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Adopting healthier lifestyle habits is essential for reducing the risks associated with cardiovascular diseases. However, low health literacy (HL) may compromise assessing, using, and understanding health information, making modification of health behavior less likely. This study aimed to clarify the relationship between HL and changes in health behavior in inpatients undergoing cardiac rehabilitation. This was a multicenter cohort study of patients undergoing phase I cardiac rehabilitation. We used the 14-item Health Literacy Scale (HLS-14) to assess HL and the transtheoretical model (TTM) to assess changes in health behavior. Behavioral changes during hospitalization were defined using the stages of the TTM. A total of 428 patients who underwent cardiac rehabilitation (mean age: 73.0\u00a0years; males: 71.5%) were included. Evaluation of the behavioral changes exhibited by the participants revealed that the pre-contemplation stage (83.2%) was common at the beginning of rehabilitation, whereas contemplation (50.7%) and preparation (38.1%) stages were common at discharge. Of the 428 participants, 83.6% exhibited behavioral changes during hospitalization. Multivariate analysis revealed that HLS-14 score was a significant explanatory variable associated with changes in health behavior (odds ratio: 1.04; 95% confidence interval: 1.00\u20131.07). The spline curves modeling the relationship between HLS-14 score and changes in health behavior showed a positive correlation in the low HL group. HL is significantly correlated with changes in health behavior, especially in individuals with a low HL level.<\/jats:p>\n                  <jats:p>\n                    <jats:bold>Graphical abstract<\/jats:bold>\n                  <\/jats:p>","DOI":"10.1007\/s00380-025-02589-5","type":"journal-article","created":{"date-parts":[[2025,7,29]],"date-time":"2025-07-29T14:31:59Z","timestamp":1753799519000},"page":"48-57","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["Low health literacy limits behavioral changes during phase I cardiac rehabilitation: a multicenter clinical study"],"prefix":"10.1007","volume":"41","author":[{"given":"Yuji","family":"Kanejima","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7262-8903","authenticated-orcid":false,"given":"Kazuhiro P.","family":"Izawa","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Masahiro","family":"Kitamura","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kodai","family":"Ishihara","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Asami","family":"Ogura","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ikko","family":"Kubo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hitomi","family":"Nagashima","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hideto","family":"Tawa","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daisuke","family":"Matsumoto","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ikki","family":"Shimizu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,7,29]]},"reference":[{"key":"2589_CR1","doi-asserted-by":"publisher","first-page":"406","DOI":"10.1161\/CIR.0b013e3181e8edf1","volume":"122","author":"NT Artinian","year":"2010","unstructured":"Artinian NT, Fletcher GF, Mozaffarian D, Kris-Etherton P, Van Horn L, Lichtenstein AH, Kumanyika S, Kraus WE, Fleg JL, Redeker NS, Meininger JC, Banks J, Stuart-Shor EM, Fletcher BJ, Miller TD, Hughes S, Braun LT, Kopin LA, Berra K, Hayman LL, Ewing LJ, Ades PA, Durstine JL, Houston-Miller N, Burke LE (2010) Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults: a scientific statement from the American heart association: a scientific statement from the American heart association. 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