Relation between health literacy and cardiac health behavior: evidence from Iranian cardiovascular disease patients

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Cardiac health behaviors are essential for transforming lifestyle patterns. In this study, we investigated the status of health literacy and cardiac health behaviors and the factors that can affect them. Subject and methods This descriptive-analytical cross-sectional involved 126 individuals with cardiovascular diseases who were referred to Ayatollah Mousavi hospital in Zanjan, Iran. Convenience sampling was conducted from August 10 to November 10, 2024. Data were collected using the Cardiac Health Behavior (CHB) scale and the Health Literacy (HL) Instrument for Adults (HELIA). Analyses were performed in Rstudio 2025.05.0 using independent t-test, one-way ANOVA, and multiple linear regression. Results The lowest HL score was in the "decision-making/ behavioral intention" domain and the highest in the "reading" domain. About 36% and 12% of participants had an adequate and excellent level of HL, respectively. The lowest CHB score was in the "physical activity" domain and the highest in the "dietary habits" domain. Women, urban residents, non-smokers, patients with adequate/ excellent levels of HL, and those with university education demonstrated better CHB scores. Conclusion According to the results, the lowest score was related to physical activity and the highest score was related to dietary habits, and health literacy was not adequate. Health policymakers should implement educational interventions to improve factors affecting heart health behaviors, which will ultimately lead to the promotion of health behaviors and prevention of cardiovascular diseases at different levels. Health literacy Cardiac health behavior Cardiovascular disease Physical activity Dietary habit Prevention Figures Figure 1 Figure 2 1 Introduction Noncommunicable diseases result from a complex interplay of genetic, physiological, environmental, and behavioral factors, and they account for over 43 million deaths globally in 2021, including approximately 18 million premature deaths before age 70 [ 1 ]; among these, cardiovascular diseases are the most prevalent and deadly[ 2 ], representing the highest mortality rate both within noncommunicable diseases and across all causes [ 1 , 3 ]. Cardiovascular diseases, responsible for over 19 million deaths globally in 2021 and showing a 99.28% increase in Iran since 1990 [ 4 ], are largely driven by modifiable risk factors such as unhealthy diet, physical inactivity, obesity, high blood glucose, hypertension, dyslipidemia, smoking, and alcohol [ 2 , 5 ], with approximately 72% of the population risk attributable to these factors. About 25% of deaths potentially preventable through proactive health behaviors and preventive care[ 6 – 8 ]. Individuals' health behaviors significantly influence health promotion, reduce the risk of disease, aid in symptom management, and prevent future health issues [ 7 ]. For patients with cardiovascular disease, engaging in consistent medication adherence, regular follow-up examinations, physical activity, smoking cessation, a balanced diet, stress management, and taking personal responsibility for health are essential cardiac health behaviors . These behaviors can influence modifiable risk factors, reduce the likelihood of adverse outcomes such as cardiac arrest, heart attack, disease recurrence, readmission, and mortality, and play a vital role in enhancing overall cardiovascular well-being [ 8 , 9 ]. A well-rounded approach to health—encompassing positive behaviors, a balanced diet, stress management, and smoking cessation—enhances overall quality of life, promotes independence, and significantly lowers the risk of chronic conditions such as diabetes, hypertension, hypercholesterolemia, and cardiovascular diseases[ 10 ]. Adopting cardiac health behaviors are essential for transforming lifestyle patterns, and education about the disease and its management is fundamental. Increased knowledge and positive attitudes lay the groundwork for behavioral change, while targeted educational programs can cultivate a healthier and more sustainable lifestyle[ 11 ]. Health literacy is vital in shaping individuals’ knowledge, attitudes, and behaviors toward cardiac health, thereby affecting outcomes, healthcare costs, treatment engagement, and overall empowerment [ 12 ]. In patients with cardiovascular diseases, low health literacy is associated with higher hospital readmission rates, diminished quality of life, poorer health choices, and overall worse health status [ 13 ]. There are numerous definitions[ 14 , 15 ] and various measurement tools have been developed to assess it[ 16 ]. Health literacy has been defined as” the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions “[ 12 ]. Different levels of health literacy have been reported in various countries and target groups. A study in European countries indicated health literacy levels ranging from 30% to 63%, with this wide range being dependent on the country studied [ 17 ]. A study by Harsch et al. conducted on people living in Afghanistan showed low health literacy among women, with age and education level impacting health literacy. Health literacy was also associated with treatment-seeking behaviors and health-related behaviors [ 18 ]. Considering the significance of cardiovascular diseases and the impact of health literacy and cadriac health behaviors on their outcomes—factors that vary across societies—this study explores the current status of these behaviors and literacy levels, as well as their interrelationship. 2 Methods This cross-sectional, descriptive-analytical study (with ethics code IR.ZUMS.REC.1403.111) involved individuals with cardiovascular diseases who had been referred to Ayatollah Mousavi hospital in Zanjan, Iran. This hospital is the only educational and therapeutic heart disease center in Zanjan. The sample size was 126 persons with a correlation coefficient of 0.25 between health literacy and self-care behaviors in heart patients (r = 0.25)[ 19 ], \(\:\alpha\:\) =0.05, and \(\:\beta\:\) =0.20 in the formula \(\:\text{n}=\frac{{\left({Z}_{1-\frac{\alpha\:}{2}}+{Z}_{1-\beta\:}\right)}^{2}}{{\left(0.5\times\:\text{Ln}\left(\frac{1+r}{1-r}\right)\:\right)}^{2}}+3\) . The inclusion criteria comprised being between the ages of 18 and 65, having informed consent and being able to read, understand and answer to questions. The exclusion criteria included having multiple underlying diseases other than heart disease and receiving treatment for psychological disorders. From August 10 to November 10, 2024, patients who seeking treatment for cardiovascular diseases at Ayatollah Mousavi Hospital in Zanjan were included in the study using on convenience sampling. The Cardiac Health Behavior (CHB) scale and the Health Literacy Instrument for Adults (HELIA) were completed to collect data. Additionally, demographic data of the patients such as age, gender, education level, marital status, residence location, employment status, monthly household income, and number of household members, were collected. Data regarding their heart disease was also gathered, including its duration, frequency of hospital addmisions related to it, family history, and type of heart disease. The CHB scale consists of 21 items divided into 5 domains: health responsibility (6 items), deitary habits (5 items), physical activity (4 items), smoking (3 items), and stress management (3 items). Responses are provided using a 4-point Likert scale: never (0), sometimes (1), often (2), and always (3). A higher score indicates higher cardiac health behavior. The Persian version of the scale was validated and found be reliable by Shafiayan et al. in 2019, with a Cronbach's alpha of 0.88 [ 20 ]. The HELIA, developed by Tavousi et al. in 2015, is intended for the Iranian population aged 18 to 65 years. This consists of 33 items categorized into 5 domains: access to information (6 items), reading (4 items), understanding (7 items), appraisal (4 items), and decision-making/ behavioral intention (12 items). Responses are given using a 5-point Likert scale. A higher score indicates higher health literacy. The domains and total score are divided into 4 categories: inadequate (0–50), not very adequate (50.1–66), adequate (66.1–84), and excellent (84.1–100). The Cronbach's alpha values for various domains ranged from 0.72 to 0.89 [ 21 ]. The Kolmogorov-Smirnov or Shapiro-Wilk test was used to assess whether the CHB scores were normally distributed. Independent t-test and one-way ANOVA (with Tukey's post hoc test) were employed to determine the factors influencing CHB. To assess the simultaneous effects of factors on the CHB score, multiple linear regression was performed using the exhaustive method, with model selection criteria based on adjusted R-squared and Mallows' Cp. The assumptions of the regression model were also evaluated. To adjust monthly household income based on family size (adjusted income), the total monthly household income was divided by the number of family members and then categorized into four groups based on quartiles. Analyses were conducted using Rstudio 2025.05.0, with a significance level set at 5%. The regsubsets function from the leaps package was used for the regression analysis. 3 Results The mean (standard deviation, SD) age was 38.40 (13.56) years, and the median (interquartile range) duration of heart disease was 3.00 (5.30) years. According to Table 1 , The majority of patients were between the ages of 33 and 44 (38.1%), male (58.7%), married (50.8%), residents of a city (73.8%), had a diploma or associate's degree (41.3%), had been ill for less than 3 years (45.2%), had never smoked (46.0%), had experienced a heart attack (22.2%), and had been hospitalized once (40.4%). Additionally, most common job status among women was housewives (50.0%) and among men, it was retired (64.9%). Additionally, 5 (9.6%) of women and 40 (54.1%) of men were smoker. Table 1 Demographic and disease-related characteristics Variable Category Frequency Percentage Age (year) \(\:\le\:\:\) 29 39 31.0 30–44 48 38.0 \(\:\ge\:\) 45 39 31.0 Gender Female 52 41.3 Male 74 58.7 Marital status Single 44 34.9 Married 64 50.8 Widowed/ Divorced 18 14.3 Residence Rural 33 26.2 Urban 93 73.8 Job status: Female Unemployed/ retired 12 23.1 Employed 14 26.9 Housewife 26 50.0 Job status: Male Unemployed 13 17.6 Retired 13 17.6 Employed 48 64.8 Education level Under diploma 36 28.6 Diploma/ associate diploma 52 41.2 Bachelor and higher 38 30.2 Smoking Yes 45 35.7 Quitted 23 18.3 No 58 46.0 Adjusted income (Million per number) < 1.50 32 25.4 1.50–60 33 26.2 6.00–12.00 32 25.4 \(\:\ge\:\) 12.00 29 23.0 Duration of heart disease (year) < 3 57 45.2 3–6 34 27.0 \(\:\ge\:\) 6 35 27.8 Family history of heart diseases No 54 42.9 Yes 72 57.1 Type of heart disease Heart attack 28 22.2 Heart failure 14 11.1 Congenital 13 10.4 Valvular 20 15.9 Cardiac arrhythmia 25 19.8 Other 15 11.9 Simultaneously two heart diseases 11 8.7 Number of hospitalization 1 56 44.4 2–4 50 39.7 \(\:\ge\:\) 5 20 15.9 The study participants' mean (SD) health literacy was 64.47 (17.09), with the lowest score in the "decision-making/ behavioral intention" domain, at 61.84 (17.50), and the highest in the "reading" domain, at 69.59 (22.43). As shown in Fig. 1 , the majority of patients (about 36%) had an adequate level of health literacy. The participants' mean (SD) CHB score was 55.95 (15.17), with the lowest score in the physical activity domain and the highest in the dietary habits domain. Figure 2 depicts the CHB based on four groups of total health literacy scores. Patients with adequate to excellent levels of health literacy demonstrated better total CHB scores. A one-way ANOVA revealed significant differences in total CHB scores based on health literacy (Test statistics = 23.16, P < 0.001). There was no difference in total CHB scores between two inadequate and not very adequate groups (P = 0.103) or between the adequate and excellent groups (P = 0.563). However, all other pairwise comparisons showed significant differences (P < 0.001). According Table 2 , age, marital status, job status, adjusted income, duration of heart disease, family history, type of heart disease, and number of hospitalizations related to heart disease did not have a significant association with CHB. Both women (P < 0.001) and urban residents (P = 0.001) had significantly higher CHB scores. Education level was significantly related to and CHB score (P < 0.001); patients with a less than a diploma had lower CHB scores than those with a diploma or associate degree (P = 0.002) and those with a bachelor's degree or higher (P = 0.007). Additionally, there was a strong association between smoking and CHB (P < 0.001), with smokers having lower CHB scores than non-smokers (P < 0.001). Table 2 The cardiac health behavior by demographic and disease-related characteristics Variable Category Mean(SD) Test statistics P-value Age (year) \(\:\le\:\:\) 29 54.29(16.62) 0.50 0.608 § 30–44 57.54(14.59) \(\:\ge\:\) 45 55.64(14.56) Gender Female 62.45(13.44) 4.31 < 0.001 + Male 51.37(14.72) Marital status Single 57.43(14.30) 0.40 0.669 § Married 54.79(15.04) Widowed/ Divorced 56.44(18.07) Residence Rural 50.70(16.45) 2.35 0.020 + Urban 57.81(14.33) Job status: Female Unemployed/ retired 63.36(12.06) 1.45 0.245 § Employed 65.01(13.77) Housewife 59.58(13.62) Job status: Male Unemployed 53.24(17.60) 0.15 0.857 § Retired 51.89(18.89) Employed 50.73(12.83) Education level Under diploma 48.28(16.19) 7.07 0.001 § Diploma/ associate diploma 59.22(14.99) Bachelor and higher 58.73(11.82) Smoking Yes 48.36(14.79) 13.01 < 0.001 § Quitted 54.59(12.30) No 62.37(13.76) Adjusted income (Million per number) < 1.50 57.94(14.02) 0.76 0.520 § 1.50–60 55.56(15.47) 6.00–12.00 52.83(15.79) \(\:\ge\:\) 12.00 57.63(15.55) Duration of heart disease (year) < 3 57.09(15.93) 1.12 0.331 § 3–6 57.38(11.75) \(\:\ge\:\) 6 52.70(16.71) Family history of heart diseases No 56.23(14.95) 0.18 0.856 + Yes 55.73(15.44) Type of heart disease Heart attack 55.02(14.15) 0.54 0.779 § Heart failure 51.36(12.69) Congenital 56.12(15.09) Valvular 59.52(16.00) Cardiac arrhythmia 56.19(14.78) Other 56.88(15.32) Simultaneously two heart diseases 54.98(21.39) Number of hospitalization 1 55.84(14.13) 0.04 0.961 § 2–4 55.71(16.09) \(\:\ge\:\) 5 56.82(16.36) + : Independent sample t-test; § : One-way ANOVA Table 3 presents the results of a multiple linear regression analysis to identify factors influencing cardiac health behavior. The model includes demographic and disease-related characteristics, as well as health literacy. Among these variables, three — gender, smoking, and total health literacy — were selected and shown to have significant effects on patients’ cardiac health behavior. On average, males scored 5.9 points lower in cardiac health behavior compared to females. Patients who had never smoked scored about 7.45 points higher than those with a history of smoking. Additionally, patients with health literacy not very adequate, adequate, and excellent level exhibited higher scores in cardiac health behavior compared to those in the inadequate category. Table 3 Results of multiple linear regression assessing the impact of demographic characteristics, disease-related factors, and health literacy on cardiac health behavior Variable Category Regression coefficient Standard error P-value Gender Female Reference Male -5.90 2.50 0.020 Smoking Yes Reference Quitted 3.57 2.87 0.216 No 7.45 2.72 0.007 Health literacy: Total score Inadequate Reference Not very adequate 7.23 2.81 0.011 Adequate 18.96 2.75 < 0.001 Excellent 23.42 3.63 < 0.001 4 Disscusion The present study aimed to investigate cardiac health behavior and health literacy in patients with cardiovascular disease. Based on the results, the cardiac health behavior score in our study population was 55.95, slightly surpassing the score of 52.92 reported by Shafieian et al. in patients with cardiovascular disease in Tehran and almost similar to the study by Serin et al. [ 22 , 23 ]. The mentioned studies reported the highest score in the physical activity and health responsibility subscales and the lowest in smoking cessation , whereas our study found the lowest score in physical activity and the highest in dietary habits . Based on the questionnaire, physical activity was assessed through behaviors such as exercising three times a week for 20–30 minutes until sweating, walking as an exercise, substituting walking for short car trips, and performing stretching exercises for muscle relaxation. Regular exercise offers numerous personal benefits, including longevity, enhanced feelings of happiness, and a decreased risk of physical disability and dependence. Also, exercise playing a crucial role in primary and primordial prevention of many diseases such as cardiovascular conditions; it improves cardiorespiratory fitness, reduces all-cause mortality, and even in individuals with low BMI, a higher fat-free mass is associated with increased lifespan [ 24 ]. Unfortunately, individuals with cardiovascular disease in our population exhibited very low levels of physical activity and more education is needed to improve physical activity and reduce sedentary activities. In our study community, the dietary habit s that includes consuming breakfast, home-cooked meals, all food groups, and natural foods received the highest score. Choosing a healthy diet refers to adopting a dietary pattern that reduces the risk of cardiovascular diseases. The Southern diet, which is high in saturated fats, fried foods, calories, processed products, and sugary drinks, and low in fiber, vegetables, and fruits, is considered one of the unhealthiest lifestyles and is associated with increased mortality and morbidity from cardiovascular diseases. In contrast, the Mediterranean diet, rich in fruits, vegetables, olive oil, nuts, and fish, is associated with a reduced risk of adverse health events [ 25 , 26 ]. A study conducted by Lesani and colleagues with 800 residents of Tehran found that over 90 percent of participants regularly ate breakfast, and their dietary patterns closely resembled those typical of Western societies [ 27 ]. Another study revealed that approximately 75 percent of Iranians maintain a relatively suitable and suitable diet [ 28 ] .This indicates that effective education in recent years has successfully improved dietary habits. The results of our study showed that less than half of the people had adequate and excellent health literacy, and the average total health literacy score was lower than similar studies [ 21 , 29 ]. Health literacy significantly influences health behavior, as individuals with high health literacy are more proactive in seeking and accessing relevant health information, which enables them to avoid risky habits such as smoking, excessive drinking, and sedentary lifestyles, ultimately leading to better health outcomes[ 30 ]. In patients with cardiovascular and low health literacy, mortality and readmissions increase, and quality of life decreases[ 31 ]. Also, high health literacy is associated with improved preventive health behaviors in chronic diseases such as cardiovascular diseases [ 32 ]. Our study confirmed that individuals with adequate and excellent health literacy exhibit cardiac healthier behaviors, particularly in health responsibility , stress management , and no smoking. Based on the results obtained and after adjusting for demographic and disease-related factors, only gender and smoking were significantly associated with health behavior. Women exhibited better cardiac health behaviors, and non-smokers—whether current or former—also demonstrated healthier habits compared to smokers. Similar studies have shown that male have worse health behaviors [ 33 , 34 ]. Regarding the difference in health behaviors between women and men, various studies have demonstrated this difference. For example, Wang et al., in a study conducted on individuals with diabetes, observed that affected men had poorer diets and higher rates of smoking and alcohol consumption, while women were more likely to experience depression and obesity and engage in insufficient physical activity [ 35 ]. The above-mentioned cases show the need for planning by health policy makers to increase awareness of health behaviors and health literacy in different groups of society. Considering that healthy people are the center of sustainable development[ 36 ], the ultimate result of implementing health-promoting health policies is improving the health status of the society, followed by the socio-economic development of countries. 5 Conclusion According to the results, the lowest score in people with cardiovascular disease participating in the study was related to physical activity and the highest score was related to dietary habits, and it is necessary to design and implement educational interventions to improve the physical activity. Less than half of the people had adequate and excellent health literacy, and people with adequate and excellent health literacy showed healthier cardiac health behaviors, especially in the health responsibility, stress management, and smoking. Health policymakers should implement educational interventions to improve the health literacy, which will ultimately lead to the promotion of health behaviors and prevention of cardiovascular diseases at different levels. Declarations Acknowledgements The authors thank all patients who participated in the research. Conflict of Interest Statement The authors declare that they have no conflicts of interest. Ethics approval and consent to participate This study was conducted according to the Declaration of Helsinki and approved by the Bioethics Committee of Zanjan University of Medical Sciences (Code: IR.ZUMS.REC.1403.111). Written informed consent was obtained from all patients for being included in the study. Data availability Data will be available upon request from the corresponding author. Also, the data in Excel file format has also been uploaded with the manuscript submission to the journal. Clinical trial number: not applicable. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7949210","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":546022430,"identity":"19a0b7d2-da03-4f01-b6c2-0a9c1ab57123","order_by":0,"name":"Hamidreza Fallahabadi","email":"","orcid":"","institution":"Zanjan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Hamidreza","middleName":"","lastName":"Fallahabadi","suffix":""},{"id":546022431,"identity":"691fc661-0a36-4d7d-ac53-a077714fdd1c","order_by":1,"name":"Farzane Ahmadi","email":"","orcid":"","institution":"Zanjan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Farzane","middleName":"","lastName":"Ahmadi","suffix":""},{"id":546022432,"identity":"73ff9aa0-73cb-477d-9153-03012f9e1fd7","order_by":2,"name":"Farzaneh Karamitanha","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA70lEQVRIiWNgGAWjYBACCTBpACJ4GBg+ACk2diK1SIC0MM4AaWEmSgsDRAszD4hJSItk+9mHn24UMNTxz+49+Nnm1zZ5PmYGxg8fc3BrkeZJN5bOATpM4s65ZOncvtuGbcwMzJIzt+HWIseQxgDWwnAjx0A6t+c2I1ALGzMvPi38z5h/g7TI38gx/m3Zc9ueoBZpiTQ2sC0GN3LMpBl+3E4kqEVyxjM26xwDCcmNQC2WvQ23k9uYGZvx+kXifBrz7Zw/NvxyQIfd+PHntu389uaDHz7i0QLTCaEY28BkA0H1SOAPKYpHwSgYBaNgpAAAqtVGYwSFpWYAAAAASUVORK5CYII=","orcid":"","institution":"Zanjan University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Farzaneh","middleName":"","lastName":"Karamitanha","suffix":""},{"id":546022433,"identity":"b229f405-0ea7-4596-9859-13afc4e6cdd8","order_by":3,"name":"Mohammadbagher 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10:08:13","extension":"xml","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":114111,"visible":true,"origin":"","legend":"","description":"","filename":"9d8967fa11c8458bb483d9ab2d2211c21structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7949210/v1/10ca6d0a5b7b25cf3029e460.xml"},{"id":96283840,"identity":"6ad9a81d-313d-4098-a056-76e5a0185eb2","added_by":"auto","created_at":"2025-11-19 11:50:44","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":126298,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7949210/v1/4beadfaedd4259779ca11890.html"},{"id":96283830,"identity":"e373a099-62c3-430c-bbf3-b3d31a7fff66","added_by":"auto","created_at":"2025-11-19 11:50:44","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":162835,"visible":true,"origin":"","legend":"\u003cp\u003eDescription of the health literacy (A) and cardiac health behavior (B)\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7949210/v1/af621fc36b612d45bafa255e.png"},{"id":96283833,"identity":"3448ac7f-7ce6-45bd-a44d-04d241ec5930","added_by":"auto","created_at":"2025-11-19 11:50:44","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":142698,"visible":true,"origin":"","legend":"\u003cp\u003eThe cardiac health behaviorand its components across level of health literacy total score\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7949210/v1/32422ec3d9ef32f09655e737.png"},{"id":105452774,"identity":"514e83da-c67a-4259-8d25-c651a6268dbc","added_by":"auto","created_at":"2026-03-26 08:27:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1577214,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7949210/v1/f627b7cf-fc21-4d63-9f4b-71cc2d73be28.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Relation between health literacy and cardiac health behavior: evidence from Iranian cardiovascular disease patients","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eNoncommunicable diseases result from a complex interplay of genetic, physiological, environmental, and behavioral factors, and they account for over 43\u0026nbsp;million deaths globally in 2021, including approximately 18\u0026nbsp;million premature deaths before age 70 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]; among these, cardiovascular diseases are the most prevalent and deadly[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], representing the highest mortality rate both within noncommunicable diseases and across all causes [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCardiovascular diseases, responsible for over 19\u0026nbsp;million deaths globally in 2021 and showing a 99.28% increase in Iran since 1990 [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], are largely driven by modifiable risk factors such as unhealthy diet, physical inactivity, obesity, high blood glucose, hypertension, dyslipidemia, smoking, and alcohol [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], with approximately 72% of the population risk attributable to these factors.\u003c/p\u003e\u003cp\u003eAbout 25% of deaths potentially preventable through proactive health behaviors and preventive care[\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Individuals' \u003cem\u003ehealth behaviors\u003c/em\u003e significantly influence health promotion, reduce the risk of disease, aid in symptom management, and prevent future health issues [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. For patients with cardiovascular disease, engaging in consistent medication adherence, regular follow-up examinations, physical activity, smoking cessation, a balanced diet, stress management, and taking personal responsibility for health are essential \u003cem\u003ecardiac health behaviors\u003c/em\u003e. These behaviors can influence modifiable risk factors, reduce the likelihood of adverse outcomes such as cardiac arrest, heart attack, disease recurrence, readmission, and mortality, and play a vital role in enhancing overall cardiovascular well-being [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA well-rounded approach to health\u0026mdash;encompassing positive behaviors, a balanced diet, stress management, and smoking cessation\u0026mdash;enhances overall quality of life, promotes independence, and significantly lowers the risk of chronic conditions such as diabetes, hypertension, hypercholesterolemia, and cardiovascular diseases[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Adopting cardiac health behaviors are essential for transforming lifestyle patterns, and education about the disease and its management is fundamental.\u003c/p\u003e\u003cp\u003eIncreased knowledge and positive attitudes lay the groundwork for behavioral change, while targeted educational programs can cultivate a healthier and more sustainable lifestyle[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. \u003cem\u003eHealth literacy\u003c/em\u003e is vital in shaping individuals\u0026rsquo; knowledge, attitudes, and behaviors toward cardiac health, thereby affecting outcomes, healthcare costs, treatment engagement, and overall empowerment [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In patients with cardiovascular diseases, low health literacy is associated with higher hospital readmission rates, diminished quality of life, poorer health choices, and overall worse health status [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThere are numerous definitions[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] and various measurement tools have been developed to assess it[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Health literacy has been defined as\u0026rdquo; the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions \u0026ldquo;[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Different levels of health literacy have been reported in various countries and target groups. A study in European countries indicated health literacy levels ranging from 30% to 63%, with this wide range being dependent on the country studied [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. A study by Harsch et al. conducted on people living in Afghanistan showed low health literacy among women, with age and education level impacting health literacy. Health literacy was also associated with treatment-seeking behaviors and health-related behaviors [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Considering the significance of cardiovascular diseases and the impact of health literacy and cadriac health behaviors on their outcomes\u0026mdash;factors that vary across societies\u0026mdash;this study explores the current status of these behaviors and literacy levels, as well as their interrelationship.\u003c/p\u003e"},{"header":"2 Methods","content":"\u003cp\u003e This cross-sectional, descriptive-analytical study (with ethics code IR.ZUMS.REC.1403.111) involved individuals with cardiovascular diseases who had been referred to Ayatollah Mousavi hospital in Zanjan, Iran. This hospital is the only educational and therapeutic heart disease center in Zanjan.\u003c/p\u003e\u003cp\u003eThe sample size was 126 persons with a correlation coefficient of 0.25 between health literacy and self-care behaviors in heart patients (r\u0026thinsp;=\u0026thinsp;0.25)[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\alpha\\:\\)\u003c/span\u003e\u003c/span\u003e=0.05, and \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:\\)\u003c/span\u003e\u003c/span\u003e=0.20 in the formula \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\text{n}=\\frac{{\\left({Z}_{1-\\frac{\\alpha\\:}{2}}+{Z}_{1-\\beta\\:}\\right)}^{2}}{{\\left(0.5\\times\\:\\text{Ln}\\left(\\frac{1+r}{1-r}\\right)\\:\\right)}^{2}}+3\\)\u003c/span\u003e\u003c/span\u003e. The inclusion criteria comprised being between the ages of 18 and 65, having informed consent and being able to read, understand and answer to questions. The exclusion criteria included having multiple underlying diseases other than heart disease and receiving treatment for psychological disorders. From August 10 to November 10, 2024, patients who seeking treatment for cardiovascular diseases at Ayatollah Mousavi Hospital in Zanjan were included in the study using on convenience sampling.\u003c/p\u003e\u003cp\u003eThe Cardiac Health Behavior (CHB) scale and the Health Literacy Instrument for Adults (HELIA) were completed to collect data. Additionally, demographic data of the patients such as age, gender, education level, marital status, residence location, employment status, monthly household income, and number of household members, were collected. Data regarding their heart disease was also gathered, including its duration, frequency of hospital addmisions related to it, family history, and type of heart disease.\u003c/p\u003e\u003cp\u003eThe CHB scale consists of 21 items divided into 5 domains: health responsibility (6 items), deitary habits (5 items), physical activity (4 items), smoking (3 items), and stress management (3 items). Responses are provided using a 4-point Likert scale: never (0), sometimes (1), often (2), and always (3). A higher score indicates higher cardiac health behavior. The Persian version of the scale was validated and found be reliable by \u003cem\u003eShafiayan et al.\u003c/em\u003e in 2019, with a Cronbach's alpha of 0.88 [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe HELIA, developed by Tavousi et al. in 2015, is intended for the Iranian population aged 18 to 65 years. This consists of 33 items categorized into 5 domains: access to information (6 items), reading (4 items), understanding (7 items), appraisal (4 items), and decision-making/ behavioral intention (12 items). Responses are given using a 5-point Likert scale. A higher score indicates higher health literacy. The domains and total score are divided into 4 categories: inadequate (0\u0026ndash;50), not very adequate (50.1\u0026ndash;66), adequate (66.1\u0026ndash;84), and excellent (84.1\u0026ndash;100). The Cronbach's alpha values for various domains ranged from 0.72 to 0.89 [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe Kolmogorov-Smirnov or Shapiro-Wilk test was used to assess whether the CHB scores were normally distributed. Independent t-test and one-way ANOVA (with Tukey's post hoc test) were employed to determine the factors influencing CHB. To assess the simultaneous effects of factors on the CHB score, multiple linear regression was performed using the exhaustive method, with model selection criteria based on adjusted R-squared and Mallows' Cp. The assumptions of the regression model were also evaluated. To adjust monthly household income based on family size (adjusted income), the total monthly household income was divided by the number of family members and then categorized into four groups based on quartiles. Analyses were conducted using Rstudio 2025.05.0, with a significance level set at 5%. The regsubsets function from the leaps package was used for the regression analysis.\u003c/p\u003e"},{"header":"3 Results","content":"\u003cp\u003eThe mean (standard deviation, SD) age was 38.40 (13.56) years, and the median (interquartile range) duration of heart disease was 3.00 (5.30) years. According to Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, The majority of patients were between the ages of 33 and 44 (38.1%), male (58.7%), married (50.8%), residents of a city (73.8%), had a diploma or associate's degree (41.3%), had been ill for less than 3 years (45.2%), had never smoked (46.0%), had experienced a heart attack (22.2%), and had been hospitalized once (40.4%). Additionally, most common job status among women was housewives (50.0%) and among men, it was retired (64.9%). Additionally, 5 (9.6%) of women and 40 (54.1%) of men were smoker.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic and disease-related characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\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=\"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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFrequency\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePercentage\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eAge (year)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\le\\:\\:\\)\u003c/span\u003e\u003c/span\u003e\u003cb\u003e29\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e31.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e30\u0026ndash;44\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e38.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\ge\\:\\)\u003c/span\u003e\u003c/span\u003e\u003cb\u003e45\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e31.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e41.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e58.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eSingle\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e34.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eMarried\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e50.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eWidowed/ Divorced\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e14.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eResidence\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eRural\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e26.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eUrban\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e73.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eJob status: Female\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eUnemployed/ retired\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e23.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eEmployed\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e26.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eHousewife\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e50.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eJob status: Male\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eUnemployed\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e17.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eRetired\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e17.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eEmployed\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e64.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eEducation level\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eUnder diploma\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e28.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eDiploma/ associate diploma\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e41.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eBachelor and higher\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e30.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eSmoking\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e35.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eQuitted\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e18.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e46.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eAdjusted income\u003c/b\u003e (Million per number)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;1.50\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e25.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e1.50\u0026ndash;60\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e26.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e6.00\u0026ndash;12.00\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e25.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\ge\\:\\)\u003c/span\u003e\u003c/span\u003e \u003cb\u003e12.00\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e23.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eDuration of heart disease\u003c/b\u003e (year)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;3\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e45.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e3\u0026ndash;6\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e27.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\ge\\:\\)\u003c/span\u003e\u003c/span\u003e \u003cb\u003e6\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e27.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eFamily history of heart diseases\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e42.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e57.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e\u003cp\u003e\u003cb\u003eType of heart disease\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eHeart attack\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e22.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eHeart failure\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e11.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eCongenital\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eValvular\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e15.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eCardiac arrhythmia\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e19.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eOther\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e11.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eSimultaneously two heart diseases\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e8.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eNumber of hospitalization\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e44.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e2\u0026ndash;4\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e39.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\ge\\:\\)\u003c/span\u003e\u003c/span\u003e \u003cb\u003e5\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e15.9\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\u003eThe study participants' mean (SD) health literacy was 64.47 (17.09), with the lowest score in the \"decision-making/ behavioral intention\" domain, at 61.84 (17.50), and the highest in the \"reading\" domain, at 69.59 (22.43). As shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, the majority of patients (about 36%) had an adequate level of health literacy. The participants' mean (SD) CHB score was 55.95 (15.17), with the lowest score in the \u003cem\u003ephysical activity\u003c/em\u003e domain and the highest in the \u003cem\u003edietary habits\u003c/em\u003e domain.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e depicts the CHB based on four groups of total health literacy scores. Patients with adequate to excellent levels of health literacy demonstrated better total CHB scores. A one-way ANOVA revealed significant differences in total CHB scores based on health literacy (Test statistics\u0026thinsp;=\u0026thinsp;23.16, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). There was no difference in total CHB scores between two inadequate and not very adequate groups (P\u0026thinsp;=\u0026thinsp;0.103) or between the adequate and excellent groups (P\u0026thinsp;=\u0026thinsp;0.563). However, all other pairwise comparisons showed significant differences (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAccording Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, age, marital status, job status, adjusted income, duration of heart disease, family history, type of heart disease, and number of hospitalizations related to heart disease did not have a significant association with CHB. Both women (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and urban residents (P\u0026thinsp;=\u0026thinsp;0.001) had significantly higher CHB scores. Education level was significantly related to and CHB score (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001); patients with a less than a diploma had lower CHB scores than those with a diploma or associate degree (P\u0026thinsp;=\u0026thinsp;0.002) and those with a bachelor's degree or higher (P\u0026thinsp;=\u0026thinsp;0.007). Additionally, there was a strong association between smoking and CHB (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with smokers having lower CHB scores than non-smokers (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\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\u003eThe cardiac health behavior by demographic and disease-related characteristics\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=\"left\" 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\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMean(SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTest statistics\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\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e (year)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\le\\:\\:\\)\u003c/span\u003e\u003c/span\u003e\u003cb\u003e29\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e54.29(16.62)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.608\u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e30\u0026ndash;44\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e57.54(14.59)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\ge\\:\\)\u003c/span\u003e\u003c/span\u003e\u003cb\u003e45\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e55.64(14.56)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e62.45(13.44)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e4.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e+\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e51.37(14.72)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eSingle\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e57.43(14.30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.669\u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eMarried\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e54.79(15.04)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eWidowed/ Divorced\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e56.44(18.07)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eResidence\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eRural\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50.70(16.45)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e2.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.020\u003csup\u003e+\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eUrban\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e57.81(14.33)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eJob status: Female\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eUnemployed/ retired\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e63.36(12.06)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e1.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.245\u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eEmployed\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e65.01(13.77)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eHousewife\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e59.58(13.62)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eJob status: Male\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eUnemployed\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e53.24(17.60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.857\u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eRetired\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e51.89(18.89)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eEmployed\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50.73(12.83)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eEducation level\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eUnder diploma\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e48.28(16.19)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e7.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.001\u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eDiploma/ associate diploma\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e59.22(14.99)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eBachelor and higher\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e58.73(11.82)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eSmoking\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e48.36(14.79)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e13.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eQuitted\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e54.59(12.30)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e62.37(13.76)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eAdjusted income\u003c/b\u003e (Million per number)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;1.50\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e57.94(14.02)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e0.76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e0.520\u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e1.50\u0026ndash;60\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e55.56(15.47)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e6.00\u0026ndash;12.00\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e52.83(15.79)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\ge\\:\\)\u003c/span\u003e\u003c/span\u003e \u003cb\u003e12.00\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e57.63(15.55)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eDuration of heart disease\u003c/b\u003e (year)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;3\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e57.09(15.93)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e1.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.331\u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e3\u0026ndash;6\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e57.38(11.75)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\ge\\:\\)\u003c/span\u003e\u003c/span\u003e \u003cb\u003e6\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e52.70(16.71)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eFamily history of heart diseases\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e56.23(14.95)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.856\u003csup\u003e+\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e55.73(15.44)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e\u003cp\u003e\u003cb\u003eType of heart disease\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eHeart attack\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e55.02(14.15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"6\" rowspan=\"7\"\u003e\u003cp\u003e0.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"6\" rowspan=\"7\"\u003e\u003cp\u003e0.779\u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eHeart failure\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e51.36(12.69)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eCongenital\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e56.12(15.09)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eValvular\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e59.52(16.00)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eCardiac arrhythmia\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e56.19(14.78)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eOther\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e56.88(15.32)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eSimultaneously two heart diseases\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e54.98(21.39)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eNumber of hospitalization\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e55.84(14.13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.961\u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e2\u0026ndash;4\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e55.71(16.09)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\ge\\:\\)\u003c/span\u003e\u003c/span\u003e \u003cb\u003e5\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e56.82(16.36)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003e+\u003c/sup\u003e: Independent sample t-test; \u003csup\u003e\u0026sect;\u003c/sup\u003e: One-way ANOVA\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents the results of a multiple linear regression analysis to identify factors influencing cardiac health behavior. The model includes demographic and disease-related characteristics, as well as health literacy. Among these variables, three \u0026mdash; gender, smoking, and total health literacy \u0026mdash; were selected and shown to have significant effects on patients\u0026rsquo; cardiac health behavior. On average, males scored 5.9 points lower in cardiac health behavior compared to females. Patients who had never smoked scored about 7.45 points higher than those with a history of smoking. Additionally, patients with health literacy not very adequate, adequate, and excellent level exhibited higher scores in cardiac health behavior compared to those in the inadequate category.\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\u003eResults of multiple linear regression assessing the impact of demographic characteristics, disease-related factors, and health literacy on cardiac health behavior\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=\"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=\"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\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRegression coefficient\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eStandard error\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\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReference\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-5.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.020\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eSmoking\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReference\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eQuitted\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.216\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.007\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eHealth literacy: Total score\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eInadequate\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReference\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eNot very adequate\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.011\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eAdequate\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eExcellent\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"4 Disscusion","content":"\u003cp\u003eThe present study aimed to investigate cardiac health behavior and health literacy in patients with cardiovascular disease. Based on the results, the \u003cem\u003ecardiac health behavior\u003c/em\u003e score in our study population was 55.95, slightly surpassing the score of 52.92 reported by Shafieian et al. in patients with cardiovascular disease in Tehran and almost similar to the study by Serin et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe mentioned studies reported the highest score in the \u003cem\u003ephysical activity\u003c/em\u003e and \u003cem\u003ehealth responsibility\u003c/em\u003e subscales and the lowest in \u003cem\u003esmoking cessation\u003c/em\u003e, whereas our study found the lowest score in \u003cem\u003ephysical activity\u003c/em\u003e and the highest in \u003cem\u003edietary habits\u003c/em\u003e.\u003c/p\u003e\u003cp\u003eBased on the questionnaire, physical activity was assessed through behaviors such as exercising three times a week for 20\u0026ndash;30 minutes until sweating, walking as an exercise, substituting walking for short car trips, and performing stretching exercises for muscle relaxation.\u003c/p\u003e\u003cp\u003eRegular exercise offers numerous personal benefits, including longevity, enhanced feelings of happiness, and a decreased risk of physical disability and dependence. Also, exercise playing a crucial role in primary and primordial prevention of many diseases such as cardiovascular conditions; it improves cardiorespiratory fitness, reduces all-cause mortality, and even in individuals with low BMI, a higher fat-free mass is associated with increased lifespan [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Unfortunately, individuals with cardiovascular disease in our population exhibited very low levels of physical activity and more education is needed to improve physical activity and reduce sedentary activities.\u003c/p\u003e\u003cp\u003eIn our study community, the \u003cem\u003edietary habit\u003c/em\u003es that includes consuming breakfast, home-cooked meals, all food groups, and natural foods received the highest score. Choosing a healthy diet refers to adopting a dietary pattern that reduces the risk of cardiovascular diseases. The Southern diet, which is high in saturated fats, fried foods, calories, processed products, and sugary drinks, and low in fiber, vegetables, and fruits, is considered one of the unhealthiest lifestyles and is associated with increased mortality and morbidity from cardiovascular diseases. In contrast, the Mediterranean diet, rich in fruits, vegetables, olive oil, nuts, and fish, is associated with a reduced risk of adverse health events [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. A study conducted by Lesani and colleagues with 800 residents of Tehran found that over 90 percent of participants regularly ate breakfast, and their dietary patterns closely resembled those typical of Western societies [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Another study revealed that approximately 75 percent of Iranians maintain a relatively suitable and suitable diet [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] .This indicates that effective education in recent years has successfully improved dietary habits.\u003c/p\u003e\u003cp\u003eThe results of our study showed that less than half of the people had adequate and excellent health literacy, and the average total health literacy score was lower than similar studies [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Health literacy significantly influences health behavior, as individuals with high health literacy are more proactive in seeking and accessing relevant health information, which enables them to avoid risky habits such as smoking, excessive drinking, and sedentary lifestyles, ultimately leading to better health outcomes[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. In patients with cardiovascular and low health literacy, mortality and readmissions increase, and quality of life decreases[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Also, high health literacy is associated with improved preventive health behaviors in chronic diseases such as cardiovascular diseases [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOur study confirmed that individuals with adequate and excellent health literacy exhibit cardiac healthier behaviors, particularly in \u003cem\u003ehealth responsibility\u003c/em\u003e, \u003cem\u003estress management\u003c/em\u003e, and \u003cem\u003eno smoking.\u003c/em\u003e Based on the results obtained and after adjusting for demographic and disease-related factors, only gender and smoking were significantly associated with health behavior. Women exhibited better cardiac health behaviors, and non-smokers\u0026mdash;whether current or former\u0026mdash;also demonstrated healthier habits compared to smokers. Similar studies have shown that male have worse health behaviors [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Regarding the difference in health behaviors between women and men, various studies have demonstrated this difference. For example, Wang et al., in a study conducted on individuals with diabetes, observed that affected men had poorer diets and higher rates of smoking and alcohol consumption, while women were more likely to experience depression and obesity and engage in insufficient physical activity [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. The above-mentioned cases show the need for planning by health policy makers to increase awareness of health behaviors and health literacy in different groups of society. Considering that healthy people are the center of sustainable development[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], the ultimate result of implementing health-promoting health policies is improving the health status of the society, followed by the socio-economic development of countries.\u003c/p\u003e"},{"header":"5 Conclusion","content":"\u003cp\u003eAccording to the results, the lowest score in people with cardiovascular disease participating in the study was related to physical activity and the highest score was related to dietary habits, and it is necessary to design and implement educational interventions to improve the physical activity. Less than half of the people had adequate and excellent health literacy, and people with adequate and excellent health literacy showed healthier cardiac health behaviors, especially in the health responsibility, stress management, and smoking. Health policymakers should implement educational interventions to improve the health literacy, which will ultimately lead to the promotion of health behaviors and prevention of cardiovascular diseases at different levels.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank all patients who participated in the research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted according to the Declaration of Helsinki and approved by the Bioethics Committee of Zanjan University of Medical Sciences (Code: IR.ZUMS.REC.1403.111). Written informed consent was obtained from all patients for being included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData will be available upon request from the corresponding author. Also, the data in Excel file format has also been uploaded with the manuscript submission to the journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Declaration:\u003c/strong\u003e We did not receive any funding from any organization for this research.\u003c/p\u003e\n\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization. Noncommunicable diseases. \u003c/li\u003e\n\u003cli\u003eMagnussen C, Ojeda FM, Leong DP, Alegre-Diaz J, Amouyel P, Aviles-Santa L, et al. Global Effect of Modifiable Risk Factors on Cardiovascular Disease and Mortality. 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Biodemography Soc Biol. 2017 Jan 2;63(1):3\u0026ndash;20. \u003c/li\u003e\n\u003cli\u003ePrihanto JB, Nurhayati F, Wahjuni ES, Matsuyama R, Tsunematsu M, Kakehashi M. Health Literacy and Health Behavior: Associated Factors in Surabaya High School Students, Indonesia. Int J Environ Res Public Health. 2021 Jul 30;18(15):8111. \u003c/li\u003e\n\u003cli\u003eWang Y, Cao P, Liu F, Chen Y, Xie J, Bai B, et al. Gender Differences in Unhealthy Lifestyle Behaviors among Adults with Diabetes in the United States between 1999 and 2018. Int J Environ Res Public Health. 2022;19(24). \u003c/li\u003e\n\u003cli\u003eMishra M, Desul S, Santos CAG, Mishra SK, Kamal AHM, Goswami S, et al. A bibliometric analysis of sustainable development goals (SDGs): a review of progress, challenges, and opportunities. Environ Dev Sustain. 2023 May 7;26(5):11101\u0026ndash;43. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Health literacy, Cardiac health behavior, Cardiovascular disease, Physical activity, Dietary habit, Prevention","lastPublishedDoi":"10.21203/rs.3.rs-7949210/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7949210/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eAim\u003c/h2\u003e\u003cp\u003eOne of the effective factors in preventing cardiovascular disease is cardiac health behaviors. Cardiac health behaviors are essential for transforming lifestyle patterns. In this study, we investigated the status of health literacy and cardiac health behaviors and the factors that can affect them.\u003c/p\u003e\u003ch2\u003eSubject and methods\u003c/h2\u003e\u003cp\u003eThis descriptive-analytical cross-sectional involved 126 individuals with cardiovascular diseases who were referred to Ayatollah Mousavi hospital in Zanjan, Iran. Convenience sampling was conducted from August 10 to November 10, 2024. Data were collected using the Cardiac Health Behavior (CHB) scale and the Health Literacy (HL) Instrument for Adults (HELIA). Analyses were performed in Rstudio 2025.05.0 using independent t-test, one-way ANOVA, and multiple linear regression.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe lowest HL score was in the \"decision-making/ behavioral intention\" domain and the highest in the \"reading\" domain. About 36% and 12% of participants had an adequate and excellent level of HL, respectively. The lowest CHB score was in the \"physical activity\" domain and the highest in the \"dietary habits\" domain. Women, urban residents, non-smokers, patients with adequate/ excellent levels of HL, and those with university education demonstrated better CHB scores.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eAccording to the results, the lowest score was related to physical activity and the highest score was related to dietary habits, and health literacy was not adequate. Health policymakers should implement educational interventions to improve factors affecting heart health behaviors, which will ultimately lead to the promotion of health behaviors and prevention of cardiovascular diseases at different levels.\u003c/p\u003e","manuscriptTitle":"Relation between health literacy and cardiac health behavior: evidence from Iranian cardiovascular disease patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-19 11:50:39","doi":"10.21203/rs.3.rs-7949210/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a26019f1-17c6-4bea-ad63-706a0c6511ad","owner":[],"postedDate":"November 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-26T08:26:58+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-19 11:50:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7949210","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7949210","identity":"rs-7949210","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}