Behavior determinants among cardiac rehabilitation patients receiving educational interventions: an application of the health action process approach

Physical Activity Interventions Framed by the Health Action Process Approach for Adults with Long-Term Conditions: A Scoping Review

BACKGROUND

Interventions that use the Health Action Process Approach (HAPA) model show promise for increasing PA frequency, duration, and intensity. However, there is limited understanding of how HAPA model variables have been operationalized for PA interventions in chronic disease to promote behavior change and sustained PA or whether the phase or continuous form of the HAPA model was used. The aim of this scoping review is to describe how the HAPA model variables for PA interventions were operationalized and provide details of implementation.

METHOD

We searched five databases to identify studies published between January 1992 and March 2024. We aimed to describe (1) the characteristics of interventions including setting, delivery mode, duration, and content; (2) which HAPA variables were operationalized and the strategies used; and (3) the physical activity measures and outcome effects.

RESULTS

The search identified 23 interventions in 30 papers (12 protocols, 3 quasi-experimental studies, and 15 randomized controlled trials (RCTs)). Seven of the 15 RCTs reported significant positive effects of the HAPA model on PA behavior outcomes. Interventions operationalized between three and nine HAPA constructs showed significant variability in how the HAPA model is used in intervention research. PA measures varied from self-report to validated objective instruments.

CONCLUSION

We found a lack of clarity in decisions about which HAPA constructs were included in interventions. The wide variability in operationalized HAPA constructs made it challenging to compare interventions. Researchers should provide more detail about intervention design and implementation procedures to enhance transparency.

Making it transparent: A worked example of articulating programme theory for a digital health application using Intervention Mapping

Objective

Digital health interventions for behaviour change are usually complex interventions, and intervention developers should 'articulate programme theory', that is, they should offer detailed descriptions of individual intervention components and their proposed mechanisms of action. However, such detailed descriptions often remain lacking. The objective of this work was to provide a conceptual case study with an applied example of 'articulating programme theory' for a newly developed digital health intervention.

Methods

Intervention Mapping methodology was applied to arrive at a detailed description of programme theory for a newly developed digital health intervention that aims to support cardiac rehabilitation patients in establishing heart-healthy physical activity habits. Based on a Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation (PRECEDE) logic model of the problem, a logic model of change was developed. The proposed mechanisms of action were visualised in an acyclic behaviour change diagram.

Results

Programme theory for this digital health intervention includes 4 sub-behaviours of the main target behaviour (i.e. habitual heart-healthy physical activity), 8 personal determinants and 12 change objectives (i.e. changes needed at the determinant level to achieve the sub-behaviours). These are linked to 12 distinct features of the digital health intervention and 12 underlying behaviour change methods.

Conclusions

This case study offers a worked example of articulating programme theory for a digital health intervention using Intervention Mapping. Intervention developers and researchers may draw on this example to replicate the method, or to reflect on most suitable approaches for their own behaviour change interventions.

Effectiveness of a virtual vs. in-person group-based education curriculum to increase disease-related knowledge and change health behaviour among cardiac rehabilitation participants

OBJECTIVE

To investigate the effectiveness of a virtual 12-week group-based education curriculum and to compare results with a retrospective cohort that received the same education in-person for 24 weeks.

METHODS

Participants completed online surveys (pre- and post-intervention) assessing disease-related knowledge, adherence to the Mediterranean diet, exercise self-efficacy, and satisfaction. The number of steps taken per day was recorded using a wearable device. Paired t tests and repeated measures ANOVA were used. A Bonferroni correction was applied(p < 0.01).

RESULTS

80 CR participants receiving virtual education completed both assessments. Following virtual education, participants significantly increased knowledge(p < 0.001), adherence to the Mediterranean diet(p < 0.001) and number of daily steps(p = 0.01). These results were similarly observed in the in-person education group(n = 80), with no significant differences between groups. Virtual education participants decreased their self-efficacy post-intervention(p < 0.001); in contrast, participants of the in-person education increased their exercise self-efficacy(p < 0.001). Overall,31% of virtual and 71% of in-person education participants reported being satisfied with the education delivery format.

CONCLUSIONS

A virtual group-based education curriculum was effective at improving knowledge and changing behaviour. Similar results were observed in those that received in-person education. Tailoring virtual education interventions to support exercise self-efficacy is warranted.

PRACTICE IMPLICATION

This study strengthens the evidence supporting virtual education in CR.

Effects of an individualised exercise programme plus Behavioural Change Enhancement (BCE) strategies for managing fatigue in frail older adults: a cluster randomised controlled trial

BACKGROUND

To the best of our knowledge, although ageing-induced fatigue could cause adverse outcomes such as frailty, there is currently no intervention for it. This study evaluated the effects of an individualised exercise programme with/without BCE strategies on reducing fatigue in older adults.

METHODS

A three-armed cluster-randomised controlled trial (RCT) was conducted with 184 participants (mean age: 79.1 ± 6.4; mean frailty score: 2.8 + 0.8) from 21 community centres (ClinicalTrials.gov: NCT03394495). They were randomised into either: the COMB group (n = 64), receiving 16 weeks of exercise training plus the BCE programme; the EXER group (n = 65), receiving exercise training and health talks; or the control group (n = 55), receiving only health talks. Fatigue was assessed using the Multi-dimensional Fatigue Inventory (range: 20 to 100, with higher scores indicating higher fatigue levels) at baseline, and immediately, 6 months, and 12 months post-intervention.

RESULTS

The GEE analyses showed significant interaction (time x group) between the COMB and control groups immediately (p < 0.001), 6 months (p < 0.001), and 12 months (p < 0.001) post-intervention. Comparing the COMB and EXER groups, there was a significant interaction immediately (p = 0.013) and at 12 months post-intervention (p = 0.007). However, no significant difference was seen between the EXER group and control group at any time point.

CONCLUSIONS

The COMB intervention showed better immediate and sustainable effects (i.e., 12 months after the intervention) on reducing fatigue in frail older adults than exercise training or health education alone.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT03394495), registered on 09/01/2018.

Women-Focused Cardiovascular Rehabilitation: An International Council of Cardiovascular Prevention and Rehabilitation Clinical Practice Guideline

Women-focused cardiovascular rehabilitation (CR; phase II) aims to better engage women, and might result in better quality of life than traditional programs. This first clinical practice guideline by the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) provides guidance on how to deliver women-focused programming. The writing panel comprised experts with diverse geographic representation, including multidisciplinary health care providers, a policy-maker, and patient partners. The guideline was developed in accordance with Appraisal of Guidelines for Research and Evaluation (AGREE) II and the Reporting Items for practice Guidelines in HealTh care (RIGHT). Initial recommendations were on the basis of a meta-analysis. These were circulated to a Delphi panel (comprised of corresponding authors from review articles and of programs delivering women-focused CR identified through ICCPR's audit; N = 76), who were asked to rate each on a 7-point Likert scale in terms of impact and implementability (higher scores positive). A Web call was convened to achieve consensus; 15 panelists confirmed strength of revised recommendations (Grading of Recommendations Assessment, Development, and Evaluation [GRADE]). The draft underwent external review from CR societies internationally and was posted for public comment. The 14 drafted recommendations related to referral (systematic, encouragement), setting (model choice, privacy, staffing), and delivery (exercise mode, psychosocial, education, self-management empowerment). Nineteen (25.0%) survey responses were received. For all but 1 recommendation, ≥ 75% voted to include; implementability ratings were < 5/7 for 4 recommendations, but only 1 for effect. Ultimately 1 recommendation was excluded, 1 separated into 2 and all revised (2 substantively); 1 recommendation was added. Overall, certainty of evidence for the final recommendations was low to moderate, and strength mostly strong. These recommendations and associated tools can support all programs to feasibly offer some women-focused programming.

Cardiac telerehabilitation in a middle-income country: analysis of adherence, effectiveness and cost through a randomized clinical trial

BACKGROUND

The benefits of cardiac rehabilitation (CR) are already well established; however, such intervention has been underused, mainly in low- and middle-income countries.

AIM

To compare adherence, effectiveness, and cost of a home CR with the traditional CR (TCR) in a middle-income country (MIC).

DESIGN

Single-blind randomized control trial.

SETTING

A university hospital.

POPULATION

Individuals with coronary disease that were eligible were invited to participate. A randomized sample of 51 individuals was selected, where two participants were not included by not meeting inclusion criteria.

METHODS

The home-CR group participated in health education activities, carried out two supervised exercise sessions, and was instructed to carry out 58 sessions at home. Weekly telephone calls were made. The TCR group held 24 supervised exercise sessions and were instructed to carry out 36 sessions at home.

RESULTS

49 individuals (42 male, 56.37±10.35years) participated in the study, 23 in the home-CR group and 26 in the TCR group. After the intervention, adherence in the home-CR and TCR groups was 94.18% and 79.08%, respectively, with no significant difference (P=0.191). Both protocols were effective for the other variables, with no differences. The cost per patient for the service was lower in the home-CR (US$ 59.31) than in the TCR group (US$ 135.05).

CONCLUSIONS

CR performed at home in an MIC demonstrated similar adherence and effectiveness compared to the TCR program, but with a lower cost for the service. The results corroborate the possibility of using home CR programs, even in MICs, after exercise risk stratification and under remote supervision.

CLINICAL REHABILITATION IMPACT

Home-CR can contribute to overcome participants' barriers with compatible cost. Home-CR is effective in improving functional capacity and risk factors control. Perform risk stratification and remote supervision are essential to offer Home-CR.

A Smartphone-Based Self-management Intervention for Individuals With Bipolar Disorder (LiveWell): Empirical and Theoretical Framework, Intervention Design, and Study Protocol for a Randomized Controlled Trial

Background

Bipolar disorder is a severe mental illness with high morbidity and mortality rates. Even with pharmacological treatment, frequent recurrence of episodes, long episode durations, and persistent interepisode symptoms are common and disruptive. Combining psychotherapy with pharmacotherapy improves outcomes; however, many individuals with bipolar disorder do not receive psychotherapy. Mental health technologies can increase access to self-management strategies derived from empirically supported bipolar disorder psychotherapies while also enhancing treatment by delivering real-time assessments, personalized feedback, and provider alerts. In addition, mental health technologies provide a platform for self-report, app use, and behavioral data collection to advance understanding of the longitudinal course of bipolar disorder, which can then be used to support ongoing improvement of treatment.

Objective

A description of the theoretical and empirically supported framework, design, and protocol for a randomized controlled trial (RCT) of LiveWell, a smartphone-based self-management intervention for individuals with bipolar disorder, is provided to facilitate the ability to replicate, improve, implement, and disseminate effective interventions for bipolar disorder. The goal of the trial is to determine the effectiveness of LiveWell for reducing relapse risk and symptom burden as well as improving quality of life (QOL) while simultaneously clarifying behavioral targets involved in staying well and better characterizing the course of bipolar disorder and treatment response.

Methods

The study is a single-blind RCT (n=205; 2:3 ratio of usual care vs usual care plus LiveWell). The primary outcome is the time to relapse. Secondary outcomes are percentage time symptomatic, symptom severity, and QOL. Longitudinal changes in target behaviors proposed to mediate the primary and secondary outcomes will also be determined, and their relationships with the outcomes will be assessed. A database of clinical status, symptom severity, real-time self-report, behavioral sensor, app use, and personalized content will be created to better predict treatment response and relapse risk.

Results

Recruitment and screening began in March 2017 and ended in April 2019. Follow-up ended in April 2020. The results of this study are expected to be published in 2022.

Conclusions

This study will examine whether LiveWell reduces relapse risk and symptom burden and improves QOL for individuals with bipolar disorder by increasing access to empirically supported self-management strategies. The role of selected target behaviors (medication adherence, sleep duration, routine, and management of signs and symptoms) in these outcomes will also be examined. Simultaneously, a database will be created to initiate the development of algorithms to personalize and improve treatment for bipolar disorder. In addition, we hope that this description of the theoretical and empirically supported framework, intervention design, and study protocol for the RCT of LiveWell will facilitate the ability to replicate, improve, implement, and disseminate effective interventions for bipolar and other mental health disorders.

Trial Registration

ClinicalTrials.gov NCT03088462; https://www.clinicaltrials.gov/ct2/show/NCT03088462

International Registered Report Identifier (IRRID)

DERR1-10.2196/30710

The impact of patient education on knowledge, attitudes, and cardiac rehabilitation attendance among patients with coronary artery disease

OBJECTIVE

Patient education (PE) delivered during exercise-based cardiac rehabilitation (CR) aims to promote health behaviour change, including attendance at CR exercise sessions, by imparting knowledge about coronary artery disease (CAD) and improving CR-related attitudes. This study evaluated the impact of PE on aspects of patient motivation (i.e., CAD-related knowledge, attitudes towards CR) and exercise session attendance.

METHODS

Adults with CAD referred to a 12-week CR program were recruited. CAD knowledge, perceived necessity/suitability of CR, exercise concerns, and barriers to CR were assessed pre/post-PE, and at 12-week follow-up. CR exercise attendance was obtained by chart review.

RESULTS

Among 90 patients (60 ± 10 years; 88% men), CAD knowledge and perceived necessity of CR improved pre- to post-PE; gains persisted at 12-weeks. Stronger pre-CR intentions to attend exercise sessions predicted greater attendance. Greater knowledge gains did not predict improvements in CR attitudes or exercise attendance.

CONCLUSION

Whereas PE may be useful for improving knowledge and attitudes regarding CAD self-management, more formative research is needed to determine whether PE can promote CR attendance.

PRACTICE IMPLICATIONS

Cardiac PE programs may be more successful in promoting exercise attendance if they target patients' behavioural intentions to attend and attitudes toward CR, rather than focussing exclusively on imparting knowledge.

Translation and evaluation of a comprehensive educational program for cardiac rehabilitation patients in Latin America: A multi-national, longitudinal study

OBJECTIVES

To translate, cross-culturally adapt and validate a comprehensive evidence- and theoretically-based CR education intervention in Latin America.

METHODS

First, best practices in translation and cross-cultural adaptation were applied through 6 steps. Then, the Spanish version was delivered to CR participants from programs in Colombia, Costa Rica and Peru for validation, such that the evaluation was pre-post, uncontrolled, pragmatic, observational, and prospective in design. Participants completed surveys assessing knowledge, health literacy, self-efficacy, and health behaviours. All outcomes were assessed pre-, and post-CR, as well as 6 months after CR completion.

RESULTS

After translation of the patient guide from English to Spanish, 5 of the 9 booklets were culturally adapted. Two-hundred and forty-nine patients consented to participate, of which 184 (74 %) completed post-CR, and 121 (48 %) completed final assessments. There was a significant improvement in disease-related knowledge pre- to post-CR, as well as in health literacy, self-efficacy, and health behaviours (all p < 0.05). These gains were sustained 6 months post-program. With adjustment, CR attendance (i.e., exposure to the education) was associated with greater post-CR knowledge (ß = 0.026; p = 0.01).

CONCLUSION

A patient education intervention for CR patients in Latin America has been validated, and wider implementation is warranted.

PRACTICE IMPLICATIONS

Application of this first-ever validated CR education program for Spanish-speaking settings may result in secondary prevention.

Contemplation-action-maintenance model of behaviour change for persons with coronary heart disease: A qualitative study

AIMS AND OBJECTIVES

To explore factors of health behaviour maintenance from the perspective of coronary heart disease (CHD) patients.

BACKGROUND

The majority of CHD patients do not achieve appropriate theory-based intervention to maintain health behaviours. Previous health behaviour change theories give little importance to behaviour maintenance.

DESIGN

A qualitative descriptive study.

METHODS

Thirty CHD patients were recruited purposively and interviewed from four hospitals in Beijing, China, during January 2017-August 2019. Data were analysed using template analysis methods. The COREQ checklist was used.

RESULTS

Perceived enjoyment and perceived effectiveness from the newly adopted behaviours emerged as vital factors for maintaining health behaviour; contemplation-action-maintenance (CAM) model to explain the behaviour change and maintenance of CHD patients was constructed.

CONCLUSIONS

The CAM model provides insight into the factors of health behaviour action and maintenance among CHD patients. Professionals can develop interventions from the perspective of patients' experiences to promote maintenance of behaviour.

RELEVANCE TO CLINICAL PRACTICE

Professionals need to consider that the goal of behavioural intervention should initially and continuously target patients' perseverance. Interventions of health behaviour that bring enjoyment may aid long-term maintenance. Also, healthcare providers can enhance patients' perception of effectiveness to motivate their behaviour maintenance in lifestyle change programmes.

Predictors of Exercise Maintenance 6 Months After Comprehensive Cardiac Rehabilitation

PURPOSE

The objectives of this study were (1) to assess the effects of a comprehensive education intervention on maintenance of knowledge, exercise behavior, heart-healthy food intake, self-efficacy, and health literacy 6 mo after comprehensive cardiac rehabilitation (CR), and (2) to identify predictors of exercise maintenance 6 mo after comprehensive CR.

METHODS

A prospective longitudinal study was conducted to test the effects of a structured educational curriculum in three CR programs in Canada. Participants completed surveys pre-, post-CR and 6 mo post-discharge to assess knowledge, heart-healthy food intake, self-efficacy, and health literacy. Exercise behavior was measured by number of steps/d using a pedometer.

RESULTS

One hundred twenty participants completed the final survey. Increases in disease-related knowledge and self-efficacy, as well as behavior changes (increases in exercise and heart-healthy food intake), were achieved in comprehensive CR and sustained 6 mo post-program. Exercise maintenance was predicted by changes in heart-healthy food intake, self-efficacy, health literacy, and exercise-related knowledge.

CONCLUSIONS

In this three-site study focusing on patient education for CR patients in Canada, the benefits of an education intervention in maintaining knowledge, exercise, healthy food intake, and self-efficacy were supported.

Validation of the Chinese Version of the Coronary Artery Disease Education Questionnaire - Short Version: A Tool to Evaluate Knowledge of Cardiac Rehabilitation Components

Background:

Patient education is the first step in implementing a cardiac rehabilitation (CR) program and a powerful tool for promoting behavioral changes in cardiac patients. In China, the clinical workload is so heavy that a short and reliable tool for assessing disease-related knowledge is needed for targeted patient education.

Objective:

The aim of this study was to translate, adapt and validate the Chinese version of the Coronary Artery Disease Education Questionnaire – Short Version (CADE-Q SV).

Methods:

The CADE-Q SV was translated to simplified Chinese and culturally adapted to the Chinese context. The translated version was reviewed by a committee of seven experts in cardiovascular disease, and the content validity of the questionnaire was established. The psychometric properties of the questionnaire were analyzed considering the responses of 240 CR patients. The Kuder-Richardson-20 (KR-20) coefficient and Cronbach’s alpha were used to assess internal consistency. The intraclass correlation coefficient (ICC) was used to assess test-retest reliability. The criterion-related validity was evaluated by determining whether there were differences in the total scores of patients with different educational levels. Confirmatory factor analysis (CFA) was used to assess the factor structure.

Results:

Three items from the original version were adapted to reflect Chinese culture. The content validity index was 0.94. The KR-20 score was 0.856. All ICC values were > 0.70. The knowledge scores of patients with different educational levels were significantly different, indicating that the criterion-related validity of the Chinese CADE-Q-SV was acceptable. CFA validated the five-factor structure of the Chinese CADE-Q-SV.

Conclusion:

The Chinese CADE-Q SV questionnaire has good reliability and validity. This short, efficient tool can be completed quickly, assess disease-related knowledge in cardiovascular patients and serve as a reference for individualized patient education in China. It can also be used to evaluate the effectiveness of CR-related patient education interventions.

Effectiveness of an education intervention associated with an exercise program in improving disease-related knowledge and health behaviours among diabetes patients

OBJECTIVE

to assess the effectiveness of an education intervention associated with an exercise program in improving knowledge and health behaviours among diabetes patients.

METHODS

Diabetes and prediabetes patients were exposed to an evidence- and theoretically-based comprehensive education intervention over 24 weeks. Patients completed surveys assessing knowledge, physical activity, food intake, self-efficacy, and health literacy. Functional capacity was measured by oxygen uptake. All outcomes were assessed pre- and post-CR. Satisfaction about the education provided was assessed at post-CR. Paired t-tests, Pearson correlation coefficients, and linear regression models were computed to investigate the effectiveness of this intervention.

RESULTS

84 patients consented to participate, of which 47(56.0%) completed post-CR assessments. There was a significant improvement in patients' overall knowledge pre- to post-CR, as well as in physical activity, food intake, self-efficacy, and health literacy (p < 0.05). Peak VO₂ has clinically significant improved. Results showed a low significant positive correlation was between post-CR knowledge and food intake(r = 0.297;p = 0.04). Linear regression analysis revealed that age(B=-0.051; p = 0.01) was influential in changing post-CR knowledge.

CONCLUSION

The benefits of an education intervention designed for diabetes and prediabetes patients associated with an exercise program have been supported.

PRACTICE IMPLICATIONS

This work shows one effective education strategy taken in place that can be replicated in different settings.

Translation, adaptation, and psychometrically validation of an instrument to assess disease-related knowledge in Spanish-speaking cardiac rehabilitation participants: The Spanish CADE-Q SV

OBJECTIVE

To validate the Spanish Coronary Artery Disease Education Questionnaire Short Version(CADE-QSV).

BACKGROUND

Knowledge assessment can tailor patient education strategies in CR.

METHODS

Ten CR experts culturally-adapted the translated tool and 249 CR patients in three countries participated in the psychometrically validation. The internal consistency was assessed using KR-20 and Cronbach's alpha. Distribution- and anchor-based methods were used to estimate the MCID for interpretability analysis. Factor structure, acceptability, floor and ceiling effects and discriminant validity were also assessed.

RESULTS

KR-20 was 0.75.Factor analysis revealed 5 factors, all internally consistent. Discriminant validity was supported by significant differences in educational level and family income at post-CR. Results showed that increases in knowledge can moderately increase mean steps per day, with MCID=3.00. Items were completed by 98% of participants. No evidence for ceiling/floor effects on total score. The area with the highest knowledge was nutrition and the lowest was medical condition.

CONCLUSION

The Spanish CADE-QSV demonstrated preliminary validity and reliability.

Effectiveness of an Education Intervention Among Cardiac Rehabilitation Patients in Canada: A Multi-Site Study

BACKGROUND

Although patient education is considered a core component of cardiac rehabilitation (CR) programs, to our knowledge, no educational program designed for CR has been standardized in Canada. This absence of standardization may be due to a lack of reliable resources to educate these patients. The objective of this study was to assess the effectiveness of an education intervention in improving knowledge and health behaviours among CR patients in 3 sites in Canada.

METHODS

CR patients were exposed to an evidence- and theoretically based comprehensive education intervention. Patients completed surveys assessing knowledge, physical activity, food intake, self-efficacy, and health literacy. All outcomes were assessed pre- and post-CR. Paired t tests were used to investigate variable changes between pre- and post-CR, Pearson correlation coefficients were used to determine the association between knowledge and behaviours, and linear regression models were computed to investigate differences in overall post-CR knowledge based on participant characteristics.

RESULTS

A total of 252 patients consented to participate, of whom 158 (63.0%) completed post-CR assessments. There was a significant improvement in patients' overall knowledge pre- to post-CR, as well as in exercise, food intake, and self-efficacy (P < 0.05). Results showed a significant positive correlation between post-CR knowledge and food intake (r = 0.203; P = 0.01), self-efficacy (r = 0.201; P = 0.01), and health literacy (r = 0.241; P = 0.002). Education level (unstandardized beta = -2.511; P = 0.04) and pre-CR knowledge (unstandardized beta = 0.433; P < 0.001) were influential in changing post-CR knowledge.

CONCLUSION

In this first-ever multi-site study focusing on patient education for CR patients in Canada, the benefits of an education intervention have been supported.

Effects of an Individualized Exercise Program Plus Behavioral Change Enhancement Strategies for Managing Fatigue in Older People Who Are Frail: Protocol for a Cluster Randomized Controlled Trial

BACKGROUND

Although the evidence suggests that general fatigue is a strong indicator of rapid aging, frailty, and disability, general fatigue is undertreated in gerontological care.

OBJECTIVE

The aim of this study is to investigate whether an individualized exercise program with and without behavioral change enhancement (BCE) strategies for older people who are frail and have general fatigue will reduce their fatigue and symptoms of frailty.

DESIGN

A 3-arm, single-blind, cluster randomized controlled trial registered with ClinicalTrials.gov (NCT03394495) will be conducted.

SETTING

The study will be conducted in a community setting.

PARTICIPANTS

Two hundred eighty-five community-dwelling older people with general fatigue will be recruited from 12 district community health centers.

INTERVENTION

People from each center will be randomized to one of three groups. The combined group will receive a 16-week combined intervention consisting of individualized exercise training and the BCE program, plus two booster sessions at 2 and 6 months after the program. The exercise group will receive exercise training and health talks only. The control group will receive health talks only.

MEASUREMENTS

Outcome measures will be collected at baseline, at the midpoint (week 8) of the program, and then at 1 week, 6 months, and 12 months after the end of the program. The primary outcome---level of fatigue---will be measured using the Multidimensional Fatigue Inventory. Secondary outcomes will include the participants' frailty status, strength, mobility, exercise self-efficacy, and habitual physical activity.

LIMITATIONS

A self-reported level of fatigue will be used.

CONCLUSIONS

The effect of exercise and BCE strategies on general fatigue among older people who are frail is not known. This study will be a pioneering interventional study on how general fatigue among older people who are frail can be managed and how fatigue-related frailty can be prevented or minimized.

The Process of Patient Engagement in Outpatient Cardiac Rehabilitation Programs

The primary aim of this study was to test the causal structure of the model of therapeutic engagement (MTE) for the first time, to examine whether the model assists in understanding the process of patient engagement in cardiac rehabilitation (CR) programs. This study used a prospective design, following up patients from the Gold Coast University Hospital Cardiology ward who attended Robina Cardiac Rehabilitation Clinic. A structural equation model of the interactions among the proposed variables within the three stages of the MTE (intention to engage in CR programs, CR initiation, and sustained engagement) revealed significant relationships among these variables in a dataset of 101 patients who attended a CR program. However, no relationship was discerned between outcome expectancies and patient intention to engage in CR. Patients’ willingness to consider the treatment also mediated the relationship between perceived self-efficacy and patient intention to engage in CR. These findings help clarify the process proposed by Lequerica and Kortte (2010) in the context of patient engagement in CR programs. The findings also reveal information on how patients engage in CR programs. Importantly, this provides new information for healthcare providers, enabling them to more effectively engage patients according to their stage of engagement.

Do compensatory health beliefs predict behavioural intention in a multiple health behaviour change context? Evidence in individuals with cardiovascular diseases?

Multiple health behaviour change (MHBC) represents one of the best ways to prevent reoccurrence of cardiovascular events. However, few individuals with cardiovascular diseases engage in this process. The present study examined the role of compensatory health beliefs (CHB; i.e., belief that a healthy behaviour compensates an unhealthy one) as a drag to engagement in this process. Some studies have shown that CHBs predict intention to engage in healthy behaviours, but no study has investigated CHBs in individuals who actually need to change multiple health behaviours. The goal was to better understand the role of CHBs in intentions formation process among individuals with cardiac diseases in an MHBC context. One hundred and four patients completed a questionnaire at the beginning of their cardiac rehabilitation program. Results showed that: (1) CHBs negatively predicted intentions (2) but only for participants with high self-efficacy or low risk perception; (3) CHBs predictions differed depending on the nature of the compensating behaviour, and were more predictive when medication intake was the compensating one. Findings only partially confirmed previous research conducted on healthy individuals who were not in an MHBC process, and emphasized the importance of considering CHBs for individuals in this process.

Validation of a Scale to Assess Patients' Comprehension of Frequently Used Cardiology Terminology: The Cardiac TERM Scale in Brazilian Portuguese

PURPOSE

The aim of this study was to psychometrically validate the translation of a questionnaire on patient understanding of cardiology terminology (TERM) to Brazilian Portuguese.

DESIGN

After piloting the translation and cross-cultural adaptation, the 16-item TERM questionnaire was psychometrically tested.

METHODS

Internal and test-retest reliability, as well as validity, were assessed in 322 cardiac patients.

FINDINGS

Internal (α = .88) and test-retest reliability (all weighted Kappa > 0.63) exceeded the minimum recommended standards. Criterion validity was supported by significant differences in mean scores by socioeconomic indicators (p < .01). Discriminant validity was supported in that cardiac rehabilitation participants had significantly higher TERM scores (p < .001). Participants did not correctly define any of the terms, and a floor effect was identified in all terms.

CONCLUSIONS

The Cardiac TERM Scale was demonstrated to have good reliability and validity.

CLINICAL RELEVANCE

The scale can be used by healthcare professionals, such as nurses. Results can be used to inform patient education, which could in turn impact patient adherence to medical advice and hence outcomes.

Validation of the Brazilian Version of CADE-Q II to Assess Knowledge of Coronary Artery Disease Patients

Background

The Coronary Artery Disease Education Questionnaire (CADE-Q), an instrument aimed at assessing patients’ knowledge about coronary artery disease (CAD), was originally developed and psychometrically validated in Brazil. It was later translated, cross-culturally adapted, and validated to English. Although both versions demonstrated good reliability and validity, new studies in the area have pointed out the need of implementing the CADE-Q with other components of cardiac rehabilitation (CR) programs, such as psychologic factors, which had not been considered in previous version and were added in the subsequent, adapted version. Thus, a second version of CADE-Q was developed in English, the CADE-Q II.

Objective

to translate, culturally adapt and psychometrically validate the CADE-Q II in Brazilian Portuguese.

Methods

After translation and review by a Committee of specialists in CR, a version in Brazilian Portuguese was generated and tested in 307 patients in CR. Test-retest reliability was assessed by intraclass correlation coefficient (ICC) in 49 patients; internal consistency was assessed using Cronbach’s alpha (α); and, criterion validity was assessed regarding patients’ educational level and family income. The level of significance adopted for all tests was 5%.

Results

After the ICC analysis, 4 items were excluded. The questionnaire was considered internally consistent (α > 0.7). Associations were found between the mean total scores and the variables schooling (p < 0.001) and income (p < 0.001). Median total score was 53 (14) points corresponding to 65.4% of the total possible score.

Conclusion

The Portuguese version of the CADE-Q II showed sufficient reliability, consistency and validity, supporting its use in future studies.

Effects of comprehensive cardiac rehabilitation on functional capacity and cardiovascular risk factors in Brazilians assisted by public health care: protocol for a randomized controlled trial

Background

Cardiovascular Disease (CVD) is the leading burden of disease worldwide. Moreover, CVD-related death rates are considered an epidemic in low- and middle-income countries (LMICs). Research shows that cardiac rehabilitation (CR) participation reduces death and improves disability and quality of life. Given the growing epidemic of CVD in LMICs and the insufficient evidence about CR programs in these countries, a Randomized Control Trial (RCT) in Latin America is warranted.

Objective

To investigate the effects of comprehensive CR on functional capacity and cardiovascular risk factors.

Method

The design is a single-blinded RCT with three parallel arms: comprehensive CR (exercise + education) versus exercise-based CR versus wait-list control (no CR). The primary outcome will be measured by the Incremental Shuttle Walk Test. Secondary outcomes are risk factors (blood pressure, dyslipidemia, dysglycemia, body mass index and waist circumference); tertiary outcomes are heart health behaviors (exercise, medication adherence, diet, and smoking), knowledge, and depressive symptoms. The CR program is six months in duration. Participants randomized to exercise-based CR will receive 24 weeks of exercise classes. The comprehensive CR group will also receive 24 educational sessions, including a workbook. Every outcome will be assessed at baseline and 6-months later, and mortality will be ascertained at six months and one year.

Conclusion

This will be the first RCT to establish the effects of CR in Latin America. If positive, results will be used to promote broader implementation of comprehensive CR and patient access in the region and to inform a larger-scale trial powered for mortality.

Knowledge and exercise behavior maintenance in cardiac rehabilitation patients receiving educational interventions

OBJECTIVES

To test whether a theoretically-based education curriculum results in more sustained knowledge, higher scores on Health Action Process Approach (HAPA) constructs, and greater exercise behavior 6 months post-cardiac rehabilitation (CR) when compared to traditional CR education.

BACKGROUND

Patient education is a core component of CR. No research has examined whether this education results in sustained improvements post-program.

METHODS

In this quasi-experimental study, participants exposed to the traditional vs HAPA-based education completed surveys pre, post-CR, and 6 months post-discharge assessing knowledge, HAPA constructs, and exercise.

RESULTS

Ninety-three participants completed the final survey. Knowledge increases post-CR were sustained 6 months post-program, with no differences by curriculum. Many improvements in HAPA constructs observed post-CR were sustained, except for some decay in self-efficacy. Minutes of exercise per week were significantly greater in participants exposed to the HAPA-based curriculum 6 months post-program.

CONCLUSIONS

HAPA-based education in CR has sustained effects on exercise.