Health Literacy as a Predictor of Health-Promoting Lifestyle in Cardiovascular Patients in Southeast Iran

Document Type : Original Article

Authors

1 Student Research Center, Zahedan University of Medical Sciences, Zahedan, Iran

2 Health Promotion Research Center, Zahedan University of Medical Sciences, Zahedan, Iran

10.58209/hehp.14.2.281
Abstract
Aims: Cardiovascular diseases are a leading cause of mortality worldwide and in Iran. Health literacy is a crucial factor in managing these conditions. This study aimed to examine the relationship between health literacy and health-promoting behaviors among patients with cardiovascular diseases in Khāsh, southeastern Iran.
Instrument & Methods: In this cross-sectional study, 350 patients with CVD from Imam Khomeini Hospital in Khāsh were selected using convenience sampling. Data were collected using two validated instruments: the Short Form of the Health Literacy for Iranian Adults and the Walker Health-Promoting Lifestyle Profile. Data were analyzed using Pearson’s correlation, multiple linear regression, and analysis of variance in SPSS 24.
Findings: The mean health literacy score was 36.25±22.65, indicating a poor overall level of health literacy. Health-promoting behaviors were at a moderate level (139.84±21.74), with the lowest score observed for physical activity (20.54±4.39). Health literacy showed the strongest correlation with physical activity (r=0.632; p<0.001) and the weakest correlation with stress management (r=0.297; p<0.001). Regression analysis identified health literacy as the strongest predictor of health-promoting behaviors (β= 0.666; p<0.001), followed by basic health literacy skills (β=0.435) and decision-making skills (β= 0.330). The model explained approximately 52% of the variance in health-promoting behaviors (R²=0.524).
Conclusion: health literacy is the strongest predictor of health-promoting behaviors among patients with cardiovascular disease.

Keywords

Subjects

1- WHO. Cardiovascular diseases (CVDs) [Internet]. Geneva: World Health Organization; 2023 [cited 2025 May 17]. Available from: https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds)
2- WHO CVD Risk Chart Working Group. World Health Organization cardiovascular disease risk charts: Revised models to estimate risk in 21 global regions. Lancet Glob Health. 2019;7(10):e1332-45.
3- Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, et al. AHA/ACC/ACCP/ASPC/NLA/PCNA guideline for the management of patients with chronic coronary disease: A report of the American Heart Association/American College of Cardiology Joint Committee on clinical practice guidelines. Circulation. 2023;148(9):e9-119.
4- Sarrafzadegan N, Mohammmadifard N. Cardiovascular disease in Iran in the last 40 years: Prevalence, mortality, morbidity, challenges and strategies for cardiovascular prevention. Arch Iran Med. 2019;22(4):204-10.
5- Joseph JJ, Deedwania P, Acharya T, Aguilar D, Bhatt DL, Chyun DA, et al. Comprehensive management of cardiovascular risk factors for adults with type 2 diabetes: A scientific statement from the American Heart Association. Circulation. 2022;145(9):e722-59.
6- WHO. Global status report on noncommunicable diseases 2022. Geneva: World Health Organization; 2022.
7- Yuyun MF, Sliwa K, Kengne AP, Mocumbi AO, Bukhman G. Cardiovascular diseases in Sub-Saharan Africa compared to high-income countries: An epidemiological perspective. Glob Heart. 2020;15(1):15.
8- Yusuf S, Joseph P, Rangarajan S, Islam S, Mente A, Hystad P, et al. Modifiable risk factors, cardiovascular disease, and mortality in 155 722 individuals from 21 high-income, middle-income, and low-income countries (PURE): A prospective cohort study. Lancet. 2020;395(10226):795-808.
9- Zamani B, Daneshzad E, Mofrad MD, Namazi N, Larijani B, Bellissimo N, Azadbakht L. Dietary quality index and cardiometabolic risk factors among adult women. Iran J Public Health. 2021;50(8):1713..
10- Csige I, Ujvárosy D, Szabó Z, Lőrincz I, Paragh G, Harangi M, et al. The impact of obesity on the cardiovascular system. J Diabetes Res. 2018;2018:3407306.
11- Kaufman JD, SV Elkind M, Bhatnagar A, Sidney S, Burroughs Pena M, Dockery DW, et al. Guidance to reduce the cardiovascular burden of ambient air pollutants: A policy statement from the American Heart Association. Circulation. 2020;142(23):e432-47.
12- Al-Kindi SG, Brook RD, Biswal S, Rajagopalan S. Environmental determinants of cardiovascular disease: Lessons learned from air pollution. Nat Rev Cardiol. 2020;17(10):656-72.
13- Lim BC, Kueh YC, Arifin WN, Ng KH. Validation of health promoting lifestyle profile-II: A confirmatory study with a Malaysian undergraduate students sample. Educ Med J. 2016;8(2):65-77.
14- Lee RLT, Yuen LAJT. Health-promoting behaviors and psychosocial well-being of university students in Hong Kong. Public Health Nurs. 2005;22(3):209-20.
15- Alzahrani SH, Malik AA, Bashawri J, Shaheen SA, Shaheen MM, Alsaib AA, Mubarak MA, Adam YS, Abdulwassi HK. Health-promoting lifestyle profile and associated factors among medical students in a Saudi university. SAGE Open Med. 2019;7:2050312119838426.
16- Nutbeam D, Lloyd JE. Understanding and responding to health literacy as a social determinant of health. Annu Rev Public Health. 2021;42:159-73.
17- Panahi R, Ramezankhani A, Tavousi M. Health literacy and preventive behaviors. J Rese Health. 2018;8(2):93-4.
18- Karami Salahodinkolah M, Pahlevan Sharif S, Sharif Nia H, Jafari H, Shafipour V. Relationship between health literacy and quality of life in patients with heart failure. J Mazandaran Univ Med Sci. 2020;30(191):121-7. [Persian]
19- Fahimfar N, Fotouhi A, Mansournia MA, Malekzadeh R, Sarrafzadegan N, Azizi F, et al. Prediction of cardiovascular disease mortality in a Middle Eastern country: Performance of the Globorisk and score functions in four population-based cohort studies of Iran. Int J Health Policy Manag. 2022;11(2):210-7.
20- Rahbari M, Bakhtiari Alilabad M. Health literacy status in Iranian society. Tehran: Social Studies Office, Research Deputy; 2020. Report No.: 17145. [Persian]
21- Tavousi M, Haeri-Mehrizi A, Sedighi J, Montazeri A, Mohammadi A, et al. Health literacy instrument for adults-short form (HELIA-SF): Development and psychometric properties. PAYESH. 2022;21(3):309-19. [Persian]
22- Mohammadi Zeidi I, Pakpour Hajiagha A, Mohammadi Zeidi B. Validity and reliability of the Persian version of health promoting lifestyle questionnaire. J Mazandaran Univ Med Sci. 2011;22(1):103-13. [Persian]
23- Sorensen K, Van Den Broucke S, Fullam J, Doyle G, Pelikan J, Slonska Z, et al. Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health. 2012;12:80.
24- Svendsen MT, Bak CK, Sorensen K, Pelikan J, Riddersholm SJ, Kuhr Skals R, et al. Associations of health literacy with socioeconomic position, health risk behavior, and health status: A large national population-based survey among Danish adults. BMC Public Health. 2020;20(1):565.
25- Fernandez DM, Larson JL, Zikmund-Fisher BJ. Associations between health literacy and preventive health behaviors among older adults: findings from the health and retirement study. BMC Public Health. 2016;16(1):596.
26- Norozi S, Rezaei R, Safa L. Mediation effect of healthy lifestyle in the relationship between health literacy and rural women’ s health-related quality of life in West Islam Abad Township. Womens Stud Sociol Psychol. 2017;15(3):1-30. [Persian]
27- Zahedi S, Darvishpoor Kakhaki A, Hosseini M, Razzaghi Z. The correlation between self-care and health literacy in patients undergoing hemodialysis. Iran J Diabetes Metab. 2018;17(4):180-8. [Persian]
28- Arriaga M, Francisco R, Nogueira P, Oliveira J, Silva C, Câmara G, et al. Health literacy in Portugal: Results of the health literacy population survey project 2019-2021. Int J Environ Res Public Health. 2022;19(7):4225.
29- Dehkordi LM. Health-promoting lifestyle among people without heart disease in Isfahan. Int J Prev Med. 2018;9:95.
30- Baharvand P, Malekshahi F, Gheydar N. A comparative study on the health-promoting behaviors of patients with and without hypertensive heart disease in Iran. J Educ Health Promot. 2022;11:47.
31- Afni N. The role of health literacy in chronic disease management: Challenges, interventions, and policies. J Health Lit Qual Res. 2021;1(2):57-68.
32- Zangger G, Mortensen SR, Tang LH, Thygesen LC, Skou ST. Association between digital health literacy and physical activity levels among individuals with and without long-term health conditions: Data from a cross-sectional survey of 19,231 individuals. Digit Health. 2024;10:20552076241233158.
33- Michou M, Panagiotakos DB, Lionis C, Costarelli V. Low health literacy and perceived stress in adults: Is there a link?. Cent Eur J Public Health. 2021;29(3):195-200.
34- Lund C, Breen A, Flisher AJ, Kakuma R, Corrigall J, Joska JA, et al. Poverty and common mental disorders in low and middle income countries: A systematic review. Soc Sci Med. 2010;71(3):517-28.
35- Zhong Y, Schroeder E, Gao Y, Guo X, Gu Y. Social support, health literacy and depressive symptoms among medical students: An analysis of mediating effects. Int J Environ Res Public Health. 2021;18(2):633.
36- Degan TJ, Kelly PJ, Robinson LD, Deane FP, Smith AM. Health literacy of people living with mental illness or substance use disorders: A systematic review. Early Interv Psychiatry. 2021;15(6):1454-69.
37- Wollburg C, Steinert JI, Reeves A, Nye E. Do cash transfers alleviate common mental disorders in low- and middle-income countries? A systematic review and meta-analysis. PLoS One. 2023;18(2):e0281283.
38- Al Sayah F, Johnson ST, Vallance J. Health literacy, pedometer, and self-reported walking among older adults. Am J Public Health. 2016;106(2):327-33.
39- Ma Y, Huang L, Tian H, Liu H, Yu H, Li H, et al. The impact of health literacy on health-promoting lifestyle among community residents: The chain-mediating role of family health and physical activity. Front Psychiatry. 2024;15.
40- Darabi F, Ziapour A, Janjani P, Motevaseli S, Rostami F. A cross-sectional study of the relationship between health literacy and health-promoting lifestyles in patients with hypertension in northwest Iran. BMC Prim Care. 2025;26(1):117.
41- Nawrozi W, Talebi B, Asadi Sharif F, Mansoori K, Abasiraki F. Prediction of preventive behaviors against Covid-19 among patients aged 30 to 50 admitted to Ardabil health centers based on health literacy. J Health Res Commun. 2023;8(4):1-12. [Persian]
42- Long Y, Jia C, Luo X, Sun Y, Zuo W, Wu Y, et al. The impact of higher education on health literacy: A comparative study between urban and rural China. Sustainability. 2022;14(19):12142.
43- Liu M, Marinacci LX, Joynt Maddox KE, Wadhera RK. Cardiovascular health among rural and urban US adults—healthcare, lifestyle, and social factors. JAMA Cardiol. 2025;10(6):585-94.
44- Vyas MV, Rijal H, Yu AYX, Austin PC, Chu A, Santiago-Jimenez M, et al. Association between neighborhood-level income and the incidence of cardiovascular events varies by immigration status: A population-based cohort study. J Am Heart Assoc. 2024;13(19):e036511.
45- Fullin K, Keen S, Harris K, Magnani JW. Impact of neighborhood on cardiovascular health: A contemporary narrative review. Curr Cardiol Rep. 2023;25(9):1015-27.
46- Zhang YB, Chen C, Pan XF, Guo J, Li Y, Franco OH, et al. Associations of healthy lifestyle and socioeconomic status with mortality and incident cardiovascular disease: Two prospective cohort studies. BMJ. 2021;14:373.