Associations between death anxiety, health literacy, and illness perception in Iranian individuals with heart failure an analytical cross sectional study

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BACKGROUND: Heart failure is a chronic condition that poses a global health concern. Death anxiety, which involves fear or worry about death and dying, is common among individuals with heart failure and has been linked to negative clinical and psychological outcomes. Several factors may contribute to death anxiety; this study aims to investigate the relationship between death anxiety, health literacy, and illness perception in individuals with heart failure. METHODS: This analytical cross-sectional study was conducted from April 2024 to June 2025 among 256 individuals with physician-confirmed heart failure who were referred to a tertiary heart failure clinic in Tehran, Iran. Participants were recruited using a convenience sampling method based on predefined inclusion and exclusion criteria. Eligible participants were aged 18 years or older and able to communicate in Persian, while individuals with a history of anxiety disorders or related pharmacological treatments were excluded. Data were collected using validated instruments, including Templer's Death Anxiety Scale, the Brief Illness Perception Questionnaire, and the Health Literacy for Iranian Adults questionnaire. Demographic data were obtained using a researcher-developed questionnaire. Statistical analyses, including independent t-tests, one-way ANOVA, and linear regression, were performed using SPSS version 22, with a significance level set at P < 0.05. RESULTS: The mean age of participants was 50.6 ± 12.2 years; 62.9% were male and 76% had a diploma or lower. Death anxiety was high (8.07 ± 3.18), with insufficient health literacy (64.24 ± 17.61) and moderate illness perception (46.91 ± 12.43). Higher death anxiety was observed in women (9.49 ± 3.19 vs. 7.22 ± 2.89, P < 0.001), those with lower education (8.28 ± 3.17 vs. 7.37 ± 3.16, P < 0.05), insufficient income (8.68 ± 3.39 vs. 7.54 ± 2.91, P < 0.004), unemployment (9.23 ± 2.93 vs. 7.19 ± 3.09, P < 0.001), negative family history (9.52 ± 2.97 vs. 6.84 ± 2.83, P < 0.001), and in heart failure classes I-II (8.84 ± 3.19 vs. 7.41 ± 3.04 in classes III-IV, P < 0.001). Death anxiety was negatively correlated with health literacy (β = - 0.44, SE = 0.01, CI [- 0.66, - 0.22], P < 0.001) and positively correlated with negative illness perception (β = 0.058, SE = 0.016, CI [0.027, 0.089], P < 0.001). CONCLUSIONS: This study indicates that higher health literacy and a positive illness perception can reduce death anxiety in individuals with heart failure. Targeted interventions, like educational programs and cognitive-behavioral therapies, can be effective in suppressing death anxiety. Additionally, addressing socioeconomic barriers and integrating palliative care with psychosocial support can enhance the quality of life and clinical outcomes of individuals with heart failure.