Bridging the health literacy gap in cardiac rehabilitation through intervention and program design.

This Letter to the Editor responds to the recent study by Kanejima et al. on the association between health literacy (HL) and behavioral changes during phase I cardiac rehabilitation (CR). While acknowledging the study's valuable contribution, we contest the conclusion that low HL is an inherent barrier to behavioral change. Drawing on recent evidence, we highlight that HL is a modifiable factor that can be improved through targeted interventions, program designs, and the rehabilitation process itself. We present six key arguments: (1) digital health technologies and structured education can enhance HL and foster behavioral adaptation in low-HL populations; (2) non-literacy barriers such as logistical constraints often play a larger role; (3) comparable cardiovascular interventions have shown sustained benefits despite low baseline HL; (4) CR programs themselves can directly improve HL; (5) modern CR designs employ adaptive, individualized approaches effective across HL levels; and (6) nurse-led and home-based strategies can successfully overcome HL limitations. Collectively, these points suggest that low HL should be viewed as a dynamic and addressable factor rather than a fixed constraint. We urge future research to incorporate HL-enhancing interventions and longitudinal follow-up to better understand HL's evolving role in CR outcomes.