared to men.\u003csup\u003e\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e\u003c/sup\u003e Differences between men and women with PAD have also been studied earlier. A review showed that men and women differ in the presentation of PAD symptoms, where women more often present atypical symptoms and rest pain and, less often, IC symptoms.\u003csup\u003e\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e\u003c/sup\u003e Since differences between men and women with IC occur both in illness perception and symptom presentation, sex differences in IC patients should be further studied. Health care professionals\u0026rsquo; awareness of potential sex differences could create preconditions for more individualized information, which could further improve the patients\u0026rsquo; self-management of secondary prevention.\u003c/p\u003e \u003cp\u003ePatients with sufficient health literacy reported less consequences and lower emotional representations of the IC than patients with insufficient health literacy. This concurred with previous studies on patients with COPD and cardiovascular disease, which showed that those with insufficient health literacy also experienced more emotional representations.\u003csup\u003e\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e\u003c/sup\u003e The current study also showed higher self-efficacy and higher QoL among patients with sufficient health literacy compared to those with insufficient health literacy, which is in line with previous research.\u003csup\u003e\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e\u003c/sup\u003e These findings suggest that improving patients\u0026rsquo; health literacy may improve their self-efficacy, which in turn may positively influence their QoL. Since health literacy can be improved by information and structured education,\u003csup\u003e\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u003c/sup\u003e patients with IC may benefit from a more active support from the health care system. Different methods \u0026ndash; such as motivational interviewing, individual or group support, and in-person or web- or telephone-based support \u0026ndash; have been beneficial for improving health literacy in patients with chronic diseases.\u003csup\u003e\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e\u003c/sup\u003e Further research is needed to assess these methods for improving health literacy in patients with IC. As previously suggested, digital formats may be more accessible for patients and perhaps more cost-effective, but they need both testing and evaluation among patients with IC.\u003c/p\u003e \u003cp\u003eIn comparisons with study populations who suffered MI or had undergone a CABG, patients with IC had a lower sense of personal and treatment control. They also had lower illness coherence of their disease compared to CABG patients. This difference in illness perception may be due to the lack of systematic secondary prevention support in patients with IC. Further, an important disparity between IC and CHD is that even if both conditions derive from atherosclerosis, the care of patients with CHD includes long-term management with rehabilitation programmes,\u003csup\u003e\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u003c/sup\u003e which hardly exist for patients with IC. Since secondary prevention is the first line of treatment, patients with IC could benefit from more support to create more control and understanding in their process of managing the disease. A study with IC patients has shown positive experiences of nurse-led units in terms of increased awareness of their disease and increased motivation for initiating lifestyle changes.\u003csup\u003e\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e\u003c/sup\u003e This kind of support could be a way to improve patients\u0026rsquo; self-management of IC.\u003c/p\u003e \u003cp\u003eConsequences and adherence to medication treatment were negative predictors of QoL in patients with IC. That the perceived consequences of the disease have an impact on daily life has earlier been confirmed in a review on patients with PAD; the patients experienced involuntary isolation and loss of independence due to their disease, which affected their self-image.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e In this study, the association between increased adherence to medication treatment and decreased QoL is a surprising result in need of consideration. A possible explanation might be that pain and loss of independence have a negative impact on QoL in patients with IC.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Since BMT aims to prevent cardiovascular events and decrease the atherosclerotic progression rather than relieve IC symptoms,\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e high adherence to medications does not directly affect QoL. This negative association between adherence to treatment and QoL has also been reported earlier in a review on patients with COPD. According to Agh et al.,\u003csup\u003e\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e\u003c/sup\u003e the treatment with inhaler therapy in COPD may affect the patients daily life due to perceived stigma when using inhalers in public, which could explain increased QoL with low adherence. However, this reason is not applicable to patients with IC since the treatment with BMT would not affect the patients\u0026rsquo; daily life. Since adherence to taking antiplatelets and statins decreases after five years,\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e future research with a longer perspective and, importantly, a combination of different methods to measure adherence would further illuminate associations between adherence and QoL in patient with IC. Another important aspect is that health care professionals should always remember to ask patients about their adherence behaviour since it is necessary information to enable evaluations of initiated treatment.\u003c/p\u003e \u003cp\u003eWhen examining changes over time, this study found a significant increase in QoL between baseline and 12 months despite no systematic secondary prevention support. This is an interesting finding that could be explained in a review on illness perception in patients with PAD: the patients experienced a process of adaptation, where they accepted their new situation and found other values in life.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e This corresponds to the description of QoL as the discrepancy between an individual\u0026rsquo;s hopes and expectations and present experiences.\u003csup\u003e\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eEven if the improvement in QoL was rather small, having knowledge of the reason for this increase despite no interactive care or support would be valuable in the process of creating a sustainable care for patients with IC. However, this was not possible with the current study design, so further research is needed, preferably with a qualitative approach that can describe the individual experiences. The fact that self-efficacy did not change over time was an expected result since managing chronic disease processes can be demanding and motivation can decrease over time.\u003csup\u003e\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e\u003c/sup\u003e Moreover, improvements in self-efficacy most likely require support to achieve, which Sol et al.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e have shown in patients with cardiovascular conditions. Even though QoL improved one year after visiting the outpatient clinic for vascular diseases, improving patients\u0026rsquo; health literacy, self-efficacy, and illness perception is necessary to further improve the self-management of the disease. This may be achieved through self-management programmes, gaming, mobile applications, or social media.\u003csup\u003e\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e\u003c/sup\u003e However, future research is needed to evaluate these methods in relation to patients with IC.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eA strength of this study is that only validated instruments were used, thereby minimizing measurement bias. Another strength is that data extracted from medical records were used to describe medical status. However, a potential weakness is that all data from the questionnaires were self- reported, which can be inaccurate due to social desirability or failure to recollect adherence behaviour.\u003csup\u003e\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e\u003c/sup\u003e Since many of the patients scored maximum points in the adherence questionnaire, the potential ceiling effect needs to be considered. This makes it impossible to distinguish differences in adherence behaviour. Similar skewness in adherence reports has been found in previous studies.\u003csup\u003e\u003cspan additionalcitationids=\"CR72\" citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e\u003c/sup\u003e Studies have shown self-reported questionnaire to overestimate patients\u0026rsquo; adherence in other chronic conditions.\u003csup\u003e\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e\u003c/sup\u003e Nevertheless, despite the limitation, self-reported medication adherence measures can provide valuable and useful information.\u003csup\u003e\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e\u003c/sup\u003e Further research on adherence in patients with IC is recommended, preferably using different research methods, such as refill-of-prescriptions records from pharmacies in combination with self-reported data.\u003c/p\u003e \u003cp\u003eThe longitudinal design of the study enabled us to determine patterns over time. However, this study required the participants to fill in questionnaires on three occasions over one year. During this time, some of the participants decided to withdraw further participation. Significant differences were found despite a somewhat small sample size; however, differences that were not detected may exist.\u003csup\u003e\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e\u003c/sup\u003e The internal consistency of the scales, which was measured through Cronbach\u0026rsquo;s alpha or psychometric tests, was appropriate (apart from MARS and in line with previous research\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e\u003c/sup\u003e), which is to be considered a strength. The dropout rate during follow-up was acceptable, and patients ceasing to participate may be considered as an unavoidable attrition.\u003csup\u003e\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIllness perception differs in some aspects in relation to the level of health literacy as well as between men and women. Further, the level of health literacy seems to be of importance for patients\u0026rsquo; self-efficacy and QoL. This illuminates the need for new strategies to improve health literacy, illness perception, and self-efficacy over time \u0026ndash; for example, by providing more tailored information regarding secondary prevention, preferably by using e-health tools, in order to strengthen self-management to further improve QoL in patients with IC.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eABI: Ankle brachial index\u003c/p\u003e\n\u003cp\u003eBMT: Best medical therapy\u003c/p\u003e\n\u003cp\u003eCABG: Coronary artery bypass graft\u003c/p\u003e\n\u003cp\u003eCHD: Coronary heart disease\u003c/p\u003e\n\u003cp\u003eCSM: Common Sense Model\u003c/p\u003e\n\u003cp\u003eHLS-EU: European Health Literacy Survey Questionnaire\u003c/p\u003e\n\u003cp\u003eHLS-EU-Q16-SE: European Health Literacy Survey Questionnaire 16 Swedish\u003c/p\u003e\n\u003cp\u003eIC: Intermittent claudication\u003c/p\u003e\n\u003cp\u003eIPQ-R: The Revised Illness Perception Questionnaire\u003c/p\u003e\n\u003cp\u003eIQR: Inter quartile range\u003c/p\u003e\n\u003cp\u003eMARS-5: Medication Adherence Report Scale\u003c/p\u003e\n\u003cp\u003eMI: Myocardial infarction\u003c/p\u003e\n\u003cp\u003ePAD: Peripheral arterial disease\u003c/p\u003e\n\u003cp\u003ePROM: Patient reported outcome measure\u003c/p\u003e\n\u003cp\u003eQoL: Quality of life\u003c/p\u003e\n\u003cp\u003eS-GSE: General Self-Efficacy Scale\u003c/p\u003e\n\u003cp\u003eVascuQoL: Vascular Quality of Life Questionnaire\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVQ6: Vascular Quality of Life Questionnaire-6\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Regional Ethical Review Board in Lund (Dnr 2017/609). All participants received oral and written information about the study, including information that it was voluntary to participate and that they could withdraw their participation at any time with no further explanation.\u003cstrong\u003eInformed consent was obtained from all participants.\u003c/strong\u003eAll methods conducted adhered to the relevant guidelines and regulations in accordance with the Declaration of Helsinki.\u003csup\u003e78\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dataset is available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the authors (RS, MZ, CK, and MA) have participated in the design, planning, and development of the study. RS was responsible for the data collection. The analysis was conducted by RS and MA, and all authors took part in the interpretation of the results.\u0026nbsp;RS drafted the manuscript, and CK, MZ, and MA reviewed and contributed with important intellectual content. The authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research team is grateful to the individuals with IC who generously gave their time to participate in the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eAboyans V, Ricco JB, Bartelink MEL et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization (ESO)The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). \u003cem\u003eEur Heart J\u003c/em\u003e. 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Can Med Assoc J Sep. 1964;12(11):619.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"illness perception, self-efficacy, health literacy, adherence to treatment, quality of life, intermittent claudication, secondary prevention","lastPublishedDoi":"10.21203/rs.3.rs-2623748/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2623748/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e: \u003c/strong\u003ePatients with intermittent claudication need lifelong treatment with secondary prevention to prevent cardiovascular events and progression of atherosclerotic disease. Illness perception, health literacy, self-efficacy, adherence to medication treatment, and quality of life are factors influencing patients’ self-management. Knowledge of these factors could be important when planning for secondary prevention in patients with intermittent claudication.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eAim: \u003c/strong\u003e\u003c/em\u003eto compare illness perception, self-efficacy, adherence to treatment, and quality of life in relation to the sex and health literacy of patients with intermittent claudication. Further, it explored changes in self-efficacy, adherence to treatment, and quality of life during the first year after diagnosis.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e A \u003c/em\u003elongitudinal cohort study was conducted with 128 participants recruited from vascular units in southern Sweden. Data were collected through medical records and questionnaires regarding illness perception, health literacy, self-efficacy, adherence to treatment, and quality of life.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eResults: \u003c/strong\u003e\u003c/em\u003e\u003cem\u003eIn the subscales in illness perception, \u003c/em\u003epatients with sufficient health literacy reported less consequences and lower emotional representations of the intermittent claudication. They also reported higher self-efficacy and higher quality of life than patients with insufficient health literacy. In comparison between men and women in illness perception, women reported higher illness coherence and emotional representations associated with intermittent claudication compared to men. A multiple regression showed that both consequences and adherence were negative predictors of quality of life. When examining changes over time, a significant increase in quality of life was seen between baseline and 12 months, but there were no significant differences in self-efficacy and adherence to treatment.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003e\u003c/em\u003eIllness perception differs in relation to level of health literacy and between men and women. Further, the level of health literacy seems to be of importance for patients’ self-efficacy and quality of life. This illuminates the need for new strategies for improving health literacy, illness perception, and self-efficacy over time. For example, more tailored information regarding secondary prevention could be provided to strengthen self-management to further improve quality of life in patients with intermittent claudication.\u003c/p\u003e","manuscriptTitle":"Illness perception, self-efficacy, health literacy, adherence, and quality of life in patients with intermittent claudication – a longitudinal cohort study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-03-14 14:44:19","doi":"10.21203/rs.3.rs-2623748/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-03-20T04:52:31+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-03-17T11:14:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"e7679299-678d-451c-a8d5-80b2604f47cf","date":"2023-03-11T13:30:15+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-03-09T11:58:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-03-09T11:55:14+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2023-03-09T10:33:33+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-03-09T10:29:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2023-02-24T08:53:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0571b6ee-a480-456b-aeab-82a90593255d","owner":[],"postedDate":"March 14th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T21:15:33+00:00","versionOfRecord":{"articleIdentity":"rs-2623748","link":"https://doi.org/10.1186/s12912-023-01329-2","journal":{"identity":"bmc-nursing","isVorOnly":false,"title":"BMC Nursing"},"publishedOn":"2023-05-17 20:50:52","publishedOnDateReadable":"May 17th, 2023"},"versionCreatedAt":"2023-03-14 14:44:19","video":"","vorDoi":"10.1186/s12912-023-01329-2","vorDoiUrl":"https://doi.org/10.1186/s12912-023-01329-2","workflowStages":[]},"version":"v1","identity":"rs-2623748","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2623748","identity":"rs-2623748","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}