{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,23]],"date-time":"2026-09-23T20:53:22Z","timestamp":1790196802970,"version":"4.1.0"},"reference-count":54,"publisher":"MDPI AG","issue":"22","license":[{"start":{"date-parts":[[2020,11,20]],"date-time":"2020-11-20T00:00:00Z","timestamp":1605830400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Interreg VA","award":["INT-VA\/048"],"award-info":[{"award-number":["INT-VA\/048"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Following a diagnosis of cardiovascular disease there is a need for patients to self-manage. Health literacy has been shown to be lower in patients with cardiovascular disease, yet research into health literacy in this population is limited. This study used the Health Literacy Questionnaire (HLQ) to examine the health literacy and associated health, health behaviours and psychological profiles of cardiac rehabilitation patients from a remote and rural regional programme in the Scottish Highlands. Consecutive patients referred to the service in a calendar year were sent a cross-sectional questionnaire by post. Hierarchical cluster analysis grouped respondents based on their health literacy profile, and nonparametric methods were used to analyse differences between clusters on the other measures. A total of 282 participants responded (45.7%). Respondents were older (median: 71 years) and more likely to be from more affluent areas. Five health literacy clusters emerged with different profiles of health, physical activity, self-efficacy, motivation and illness perceptions. There was no difference in relation to cardiac rehabilitation attendance by health literacy cluster, but those with lower health literacy were less likely to be aware of the referral. Patterns of health literacy are associated with health, health behaviours and some psychological constructs. Knowledge of distinct cluster characteristics may help services better target interventions.<\/jats:p>","DOI":"10.3390\/ijerph17228641","type":"journal-article","created":{"date-parts":[[2020,11,20]],"date-time":"2020-11-20T09:46:18Z","timestamp":1605865578000},"page":"8641","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":22,"title":["Health Literacy for Cardiac Rehabilitation: An Examination of Associated Illness Perceptions, Self-Efficacy, Motivation and Physical Activity"],"prefix":"10.3390","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9330-9909","authenticated-orcid":false,"given":"Ronie","family":"Walters","sequence":"first","affiliation":[{"name":"Department of Nursing and Midwifery, Centre for Health Science, University of the Highlands and Islands, Inverness IV2 3JH, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stephen J.","family":"Leslie","sequence":"additional","affiliation":[{"name":"Department of Nursing and Midwifery, Centre for Health Science, University of the Highlands and Islands, Inverness IV2 3JH, UK"},{"name":"Cardiac Department, Raigmore Hospital, Inverness IV2 3UJ, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jane","family":"Sixsmith","sequence":"additional","affiliation":[{"name":"Health Promotion Research Centre, National University of Ireland Galway,  H91 TK33 Galway, Ireland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7367-0679","authenticated-orcid":false,"given":"Trish","family":"Gorely","sequence":"additional","affiliation":[{"name":"Department of Nursing and Midwifery, Centre for Health Science, University of the Highlands and Islands, Inverness IV2 3JH, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2020,11,20]]},"reference":[{"key":"ref_1","unstructured":"World Health Organization (2020, October 10). The Top 10 Causes of Death. Available online: https:\/\/www.who.int\/news-room\/fact-sheets\/detail\/the-top-10-causes-of-death."},{"key":"ref_2","unstructured":"Cheong, C.K., Dean, L., Dougall, I., Hinchliffe, S., Mirani, K., Vosnaki, K., and Wilson, V. (2020). The Scottish Health Survey 2018 Edition, Amended in February 2020: Volume 1, Main Report."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.jacc.2015.10.044","article-title":"Exercise-Based Cardiac Rehabilitation for Coronary Heart Disease: Cochrane Systematic Review and Meta-Analysis","volume":"67","author":"Anderson","year":"2016","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.hrtlng.2018.09.011","article-title":"Effect of exercise-based cardiac rehabilitation on anxiety and depression in patients with myocardial infarction: A systematic review and meta-analysis","volume":"48","author":"Zheng","year":"2019","journal-title":"Heart Lung"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"579","DOI":"10.1007\/s11136-019-02338-y","article-title":"Health-related quality of life and exercise-based cardiac rehabilitation in contemporary acute coronary syndrome patients: A systematic review and meta-analysis","volume":"29","author":"Candelaria","year":"2020","journal-title":"Qual. Life Res."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1914","DOI":"10.1177\/2047487316671181","article-title":"The prognostic effect of cardiac rehabilitation in the era of acute revascularisation and statin therapy: A systematic review and meta-analysis of randomized and non-randomized studies\u2014The Cardiac Rehabilitation Outcome Study (CROS)","volume":"23","author":"Rauch","year":"2016","journal-title":"Eur. J. Prev. Cardiol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"436","DOI":"10.1016\/j.ijcard.2016.08.120","article-title":"Participation and adherence to cardiac rehabilitation programs. A systematic review","volume":"223","author":"Raposeiras","year":"2016","journal-title":"Int. J. Cardiol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"38","DOI":"10.1177\/1474515118783157","article-title":"Factors associated with non-participation in and dropout from cardiac rehabilitation programmes: A systematic review of prospective cohort studies","volume":"18","author":"Pastor","year":"2019","journal-title":"Eur. J. Cardiovasc. Nurs."},{"key":"ref_9","unstructured":"British Heart Foundation (2020, October 10). Cardiovascular Statistics 2020. Available online: https:\/\/www.bhf.org.uk\/what-we-do\/our-research\/heart-statistics\/heart-statistics-publications\/cardiovascular-disease-statistics-2020."},{"key":"ref_10","unstructured":"NHS Highland (2020, October 07). About Us. Available online: https:\/\/www.nhshighland.scot.nhs.uk\/AboutUs\/Pages\/AboutUs.aspx."},{"key":"ref_11","unstructured":"British Heart Foundation (2020, October 10). National Audit of Cardiac Rehabilitation (NACR) Quality and Outcomes Report 2019. Available online: https:\/\/www.bhf.org.uk\/informationsupport\/publications\/statistics\/national-audit-of-cardiac-rehabilitation-quality-and-outcomes-report-2019."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"57","DOI":"10.1177\/1757975918788300","article-title":"Health literacy as a determinant, mediator and\/or moderator of health: Empirical models using the European Health Literacy Survey dataset","volume":"25","author":"Pelikan","year":"2018","journal-title":"Glob. Health Promot."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1016\/j.puhe.2016.01.001","article-title":"Health literacy: Applying current concepts to improve health services and reduce health inequalities","volume":"132","author":"Batterham","year":"2016","journal-title":"Public Health"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1016\/j.pec.2016.07.007","article-title":"Improving low health literacy and patient engagement: A social ecological approach","volume":"100","author":"McCormack","year":"2017","journal-title":"Patient Educ. Couns."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"2072","DOI":"10.1016\/j.socscimed.2008.09.050","article-title":"The evolving concept of health literacy","volume":"67","author":"Nutbeam","year":"2008","journal-title":"Soc. Sci. Med."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1481","DOI":"10.1080\/10810730.2014.954083","article-title":"Advancing Health Literacy Measurement: A Pathway to Better Health and Health System Performance","volume":"19","author":"Pleasant","year":"2014","journal-title":"J. Health Commun."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1053","DOI":"10.1093\/eurpub\/ckv043","article-title":"Health literacy in Europe: Comparative results of the European health literacy survey (HLS-EU)","volume":"25","author":"Pelikan","year":"2015","journal-title":"Eur. J. Public Health"},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Beauchamp, A., Buchbinder, R., Dodson, S., Batterham, R.W., Elsworth, G.R., McPhee, C., Sparkes, L., Hawkins, M., and Osborne, R.H. (2015). Distribution of health literacy strengths and weaknesses across socio-demographic groups: A cross-sectional survey using the Health Literacy Questionnaire (HLQ). BMC Public Health, 15.","DOI":"10.1186\/s12889-015-2056-z"},{"key":"ref_19","unstructured":"World Health Organization (2013). Health Literacy: The Solid Facts, World Health Organization Regional Office for Europe."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"e009627","DOI":"10.1136\/bmjopen-2015-009627","article-title":"Gaps in understanding health and engagement with healthcare providers across common long-term conditions: A population survey of health literacy in 29,473 Danish citizens","volume":"6","author":"Friis","year":"2016","journal-title":"BMJ Open"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s12889-020-08498-8","article-title":"Associations of health literacy with socioeconomic position, health risk behavior, and health status: A large national population-based survey among Danish adults","volume":"20","author":"Svendsen","year":"2020","journal-title":"BMC Public Health"},{"key":"ref_22","first-page":"75","article-title":"Large diversity in Danish health literacy profiles: Perspectives for care of long-term illness and multimorbidity","volume":"30","author":"Aaby","year":"2020","journal-title":"Eur. J. Public Health"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"e48","DOI":"10.1161\/CIR.0000000000000579","article-title":"Health Literacy and Cardiovascular Disease: Fundamental Relevance to Primary and Secondary Prevention: A Scientific Statement From the American Heart Association","volume":"138","author":"Magnani","year":"2018","journal-title":"Circulation"},{"key":"ref_24","unstructured":"British Association for Cardiovascular Prevention and Rehabilitation (2017). The BACPR Standards and Core Components for Cardiovascular Disease Prevention and Rehabilitation, BACPR."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"177","DOI":"10.1016\/j.pec.2017.09.002","article-title":"Health literacy and coronary artery disease: A systematic review","volume":"101","author":"Ghisi","year":"2018","journal-title":"Patient Educ. Couns."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"96","DOI":"10.1177\/0017896914522029","article-title":"Health literacy predicts cardiac knowledge gains in cardiac rehabilitation participants","volume":"74","author":"Mattson","year":"2015","journal-title":"Health Educ. J."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"376","DOI":"10.1177\/1474515119885325","article-title":"Tele-rehabilitation and hospital-based cardiac rehabilitation are comparable in increasing patient activation and health literacy: A pilot study","volume":"19","author":"Knudsen","year":"2019","journal-title":"Eur. J. Cardiovasc. Nurs."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"249","DOI":"10.1097\/HCR.0000000000000473","article-title":"Health Literacy of Patients Attending Cardiac Rehabilitation","volume":"40","author":"Beauchamp","year":"2020","journal-title":"J. Cardiopulm. Rehabilitation Prev."},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Aaby, A., Friis, K., Christensen, B., and Maindal, H.T. (2020). Health Literacy among People in Cardiac Rehabilitation: Associations with Participation and Health-Related Quality of Life in the Heart Skills Study in Denmark. Int. J. Environ. Res. Public Health, 17.","DOI":"10.3390\/ijerph17020443"},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"Osborne, R.H., Batterham, R.W., Elsworth, G.R., Hawkins, M., and Buchbinder, R. (2013). The grounded psychometric development and initial validation of the Health Literacy Questionnaire (HLQ). BMC Public Health, 13.","DOI":"10.1186\/1471-2458-13-658"},{"key":"ref_31","unstructured":"Foster, E.J., Munoz, S.-A., Crabtree, D., Leslie, S.J., and Gorely, T. (2019). Barriers and facilitators to participating in cardiac rehabilitation and physical activity in a remote and rural population; a cross-sectional survey. Cardiol. J."},{"key":"ref_32","unstructured":"National Institute for Health and Care Excellence (2020). Behaviour Change: Individual Approaches (PH49), National Institute for Health and Care Excellence."},{"key":"ref_33","unstructured":"Scottish Government (2020, October 20). Scottish Index of Multiple Deprivation 2016: Introductory Booklet, Available online: https:\/\/www.gov.scot\/publications\/scottish-index-multiple-deprivation-2016\/."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"292","DOI":"10.1007\/s12160-008-9065-4","article-title":"Psychological factors influencing self-assessments of health: Toward an understanding of the mechanisms underlying how people rate their own health","volume":"36","author":"Mora","year":"2008","journal-title":"Ann. Behav. Med."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"276","DOI":"10.1002\/osp4.155","article-title":"Validation of the Stanford Leisure-Time Activity Categorical Item (L-Cat) using armband activity monitor data","volume":"4","author":"Ross","year":"2018","journal-title":"Obes. Sci. Pr."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"269","DOI":"10.1123\/jpah.2017-0284","article-title":"The Relationship Between the Stanford Leisure-Time Activity Categorical Item and the Godin Leisure-Time Exercise Questionnaire Among Rural Intervention Participants of Varying Health Literacy Status","volume":"15","author":"Kruzliakova","year":"2018","journal-title":"J. Phys. Act. Health"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1080\/08870440290001494","article-title":"The revised illness perception questionnaire (IPQ-R)","volume":"17","author":"Weinman","year":"2002","journal-title":"Psychol. Health"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"46","DOI":"10.1016\/j.eclinm.2019.06.006","article-title":"Nature of cardiac rehabilitation around the globe","volume":"13","author":"Supervia","year":"2019","journal-title":"EClinicalMedicine"},{"key":"ref_39","first-page":"307","article-title":"Guide for constructing self-efficacy scales","volume":"Volume 5","author":"Bandura","year":"2006","journal-title":"Self-Efficacy Beliefs of Adolescents"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"191","DOI":"10.1123\/jsep.26.2.191","article-title":"A modification to the behavioural regulation in exercise questionnaire to include an assessment of amotivation","volume":"26","author":"Markland","year":"2004","journal-title":"J. Sport Exerc. Psychol."},{"key":"ref_41","unstructured":"IBM (2017). SPSS Statistics for Windows, 25.0, IBM Corp."},{"key":"ref_42","unstructured":"Beauchamp, A., Dodson, S., Batterham, R., and Osborne, R.H. (2017). Ophelia Templates and Additional Resources-Templates and Resources to Support Application of the Ophelia Manual 2017, Deakin University."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"411","DOI":"10.1177\/1474515119885240","article-title":"Acceptance of illness mediate the effects of health literacy on self-management behaviour","volume":"19","author":"Qiu","year":"2020","journal-title":"Eur. J. Cardiovasc. Nurs."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"2039","DOI":"10.1002\/nop2.599","article-title":"The roles of health literacy and social support in improving adherence to self-care behaviours among older adults with heart failure","volume":"7","author":"Jo","year":"2020","journal-title":"Nurs. Open"},{"key":"ref_45","first-page":"e104","article-title":"Facilitators and Barriers to the Development of Health Literacy Capacities Over Time for Self-Management","volume":"4","author":"McKenna","year":"2020","journal-title":"Health Lit. Res. Pract."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"41","DOI":"10.1016\/j.pec.2014.10.006","article-title":"Functional, communicative and critical health literacy of chronic disease patients and their importance for self-management","volume":"98","author":"Heijmans","year":"2015","journal-title":"Patient Educ. Couns."},{"key":"ref_47","doi-asserted-by":"crossref","unstructured":"Walters, R., Leslie, S.J., Polson, R., Cusack, T., and Gorely, T. (2020). Establishing the efficacy of interventions to improve health literacy and health behaviours: A systematic review. BMC Public Health, 20.","DOI":"10.1186\/s12889-020-08991-0"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"510","DOI":"10.1007\/s11606-017-4265-x","article-title":"The Effectiveness of Self-Management Interventions for Individuals with Low Health Literacy and\/or Low Income: A Descriptive Systematic Review","volume":"33","author":"Schaffler","year":"2018","journal-title":"J. Gen. Intern. Med."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"1295","DOI":"10.1016\/j.pec.2015.04.003","article-title":"Optimal health literacy measurement for the clinical setting: A systematic review","volume":"98","author":"Duell","year":"2015","journal-title":"Patient Educ. Couns."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"100","DOI":"10.1007\/s11606-007-0447-2","article-title":"Evidence does not support clinical screening of literacy","volume":"23","author":"Wolf","year":"2008","journal-title":"J. Gen. Intern. Med."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"1819","DOI":"10.1080\/09638288.2018.1538392","article-title":"Nursing and allied health professionals\u2019 views about using health literacy screening tools and a universal precautions approach to communication with older adults: A qualitative study","volume":"42","author":"Brooks","year":"2020","journal-title":"Disabil. Rehabil."},{"key":"ref_52","doi-asserted-by":"crossref","unstructured":"Kaper, M.S., Winter, A.F.d., Bevilacqua, R., Giammarchi, C., McCusker, A., Sixsmith, J., Koot, J.A.R., and Reijneveld, S.A. (2019). Positive Outcomes of a Comprehensive Health Literacy Communication Training for Health Professionals in Three European Countries: A Multi-centre Pre-post Intervention Study. Int. J. Environ. Res. Public Health, 16.","DOI":"10.3390\/ijerph16203923"},{"key":"ref_53","doi-asserted-by":"crossref","unstructured":"Batterham, R.W., Buchbinder, R., Beauchamp, A., Dodson, S., Elsworth, G.R., and Osborne, R.H. (2014). The OPtimising HEalth LIterAcy (Ophelia) process: Study protocol for using health literacy profiling and community engagement to create and implement health reform. BMC Public Health, 14.","DOI":"10.1186\/1471-2458-14-694"},{"key":"ref_54","doi-asserted-by":"crossref","unstructured":"Hawkins, M., Gill, S.D., Batterham, R., Elsworth, G.R., and Osborne, R.H. (2017). The Health Literacy Questionnaire (HLQ) at the patient-clinician interface: A qualitative study of what patients and clinicians mean by their HLQ scores. BMC Health Serv. Res., 17.","DOI":"10.1186\/s12913-017-2254-8"}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/17\/22\/8641\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T10:35:09Z","timestamp":1760178909000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/17\/22\/8641"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,11,20]]},"references-count":54,"journal-issue":{"issue":"22","published-online":{"date-parts":[[2020,11]]}},"alternative-id":["ijerph17228641"],"URL":"https:\/\/doi.org\/10.3390\/ijerph17228641","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,11,20]]}}}