Change in self-efficacy during cardiac rehabilitation and the role of perceived overprotectiveness

Associations Between Psychological Factors and Adherence to Health Behaviors After Percutaneous Coronary Intervention: The Role of Cardiac Rehabilitation

BACKGROUND

Cardiac rehabilitation (CR) participation after percutaneous coronary intervention (PCI) for coronary heart disease lowers the disease burden and risk of recurrent cardiac events. Examining psychological factors may improve post-PCI health behavior adherence.

PURPOSE

To determine whether psychological factors are associated with post-PCI health behavior adherence, and the role of CR participation.

METHODS

Data from 1,682 patients (22.1% female, Mage = 64.0, SDage = 10.5 years) from the THORESCI cohort were included. Adjusted mixed models were used to examine associations between psychological factors and the 1-year course of health behaviors, using interactions to test for moderation by CR participation.

RESULTS

Psychological factors were associated with the trajectories of adherence to medical advice, exercise, and diet. The strongest association found was between optimism and the trajectory of dietary adherence (B: = -0.09, p = .026). Patients with high optimism levels had a worse trajectory of dietary adherence compared to patients with low to middle optimism levels. Participation in CR buffered the associations of high anxiety, pessimism, and low to middle resilience, but strengthened the associations of high stress in the past year with the probability of smoking.

CONCLUSIONS

Psychological factors are associated with post-PCI health behavior adherence, but the pattern of associations is complex. Patients with high levels of anxiety, pessimism, and low to middle resilience levels may disproportionately benefit from CR. Cardiac rehabilitation programs could consider this to improve post-PCI health behavior adherence.

CLINICAL TRIALS REGISTRATION #

NCT02621216.

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.

A Structural Equation Model of Gratitude, Self-efficacy, and Medication Adherence in Patients With Stage B Heart Failure

BACKGROUND

Consistent self-care slows the progression of heart failure (HF). Gratitude, the practice of appreciating the positive aspects of life, may influence self-efficacy, which in turn is known to improve self-care. However, little is known about the relationships among gratitude, self-efficacy, and medication adherence in HF.

OBJECTIVE

The aim of this study was to test a model to determine if self-efficacy mediates the relationship between gratitude and medication adherence in asymptomatic patients with HF.

METHOD

This is a secondary analysis of data from a prospective observational study. Data were analyzed using a structural equation model to examine associations between gratitude, cardiac-specific self-efficacy, and medication adherence in 153 patients with HF. Gratitude, self-efficacy, and medication adherence were assessed using the Gratitude Questionnaire-6, Cardiac Self-efficacy Scale-Maintain Function Subscale, and the Morisky Medication Adherence Scale, respectively.

RESULTS

Patient mean (SD) age was 66 (11) years, and 95% of the participants were men. Patients were primarily white (79%), black (12%), or Asian (6%). Gratitude exerted an indirect effect on medication adherence through self-efficacy (b = 0.16; P < .05). Gratitude was positively related to self-efficacy (b = 0.50; P < .05), and self-efficacy was positively related to medication adherence (b = 0.31; P < .05). The model fit was acceptable (comparative fit index = 0.92, Tucker-Lewis index = 0.90, root-mean-square error of approximation = 0.08).

CONCLUSION

In this study, we found evidence that self-efficacy was a mechanism through which gratitude was associated with medication adherence in asymptomatic patients with HF, suggesting a way to improve self-care nonpharmacologically. Future work will examine whether gratitude intervention results in improved self-care.

Association of social relationships with incident cardiovascular events and all-cause mortality

Objective

To examine how different aspects of social relationships are associated with incident cardiovascular events and all-cause mortality.

Methods

In 4139 participants from the population-based Heinz Nixdorf Recall study without previous cardiovascular disease (mean (SD) age 59.1 (7.7) years, 46.7% men), the association of self-reported instrumental, emotional and financial support and social integration at baseline with incident fatal and non-fatal cardiovascular events and all-cause mortality during 13.4-year follow-up was assessed in five different multivariable Cox proportional hazards regression models: minimally adjusted model (adjusting for age, sex, social integration or social support, respectively); biological model (minimally adjusted+systolic blood pressure, low-density and high-density lipoprotein cholesterol, glycated haemoglobin, body mass index, antihypertensive medication, lipid-lowering medication and antidiabetic medication); health behaviour model (minimally adjusted+alcohol consumption, smoking and physical activity); socioeconomic model (minimally adjusted+income, education and employment); and depression model (minimally adjusted+depression, antidepressants and anxiolytics).

Results

339 cardiovascular events and 530 deaths occurred during follow-up. Lack of financial support was associated with an increased cardiovascular event risk (minimally adjusted HR=1.30(95% CI 1.01 to 1.67)). Lack of social integration (social isolation) was associated with increased mortality (minimally adjusted HR=1.47 (95% CI 1.09 to 1.97)). Effect estimates did not decrease to a relevant extent in any regression model.

Conclusions

Perceiving a lack of financial support is associated with a higher cardiovascular event incidence, and being socially isolated is associated with increased all-cause mortality. Future studies should investigate how persons with deficient social relationships could benefit from targeted interventions.

Cardiac Rehabilitation in Primary Care. Impact of an Intervention on Perceived Self-Efficacy

Cardiac rehabilitation is cost-effective and should be considered a part of the care system provided to patients who have suffered a myocardial infarction or another heart disease. The main variable to study was the scoring, prior to and after the intervention in the General Scale of Self-Efficacy by Baessler & Schwarzer. A clinical community trial that was open controlled and randomised was used. All adult subjects of both sexes who had completed a cardiac rehabilitation program for 12 months at the reference hospital were selected and offered to participate. The psychometric variables registered were the Salamanca screening questionnaire, the Hamilton Anxiety Rating Scale, and the Beck Depression Inventory. Eighty-nine subjects accepted to participate in the study (93.89% response rate), with an average age of 63.01 years (SD 8.75). Once the study was concluded, the main outcome was a difference in means of 6.09 points in the General Scale of Self-Efficacy (p < 0.0053, 96% confidence interval-4.1950-10.29), showing that the group exposed to the intervention reached a higher score in the above-mentioned scale. However, there were no significant differences (t-student 0.1211; p = 0.943) after the estimation and contrast of population means for score differences between the groups regarding the Hamilton scale. Similarly, there were no significant differences between the groups regarding the means obtained in the variable score difference in the Beck Depression Inventory (t-student -0.1281; p = 0.8987). The results showed an increase in those scores related to general self-efficacy among the population that completed the intervention program, as compared to the control group.

Dyadic Coping in Couples: A Conceptual Integration and a Review of the Empirical Literature

The present review on dyadic coping (DC) aims at providing a critical integration of both the conceptual and empirical DC literature and overcoming the limitations of past reviews by (a) describing, comparing, and integrating all the DC models, (b) presenting and integrating findings from studies based on DC models, and (c) suggesting directions for further research. The DC models identified and compared include: The congruence model (Revenson, 1994), the relationship-focused model (Coyne and Smith, 1991; O'Brien and DeLongis, 1996), the communal coping model (Lyons et al., 1998), the systemic-transactional model (Bodenmann, 1995, 1997), the relational-cultural model (Kayser et al., 2007), and the developmental-contextual coping model (Berg and Upchurch, 2007). After discussing each DC model, we advance a conceptual integration of all models, which serves as the framework to organize the review of the empirical literature. This integration includes the following DC dimensions: (a) Stress Communication, (b) Positive DC by One Partner (supportive DC, empathic responding, delegated DC, active engagement), (c) Positive Conjoint DC (common, collaborative, communal, mutual responsiveness); (d) Negative DC by One Partner (protective buffering, overprotection, and hostility/ambivalence), and (e) Negative Conjoint DC (common negative DC, disengaged avoidance). Developmental, relational, and contextual variables are included as factors shaping DC. To be included in the empirical review, articles had to be published in or a peer-reviewed journal in English and/or German before 2017 and include an original empirical study guided by one of the DC models. The review included 139 studies and, with the exception of the congruence model whose findings were discussed separately, findings were presented for overall DC and each of the dimensions identified in the conceptual integration. Findings were grouped also according to whether the stressor related or not to a medical or mental health condition. Demographic and cultural factors affecting DC were discussed. Overall, the empirical review suggests that in Western couples, positive individual, and conjoint DC forms, taken together or separately, have individual and relational benefits for couples coping with stress in general and/or mental health or medical stressors. Research on DC can be expanded to include other populations and stressors and use improved designs.

Evaluating Perceptions of Self-efficacy and Quality of Life in Patients Having Coronary Artery Bypass Grafting and Their Family Caregivers

BACKGROUND

Self-efficacy is a critical factor for quality of life in patients who undergo coronary artery bypass grafting, as well as for their family caregivers. However, there is lack of knowledge about whether patients' self-efficacy and caregivers' perceptions of patient self-efficacy are associated with quality of life in patient and caregiver dyads.

OBJECTIVES

The aims of this study were to compare self-efficacy and quality of life between patients and family caregivers and to examine whether patients' and caregivers' perceptions of patient self-efficacy were associated with their own and their partner's quality of life in patient and caregiver dyads who were waiting for patients' coronary artery bypass grafting.

METHODS

In this cross-sectional study, 84 dyads (85% male patients and 87% female caregivers) completed the Cardiac Self-efficacy Scale, which consists of self-efficacy for controlling symptoms and self-efficacy for maintaining function subscales, and the Short-Form 12 Health Survey for quality of life. Data were analyzed using the Actor-Partner Interdependence Model.

RESULTS

Caregivers rated patient self-efficacy for maintaining function higher than did patients themselves and caregivers' perceptions were positively correlated with patients' physical health. Patients' self-efficacy for maintaining function exhibited an actor effect on their own mental health. There were no other actor or partner effects of self-efficacy on quality of life.

CONCLUSIONS

Differences between patients' and caregivers' perceptions of patient self-efficacy for maintaining function should be addressed before surgery to reduce discordance. Patients' self-efficacy for maintaining function was associated with their own quality of life. There was no partner (relationship) effect of self-efficacy on quality of life. More research is needed in this area.

Chinese translation and psychometric testing of the cardiac self-efficacy scale in patients with coronary heart disease in mainland China

Background

A person’s self-efficacy plays a critical role during the chronic management process of a health condition. Assessment of self-efficacy for patients with heart diseases is essential for healthcare professionals to provide tailored interventions to help patient to manage the disease.

Objective

To translate and test the psychometric properties of the Chinese version of Cardiac Self-efficacy Scale (C-CSES) as a disease-specific instrument for patients with coronary heart disease (CHD) in mainland China.

Methods

The original English version of the CSES was translated into Chinese using a forward-backward translation approach. A convenience sample consisting of 224 Chinese patients with CHD were recruited from a university-affiliated hospital in Shiyan, China. The C-CSES and the General Self-efficacy Scale (GSES) were used in this study. The factor structure, convergent and discriminative validities, and internal consistency of the C-CSES were evaluated.

Results

The confirmatory factor analysis (CFA) supported a three-factor high-order structure of the C-CSES with model fit indexes (RMSEA = 0.084, CFI = 0.954, NNFI = 0.927, IFI = 0.954 and χ ² /df = 2.572). The C-CSES has good internal consistency with a Cronbach’s alpha of 0.926. The convergent validity of the C-CSES was established with significantly moderate correlations between the C-CSES and the Chinese version of the GSES (p < 0.001). The C-CSES has also shown good discriminative validity with significant differences of cardiac self-efficacy being found between patients with and without comorbidities of hypertension, diabetes, or heart failure.

Conclusion

The empirical data supported that the C-CSES is a valid and reliable disease-specific instrument for assessing the self-efficacy of Chinese patients with CHD.

Development of a physical literacy model for older adults - a consensus process by the collaborative working group on physical literacy for older Canadians

BACKGROUND

Arguably the uptake and usability of the physical activity (PA) guidelines for older adults has not been effective with only 12% of this population meeting the minimum guidelines to maintain health. Health promoters must consider innovative ways to increase PA adoption and long-term sustainability. Physical literacy (PL) is emerging as a promising strategy to increase lifelong PA participation in younger age-groups, yet there is relatively little evidence of PL being used to support older adults in achieving the PA guidelines.

METHODS

An iterative and mixed-methods consensus development process was utilized over a series of six informed processes and meetings to develop a model of physical literacy for adults aged 65 years and older.

RESULTS

A multi-disciplinary collaborative working group (n = 9) from diverse practice settings across Canada, and representative and reflective of the full range of key elements of PL, was assembled. Three consensus meetings and two Delphi surveys, using an international cohort of 65 expert researchers, practitioners, non-government organizations and older adults, was conducted. 45% responded on the first round and consensus was achieved; however, we elected to run a second survey to support our results. With 79% response rate, there was consensus to support the new PL model for older adults.

CONCLUSION

Older adults are a unique group who have yet to be exposed to PL as a means to promote long-term PA participation. This new PL model uses an ecological approach to integrate PL into the lifestyles of most older adults. Understanding the interactions between components and elements that facilitate PL will ultimately provide a new and effective tool to target PA promotion and adherence for all older Canadians.

La autoeficacia en el post-infarto

Introducción. Después de un infarto agudo de miocardio, los pacientes experimentan altos niveles de estrés emocional y ansiedad. Estas percepciones limitan sus comportamientos saludables.Objetivo. Determinar el nivel de autoeficacia general en pacientes post-infarto agudo de miocardio según la edad, género, estado de rehabilitación y atención en una unidad de cardiología en Girardot.Materiales y métodos. Investigación descriptiva, evaluada a través de la Escala general de autoeficacia versión ll, en una población de 149 personas entre los 35 y 65 años. Para el análisis estadístico de los resultados se utilizaron medidas estadísticas descriptivas y pruebas de correlación.Resultados. La edad de los participantes tuvo una media de 52 años. El análisis de la autoeficacia por grupo de edad evidenció incidencia mínima de la autoeficacia en el grupo de edad. Según el género, los hombres se percibieron más autoeficaces que las mujeres. Además, los pacientes que no asistieron a la rehabilitación cardíaca tuvieron un nivel de autoeficacia general ligeramente mayor en comparación con los rehabilitados.Conclusiones. No hubo relación entre la edad, el género y la rehabilitación frente al nivel de autoeficacia. Estas variables dependieron de otras diferentes a las del estudio.

The MOTIV-HEART Study: A Prospective, Randomized, Single-Blind Pilot Study of Brief Strategic Therapy and Motivational Interviewing among Cardiac Rehabilitation Patients

Background: Psychological distress, biomedical parameters, and unhealthy lifestyles contribute to a poorer prognosis for cardiac disease. Public health's challenge is to motivate patients to utilize self-care. Objective: This prospective, randomized, single-blind pilot study aimed at testing the incremental efficacy of Brief Strategic Therapy (BST) combined with Motivational Interviewing (MI) in improving selected biomedical and psychological outcomes over and beyond those of the stand-alone BST in a residential Cardiac Rehabilitation (CR) program. Method: Fourty-two inpatients (17 females), enrolled in a 1-month CR program, were randomly allocated into two conditions: (a) Three sessions of BST and (b) Three sessions of BST plus MI. Data were collected at baseline, discharge, and after 3 months through phone interviews. Results: At discharge, no significant between-group difference was found in any outcome variable. Changes from pre- to post-treatment within each condition showed significant improvements only in the BST group, where the level of external regulation diminished, and both the participants' self-regulation (Relative Autonomous Motivation Index, RAI) and willingness to change improved. At the 3-month follow-up, within-group analyses on responders (BST = 9; BST + MI = 11) showed a statistically significant improvement in the level of systolic blood pressure in both groups. Discussion: Findings showed no evidence of the incremental efficacy of combining BST and MI over and beyond BST alone on either selected biomedical or psychological outcomes among CR patients. Conclusions: Ends and limitations from the present pilot study should be considered and addressed in future investigations.

Perceived health competence predicts health behavior and health-related quality of life in patients with cardiovascular disease

OBJECTIVE

Evaluate the effect of perceived health competence, a patient's belief in his or her ability to achieve health-related goals, on health behavior and health-related quality of life.

METHODS

We analyzed 2063 patients hospitalized with acute coronary syndrome and/or congestive heart failure at a large academic hospital in the United States. Multivariable linear regression models investigated associations between the two-item perceived health competence scale (PHCS-2) and positive health behaviors such as medication adherence and exercise (Health Behavior Index) as well as health-related quality of life (5-item Patient Reported Outcome Information Measurement System Global Health Scale).

RESULTS

After multivariable adjustment, perceived health competence was highly associated with health behaviors (p<0.001) and health-related quality of life (p<0.001). Low perceived health competence was associated with a decrease in health-related quality of life between hospitalization and 90days after discharge (p<0.001).

CONCLUSIONS

Perceived health competence predicts health behavior and health-related quality of life in patients hospitalized with cardiovascular disease as well as change in health-related quality of life after discharge.

PRACTICE IMPLICATIONS

Patients with low perceived health competence may be at risk for a decline in health-related quality of life after hospitalization and thus a potential target for counseling and other behavioral interventions.

Interrelation and independence of positive and negative psychological constructs in predicting general treatment adherence in coronary artery patients - Results from the THORESCI study

BACKGROUND

In cardiac patients, positive psychological factors have been associated with improved medical and psychological outcomes. The current study examined the interrelation between and independence of multiple positive and negative psychological constructs. Furthermore, the potential added predictive value of positive psychological functioning regarding the prediction of patients' treatment adherence and participation in cardiac rehabilitation (CR) was investigated.

METHOD

409 percutaneous coronary intervention (PCI) patients were included (mean age = 65.6 ± 9.5; 78% male). Self-report questionnaires were administered one month post-PCI. Positive psychological constructs included positive affect (GMS) and optimism (LOT-R); negative constructs were depression (PHQ-9, BDI), anxiety (GAD-7) and negative affect (GMS). Six months post-PCI self-reported general adherence (MOS) and CR participation were determined.

RESULTS

Factor Analysis (Oblimin rotation) revealed two components (r = − 0.56), reflecting positive and negative psychological constructs. Linear regression analyses showed that in unadjusted analyses both optimism and positive affect were associated with better general treatment adherence at six months (p < 0.05). In adjusted analyses, optimism's predictive values remained, independent of sex, age, PCI indication, depression and anxiety. Univariate logistic regression analysis showed that in patients with a cardiac history, positive affect was significantly associated with CR participation. After controlling for multiple covariates, this relation was no longer significant.

CONCLUSIONS

Positive and negative constructs should be considered as two distinct dimensions. Positive psychological constructs (i.e. optimism) may be of incremental value to negative psychological constructs in predicting patients' treatment adherence. A more complete view of a patients' psychological functioning will open new avenues for treatment. Additional research is needed to investigate the relationship between positive psychological factors and other cardiac outcomes, such as cardiac events and mortality.

Identifying predictors of resilience at inpatient and 3-month post-spinal cord injury

OBJECTIVES

To identify (1) changes in psychosocial factors, (2) relationships between psychosocial factors, and (3) significant predictors of resilience in adults with spinal cord injury (SCI) during inpatient rehabilitation and at 3-month post-discharge.

DESIGN

Cross sectional with convenience sample based on inclusion/exclusion criteria.

SETTING

Inpatient rehabilitation hospital and community-based follow-up.

PARTICIPANTS

Individuals with a SCI.

INTERVENTIONS

Not applicable.

OUTCOME MEASURES

Demographic, resilience, self-efficacy for managing a chronic health issue, depression, social roles/activity limitations, and pain.

RESULTS

The final sample consisted of 44 respondents (16 women and 28 men). Results of repeated measure analyses of variance indicated no significant changes in variables between inpatient and 3-month follow-up. Bivariate correlations revealed associations between resilience and self-efficacy at inpatient (r = 0.54, P < 0.001), and resilience and depression (r = -0.69, P < 0.001) and self-efficacy (r = 0.67, P < 0.001) at 3-month follow-up. Hierarchical regression analyses a significant model predicting resilience at inpatient stay (R = 0.61; adjusted R(2) = 0.24, P = 0.023), and at 3-month follow-up (R = 0.83; adjusted R(2) = 0.49, P = 0.022). Self-efficacy was the strongest predictor at inpatient stay (β = 0.46, P = 0.006) and depression was strongest at 3-month follow-up (β = -0.80, P = 0.007).

CONCLUSION

Results suggest that although resilience appears to be stable from inpatient to 3-month follow-up, different factors are stronger predictors of resilience across time. Based on current results, an assessment of self-efficacy during inpatient rehabilitation and an identification of depression at 3-month follow-up may be important factors to help identify those at risk of health issues overtime.

The Cardiac Self-Efficacy Scale, a useful tool with potential to evaluate person-centred care

BACKGROUND

Cardiac self-efficacy is a person's belief in his/her ability to manage the challenges posed by a coronary disease, and its role has been evaluated in several coronary populations using the Cardiac Self-Efficacy Scale (CSE Scale). Self-efficacy has an important role in person-centred care, however there is a lack of appropriate instruments that evaluate person-centred interventions.

AIM

The purpose of this study was to validate the CSE Scale by examining its psychometric properties as a first step in evaluating a person-centred care intervention in persons with acute coronary syndrome (ACS).

METHODS

The study sample consisted of 288 persons (72 women, 216 men) who completed the Swedish version of the CSE Scale two months after hospitalisation for an ACS event. Construct validity was psychometrically evaluated using confirmatory factor analysis. Additionally, convergent and discriminant validity were tested using correlation analyses.

RESULTS

The results revealed that the CSE Scale was represented by three dimensions (control symptoms, control illness and maintain functioning). The analyses also showed that the CSE Scale is suitable for providing a total summary score that represents a global cardiac self-efficacy dimension. Evaluation of convergent and discriminant validity showed the expected correlations.

CONCLUSION

The CSE Scale is a valid and reliable measure when evaluating self-efficacy in patients with ACS. It also seems to be a useful tool to promote person-centred care in clinical practice since it may offer useful guidance in the dialogue with the patient in the common creation of a personal health plan.

Social cognitive changes following weight loss and physical activity interventions in obese, older adults in poor cardiovascular health

BACKGROUND

The study objectives were to determine (a) the effects of group-mediated cognitive-behavioral interventions on change in performance self-efficacy, satisfaction with function, and with appearance among older, overweight/obese adults in poor cardiovascular health and (b) whether self-efficacy mediated change in 400-m walk time.

METHODS

This translational, randomized controlled trial of physical activity and weight loss was conducted within community Cooperative Extension Centers. Participants were randomized to three intervention arms: Physical Activity, Weight Loss + Physical Activity, or a Successful Aging education control.

RESULTS

Across 18 months, the Weight Loss + Physical Activity intervention demonstrated greater improvements in self-efficacy, satisfaction with function, and appearance versus other trial arms. Physical Activity intervention participants also experienced significant improvements in self-efficacy and satisfaction with function versus those in Successful Aging. Self-efficacy mediated 400-m walk time at 18 months.

CONCLUSIONS

Both group-mediated cognitive-behavioral interventions yielded desirable improvements in social cognitions and preserved mobility improvements post-intervention.

General self-efficacy and health-related quality of life after myocardial infarction

Fatigue after myocardial infarction (MI) has been found to be distressing. A person's self-efficacy will influence his/her health behavior and plays an active role in tackling illness consequences. This study investigated associations between fatigue, disturbed sleep, general self-efficacy, and health-related quality of life (HRQoL) in a sample of 145 respondents admitted to hospital for MI two years earlier. The aim was to identify the predictive value of general self-efficacy and to elucidate mediating factors between self-efficacy and HRQoL. General self-efficacy measured four months after MI was positively related to HRQoL after two years. In tests of indirect effects, fatigue meditated the effects between self-efficacy and the physical and the mental dimension of HRQoL, respectively. The indirect effect of disturbed sleep went through that of fatigue. To conclude, patients who suffer from post-MI fatigue may need support aimed at helping them increase their self-efficacy as well as helping them adapt to sleep hygiene principles and cope with fatigue, both of which will have positive influences on HRQoL.

Thinking about maintaining exercise therapy: Does being positive or negative make a difference?

Objective: To investigate social-cognitive and exercise differences in individuals who think positively or negatively about upcoming exercise while engaged in programs of maintenance exercise therapy for cardiovascular disease and other chronic health conditions. Method and Results: Participants ( n = 40) completed measures relative to exercise adherence. MANOVA revealed positive thinkers were significantly higher in exercise frequency, self-regulatory efficacy, positive affect, willingness to adapt and lower in decisional struggle than negative thinkers. Conclusions: Thoughts about exercise therapy are related to social cognitions crucial to motivating self-regulatory actions influencing exercise. Negative thoughts may suggest less ability to adapt to maintenance exercise challenges.

Self-efficacy as a marker of cardiac function and predictor of heart failure hospitalization and mortality in patients with stable coronary heart disease: findings from the Heart and Soul Study

OBJECTIVE

The authors sought to evaluate the association of self-efficacy with objective measures of cardiac function, subsequent hospitalization for heart failure (HF), and all-cause mortality.

DESIGN

Observational cohort of ambulatory patients with stable CHD. The authors measured self-efficacy using a published, validated, 5-item summative scale, the Sullivan Self-Efficacy to Maintain Function Scale. The authors also performed a cardiac assessment, including an exercise treadmill test with stress echocardiography.

MAIN OUTCOME MEASURES

Hospitalizations for HF, as determined by blinded review of medical records, and all-cause mortality, with adjustment for demographics, medical history, medication use, depressive symptoms, and social support.

RESULTS

Of the 1,024 predominately male, older CHD patients, 1013 (99%) were available for follow-up, 124 (12%) were hospitalized for HF, and 235 (23%) died during 4.3 years of follow-up. Mean cardiac self-efficacy score was 9.7 (SD 4.5, range 0-20), corresponding to responses between "not at all confident" and "somewhat confident" for ability to maintain function. Lower self-efficacy predicted subsequent HF hospitalization (OR per SD decrease = 1.4, p = .0006), and all-cause mortality (OR per SD decrease = 1.4, p < .0001). After adjustment, the association of cardiac self-efficacy with both HF hospitalization and mortality was explained by worse baseline cardiac function.

CONCLUSION

Among patients with CHD, self-efficacy was a reasonable proxy for predicting HF hospitalizations. The increased risk of HF associated with lower baseline self-efficacy was explained by worse cardiac function. These findings indicate that measuring cardiac self-efficacy provides a rapid and potentially useful assessment of cardiac function among outpatients with CHD.

Self-efficacy for exercise in cardiac rehabilitation: review and recommendations

Despite the numerous physical and psychosocial benefits of exercise for coronary heart disease survivors, non-adherence to cardiac rehabilitation (CR) exercise is a major problem. Adherence to the lifestyle behavior change associated with CR involves both physical and self-regulatory skills. While self-regulatory efficacy is clearly linked to exercise adherence and adjustment, the literature on the relationship between self-efficacy and exercise among CR participants has not been systematically reviewed. A search of relevant databases identified 41 CR studies. Few studies measured self-regulatory efficacy for actions that facilitate adherence. Most studies examined self-efficacy during the intensive center-based phase of CR, with little attention to long-term maintenance. The CR literature could benefit by examining (a) self-efficacy as a major rehabilitation outcome, (b) measurement of self-regulatory efficacy for behavior change, (c) suspected moderators of self-efficacy (i.e. gender, age), and (d) self-efficacy relative to maintenance.

The role of self-efficacy in vascular risk factor management: a randomized controlled trial

OBJECTIVE

Given the large number of patients at high risk of vascular events, new strategies are needed to reduce vascular risk. We investigated whether self-efficacy promotion could change self-efficacy levels in patients with vascular diseases and whether baseline self-efficacy and changes in self-efficacy were related to changes in vascular risk factors.

METHODS

One hundred fifty-three recently referred patients with symptomatic vascular diseases (cerebrovascular, abdominal, or peripheral arterial) participated in a randomized trial investigating the effect of nursing care, as compared with usual care, on vascular risk factors. Nursing care consisted of self-efficacy promotion and medical treatment of vascular risk factors. Self-efficacy and vascular risk factors (smoking, BMI, waist, blood pressure, lipid, and glucose levels) were measured at baseline and after 1 year.

RESULTS

While total self-efficacy did not change over the 1-year intervention period in either treatment group, self-efficacy in choosing healthy food (mean +0.4+/-1.4, p-value 0.01) and in doing extra exercise (mean +0.3+/-1.3, p-value 0.03) increased in the intervention group. No relation was seen between baseline total self-efficacy or change in composite self-efficacy and change in vascular risk factors.

CONCLUSION

The nursing intervention did not influence total self-efficacy but did improve self-efficacy in choosing healthy food and doing extra exercise. Change in composite self-efficacy was not related to change in vascular risk factors in patients at high risk of developing (new) cardiovascular diseases.

PRACTICE IMPLICATIONS

Influencing self-efficacy in choosing healthy food and doing extra exercise could be incorporated in vascular risk reduction programs in addition to medical treatment of vascular risk factors.

Self-efficacy and health status in patients with coronary heart disease: findings from the heart and soul study

OBJECTIVE

To examine the relationship between cardiac self-efficacy and health status, including symptom burden, physical limitation, quality of life, and overall health among outpatients with stable coronary heart disease (CHD). We hypothesized that lower self-efficacy would predict worse health status, independent of CHD severity and depression.

METHODS

We performed a cross-sectional study of 1024 outpatients with CHD, who were recruited between 2000 and 2002 for the Heart and Soul Study. We administered a validated measure of cardiac self-efficacy, assessed cardiac function using exercise treadmill testing with stress echocardiography, and measured depressive symptoms using the Patient Health Questionnaire. Health status outcomes (symptom burden, physical limitation, and quality of life) were assessed using the Seattle Angina Questionnaire, and overall health was measured as fair or poor (versus good, very good, or excellent).

RESULTS

After adjustment for CHD severity and depressive symptoms, each standard deviation (4.5-point) decrease in self-efficacy score was independently associated with greater symptom burden (adjusted odds ratio (OR) = 2.1, p = .001), greater physical limitation (OR = 1.8, p < .0001), worse quality of life (OR = 1.6, p < .0001), and worse overall health (OR = 1.9, p < .0001). Depressive symptoms and poor treadmill exercise capacity were also associated with poor health status, but left ventricular ejection fraction and ischemia were not.

CONCLUSIONS

Among patients with CHD, low cardiac self-efficacy is associated with poor health status, independent of CHD severity and depressive symptoms. Further study should examine if self-efficacy constitutes a useful target for cardiovascular disease management interventions.

Self-efficacy and overprotection are related to quality of life, psychological well-being and self-management in cardiac patients

This repeated-measures study explores how self-efficacy and overprotection relate to psychological well-being, health-related quality of life and self-management. Eighty-two cardiac patients, suffering from congestive heart failure (CHF) or myocardial infarction (MI), completed questionnaires at T1 and three months later. Perceived overprotection is associated with concurrent levels of anxiety and depression, and lowered quality of life. Self-efficacy is related to psychological well-being in both patient groups, but only associated with quality of life in CHF patients. In addition, self-efficacy predicts MI patients' self-management behaviours in the medium term. Findings have implications for cardiac rehabilitation, where attention may usefully be focused on enhancing self-efficacy and dealing with issues of support and overprotection by the partner.

Effects of home-based cardiac exercise program on the exercise tolerance, serum lipid values and self-efficacy of coronary patients

BACKGROUND

Exercise-based cardiac rehabilitation improves exercise capacity and reduces cardiac risk factors. The purpose of this pilot study was to examine the effects of a home-based cardiac exercise program (HBCEP) on exercise tolerance, serum lipids, and self-efficacy in coronary heart disease patients in Turkey. Self-efficacy theory provided the framework for this study's intervention.

DESIGN

The study design was a pre-test and post-test experimental, randomized assignment.

METHOD

The study included 30 participants in a home-based cardiac exercise program (HBCEP; mean age=54.7+/-7.8) and 30 in control (C; mean age=52.7+/-6.5). The Phase II cardiac exercise program included three 45-60-min sessions per week for 12 weeks, and the enhancement of self-efficacy through educational sessions and the use of goal setting, modelling, and physiological feedback strategies. Both groups were comparable in their medical regimen, exercise capacity, and other measured variables pre-intervention. At baseline and after 12 weeks, exercise capacity was evaluated by exercise testing using the Bruce Protocol, self-efficacy was measured with the Cardiac Exercise Self Efficacy Index, and serum lipid values were measured.

RESULTS

At the completion of the 12-week exercise program, the exercise capacity (P<0.001), total cholesterol (P=0.004), triglycerides (P=0.048), high-density lipoprotein-cholesterol (P=0.001), low-density lipoprotein-cholesterol (P=0.039), and self-efficacy (P<0.001) of the HBCEP Group were significantly improved compared to the control group.

CONCLUSION

These results suggest that a first-time HBCEP in Turkey can be successful in having patients adhere to a prescribed exercise program and reduce risk factors. Enhanced self-efficacy may have mediated the improved behavioural outcomes.

Expressed emotion, adaptation, and patient survival among couples coping with chronic heart failure

Previous research (J. C. Coyne et al., 2001) that showed that marital functioning predicted mortality among patients with chronic heart failure (CHF) led to an examination of whether expressed emotion (EE) captured negative marital influences on patient survival. The authors assessed EE using 5-min speech samples obtained from patients (137 men and 47 women) and their spouses. Prevalence of EE was low, and patient and spouse EE were unrelated. Spouse EE was not associated with survival, after the authors controlled for severity of illness. Among patient EE variables, high EE status predicted survival, but in the opposite direction of what was anticipated. Overall, relations between EE and self-report measures of adaptation were weak and inconsistent. Despite the strength of findings concerning EE and psychiatric outcomes, EE does not show promise in predicting adaptation to CHF, and researchers and clinicians should instead seek to identify positive marital factors that may promote patient survival.

Changes in personal control as a predictor of quality of life after pulmonary rehabilitation

OBJECTIVE

Perceptions of mastery and self-efficacy may be related to better outcomes in pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPD). This study examined (1) whether patients with COPD improved during a rehabilitation programme with respect to quality of life (QoL) and perceptions of self-efficacy and mastery, and (2) whether increased perceptions of mastery and self-efficacy contributed to a higher QoL after rehabilitation.

METHODS

Thirty-nine consecutive COPD patients (aged 60.5 +/- 9.0) were included from a rehabilitation centre and completed self-report questionnaires assessing symptoms, QoL, and perceptions of personal control.

RESULTS

COPD patients improved during rehabilitation in overall QoL and self-efficacy, although no significant changes were found in QoL domains and mastery. Changes in self-efficacy during rehabilitation contributed to the explanation of the social and psychological functioning QoL domains.

CONCLUSION

Even in seriously impaired COPD patients in advanced stages of illness, positive changes in self-efficacy and overall well-being can be established during rehabilitation. Changes in self-efficacy were related to a better QoL, suggesting the importance of personal control in the adjustment to COPD.

PRACTICE IMPLICATIONS

Focussing more explicitly on the enhancement of perceptions of personal control in COPD patients may be an important aim of pulmonary rehabilitation.

Implementation of efficacy enhancement nursing interventions with cardiac elders

Intervention strategies based on social cognitive theory and encompassing the bio-psycho-behavioral domains are proposed to enhance self-efficacy in men and women 65 years and older recovering from myocardial infarction and coronary artery bypass grafting. This paper describes a study in which the theory-based development of efficacy enhancement (EE) nursing interventions and their implementation and utilization with interventions from the Nursing Interventions Classification (NIC) were used with cardiac elders in the treatment group of the community-based randomized clinical, trial, "Improving Health Outcomes in Unpartnered Cardiac Elders." Advanced practice nurses (APNs) provided the nursing intervention to 110 participants (mean age = 76.2, SD = 6.0) for the first 12 weeks after discharge to home. After an initial introductory meeting in the acute-care setting, participant contacts by the APNs were made at a home visit and telephone calls at 2, 6, and 10 weeks. Results describe the number of participants receiving interventions at all contacts over 12 weeks, at specified contact points, and the intensity (nurse time) of the interventions. Verbal encouragement and mastery were EE interventions used with the greatest number of participants. Exercise promotion, energy management and active listening were NIC interventions used with the most participants. Variations in the use of interventions over 12 weeks and their intensities, suggest patterns of recovery in the elders. During rehabilitation EE interventions can be successfully implemented with men and women 65 years and older and individualized to the recovery trajectory. Nurses can integrate specific EE interventions with more general interventions from the bio-psycho-behavioral domains to enhance the recovery process for cardiac elders.

Engaging patients in managing their cardiovascular health

Psychological factors play a major part in the impact, course, and treatment of cardiovascular disease. Patients' cognitions and emotions feed into their responses to their illness and its treatments and can, for example, affect the likelihood of attendance at cardiac rehabilitation programmes. It is important to view the rehabilitation process from the perspective of the patient and to examine and assess patients' beliefs. Self management and self efficacy need to be encouraged. Depression and anxiety are common after myocardial infarction and can influence outcome. A patient's mood state should be assessed routinely and regularly.